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Introduction Controlled substance waste processes in perioperative areas can be cumbersome. Streamlining this process is a critical component of improving operating room efficiency. At our institution, unused controlled substances require a two-person waste prior to disposal. We hypothesized that access to a centrally located automated medication dispensing system to conduct medication waste would decrease the amount of time required to perform a two-person waste and dispose of unused medications after the completion of a case. We further hypothesized that a decrease in the time required to waste would improve user satisfaction with the waste process. Methods This was a single-center, retrospective, IRB-approved quality assurance analysis. Research Electronic Data Capture (REDCap, Stony Brook, NY, United States) software was used to design an anonymous survey, which was distributed via email from 06/09/2021 to 09/09/2021. Wilcoxon signed-rank tests were used to compare before and after paired responses for individuals. Analyses were performed using SAS 9.4 © (Cary, NC, United States) software. Results Participants reported a significant decrease in time carrying used narcotics after a surgical case. For the primary outcome, median (IQR) scores demonstrated a significant decrease from 2, representing "10-20 minutes" (IQR 1-3), to 1, indicating "<10 minutes" (IQR 1-2) spent carrying used narcotics (p < 0.0001). Reported satisfaction with the process significantly increased from 2 to 3 points, on a scale of 5, after using the new centrally located Pyxis (p < 0.0001). Participants reported the wasting process as less time-consuming, carried fewer used controlled substances, and were less likely to wait until the end of the shift to waste. Conclusions By improving the ergonomics of the waste process after adding a Pyxis system in a more central location, the time anesthesia clinicians spent carrying used controlled substances decreased. Additionally, provider satisfaction increased, likely related to the ease of finding a partner to witness wasted medications.

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BACKGROUND AND PURPOSE: Pharmacy robberies are a common occurrence. From 2010 to 2019, there were over 7500 prescription drug-related armed robbery incidents in the United States. A lecture on pharmacy robbery was added to the pharmacy curriculum in 2017 at Butler University. The primary objective of this study was to assess whether the pharmacy robbery lecture given during the first year of the pharmacy program is adequate, with a secondary objective comparing the results of this survey to one conducted prior to the curricular addition. This information provides an opportunity for schools of pharmacy to consider adding or enhancing drug diversion content into their curriculum. EDUCATIONAL ACTIVITY AND SETTING: A cross-sectional survey of all students enrolled in each professional year of the Doctor of Pharmacy program was conducted spring 2022 to collect information on pharmacy students' knowledge and experience regarding community pharmacy robberies and their perceptions of the pharmacy robbery education in the curriculum. FINDINGS: A total of 285 of 407 students responded for a 70% response rate. More than half (53.5%) feel the pharmacy robbery education received is adequate and 63.9% feel prepared to properly manage a pharmacy robbery situation. The survey asked two pharmacy robbery knowledge-based questions and most students selected the correct response to both (89.9% and 97.8%). More than one-fourth (27.1%) of the respondents reported that the pharmacy they work/worked at had been robbed. When asked if students considered changing their career path because of pharmacy robberies, 9% responded yes. SUMMARY: Pharmacy robbery still exists, and having proper education helps students prepare for and handle community pharmacy robbery situations.

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PURPOSE: This study investigated the impact of an advanced analytics software solution in the operating room (OR) on tracking and evaluating controlled substance discrepancies. The authors hypothesized that the software would increase identification of these discrepancies and improve the efficiency of the preexisting manual process. METHODS: In this evaluation comparing data from before to after implementation of the software, data were collected using the preexisting manual process for 50 days before implementation, followed by a 25-day period for acclimation to the new software, and ending with a 49-day postimplementation review period. Data collected included the total number of medication discrepancies, time required for discrepancy review and reconciliation by an OR analyst, types of discrepancies, and number of discrepancies leading to provider audits. RESULTS: Before implementation of the analytics software, there were 7,635 OR cases with a total of 674 charting discrepancies (8.83 discrepancies per 100 total OR cases) discovered across 439 OR cases. After implementation, there were 7,454 OR cases with a total of 930 charting discrepancies (12.48 discrepancies per 100 total OR cases; P < 0.0001) discovered across 680 OR cases. While discrepancies increased by 38%, the median review time for the OR analyst per case decreased (P < 0.0001) and the percentage of incidents resolved by the OR analyst increased by 14% while the number of cases requiring additional documentation by the provider decreased by 10%. CONCLUSION: Implementation of advanced analytics software in the OR significantly increased the number of controlled substance charting discrepancies identified compared to the preimplementation review process while increasing the efficiency of the OR analyst.

