Available Until 7/21/2025

Mind the Gaps: Update on Best Practice Guidance to Mitigate Controlled Substance Diversion

ACPE Number: 0204-0000-22-069-H04 P/T
Content Release Date: 08/01/2022
Expiration Date: 07/21/2025
Activity Type: Knowledge-based 
CE Credits: 1.0 contact hours
Activity Fee: Free to members/not available to non-members

Activity Overview

ASHP has revised the national guidelines, first published in 2016, designed to help healthcare organizations devise and implement strategies to mitigate the diversion of controlled substances. The guidelines include a framework for creating a collaborative, comprehensive controlled substances diversion prevention program (CSDPP) to protect patients, employees, organizations, and the community. According to the 2020 National Drug Threat Assessment, controlled prescription drugs remain a prevalent concern within the United States. Although controlled prescription drug diversion continues to decrease across most categories at the national level, some states report an increase in the number of incidents. 

Pharmacists face increasing pressure to ensure the security of controlled substances across large healthcare organizations, even as those organizations seek to identify and prevent diversion and misuse of prescription drugs by healthcare workers. An expert panel revised the guidelines based on recommendations and best practices from peer-reviewed literature, state hospital association guidance, Drug Enforcement Administration resources, and public comment. 

The recommendations are applicable to a variety of patient care settings in which pharmacists typically have responsibility for purchasing, procuring, monitoring, and distributing controlled substances, including inpatient and outpatient settings and community pharmacies. The guidelines encourage healthcare organizations to develop a CSDPP that complies with applicable federal and state laws and regulations; supports rigorous monitoring and surveillance, human resource management, and substance abuse treatment programs; and establishes systems to positively influence prescribing, procurement, dispensing, administration, and proper disposal and wasting of controlled substances. Other elements of an effective CSDPP include use of technology to routinely review process compliance and effectiveness, strengthen controls, and proactively prevent diversion as well as staff education on the signs and symptoms of impaired healthcare workers.

The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

This activity is intended for pharmacists, pharmacy technicians, and pharmacy administrators who play a part in controlled substance management and oversight.

After completing this activity, the learner should be able to:

  • Describe factors supporting the use of a controlled substances diversion prevention program (CSDPP).
  • Summarize the key changes in the revised ASHP Guidelines on Preventing Diversion of Controlled Substances.
  • Identify three strategies for operating a CSDPP.

* Introduction
* Presentation
* Q&A

Eric M. Maroyka, Pharm.D., BCPS, Activity Chair
Senior Director, Center on Pharmacy Practice Advancement
Bethesda, Maryland

Eric Maroyka, Pharm.D., BCPS, is Senior Director, Center on Pharmacy Practice Advancement at ASHP. He earned a Bachelors Degree in Pharmacy and Pharm.D. from Rutgers University and completed a Pharmacy Practice Residency at Walter Reed Army Medical Center. Previously, he was the Director of Pharmacy at Fauquier Health in Warrenton, Virginia and served over 22 years in the United States Army working in a variety of pharmacy and senior healthcare leadership roles. 

Jordan Rush, Pharm.D., MS,
Director of System Retail and Outpatient Pharmacy Services
UNC Health
Chapel Hill, North Carolina

Jordan Rush, PharmD, MS, is Director of Pharmacy for System Retail and Outpatient Pharmacy Services for UNC Health, overseeing outpatient pharmacies across the system, meds to beds programs, a medication history team, and a PGY1 Community Pharmacy Residency practice site in collaboration with the UNC Eshelman School of Pharmacy. She earned her Pharm.D. from MCPHS and received her M.S. from the University of Wisconsin. Jordan completed a combined PGY1/PGY2 Health System Pharmacy Administration Residency at the University of Wisconsin Hospital and Clinics. 

Kristi Gullickson, Pharm.D., MBA, FASHP, FMSHP
Director of Pharmacy
Allina Health
Minneapolis, Minnesota

Kristine Gullickson, PharmD, MBA, FASHP, FMSHP, is Director of Pharmacy at Allina Health, Abbott Northwestern Hospital, a 630 staffed-bed teaching hospital in Minneapolis, MN. Gullickson chairs the Allina Health Pharmacy Operations Committee responsible for strategy and operational alignment across the 11-hospital health system. She is the Residency Program Director for the hospital’s PGY2 Health-System Pharmacy Administration and Leadership residency program. She received her pharmacy degree from North Dakota State University, completed a PGY1 Pharmacy Practice Residency, and received her MBA from New England College. She has held a number of leadership positions, including as a member of the MHA and MN Dept of Health Controlled Substance Diversion Prevention Task Force which published the MN Roadmap to Controlled Substance Diversion Prevention in 2014. 

Brian O’Neal, Pharm.D., MS, FASHP
Senior Vice President – Allied Health
The Children’s Mercy Hospital
Kansas City, Missouri

Brian O’Neal, PharmD, MS, FASHP, is Senior Vice President – Allied Health, The Children’s Mercy Hospital, Kansas City, Missouri, with responsibility for the departments of pharmacy, radiology, laboratory medicine, physical therapy/occupational therapy, biomedical engineering, audiology, speech pathology, and home care services. Prior to his current role, Brian worked at Children’s Mercy as Senior Director of Pharmacy, and before that at the University of Kansas Hospital as Inpatient Pharmacy Operations Manager and Assistant Director of Pharmacy. Brian received his Pharm.D. from The University of Kansas, and his M.S. in Health-System Pharmacy Administration from The Ohio State University in Columbus. He also completed a two-year administrative residency at The Ohio State University Medical Center. Brian has had an interest in controlled substance diversion detection and prevention for several decades, with nine peer-reviewed publications and many presentations to his credit, dating back to 2004.

No one in control of the content of this activity has a relevant financial relationship (RFR) with an ineligible company.

As defined by the Standards of Integrity and Independence in Accredited Continuing Education definition of ineligible company. All relevant financial relationships have been mitigated prior to the CPE activity

This activity consists of recordings of faculty slides presentations, active learning activities, discussion, and handouts. Participants must participate in the activity in its entirety to claim continuing pharmacy education credit online at ASHP Learning Center. Follow the prompts online to complete the evaluation, claim credit and view the statement of credit immediately after completing the activity. Per ACPE requirements, CPE credit must be claimed within 60 days of being earned. Once you have processed and claimed your CE credit, we encourage you to check your NABP eProfile account to verify your credits were transferred successfully before the ACPE 60-day deadline. It is an electronic direct-report process so your credits should appear in your account within a few minutes. After the 60 day deadline, ASHP will no longer be able to report your credit(s) for this activity.