Strengthening program efficacy by monitoring the diversion of non-controlled substances

It is easy to forget that the scope of medication diversion can move beyond controlled, and highly regulated substances. Non-regulated drugs can be inexpensive, accessible, and overlooked by drug diversion programs. However, they still pose a risk to patients and the nurses diverting.

Challenges of tracking diversion of non-controlled substances

Non-controlled substances have no central database tracking trends and theft, and can be even more complicated due to varying regulations from state to state. Let’s look at a scenario from the early days of drug diversion detection programs.

In the beginning, most detection consisted of manual processes. One day, during my time as an investigator, I was monitoring reports for the “usual suspects” by analyzing activity involving fentanyl, hydromorphone, morphine, and similar medications. However, on that day, I received a call from a nurse leader who wanted to share concerns regarding activity shown for a nurse on her unit. The nurse had missing doses of ondansetron (Zofran). This was not one of the top medications aggressively monitored, but the idea of the medication being diverted for someone with a substance abuse disorder aligned. It was at this moment that I realized we should check the rest of the medications that are not closely monitored.

The nurse in question exhibited concerning activities around gabapentin and cyclobenzaprine. Large quantities of dispensed medications without administration, returned medications, and full dose wastes were just a few of the activities that were cause for concern. The nurse was interviewed immediately, and upon discovery of their activity, they admitted to everything, including diversion of additional non-controlled drugs, hydrocodone and hydromorphone. The interview revealed that the nurse targeted these medications because of the limited oversight.

In addition, they admitted that the Ondansetron was diverted to keep withdrawal symptoms under control, all while they were taking care of patients. This single case made it clear that the way medication diversion was tracked in the hospitals needed to change. From then on, that organization added non-controlled substances that could be targeted for diversion, in addition to the controlled substances already monitored.

What to know about medication diversion in hospitals

Once non-controlled substances were added to the list of items to track, the activity was eye-opening. Within a few months, numerous instances of diversion were identified. In one instance, a pharmacy technician admitted to diverting insulin, which they used as a performance enhancer when working out and participating in competitive sports. During the interview they confessed they had been removing it for some time without detection because the security measures were focused on “dangerous medications like pain medicine”.

Non-controlled medication diversion often occurs without detection because these substances are not monitored or regulated by policy in the same way that controlled substances are monitored and regulated. However, these drugs may have similar effects as a controlled medication, may elevate the effect of a controlled medication when used together, or may be used to mask symptoms of substance use disorder by treating nausea and assisting with sleep. Regardless of the effect, each of these uses makes them highly attractive to individuals who are diverting medications and can put patients at risk.

Commonly diverted non-controlled medications

While controlled substance diversion receives substantial regulatory attention, the diversion of non-controlled medications represents an under-recognized yet growing risk within healthcare systems. These drugs — such as gabapentin, quetiapine, clonidine, and promethazine — are frequently misused due to their psychoactive or sedative properties. The lack of DEA scheduling can create blind spots in monitoring, policy enforcement, and data analytics, leaving organizations vulnerable to patient safety risks and reputational damage.

Some of the commonly diverted non-controlled medications include, but are not limited to, the following:

There are several factors that contribute to increased the risk of diversion of these non-controlled substances. As mentioned previously, limited oversight enables the person diverting to obtain these medications with less risk of detection. These medications are often stocked throughout the organization with no significant tracking measures in place. In addition, the lack of DEA scheduling often results in a false perception that these medications are at low or no risk of addiction or abuse. Underestimating the potential risk for these medications can lead to higher occurrences and higher quantities of diversion. Since occupational stress is nothing new in healthcare, and has continued to worsen, the temptation to self-medicate remains high.

While not under the scheduling of the DEA, there is still a responsibility for the organization to protect against the diversion of these medications. Accreditation organizations like The Joint Commission, along with professional organizations such as the American Society of Hospital Pharmacists (ASHP), strongly encourage the identification and inclusion of all high-risk medications (including non-controlled) in their drug diversion prevention programs. In fact, The Joint Commission mentions gabapentin and quetiapine specifically as diversion risks.

How to track the diversion of non-regulated drugs

A hospital doesn’t need to worry about the added complexity, as there is guidance available to improve your program. Follow these suggested detection and prevention strategies to include non-controlled medications in a drug diversion prevention program:

1. Developing a high-risk non-controlled medication watchlist: Identify medications frequently abused and include them in internal audits.
2. Expanding auditing to non-controlled drugs: Include dispensing, waste, and usage patterns from Automated Dispensing Cabinets (ADCs) and EMRs.
3. Restricting stock and ADC access: Limit to patient-specific dispensing whenever possible.
4. Educating and training staff: Include non-controlled diversion in annual compliance education.
5. Integrating with controlled substance monitoring programs: Treat non-controlled high-risk medications with the same vigilance as C-II–V drugs.

Tracking diversion of non-controlled substances should be part of your program

Diversion of non-controlled medications can become a well-hidden risk but implementing these strategies and monitoring high-risk non-controlled medications in similar fashion as controlled medications can result in earlier identification and prevention. This can close a significant gap and increase protection of both patients and staff, recognizing this need and addressing appropriately.

Top US healthcare institutions rely on Sentri7 Drug Diversion to proactively detect and prevent drug diversion at every stage—from purchase to patient. Leveraging machine learning, Sentri7 analyzes drug transactions rapidly to identify patterns of diversion for both controlled and non-controlled substances. With comprehensive monitoring across pharmacy, nursing, and anesthesia, Sentri7 safeguards patient safety, ensures regulatory compliance, and streamlines operations, giving healthcare leaders the tools they need to protect their patients and their organization.