Implementation of pharmaceutical alternatives to a toxic drug supply in British Columbia: A mixed methods study.

BACKGROUND: North America has been in an unrelenting overdose crisis for almost a decade. British Columbia (BC), Canada declared a public health emergency due to overdoses in 2016. Risk Mitigation Guidance (RMG) for prescribing pharmaceutical opioids, stimulants and benzodiazepine alternatives to the toxic drug supply ("safer supply") was implemented in March 2020 in an attempt to reduce harms of COVID-19 and overdose deaths in BC during dual declared public health emergencies. Our objective was to describe early implementation of RMG among prescribers in BC. METHODS: We conducted a convergent mixed methods study drawing population-level linked administrative health data and qualitative interviews with 17 prescribers. The Consolidated Framework for Implementation Research (CFIR) informs our work. The study utilized seven linked databases, capturing the characteristics of prescribers for people with substance use disorder to describe the characteristics of those prescribing under the RMG using univariate summary statistics and logistic regression analysis. For the qualitative analysis, we drew on interpretative descriptive methodology to identify barriers and facilitators to implementation. RESULTS: Analysis of administrative databases demonstrated limited uptake of the intervention outside large urban centres and a highly specific profile of urban prescribers, with larger and more complex caseloads associated with RMG prescribing. Nurse practitioners were three times more likely to prescribe than general practitioners. Qualitatively, the study identified five themes related to the five CFIR domains: 1) RMG is helpful but controversial; 2) Motivations and challenges to prescribing; 3) New options and opportunities for care but not enough to 'win the arms race'; 4) Lack of implementation support and resources; 5) Limited infrastructure. CONCLUSIONS: BC's implementation of RMG was limited in scope, prescriber uptake and geographic scale up. Systemic, organizational and individual barriers and facilitators point to the importance of engaging professional regulatory colleges, implementation planning and organizational infrastructure to ensure effective implementation and adaptation to context.

Real or fake? Sourcing and marketing of non-prescribed benzodiazepines amongst two samples of people who regularly use illicit drugs in Australia.

INTRODUCTION: There is concern around non-prescribed benzodiazepine use, particularly with increasing detections of counterfeit products containing high-risk novel compounds. The aims of this study were to investigate how and which non-prescribed benzodiazepines are being sourced; forms, appearance and packaging; and awareness of risks associated with non-prescribed benzodiazepines. METHODS: Data were collected from a sample of Australians who inject drugs or use ecstasy and/or other illicit stimulants on a monthly or more frequent basis, and who reported past 6-month use of non-prescribed benzodiazepines (n = 235 and n = 250, respectively). Data were collected on source, diversion from a known/trusted prescription, product name and aesthetic characteristics for the last non-prescribed benzodiazepine obtained. RESULTS: Amongst participants who injected drugs, 71% reported that their last non-prescribed benzodiazepines were diverted from a known/trusted prescription, compared to 59% of participants who used ecstasy/other stimulants. Sourcing via cryptomarkets was rare. Across both samples, the majority reported last obtaining substances sold/marketed as diazepam or alprazolam. Participants sourcing via non-diverted means were twice as likely to obtain alprazolam. Known sourcing of novel compounds was rare. Amongst participants who used ecstasy/other stimulants, 36% reported confidence in the content/dose of non-prescribed benzodiazepines even when the source is unknown. DISCUSSION AND CONCLUSIONS: Most participants obtained substances sold as classic/registered benzodiazepines, mostly via diverted prescriptions, with a substantial minority potentially unaware of counterfeits circulating. While diverted use undeniably presents risks, tightening of prescriptions in Australia could inadvertently lead to greater supply of novel benzodiazepines as seen internationally, reinforcing prioritisation of demand and harm reduction strategies.

Psychotropic medicine prescribing and polypharmacy for people with dementia entering residential aged care: the influence of changing general practitioners.

