Stigma Related to the Non-Medical Use and Diversion of Prescription Stimulant Drugs: Should We Care.

BACKGROUND: Non-medical use (NMU) and diversion of prescription stimulants are prevalent on college campuses. Diversion represents a primary source of acquisition for NMU among young adults. This study examined relationships between stigmatizing beliefs related to NMU and diversion of stimulant medications and engagement in these behaviors, as well as how such perceptions are associated with indicators of psychological distress among those who engage in these behaviors. METHODS: Young adults (N = 384) were recruited from a large US university to participate in this cross-sectional electronic survey-based study. Relationships between stigma variables and NMU and diversion were assessed. Among those who engage in NMU and diversion, we tested relationships between stigma variables and indicators of psychological distress, using validated instruments. RESULTS: Perceived social and personal stigmatic beliefs did not significantly predict NMU. However, perceived social and personal stigma of diversion significantly reduced diversion likelihood. For NMU, associations were found between stigma variables and indicators of psychological distress. Markedly, we found that as stigmatic perceptions of NMU increased, so did depressive, anxiolytic, and suicidal symptomatology among those who engage in NMU. CONCLUSIONS: Stigmatization does not deter NMU; however, stigmatization is positively associated with psychological harm among those who engage in NMU. Interventions should be developed to reduce stigmatization in order to improve psychological health among those who engage in NMU. Stigmatic perceptions of diversion were not predictive of psychological harm, though they are negatively associated with diversion behavior.

Knowledge, Attitudes, and Practice Patterns of Health Professionals Toward Medical and Non-medical Stimulant Use by Young Adults.

BACKGROUND: The role of family physicians (FPs) and college health professionals (CHPs) in stimulant treatment and nonmedical use of stimulants is not clear. OBJECTIVE: To investigate the current practices, concerns, needs, beliefs, barriers, and facilitators to appropriate pharmacological treatment of teens and young adults with attention deficit hyperactivity disorder (ADHD) and prevention of nonmedical use and diversion. METHODS: A cross-sectional survey developed by the project team and experts in the field, delivered to national sample of FPs and CHPs. RESULTS: A total of 794 completed surveys were analyzed. The average age of respondents was 51.6 ± 10.3 years; 50.6% of the respondents were female. The majority of CHPs (80.6%) reported they spend 75% to 100% of their time with patients age 17 to 24 years and 74.0% of FPs reported they spend less than 25% of their time with this age group. The majority (91.7%) of the respondents indicated that untreated ADHD affects quality of life, and 76.4% indicated untreated ADHD is often associated with risky behaviors. More CHPs than FPs always refer out for ADHD diagnosis (70.7% vs 52.1%; P < .001). Most respondents (81.2%) were concerned with ADHD medication diversion, and 84.2% believed that diversion or abuse is a problem overall. Respondents indicated they are unprepared to provide patient education on decisions about pharmacotherapy or behavioral therapy choices for adult ADHD. CONCLUSION: There is an opportunity to enhance safety and effectiveness of ADHD management in young adults. Additional resources and interventions are needed to improve medication management, reduce misuse, and ensure safe and appropriate use of stimulants.

Characterization of diverted buprenorphine use among adults entering corrections-based drug treatment in Kentucky.

BACKGROUND: Illicit, medically unsupervised use of buprenorphine (i.e., "diverted use") among vulnerable and underserved populations, such as corrections-involved adults, remains underexplored. METHODS: Survey data (2016-2017) collected as part of a clinical assessment of incarcerated adults entering corrections-based substance use treatment in Kentucky were analyzed. For years examined, 12,915 completed the survey. Removing cases for participants who did not reside in Kentucky for >6 months during the one-year pre-incarceration period (n = 908) resulted in a final sample size of 12,007. RESULTS: Over a quarter of the sample reported past-year diverted buprenorphine use prior to incarceration and 21.8 % reported use during the 30-days prior to incarceration, using 6.5 months and 14.3 days on average, respectively. A greater proportion of participants who reported diverted buprenorphine use had previously been engaged with some substance use treatment (77.0 %) and reported greater perceived need for treatment (79.4 %) compared to those who did not report use. Use was more likely among participants who were younger, white, male, and who reported rural or Appalachian residence. Diverted buprenorphine users also evidenced extensive polydrug use and presented with greater substance use disorder severity. Non-medical prescription opioid, heroin, and diverted methadone use were associated with increased odds of diverted buprenorphine use while kratom was not. Diverted methadone use was associated with a 252.9 % increased likelihood of diverted buprenorphine use. CONCLUSIONS: Diverted buprenorphine use among participants in this sample was associated with concerning high-risk behaviors and may indicate barriers to accessing opioid agonist therapies for corrections-involved Kentucky residents, particularly those in rural Appalachia.

