Drug Diversion and Substance Use: A Quiet Risk Inside Long-Term Care

You visit your parent or spouse in a long-term care facility, and you assume their pain is being managed. You expect medications to be given as ordered. When your loved one needs help going to the bathroom, eating, or bathing, you expect professional, compassionate, and timely assistance.

However, as some facilities face staffing shortages and a growing demand for long-term care services, basic services such as pain management and ADL assistance are sometimes delayed or forgotten.

The staff in long-term care facilities face high levels of stress and usually do the best they can in sometimes difficult situations. However, when that trust is broken, it is rarely obvious at first.

In long-term care settings, substance use and drug diversion can unfold quietly, sometimes for months, before anyone connects the dots.

Experts who work inside the system say the problem is more common than most families realize.

Substance Use is Not Rare in Health Care

National nursing regulators have long acknowledged that substance use affects a meaningful share of the health care workforce over the course of a career.

The National Council of State Boards of Nursing has repeatedly warned that addiction and impairment are not isolated events but ongoing professional risks that require education, monitoring, and early intervention.

Peer-reviewed research reinforces those concerns. A 2022 study published in Nurse Worklife and Wellness found that nurses working in home health, hospice, and nursing homes reported higher rates of substance use than in many other care settings. The authors pointed to workload, emotional strain, access to medications, and isolation as contributing factors.

Source: Trinkoff et al., 2022, ScienceDirect (U.S. data).

Those risks collide with a long-term care system under pressure. Facilities are caring for more residents with fewer staff, especially in Medicaid-dependent nursing homes.

Yet even with better private-pay facilities, the pressures of growing demand for care and limited staff availability are real.

Whether your loved one is dependent on Medicaid or has a quality facility being paid by Long-Term Care Insurance or personal funds, they deserve the best quality care possible.

How the Problem Shows Up in Long-Term Care

Danielle “Dani” Martin, MSN, RN, NHA, a national consultant specializing in long-term care compliance, and a compliance specialist for Friends Services Alliance Compliance Collaborative, says substance-related risks typically fall into two categories.

“The first is drug diversion, which is stealing a resident’s medication,” Martin said.

The second is impairment in the workplace, where the substance may or may not have come from the facility. — Dani Martin, MSN, RN, NHA.

Martin has served as a director of nursing, a nursing home administrator, and a compliance officer. Across those roles, she says she has seen both overt and subtle warning signs.

“Sometimes it is obvious, like slurred speech or poor coordination,” Martin told LTC News. “Other times, it looks like missed doses, unresolved pain, or staff behavior that just feels off.”

Why Drug Diversion Often Goes Undetected

Long-term care faces structural challenges that make detection harder than in hospitals.

Heavy Reliance on Agency Staff

Temporary nurses are often assigned to nights, weekends, and holidays, when supervision is limited. Rotating staff also makes it harder to spot patterns.

Limited Training for Supervisors

Charge nurses and managers may never receive formal training on recognizing impairment or conducting a proper investigation.

Fear of Reporting

Certified nursing assistants or junior staff may notice problems but hesitate to report to a supervisor, especially during staffing shortages.

After-Hours Gaps

Many incidents occur when human resources and leadership are not on site, delaying response and documentation.

Outdated Medication Systems Increase Risk

Unlike hospitals, most long-term care facilities still rely on manual narcotic counts and paper logs.

“These systems are very people-dependent,” Martin said.

If counts are skipped or staff sign without verifying quantities, diversion can go unnoticed.

Hospitals commonly use automated dispensing systems, such as Pyxis, which electronically track access and dosing. Long-term care has been slower to adopt similar safeguards, leaving more room for error and abuse.

Warning Signs Families Should Watch For

Drug diversion does not always look dramatic. Families often notice patterns before staff do.

Behavioral changes

• Mood swings or unusual irritability
• Withdrawal or defensiveness

Work pattern concerns

• Frequent late arrivals or early departures
• Repeated shift changes

Physical red flags

• Poor coordination
• Disheveled appearance or odor of alcohol

Medication clues

• Pain that worsens during certain shifts
• “As-needed” medications that do not seem to help
• Inconsistent explanations about dosing

If your loved one reports ongoing pain despite documented medication, that discrepancy deserves attention.

Unpaid Family Caregivers Face Risks Too

Substance misuse is not limited to paid caregivers. Unpaid family members providing care at home face emotional strain with little oversight.