OBJECTIVE: To examine relationships between changing general practitioner after entering residential aged care and overall medicines prescribing (including polypharmacy) and that of psychotropic medicines in particular. DESIGN: Retrospective data linkage study. SETTING, PARTICIPANTS: 45 and Up Study participants in New South Wales with dementia who were PBS concession card holders and entered permanent residential aged care during January 2010 - June 2014 and were alive six months after entry. MAIN OUTCOME MEASURES: Inverse probability of treatment-weighted numbers of medicines dispensed to residents and proportions of residents dispensed antipsychotics, benzodiazepines, and antidepressants in the six months after residential care entry, by most frequent residential care GP category: usual (same as during two years preceding entry), known (another GP, but known to the resident), or new GP. RESULTS: Of 2250 new residents with dementia (mean age, 84.1 years; SD, 7.0 years; 1236 women [55%]), 625 most frequently saw their usual GPs (28%), 645 saw known GPs (29%), and 980 saw new GPs (44%). The increase in mean number of dispensed medicines after residential care entry was larger for residents with new GPs (+1.6 medicines; 95% CI, 1.4-1.9 medicines) than for those attended by their usual GPs (+0.7 medicines; 95% CI, 0.4-1.1 medicines; adjusted rate ratio, 2.42; 95% CI, 1.59-3.70). The odds of being dispensed antipsychotics (adjusted odds ratio [aOR], 1.59; 95% CI, 1.18-2.12) or benzodiazepines (aOR, 1.69; 95% CI, 1.25-2.30), but not antidepressants (aOR, 1.32; 95% CI, 0.98-1.77), were also higher for the new GP group. Differences between the known and usual GP groups were not statistically significant. CONCLUSIONS: Increases in medicine use and rates of psychotropic dispensing were higher for people with dementia who changed GP when they entered residential care. Facilitating continuity of GP care for new residents and more structured transfer of GP care may prevent potentially inappropriate initiation of psychotropic medicines.

Benzodiazepine and Z-drug prescribing in Ireland: analysis of national prescribing trends from 2005 to 2015.

AIMS: The aim of this study was to examine prescribing trends for benzodiazepines and Z-drugs to General Medical Services (GMS) patients in Ireland. METHODS: A repeated cross-sectional analysis of the national pharmacy claims database was conducted for GMS patients aged ≥16 years from 2005 to 2015. Prescribing rates per 1000 eligible GMS population were calculated with 95% confidence intervals (CIs). Negative binomial regression was used to determine longitudinal trends and compare prescribing rates across years, gender and age groups. Duration of supply and rates of concomitant benzodiazepine and Z-drug prescribing were determined. Age (16-44, 45-64, ≥65 years) and gender trends were investigated. RESULTS: Benzodiazepine prescribing rates decreased significantly from 225.92/1000 population (95% CI 224.94-226.89) in 2005 to 166.07/1000 population (95% CI 165.38-166.75) in 2015 (P < 0.0001). Z-drug prescribing rates increased significantly from 95.36/1000 population (95% CI 94.73-96.00) in 2005 to 109.11/1000 population (95% CI 108.56-109.67) in 2015 (P = 0.048). Approximately one-third of individuals dispensed either benzodiazepines or Z-drugs were receiving long-term prescriptions (>90 days). The proportion of those receiving >1 benzodiazepine and/or Z-drug concomitantly increased from 11.9% in 2005 to 15.3% in 2015. Benzodiazepine and Z-drug prescribing rates were highest for older women (≥65 years) throughout the study period. CONCLUSIONS: Benzodiazepine prescribing to the GMS population in Ireland decreased significantly from 2005 to 2015, and was coupled with significant increases in Z-drug prescribing. The study shows that benzodiazepine and Z-drug prescribing is common in this population, with high proportions of individuals receiving long-term prescriptions. Targeted interventions are needed to reduce potentially inappropriate long-term prescribing and use of these medications in Ireland.

Increasing availability of benzodiazepines among people who inject drugs in a Canadian setting.

BACKGROUND: Benzodiazepine misuse is associated with mortality and is common among people who inject drugs (PWID). This study aimed to examine the temporal trends in the availability of benzodiazepines among PWID in a Canadian setting, and to identify factors associated with more immediate access to benzodiazepines. METHODS: Data were derived from 3 prospective cohorts of PWID in Vancouver, Canada, between June 2012 and May 2015. The primary outcome was the perceived availability of benzodiazepines, measured in 3 levels: not available, delayed availability (available in ≥10 minutes), and immediate availability (available in <10 minutes). The authors used multivariable generalized estimating equations to identify factors associated with availability of benzodiazepines. RESULTS: In total, 1641 individuals were included in these analyses. In multivariable analyses, factors associated with immediate benzodiazepine availability included incarceration (adjusted odds ratio [AOR]: 1.42, 95% confidence interval [CI]: 1.06, 1.89) and participation in methadone maintenance therapy (MMT) (AOR: 1.35, 95% CI: 1.14, 1.60). Factors associated with delayed benzodiazepine availability included incarceration (AOR: 1.45, 95% CI: 1.02, 2.07) and participation in MMT (AOR: 1.77, 95% CI: 1.48, 2.12). Benzodiazepine availability increased throughout the study period for both immediate (AOR: 1.14, 95% CI: 1.10, 1.18 per 6-month follow-up period) and delayed (AOR: 1.17, 95% CI: 1.12, 1.22 per 6-month follow-up period) availability. CONCLUSIONS: Among our sample of PWID, benzodiazepine availability is increasing and was associated with health and criminal justice system characteristics. Our findings indicate a need to examine prescribing practices and educate both PWID and health care providers about the risks associated with benzodiazepine use.

