Drug substitution through visual or pharmacological mimicry can facilitate drug diversion. Drug manufacturers should employ unique visual standards that include shape, color, texture, and color grading to distinguish drug class and potency.

ABSTRACT

This case report describes the novel use of oxybutynin and acetaminophen as a substitution for oxycodone for the express purpose of diverting oxycodone in a hospital-based post-anesthesia care unit (PACU). The report outlines how the physical properties and pharmacologic effects of non-controlled medications in the PACU, like oxybutynin, can be visually mistaken and even mimic the side effects of controlled substances like oxycodone. Substituting oxybutynin for controlled substances can circumvent diversion surveillance software. The authors describe how the diversion was identified and the process improvements that should be implemented for proactive identification moving forward.