February 17, 2022

Back to Basics: Perspectives from a CRNA on Preventing Drug Diversion

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Back to Basics: Perspectives from a CRNA on Preventing Drug Diversion

Bernadette Henrichs, PhD, CRNA, CCRN, CHSE, FAANA

Director, Nurse Anesthesia Program, Goldfarb School of Nursing-Barnes Jewish College, Director, CRNA Education and Research, Washington University Department of Anesthesiology, St. Louis, Missouri

Bernadette Henrichs, PhD, CRNA, CCRN, CHSE, FAANA, is Professor and Director of the Nurse Anesthesia and PhD in Nursing Programs at Goldfarb School of Nursing-Barnes-Jewish College. She is Director of CRNA Education and Research in the Anesthesiology Department at Washington University, St. Louis. She received her anesthesia training in 1994 from Washington University and her MSN in 1993 and her PhD in 1999 from St. Louis University. She received the AANA Program Director of the Year in 2017 and was inducted as a Fellow of the AANA in August. She serves on the Drug Diversity Committee for Barnes-Jewish Hospital and is passionate about preventing drug diversion in the hospital.


Which of the following have you done at your institution to prevent drug diversion? (Select all that apply)

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Drug diversion in healthcare systems is a very serious concern, especially with the opioid epidemic occurring in the United States. Drug diversion can be described as unlawful use of a regulated medication for illicit use.  The person diverting the medication may be selling it for illicit use or the person may illegally be taking the medication himself. This behavior can lead to substance abuse and addiction in the individual who is diverting the prescription medication. It is critically important that healthcare organizations take the appropriate steps in preventing drug diversion, identifying it early if it does occur, and responding immediately when it is identified or discovered.  Preventing diversion takes an interprofessional and multidisciplinary team approach. All of those involved with prescription medications, including patients, must be educated on how to prevent drug diversion and subsequent substance abuse. The key step in preventing drug diversion is education.

Let’s discuss some specific groups below:

Surgeons must be educated on the dangers of prescribing controlled substances after surgery. According to a publication by Overton et al, surgeons prescribe the highest rate of opioid pain medications in the United States, and often prescribe more tablets than needed1.  Recent data suggest that 70% to 80% of opioids are not used after surgery1.  Unfortunately, one in 16 surgical patients prescribed opioids becomes a long-term user1. Overprescribing opioid analgesics for postoperative pain must be addressed since it is an important risk factor for persistent or chronic opioid use. Does the surgical procedure warrant prescription medications? If so, how long will the patient experience pain that warrants opioids to control such pain?  The surgeon should encourage the patient to initially take non-opioid medications such as acetaminophen or nonsteroid anti-inflammatory medications if there is no contraindication to taking these medications. If prescription opioids are necessary, the least number of opioid tablets should be prescribed for postoperative pain. According to Overton et al, the prescribed opioid tablets should never exceed 20 tablets for most common surgical procedures1. Once the prescription runs out and the tablets are taken, if the patient is still experiencing moderate to severe pain, they should see the surgeon for an assessment of the pain. This will prevent the surgeon from prescribing more opioid medications than needed. If opioid analgesics are prescribed and not utilized, the pills should immediately be safely discarded so they do not get into the hands of someone who may divert the medication.

Patients must also be educated on the dangers of taking prescribed opioid medications. Although opioids work well in controlling moderate to severe pain, they should not be taken for a prolonged length of time and they should not be taken for mild pain.  Patients must be informed of the dangers of becoming addicted to opioids.  Opioids have many side effects, including respiratory depression, lethargy, nausea, vomiting, constipation, and confusion, especially in the elderly. These side effects can lead to increased morbidity and mortality of surgical patients. Patients should be encouraged to take non-opioid medications to control their pain, including acetaminophen and nonsteroid anti-inflammatory medications if not contraindicated.  They should also be encouraged to ask the anesthesia provider and surgeon about receiving a peripheral nerve block or local anesthesia to the surgical site.  If pain is still experienced and it is moderate to severe, then the patient may need to take opioid medications. However, they must realize that the goal is not to completely eliminate the pain but to make the pain tolerable so they can participate in activities and exercise, including physical therapy.

Anesthesia Providers
Anesthesia providers must be educated on best practices for treating pain in surgical patients.  The first choice should be to administer local anesthetics and regional blocks to address surgical pain. Giving nonopioid medications, including acetaminophen, gabapentin, ketamine, alpha-2 agonists, magnesium, and/or nonsteroid anti-inflammatory medications, is an important part of the anesthesia provider’s role in administering anesthesia.  If the patient still experiences pain, then an opioid medication can be considered. Opioids should be the final option for the patient rather than the first option. This will help in preventing opioid addiction.

Pharmacists, Nurses, Physicians, other Healthcare Providers
Pharmacists, nurses, physicians, and other healthcare providers must be educated on the dangers of substance abuse and diversion of drugs. Mandatory training should occur regarding medication safety, the security of controlled substances, and drug diversion policies and procedures. Healthcare providers must be knowledgeable about the dangers of diverting drugs. If the employee is trying to deal with anxiety, depression or lack of sleep, he/she must realize that diverting drugs not prescribed for them can lead to addiction.  They should be informed that abusing prescription drugs is a crime if they are stolen from the patient or the institution and this can lead to legal consequences, including incarceration.  If discovered, those diverting drugs can lose their job, their professional license, their career, and even their family and friends. Employers should educate employees on programs available to them. It is important for institutions to offer wellness programs to their employees, including employee assistance and counseling.

Students enrolled in health-related programs must be informed of the dangers of substance abuse and drug diversion.  They should be informed early in their education, and this should be enforced throughout the program.  Resources are available for teaching students about the dangers. Having someone who has abused drugs in the past tell their story to the students and their significant others may be helpful for them to hear and ask questions.  Informing the spouses/significant others of the dangers and the signs and symptoms is important as it may be the spouse/significant other who recognizes the signs and can intervene. By intervening, the person can receive help and death may be prevented as this is how it is often discovered.

Bottom Line for Me
Preventing drug diversion in a healthcare system is an important goal for all healthcare providers. The first step in prevention is education followed by early detection and intervention.  Education plays a key role in preventing drug diversion. It is our professional duty to prevent drug diversion in our workplace so that patients and healthcare providers are not harmed.

More Information


Overton HN, Hanna MN, Bruhn WE, Hutfless S, Bicket MC & Makary MA: Opioid-prescribing guidelines for common surgical procedures: An expert panel consensus. J Am Coll Surg 2018; 227(4): 411-418. https://doi.org/10.1016/j.jamcollsurg.2018.07.659