Diversion Case Studies

Warren County pharmacy: former pharmacist-in-charge and hospital pharmacy technician charged in alleged oxycodone diversion scheme

The New Jersey Attorney General announced that four people, including the former pharmacist-in-charge of a Warren County retail pharmacy, were arrested on charges that they conspired to obtain and distribute oxycodone and promethazine using falsified prescriptions. Prosecutors allege that, based on prescription records, more than 30,000 high-dose 30 milligram oxycodone tablets were diverted from the pharmacy between April 2018 and about October 2019. A pharmacy technician at a Paterson hospital is accused of stealing the prescription blanks used to create the falsified prescriptions. The charges are allegations; the pharmacist had earlier surrendered her license under a consent order treated as a temporary suspension pending further board action.

Roanoke Pharmacist Sentenced for Tampering with Hydromorphone Vials

Roanoke, Virginia

Bryan Wade Lewis, a pharmacist at Home Choice Partners in Roanoke, Virginia, admitted replacing hydromorphone in a narcotics-cabinet vial with saline over a nine-month period, diverting medication meant for cancer and hospice patients. He pleaded guilty to tampering with a consumer product and was sentenced in January 2021 to 12 months and one day in federal prison.

Michigan hospital network paid $7.75 million to settle allegations its pharmacies enabled opioid diversion

McLaren Health Care Corporation agreed to pay $7.75 million to resolve claims that some of its pharmacies mishandled controlled substances for years and allowed them to reach the wrong hands. Federal prosecutors alleged that a subsidiary pharmacy filled prescriptions for an unregistered substance abuse treatment facility, that pharmacies ignored red flags in prescriptions, that the corporation failed to notify DEA of known employee thefts, and that a pharmacist at a Port Huron retail pharmacy diverted opioids for personal use and was terminated in 2018. Prosecutors called it the largest civil Controlled Substances Act settlement involving a health care system at the time. A settlement resolves allegations and is not a finding of liability.

Rural Pennsylvania hospital pharmacy technician charged after 2,100 oxycodone tablets went missing

A pharmacy technician was charged following an investigation by an agent of the Pennsylvania Attorney General's Office into altered narcotic counts at a hospital pharmacy. The affidavit of probable cause alleges that on nine occasions across January, February and March, incoming oxycodone orders were logged at lower quantities than the invoices showed, with the invoices missing from pharmacy records, leaving 2,100 tablets unaccounted for. The charges include nine felony counts of acquiring a controlled substance by misrepresentation and related misdemeanors. These are allegations, and the account reports only that a preliminary hearing was scheduled.

Rawlins physician sentenced federally for dispensing medically unnecessary controlled substances

Rawlins, WY

A physician practicing in Rawlins, Wyoming, pleaded guilty in February to 20 counts of dispensing medically unnecessary controlled substances, including oxycodone, alprazolam, hydrocodone and tramadol. At a December sentencing hearing, prosecutors said some of the patients were addicts or became addicted, some sold the drugs, four patients died from overdoses, and that the physician sometimes traded drugs for sexual favors. The federal court sentenced him to 20 concurrent five-year prison terms, followed by six years of supervised release, a $2,000 special assessment and $400 in restitution. The state board of medicine had suspended his license in 2017.

Former Ennis pharmacist pleaded guilty to opioid distribution and was sentenced to prison and fined

A pharmacist in Ennis pleaded guilty in federal court to opioid distribution, with the U.S. Attorney stating that the case involved a licensed provider abusing his position to divert and steal opioids. A later release reported that the former pharmacist was sentenced to prison and fined. The available excerpts do not state the length of the sentence, the fine amount, the specific drugs or how the conduct was detected.

Southwest Michigan nurse summarily suspended over alleged fentanyl-for-saline substitution

On October 28, 2020, Michigan's Department of Licensing and Regulatory Affairs served an order summarily suspending the license of a southwest Michigan registered nurse and filed an administrative complaint. The complaint alleges the nurse diverted fentanyl from the workplace and replaced it with saline to conceal the thefts, putting numerous patients at risk of receiving saline instead of fentanyl for pain control. The summary suspension is a temporary protective measure and not a final determination of a Public Health Code violation.

Maui physician charged with unlawful distribution of hydrocodone after undercover visits

A Wailuku physician was charged by a federal criminal complaint, unsealed in October 2020, with six counts of unlawfully distributing hydrocodone. According to the affidavit, an undercover DEA agent posing as a new patient received a hydrocodone prescription at each of six visits between December 2018 and May 2019 after little or no examination. Prosecutors allege the medical records contained false information about the visits. The complaint contains allegations only, and each count carries a statutory maximum of 20 years in prison.

