A Little Diversion

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Medication-Assisted Treatment (MAT) facilities have struggled for a long time with some patients using their medication as a source of supplemental income. This happens more often than you would expect, and not just at methadone clinics. It happens at pain management clinics, and it happens at regular physicians’ offices. Selling one’s prescribed medications is called diversion, and it is a criminal offense.

You would think that it would be more likely to occur at a place like a methadone clinic. After all, those people are addicts, of course they engage in illegal activity. Well, think again. People suffering from addiction are not, in fact, the only ones engaging in this behavior. In fact, you likely know someone that has done it, or is currently doing it to make some extra cash. It isn’t difficult these days to obtain a prescription for pain meds, or for anxiety meds. These are among the most frequently diverted medications. And, if it is done through a physician’s office, there is little danger of the physician finding out. There really are no safeguards in place to prevent diversion at physicians’ offices, as there are at methadone clinics and other MAT facilities.

At MAT facilities, there are protocols in place to minimize diversion. The first is the inability to come into treatment and leave with medication to take home with you right away. In MAT, it takes time to earn takeout medication privileges. Patients are required initially to take their medication daily in front of the pharmacist at a dosing window. They have to be regularly monitored by various treatment team members for signs of over-sedation, and are monitored via random weekly urine drug screens for at least the first month. They are also required to see their counselor very regularly for addictions therapy and ongoing counseling sessions throughout the treatment episode.

Once a patient reaches a stabilizing dosage and begins testing negative for illicit substances, he/she is eligible to begin doing random urine drug screens once per month. It is at that point (usually after about a month in treatment) that the treatment team  examines the patient’s individual progress to determine if he/she is ready to have the first level of takeout medication, one takeout. The patient is instructed prior to the start of each new “phase” regarding the handling of the medication, the dangers of taking it in ways other than prescribed and of taking other substances or OTC medications with the medication, and in the consequences of mishandling or misusing the medication. If the patient continues to be compliant in treatment for the subsequent ninety days, continuing to test negative for illicit substances, continuing to see the counselor regularly, and continuing to have no legal issues relating to drug use and no behavioral issues at the facility,  he/she is again examined for eligibility and readiness for the next “phase,” or takeout level, two takeouts. After another ninety days of continued compliance, the patient is again examined for eligibility and readiness for the next “phase,” three takeouts. After another ninety days of continued compliance, the patient is again examined for eligibility and readiness for the next “phase,” six takeouts, meaning he/she attends clinic once per week. After another ninety days of continued compliance, the patient is again examined for eligibility and readiness for the next “phase,” thirteen takeouts, meaning he/she attends clinic once every two weeks.

The purpose of slowly increasing the allowance of takeout medications is twofold: to help the patient to avoid the addictive impulse to take more medication than he/she is prescribed, and to limit the patient’s ability to divert his/her medication. During the “phase-up” process, patients are taught to manage cravings and triggers, and taught how to handle having medication on hand without abusing it. Higher “phase” patients are still required to attend regular counseling sessions, and submit to regular random urine drug screens. It is worth noting that if, at any point in treatment a patient begins testing positive for illicit substances while he/she has takeout medication, the counselor will, depending on the situation, reduce or eliminate the number of takeouts and make the patient attend clinic more frequently for closer monitoring, and the patient will resume a weekly random urine drug screen schedule until he/she begins testing negative for illicit substances once again.

The second protocol is regular monitoring for diversion. To that end, patients having a higher “phase” are randomly phoned at least twice per year for a bottle recall. The patient is phoned in the middle of a pickup cycle and told to return to the clinic within 24 hours of the call. He/she is told to bring all bottles of medication with him/her, both empty and full. An observed drug screen (one in  which a counselor of the same sex, or a medical staff member goes into the restroom with the patient) is done when he/she arrives to ensure that the patient is not bringing urine in, or falsifying urine drug screen results in any way. If the patient is selling and not ingesting the medication, the observed urine drug screen results would show negative (or a lower level)  for the prescribed medication. After completing the observed urine drug screen, the patient is brought to the dosing window by the counselor, and the pharmacist inspects all of the medication bottles. The patient is then given his/her dose for that day and is instructed to medicate at the dosing window. If the seal on any of the remaining bottles is broken, if any of the medication is missing or appears to have been tampered with, it is considered a failed bottle recall and the patient is required to attend daily and begin the “phase-up” process all over again. If a patient does not answer the bottle recall phone call, does not check any messages left by the counselor, or just does not show up to complete the recall, it is considered a failed bottle recall and the consequences (loss of takeout privileges) is the same. Some MAT facilities will also require a patient to bring in any regularly prescribed medications with him/her to also have a pill count during a bottle recall to ensure that he/she is taking his/her outside medications correctly to monitor for abuse of other prescribed medications such as benzodiazepines for comorbid anxiety issues. Some MAT facilities will do a random monthly pill count for outside meds on an ongoing basis for more thorough monitoring, but will do an extra one during a bottle recall.

To further monitor for diversion issues, pharmacists and physicians at MAT facilities may utilize what’s known as the PDMP, which is a pharmacy database. This is the third protocol. The PDMP allows a pharmacist to run a patient’s information through the database to obtain information regarding a patient’s current prescriptions. This assists in preventing dual enrollment of patients, which is illegal. (Dual enrollment is when a patient is either concurrently enrolled in multiple MAT facilities, or when a patient is enrolled at an MAT facility and is also receiving prescriptions for opioids or for MAT medication at a private physician’s office.) It is especially important for MAT facilities to regularly use the PDMP because physicians’ offices cannot access prescription records for prescriptions patients receive at MAT facilities due to CFR 42.2 federal confidentiality regualtions for substance abuse treatment records. That is also the reason it is vital that MAT facilities make every effort coordinate care with patients’ physicians. Coordinating care with a patient’s physician ensures a higher level of patient safety, as the patient will be regularly monitored by both physicians.

Diversion may seem like an easy way to make extra cash, but it isn’t the primrose path it purports to be. Recently some states have passed bills allowing drug dealers and other people diverting their medications to be charged with murder if someone they sold substances or meds to happens to overdose and die. And it looks like similar bills being passed will be more common in the future as the number of prescription drug overdoses continues to increase. With the epidemic of prescription overdoses, it may behoove physicians with private practices to begin instituting protocols similar to those used in MAT facilities to minimize overdoses and diversion. First, do no harm. Where have I heard that before? Hmmm.