A longitudinal cohort study on the impact of the clobazam shortage on patients with epilepsy.

OBJECTIVE: Drug shortages are occurring at an increasing rate. From May to October 2016, there was a shortage of a level I critical antiepileptic drug, clobazam. We aimed to study the impact of this shortage on patients with epilepsy. METHODS: Adult patients from Calgary's Comprehensive Epilepsy Program who were taking clobazam were approached to participate in the study. Baseline data from the clinic prospective registry included clinical variables and presurvey patient-reported outcomes (PROs) such as the Global Assessment of Severity of Epilepsy, the Global Assessment of Disability Associated with Seizures, and the Quality of Life in Epilepsy questionnaire. We used a mixed-methods cross-sectional questionnaire via telephone. We analyzed quantitative data using descriptive methods and qualitative data using a phenomenological approach. RESULTS: Of the 85 eligible patients, 84% (n = 71) agreed to participate. Participants ranged from 18 to 78 years old, and 59.2% of participants were female. Overall, 80% of participants experienced some form of medication change due to the shortage. No significant differences were found in the pre- and during-shortage PRO data. However, 6 important themes emerged regarding the impact of the antiepileptic drug shortage on patients: (1) communication and awareness, (2) burden on patients and caregivers, (3) physical impact, (4) psychological impact, (5) health care provider assistance in navigating the shortage, and (6) policy change. SIGNIFICANCE: We examined the impact of the clobazam shortage on patients with epilepsy from the patient's perspective and identified 6 important themes. As a result, we were able to gain insight into what patients need to cope with drug shortages and make recommendations that can help mitigate the impact of shortages on patients in the future. Further research is needed to better understand drug shortages from the patient's perspective in various settings and conditions.

Community pharmacists' role in benzodiazepine supply in Ireland: a questionnaire of pharmacists' views and experiences.

OBJECTIVE: To investigate the views and experiences of community pharmacists in Ireland regarding their role in benzodiazepine supply and the potential for role expansion. METHODS: A postal questionnaire was issued to a random, geographically stratified sample of community pharmacies in Ireland. KEY FINDINGS: The response rate was 37.6%. Pharmacists' awareness of the national source of benzodiazepine guidelines was low (26.6% previously aware). Benzodiazepine prescriptions were frequently encountered in practice and commonly for extended durations of 28 days. Pharmacists' involvement in roles extending beyond dispensing was limited. In the 6 months prior to the questionnaire, fewer than half of pharmacists reported having suggested discontinuation to a patient (43.7%) or having contacted a prescriber about a patient's benzodiazepine use (47.1%). Pharmacists acknowledged their potential to undertake a more extensive role in benzodiazepine supply and expressed willingness to do so in practice. CONCLUSIONS: This study adds to the limited body of existing literature regarding community pharmacists' role in benzodiazepine supply. The findings indicate the need to revisit existing benzodiazepine guidelines to improve pharmacists' awareness of them and to address long-term prescribing. The apparent lack of active pharmacist involvement in roles and activities extending beyond dispensing needs to be addressed. Given that most pharmacists encountered benzodiazepine prescriptions at least once daily in practice, they are well positioned to promote safe and appropriate benzodiazepine use. Sizeable proportions of pharmacists expressed willingness to expand upon their existing role and facilitate long-term patients in attempting discontinuation. Further research is needed to explore barriers and facilitators to pharmacists undertaking extended roles in benzodiazepine supply in greater detail.

[Can one talk of benzodiazepine "drunkenness"? About acute benzodiazepine intoxication, without suicidal or mortiferous tendencies]. / Peut-on parler d'ivresse benzodiazépinique ? À propos d'intoxications benzodiazépiniques aiguës, ni suicidaires ni mortifères.

