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Controlled Substance Drug Diversion by Healthcare Workers as a Threat to Patient Safety—Part I

Drug diversion by healthcare workers is a clandestine activity and is certainly underestimated and underreported.1 Practitioners see firsthand the clinical effects of medications on patients, and many who divert drugs may harbor the false belief that they are in control of the situation and unlikely to harm patients or become addicted themselves.2  Besides significant legal, financial, and personal risks that healthcare workers take when diverting medications, the true cost of drug diversion includes considerable risk downstream to unknowing bystanders, including healthcare facilities, the public, and especially patients. Pressures related to the coronavirus disease 2019 (COVID-19) pandemic have contributed to increased rates of anxiety in general, and this has certainly impacted healthcare workers. Coupling that with opportunities to access controlled substances, sets the stage for increased potential for diversion, making this a timely issue.

The most commonly diverted medications in healthcare include opioids, particularly HYDROmorphone, morphine, fentaNYL (including patches), HYDROcodone, oxyCODONE, methadone, and SUBOXONE (buprenorphine/naloxone); propofol; central nervous system depressants such as benzodiazepines (e.g., ALPRAZolam, clonazePAM); sedative hypnotics; and stimulants such as dextroamphetamine and methylphenidate.3 While these medications are most likely to be associated with substance use disorder, and are the most common targets for diversion detection programs, it is important to note that diversion involves all prescription drugs. Other targets include high-value medications that could be sold or used for family members such as antiretroviral agents and certain cancer medications; performance-enhancing agents like erythropoietin and anabolic steroids; and other medications associated with opioid use disorder such as ondansetron (to control opioid withdrawal symptoms) and naloxone (in case of an overdose).3-5 However, the focus of this article is controlled substance diversion as a risk to patient harm.

In Part I, we discuss drug diversion, as it impacts patient safety. In Part II, which will be published in an upcoming issue, we will provide recommendations for implementing a proactive approach to prevent, identify, report, and respond to healthcare worker controlled substance diversion.


According to the National Association of Drug Diversion Investigators, drug diversion is a medical and legal concept involving the illegal movement, adulteration, marketing, or transfer of any legal controlled substance anywhere within the supply chain, from the manufacturer to the end user.6 Diversion occurs whenever a medication is redirected from its intended destination, for personal use, sale, or redistribution to others.


One in 10 healthcare workers misuse drugs (or alcohol) during their career, which is similar to the percentage seen in the general population; however, the diversion trend is slightly different in healthcare, as workers in this setting are more likely to misuse prescription drugs rather than illicit drugs.7 Drug diversion is thought to occur in all facilities that handle controlled substances.1,8 A 2020 survey of healthcare executives showed that 96% agreed that drug diversion is occurring in US hospitals.9 Many healthcare workers who divert drugs start with injectables.4  In fact, tampering with an injectable medication, or removing the medication from a syringe or vial and replacing or diluting it with saline, water, or another substance, is the most serious type of drug diversion because it likely results in patient harm and is a desperate sign of a worker struggling with addiction.8 The COVID-19 pandemic though has made the detection of diversion more difficult. In 2020, almost half (47%) of surveyed healthcare executives reported that staff turnover due to COVID-19 made it more difficult to track drug diversion, and more than one out of three (38%) had to cut their budget allocated to diversion investigations during the pandemic.9 

Methods of Diversion

Medication-use processes in acute care settings are complex and involve many handoffs as medications move through the facility. Therefore, the methods used for drug diversion are often numerous, creative, and varied, and may occur during receipt, storage, compounding, dispensing, retrieval from storage locations, administration, and disposal to name a few.4 

For example, in the main article, Partially filled vials and syringes in sharps containers are a key source of drugs for diversion, in our March 10, 2016 newsletter, a 36-year-old nursing assistant who had been diverting discarded drugs died after self-administering what they likely thought might be an opioid but was actually a neuromuscular blocking agent.

