Question 1: What are some examples of balanced and unbalanced approaches to stemming the diversion and abuse of opioid drugs?

Raymond Sinatra, MD: David, I'd like to go back to your opening statement, and you talked about approaches to diversion that are balanced and unbalanced. Could you give me some ideas what you mean by balanced and unbalanced?

David Joranson, MSSW: Right, starting with sort of an operational definition of something ... an approach that would be balanced is one that has a high potential for actually detecting and addressing a source of diversion and a low potential for interfering in medical practice and patient care. An example would be ... well, let's see, there's been a lot of newspaper discussion recently about approaches taken in different states to use the Medicaid system to respond to the diversion of oxycodone. In one case I think I recall one state has completely eliminated payment for the OxyContin product or else has put it on prior authorization. This would seem to affect all the prescribers and all of the patients who would be eligible for that as an appropriate prescription. So in that case I would consider that to have a pretty high potential for interfering with medical practice and patient care. And at the same time, a low potential for addressing diversion when you understand that the Medicaid program and the drug utilization review part of it was actually designed to give state officials the capability of doing computer searches in their database of recipients and providers, that is both prescribers and dispensers, to identify unusual or suspicious prescribing or dispensing patterns, and as well to identify particular patients that are seeing more than one physician to get the same drug or are filling their prescriptions at more than one pharmacy. It's been listed as a very effective way of identifying diversion by several federal government reports by the general accounting office. So to summarize, taking a drug off the formulary or refusing to pay for it is not a good way to deal with diversion and it has a high potential for getting involved with or interfering with medical practice and patient care.