Substance Abuse Education for Delaware Nurses
Best-Practice Prescribing, Drug Diversion, and Impaired Practice

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this continuing education course, you will better understand best-practice prescribing of controlled substances, how to prevent drug diversion, and how to administer an opioid antagonist. Specific learning objectives to address potential knowledge gaps include:

• Identify components of best-practice prescribing for opioid medications.
• Summarize the CDC and Delaware Guideline for Prescribing Opioids for Chronic Pain.
• Explain various strategies designed to prevent prescription drug misuse and diversion.
• Describe considerations for the use of the opioid antagonist naloxone.
• Discuss chemical dependency and impairment in the workplace.

SCOPE OF THE PROBLEM

Overdoses are the leading injury-related cause of death in the United States. According to provisional data from the National Center for Health Statistics, an estimated 107,543 people died from drug overdoses in 2023, with 81,083 (75%) of those deaths involving an opioid. This represents a decrease of 3% from estimated deaths in 2022 (CDC, 2024a). In 2022, the drug overdose death rate in Delaware was 55.3 per 100,000, which was fourth highest in the nation following West Virginia, the District of Columbia, and Tennessee (CDC, 2025).

The crisis is far from resolved. Data indicate that a large number of individuals continue to misuse prescription drugs. The National Survey on Drug Use and Health estimates that in 2023:

• 8.6 million people ages 12 and older misused prescription pain relievers.
• 828,00 people ages 12 and older misused prescription or illegally made fentanyl.
• 48.5 million people ages 12 and older had a substance use disorder in the past year. (SAMHSA, 2023a)

One of the biggest challenges in healthcare practice is providing safe and appropriate pain care without contributing to the crisis of prescription drug misuse, drug diversion, and drug overdose deaths. Nurses in particular are in a unique position to address this problem since they care for more patients than any other health profession. Nurses who understand the risks associated with prescription drug abuse will be better prepared to identify and intervene with patients and colleagues who may be at risk.

BEST-PRACTICE OPIOID PRESCRIBING

The serious and deadly consequences of the opioid crisis prompted the medical community to reevaluate chronic pain treatment and prescribing practices. Responsible prescribing involves individual prescribers following best practices and taking action to balance the risks and benefits of opioid pain management for each patient. Three important components to responsible prescribing include:

• Thorough patient evaluation, including risk assessment
• Treatment plan design that incorporates functional goals
• Periodic review and monitoring

Best practices are also described in evidence-based guidelines for prescribing opioids for chronic pain released in 2016 by the Centers for Disease Control and Prevention (CDC) and updated in 2022 (Dowell et al., 2022) as well as in the Delaware Prescription Opioid Guidelines for Health Care Providers (DDPH, 2017).

Patient Evaluation and Risk Assessment

A thorough patient assessment is critical prior to prescribing opioid medication for chronic pain. It is important to properly diagnose the condition to determine if opioid medication is an appropriate treatment. A comprehensive pain assessment includes a history of the pain, behavioral observations, past medical history, medications, family history, a physical examination, and if necessary, diagnostic testing.

PAIN HISTORY

A pain assessment begins with the history of the problem and can be obtained from written documents and from interviews with the person in pain as well as family members and other caregivers. Pain is a subjective symptom, and pain assessment is, therefore, based on the patient’s own perception of pain and its severity.

Because pain is subjective, a self-report is considered the gold standard, or the best, most accurate measure of a person’s pain. One method to obtain a complete pain history is the PQRST assessment (see box).

BEHAVIORAL OBSERVATIONS

Most people who are experiencing pain usually show it either by verbal complaint or nonverbal behaviors or indicators. It is important, however, to remember that people in pain may or may not display behaviors that are considered an indication of “being in pain,” and making judgments about their honesty is inappropriate. Nonverbal indicators of pain may include:

• Restlessness or pacing
• Groaning or moaning
• Crying
• Gasping or grunting
• Nausea or vomiting
• Diaphoresis
• Clenching of the teeth and facial expressions
• Tachycardia or blood pressure changes
• Panting or increased respiratory rate
• Clutching or protecting a part of the body
• Unable to speak or open eyes
• Decreased interest in activities, social gatherings, or old routines
  (Toney-Butler, 2023)

RISK ASSESSMENT

When clinicians assess patients with chronic pain, it is important to recognize two categories of risk due to opioid therapy: medical conditions that increase their risk for adverse events (e.g., respiratory depression) and risk of misuse, abuse, or addiction.

Risk of Adverse Events

Risk due to medical conditions are assessed and documented as part of the patient’s history and physical examination and the treatment plan adjusted accordingly to reduce risk of adverse events with opioid therapy. Older adults may be at higher risk because of cognitive decline and increased potential for falls. Patients with impaired renal or hepatic function, cardiopulmonary disease, mental health conditions, obesity, and sleep apnea are also at higher risk for adverse consequences when prescribed opioid medications.

Risk for Misuse, Abuse, and Addiction

Variables that have been associated with a higher risk for misuse, abuse, and addiction include history of addiction in biological parents, current drug addiction in the family, regular contact with high-risk groups or activities, and personal history of illicit drug use or alcohol addiction. (See also “Recognizing Aberrant Drug-Related Behaviors” later in this course.)