Readers may also recall an incident we described in our January 29, 2004, newsletter involving Carpuject syringe tampering. Some controlled substances and other medications are provided in boxes of 10 tamper-resistant Carpujects, with syringes in two bundles of five, held together by a clear, wide plastic band. Unless they are properly inventoried, they can also facilitate drug diversion, and possibly even contribute to medication errors. A pharmacist reported that they noticed three instances in which someone had slipped an opioid syringe out of a bundle and swapped it with a promethazine syringe. In another case, someone replaced morphine 8 mg Carpuject syringes with 2 mg and 4 mg syringes. Nurses may overlook the swaps when they count controlled substances, observing the sealed syringes without looking at the labels. It is also possible to turn the Carpuject so the drug name is towards the middle of the bundle, making identification more difficult. Pharmacists have also missed swapped syringes when products were returned to the pharmacy. Unless you take the time to inspect the drug name on each syringe, you could easily assume that the count is correct if the number of syringes matches the expected quantity.

Aside from the obvious drug diversion problem, storing a medication in the wrong box may lead to an error. A nurse, for example, may unknowingly remove a syringe from the HYDROmorphone box without closely reading the label, assume that it is indeed HYDROmorphone, and then mistakenly give the wrong drug to the patient. Keep in mind, that the syringe packaging is tamper resistant, not tamper proof. People have always found ways to defeat safeguards (e.g., prying off seals, slitting plastic containers). An informed clinician who understands this risk, and why the syringe labels need to be read during controlled substances counts, can vastly reduce the risk of diversion and medication errors.


As previously stated, drug diversion is not a victimless crime; it not only causes harm to healthcare workers who divert drugs, but also to coworkers, employers, and patients. Healthcare workers who divert medications risk criminal prosecution, medical malpractice lawsuits, loss of professional license/career, substance use disorder, overdose, and death. Coworkers may be forced to pick up an impaired colleague’s workload or may feel guilty for not identifying the signs or speaking up. Employers bear the burden of fines, loss of Medicare and Medicaid reimbursement eligibility, civil and regulatory liability, and compromised public trust.1 But the risks of drug diversion for unsuspecting patients are especially daunting. These risks include outright theft of medications charged to the patient; unrelieved pain or anxiety from receiving a substituted or diluted dose; substandard care and reckless endangerment from impaired healthcare workers; bloodstream infections from adulterated products or contaminated syringes;10,11 adverse drug or hypersensitivity reactions if patients have been unknowingly provided with medications they should not receive; and inaccurate or falsified documentation in the patient’s medical record.

Lack of Recognition

Because of the covert nature of diversion, it may be overlooked and may not be suspected or identified at all if detection systems are not in place.4 Studies have shown that, while healthcare executives acknowledge that substance abuse is an issue in healthcare, only 17% believed the problem existed in their facility.12 Healthcare workers may fail to report drug diversion out of fear of repercussions, acceptance of diversion as a part of the culture, or lack of education on its impact or knowledge of the resources available for reporting.4 Drug diversion may not be identified until many patients have been harmed, and even when diversion is suspected, the risk of patient harm may be overlooked.4,12

Signs of Diversion

Possible signs of diversion can manifest in a worker’s physical appearance, behavior, or work habits and performance.13-15 These may be the only clues of diversion, so personal observation is vital.4 Physical signs may include wearing long-sleeved clothing even in warm environments, shakiness, tremors, slurred speech, sweating, bloodshot eyes, appearing visibly intoxicated, or deterioration in one’s personal appearance.15 Behaviors of an employee who may be diverting drugs include increased isolation and social avoidance at work, frequent illnesses or absences from work, frequent trips to the restroom or locker room and other unexplained absences, increased accidents or injuries, refusing drug testing, being unreliable, taking greater effort or more time to complete ordinary tasks, or providing elaborate excuses.15 Suspicious work habits and performance indicators of a worker who may be diverting drugs include consistently arriving early, staying late, volunteering for overtime, “wasting” controlled substances more often than peers, or transporting/storing controlled substances in their pockets.13,15 Additional at-risk behaviors worth investigating include unnecessary dilution practices; access to the automated dispensing cabinet (ADC) more than 30 minutes prior to the administration time; removal of larger than required doses, resulting in the need for wasting; removal for a patient not assigned to them; and wasting of complete doses.