Nursing Home Nurse Pleads Guilty to Tampering with Hospice Patient's Oxycodone

Dighton, Massachusetts

A registered nurse at Dighton Care and Rehabilitation Center tampered with three blister-card packages of oxycodone prescribed to an 89-year-old hospice patient with Alzheimer's, severe dementia, and breast cancer. She removed the oxycodone and replaced it with other prescription pills disguised to look identical, depriving the patient of her prescribed pain medication for over a month and causing her to ingest at least 77 unnecessary tablets. The scheme was uncovered through an investigation involving the FDA and HHS-OIG. She pleaded guilty in federal court in Boston to tampering with a consumer product.

Minnesota pharmacy technician shorted patient prescriptions of oxycodone-acetaminophen; registration revoked

In or around September 2018, a Minnesota pharmacy technician diverted controlled substances from the pharmacy where she worked, at least twice by removing tablets from prescription vials already filled for patients, so those patients did not receive their full prescribed quantity of oxycodone-acetaminophen. The technician met with the pharmacy's asset protection manager and signed a handwritten statement admitting to stealing Schedule II medications. The pharmacy attributed the loss of 167 tablets to her, and the Board of Pharmacy revoked her registration at its October 2020 meeting.

Paramedic Stole and Diluted Ambulance Fentanyl and Hydromorphone

Carthage / Mount Vernon, Missouri

James Poole, an EMT with Mercy Medical Center's Carthage and Mount Vernon, Missouri EMS operations, tampered with dozens of fentanyl and hydromorphone vials stocked on ambulances and in office supply, replacing part of the contents with saline or water. He was caught after paramedics noticed puncture marks and low fluid levels in vials; lab testing found 26 fentanyl and 43 hydromorphone vials at one facility alone had been adulterated, and Poole tested positive for a fentanyl metabolite and admitted diverting a 50mcg dose from a patient he had under-dosed. He pleaded guilty in September 2020 to tampering with a consumer product.

New York Psychiatrist Pleads Guilty to Diverting Medication Using Patient's Children's Identities

Clifton Park, New York

A psychiatrist and addiction-medicine physician with a practice in Clifton Park, New York prescribed methylphenidate (generic Ritalin) to a patient with the arrangement that the patient would kick back part of each filled prescription to him for his own use. To obtain more of the drug, he fraudulently used the names and birthdates of that patient's children to issue additional methylphenidate prescriptions in their identities, which the patient then picked up and split with him. He pleaded guilty to distributing controlled substances outside the course of professional practice and to misusing personal identifying information, and separately settled civil claims over improper ketamine prescribing and recordkeeping failures at his practice.

Buffalo-Area Medical Office Manager Sentenced for Stealing Controlled Substances via Forged Prescriptions

Buffalo, New York

An office manager for a Williamsville, New York physician's practice used her access to the physician's prescription pad and state-issued electronic prescribing credential to issue 166 fraudulent prescriptions for hydrocodone and oxycodone — totaling roughly 11,885 dosage units — without the physician's knowledge. The prescriptions were written in her own name, associates' names, and fictitious patients, and she filled them at local pharmacies for personal use. The scheme unraveled when a Rite Aid pharmacist questioned a prescription's legitimacy and called the physician directly. She was convicted of obtaining a controlled substance by fraud and sentenced to probation and restitution.

Nurse Sentenced to 5 Years for Tampering with Hospice Patient's Morphine

Danvers / Amesbury, Massachusetts

Brianna Duffy tampered with morphine prescribed to an 89-year-old hospice patient on March 17-18, 2019, diluting it to just 26% of the prescribed concentration by replacing the withdrawn drug with another liquid. She was sentenced in 2020 to five years in federal prison.

Minnesota pharmacist-in-charge reprimanded after technician diverted over 18,000 doses of controlled substances

While a Minnesota pharmacist served as pharmacist-in-charge, a pharmacy technician diverted various controlled substances. The DEA loss report listed shortages of twenty-five different controlled substances totaling 18,269 tablets and capsules and 143 ml of liquids and injectables, and a large quantity of gabapentin was also missing. The Board of Pharmacy found the pharmacist-in-charge had given the technician full control of the controlled substance inventory with no separation of duties or pharmacist verification, and in September 2020 it reprimanded her and barred her from serving as pharmacist-in-charge.

Montana Pharmacist Pleads Guilty to Filling Fraudulent Opioid Prescriptions for Himself

Ennis, Montana

The pharmacist-in-charge at Ennis Pharmacy in Montana filled hydrocodone prescriptions for himself under a doctor's name and signature without that doctor ever authorizing or seeing him as a patient. He also altered a friend's legitimate prescription to double the strength and nearly triple the pill count before filling it himself and mailing the drugs out of state. A routine DEA administrative inspection of the pharmacy uncovered the scheme. He pleaded guilty to dispensing a controlled substance by a practitioner and obtaining a controlled substance by fraud; in a separate civil case, Ennis Pharmacy itself agreed to pay a $125,000 fine and overhaul its operating procedures.