How to say "no" most effectively: Evaluating resistance strategies for prescription stimulant diversion to inform preventive interventions.

OBJECTIVE: We evaluated the perceived effectiveness of resistance strategies students could employ if approached to give away, trade, or sell their prescription stimulant medication, a growing concern on college campuses. Participants: We sampled undergraduates (N = 1,521) at three demographically dissimilar institutions between Fall 2017 and Spring 2018. Methods: We administered an anonymous, online survey and used linear mixed models to examine the effects of strategy type, face support (ie, adding politeness), and substance use history on perceived strategy effectiveness. Results: Internal (eg, "I am not comfortable sharing my medication") and external (eg, "My doctor won't prescribe me if I share") explanations were perceived to be most effective. Excuses, direct refusals, and suggesting an alternative (eg, energy drink) were less preferred. Adding face support improved perceived effectiveness for direct refusals and internal explanations. Conclusion: Preventive interventions for stimulant diversion could encourage the use of internal or external explanations or direct refusals with face support.

Drug sourcing and motivations among a sample of people involved in the supply of pharmaceutical drugs in Australia.

BACKGROUND: The non-medical use (NMU) of pharmaceuticals is increasing internationally, along with mortality. Previous research indicates that end-users access pharmaceuticals through social networks, however little is known about supplier sources particularly outside the US. This study examined sourcing and motivations among a sample of people involved in pharmaceutical diversion and supply in Australia. METHODS: Semi-structured, telephone interviews were conducted with 51 people involved in supplying pharmaceuticals in the previous six months. Multi-stage recruitment involved the distribution of flyers to participants of two Australian drug-monitoring programs: the Ecstasy and related Drugs Reporting System (capturing regular psycho-stimulant users) and the Illicit Drug Reporting System (capturing people who regularly inject drugs), followed by a screening of interested participants. Interviews were audio-recorded, transcribed and analysed using a mixed methods approach. First, correlates of drug sourcing and motivations were examined including demographics, frequency and quantity of supply. Second, thematic analysis of the qualitative data was undertaken on strategies for obtaining the drugs and motivating factors. RESULTS: Drug supplies were sourced from a variety of medical and non-medical sources, primarily legitimately obtained prescriptions (47%), friends or family (18%) and dealers (14%). Suppliers using medical sources were more likely to be unemployed/retired and reported supplying for therapeutic purposes, while suppliers using non-medical sources were more likely to be employed/students, earned higher incomes and reported supplying for recreational purposes. Those who sourced via doctor shopping (IRR = 47.5) and friends and family (IRR = 10.1) distributed higher quantities, while those who sourced legitimately obtained prescriptions (IRR = 0.1) and from illicit drug dealers (IRR = 0.0) distributed lower quantities. Similar proportions supplied for financial (65%) and altruistic (61%) reasons, however the latter supplied lower quantities (IRR = 0.1). CONCLUSION: This study offers novel insight into the diversion of pharmaceuticals from the supplier perspective. A nuanced policy approach is required to address varied supply practices by source and motive.

The source and diversion of pharmaceutical drugs for non-medical use: A systematic review and meta-analysis.

BACKGROUND: The non-medical use (NMU) of pharmaceutical drugs is an increasing public health concern. This systematic review consolidates current knowledge about how pharmaceutical drugs are obtained for NMU and the processes and people involved in diversion. METHODS: Peer-reviewed and grey literature databases were searched for empirical studies published between 1996 and 2017 that examined the source or diversion of pharmaceutical opioids, sedatives or stimulants for NMU in countries with reported misuse problems. Pooled prevalence meta-analyses using random effects models were used to estimate the prevalence of medical and non-medical sourcing reported by end-users, and gifting, selling and trading by various populations. RESULTS: This review synthesizes the findings of 54 cross-sectional studies via meta-analyses, with a remaining 95 studies examined through narrative review. Pharmaceutical drugs are primarily sourced for NMU from friends and family (57%, 95% CI 53%-62%, I2 = 98.5, n = 30) and despite perceptions of healthcare professionals to the contrary, illegitimate practices such as doctor shopping are uncommon (7%, 95% CI 6%-10%, I2 = 97.4, n = 29). Those at risk of diversion include patients displaying aberrant medication behaviors, people with substance use issues and students in fraternity/sorority environments. Sourcing via dealers is also common (32%, 95% CI 23%-41%, I2 = 99.8, n = 25) and particularly so among people who use illicit drugs (47%, 95% CI 35%-60%, I2 = 99.1, n = 15). There is little to no organized criminal involvement in the pharmaceutical black market. CONCLUSION: Pharmaceutical drugs for NMU are primarily sourced by end-users through social networks. Future research should examine how dealers source pharmaceutical drugs.