The use of screening tools is recommended, and multiple tools are available that can help healthcare providers to assess these risks. Examples of screening tools to assess opioid risk or misuse include:

• Opioid Risk Tool: Administered at initial visit prior to beginning opioid therapy; questions address age, family, and personal history of substance abuse, history of preadolescent sexual abuse, and psychological diseases (see below)
• Screening to Brief Intervention (S2BI): A series of questions regarding frequency-of-use in adolescent patients of substances most commonly used
• Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS): A combined screening and brief assessment that addresses use-related behaviors and generates a risk level for each substance class
• Brief Intervention tool: A 26 item “yes–no” questionnaire to identify signs of opioid addiction or abuse
• CAGE, CAGE-AID, and CAGE-Opioid: CAGE (Cut down, Annoyed, Guilty, and Eye-opener) questionnaires consisting of four questions to assess for alcohol abuse and substance abuse (AID and Opioid versions)
• Current Opioid Misuse Measure (COMM): A 17-item patient self-report assessment designed to identify abuse in chronic pain patients in terms of aberrant behaviors associated with misuse, especially in patients who are already receiving long-term opioid therapy
• Diagnosis, Intractability, Risk and Efficacy (DIRE) tool: A clinician-rated questionnaire to predict patient compliance with long-term opioid therapy
• Screener and Opioid Assessment for Patients with Pain—Revised (SOAPP-R): A screening questionnaire addressing history of alcohol or substance abuse, cravings, mood disorders, and stress
• Urine Drug Test (UDT): Can be used to evaluate for the use of the medication prescribed and in detecting any unsanctioned drug use
• Rapid Oрioid Dependence Screen (RODS): An eight-item screening tool for οрiоid dependence; can be administered as a stand-alone instrument or as part of a comprehensive interview
• OWLS: A four-item self-administered screening tool to detect prescription ΟUD in persons prescribed long-term оpiοid therapy
  (Dydyk, 2023; Strain, 2024)

(See also “Resources” at the end of this course.)

SAMPLE OPIOID ABUSE RISK TOOL
Administer to patients upon an initial visit prior to beginning opioid therapy for pain management. Mark each box that applies.

	Female	Male
(Sources: Delaware Division of Professional Regulation, Partnership for a Drug Free America, and U.S. Surgeon General Turn the Tide Program.)
Family history of substance abuse
Alcohol	1	3
Illegal drugs	2	3
Prescription drugs	4	3
Personal history of substance abuse
Alcohol	3	3
Illegal drugs	4	4
Prescription drugs	5	5
Age 16–45 years	1	1
History of preadolescent sexual abuse	3	0
Psychological disease
ADD, OCD, bipolar, schizophrenia	2	2
Depression	1	1
Scoring totals ≤3 = low risk for future opioid abuse 4–7 = moderate risk ≥8 = high risk for opioid abuse

Treatment Plans

Responsible opioid prescribing requires clinicians to develop treatment plans that focus on patient-centered outcomes and functional goals that improve quality of life. A function-based treatment strategy that aims to maximize the patient’s quality of life and minimize the burden of their pain includes a mutual understanding between prescriber and patient covering the following principles:

• Complete elimination of all pain is often not possible.
• The goal of treatment is to successfully manage pain and not exclusively to reduce a pain scale score.
• Functional goals will be collaboratively set, with the aim of improving quality of life; these goals must be realistic, achievable, verifiable, and meaningful.
• Risks, benefits, side effects, and potential adverse consequences of opioid use will be fully disclosed.
• Education about safe use, storage, and disposal of opioid medication will be provided.

The treatment plan must be documented and include informed consent and patient education.

Periodic Monitoring

It is critical to regularly reevaluate the appropriateness of continuing opioid therapy due to changes in pain etiology, health condition, progress toward functional goals, and addiction risk. To corroborate self-reports, review of data within the prescription drug monitoring program should be conducted at each visit (see “Prescription Drug Monitoring Programs” later in this course). Periodic monitoring should also include urine tests and pill counts when appropriate.

Clinicians must utilize screening and monitoring for all patients on chronic opioid therapy to document patient outcomes and progress toward functional goals. The Pain Assessment and Documentation Tool (PADT) is a practical tool that clinicians can use at each patient visit and incorporate into electronic records (see “Resources” at the end of this course). It offers a simple checklist to monitor the “Five As” of pain management (Dydyk, 2023).

THE FIVE As OF PAIN MANAGEMENT

Analgesia	A reduction in pain
Activities of daily living	Improvement in level of function
Affect	Changes in mood
Adverse effects	Falls, decreased cognitive function, constipation, etc.
ADRBs	Aberrant drug-related behaviors

Periodic monitoring timing will vary with each patient. CDC guidelines recommend monitoring every three months at the minimum and before refilling an opioid prescription at any time (Dowell et al., 2022).

CDC Clinical Practice Guideline for Prescribing Opioids for Pain

In 2022, the CDC updated its guidelines for prescribing opioids for the treatment of pain. The guidelines address four main issues, including:

• Making a determination about whether or not to initiate opioids for pain
• Selecting the appropriate opioid and determining the dosage
• Deciding the duration of the initial opioid prescription and conducting follow-up
• Assessing the risk and addressing the potential harms of opioid use with the patient

These recommendations aim to improve communication between clinicians and patients about the risks and effectiveness of pain treatment; improve pain, function, and quality of life for persons with pain; and reduce the risks associated with opioid pain treatment (including opioid use disorder, overdose, and death) as well as with other pain treatment.

The practice guidelines include 12 recommendations for clinicians who are prescribing opioids for outpatients ages 18 years and older with pain that is acute (duration of <1 month), subacute (duration of 1–3 months), or chronic (duration of >3 months), excluding pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care.

1. Nonopioid therapies are at least as effective as opioids for many common types of pain. Maximize the use of nonpharmacologic and nonopioid pharmacologic therapies appropriate for the condition and the patient, and only consider opioid therapy for acute pain if benefits are expected to outweigh risks to the patient. Discuss benefits and risks with the patient prior to prescribing opioid therapy.
2. Nonopioid therapies are preferred for subacute and chronic pain. Maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient. Consider opioid therapy if expected benefits are anticipated to outweigh risks, and work with the patient to establish treatment goals for pain and function. Consider how opioid therapy will be discontinued if benefits do not outweigh risks.
3. When starting opioid therapy for acute, subacute, or chronic pain, prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids.
4. When opioids are initiated for opioid-naive patients with acute, subacute, or chronic pain, prescribe the lowest effective dosage. If opioids are continued for subacute or chronic pain, prescribe the lowest effective dosage. Avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks.
5. For those patients already receiving opioid therapy, carefully weigh benefits and risks and exercise care when changing opioid dosages. Work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If benefits do not outweigh risk of continued opioid therapy, optimize other therapies and work closely with patients to gradually taper to lower dosages, or appropriately taper and discontinue opioids. Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages.
6. When opioids are needed for acute pain, prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.
7. Evaluate benefits and risks with patients within 1–4 weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Regularly re-evaluate benefits and risks of continued opioid therapy with patients.
8. Before starting and periodically during continuation of opioid therapy, evaluate risks for opioid-related harms and discuss risks with patients. Work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone.
9. When prescribing initial opioid therapy for acute, subacute, or chronic pain and periodically during opioid therapy for chronic pain, review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose.
10. When prescribing opioids for subacute or chronic pain, consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances.
11. Use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants.
12. Offer or arrange treatment with evidence-based medications for patients with opioid use disorder. Detoxification on its own, without medications for opioid use disorder, is not recommended because of increased risks for resuming drug use, overdose, and overdose death.
    (Dowell et al., 2022)