In hospice situations, family caregivers may misuse a loved one’s pain medication. Often, there is no formal reporting, and the behavior goes undocumented. — Dani Martin, MSN, RN, NHA.

That concern intersects with a broader caregiving reality. According to LTC News reporting, tens of millions of Americans provide unpaid care, often while juggling jobs and families. The lack of advance planning creates a family crisis, placing tremendous stress and burden on family members. Burnout increases the risk for mistakes and misuse, especially when controlled substances are involved.

The Impact on Residents and Facilities

For residents, the consequences are immediate.

• Missed or diluted medications
• Uncontrolled pain
• Unsafe care

For facilities, the fallout can be lasting.

• Regulatory citations and fines
• Legal exposure
• Reputation damage
• Staff turnover during an ongoing workforce shortage

“Buddy Wasting” and Other Hidden Risks

One lesser-known red flag is “buddy wasting.” Controlled substances often require two signatures for disposal. When both staff members collude, diversion becomes easier to hide.

“Administrators need to understand this risk,” Martin said. “It is not just about one bad actor.”

How Mock Surveys Help Catch Problems Early

Third-party mock surveys simulate state inspections. Auditors review medication handling, documentation, incident reports, and resident interviews.

They expose vulnerabilities before residents are harmed or regulators arrive. — Dani Martin, MSN, RN, NHA.

Post-survey follow-up often includes policy updates, staff education, and recommendations to modernize medication tracking.

What a Proper Investigation Requires

When diversion or impairment is suspected, timing matters.

A proper investigation should:

• Begin immediately
• Follow a documented reasonable-suspicion policy
• Include interviews with all staff present
• Involve pharmacy partners when appropriate
• Remain flexible as new information emerges

An open culture encourages staff to share concerns without fear.

Supporting Recovery While Protecting Residents

Martin emphasizes that punishment alone can drive problems underground.

Facilities that balance accountability with support may:

• Temporarily remove staff from medication access
• Offer treatment options through Family and Medical Leave Act protections
• Consider the Americans with Disabilities Act requirements when applicable
• Provide structured reintegration when safe

“In a staffing crisis, supporting recovery benefits residents and facilities,” she said.

Lessons From the Field

Martin shared anonymized examples from her work:

• Liquid morphine bottles discovered with pinholes, later found diluted
• Missing GLP-1 medication doses, leading to tighter storage controls

Small inconsistencies often reveal larger problems.

What Families Can Do

If something feels wrong, trust that instinct.

• Ask clear questions about pain management
• Track patterns by shift
• Escalate concerns to the director of nursing or administrator
• Follow up if problems persist

Advocacy matters.

One Change That Could Make a Difference

If Martin could change one industry practice, it would be mandatory education.

“Many people do not recognize diversion as abuse,” she said. “Stealing a resident’s medication directly harms them.”

The Takeaway

Drug diversion and substance use are not rare events in long-term care. They are predictable risks in a strained system. Modern safeguards, clear policies, and a culture of accountability protect residents and staff alike.

While a private-pay long-term care facility will often provide better-quality care, that is not always the case. When a loved one requires long-term care services, be sure to do a comprehensive search and visit several facilities.

The LTC News Caregiver Directory is a good first start. However, visit the facilities more than once and at different hours. If your loved one has Long-Term Care Insurance, be sure to inform the admissions director. Some LTC policies offer case management services and may include information on the facility's quality and past experience.

Caregivers and staff are human. They feel stress, pressure, and exhaustion, just like anyone else. Family caregivers often carry an even heavier burden, balancing work, finances, and their own health while caring for someone they love. That emotional weight is exactly what most people hope to spare their families. 

Once your loved one is in a long-term care facility be sure to pay attention. Martin says that when you come to see their mom or dad in a nursing home or assisted living facility and every day, she’s in pain, but when they talk to the nursing staff, they say that she’s receiving her medication, then that should be a trigger.

Be sure to ask questions and don’t ignore the obvious. Also, listen to what your loved one is telling you. Just because they are older and are living in a long-term care facility doesn’t mean you should ignore what they are telling you about their care. Listen and investigate.

Planning ahead helps reduce that strain before a crisis hits. When a loved one already needs extended care, your role shifts. You stay vigilant. You ask questions. You watch closely to make sure their needs are being met safely, respectfully, and with compassion.