Medical prescriptions falsified by the patients: a 12-year national monitoring to assess prescription drug diversion.

Diversion of prescription drugs is difficult to assess in quality and quantity. This study aimed to characterize diversion of prescription drugs in France through a comparative analysis of falsified prescriptions collected during three periods from 2001 to 2012. The data recorded in a national program which records all falsified prescriptions presented to community pharmacies were studied. Included data regarded: subjects, prescription forms, and drugs. Description of the dataset in three periods (2001-2004, 2005-2008, and 2009-2012) was completed with clustering analyses to characterize profiles of prescriptions and subjects associated with the most reported drugs. The 4469 falsified prescriptions concerned most often females (51.6%). Average age was 46.5 years. Zolpidem, bromazepam, and buprenorphine were the most frequent drugs. Alone, 13 drugs (1.7%, 13/772) represented more than 40% of the total reports (3055/7272). They were associated with three diversion profiles: (i) buprenorphine, flunitrazepam, and morphine were mentioned on overlapping secure prescription forms presented by young men; (ii) alprazolam, bromazepam, zolpidem, codeine/acetaminophen were mentioned on simple prescription forms presented by experienced women; and (iii) acetaminophen and lorazepam were mentioned on modified prescription forms presented by elderly subjects. Clonazepam, clorazepate, dextropropoxyphene, zopiclone moved between those profiles. The patterns of falsified prescriptions provided in this study contribute to enhance the scientific knowledge on the most diverted prescription drugs. The latter follow distinct trajectories across time depending on their pharmacology (including their abuse/addiction potential) and on their regulation's history. The close and continuous analysis of falsified prescriptions is an excellent way to monitor prescription drug diversion.

[The diversion of prescribed stimulant medications of 10th graders in Iceland].

INTRODUCTION: ADHD is a neurodevelopmental disorder that usually surfaces before seven years of age. Stimulants are commonly used medications for the treatment of this disorder in Iceland, but they carry with them a significant risk of both abuse and diversion - i.e. when it is used by an individual other than it was prescribed for by a physician. The purpose of this study was to estimate the prevalence of diversion amongst Icelandic adolescents. MATERIAL AND METHODS: This study is based on data collected in the Icelandic portion of the European School Survey Project on Alcohol and Other Drugs (ESPAD) focused on the drug and alcohol use of 10th graders in Europe. RESULTS: Of the 2,306 students that participated in the study 91% (2,098) claimed they had never been prescribed stimulant medications while 9% (208) claimed they had. Boys were twice as likely to get a stimulant prescription compared to girls. Almost 18% of the participants that had been prescribed simulants said they had at some point in time diverted their stimulant medication. CONCLUSION: The diversion of stimulants by 10th graders in Iceland is quite common compared to studies from other countries where the prevalence is closer to 5-10%. These findings demonstrate the importance of carefully overseeing stimulant use of adolescents, for the benefit of both those who divert as well as those diverted to.

Non-prescribed use of opioid substitution medication: Patterns and trends in sub-populations of opioid users in Germany.

