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To provide a clinician's perspective on the problem of diversion of prescribed pharmaceuticals.The paper provides a personal account of working in a treatment context where diversion from opioid substitution treatment (OST) became a political issue potentially compromising the continued delivery of OST. It summarizes evidence on the impact of diversion, and measures to contain it, from the United Kingdom 1986–2006, Australia 1996–2008 and the United States and France from the mid-1990s.Opioid diversion to the black market occurs in proportion to the amount of opioids prescribed to be taken without supervision, and in inverse proportion to the availability of heroin. Diversion for OST programmes using supervision of dosing is less than diversion of opioids prescribed for pain, which is now a growing public health problem. Adverse consequences of diversion include opioid overdose fatalities, an increased incidence of addiction (particularly in jurisdictions where heroin is scarce) and compromising the public acceptance of long-term opioid prescribing. All long-term opioid prescribing requires monitoring of risk and appropriate dispensing arrangements—including dilution of methadone take-aways, supervision of administration for high-risk patients and random urine testing. Clinical guidelines influence practice, although prescribing often deviates from guidelines.Clinical guidelines and clinical audit to enhance compliance with guidelines are helpful in maintaining the quality and integrity of the treatment system, and can contribute to keeping diversion within acceptable levels.