Delaware Guidelines for Use of Controlled Substances for Treatment of Pain

In April 2017, Delaware issued regulations for safer opioid prescribing and better pain management practices, supporting the CDC Guideline for Prescribing Opioids for Chronic Pain, 2016 (DDPH, 2025). (See above for the 2022 update to the CDC guidelines.)

These regulations are aimed at stopping addiction before it starts by controlling the amount of opiates given to new patients and aggressively monitoring their treatment. These Delaware opioid prescribing rules stipulate that first-time opiate prescriptions are not to exceed a one-week supply. If further opiate prescriptions are deemed necessary, then further action must be taken by the prescriber, including a query of the statewide Prescription Monitoring Program database and a physical exam with discussion of relevant patient history and the risks of opiates (DDOS, 2017).

KEY ELEMENTS OF DELAWARE PRESCRIBING RULES

For an acute episode (injury or procedure):

• A first-time prescription to an adult patient for an acute episode cannot exceed a seven-day supply.
• No prescription to a minor can exceed a seven-day supply at any time.
• If professional judgment dictates more than a seven-day supply is necessary:
  • Document the condition triggering the prescription.
  • Query the Prescription Monitoring Program to obtain a prescription history.
  • Indicate that a nonopiate alternative was not appropriate.
  • Obtain informed consent, which must include information on:
    • The drug’s potential for addiction, abuse, and misuse
    • The risks of life-threatening respiratory depression associated with the drug
    • The potential for fatal overdose as a result of accidental exposure, especially in children
    • Neonatal opioid withdrawal symptoms
    • The potential for fatal overdose when interacting with alcohol
    • Other potentially fatal drug interactions, such as with benzodiazepines
  • Administer a fluid drug screen, at the discretion of the provider.
  • Conduct a physical examination, which must include a documented discussion to elicit relevant history, explain risks/benefits of opioid analgesics and possible alternatives, and establish other treatments tried or considered.
  • Schedule periodic follow-up visits and evaluations to monitor progress, whether there is an available alternative to opiate use, and whether to refer the patient for a pain management or substance abuse consultation.

For chronic, long-term treatment with an opioid:

• Document the condition triggering the prescription, indicating that a nonopioid alternative was considered but not appropriate, obtain informed consent, and follow up with evaluations to monitor progress toward treatment goals.
• Query the Prescription Monitoring Program:
  • At least every six months and more frequently if clinically indicated
  • Whenever the patient is also being prescribed a benzodiazepine
  • Whenever the patient is assessed to potentially be at risk for substance abuse or misuse
  • Whenever the patient demonstrates loss of prescriptions, requests for early refills, or similar behavior
• Administer fluid drug screens at least every six months.
• Obtain a signed treatment agreement, which must include:
  • The patient’s agreement to take medications at the dose and frequency prescribed, with a specific protocol for lost prescriptions and early refills
  • Reasons for which medication therapy may be re-evaluated, tapered, or discontinued, including but not limited to violation of the treatment agreement or lack of effectiveness
  • The requirement that all chronic pain management prescriptions are provided by a single practitioner or a limited, agreed-upon group of practitioners
  • The patient’s agreement to not abuse alcohol or use other medically unauthorized substances or medications
  • Acknowledgment that a violation of the agreement may result in action as deemed appropriate by the prescribing practitioner such as a change in the treatment plan, a referral to a pain specialist, or referral to an addiction treatment program
  • The requirement that fluid drug screens be performed at random intervals at the practitioner’s discretion, but no less than every six months
(DDPH, 2017)

PREVENTING PRESCRIPTION DRUG MISUSE

Various actions by healthcare providers can help prevent prescription drug misuse and diversion. These include:

• Educating patients on safe use, storage, and disposal of medications
• Understanding which drugs are commonly misused or diverted
• Recognizing aberrant drug-related behaviors (ADRB) (behaviors that may be associated with misuse of prescription opioids)
• Detecting and responding to drug diversion by patients

Institutional measures are also an important part of addressing the opioid epidemic, such as:

• Medication formulation and abuse-deterrent formulations
• Prescription drug monitoring programs (PDMPs)
• Surveillance systems

Teaching Safe Use, Storage, and Disposal of Prescription Medications

Educating patients on safe use, storage, and disposal of medications is an essential part of addressing the opioid and drug diversion epidemic. Nurses and prescribers can address the following points with patients who have been prescribed opioids.

SAFE USE

• Since opioids come in different forms, understand what type you were prescribed and read the information that comes with your prescription.
• Only take opioids prescribed to you and as directed by your healthcare provider; never take opioids that were not prescribed to you.
• Before you are prescribed opioids, tell your healthcare provider about all other medications and supplements you are taking.
• Do not drink alcohol while you are taking οрiоiԁѕ.
• Do not take οрiоidѕ with medicines that make you sleepy unless your healthcare provider tells you to. Examples include diazepam (Valium), alprazolam (Xanax), abapentin (Neurontin), pregabalin (Lyrica), baclofen, cyclobenzaprine, zolpidem (Ambien).
• Talk to your healthcare provider about your risk for overdose. Tell your healthcare provider if you or your family has a history of alcohol or drug addiction.
• Don’t share your medications with others because they may cause harm to someone else.
• Tell your healthcare provider if you experience changes in your mood, balance, sleep, or pain level and if you find it difficult to stop or decrease opioid use.
• Talk to your healthcare provider about whether it is safe to drive.
• Discuss with your healthcare provider alternative ways to manage your pain.
  (AAFP, 2023; UpToDate, 2025)

SAFE STORAGE

Opioids are controlled substances, and their possession and use is regulated by state and federal laws. More than 70% of people who misuse prescription opioids obtain them from family and friends. Therefore, it is important that patients safely store their prescription medications. The CDC also recommends that prescribers discuss risks to household members and other individuals if opioids are intentionally or unintentionally shared with others for whom they are not prescribed, including the possibility that others might experience overdose at the same or at lower dosage than prescribed for the patient.

