ASHP Releases Revised Guidelines on Preventing Diversion of Controlled Substances

Today, ASHP released the revised ASHP Guidelines on Preventing Diversion of Controlled Substances. The guidelines outline the latest strategies to help healthcare organizations develop and implement a collaborative, comprehensive controlled substance diversion prevention program.

Approved by the ASHP Board of Directors, the revised guidelines include a number of additions on key issues since it was last published in 2016 to close gaps in best practices for controlled substance diversion and address recommendations from the ASHP Opioid Task Force.

“Drug diversion in healthcare results in harm to patients, significant fines, and damage to institutional reputation,” said Eric Maroyka, PharmD, BCPS, senior director, ASHP Center on Pharmacy Practice Advancement. “The revised guidelines serve as a resource to help decrease the risk of an organization being out of compliance with federal law and offers ways to identify gaps in compliance. The guidelines also include best-practice recommendations for preventing diversion of controlled substances.”

Among the changes in the revised guidelines are:

• A new community and mail order pharmacies section, which includes new recommendations for ambulatory settings
• Better use of surveillance technology, including advanced analytics capabilities
• Strengthened automation requirements (e.g., automated dispensing cabinets)
• Handling of patient’s own medications
• Emphasizing a culture of recovery for healthcare workers with substance use disorder

In February 2021, the ASHP Council on Pharmacy Management reviewed the established guidelines and recommended revisions due to interest from ASHP membership and recommendations from the ASHP Opioid Task Force. The council proposed how the guidelines could be improved by offering higher-level concepts that were addressed more in-depth by an ASHP member panel of experts.

Over the past 15 months, the expert panel, including representation from the council, worked to revise the guidelines. This revision process received more than 400 comments during the public comment period, and it was reviewed by more than 40 individuals and organizations, including representatives from the National Association of Boards of Pharmacy, Society of Hospital Medicine, and California Society of Health-System Pharmacists.

The revised guidelines are available online and will be published in an upcoming issue of AJHP in early fall. The revised guidelines are also featured in an on-demand webinar, Mind the Gaps: Update on Best Practice Guidance to Mitigate Controlled Substance Diversion (CE).