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PURPOSE: The purpose of this study was to describe the county-level availability of drug disposal receptacles in Kentucky community pharmacies and show the relationship between installed receptacles and opioid analgesic (OA)/controlled substance dispensing rates, stratifying where possible by urban-rural classification. METHODS: Using 2020 data from the Kentucky All Schedule Prescription Electronic Reporting program and disposal receptacle data from the US Drug Enforcement Agency, county-level comparisons were made between number of receptacles and OA/controlled substance dispensing rates. Logistic and negative binomial regression models were used to assess for differences between rural/urban county designation and odds of ≥1 disposal receptacle and compare the rates of receptacles per dispensed OA dose in rural/urban counties. FINDINGS: While rural counties saw higher OA and controlled substance dispensing rates, the majority (55.6%) of disposal receptacles were in urban locations. The odds of having at least 1 receptacle were higher in urban counties (OR 2.60, 95% CI: 1.15, 5.92) compared to rural. The estimated rate of disposal receptacles per million dispensed OA doses was found to be 0.47 (95% CI: 0.36, 0.61) in urban counties compared to 0.32 (95% CI: 0.25, 0.42) in rural counties, with an estimated rate ratio of 1.45 (95% CI: 1.01, 2.10). CONCLUSIONS: A mismatch between the availability of county-level disposal receptacles in community pharmacies and the volume of dispensed OAs/controlled substances exists, resulting in fewer receptacles per dispensed OA in rural counties compared to urban counties. Future efforts are necessary to increase access to convenient disposal receptacles located in community pharmacies, particularly in rural communities.

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PURPOSE: To present and discuss the results of the National Hospital and Health-System Controlled Substances Drug Diversion Prevention & Surveillance Program Assessment Survey. METHODS: The survey was emailed to 1,529 chief pharmacy officers utilizing the list of directors of pharmacy from the American Society of Health-System Pharmacists. The survey opened September 15, 2021, and closed October 4, 2021. Forty-nine questions were included in 5 different sections, and participants were also given the option to respond to 39 additional questions. RESULTS: The survey response rate was 12.75%, with the results showing consistencies in practice around drug security and human resource management. Sixty-two percent of sites had a formalized drug diversion committee, half of which had been implemented since 2018. Adoption of electronic controlled substance systems continues to increase, with 50% of sites having implemented such a system in the previous 3 years. At the time of the survey, 18% of organizations did not have an electronic system, but 90% of sites had implemented or intended to implement one by 2023. Over 40% of sites that utilized an electronic system were looking to upgrade to a next-generation system. Most organizations had 0.5 to 1 full-time equivalent dedicated to diversion prevention, and two-thirds of sites had a formalized diversion committee. The majority of sites defined "significant loss" by utilizing professional judgement, based on the scenario, as a percentage of inventory or as a range of units. Community practice consensus is needed around auditing adjustments to controlled substance inventory and for perpetual inventory processes. Respondents reported 1 to 2 (29%), 3 to 5 (26%), and more than 10 (26%) formal drug diversion investigations annually. CONCLUSION: This first-time survey provided significant insight into the realities of drug diversion prevention practices in hospitals and health systems nationally.

