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How can prescribers prevent pharmaceutical drug diversion? INTERVIEW with Warren Rivera

Rx drugs are getting into the wrong hands

“Drug diversion” is the use of drugs for unintended purposes and the channeling of prescription drugs from legal sources to the illicit marketplace or their use. The diversion of prescription drugs can occur along all points in the drug delivery process, from manufacturer to wholesale distributors, to pharmacies, and ultimately to the patient.

The results of drug diversions are very serious and can be the reason for the occurrence of:

  • drug addictions
  • drug-related emergency room visits
  • death from overdoses

And drug diversions have contributed to a significant increase in substance abuse treatment admissions.

We’ve asked a former DEA expert

In this exclusive Q&A with expert Warren Rivera, founder of Training i.D.E.A. and retired Drug Enforcement Administration Assistant Special Agent in Charge, we discuss how medical professionals can prevent pharmaceutical drug diversion.

In his 30 years of federal experience in the war on drugs, Warren Rivera has put his efforts into fighting against prescription drug abuse and the surge in heroin use. Further, he has extensive experience educating and providing consultations to physicians. Today, Warren shares his experience about the ways prescribers can participate in the process of prevention of pharmaceutical drug diversion.

Still have questions for Warren after the interview? Please use the comments section to leave any questions or comments your have. We will do our best to respond personally and promptly.

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ADDICTION BLOG: For a start, can you please explain for our readers what drug diversion means?

WARREN RIVERA: Drug diversion occurs when a legally prescribed controlled substance is diverted from the individual for whom it was prescribed to another person for any illicit use.

For example, if a patient is prescribed a 30 day supply of pain pills but only takes it for five days, the remaining pills are subject to diversion. If a family member or another person steals these pills and either takes them or sells them on the street, this is an example of diversion

ADDICTION BLOG: Which drug classes have the highest potential for diversion and abuse, or which drugs are most commonly the subject of diversion?

WARREN RIVERA: 1. The most commonly diverted pharmaceuticals are the opioid pain medications. Some common brand names of these are OxyContin, Vicodin, Duragesic and Opana. The main ingredients usually include:

2. The second most commonly diverted class of drugs are the benzodiazepines which are psychoactive drugs to treat anxiety. Some common brand names are Xanax, Valium and Klonopin. Examples of benzodiazepines are:

  • alprazolam
  • clonazepam
  • diazepam

3. Other commonly diverted drugs are muscle relaxants such as Carisoprodol (Soma) and amphetamines such as Adderall.

ADDICTION BLOG: What are the consequences for the users and the prescribers in case of drug diversion?

WARREN RIVERA: Persons who divert controlled substances are subject to criminal prosecution and civil forfeiture action on proceeds obtained by the illegal sale of controlled substances. Physicians who are found to prescribe controlled substances outside the usual course of professional practice with no legitimate medical purpose are subject to administrative, civil and criminal penalties.

ADDICTION BLOG: Is there a way to recognize drug diversion? What are the signs?

WARREN RIVERA: Drug Diversion can occur at any level of the distribution chain. From the manufacturer/wholesaler/importer to the prescribing physician and patient.

Drug Enforcement Administration (DEA) investigators utilize record keeping systems to look for suspicious or excessive orders of controlled substances imported or distributed to wholesalers or pharmacies. The DEA often receives leads relative to diversion from:

  • physicians
  • pharmacists
  • patients and
  • concerned family members

Physicians who prescribe excessive amounts of the most addictive pain medications (Schedule II) will likely be interviewed by the DEA to ensure they are compliant with DEA policy and procedures. Patients who receive overlapping prescriptions by “Doctor-shopping” will be investigated.

ADDICTION BLOG: How can a health care professional determine if a patient is seeking drugs for illicit purposes? What are the behavioral signs of a drug abuser and how are they typically manifested?

WARREN RIVERA: Patients who are diverting or abusing drugs exhibit behaviors such as:

  • requesting or demanding specific drugs
  • continually asking for early refills due to loss or theft of their prescription
  • continually request the dosages to be increased because the current dose does not relieve their pain

Drug abusers often can recite their symptoms with textbook definitions hoping that the language will ensure they are prescribed their choice medications. Drug abusers are typically vague about their medical history and often evasive when answering questions. Drug abusers seldom provide references or names of other physicians who previously treated their condition and they are reluctant to accept other forms of therapy other than controlled substances.

ADDICTION BLOG: Which types or methods of prescription drug diversion are most common?