BACKGROUND: Non-prescribed use of opioid substitution medication (NPU) appears to represent a relevant source of opioids among European drug users. Little is known about the prevalence of NPU in Germany and possible differences between subgroups of opioid users. The present study examines NPU and other drug use patterns among drug consumption room (DCR) clients, opioid substituted DCR clients, and patients recruited in opioid substitution treatment (OST) practices. METHODS: Cross-sectional data was collected in 2011 from 842 opioid users in 10 DCRs and 12 OST practices across 11 German cities. Structured interviews comprised indicators for socio-demographics, health status, drug use, motives for NPU, and the availability and price of illicit substitution medication. Group differences were examined with one-way ANOVAs, chi-square tests, or t-tests, and factors for NPU were included in a multivariate model. Over-time comparisons were performed with similar data collected in 2008. RESULTS: Lifetime, 30-day and 24-h NPU prevalence for the total sample was 76.5%, 21.9%, and 9.3%, respectively, with methadone being the most frequently used substance. NPU, poly-drug use and injection drug use were more common among DCR clients, especially among DCR clients not in OST. The three groups featured distinct socio-demographic characteristics, with substituted patients being more socially integrated, while few differences in health parameters emerged. Motives for NPU were mostly related to potential shortcomings of OST, such as insufficient dosages, difficulties with transportation, and lack of access. NPU prevalence was found to be higher than in 2008, while injection rate of substitution medication was similarly low. Main factors associated with NPU were not being in OST, past 24-h use of other drugs, and younger age. CONCLUSION: Although diverted methadone or buprenorphine are rarely used as main drugs, NPU is prevalent among opioid users, particularly among DCR clients not in OST. OST reduces NPU if opioid users' needs are met.

Diversion of methadone and buprenorphine from opioid substitution treatment: the importance of patients' attitudes and norms.

AIMS: Methadone and buprenorphine diversion by patients in opioid substitution treatment (OST) is a poorly understood phenomenon. We study the norms and attitudes on diversion among OST patients, including the role these norms and attitudes play as diversion risk factors. We also study whether perceived quality of care, social bonds to treatment staff, and deterrence can be associated with diversion. METHODS: Structured interviews were conducted with 411 patients from eleven OST programs. In total, 280 interviews were done on site by the researchers, while 131 interviews were conducted through peer interviewing by specially trained patients. The data was analyzed through frequency- and averages-calculations, cross-tabulations, and logistic regression analysis. RESULTS: Most patients consider diversion as mostly positive (83.7%), morally right (76.8%), and without any significant risk of detection (66.9%). Individual differences in norms and risk perceptions may play a role in explaining variations in diversion; patients who consider it right to share medication with friends report higher treatment-episode diversion than other patients (OR 1.455, p = 0.016). Patients who perceive control measures as effective report lower diversion than other patients (OR = 0.655, p = 0.013). Furthermore, data indicate that patients who are satisfied with the care and service are less prone to engage in diversion. Social bonds with treatment staff seem to be less importance. CONCLUSIONS: The norm system described by patients resemble Bourgois' 'moral economy of sharing' concept-not sharing drugs with friends in withdrawal is considered unethical. Efforts to decrease diversion may focus on lifestyle-changing interventions, and reducing black market demand for illicit medications by expanding access to treatment.

Everyday drug diversions: a qualitative study of the illicit exchange and non-medical use of prescription stimulants on a university campus.

This article investigates everyday experiences and practises that are associated with processes of pharmaceuticalization and with practices of 'drug diversion'--that is, the illicit exchange and non-medical use of prescription drugs. It reports results from a qualitative study that was designed to examine the everyday dimensions of non-medical prescription stimulant use among students on an American university campus, which involved 38 semi-structured interviews with individuals who used prescription stimulants as a means of improving academic performance. While discussions of drug diversion are often framed in terms of broad, population-level patterns and demographic trends, the present analysis provides a complementary sociocultural perspective that is attuned to the local and everyday phenomena. Results are reported in relation to the acquisition of supplies of medications intended for nonmedical use. An analysis is provided which identifies four different sources of diverted medications (friends; family members; black-market vendors; deceived clinicians), and describes particular sets of understandings, practices and experiences that arise in relation to each different source. Findings suggest that at the level of everyday experience and practice, the phenomenon of prescription stimulant diversion is characterised by a significant degree of complexity and heterogeneity.

Diversion of methadone and buprenorphine from opioid substitution treatment: patients who regularly sell or share their medication.

Diversion-the practice of patients selling or sharing their medication-is a much debated problem of opioid substitution treatment. Regular diversion by patients was studied at 11 opioid substitution treatment programs in the south of Sweden. Using quantitative and qualitative data, it was investigated whether those patients differ from other patients, their motives for and means of diversion, and who the recipients are. Regular diverters are a small, yet heterogeneous group. Continued illicit drug use, however, stands out as a common risk factor. Pecuniary need and a desire to help friends are other important motives. The client base mainly consists of people from the regular diverters' own drug milieus.

Prescription drug diversion among substance-impaired pharmacists.

