Process improvement for behavioral health

Checklist to help detect diversion and misuse while in treatment 1

Practice Explanation/examples
  • Define diversion and misuse with each patient
  • Ask patient to give examples of each from their experience with illicit drug use
  • Discuss potential triggers for each patient
  • Develop strategies to combat these behaviors
  • Follow up at each visit about occurrences or close calls of medication diversion and misuse, just as with use of illicit opioid of choice
  • Discuss openly throughout treatment
  • Non-healing or fresh track marks or intranasal erythema may indicate buprenorphine injection or intranasal use, respectively, or that other substances are being misused whereby the medication could be sold/traded for the opioid of choice.
  • Lack of objective signs of opioid withdrawal despite patient report of severe withdrawal
  • Repeated requests for early refills due to various reasons: lost, stolen, or washed (forgot to take out of clothing) medications
  • Missing appointments
  • Incorrect medication tablet film/counts
  • Urine test with absence of buprenorphine and/or norbuprenorphine
  • Unexpected medical problems for a patient believed to be in recovery (e.g., abscesses)
  • State prescription monitoring reports showing ongoing receipt of prescription opioids or other controlled substances that the patient denied being prescribed, and / or multiple prescriptions from different OBOT providers over the same period.
  • Feedback from pharmacist about unusual behavior from patient, such as appearing intoxicated or being accompanied by someone who appears to be overly interested in the medication; exchange of something in parking lot or waiting area.
  • Counselor and family members who are not currently addicted and who have the patient’s best interest in mind report patient contact with old drug-using friends or non-adherence with medication if they are supervising ingestion.


Updated 10/16/20


1 Lofwall, M. R., & Walsh, S. L. (2013). A review of buprenorphine diversion and misuse: the current evidence base and experiences from around the world. Journal of addiction medicine8(5), 315-326