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Want vs. Need: Recognizing drug diversion in the ED

May 25, 2015 03:04PM ● By MED Magazine

By Trish Lugtu

Prescription drug abuse continues to rise. Overdose deaths from prescription painkillers have quadrupled since 1999, and 1.4 million emergency department (ED) visits in 2011 were related to drug misuse, or to abuse of pharmaceuticals.

According to the Centers for Disease Control (CDC), more than 22,000 deaths in the U.S. in 2010 were related to pharmaceuticals, comprising 60 percent of all drug overdose deaths and exceeding deaths by overdose of illicit drugs like heroin and cocaine. Pharmaceutical drugs make their way into the hands of illicit drug users through sharing among friends and family, doctor shopping, prescription fraud and theft — making the ED physician‑patient relationship an ideal target to exploit.

ED physicians practice medicine in unique circumstances. Without a prior relationship with a patient, these physicians must quickly build trust, assess circumstances, and determine the best course of treatment, often within minutes or seconds. The short‑lived relationship between physician and patient makes the ED a perfect target for drug‑seekers. But it is also these physicians’ excellent situational awareness that strengthens their ability to recognize potential drug‑seeking behavior, and to respond safely and effectively.

Recognizing drug‑seeking behaviors

The Office of Diversion Control within the Drug Enforcement Administration (DEA) published a

  brochure, Recognizing the Drug Abuser*, which describes the common behaviors of drug diverters in the ED. For example, they might show an unusual knowledge of controlled substances, give evasive or vague answers when questioned on medical history, show reluctance to provide reference information, claim to have no regular doctor or health insurance, or request specific controlled drugs while resisting a different recommendation.

The brochure also describes the modus operandi often used by drug abusers: feigning physical or psychological symptoms and trying to apply pressure to the physician through sympathy, guilt, or even direct threat. He or she may also offer excuses for not going to their regular physician, such as claiming to be an out‑of‑town visitor, that his or her regular physician is unavailable, or other scenarios.

Responsibilities of the physician

Physicians carry legal and ethical responsibilities to uphold the law and protect society from drug abuse, a professional responsibility to prescribe controlled substances appropriately, and a personal responsibility to protect his or her organization from being a target of drug diversion. Fortunately, the burden of success is not on the provider’s shoulders alone. The Office of Diversion Control is also tasked with preventing, detecting, and investigating the diversion of controlled pharmaceuticals. Toward this effort, the DEA has developed guidelines for deterring drug diversion, and the CDC has joined in the effort with additional resources.

The DEA’s guidelines include steps such as following responsible prescribing, screening for substance abuse, prescribing painkillers only when other treatments have not been effective for pain, prescribing only the quantity needed based on expected length of pain, and referencing your state’s Prescription Drug Monitoring Program. Additionally, the CDC highlights the importance of incorporating awareness of state law in strategies to deter drug diversion
in the ED.

* Available online at


‘Do’s and Don’ts’ for Responding to Drug Seeking Behavior


  • Perform a thorough examination appropriate to the patient’s condition
  • Document examination results and questions you asked the patient
  • Request picture ID, or other ID, and social security number — photocopy these documents and include them in the patient’s record
  • Call a previous practitioner, pharmacist or hospital to confirm the patient’s story
  • Confirm a telephone number, if provided by the patient
  • Confirm the patient’s current address at each visit
  • Write prescriptions for limited quantities


  • “Take their word for it” when you are suspicious
  •  Dispense drugs just to get rid of drug‑seeking patients
  •  Prescribe, dispense or administer controlled substances outside the scope of your professional practice or in the absence of a formal practitioner-patient relationship

Source: U.S. Department of Justice, Drug Enforcement Administration, Office of Diversion Control

Trish Lugtu, BS, CPHIMS, CHP, CHSS is R & D Manager with MMIC.

Note: This article originally appeared in the Winter 2014 issue of Brink, a quarterly risk solutions magazine published by MMIC. For more information, visit