Walgreens pharmacy technician diverted Norco 10 and Norco 7.5

A pharmacy technician was alleged to have committed theft or embezzlement of prescription drugs and controlled substances from a permitted facility. The technician admitted to taking Norco 10 and Norco 7.5 from the Walgreens pharmacy where she worked, and the board found the violation as charged. The board accepted the voluntary surrender of her registration, revoked it, and imposed $250 in investigation costs.

Walgreens pharmacist diverted Adderall and Allegra D

McComb, MS

A pharmacist was alleged to have committed theft or embezzlement of prescription drugs and controlled substances from a permitted facility. The pharmacist admitted to taking Adderall and Allegra D from the Walgreens pharmacy in McComb, MS where she worked, and the board found the violation as charged. The board accepted the voluntary surrender of her license, revoked it, and imposed $750 in investigation costs.

Pharmacy technician diverted OxyContin from AccuDose machines at Baptist Medical Center

A pharmacy technician was alleged to have committed theft or embezzlement of prescription drugs and controlled substances from a permitted facility. The technician admitted to taking OxyContin from the AccuDose machines at Baptist Medical Center, and the board found the violation as charged. The board accepted the voluntary surrender of her registration, revoked it, and imposed $250 in investigation costs.

Pharmacy technician diverted Norco, Percocet, and MS Contin from Magee General Hospital pharmacy

A pharmacy technician was alleged to have committed theft or embezzlement of prescription drugs and controlled substances from a permitted facility. The technician admitted to taking Norco, Percocet and MS Contin from the pharmacy at Magee General Hospital where she worked, and the board found the violation as charged. The board accepted the voluntary surrender of her registration, revoked it, and imposed $350 in investigation costs.

Eastern Iowa ICU Nurse Sentenced for Stealing Patient's Fentanyl and Morphine

Cedar Rapids, Iowa

Kelly Kristin Postel, an ICU nurse at a Cedar Rapids, Iowa hospital, obtained excess fentanyl and morphine from the hospital pharmacy for patients between October and December 2018, administered only the prescribed amount, and kept the remainder for her own use while still on duty. On December 10, 2018, she withdrew pain medication directly from an unconscious patient's IV line in the ICU. She pleaded guilty in February 2020 to acquiring controlled substances and was sentenced in June 2020 to federal prison.

ICU Nurse Steals Fentanyl IV Bags at Research Medical Center

Kansas City, Missouri

Julie Lynne Grant, an ICU nurse at Research Medical Center, ordered a compounded fentanyl IV bag on April 4, 2019, falsely telling the pharmacy a patient's bag had run dry. A pharmacist grew suspicious, and Grant admitted extracting the fentanyl and refilling the bag with an unknown liquid.

South Dakota ICU nurse's lawsuit over termination for fentanyl discrepancies rejected on appeal

A hospital terminated an intensive care unit nurse in March 2016 after an internal review, prompted by an automated dispensing cabinet report showing an atypically high fentanyl removal rate, found documentation errors and small quantities of fentanyl, lorazepam and hydromorphone that could not be accounted for. The nurse denied any wrongdoing and sued for wrongful discharge, breach of contract and defamation. The circuit court granted summary judgment to the hospital, and the South Dakota Supreme Court affirmed in June 2020. The opinion excerpt records no criminal charge or board finding of diversion.

South Dakota ICU nurse fired after fentanyl accountability review; wrongful-discharge suit fails on appeal

A hospital's automated dispensing cabinet reports flagged an intensive care nurse for an atypically high fentanyl removal rate over a one-year period, and a chart review found small quantities of fentanyl, lorazepam and hydromorphone that could not be accounted for along with scanning omissions. The nurse denied any use, sale or diversion of drugs, and a same-day urinalysis was reportedly negative; the hospital terminated her and reported suspected diversion to state and federal agencies, none of which took disciplinary action beyond a confidential letter of concern from the Board of Nursing. She sued for wrongful discharge, breach of contract and defamation, and in June 2020 the South Dakota Supreme Court affirmed summary judgment for the hospital, holding that she was an at-will employee and that the reports of suspected diversion were privileged. The opinion records suspicion and documentation failures, not a finding that diversion occurred.

Savage Family Pharmacy Pays $180,480 to Settle Controlled Substances Act Recordkeeping Violations

Waynesboro, Pennsylvania

Savage Family Pharmacy in Waynesboro, Pennsylvania agreed to pay $180,480 in civil penalties after the DEA alleged the pharmacy failed to comply with Controlled Substances Act recordkeeping requirements between 2015 and 2019. Investigators found inventories were not reconciled with the pharmacy's perpetual log, incoming and dispensed counts had been altered, and pages of the perpetual log had been removed, allowing tens of thousands of doses of oxycodone and hydrocodone to go unaccounted for and potentially diverted. The civil investigation was triggered by an act of employee theft of controlled substances at the pharmacy in May 2019. The pharmacy has since overhauled its inventory-reconciliation practices.