(Management Case Study) Setting the Boundaries — Establishing an Effective Controlled Substance Monitoring and Drug Diversion Program Within a Health System

Purpose: To describe the establishment of an effective controlled substances and drug diversion program, inclusive of a drug diversion reduction committee oversight, controlled substances monitoring, opioid stewardship, and pharmacy operations facets.

Methods: irst, A multidisciplinary committee was developed to establish core structure, policies, and oversight of controlled substances and drug diversion. Secondly, a drug diversion response task force (DDRT) was created for proactive investigation and employee follow-up, metrics monitoring, and reporting to the DDRT Committee. This group is comprised of a pharmacy regulatory manager, nurse, and pharmacy analyst that proactively identify and/or investigate events that are submitted by the pharmacy operations leaders that are unable to be resolved. The third facet of this program involves the pharmacy operations team and involves appropriate controlled substance medication storage, discrepancy reporting and resolution by controlled substances specialized technicians, and escalation of unresolved discrepancies as needed. Finally, an opioid stewardship committee was developed to determine current utilization and areas for improvement and guide prescribing of controlled substance medications.

Results: A dashboard was created to track automated dispensing cabinet dispenses and discrepancies generated and resolved, surveillance auditing completed per facility by the DDRT team, and inpatient pharmacy inventory control metrics. This dashboard is reported monthly both to pharmacy leadership and to the DDC. In 2024 thus far, 24 instances of diversion have been investigated by the DDRC. As part of this committee's work in combination with nursing and pharmacy operations leadership, nursing end of shift inventory count compliance rates have increased from an average of 85% to 92% over a 6-month timeframe.

Conclusion: A comprehensive controlled substances oversight and drug diversion program provides the structure necessary for early detection, facilitation of investigations, and rapid closure of controlled substance diversion cases as well as ensures appropriate utilization and handling of controlled substance medications throughout health care organizations.