Preventing and Managing Diversion

HOW

Action Items

1. Create MOUD dosing protocols and procedures that minimize opportunities for diversion. Update as needed using the recommendations for preventing diversion as well as the tips and tricks listed below.
2. Ensure that your policies and procedures for your MOUD program include diversion-reducing steps for medication storage, medication dispensing, and roles and responsibilities of medical and custody staff. See MOMCARE Dosing Logistics and Tips and Tricks below for details.
3. Train all staff on ways to prevent diversion. Custody and medical staff involved in MOUD medication delivery should be trained together to ensure agreeance and understanding of roles.
4. Create a plan for what to do if diversion occurs.
   • Review each incident on an individual basis, which must include referring patients to medical for discussion of reasons and a medical response, such as dose adjustments.
   • Do not have a policy that reflexively kicks someone out of the program.
   • If diversion is with buprenorphine, consider switching to methadone.
   • The plan for multiple instances of diversion from one person should include a graduated response that includes a medical discussion of whether that person wants to continue to be in the MOUD program.
   • Here is a step-by-step pathway that guides you on what to do if you discover someone has diverted. Note that this pathway is not specific to pregnancy, and so the naltrexone and injectable buprenorphine recommended in this pathway should not be used.
5. Seek technical assistance to discuss issues with diversion and other ways to reduce the risk. See MOMCARE Technical Assistance for details.

Methadone and buprenorphine are highly regulated medications that require strict oversight. Some MOUD medications are easier to divert than others (e.g. buprenorphine compared to methadone). Your diversion plan may differ depending on your jail’s physical space, staffing, MOUD medication type, delivery model, and how many patients you have on MOUD.

The table below highlights the diversion risk for each medication by form.

*Injectable MOUD is not recommended in pregnancy due to the inability to frequently adjust the dose.

6 Key Strategies for Preventing MOUD Diversion in Jail-Based Treatment Programs

1. Determine reasons for diverting medications which enables the staff to tailor their response to different types of diversion (e.g., coerced, euphoria, split-dosing, and accidental)
2. Use routine but flexible dosing protocols that can be adapted to patients’ needs.
3. Communicate with and educate patients about how jail staff are effective at intercepting and preventing diversion as well as medication safety.
4. Provide a sufficient staff-to-patient ratio to ensure adequate and constant supervision during MOUD initiation.
5. Conduct routine surveillance to detect potential diversion, including searching housing units, monitoring phone calls for mention of diversion or substance use, and checking urine testing results.
6. Develop strategies to respond to diversion that provide patients opportunities to continue treatment, such as changes to medication type, dosage amount, individual counseling sessions, and being dosed individually.

Recommendations for preventing diversion:

• Train and educate staff on reasons for diversion and diversion prevention protocols.
• Thorough communication and coordination between medical and custody staff.
• Per FDA regulations, MOUD must be counted, recorded, and stored in locked cabinets.
• Following strict MOUD dosing protocols including a sufficient staff-patient ratio in-person, and mouth checks by custody before and after medical staff give the dose.
• Random drug testing to confirm that people on MOUD are taking their prescribed medications.
• Before starting a patient in the jail’s MOUD program, educate patients about why the medication should be taken as prescribed. Consider a “treatment agreement” to communicate in writing what is expected of them while on MOUD and what steps will be taken if they are caught diverting medications
• Specialized housing for MOUD patients can increase program efficiencies, but also has some downsides and may not be feasible in small jails.
• Responding timely and thoroughly to a potential case of diversion including an incident review with corrective actions
• Focus on creating therapeutic environments
• Spot-audits by supervisors to ensure policies and procedures are followed consistently and safely
• Use of electronic health records to keep track of MOUD program care, share data more easily, and identify any inconsistencies.

WHY 

Diversion of medications is a valid concern for jails that offer MOUD, although it happens less often than people think.  Diversion is defined as when someone who is medically authorized to take MOUD does not take some or all of their dose when it’s given and instead hides it (commonly in the mouth or clothing) and then hoards, shares, sells, or trades it with others who use it in illegal and non-medically authorized ways.

It is important to understand reasons why some people in a MOUD program in jail might divert because diversion is usually a symptom of something else going on.

• Saving dose– Occasionally, people may divert to save a large enough dose to feel euphoria. More commonly, patients might divert their medication so they can split their dose to take some during the assigned dose time and some later if they feel they are having withdrawal symptoms before their next MOUD dose. Adjusting their dose can often address this.  
• Coercion by another incarcerated individual- Someone receiving MOUD may be bullied by another incarcerated individual to divert and give them their dose, sometimes for a high or because they have opioid cravings—and would benefit from medically authorized MOUD.

Many correctional staff are reluctant or hesitant to implement an MOUD program due to diversion concerns. However, there are feasible policies and practices to prevent and manage diversion when it happens while making sure the people who need MOUD are on it and maintaining the efficacy of your MOUD program.

Automatically “Kicking someone out” of the MOUD program when they are caught diverting is not appropriate. People should receive counseling and dose assessment from medical providers. Multiple diversion occurrences warrant a discussion of whether the patient is ready to be on MOUD and in recovery.

Additionally, many jails that offer MOUD have acknowledged that having MOUD available to people who clinically need it helped decrease diversion and the amount of illicit drugs in the facility. They also noted that disciplinary infractions decreased and staff and resident safety increased after implementing MOUD.  

• Diversion Response Pathway (1-page quick reference), Health Management Associates
• Medication-assisted Treatment Inside Correctional Facilities: Addressing Medication Diversion – SAMHSA & BJA (August 2019)
• See MOMCARE  Dose Logistics for information on the different formulas of MOUD and the best way to dose them to prevent diversion
• 15 Key Buprenorphine Dosing Recommendations for Jail-Based Treatment Programs (JCOIIN, 2022)
• Medication-Assisted Treatment for Opioid Use Disorder in Jails and Prisons (Vital Strategies and National Council for Behavioral Health, 2023)
  • Develop protocols to control medication diversion (p.39)
• 6 Key Strategies for Preventing MOUD Diversion in Jail-Based Treatment Programs– MA JCOIN/Addiction Policy Forum
• If your arrangement for methadone involves storing a certain amount at your jail (e.g. weekly supply), here is a narcotics safe you can purchase for secure, FDA-approved storage.
• If your jail stocks and uses the buprenorphine pill, consider purchasing this pill crusher before administration to help prevent diversion.
• Webinar: Strategies to reduce recidivism and prevent MOUD diversion in jails and prisons (JCOIN, December 2023)

This webinar describes ways to prevent diversion including recommendations from the perspectives of jail staff and incarcerated individuals. Minute 27 begins the diversion conversation.