Checklist to help detect diversion and misuse while in treatment 1

Practice	Explanation/examples
Talk	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
Examine	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
Listen	Repeated requests for early refills due to various reasons: lost, stolen, or washed (forgot to take out of clothing) medications
Monitor	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.
Collaborate	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 medicine, 8(5), 315-326