• Store opioids in their original packaging inside a locked cabinet, a lockbox, or other secure location.
• Do not store opioids in obvious places like bathroom cabinets or on kitchen counters where others might find them.
• Note when and how much medication you take in order to keep track of the amount left.
  (AAFP, 2023)

SAFE MEDICATION DISPOSAL

Prescribers and pharmacists often provide specific disposal instructions for unused or expired medicines, and patients are educated to follow those instructions. There are a variety of ways to dispose of medications. The U.S. Food and Drug Administration (U.S. FDA, 2024a) outlines three options for drug disposal according to the type of drug: a take-back site, the flush list, or household trash.

Take-Back Programs

The best way to dispose of most types of unused or expired medicines (both prescription and over the counter) is to immediately drop off the medicine at a drug take-back site, location, or program. Pharmacies, firehouses, or police departments will often “take back” unused medications, particularly opioids. Some areas have specific dates on which they offer this service; other sites will take back medications at any time. Alternately, unused medicines can be sent using a prepaid drug mail-back envelope.

The Drug Enforcement Agency (DEA) website provides a locator app where the user can search for drug drop-off points within a 10- to 100-mile radius, and each year the DEA sponsors a National Prescription Take-Back Day. Delaware currently has permanent medication collection boxes located across the state. Expired, unused, or unwanted medication can be dropped off at these locations to ensure proper disposal (DDPH, n.d.-c).

(See “Resources” at the end of this course to locate a disposal location.)

Flushing Disposal

If a drug take-back option or DEA-authorized collector is not available and a medication is on the FDA flush list (see table below), the FDA recommends safely flushing such approved medications down the toilet. The medicines on the flush list are those sought after for their misuse and abuse potential or those that can result in death from one dose if inappropriately taken. For these reasons, FDA recommends that patients flush them down the toilet to immediately and permanently remove these risks from their home.

Based on the available data, FDA believes that the known risk of harm, including toxicity and death, to humans from accidental exposure to medicines on the flush list far outweighs any potential risk to human health and the environment from flushing these unused or expired medicines (U.S. FDA, 2024b; AAFP, 2023).

FDA FLUSH LIST

Drug Name	Examples
Drugs That Contain Opioids
(U.S. FDA, 2024b)
Any drug that contains the word buprenorphine	Belbuca, Buavail, Butrans, Suboxone, Subutex, Zubsolv
Any drug that contains the word fentanyl	Abstral, Actiq, Duragesic, Fentora, Onsolis
Any drug that contains the words hydrocodone or benzhydrocodone	Apadaz, Hysingla ER, Norco, Reprexain, Vicodin, Vicodin ES, Vicodin HP, Vicoprofen, Zohydro ER
Any drug that contains the word hydromorphone	Exalgo
Any drug that contains the word meperidine	Demerol
Any drug that contains the word methadone	Dolophine, Methadose
Any drug that contains the word morphine	Arymo Er, Avinza, Embeda, Kadian, Morphabond ER, MS Contin, Oramorph SR
Any drug that contains the word oxycodone	Codoxy, Combunox, Oxadydo (formerly Oxecta), Oxycet, Oxycontin, Percocet, Percodan, Roxicet, Roxicodone, Roxilox, Roxybond, Targiniq ER, Troxyca ER, Tylox, Xartemis XR, Xtampza ER
Any drug that contains the word oxymorphone	Opana, Opana ER
Any drug that contains the word tapentadol	Nucynta, Nucynta ER
Drugs That Do Not Contain Opioids
Any drug that contains the term sodium oxybate or sodium oxybates	Xyrem, Xywav
Diazepam rectal gel	Diastat, Diastat Acudial
Methylphenidate transdermal system	Daytrana

Household Trash Disposal

If a drug take-back program is not available and a medication is not on the flush list, the FDA provides the following guidance on how to dispose of drugs via household trash:

1. Remove the drugs from their original containers.
2. Mix medicines (liquid or pills; do not crush tablets or capsules) with an unappealing substance such as dirt, cat litter, or used coffee grounds.
3. Place the mixture in a container such as a sealed plastic bag.
4. Throw away the container in the trash at home.
5. Scratch out all personal information on the prescription label of empty medicine bottles or medicine packaging, then trash or recycle the empty bottle or packaging.

Even after fentanyl patches have been used, some medication remains. The FDA recommends promptly disposing of used patches by folding them in half with the sticky sides together and then flushing them down a toilet. Patches should not be placed in the household trash, where children or pets can find them.

Since inhalers are dangerous if punctured or if they come in contact with fire, they must be treated with care. Local trash and recycling facilities typically provide information on how to properly dispose of inhalers in their area (U.S. FDA, 2024a).

Understanding Commonly Abused/Misused Drugs

The Controlled Substances Act regulates five classes of drugs: narcotics/opioids, depressants, hallucinogens, stimulants, and anabolic steroids. All controlled substances have abuse potential or are immediate precursors to substances with abuse potential. The nonsanctioned use of these substances is considered drug misuse. The extent to which the drug is reliably capable of producing intensely pleasurable feelings (euphoria) increases the likelihood of that substance being abused (U.S. DEA, 2024b).

