Facing the Challenge of Drug Diversion in Healthcare Settings
Substance addiction and abuse in the United States has reached alarming proportions. The epidemic is so severe that drug overdoses are one of the most common causes of death for Americans under the age of 50. The Centers for Disease Control and Prevention (CDC) found in a 2017 study that overdoses killed approximately 64,000 people in 2016. That’s an increase of more than 22 percent from 2015. Most of the deaths, about 50,000, were the result of opioid drugs, including prescription medications like OxyContin and Vicodin, as well as synthetic opioids including fentanyl and heroin.
Drug Diversion Defined
The Uniform Controlled Substances Act of 1994 states that “Diversion means the transfer of a controlled substance from a lawful to an unlawful channel of distribution or use.” In other words, drug diversion happens when prescription drugs are used or distributed in any way not intended by the legal prescriber.
With the increase of people who abuse drugs, the demand for prescription drugs, mainly controlled substances, is rising sharply. Prescription drugs are favored among abusers because of their perceived purity and consistent strength. These drugs often sell on the street for far more than their retail price.
Specialty medications and lifestyle drugs with high retail prices represent a financial opportunity for those positioned and willing to procure them illegally. However, the drugs that are most often diverted and abused are substances which have been classified by the U.S. Drug Enforcement Administration (DEA) as controlled substances based on their intended clinical use and their potential for dependence or abuse. These drugs include opioids, anabolic steroids, hallucinogens, stimulants, and depressants.
Drug diversion has serious public health consequences. It contributes to an increase in substance abuse admissions, drug-related hospitalizations, and overdose deaths. All of this places upward pressure on healthcare and insurance costs, impacting everyone. There have also been instances of drug diversion leading to disease outbreaks as a result of needle sharing.
Common Diversion Methods
Prescription drug diversion happens in several ways. Some patients sell their legally obtained drugs; others engage in “doctor shopping” by visiting multiple providers and using false stories to receive prescriptions for opioids and other controlled substances. Diversion also happens when prescription pads are stolen or forged. Sometimes prescriptions are altered to obtain a quantity of medication that the prescriber did not intend. Unfortunately, physicians and other providers can become complicit in drug diversion by intentionally writing prescriptions for unnecessary drugs or by doling out larger quantities than medically required.
The Impact of Drug Diversion in Healthcare Settings
In hospitals and other healthcare settings, there are many risk points in the supply chain as medications are moved from the manufacturer to distributors, to pharmacies, to specific units, and finally to the patients. Hospitals are at particularly high risk because of the need to store and administer controlled substances. However, the majority of prescription drugs are used in outpatient settings, so that’s where most of the drug diversions occur.
The primary driver of drug diversion in healthcare isn’t money. It’s addiction. The American Nurses Association estimates that as many as one in ten nurses is facing drug or alcohol addiction. Addiction rates are high for other healthcare professionals who have access to controlled substances, such as people involved in anesthesiology. One recent diversion case involved a radiology technician with access to unsecured operating rooms.
Risks to Patients
Healthcare workers use a variety of methods for diverting medications, including under-dosing patients, stealing vials or syringes, pocketing waste, switching patient mediations, and accessing sharps disposal containers. Many of these methods represent a severe threat to patient safety. Patients may suffer from not receiving the correct medication or getting a lower dose than is needed. Corrupting injectable medications can expose patients to bacterial or viral infections. On top of that, impaired healthcare workers with slower reaction time and potentially questionable judgment represent a risk to patients.
Risks to Organizations and Healthcare Workers
Patient safety and satisfaction are not the only concerns. Hospitals and other healthcare organizations that have been found to have inadequate drug diversion controls in effect are at risk for civil and even criminal penalties. Just last August, the University of Michigan Health System agreed to pay $4.3 million as part of a settlement resolving allegations that it violated specific provisions of the Controlled Substances Act. On the same day, a doctor and a nurse both overdosed on stolen opioid medication in different units of the system. Each was found in a hospital bathroom with drugs intended for patients injected into their own bodies. Similar cases have been recently settled in Massachusetts and California.
Healthcare workers involved in drug diversion take on considerable personal and professional risk. They face the risk of addiction, overdose, exposure to disease, and even death. If discovered, they may lose their job, or professional licenses may be rescinded. They may also face state or federal criminal charges on top of possible civil actions related to malpractice. This type of drug theft also hurts the reputation of the healthcare organization and the medical profession more generally, especially when the diversion results in harm to patients.
Healthcare facilities that dispense and store medications, particularly controlled substances, have a responsibility to their patients, staff, and the general public to have a comprehensive approach to preventing drug diversion. Effective programs include measures for reducing the opportunity for employees to divert drugs, systems for detecting illicit activity, and policies and procedures for dealing with workers who are facing substance abuse. The approach must be comprehensive enough to cover every employee that may come into the presence of prescription drugs, not just pharmacy technicians and nurses.
Elements of the prevention plan include:
Audits are an essential step in identifying and stopping drug diversion. They should consist of inventory management of controlled substances, daily review of information about controlled substances, and medical record reviews. Software can be used to look for usage trends and unusual activities by individual staff members.
A number of physical controls are necessary in a healthcare setting to prevent unauthorized access to medications. Technology enabled automated dispensing cabinets (ACDs) are equipped with software for controlling and logging access, as well as managing medication and supply inventory. Today, point-of-use cabinets, which allow the pharmacy to dispense and securely store medication in patient rooms, are becoming a popular way to prevent drug diversion between the medication room and the patient’s location.
Education and Training
Healthcare workers benefit greatly from training programs that educate them about drug addiction in healthcare settings and the dangers of abuse. Each person with access to medications should understand the related regulations and the impacts of drug diversion to patients and the organization. They should be well versed and consistently reminded about hospital policies and procedures designed to stop diversion, including what they should do if they suspect diversion has occurred.
Healthcare workers have the ethical responsibility to ensure patient safety by reporting a colleague who may be impaired. Training should include the signs of addiction such as missed work, reduced productivity, changes in appearance, irritability, and mood swings. Complaints from patients about ineffective pain medications should be taken seriously and investigated.
Substance addiction is a complex problem, and there is no simple solution. While we would like to believe that healthcare settings are immune to the drug abuse epidemic, it is simply not the case. Hospitals and other healthcare organizations must address the problem on multiple fronts. The risks of inaction are simply too high.
Related: The International Health Facility Diversion Association (IHFDA)
Founded in 2015, the International Health Facility Diversion Association, or IHFDA, is a network of healthcare and security professionals who connect to share solutions, knowledge, and insight on how to prevent, detect, and properly respond to drug diversion by healthcare personnel. If you are looking for additional resources to build your diversion prevention program, they may be a valuable resource. They hold annual and regional conferences. There is a cost for membership, but some material and webinars are available for free.