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The most popu- lar technique for diverting drugs is substitution. Instead of admin- istering fentanyl, a provider may replace it or cut it with saline or ster- ile water. Improper charting and withdrawing of meds are also popular ploys, as is outright theft. Opioids (painkillers, keta- mine, propofol and inhalation agents) and ben- zodiazepines are the most com- monly diverted drugs, according to CMS. Anything that's not in a blis- ter pack is an easy mark. It's easy to replace a few Anesthesia Alert AA 3 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • J U L Y 2 0 1 7 Detecting Diverters: Signs Are Plentiful It's easy to spot the signs when a surgical team member is diverting drugs — if, that is, you know where to look. This table outlines the signs and actions of a diverter. Behavioral Signs Physical Signs Actions Excessive and/or unexpected absenteeism Changes in appear- ance and hygiene Heavy wastage of drugs Frequent and sometimes long breaks Shakes (until they can get more meds on board) Drug shortages, slop- py records or suspect opioid removals Excessive time spent in the medication room Coincidental alcohol on breath (alcohol is often used as a "bridge" until more drug can be diverted) Discrepancies between recorded medication adminis- tration and expected patient response Performance issues, mistakes, poor judgment and bad decisions "Blood dots" on scrubs from injection sites (yes, some desperate addicts will inject directly through scrubs) Evidence of tampering with vials or drug con- tainers, and frequent controlled substance ampule breakage Confusion or diffi- culty concentrating or recalling details and instructions Chronic count discrepancies and failing to obtain co-signatures Deteriorating handwriting and charting Offering to set up rooms for fellow providers and asking for their benzodi- azepines or opioids Mood swings, anxiety, depression and irritability Patients consistently waking up in pain disproportionate to the amount of opioid used and using inappropriate amounts for procedures Unwillingness to admit or take responsibility for errors Consistently signing out more opioids than other anesthesia providers Attitude that gener- ates complaints from patients and staff Requests for long cases (to justify sign- ing out more opioids)