Medication Management: Reducing Drug Diversion

The cost of prescription drug diversion has skyrocketed over the past 20 years. In dollar terms, the DEA estimates drug diversion is a $25 billion industry, not to mention to cost to patient safety, organizational reputation, and bottom lines in terms of penalties, fees, and lawsuits. With all of the collateral damage included, Pharmacy Times puts the number closer to $73 billion. Medication management, therefore, has taken center stage as hospitals, pharmacies, and health care facilities grapple with their responsibility to safeguard medications from the wrong hands.

The Opioid Crisis

Effective medication management can lay the foundation for the prevention or reduction of drug diversion in the medical setting. One of the biggest culprits to drug diversion is the nation’s opioid epidemic. According to the U.S. Department of Health and Human Services, the opioid crisis is alarming and has had devastating consequences to those addicted, communities, healthcare systems, and the national economy.

  • More than 130 people die every day from opioid-related overdoses
  • Opioid overdoses accounted for more than 42,000 deaths in 2016
  • 2.1 million people have an opioid use disorder

Sadly, overdose deaths have dramatically increased over the past 18 years. The National Institute on Drug Abuse reported that more than 70,200 Americans died from drug overdoses in 2017, including drugs and prescription opioids – a 2-fold increase in a decade and nearly a 4-fold increase from 1999.

There are many reasons why people begin abusing opioids. Many were prescribed painkillers following surgeries or injuries and quickly became addicted. Others gained access to the medications without doctor supervision, using them to self-treat symptoms or as a recreational drug of choice. Because opioids are highly addictive, it doesn’t take long before a seemingly innocent decision becomes a life-threatening battle of addiction. Today, many doctors are being scrutinized for their over-prescribing and over-dosing of these powerful drugs to treat conditions that can effectively be treated with less addictive medications.

A Case Study in Drug Diversion

Modern Healthcare reported a fascinating and tragic story of the death of a Michigan nurse and an anesthesiology resident at the hands of drug diversion. Not only did both hospital staff members lose their lives, but the hospital system paid $4.3 million to settle allegations that it failed to properly manage its opioids. According to the article, “Some 16,000 hydrocodone pills were stolen by one or more University of Michigan Health System employees between May 2011 and January 2012.”

The diverted drugs were fentanyl, midazolam, and morphine. The DEA reported that some of the diverted narcotics were “stolen, lost, or could not be accounted for” and the hospital system failed to track the transport of its narcotics from the main hospital’s pharmacy to patients in their hospitals and 15 off-site ambulatory care locations throughout the state. They were also cited for “significant record-keeping violations.” One of the noted mishandlings involved nurses who were stealing vials of fentanyl and refilling them with saline before returning them to the medication storage area. This behavior continued for years without detection.

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This case, particularly because of its record-breaking settlement fee, highlights the need for even large healthcare systems to do more to protect their patients, staff, and communities. The “first, do no harm” commitment to which every medical student makes includes controlling drug inventory. Without proper protocols, oversight, and technology solutions in place, however, improper medication management will lead to drug diversion.

Technology and Drug Diversion

Drug diversion is contributing to the opioid crisis, with healthcare workers in the crosshairs. One report found more than 100,000 healthcare workers abuse prescription drugs every year and 10 percent of them suffer from drug addiction. Because many healthcare workers have daily access to medications, it can be relatively easy for them to steal unopened vials, dilute vials or give patients partial doses and keeping the rest.

Many hospitals and healthcare facilities lack an effective and consistent method for tracking drug diversion. Thankfully, technology is catching up and providing reliable means for improving medication management to reduce the instances of drug diversion.

Medication management begins with developing an operating model that sets the precedence for the secure handling of medications, particularly those with the highest propensity for drug diversion. Opioids are the most commonly diverted drugs and include hydrocodone, oxycodone, hydromorphone, and fentanyl.

One of the best preventative strategies is using point-of-use dispensing cabinets with embedded access control technology. The cabinets are located in the patient’s room, eliminating the need for nurses to retrieve medications from bulk storage at the central pharmacy or medication cabinets in medication rooms. Pharmacy technicians stock the point-of-use cabinets with only the medications and dosages for that particular patient.