Three specific classes are most commonly abused and thus most susceptible to diversion for nonmedical use:

• Pain medications/narcotics. Opioid pain relievers (narcotics) are the most commonly diverted controlled prescription drugs. Opioid medications are effective for the treatment of pain and have been used appropriately to manage pain for millions of people; however, increased rates of abuse and overdose deaths have raised concerns about proper use of these medications in the treatment of chronic pain. Fentanyl is a potent synthetic opioid drug approved by the FDA for use as an analgesic and anesthetic; it is approximately 100 times more potent than morphine and 50 times more potent than heroin. Overdoses of narcotics are not uncommon and can be fatal.
• Central nervous system (CNS) depressants/sedatives/hypnotics. CNS depressants slow brain activity and are useful for treating anxiety and sleep disorders. Since many patients with pain also experience anxiety or sleep disturbances, increased prescribing of sedative hypnotics has paralleled the increase in prescribing of opioids. Clinicians who add sedative hypnotics to the treatment plan for chronic pain patients may potentiate the risk for patients who are also prescribed opioid medication. In 2023, 3.9 million people misused a prescribed CNS stimulant in the past year, down from 4.3 million in 2022 (SAMHSA, 2024).
• Stimulants. Stimulants are prescribed primarily for treatment of attention deficit hyperactivity disorder (ADHD) and narcolepsy. They may also be used as an adjunct medication in the treatment of depression. When taken nonmedically, stimulants can induce a feeling of euphoria and thus have a high potential for abuse and diversion. They also have a cognitive enhancement effect that has contributed to non-medical use by professionals, athletes, and other individuals who rely on productivity. Nonmedical use of stimulants poses serious health consequences, including addiction, cardiovascular events, and psychosis.
  (NIDA, 2023; U.S. DEA, 2024b)

Recognizing Aberrant Drug-Related Behaviors

Some patients who are prescribed opioid pain medication are at increased risk for opioid misuse and diversion. These patients may demonstrate certain misuse behaviors that can provide clues to the clinician. By recognizing what are called aberrant drug-related behaviors (ADRBs), nurses can respond appropriately and help patients to remain safe.

ADRBs may occur because a patient is experiencing poor pain control or has a fear of uncontrolled pain, which can lead to hoarding of medication. The behaviors may also be attributed to elective use of opioid medication for the euphoric effect or for non-pain-related symptoms such as anxiety, depression, insomnia, and stress.

ADRBs in patients who are prescribed opioids should trigger clinicians to the possibility of addiction. Current literature suggests a range of aberrant drug-related behaviors, with some more predictive of addiction than others. Being aware of the behaviors described in the following box can help guide clinicians who are treating and monitoring patients who are receiving prescription opioid therapy for long-term pain management.

The presence of aberrant behaviors, however, may indicate a range of problems other than misuse or diversion, and the clinician must explore a differential diagnosis. Possible etiologies include addiction, pseudo-addiction, another psychiatric disorder, personality disorder, chronic boredom, mild encephalopathy, withdrawal states, and genuine undertreatment of pain. Therefore, it is important to monitor, document, and communicate any aberrant behaviors using objective means and in a team-based fashion over the patient’s entire course of care. This process will also remove any bias on the part of a single provider.

In the hospital setting, monitoring and responding to ADRBs is important in order to:

• Determine the success or failure of treatment
• Help prevent the transition of chronic pain to opioid dependence and SUD
• Help prevent psychiatric disorders such as anxiety and depression
• Identify undiagnosed SUD
• Identify patients at high risk for diversion
• Identify possible complications of opioid therapy
  (Maumus et al., 2020)

System Measures to Prevent Prescription Drug Misuse

System measures are also an important part of addressing the opioid epidemic. Several such measures are discussed below.

MEDICATION FORMULATION

Abuse-deterrent formulations (ADFs) have been developed to help reduce or prevent altered routes of administration—particularly chewing, crushing then smoking, or intravenous injection—used by individuals who misuse opioids. However, questions remain regarding whether prescribing ADF opioids reduces overall opioid misuse. ADFs do not prevent people from taking more than prescribed or change the drugs’ addictive properties.

Abuse-deterrent strategies currently being used include:

• Physical/chemical barriers that prevent chewing, crushing, cutting, grinding, or dissolving, or render it difficult to inhale or inject
• Agonist/antagonist combinations that cause an antagonist (which will counteract the effect of the drug) to be released if the product is manipulated
• Aversive substances that are added to create unpleasant sensations if the drug is taken in a way other than directed
• Delivery systems such as long-acting injections or implants that slowly release the drug over time
• New molecular entities or prodrugs that attach a chemical extension to a drug that renders it inactive unless taken orally
  (Rosenquist, 2025)

FDA-APPROVED ABUSE-DETERRENT OPIOIDS

Compound	ADF mechanism
(Rosenquist, 2025)
Oxycontin (oxycodone extended-release) and abuse-deterrent generic equivalent	Difficult to crush; if dissolved, the tablet forms a viscous gel that is difficult to inject IV.
Xtampza ER (oxycodone extended-release)	Capsules contain microspheres of oxycodone and inactive ingredients that hinder dosage dumping via intranasal and oral misuse; microspheres cannot be readily dissolved and will solidify within a needle to prevent injection.
Targin (oxycodone extended-release plus naloxone)	Contains naloxone (opioid antagonist), which is not active when taken orally but blocks opioid associated euphoria when injected or inhaled.
Roxybond (oxycodone immediate-release)	Difficult to crush; if dissolved, the tablet forms a viscous gel that is difficult to inject IV.
Hysingla ER (hydrocodone extended-release tablet) and abuse-deterrent generic equivalent	Difficult to crush; if dissolved, the tablet forms a viscous gel that is difficult to inject IV.

PRESCRIPTION DRUG MONITORING PROGRAMS

Prescription drug monitoring programs (PDMPs) are statewide electronic databases that track controlled substance prescription. They can provide health authorities with timely information about both prescribing and patient behaviors, thereby improving opioid prescribing, informing clinical practice, and protecting patients at risk (CDC, 2024d).

Some states have implemented polices that require providers to check a state PDMP prior to prescribing certain controlled substances. When pharmacists dispense controlled substances to patients, they have to enter the prescription into the state PDMP. However, pharmacies submit this data to state PDMPs at varying intervals—ranging from monthly to daily to “real-time,” i.e., under five minutes.