WARREN RIVERA: The majority of diverted medications come from heft of residential medicine cabinets. Prescription fraud is also very common and occurs when patients either increase the dosage or strength of the drug on the paper prescription or they write their own fraudulent prescriptions on stolen prescription pads and forge the physician’s signature.

Another common method of diversion occurs when patients visit multiple doctors to obtain as much as the medication as possible. This is referred to as “Doctor-Shopping” and has declined drastically after implementation of Prescription Drug Monitoring Programs. “Pill Mills” or rogue pain clinics are common and continue to be a source of diverted prescription medications.

ADDICTION BLOG: What steps should a prescriber take in order to minimize drug diversion?

WARREN RIVERA: Physicians can minimize diversion by conducting random urine drug testing on their patients to determine if any illicit drugs are present in the patient’s system and whether or not the patient is actually using the medication prescribed.

Physicians should also conduct pill counts and run the patient’s name in the Prescription Drug Monitoring Program to ensure the patient is not seeing multiple doctors for the same prescriptions. Further, physicians should not prescribe opiate pain killers to patients with a history of substance abuse. When prescribing opiate pain killers, the lowest possible effective dosage should be prescribed to minimize diversion and abuse.

ADDICTION BLOG: Are there any clinical principles and practices that can prevent the occurrence of drug diversion?

WARREN RIVERA: Physicians should review the DEA Diversion website and also review the CDC (Centers for Disease Control and Prevention) Guidelines for Prescribing Opioids for Chronic Pain in the United States published on March 15, 2016. In this document are recommendations to reduce diversion and the abuse of pain medications.

Physicians, particularly general practitioners, receive minimal training in pain management and little to no training on DEA policy and procedures in medical school. This is why I formed my consulting business (www.trainingidea.com) hoping to educate physicians on how to remain DEA compliant when prescribing controlled substances.

ADDICTION BLOG: What is the procedure for reporting a suspected drug diversion?

WARREN RIVERA: Physicians, pharmacists and concerned citizens can report diversion to their local DEA office. It is best to call either the Diversion Group or the Tactical Diversion Squad at the DEA. They can also call their local police department and ask for the group who works cases involving pharmaceutical diversion.

ADDICTION BLOG: Are there any penalties for drug diversion?

WARREN RIVERA: Drug diversion can occur at many levels beyond the prescriber and users. DEA monitors all controlled substances including the importation of controlled substance precursors and distribution by wholesalers.

Penalties for those who violate the Controlled Substances Act are also subject to administrative, civil and criminal penalties. All persons who manufacture, import, export, conduct research or chemical analysis, distribute or dispense controlled substances require a DEA Registration.
An example of an administrative sanction would be for DEA to revoke or suspend their registration for any violations. A civil sanction involves either a civil fine or asset forfeiture and a criminal penalty can result in fines and incarceration.

ADDICTION BLOG: Did the Affordable Care Act cause some changes regarding drug diversion?

WARREN RIVERA: The Affordable Care Act or “Obamacare” expanded prescription coverage for eligible Medicaid and Medicare patients. As a result, more prescriptions are being dispersed to patients who could not previously afford it. Logically, the more prescriptions issued means there is more medication available on the market to be diverted.

Additionally, as part of an Obamacare initiative meant to reward quality care, the Centers for Medicare and Medicaid Services (CMS) is allocating some $1.5 billion in Medicare payments to hospitals based on criteria that include patient satisfaction surveys. Some physicians are issuing controlled substances to apparent drug seekers at the patient’s request in order to keep their patient satisfaction surveys at a high level so they will receive the highest possible reimbursement from CMS. Drug seekers are wise to these surveys and use it as a tool to receive controlled substances.

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About the Interviewee: Warren Rivera founded the training i.D.E.A. after thirty years of experience as an Assistant Special Agent in Charge (ASAC) of the Drug Enforcement Administration (DEA). He has a Bachelor’s Degree with Concentration in Criminal Justice from the University of New Orleans and a Master’s Degree in Organizational Management. As an agent working the streets in Los Angeles, he witnessed the overwhelming and increasing importation of cocaine from South America and heroin from Southeast Asia and Mexico. From Los Angeles to South America, he served the DEA in six different duty stations throughout the U.S. and abroad.
Warren Rivera supervised a Tactical Diversion Squad (TDS) for several years until he was promoted to the position of ASAC over the TDS, as well as other enforcement groups and DEA Task Forces. Throughout his DEA career, he provided extensive and in-depth training on various topics at the DEA Academy in Quantico, Virginia and to Federal, State and local authorities throughout the country. He also trained DEA Registrants and medical professionals on topics related to the DEA Mission.

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