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INTRODUCTION: This paper explores the fate of South Australia's highly regarded Police Drug Diversion Initiative over the past 10 years. METHODS: The paper uses historical and legal analysis, including publicly available data as to rates of drug use, arrests and diversions, media reports, legislation and Hansard debates. RESULTS: In the mid-2010s, amidst growing anxiety about levels of amphetamine-type stimulants use in Adelaide, a coroner's report became the poster child for what was seen by the Liberal opposition as the excessive leniency and 'waste of resources' of the Police Drug Diversion Initiative. Despite being universally praised for its efficacy, the Liberal government, when elected, passed amendments to the legislation which 'capped' diversions at two. This ended the period in which diversions from criminal to social justice systems was mandatory for all persons charged with simple drug possession. But since then, the diversion rate in South Australia has plummeted in ways that cannot be explained merely because of these amendments. DISCUSSION AND CONCLUSIONS: The most highly regarded scheme for diversion of minor drug offenders to treatment is no longer effective. Indeed, the best scheme in the country may now be the worst. The essay draws attention to a catastrophe whose extent is not yet fully appreciated and suggests ways in which we can begin to explain why such a small change has had such dramatic and unforeseen consequences. Like some sort of perverse alchemy, Australia's gold standard for drug diversion has been turned into lead.

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Abstract Diversion of substances from the care of the intended patient is a significant problem in healthcare. Patients are harmed by the undertreatment of pain and suffering, transmission of disease, as well as the risk associated with impaired vigilance. Healthcare providers may be harmed by the physical and mental impact of their addictions. Healthcare systems are placed in jeopardy by the legal impact associated with illegal routes of drug release including sanction and financial liability and loss of public trust. Healthcare institutions have implemented many measures to reduce diversion from the perioperative area. These efforts include education, medical record surveillance, automated medication dispensing systems, urine drug testing, substance waste management systems, and drug diversion prevention teams. This narrative review evaluates strengths, weaknesses, and effectiveness of these systems and provides recommendations for leaders and care providers.

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Diversion of substances from the care of the intended patient is a significant problem in healthcare. Patients are harmed by the undertreatment of pain and suffering, transmission of disease, as well as the risk associated with impaired vigilance. Healthcare providers may be harmed by the physical and mental impact of their addictions. Healthcare systems are placed in jeopardy by the legal impact associated with illegal routes of drug release including sanction and financial liability and loss of public trust. Healthcare institutions have implemented many measures to reduce diversion from the perioperative area. These efforts include education, medical record surveillance, automated medication dispensing systems, urine drug testing, substance waste management systems, and drug diversion prevention teams. This narrative review evaluates strengths, weaknesses, and effectiveness of these systems and provides recommendations for leaders and care providers.

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The study examined public perception in Israel of the severity of medical cannabis diversion, its morality, and normativeness. The sample included 380 participants who completed a quantitative questionnaire to respond to four scenarios about diverting medical cannabis to a person with/without a license and with/without a small payment (a 2×2 design). The findings show that although the participants received advance information about the severity of medical cannabis diversion as a drug trafficking offense, they perceived the severity of the offense as moderate, and as an act that is at least moderately moral and normative. The findings are explained based on moral theories. We discuss the implications of the findings in relation to the gap between public attitudes and legal policy.

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PURPOSE: Challenges with monitoring and detecting drug diversion in healthcare facilities continue to be a trending topic amid the opioid epidemic. This article aims to provide insight into the expansion of an academic medical center's drug diversion and controlled substances compliance program. The justification and structure of a multihospital, centralized program are discussed. SUMMARY: Establishing dedicated controlled substances compliance and drug diversion resources has become increasingly common as awareness of the widespread healthcare impact has grown. One academic medical center recognized the value in expanding from 2 dedicated full-time equivalents (FTEs) with a scope of one facility to multiple FTEs with a scope of 5 facilities. The expansion included considering current practices at each facility, establishing the centralized team's scope, gaining organizational support, recruiting a diverse team, and forming an effective committee structure. CONCLUSION: There are multiple organizational benefits from establishing a centralized controlled substances compliance and drug diversion program, including standardization of processes, associated efficiencies, and effective risk mitigation by identifying inconsistent practices across the multifacility organization.

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An intervention is sometimes needed in situations where those struggling with a substance use disorder (SUD) require outside assistance, motivation, support, or predetermined consequences to help curb the behaviors associated with the SUD. A multidisciplinary team approach which incorporates safety, compliance, and access to care is ideal. The intervention is often the final step in an investigative process that also includes surveillance, interviews, drug testing, and chart audits. Additionally, the culture of the institution helps to formulate policies that are in line with the mission, vision, and values of the company. A punitive system-wide culture, for example, can expect a far different intervention outcome than one that is support and treatment-centric.