The Delaware Prescription Monitoring Act (16 Del. C.§ 4798) authorizes the Office of Controlled Substances (OCS) in the Delaware Division of Professional Regulation to establish, maintain, and monitor the Delaware Prescription Monitoring Program (PMP). The purpose of the PMP is to reduce misuse of controlled substances in Delaware and to promote improved professional practice and patient care.

The PMP is a system that collects information on all controlled substance (schedules II–V) prescriptions. Using the PMP website, Delaware-licensed pharmacies and prescribers who dispense controlled substances report prescription data to the PMP daily. Prescribers and dispensers registered with the PMP can obtain immediate access to an online report of their current or prospective patient’s controlled substance prescription history. This PMP website is available 24/7 and is to be used for healthcare purposes only (DDPR, n.d.).

(See also “Resources” at the end of this course.)

PRESCRIBING AND ADMINISTERING OPIOID ANTAGONISTS (NALOXONE)

The availability of the opioid overdose-reversal drug naloxone has been shown to reduce the rate of these overdose deaths, and laws have been enacted in all U.S. states, including Delaware, to expand access to this life-saving medication.

Prescribing Naloxone

Naloxone is an opioid antagonist that blocks opioid receptors. The drug comes in intravenous, intramuscular, and intranasal formulations and is FDA-approved for use in an opioid overdose and for the reversal of respiratory depression associated with opioid use. In 2023, the FDA approved over-the-counter (nonprescription) naloxone nasal spray (Narcan) (U.S. FDA, 2023). OTC Narcan is now available without a prescription in all states; Washington, DC; and Puerto Rico.

Naloxone can reverse the effects of an overdose from opioids, including:

• Heroin
• Morphine
• Oxycodone (Oxycontin)
• Methadone
• Fentanyl
• Hydrocodone (Vicodin)
• Codeine
• Hydromorphone

CDC guidelines for prescribing opioids recommend that naloxone be coprescribed to any individual who is prescribed high-dose opioid therapy (≥50 MME per day) or any combination of opioids and benzodiazepines. Recommendations also call for overdose prevention education to both patient and household members (Dowell et al., 2022).

Candidates for naloxone include individuals who are concerned about the risk of an opioid overdose, including people who use prescription or illicit opioids, their family members, friends, caregivers, and concerned members of the public. This includes patients:

• Receiving >50 mg morphine milligram equivalent (MME) of opioid treatment
• With a respiratory condition (e.g., COPD, asthma, sleep apnea)
• Who smoke marijuana, hooka, tobacco, etc.
• Being treated for opioid use disorder (DSM‐V)
• With a personal or family history of substance misuse (alcohol or drugs)
• Released after having experienced an opioid overdose
• Taking benzodiazepines, hypnotics, muscle relaxers, or other sedative use
• Being switched between opioids product formulations
• With difficult access to emergency services (e.g., rural)
• With heavy alcohol use
• By voluntary request from patient or caregiver
  (SAMHSA, 2023b; WV DHHR, 2025b)

Patient Education Regarding Naloxone Administration

Patient education includes showing patients, their family members, or caregivers how to administer naloxone (see below). The medication can be given by intranasal spray or intramuscular, subcutaneous, or intravenous injection.

Individuals who are provided with an automatic injection device or nasal spray should keep the item available at all times. The medication must be replaced when the expiration date passes and if exposed to temperatures below 39 °F or above 104 °F.

Naloxone is effective if opioids are misused in combination with other sedatives or stimulants. However, it typically is not effective in treating overdoses of benzodiazepines or stimulant overdoses involving cocaine and amphetamines unless they are mixed with opioids, such as fentanyl (CDC, 2024e).

Since naloxone is a temporary treatment and its effects will wear off, medical assistance must be obtained as soon as possible after administering/receiving naloxone. Patients must be educated to immediately call 911 after recognizing a possible overdose and before administering naloxone. Individuals who have overdosed may again experience overdose symptoms once the effects of naloxone have worn off, typically after 30–90 minutes.

Side effects of naloxone may include an allergic reaction from naloxone, such as hives or swelling in the face, lips, or throat, for which medical help should be sought immediately. Use of naloxone also causes symptoms of opioid withdrawal. Opioid withdrawal symptoms include:

• Feeling nervous, restless, or irritable
• Body aches
• Dizziness or weakness
• Diarrhea, stomach pain, or nausea
• Fever, chills, or goose bumps
• Sneezing or runny nose in the absence of a cold

Administering Naloxone

Following are instructions on how to administer naloxone.

Step 1. Identify an opioid overdose: Shout to see if the individual responds and gently shake their shoulder. Rub your knuckles on their upper lip or up and down the front of their rib cage.

Step 2. If the individual is unresponsive, call 911.

1. State that the individual’s breathing has stopped and they are unresponsive.
2. Provide the exact location of the individual.
3. Indicate whether or not naloxone has already been given to the individual and if it helped.

Step 3. Perform rescue breathing.

1. Place the individual on their back. Place one hand on their forehead and the other under their chin.
2. Tilt their chin up gently to open the airway.
3. Check to see if there is anything in their mouth blocking their airway, such as gum, a toothpick, undissolved pills, a syringe cap, a fentanyl patch, etc. If so, remove it.
4. Pinch their nose with one hand and keep chin tilted up with the other hand. Create an airtight mouth-to-mouth seal and give two even, regular-sized breaths. Blow enough air into their lungs to make their chest rise. If the chest does not rise, make sure you pinch their nose and tilt their head back with each breath.
5. Give one breath every five seconds.

Step 4. Give naloxone.

1. Follow the instructions provided with the naloxone medication (see below).
2. While getting ready to give naloxone, make sure you are not waiting too long between rescue breaths.
3. After giving naloxone, continue rescue breathing with one breath every five seconds until emergency responders arrive.
4. If victim is still not responding, additional doses of naloxone can be repeated at 2- to 3-minute intervals.

Step 5. Stay until help arrives: Naloxone can reverse an overdose but can also make someone enter withdrawal. After someone is given naloxone, make sure they do not take any more opioids, because they could go back into overdose after the naloxone wears off. They can also go back into overdose if they took a long-acting opioid. In these situations, repeat doses of naloxone may be needed.