BACKGROUND AND OBJECTIVES: Prescription drug addiction is a significant problem affecting healthcare professionals. The purpose of the present study was to identify common mechanisms of prescription drug diversion by pharmacists, in order to facilitate the development of effective prevention programs and policies for this high-risk group. METHODS: A total of 32 pharmacists (71% male) who were being monitored by their State professional health program (PHP) due to substance-related impairment participated in anonymous guided group discussions. RESULTS: Participants documented six primary methods of drug diversion by pharmacists: (1) taking expired drugs that can no longer be sold by the pharmacy and are awaiting disposal; (2) assuming responsibility for managing the pharmacy inventory and/or changing inventory records to prevent detection of missing drugs; (3) forging prescriptions for themselves, family members, friends, or customers in order to gain access to the drugs; (4) using "sleight of hand" techniques to acquire drugs while filling prescriptions or shelving products; (5) blatantly stealing drugs from the pharmacy, even in front of coworkers or video cameras, and (6) collecting patients' unused medications and keeping them. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Efforts to address the problem of prescription drug abuse and diversion by pharmacists should be expanded in order to safeguard pharmacies and the patients they serve. Future research should extend this study to larger samples and assess best practices for decreasing prescription drug diversion by pharmacists with addiction.

Sources of pharmaceutical opioids for non-medical use among young adults.

The study uses qualitative and quantitative data to describe sources of pain pills for illicit use among young adult (18- to 23-year-old) users. Respondent-driven sampling was used to recruit 383 individuals in the Columbus, Ohio, area. The sample was almost 50% Caucasian and about 55% male. Qualitative interview participants (n = 45) were selected from the larger sample. Qualitative data suggest that pharmaceutical opioid availability was so pervasive that most individuals did not have to venture outside of their immediate social networks to find people who sold or shared pills. Participants emphasized differences between those who are actively involved in obtaining pills and those who play a more passive role. Active involvement was described as going out searching for pills and paying money to obtain them. In contrast, passive role included obtaining pills when somebody offered or shared them free of charge. Multiple logistic regression analysis indicates that a more active role in obtaining pharmaceutical opioids was related to being White, more frequent use of pharmaceutical opioids, extended-release oxycodone use, and using pharmaceutical opioids to get high, as opposed to self-treating a health problem. The study results can help inform drug use epidemiology, interventions, and policy.

The misuse of prescription pain medication and borderline personality symptomatology.

OBJECTIVE: Despite the known high rates of substance misuse among individuals with borderline personality disorder (BPD), little empirical data are available regarding the explicit nature of such misuse with prescribed pain medications-the focus of the present study. SETTING: A primary care outpatient setting, with predominantly resident providers, in a midsized mid-western US city. PATIENTS: Consecutive outpatients who currently or have previously been prescribed pain medication (ie, lifetime pain medication exposure) (n = 185). MAIN OUTCOME MEASURES: Relationships between BPD, according to two measures, and eight author-developed items reflecting prescription pain medication misuse. RESULTS: With the exception of requesting a prescription for pain medication but not having pain (n.s.), all other measures of prescription pain medication misuse were statistically significantly associated with BPD symptoms. There were also some statistically significant interactions between male gender and BPD symptoms in the prediction of pain medication misuse (ie, mixing prescribed pain medications with drugs to get high, using prescribed pain medication for recreational purposes, and selling prescribed pain medications for money). CONCLUSIONS: Individuals with BPD are at risk for misusing prescribed pain medications, and this is especially evident regarding particular forms of misuse among men with BPD symptomatology.

Coping and emotion regulation profiles as predictors of nonmedical prescription drug and illicit drug use among high-risk young adults.

BACKGROUND: Deficits in the ability to organize, integrate, and modulate emotions, thoughts, and behaviors when dealing with stress have been found to be related to the onset and escalation of substance use among adolescents and young adults. However, limited research has focused on understanding how coping and emotion regulation tendencies might be associated with different patterns of prescription and illicit drug use, particularly among high-risk young adults who may already face additional challenges relative to lower-risk populations. METHODS: Young adults aged 16-25 years who had misused prescription drugs within the past 90 days were interviewed in Los Angeles and New York. The current study utilized latent profile analysis to empirically derive coping and emotion regulation typologies/profiles that are then used to predict different patterns of substance use (N=560). RESULTS: Four latent classes/groups were identified: (1) suppressors, (2) others-reliant copers, (3) self-reliant copers and (4) active copers. Distinct patterns of prescription and illicit drug misuse were found among different coping/emotion regulation profiles, including differences in age of initiation of opiates, tranquilizers, and illicit drugs, recent injection drug use, substance use-related problems, and past 90-day use of tranquilizers, heroin, and cocaine. Specifically, suppressors and others-reliant copers evidenced more problematic patterns of substance use compared to active copers. CONCLUSION: This is among the first studies to show how coping and emotion regulation profiles predict distinct patterns of substance use. Results provide the groundwork for additional investigations that could have significant prevention and clinical implications for substance-using high-risk young adults.