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Substance use disorder in health care professionals may adversely affect patient care. To reduce the risks of harm, raising awareness among all staff for early identification and response is a primary goal. Knowledgeable co-workers play an essential role to identify signs and behaviors indicating at-risk substance use by observed impairment or suspicion of drug diversion and report to a supervisor. Response protocol for a timely, confidential, safe and non-punitive intervention can help connect the clinician to needed assessment and treatment help and potentially save a life and provide a hopeful outcome to retain their license and career.

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BACKGROUND: Substance misuse is an occupational health problem for anesthesia providers (APs). More than 10% of nurse anesthetists misuse and divert medications. No standard exists for addressing AP drug diversion. The purpose of this quality improvement project was to evaluate the use of a knowledge and needs assessment to inform the development of a successful drug diversion prevention program for certified registered nurse anesthetists (CRNAs) and student registered nurse anesthetists (SRNAs). METHODS: A 28-item questionnaire, using the health belief model (HBM) and the risk perception attitude (RPA) framework, was developed to assess knowledge, beliefs, and practices of substance misuse and diversion. RPA groups were determined by level of belief in self-risk and perceived efficacy of prevention strategies. The survey was emailed to 100 CRNAs and over 100 SRNAs. Survey results were organized using the RPA framework. FINDINGS: One hundred twelve surveys were completed. The RPA avoidant category (high-risk belief and low perceived efficacy of preventive interventions) comprised 52.5% of CRNAs; SRNAs were divided primarily among the RPA responsive category with high perceived risk and high-efficacy beliefs (38.9%) and the indifferent category of low-risk beliefs and low perceived efficacy (31.9%). CONCLUSIONS/APPLICATIONS TO PRACTICE: Anesthesia providers have varying beliefs regarding drug misuse and diversion risks and perceptions of their ability to be successful with preventive strategies. Failure to address nurse anesthesia needs-based diversion prevention may result in missed opportunities to educate this group. Implementation of RPA-tailored interventions by health care organizations may produce effective, long-term outcomes for drug diversion within the profession.

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BACKGROUND: During the past decade, the misuse of over-the-counter (OTC) medicines has become a global public health concern, especially among young people. In this study, we aimed to explore the OTC consumption and related misuse in Italy and identify the demographic characteristics of people/individuals involved in this phenomenon, understanding eventual risk factors. METHODS: The study consisted of an anonymous online survey distributed by direct contact and via the Internet between June-November 2021 to the general population living in Italy. Descriptive statistics were reported, and binary regression analyses were performed to identify risk factors for lifetime misuse of OTC. The University of Hertfordshire approved the study (aLMS/SF/UH/02951). RESULTS: The final sample size was composed of 717 respondents. The sample was mainly represented by female (69.3%) students (39.9%) in the 20-25 years age group (30.0%). Based on the survey responses, study participants were divided into two groups according to the presence/absence of OTC abuse/misuse (127 versus 590), which were compared for possible predictors of OTC diversion. Multivariate regression showed that OTC abuse/misuse was associated with the knowledge of the effects of OTC [odds ratio/OR = 2.711, 95%Confidence Interval/CI 1.794-4.097, p <0.001]. On the contrary, the educational level appeared to be a protective factor [OR = 0.695, 95%CI 0.58-0.94, p = 0.016]. CONCLUSION: Although, according to our data, the phenomenon of OTC abuse appeared to be limited, increasing attention is needed because of possible underestimation and high-risk outcomes. Preventive strategies, including simplified access to information, may play a key role in limiting OTC misuse.

