Reducing Supply of Opioids Will Not Stop Drug Diversion
Drug diversion is a massive problem. It plagues the entire drug supply chain, from manufacturer through wholesaler and distributor, to drug stores and dispensaries, all the way to consumers. It is particularly important for opioid pain medications because of the ongoing opioid crisis.
It is well established that the non-medical use of pharmaceutical drugs is an increasing public health concern. Most pharmaceutical drugs used non-medically are obtained from family and friends. There is little to no organized crime involved. And importantly, doctor shopping is rare.
An under-appreciated issue here is scale.
According to the DEA, less than 1 percent of legally prescribed opioids are diverted.
The sharing or selling of individual prescription pills is small compared to the impact of diversion higher up in the supply chain. For instance, Effingham Health systems just agreed to pay a $4.1 million settlement as a result of a DEA investigation into reports that tens of thousands of oxycodone tablets were believed to have been diverted for four years.
Similar reports about large-scale diversion abound. The Associated Press reported incidents of diversion at about 1,200 VA facilities rose from 272 in 2009 to 2,926 in 2015.
And in 2013 Walgreens was charged $80 million for poor record-keeping and dispensing violations that let millions of doses of controlled substances to enter the black market.
In 2007, the Drug Enforcement Administration estimated that prescription drug diversion in the United States was a $25 billion-a-year industry.
About one of every four thefts of methadone and OxyContin were attributed by the DEA to employee pilferage at pharmacies, hospitals and other healthcare facilities.
More recently, a 2017 survey by Porter Research, 96 percent of healthcare workers said drug diversion occurs frequently in healthcare. And 65 percent believe most diversion goes undetected.
Pill mills are even worse. In the book “American Pain,” journalist John Temple describes the impact of Florida pill mills on the east coast a decade ago.
“Florida pumped millions upon millions of doses of those narcotics—oxycodone, mostly—northward, not through a major criminal organization like the cartels of Mexico, but via thousands of individuals who streamed up and down Interstate 75 or flew from Tri-Sate Airport in Huntington, West Virginia, to Miami International, on a flight nicknamed the Oxy Express,” Temple wrote.
And none of this is remotely new. In the book “Dark Paradise,” historian David Courtwright explains: “Diversion from maintenance programs posed a real danger, given that perhaps half of all licitly manufactured barbiturates and amphetamines ended up on the black market.”
So the claim by Attorney General Jeff Sessions that “It’s a common sense idea: the more a drug is diverted, the more its production should be limited” is both simplistic and misguided.
Sessions is assuming that limiting production will reduce diversion. But economic theory suggests the opposite may be true. Reducing supply leads to scarcity, which generally increases value. This in turn may create stronger incentives to divert more opioids into the black market.
Moreover, there is no evidence that people who divert medication are aware of and responding to DEA production quotas. Instead, the consensus is that people divert what they need and think they can get away with. In other words, diversion is an exercise in what economists call the “Tragedy of the Commons,” in which individuals each use a collective resource for their own benefit without regard for the effects on others.
And Sessions’ idea implies that reducing production won’t have any effect on medical practice. But there is an abundance of evidence to the contrary. There is an ongoing shortage of injectable opioids at hospitals around the country. And despite claims to the contrary, opioid analgesics cannot always be replaced or substituted with other pain relievers.
Thus, more intelligent and nuanced approaches are needed. For instance, the NIH is sponsoring research to use advanced data analytics to detect drug theft and diversion in hospitals. Similar efforts at wholesalers, distributors, pharmacies and dispensaries are worth considering.
So while diversion is a major problem, it is neither new nor limited to individual consumers with prescriptions for opioids or other medications that have a street value or abuse potential. The seemingly obvious response of reducing supply could easily backfire. Instead, securing the entire supply chain, from manufacturer through distributor to point-of-sale to consumers, is a vital step in making sure that only the intended recipients of pharmaceutical drugs have access to them.