Non-medical use of prescription drugs, polysubstance use, and mental health in transgender adults.

BACKGROUND: In recent years, the non-medical use of prescription drugs (NMUPD) has increased dramatically and has been associated with adverse health outcomes. Prior work has not examined this behavior in large samples of transgender adults. METHODS: Transgender adults (N=155) recruited from community venues in the Mid-Atlantic region completed anonymous, self-administered surveys assessing demographic information, NMUPD and other substance use, the non-medical use of hormones, psychosocial factors, and psychiatric symptoms. RESULTS: Overall, 26.5% of participants reported lifetime NMUPD with the most commonly reported medications used non-medically being prescription analgesics (23.9%), anxiolytics (17.4%), stimulants (13.5%), and sedatives (8.4%). Non-medical use of hormones was also frequently reported (30.3%). Participants reporting NMUPD were also more likely to report the use of illicit drugs. NMUPD, but not the non-medical use of hormones, was associated with lower self-esteem, more gender identity-based discrimination, and more self-reported symptoms of anxiety, depression, and somatic distress. Psychiatric symptoms remained statistically associated with NMUPD after controlling for demographic factors and other substance use. CONCLUSIONS: Prescription drug misuse was relatively common in this sample and was robustly associated with emotional distress. Substance use and mental health interventions for this population may benefit from incorporating the assessment and treatment of NMUPD.

Collaboration or coercion? Partnering to divert prescription opioid medications.

Diversion of prescription opioids is a widespread problem in the USA. While "doctor shopping" and pill brokering are well-described types of medication diversion, we sought to understand the social dynamic of diversion of prescription opioids and identify other diversion methods. Using qualitative data collected as part of a 12-week Rapid Assessment and Response study of prescription opioid overdose and abuse (the RARx Study) conducted in three communities in two New England states, we reviewed and thematically coded 195 interviews. Diversion took many forms: doctor shopping, pill brokering, and, most commonly, siphoning from the family medicine chest. Partnering-of patients with other "patients," of patients with "caregivers"- to obtain prescription opioids was also described. Motivations for partnering indicated doing so out of fear of violence, for financial benefit, or in exchange for transportation or other services. Partnering for prescription opioids exhibited a range of power differentials, from collaboration to coercion, and tended to involve vulnerable populations such as the elderly, disabled, or destitute. Increased awareness among health providers of the ease of access and diversion of prescription opioids is needed to promote patient safety and prevent interpersonal violence.

Exploring prison buprenorphine misuse in the United Kingdom: a qualitative study of former prisoners.

The United Kingdom Ministry of Justice recently highlighted the extent of buprenorphine (Subutex) misuse in English andWelsh prisons, naming it the third most misused drug overall. Yet little is known regarding how illicit buprenorphine is obtained in prison and what influences prisoners to use it. Qualitative research was used to explore prison drug using practices. Thirty men who were former prisoners with a history of injecting drug use were interviewed in depth about their illicit prison drug use, including buprenorphine. Interviews were conducted over 18 months, from August 2006 to January 2008 and were analysed using Framework. The misuse of Subutex by snorting emerged as a significant theme. Accounts suggested that the diversion of prison prescribed Subutex was widespread and prisoners used various tactics to obtain the medication. Various complex and interlinked reasons were given to explain why Subutex was snorted in prison. The main motivation for snorting was to experience a prolonged euphoric opiate effect, believed to help to combat the boredom of being in prison. The price of illicit Subutex in prison was linked to its availability, but it was generally cheaper than heroin, thus contributing to its use. Participants'narratives identified the belief that snorting Subutex in prison was not risk free, but risks were lower than continuing to use other drugs, particularly injecting illicit opiates. The implications of prison Subutex misuse for prisoners, prison medical services, commissioners, and prescribing policy and practice are discussed.