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BACKGROUND: Opioid misuse is a public health crisis, and unused postoperative opioids are an important source. Although 70% of pills prescribed go unused, only 9% are discarded. This study evaluated whether an inexpensive pill-dispensing device with mail return capacity could enhance disposal of unused opioids after cancer surgery. METHODS: A prospective pilot study was conducted among adult patients who underwent major cancer-related surgery. Patients received opioid prescriptions in a mechanical device (Addinex) linked to a smartphone application (app). The app provided passwords on a prescriber-defined schedule. Patients could enter a password into the device and receive a pill if the prescribed time had elapsed. Patients were instructed to return the device and any unused pills in a disposal mailer. The primary end point was feasibility of device return, defined as ≥50% of patients returning the device within 6 weeks of surgery. Also explored was total pill use and return as well as patient satisfaction. RESULTS: Among 30 patients enrolled, the majority (n = 24, 80%) returned the device, and 17 (57%) returned it within 6 weeks of surgery. In total, 567 opioid pills were prescribed and 170 (30%) were used. Of 397 excess pills, 332 (84% of unused pills, 59% of all pills prescribed) were disposed of by mail. Among 19 patients who obtained opioids from the device, most (n = 14, 74%) felt the benefits of the device justified the added steps involved. CONCLUSIONS: Use of an inexpensive pill-dispensing device with mail return capacity is a feasible strategy to enhance disposal of unused postoperative opioids.

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In South Africa, 62% of female sex workers (FSW) are estimated to be living with HIV. Qualitative research indicates that FSW share antiretroviral therapy (ART) with peers to surmount treatment barriers. We quantitatively described ART sharing, its correlates, and its relationship with viral suppression (VS) among FSW living with HIV in eThekwini, South Africa. Among FSW on ART (n = 890), 30% ever shared (gave and/or received) ART. Sharing ART was more likely among those with higher levels of alcohol use, illicit drug use, depression severity, and physical/sexual violence in the adjusted model. There was a positive, dose-response relationship between number of pills given to peers in the last 30 days and VS likelihood (aPR: 1.05, 95% CI: 1.02, 1.08; p < 0.01). Giving pills may strengthen peer relationships, which may facilitate ART adherence. ART distribution through peer networks holds promise as a context-appropriate intervention for improving ART adherence among FSW in this setting.

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Hospitals, clinics, and organizations using controlled substances must have policies and procedures in place for disposing of these substances and to avoid potential drug diversion as well as environmental pollution. Challenging, particularly to hospitals, is the ability to dispose of the waste of any number of hundreds of products every day, some of which require specific handling and protocols for safety. Incineration might be appropriate but many hospitals and certainly smaller clinics lack the appropriate facilities. Clinics and facilities that use controlled substances must maintain adequate and detailed records, but individual healthcare systems impose their own specific requirements. Some, for example, require drug disposal to be witnessed. However, recordkeeping systems must be robust and frequently audited to prevent diversion. Most healthcare systems want to dispose of controlled substances in an environmentally responsible way but in addition to federal laws in the United States, most states have their own environmental agencies and may have local regulations. Navigating this system can be complex, and since all regulations are subject to change, it requires vigilance and expertise.

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PURPOSE: The theft of drugs from healthcare facilities, also known as drug diversion, occurs frequently but is often undetected. This paper describes a research study to develop and test novel drug diversion detection methods. Improved diversion detection and reduction in diversion improves patient safety, limits harm to the person diverting, reduces the public health impact of substance use disorder, and mitigates significant liability risk to pharmacists and their organizations. METHODS: Ten acute care inpatient hospitals across 4 independent health systems extracted 2 datasets from various health information technology systems. Both datasets were consolidated, normalized, classified, and sampled to provide a harmonious dataset for analysis. Supervised machine learning methods were iteratively used on the initial sample dataset to train algorithms to classify medication movement transactions as involving a low or high risk of diversion. Thereafter, the resulting machine learning model classified the risk of diversion in a historical dataset capturing 8 to 24 months of history that included 27.9 million medication movement transactions by 19,037 nursing, 1,047 pharmacy, and 712 anesthesia clinicians and that included 22 known, blinded diversion cases to measure when the model would have detected the diversion compared to when the diversion was actually detected by existing methods. RESULTS: The machine learning model had 96.3% accuracy, 95.9% specificity, and 96.6% sensitivity in detecting transactions involving a high risk of diversion using the initial sample dataset. In subsequent testing using the much larger historical dataset, the analytics detected known diversion cases (n = 22) in blinded data faster than existing detection methods (a mean of 160 days and a median of 74 days faster; range, 7-579 days faster). CONCLUSION: The study showed that (1) consolidated datasets and (2) supervised machine learning can detect known diversion cases faster than existing detection methods. Users of the technology also noted improved investigation efficiency.

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