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Outbreaks Highlight Infection Risks Associated with Drug Diversion

Categories: Injection Safety

Joseph Perz, DrPH, MA

Joseph Perz, DrPH, MA

Author: Joseph Perz, DrPH, MA
Quality Standards and Safety Team Leader
for the Division of Healthcare Quality Promotion,
Centers for Disease Control and Prevention

When prescription medicines are stolen or used illegally, it is called drug diversion.

Prescription opioid addiction has reached epidemic proportions and is a major driver of drug diversion. One aspect of drug diversion that is not well recognized involves healthcare personnel who steal controlled substances for their personal use. Under these circumstances, patient harm can take many forms. These include:

  • Substandard care delivered by an impaired healthcare provider,
  • Denial of essential pain medication or therapy, or
  • Risks of infection (hepatitis C virus, hepatitis B virus, HIV, bacterial infection) if a provider tampers with injectable drugs.

CDC and state and local health departments have helped investigate outbreaks that occurred when healthcare providers tampered with injectable drugs. Along with my CDC colleague Dr. Melissa Schaefer and I recently published a summary of six of these outbreaks, which were investigated over the last ten years.

These outbreaks revealed gaps in prevention, detection, and response to drug diversion. To prevent diversion, healthcare facilities should enforce strong narcotics security measures and maintain active monitoring systems. Appropriate response when diversion is suspected or identified includes prompt reporting to enforcement agencies and assessment of harm to patients, including assessment of possible infection risks.

Public Comments

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this blog is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy ».

  1. June 23, 2014 at 3:10 am ET  -   sc

    I know there was something very strange going on with drugs that my mom got. I’m not sure if it was drug diversion. Her medical care put her in terrible danger. She was given sedatives that were very dangerous to her heath that almost killed her several times and she was given the wrong medicine that did kill her even though the staff knew that the meds that they gave her would kill her. I don’t think that what was done to my mom could have possibly been considered a medical mistake. It haunts me to this day.

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  2. AUTHOR COMMENT June 12, 2014 at 5:25 am ET  -   CDC's Safe Healthcare Blog

    The issue you raise does deserve attention, and reminds us that additional follow-up is needed when drug diversion is suspected. This includes informing the appropriate professional board and law enforcement. Learn more about drug diversion, prevention, and enforcement agencies on CDC’s new webpage (link to http://www.cdc.gov/injectionsafety/drugdiversion/index.html )

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  3. June 4, 2014 at 4:49 pm ET  -   DHQP

    The issue you raise does deserve attention, and reminds us that additional follow-up is needed when drug diversion is suspected. This includes informing the appropriate professional board and law enforcement. Learn more about drug diversion, prevention, and enforcement agencies on CDC’s new webpage

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  4. June 3, 2014 at 1:07 am ET  -   suki Mann

    I know of midwifes who took a birthing drug, shot in their leg to overcome being drunk on duty. Taken regularly by some staff to keep alert and awake/ this drug did not need to be assigned to a patient and stocks not regulated. When found out one was suspended for 6 months and then returned to be promoted! Since hearing the story I worry that birthing care is compromised!

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