BACKGROUNDS: When we refer to "drunkenness", more often than not, we think of alcohol or cannabis being the instigator rather than pharmacological drugs, even if outside the toxic origins, "drunkenness" may also occur without any substance intake: one can be drunk on love, poetry, music and even mania. Benzodiazepine "drunkenness" is not a classical notion in medicine. But the concept of addictology allows one to enlarge different approaches and to consider the relationship with psychoactive substances according to the same references. So, in a single fashion, between use and misuse, is it possible to resort to the same concepts for pharmacological drugs, including "drunkenness"? CLINICAL FINDINGS: Any intake of a psychoactive substance, limited in time, which will take the consumer some time to recover from, can be called simple use, intoxication or drunkenness. Intoxication is rather a classical medical concept linked with poisoning, and hence the toxicological aspects prevail particularly through the concept of a toxidrome. However, little research has been done on "drunkenness" in other medical aspects, neither psychological aspects nor sociological aspects. If poisoning is defined as soon as a poison is introduced into the body, the intoxication arises after a threshold (that toxicology usually defines), but no means are available to measure the onset of the inebriation, neither any ingested amounts nor any toxic concentration in the body. It is hard to define "drunkenness" simply. At first, it is most often seen as a pathology in medicine, unlike in every day life. "Drunkenness" can be the result of physiological disturbances, notably through the effects of substances and can therefore be the manifestation of a cerebral dysfunction. Alternatively, it can arise from a variation of emotional or sensorial stimuli. If the feelings associated with drunkenness are positive and pleasant a repetition will occur in the search to reproduce enjoyable effects in reference to neurophysiological models of reward systems of the brain, and can tend to be limited to a search for pleasure. Moreover, "drunkenness" may be considered as a leak, a regression or a kind of renouncement. It may sometimes be a search for sedation, for conscious sleep, or to avoid reality. And, finally, "drunkenness" may be suicidal. Since the launch of benzodiazepines on the market during the sixties, their prescription has developed, making them so readily available in France that they are nearly as easy to obtain as alcohol. The widespread diffusion of these psychoactive substances, obtained with or without medical prescription, renders them one of the principle means of chemically modulating thought and consciousness that has become accessible to all. One of the first reasons for this is the easy and wide prescription of these drugs by almost all practitioners. Choosing between benzodiazepines or alcohol (or associating both substances) is not fortuitous. Besides intoxication with pharmacological drugs, whether voluntary or otherwise, medication overdose and iatrogenic effects, there is an incidence of a substantial use of over the counter psychoactive drugs in order to trigger other effects than suicide or self-harm. This use of pharmacological drugs, sometimes referred to as "entertaining", can lead to massive intake with dramatic behavioural response. Is it then possible to use the same term "drunkenness" for a pharmacological drug-induced state as for a state provoked by other psychoactive substances with addictive potential ? The clinical presentation of benzodiazepine "drunkenness" resembles the pharmacological effects of these drugs. If we link alcoholic and benzodiazepine "drunkenness", we can draw a parallel between the properties, the action mechanisms, the effects and the risks incurred by the consumption of these two classes of psychotropics. The similarities concern the existence of a preclinical phase, of the same biochemical or neurophysiological basis, of the same properties, notably complex relationships with anxiety. They also have the same amnesiac effects, possible paradoxical effects, or sedation potentialities that may lead to coma, respiratory depression and death. But differences exist for benzodiazepines, in the lack of disinhibition effects, the lack of cerebellar effects, the variability of elimination kinetics according to the molecules, the rarity or the lack of "recreational" intakes, and the lack of easy blood level measurements. CONCLUSION: An attempt is made to outline the definition of benzodiazepine "drunkenness", including sociological, psychological, and medical dimensions beyond the sole toxicological aspects. So, studying the misuse of benzodiazepines in more detail including the acute effects such as "drunkenness", except suicidal or mortiferous tendencies, can allow further development of its recognition, screening and prevention.

Benzodiazepine reduction in general practice. Are the elderly neglected?

