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3 signs of drug diversion to be on the lookout for

Look for tampered packaging, excessive use and false documentation to identify a drug diversion in your EMS agency


High access to a wide array of pharmaceuticals, combined with varying degrees of loose policies and safeguards has led to tampering with, abuse and false replacement of many different medications, particularly opioids and benzodiazepines.

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You begin your shift just like every other day, arrive to your station, store some items into your locker, touch base with your supervisor and head out to the ambulance bay to begin your daily rig checks.

While scoping out your med bags, supply cabinets and drug kit, you notice something different ... something out of the ordinary. The cap on one of your medications is taped back on. You’ve never seen this done before.

You ask the off-going crew about this medication and the medic somewhat brushes it aside, nonchalantly stating “oh yeah, the cap fell off when I was re-stocking it yesterday, so I just taped it back on.”

Something in your gut doesn’t sit right about this. This has never happened before.

Drug diversion, unfortunately, is a real consideration within the healthcare industry. High access to a wide array of pharmaceuticals, combined with varying degrees of loose policies and safeguards has led to tampering with, abuse and false replacement of many different medications, particularly opioids and benzodiazepines.

How can we see drug diversion manifested within EMS? How can we combat it? Here are three signs to identify a drug diversion in your agency.

1. Tampered packaging

Controlled substances, among other high-profile medications, require a higher degree of security than most other ALS medications. Utilizing labeled tags for kits, wall-mounted security boxes, and ID-scanning or code-entry safes can all be great deterrents to drug diversion. The following are signs that a medication has been tampered with:

  • Removed caps from vials
  • Missing liquid from containers
  • Missing or torn sticker/label seals
  • Needle marks in vial rubber stoppers
  • Apparent attempts to re-connect vial caps

2. Excessive use

It’s one thing to have a coincidental week full of trips, slips and falls that result in documented patient fractures that require pain management ... but it’s entirely another thing to have this pattern continue over an extended period of time.

Breaking away from the pattern and norms of an organization’s medication administration habits can certainly make certain EMS providers stand out from the crowd, especially when you’re able to look back at a provider’s patient care reports to investigate a little further.

“John” consistently seems to be administering fentanyl to any patient with a pain value of greater than 3/10. On top of that, he consistently administers lower doses of the medication; like only 25 mcg, when the protocol clearly outlines the indication to potentially administer more for certain pain levels (or none at all).

Excessive use or drug diversion can best be identified, tracked and monitored through patient care report reviews. Each time that a provider administers an opioid, for example, his/her patient care report may be reviewed by a supervisor to ensure both appropriate administration and proper documentation are accounted for.

3. False documentation

Noticing inconsistencies within reports, a failure to obtain nursing staff hand-off signatures or inappropriate medication waste procedure documentation can all be red flags for drug diversion.

When one portion of the report indicates that 4 mg of morphine was administered, while another states 2 mg, further investigation is needed to clarify which point is the truth.

Asking a partner to “just sign the form,” even though he/she hasn’t laid their eyes on the medication being wasted, can also be a red flag indicator of drug diversion. When documentation practices aren’t followed to their full extent, the ability to divert medications becomes much more likely. These failures can occur on daily log sheets, on after-use reporting forms or on medication exchange forms, too. Consistently seeing incorrect documentation elements may be a symptom of more than just non-compliance with documentation ... they may be a sign of panic in the provider that is trying to cover up his or her tracks.

Drug diversion prevention strategies

Looking for signs of incomplete documentation, secrecy during administration, tampered vials, missing liquid, or even events where a provider asks to use a colleague’s passcode to access the medication safe can all be examples of drug diversion lurking amongst your organization.

Requiring multiple signatures, integrating user-specific passcodes for lockbox or safe entry, and integrating a quality review process to track medication administration can all be means that your agency incorporates into its drug diversion prevention plan.

Along with trying to help those who suffer from addiction, keeping your organization’s medications secure before the call can go a long way toward keeping your organization clean and healthy after the call.

Tim is the founder and CEO of Emergency Medical Solutions, LLC, an EMS training and consulting company that he developed in 2010. He has nearly two decades of experience in the emergency services industry, having worked as a career firefighter, paramedic and critical care paramedic in a variety of urban, suburban, rural and in-hospital environments. His background includes nearly a decade of company officer and chief officer level experience, in addition to training content delivery and program development spanning his entire career. He is experienced in EMS operations, community paramedicine, quality assurance, data management, training, special operations and administration disciplines, and holds credentials as both a supervising and managing paramedic officer.

Tim also has active experience as a columnist and content developer with over 200 published works and over 100 hours of education content available online, and is a social media influencer on LinkedIn within the EMS industry. Connect with him on LinkedIn or at