(DDPH, n.d.-d)

SUBSTANCE MISUSE AND DRUG DIVERSION IN THE WORKPLACE

Nurses may be at increased risk for misuse or diversion of prescription medications due to working in environments where frequent and easy access to controlled substances is part of their daily work routine.

Drug Diversion among Healthcare Professionals

Drug diversion from the workplace is seen across all clinical disciplines and all levels of an organization, from management to frontline staff. Diversion may occur with opened or unopened vials, partially used doses of medication that are not wasted, and medication that has been disposed of and left in sharps containers. The drugs most commonly diverted from healthcare settings are opioids. While drug diversion is substantially underestimated, undetected, and unreported, an increasing number of drug diversion incidents has accompanied the rise of the opioid epidemic. For instance:

• In 2024, a nurse was sentenced to 12 months in prison for stealing fentanyl and hydromorphone intended for intensive care patients. She admitted to removing the pain medication from their vials, refilling the vials with tap water, and returning the vials to the controlled storage locker.
• In 2023, a nurse pled guilty to diverting controlled substances from her hospital for her own use, including falsely documenting she had administered medications to patients.
  (Nyhus, 2021; HealthcareDiversion.org, 2025)

Practitioners, including prescribers, may also be motivated to divert drugs for several reasons:

• Money/financial gain
• Fear
• Stop blackmail
• Sexual favors
• Stay in business/codependency
• Addicted family members
• Personal use/misuse
  (U.S. DEA, 2018)

RECOGNIZING WORKPLACE DIVERSION

Every nurse plays an important role in drug diversion prevention and should be able to recognize patterns, trends, and behaviors associated with drug diversion in the workplace. These may include:

• Consistently arriving early, staying late, or frequently volunteering for overtime
• Frequent breaks or trips to bathroom
• Heavy wastage of drugs
• Drugs and syringes in pockets
• Anesthesia record that does not reconcile with drug dispensed and administered to patient
• Patient with unusually significant or uncontrolled pain after anesthesia
• Patients with a higher pain score as compared to other anesthesia providers
• Times of cases that do not correlate with when provider dispenses drug from automated dispenser
• Inappropriate drug choices and doses for patients
• Missing medications or prescription pads
• Drugs, syringes, or needles improperly stored
• Signs of medication tampering, including broken vials returned to pharmacy
• Compromised product containers
• Frequent medication losses, spills, or wasting
• Controlled substances removed without a prescriber’s order
• Controlled substances removed on recently discharged or transferred patient
• Controlled substances removed for a patient not assigned to the nurse
• Medication documented as given but not administered to the patient
• Frequent reports of ineffective pain relief from patients
• Frequent unexplained disappearances from the unit
• Incorrect controlled substance counts
• Consistently documenting administration of more controlled substances than other nurses
• Numerous corrections on medication records
• Offers to medicate coworkers’ patients for pain
• Saving extra controlled substances for administration at a later time
• Altered verbal or phone medication orders
• Variations in controlled substance discrepancies among shifts or days of the week
  (AANA, n.d.)

PREVENTING WORKPLACE DIVERSION

A comprehensive strategy to prevent the diversion of controlled substances includes efforts at the points in the medication management process where diversion may occur. Organizational prevention programs include elements across multiple levels:

• Administrative level: following all legal and regulatory requirements, providing organizational oversight and accountability
• System level: human resources management, automated dispensing technology, monitoring and surveillance, and investigation and reporting
• Individual level: chain of custody; storage and security; internal pharmacy controls; prescribing and administration; returns, waste, and disposal
  (Clark et al., 2022)

Specific controls shown to be effective against diversion of controlled substances include:

• Following all policies and procedures
• Using the PDMP regularly
• Keeping complete and accurate records
• Limiting access to drug inventory
• Storing controlled substances in a securely locked cabinet
• Not sharing passwords
• Conducting audits to discover discrepancies, losses, or thefts
• Verifying destructions
• Training and updating staff
• Being vigilant of staff members
• Conducting background checks of prospective employees
• Conducting drug testing at hiring and random drug testing thereafter
• Questioning and reporting suspicious activities/transactions
• Using electronic prescriptions to reduce forged/altered/fraudulent scripts
• Never signing prescription blanks in advance
• Keeping prescription pads locked when not in use; not leaving prescription pads unsecured (e.g., in jacket pocket)
• Inspecting and numbering prescription pads
• Clearly indicating/writing the amount prescribed
  (U.S. DEA, 2018)

Recognizing Impairment in the Workplace

Impairment from substance use disorder, drug diversion, or other physical or psychological causes has far-reaching impact. It not only threatens the health and safety of patients but also creates serious consequences for the impaired professional, colleagues, and the healthcare facility that employs the impaired clinician.

The Nurse Worklife and Wellness Study found that in the year prior to the study illicit drug use among nurses was 5.7% and misuse of prescription drugs was 9.9% (Trinkoff et al., 2022). The exact number of nurses afflicted is unknown, but the prevalence of addiction among nurses is believed to mirror the general population.

RISK FACTORS FOR SUBSTANCE ABUSE

Healthcare professionals may be at increased risk for abuse of prescription-type medication due to the added risk of working in environments where frequent and easy access to controlled substances is part of their daily work routine. For instance, evidence suggests the types of drugs abused by nurses may depend on what drugs are most accessible in their individual work environments. The most common prescription drugs abused by nurses are benzodiazepines and opioid painkillers such as fentanyl and hydrocodone. Nurses who abuse prescription drugs are those who have the greatest access, with the highest rates of abuse among nurse anesthetists (American Addiction Centers, 2023).

SIGNS OF SUBSTANCE ABUSE AND IMPAIRED PRACTICE

Impairment renders a clinician unsafe to provide patient care. Physical, psychosocial, and behavioral clues, however, can be subtle and easily overlooked. Colleagues may notice clues but seek other explanations and avoid suggesting substance abuse as a possible cause.