In two Danish general practices a few simple rules applicable to all age groups were introduced in order to reduce consumption of benzodiazepines (BZ) and cyclopyrrolones (CP). These rules, termed the "Thyborøn-Model", included the termination of telephone prescriptions, the issuance of prescriptions only following personal consultation and the restriction of prescriptions to a maximum of a single month's consumption. The purpose of the present demographic analysis is to investigate whether the intervention was successful for the elderly, who are considered to be a special target group. The findings presented here reveal that the number of BZ and CP users increased with increasing age. Furthermore, the results indicate that the intervention was effective in reducing the consumption of BZ and CP for middle-aged and elderly patients, and that there is a significantly better effect of this model for middle-aged than for elderly patients. These findings constitute the first demographic evaluation of the effects of the "Thyborøn-Model" with focus on the special target group of elderly patients, and indicate that it is advisable to introduce these simple rules for all age groups, especially since they also are effective on elderly patients.

Benzodiazepine dependence in Singapore.

The study, conducted in 2003-2005, was aimed at investigating the pattern of benzodiazepine (BZD) use and the attitudes and perceptions of doctors' prescribing practices by a hundred BZD-dependent patients in Singapore. Data on patients' demographic characteristics, psychiatric profiles, patterns of BZD use, and perceptions about doctors' prescribing practices were collected. A benzodiazepine dependence self-report questionnaire (Bendep-SRQ) was also administered. The mean age of the study participants was 39.4 years (SD = 9.7); 88% were Chinese, 58% were males, 46% were married, 48% had received secondary school education, and 48% were unemployed. BZD abuse in Singapore is contributed to by both doctor-shopping behavior and doctors' prescribing practices. Doctors need training on the assessment and management of BZD dependence. The study's limitations were noted. This project was supported by an institutional block grant received from the National Medical Research Council, Singapore.

Use of surveillance data in developing geographic dissemination strategies: a study of the diffusion of olanzapine to Michigan children insured by medicaid.

OBJECTIVE: The purpose of this study was to examine the diffusion of olanzapine to urban and rural children insured by Medicaid in Michigan by identifying prescribing clusters through surveillance of claims records. METHODS: Prescription claims records for all antipsychotic medications for 3,567 children insured by Medicaid in Michigan from 1996 through 1998 were examined through the state Medicaid database. There were 29,069 pediatric prescriptions for antipsychotic medications; 2949 were for olanzapine (576 children, 510 providers). These data were linked to the Area Resource File, Provider Enrollment File, and Rural-Urban Commuting Area codes. Patient and provider locations were geocoded by ZIP code. Mixed logistic regression analysis was performed to determine the probability of a child's being prescribed olanzapine given certain community, patient, and provider characteristics. Spatial clusters were identified through the local Moron's L statistic and empirical Bayes standardized incidence rates. RESULTS: Rural children were more likely than urban children to be prescribed olanzapine (odds ratio [OR], 1.29; P < 0.001). There were significant differences by age and sex, with older children and girls more likely than younger children and boys to be prescribed olanzapine (OR, 1.30 and 1.37, respectively; both, P < 0.001). At the county level, the number of pediatricians per primary care physician reduced the likelihood of a child's being prescribed olanzapine (OR, 0.88; P = 0.039). The effect of the number of available mental health professionals was not significant. The global Moran's L statistic was U indicating moderate clustering of the use of olanzapine. CONCLUSION: Graphic surveillance data may be useful for studying the delivery and use of health cue services. Further research is needed to determine how this method can be used strategically to facilitate or impede the diffusion of new medications.

[Study on the use of benzodiazepine among middle school students in Wuhan City].

OBJECTIVE: In order to understand the status of benzodiazepine (BZD) use in middleschool students from Wuhan city. METHODS: In the Wuhan city zone, twenty-eight middle-schools were chosen randomly to the even numbers, with students from grade 8 to 12 had been studied. Altogether, 258 classes were investigated with 12 345 questionnaires were filled in by the subjects anonymously. SPSS 10.0 was used for data analysis. RESULTS: Rate of BZD use in Wuhan middle school students was 4.0% with the rate of dependence as 4.1per thousand. There were differences in gender and grade: male students tend to be higher than females (P< 0.01), and senior higher than junior's (P < 0.01). More commonly used drugs would include Diazepam (59%) and Surazepam (29.7%). Among students who used drugs, 43.3% used for 1-7 day and 8.2% of them used 6 tablets or more. 57.6% used 1 tablet once a day (46.2%) before bed time (40.8%). The major reason for using drug was insomnia (43%), followed by pressure from school. The reasons for BZD abuse were: relief of anxiety (14.1%), curiosity (13.3%), peer pressure (10.8%), and fun seeking (9.85%), etc. The source of drugs was from their families (29%). By Multinomial logistic regression, the risk factors of abuse BZD were: ignorance of drug prescription, sex, regular alcohol intake, knowing that BZD use can bring amusement regular, smoking cigarettes, relationship with parents, mother's way of providing education, schooling of fathers, relationship between parents. CONCLUSION: Difference was seen in the use of BZD between gender and age of the students. Multiple factors showed that: personal, family and social factors were related to the use of BZD.

