Suspected Opioid Diversion in Home Hospice

I would start with objective data: pill counts, refill dates, pharmacy records, PDMP if available, the son's observed drowsiness, and the patient's pain and function. I would assess Mr. K's capacity, his understanding of the risk, his relationship with his son, and whether he is being coerced or exploited. I would ask nonjudgmental questions: 'Who else has access to the bottle? What happens when you run out early? Has anyone offered to sell or trade your medication?' I would screen for depression, anxiety, and the son's possible substance use. The patient's denial does not erase the risk. I would not accuse the son without evidence, but I would not collude with a plan that leaves the patient unsafe. If there is immediate danger, I would arrange emergency evaluation. The judgment is to treat diversion as a safety and pain-control problem, not a morality problem.

I would recommend an interdisciplinary meeting with the patient, son, physician, nurse, pharmacist, and me. Options include a locked box with a sign-out sheet, nurse-administered doses, daily check-ins, and changing the long-acting opioid only if clinically appropriate, not as a punishment. I would increase hospice aide and volunteer support and offer the son naloxone and substance use treatment. I would assess whether the patient is safe alone and whether the son is exploiting him; if adult protective services criteria are met, I would report. I would also consider respite or inpatient hospice for pain stabilization. The plan must not undertreat pain: untreated pain is a harm. If the son refuses all safeguards, I would document and escalate to the medical director and ethics committee. The patient's refusal to change his living situation must be respected if he has capacity, but the team can still set boundaries around medication handling.

Legal reporting of diversion varies by state and hospice policy; I would report internally to the medical director and pharmacy and consult the agency's legal counsel. I would not necessarily call police. Documentation should be factual: pill counts, dates, observed behavior, patient statements, education given, and the plan. I would avoid defamatory labels such as 'addict' or 'thief.' Ethically, confidentiality applies to the patient; I would not discuss the son's history with others without the patient's permission unless safety requires it. There is a conflict of interest if the son is both caregiver and suspected divertor. I would ensure the patient's pain is treated and that he is not abandoned. If the patient lacks capacity, the son's proxy role creates an ethics conflict; request consultation. The social worker should be transparent about limits of confidentiality.