Generally, disruptions in family, personal health, and social life manifest long before an individual shows evidence of impairment at work. Thus, all indicators, no matter how subtle, appearing in the workplace must be taken seriously. Any of the following may be signs of impairment in the workplace, and patterns of such behavior and a combination of these signs are cause for increased suspicion.

COMMON SIGNS OF IMPAIRMENT

Type	Signs
(Nyhus, 2021; AANA, n.d.; Kopitnik & Siela, 2024)
Physical	Progressive deterioration in personal appearance Wearing long sleeves when inappropriate Diminished alertness, confusion, or memory lapses Frequent runny nose Dilated or constricted pupils Bloodshot or glassy eyes Unsteady gait Slurred speech Diaphoresis Frequent nausea, vomiting, or diarrhea Tremors or shakes, restlessness Weight gain or loss
Psychosocial	Increasing isolation or withdrawal from colleagues Personal relationship problems Dishonesty with self and others Intoxication at social functions Defensiveness (e.g., denial, rationalization) Inappropriate verbal or emotional responses Mood swings, overreaction to criticism, overexcitement Personality change (mood swings, anxiety, panic attacks, depression, lack of impulse control, suicidal thoughts or gestures, feelings of impending doom, paranoid ideation) Feelings of shame, guilt, loneliness, sadness
Behavioral	Absenteeism (absences without notification, excessive use of sick days, excessive tardiness) Confusion, memory loss, and difficulty concentrating or recalling details and instructions Ordinary tasks requiring greater effort and consuming more time Frequent complaints of vague illness, injury, pain Insomnia Rarely admitting errors or accepting blame for errors or oversight Unreliability in keeping appointments and meeting deadlines Work performance that alternates between periods of high and low productivity Working excessive amounts and showing up on days not scheduled Making mistakes due to inattention, poor judgment, bad decision-making Sleeping on the job Elaborate, implausible excuses for behavior

INTERVENING IN CASES OF IMPAIRED PRACTICE IN A COLLEAGUE

When planning to intervene in a case of suspected impairment, the first step is knowing Delaware state laws and rules pertaining to substance abuse and impairment in the workplace among licensed healthcare providers. It is also important to be familiar with and to follow an employer’s policies and procedures relating to substance abuse and impairment.

Healthcare professionals can follow these steps when they begin to notice possible impaired practice in a colleague:

• Observe job performance; be aware of signs and symptoms of impairment that are common in the workplace.
• Look for patterns of behavior indicating possible impairment that are consistent over a period of time.
• Document (date, time, place, witnesses) any inappropriate behavior; be concise and include objective, clear, and factual information:
  • What happened?
  • Who was involved?
  • When did the incident occur?
  • How was it discovered?
  • Where did it occur?
  • Were there any witnesses?

Supervisors should be involved in planning an intervention and taking steps to respond to concerns about impairment in the workplace.

• Planning and participating in an intervention are critical responsibilities of the manager, and it should never be implemented alone.
• It is important to develop a careful plan of action before implementing an intervention and also important to secure help.
• Interventions should focus on documented facts.
• The primary objective of an intervention is to request the clinician refrain from practice until a fitness-to-practice evaluation has been completed (IPN, 2023).
• To assure safety, a clinician who is impaired should never be left alone and should not be permitted to drive.

REPORTING IMPAIRED PRACTICE IN DELAWARE

Delaware Administrative Code, Title 24 §1900, Board of Nursing, describes regulations pertaining to impaired practice by nurses. Such practice is considered “unprofessional conduct” and grounds for discipline. It is defined as “practicing nursing when unfit to perform procedures and make decisions in accordance with the license held because of physical or mental impairment or dependence on alcohol or drugs.”

Under Delaware code, any licensed nurse is required to report, on a complaint form, names of subject individuals to the Board of Nursing if the nurse has reasonable cause to suspect that a nurse or an applicant has violated any of the grounds for discipline. This report must be made within 30 days of becoming aware of such information.

VOLUNTARY TREATMENT OPTION

As an alternative to discipline, the Delaware code also provides for a voluntary treatment option for licensed professionals determined to have violated the professional conduct standard related to impairment or dependence on alcohol or drugs. They may be permitted to continue to practice, subject to any limitations on practice established by the Board of Nursing and only if the nurse presents no danger to public health, welfare, or safety. The nurse must enter into and comply with all terms of a program agreement, which include but are not limited to:

• Enter and progress satisfactorily in a treatment program approved by the Board of Nursing
• Consent to progress reports from the treatment program to the Board
• Assume all costs and charges associated with the voluntary treatment option and treatment program(s)
• Comply with any terms or restrictions placed on professional practice
• Disqualification from the voluntary treatment option for failing to comply with the terms or to make satisfactory progress

(See Delaware Professionals’ Health Monitoring Program listed in the “Resources” section at the end of this course.)

CONCLUSION

Currently, there is an epidemic of prescription drug misuse, diversion, and overdose deaths not only in Delaware but also across the country. The complexity of this crisis creates challenges for federal, state, and local governments as well as nongovernmental partners who must confront the growing impacts on the community.

Overprescribing opioids for more than a decade has contributed to prescription opioid addiction and led to a sharp increase in opioid addiction, including overdose deaths. A multifaceted public health approach is necessary in order to effectively reduce opioid-related morbidity and mortality.

The opioid epidemic in this country has evolved and escalated along with an epidemic of chronic pain. With current evidence affirming that less-risky pain alternatives are just as effective as opioids for managing chronic pain, it is clear that there must be a cultural shift away from treating chronic pain with opioid medication.

Nurses are in a unique position to address this crisis with the right clinical skills and knowledge in assessment and management of addiction risk and best practices for safe opioid prescribing. A comprehensive approach that supports safe and effective pain management without increasing patient risk for addiction must be priority in every clinical practice setting.

Nurses are also responsible for the safety of patients, and it is every nurse’s duty to recognize and respond to impairment in the workplace. This requires that all nurses understand substance use disorder as an occupational hazard and be able to recognize signs and behaviors associated with impairment. It also requires nurses to be vigilant about their own risk and take steps to support healthy work environments that encourage education about substance use disorder and support for nurses who need help.