Regional variation in the use of medications by older Canadians--a persistent and incompletely understood phenomena.

BACKGROUND: We have previously reported on regional variability in medication consumption by older Canadians. In this study, we used longitudinal data to determine whether regional differences in commonly consumed medications persisted and to explore potential explanatory factors for observed differences. METHODS: We utilized data from the second phase of the Canadian Study of Health and Aging to assess the number, types, and variability of medications used between regions. Linear and logistic regressions (LRs) were used to predict the number of medications and the use of specific agents where significant regional variability was found to exist. RESULTS: There were significant regional differences in the number of medications consumed and in the prevalence of use of acetaminophen (p < 0.002), benzodiazepines (p < 0.020), nitrates (p = 0.040), and complementary and alternative medicines (CAMs; p < 0.020). The proportion of subjects using acetaminophen was highest in British Columbia (44.6%) and lowest in Quebec (27.3%). Benzodiazepine and nitrate consumption was highest in Quebec (35.9 and 19%, respectively) and lowest in the Praires (18.2%) and Atlantic Canada (6.6%). CAM use was highest in British Columbia (47.1%) and lowest in the Atlantic region (26.8%). Similar inter-regional differences had been found 5 years previously. There were no significant regional differences in the prevalence of hypertension, myocardial infarction, diabetes, arthritis/rheumatism, or depression. Region remained a significant explanatory variable for the number of medications and nitrate, benzodiazepine, and CAM use in our multivariate models. CONCLUSIONS: Regional differences in medication use persisted over the course of this longitudinal study. Much of the variability remains unexplained. The reasons for regional differences in consumption of drugs and their clinical significance should be addressed.

Prevalence of alcohol and drug use in a highly educated workforce.

This study examined alcohol and licit and illicit drug use in a highly educated workforce. A comprehensive health survey of a 10% random sample of a workforce (n = 8,567) yielded a 60% response rate (n = 504) after accounting for 15 undeliverable surveys. Many respondents reported past-year use of alcohol (87%). Thirteen percent of respondents consumed three or more drinks daily; 15% were binge drinkers. Twelve percent of the workforce was assessed as having a high likelihood of lifetime alcohol dependence; 5% of respondents met criteria for current problem drinking. Overall, 42% reported using mood-altering prescription drugs (analgesics, antidepressants, sedatives, or tranquilizers). Eleven percent reported using illicit drugs (cocaine, hallucinogens, heroin, or marijuana) in the past year. Significant relationships were found between gender, age, ethnicity, and occupation with some measures of alcohol consumption and use of mood-altering drugs. These results indicate prevention and early intervention programs need to address use of mood-altering substances (including alcohol) in highly educated workforces.

Diversion of prescribed drugs by drug users in treatment: analysis of the UK market and new data from London.

AIMS: To review the available knowledge about the diversion to the illicit market of drugs prescribed to drug users in treatment in the United Kingdom, and to identify aspects of the London market in more detail. METHOD: An analysis of the literature and new data in terms of the extent and nature of the market, the practicalities of trade, motives for selling, reasons for demand and the influence of variations in prescribing practice on diversion. Prices of diverted prescription drugs and details of their availability in London are presented. FINDINGS: The size of the market is substantial and appears to involve a large number of individuals, each diverting small amounts of their own prescribed drugs. Major motives for selling prescribed drugs are to raise funds to buy other, preferred, drugs and/or to pay for a private prescription. Buyers in treatment appear to be motivated by a desire to supplement their own prescriptions because they are dissatisfied with the particular drug prescribed, dosage and formulation. Drug users in treatment can exploit the variations in prescribing practice--such as how much 'take-home' medication they are allowed and whether tests are conducted to ascertain if they are using it themselves--and divert their prescribed drugs. Prices of prescription drugs on the illicit market can fluctuate on a daily basis according to supply and demand. CONCLUSIONS: The results suggest that, to be effective, diversion control must simultaneously involve deterrents from prescribers, drug treatment services, law enforcement agencies and dispensing pharmacists. Finally, some suggestions for further research on this under-studied issue are suggested.