Other patterns or trends that may be identified within the organization’s medication-use system include frequent incorrect controlled substance counts and discrepancies, increases in usage of controlled substances outside of normal levels, missing medications, signs of tampering with medication packaging, improper storage of controlled substances, frequent overrides in drug dispensing technologies, waste not being appropriately witnessed or large and inconsistent amounts of waste, controlled substances being removed from an unsecured waste container, or expired controlled substances being removed from their holding area.14,15 Other signs include poor documentation of the chain of custody of controlled substances, which could include late documentation, coworkers habitually helping each other in completing documentation, or inappropriate documentation “batching.”13,15 Additional potential warning signs include leaking intravenous (IV) infusions containing controlled substances, complaints of poor pain management by patients, medical records that demonstrate erratic pain relief, and unexplained transmission of infection.16

Up next

Be on the lookout for Part II on this topic in an upcoming newsletter, which will discuss tools for preventing, identifying, reporting, and responding to diversion. For further information, please join us or listen to the recording of the following drug diversion webinars: Part I: The Pursuit of Prevention—Confronting Drug Diversion and Part II: Reducing the Risk and Infection Outbreaks from Drug Diversion.  


  1. Nyhus J. Drug diversion in healthcare. American Nurse. 2021;15(5):23-7. Accessed December 13, 2022. 
  2. Michalek C, Fortier C, Haumschild R. Prevention of drug diversion in the healthcare setting. Institute for Safe Medication Practices (ISMP) webinar. May 18, 2020. Accessed March 10, 2022. 
  3. National Institute on Drug Abuse (NIDA). Misuse of prescription drugs research report. What classes of prescription drugs are commonly misused? National Institute on Drug Abuse; 2020. Accessed December 14, 2022. 
  4. New K. Institutional diversion prevention, detection, and response. Presentation at: National Association of Drug Diversion Investigators (NADDI) Tennessee Chapter Meeting; 2013. Accessed December 15, 2022. 
  5. Knight T. Is your organization protected from diversion of high-value drugs? Healthcare Business Today. December 9, 2021. Accessed December 14, 2022. 
  6. National Association of Drug Diversion Investigators (NADDI). Drug diversion. 2022. Accessed December 19, 2022. 
  7. Baldisseri MR. Impaired healthcare professional. Crit Care Med. 2007;35(suppl):S106-16.
  8. New K. Drug diversion in health care settings can put patients at risk for viral hepatitis. Minority HIV/AIDS Fund, US Department of Health & Human Services blog. May 2, 2014. Accessed December 16, 2022. 
  9. Invistics. Porter Research study 2020: a comprehensive look at drug diversion from the view of healthcare executives [White paper]. Norcross, GA: Invistics. 2021. Accessed December 15, 2022. 
  10. Rosa K. Understanding infectious disease risks associated with drug diversion & how to prevent events. ContagionLive. April 23, 2018. Accessed December 15, 2022. 
  11. Eisler P. Doctors, medical staff on drugs put patients at risk. USA Today. April 17, 2014. Accessed December 13, 2022. 
  12. Tribble DA. How big is the drug diversion problem? Nobody knows! BD. December 2, 2019. Accessed October 11, 2022. 
  13. Clark J, Fera T, Fortier C, et al. ASHP guidelines on preventing diversion of controlled substances. Am J Health Syst Pharm. 2022;79(24): 2279-306.
  14. The Joint Commission (TJC). Drug diversion and impaired health care workers. Quick Safety. 2019;(48):1-3. 
  15. American Association of Nurse Anesthesiology (AANA). Signs and behaviors associated with substance use disorder and drug diversion. American Association of Nurse Anesthesiology. Accessed October 4, 2022. 
  16. New K. The role of security in the prevention, detection and response to drug diversion by healthcare personnel. J Healthc Prot Manage. 2016;32(2):33-8.


Suggested citation:

Institute for Safe Medication Practices (ISMP). Controlled substance drug diversion by healthcare workers as a threat to patient safety – part I. ISMP Medication Safety Alert! Acute Care. 2023;28(4):1-4.