How to Leverage the Revised ASHP Guidelines to Prevent the Diversion of Controlled Substances at Hospitals


A controlled substances diversion prevention program (CSDPP) that aligns with the revised ASHP guidelines is critical to ensure patients are protected from occurrences of drug diversion.

In 2020, nearly 92,000 individuals in the United States died of drug overdoses, including both illicit drugs and prescription opioids, which is an increase of more than 21,000 deaths from 2019.1 One of the underlying factors of the ongoing opioid crisis is drug diversion, which is defined by the American Society of Health System Pharmacists (ASHP) as the redirection of medication from its predetermined target for other purposes such as personal use, sale, or distribution.

This year, ASHP released revised guidelines on the diversion of controlled substances (CS), and it’s clear that hospitals and health systems need a cohesive plan to mitigate its repercussions.2 Data released from ControlCheck, a drug diversion monitoring software, showed that confirmed cases of diversion increased by 19.3% between July and September of 2022. Partially because of this increase, the regulations were amended for the first time since 2016, offering a unique opportunity for provider organizations to equip themselves with the necessary tools to prevent, identify, and address any potential unsanctioned drug redirection.

Drug diversion poses a unique risk to healthcare workers due to underestimation, minimal detection, and underreporting.3 This is likely a result of a combination of challenges including limited resources due to staff burnout and turnover, lack of relevant expertise and training, and competing priorities in the presence of frequent crises and operational urgencies.4 The revision of the guidelines impacts the entire health care industry because it indicates a new recommended approach to medication management, and hospitals must take these changes into account if they want to keep employees, their reputation, and, most importantly, their patients, safe from the threats of diversion.

Who Should Take Responsibility for a Successful Diversion Detection Program?

The revisions made to the ASHP guidelines illustrate the importance of establishing a dedicated program to address drug diversion in hospitals and health systems. Diversion is particularly dangerous within health care settings on account of distinctive consequences for staff, including loss of license, punitive damages, incarceration, contagious disease outbreaks, acute patient harm, and even death. In addition to having to contend with these consequences, staff who are engaging in diversion are often battling substance use disorder (SUD), which can have long-term consequences like organ damage, depression, and even death. From a human resources standpoint, the absence of a controlled substance diversion prevention program (CSDPP) can affect employee satisfaction due to a lack of both resources and labor.

To ensure meaningful change, hospitals must apply a top-down approach by gaining approval from the executive leadership team to implement a thorough diversion detection and prevention program. Key leaders, including pharmacy leaders, CFOs, COOs and CIOs, clinical directors, and nursing managers would benefit from collaborating with the hospital’s legal team to review and consider legal, regulatory, and accreditation requirements regarding controlled substances, in addition to the rights of individual patients, during the creation of the organization’s policies.

Additionally, hospitals should assign specific leadership—from both the clinical and executive teams—to help guide the program. This ensures that the primary responsibility for diversion prevention does not fall into a gray area where nurses, pharmacists, and other clinical staff feel obligated to file reports against coworkers who they feel may be diverting controlled substances.

The Crucial Role of Technology and Achieving Staff Buy-In

Technology is a major factor in a successful CSDPP, and it must be prioritized when creating an operational and programming budget; this is part of why it’s so important to engage executive leadership in conversations around this topic. ASHP recommends the adoption of automated dispensing cabinets (ADCs) and consistent reviews of ADC reports by pharmacy professionals and patient care managers, as well as the integration of diversion monitoring software.

Manual tracking and reconciliation can be time consuming and detract from more important work clinical staff need to do. A drug diversion solution that uses advanced technology like artificial intelligence and machine learning to track patterns of behavior is beneficial due to its ability to learn and identify anomalous behavior specific to your hospital that may be indicative of diversion. A more thorough solution can also cut down on false flag reporting that can often be laborious and inefficient. Some technological factors to consider when choosing a solution include alignment with existing workflows, efficient tracking for a follow-up of inaccurate records, and complete visibility into medication transactions. These factors will determine how well a solution aligns with these guidelines.

Achieving buy-in from leaders requires bringing concrete evidence of how technology can help mitigate negative effects as well as displaying hard data related to the benefits of CS diversion prevention programs. Setting key performance indicators (KPIs) for tasks, such as time to document, anesthesia post-case reconciliation, and time between identification resolution, help present tangible goals to leadership and help drive implementation of new technologies. Furthermore, if these technologies are able to better achieve these KPIs and can alleviate some of the pressure on staff, leaders may be more inclined to support their implementation and use.

Supporting a CSDDP With Other Resources

To support their CSDDP, hospitals and health systems should also develop and require formalized training programs for staff members to ensure all employees understand the consequences of diversion, including disciplinary actions. The occurrence of diversion is often a sign of SUD, and there are significant ramifications for staff diverting drugs including license suspensions and job terminations. One pharmacist in recovery from SUD stated that it was eye opening for his peers to learn that he was struggling with SUD after he became embroiled in multiple personal and legal issues stemming from drug diversion. Staff who are aware of the gravity of diversion will be better equipped to handle instances of it in the future, and it can be helpful for them to hear the stories of the people who have been impacted.

It is the ultimate responsibility of health care workers to protect patients, and not having a CSDPP can significantly interfere with this mission. Patients who are affected by drug diversion may never receive the treatment they need, and their conditions can worsen over time. In one example,an infected health care worker in the Denver, Colorado, area, in the process of diverting narcotics for self-use, passed on hepatitis C virus to approximately 36 patients.5 It is the responsibility of everyone in the clinical care setting to ensure that patients are protected and receive the best possible care, and a CSDPP that aligns with the revised ASHP guidelines is the first step in the right direction.

About the Author

Doug Zurawski, PharmD, is the senior vice president of strategic accounts at Bluesight.


  1. Overdose Death Rates. National Institutes of Health. Published July 21, 2022. Accessed November 1, 2022.
  2. Clark J, Fera T, Fortier C, et al. ASHP Guidelines on Preventing Diversion of Controlled Substances. American Society of Health-System Pharmacists. Published August 2, 2022. Accessed October 17, 2022.
  3. Nyhus J. Drug Diversion in Healthcare. American Nurse Journal. 2021;15(5):26-29. Accessed November 1, 2022.
  4. 5 Signs That You May Need Outside Help with Your Drug Diversion Program. Kit Check. Accessed November 22, 2022.
  5. AP Daily News Staff Writer Heroin-addicted technician Kristen Diane Parker infected 3 dozen with hepatitis C. York Daily News. Accessed March 19, 2012.
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