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Detecting Drug Diversion in the Health Care Workforce

05/28/2019

By Robert Campbell, PharmD, director, Clinical Standards Interpretation Hospital/Ambulatory Programs, and director, Medication Management

According to a report by data firm Protenus, 166% more legally prescribed opioids were stolen in 2018 than the year prior. Of these, 34% of incidents of diverted opioids happened in hospitals, followed by private practices, long-term care facilities and pharmacies. 

In many of these cases, health care workers pilfered their patients’ pain medication. According to the report , doctors and nurses are responsible for opioid diversion 67% of the time.

Due to the availability of and access to medications in health care organizations, diversion of controlled substances can be difficult to detect and prevent without a comprehensive controlled substances diversion prevention program (CSDPP).

In every organization, drug diversion is a potential threat to patient safety. Risks to patients include:

  • inadequate pain relief
  • exposure to infectious diseases from contaminated needles and drugs
  • potentially unsafe care due to the health care worker’s impaired performance
  • undue suffering to patients who don’t receive analgesic relief
  • cost to an organization in reputation damage
  •  possible major civil and criminal monetary penalties

The Drug Enforcement Administration (DEA) recognizes five classes of drugs that are frequently abused: 

  • opioids
  • antidepressants
  • hallucinogens
  • stimulants
  • anabolic steroids

According to the report, the most common diverted drug was oxycodone, followed by hydrocodone and fentanyl. Diversion of opioids in injectable and oral forms is seen across all levels of an organization, from chiefs to frontline staff, and across all clinical disciplines.

Experts believe that only a fraction of those who divert drugs are ever caught, despite clear signals such as:

  • abnormal behaviors
  • altered physical appearance
  • poor job performance

Diversion Program Elements
Direct observation may be the only way to identify an impaired colleague. In organizations where controlled substances are used, all staff should implement a CSDPP that includes:

  • leadership oversight
  • legal and regulatory requirements
  • monitoring and surveillance
  • automation and technology
  • pharmacy controls

The organization’s culture must support empowerment of staff to stop, question and act.

Detecting Diversion
While all staff may be implicated in diversion, evidence suggests that those employees with the greatest access to controlled substances are at the highest risk. Statistics from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) and the American Nurses Association (ANA) suggest that about 10% of health care workers abuse drugs.

The focus of comprehensive surveillance should be on patterns and trends. Important areas of concentration for surveillance purposes are highlighted below.

Removing controlled substances:

  • without a doctor’s order
  • for patients not assigned to the nurse
  • for recently discharged or transferred patients

Substitute drugs often raise a red flag, as they’re sometimes removed and administered while controlled substances are diverted.

Written prescriptions altered by patients or compromised product containers should also be identified as suspicious.

Order Inconsistencies
Organizations need to investigate when discrepancies arise in the physician’s order. Situations include:

  • verbal orders created for controlled substances but not verified by prescribe
  • prescription pads that may have been diverted and forged 
  • self-prescribed controlled substances 

Volume Issues
Prescription volume needs to be closely watched as the following situations are somewhat common:

  • volume is removed from premixed infusion
  • multidose vial overfill diverted
  • prepared syringe contents replaced with saline solution

Documentation Clues
Many organizations have discovered drug diversion after reviewing patient documentation. Be aware of the following practices:

  • medication is documented as given but not administered to the patient
  • excessive pulls for PRN or “as needed” medications for one provider compared to peers
  • drug dispensing machines showing discrepancies or overrides

Potential falsification of medical records is indicated by:

  • late documentation of certain medications only
  • co-workers assisting others in completing documentation
  • “batching” assessments and treatments for pain
  • frequent efforts to help other nurses administer pain medication
  • patients continued complaints about excessive pain, despite documented administration of pain medication
  • unauthorized individual orders for controlled substances on stolen DEA Form 222

Waste Indicators
The waste itself often offers hints about drug diversion, particularly if waste is not adequately witnessed. Drug diverters have been known to: 

  • remove controlled substance waste from unsecure waste containers
  • replace controlled substance waste in syringe with saline
  • confiscate expired controlled substances from holding area

In my next post, I’ll discuss how organizations can prevent and respond to drug diversion. Stay tuned!

 

Robert Campbell, Pharm.D. currently serves as the Clinical Director, Standards Interpretation Group for Hospital and Ambulatory Programs at The Joint Commission. Dr. Campbell also serves as the Director of Medication Management for the Joint Commission Enterprise. Prior to joining The Joint Commission, Dr. Campbell worked in health care organizations and held leadership positions with oversight responsibilities for performance improvement, accreditation readiness, risk management, infection control, medical staff services, and inpatient and outpatient pharmacy services.