Filed under: General Problems
I have experienced drug diversion once at my local ER. I am a General Contractor (or was) and I fell from a step ladder, broke my wrist about 10 years ago. I was already a pain management patient for some 13 years when the accident occurred. At that point in time, even though a pain managment patient “under contract” with my specialist, if an injury ocurred to patients already on a dosage of opioid medication for continuous, non correctable pain from disease or injury, the ER would still give an injection, at least for a broken bone…..no problem until the patient could relate the incident to the pain managment specialist. I went to the ER, I knew that a bone was broken,and a nurse prepared an injection of opioid medication for me. She said the injection had to be placed in the “hip” so I prepared myself for the injetion by relaxing. I felt NO pain after she said she had given the injection from the needle and I KNEW that she had NOT gave me an injection. After about 10 minutes I begn ti become more nausiated from pain. I grabbed a different nurse and told her I was still in great pain and that I did not beieve that I had actually gotten the injection. She did not seem to be surprised. She said she would personally request from the pharmacy another injection and give it to me….personally. She did so and as it should be there was a slight pinch, I felt the fluid in my hip and in less than 4 minutes, the pain decreased to a tolerable level. The first nurse that said she gave me an injection seemed extremely “happy”. The second nurse after considring the entire incident seemed to be VERY aware and not surprised at the entire incident. I, we the pain management patients of this nation fully realize that medication can and is diverted even in a hospital environment. I now often think of the elderly folks in an assisted living facility of how bad the patients that trully need pain management suffer because of incidents such as my experience. This being said, as a pain managment patient very beneficially and successfully treated with opioid medication therapy for 23 years after an inoperable spine conditon after two surgeries, one very invasive KNOWN to induce pain for the rest of the patients life, I can NOT understand why those of us treated with opioid medication therapy as the very last effective therapy for pain managment have been attacked, abandoned, and will NOT be heard. As far ass AG Jeff Sessions, he needs to practice law, and not medicine. His antiquated “judgement” of the ever ending war on drugs is ASININE. I f one has never had an injury worse than a hangnail, how can one make ANY determination of a pain management patients needs. I am sure drug diversion will NEVER be irradicated but, my curret specialist urine screens, pill counts and formed a data base on myself as well as other physicians across the country and KNOW who is using their tailored medication “as directed”. When the elect ignores the bare facts of an issue concerning millons of citizens, forming their own “opinions”, capable of introducing new law concerning ANY issue without propelyr informed infromation, we are headed for a dangerous “democracy”. I still say PROVE that every single pain management patient is diverting their personal medication . There IS documentation of proper, appropriate prescribing and patient use of medication yet, all patients have been damned to a lifetime of intolerable pain because we are all diverting the ONLY medication therapy that helps give purpose and meaning to what “life” we have left, young and old. I find it simply incomprehensible. I hope for the bet and that reason, statistics, and intelligent judgement prevails but, I am worried about the Gestapo thinking if you can even call it thinking that millions of patients that have benefitted form opioid medication use and the forced “tapering” down from effective pain management that we seem to be headed for. How can someone with ZERO medical training and education rave about “good people don’t use marijuana” when he has NO CLUE what he is talking about. I am not sure how to unite the voices of the millions of patients that effective, appropriately prescribed medication has benefitted from for years and decades effective enough for many to survive. and why our voices are not heard In Washington. The “elect” get the BEST medical services knon to man and medicine that INCLUDES Opioid medication therapy when neccessary. AG Jeff Sessions needs to do what he was appointed to do and leave medicine to our physicians, our medical boards, and of course last and evidently least, the patients that can prove that not all patients divert, abuse, or profit from an effective dosage of the last therpy that keeps a patient from considering suicide on a daily basis. SAD “state” of affairs.I am sorry to be so long winded but, I have no choice at this point. It IS a matter of urvival for enough citizens of this country to begin to raise hell if that i what it takes. We hav NOTHING more to lose than our mobility, ability, and our lives.
I must be dense or stupid. If drug diversion is a massive problem and people are getting the drugs from family and/or friends as the article states, then why are Chronic Pain Patients being abandoned by their doctors who are fearful to prescribe oipiods? Where are “the family and friends” getting the drugs that people are diverting?
And how can employees at hospitals, pharmacies, etc., steal these drugs to sell them? I just don’t get this!
We could actually STUDY this.
Put a marker on each pill.
Trace each overdose or diverted pill.
Like fingerprints or
Bullet rifling patterns.
Track opiates back to their source.
We will find this:
Most pills are counterfeit ( think Prince, Tom Petty)
The scarcer Rx pills are,
The more demand for counterfeits.
Once again,
The law of unintended consequences is at play