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The technology enables leaders to establish the levels of security per medication for a predetermined list of users. Individual locking compartments can only be opened by pre-authorized staff for one patient at a time. The software tracks who opened the cabinet, when the cabinet was opened, which compartments were opened, and when the cabinet was locked. Management can quickly download usage reports to identify trends and potential problems.

Benefits for Hospital and Staff

When hospitals implement the right medication management technology, they greatly reduce their risk of drug diversion. While most nurses do not divert drugs, having systems and tools in place to track medications and staff establish a strong deterrent for those who may consider it. When staff know they and the medications are being monitored, and they only have access to small quantities of medications at a time, they are much less likely to steal or tamper with the drugs.

Further, the point-of-use medication cabinets enable nurses to be more efficient and effective in caring for patients. Instead of walking back and forth to the central pharmacy or on-floor pharmacy medication room to retrieve patient medications, they have the exact medications already stocked in their patients’ rooms. This enables them to deliver faster and better care while reducing the risk of medication errors.

Hospitals, too, benefit from their nurse’s efficiency. With nursing shortages at an all-time high (more than 438,000 new registered nursing positions are projected to be added to the workforce), hospitals are looking for solutions. Even something as simple as a point-of-use medication dispensing cabinet can give nurses more time to care for more patients. Of course, hospitals will still need to balance nurse-to-patient ratios to prevent nursing burnout, but putting the tools nurses need to do their jobs more effectively goes a long way in promoting better job satisfaction.

Beyond nursing, the pharmacy also achieves benefits. They gain more control of the medication inventory with this new operating model. When the risk of nursing losing, stealing, or not finding medication is reduced, the hospital saves money and reduces urgent calls from nurses to refill out-of-stock medications. The point-of-use medication storage enables the pharmacy to reduce their workload, improve inventory accuracy, and reduce the risk of patients receiving the wrong medications.

While all of these benefits directly impact the quality of patient care, optimizing workflows with medication management technology and protocols also reduce the risk for the hospital to experience legal and regulatory compliance issues. The fines can be astronomical and the time spent managing these crises drain precious resources. Damage to hospital reputations cannot be understated as many of the hospitals who are forced to manage the PR nightmare take years to recover the trust of patients, if ever at all. Not every medication management risk can be averted, however, there are plenty of proactive steps hospitals and healthcare facilities can take to safeguard against the most prolific threats.

Where We Go from Here

The opioid crisis can be contained, however, it will take every involved party to own their responsibility in altering the trajectory. The government, doctors, pharmacists, hospitals and patients all have their respective duties in ensuring the epidemic claims fewer lives in the coming years. It won’t be easy.

The opioid crisis is at such levels that in 2017, President Trump declared a national Public Health Emergency and established the President’s Opioid Initiative. His declaration aims to address the factors that fuel the epidemic, such as over-prescribing, illicit drug supplies, and insufficient access to evidence-based treatment, primary prevention, and recovery support services.

Doctors will play a key role. They must work with the pharmacy to determine which medications are truly necessary and at which dose and duration. Many of the surgeries and injuries for which they are prescribed can be equally treated using less addictive and dangerous drugs. For instance, in an article published by Beaumont.org, a member of the Michigan Prescription Drug and Opioid Abuse Commission provided several alternatives to opioids for many medical cases, including nonsteroidal anti-inflammatories, acetaminophen, localized numbing, and a combination of anti-inflammatories, acetaminophen, and tricyclic antidepressants or gabapentinoids.

Further, doctors should educate the patients for which they must prescribe these drugs on the proper use of the opioids and their addictive qualities. Many of the patients who take the prescribed opioids are unaware of how easily they can become addictive if they are used improperly or for a longer period of time than prescribed. The https://www.mayoclinic.org/diseases-conditions/prescription-drug-abuse/in-depth/how-to-use-opioids-safely/art-20360373Mayo Clinic says, “After just five days of prescription opioid use, the likelihood that you’ll develop long-term dependencies on these drugs rises steeply, increasing your risk of eventual addiction and overdose.”

Hospitals will have to do their part as well, investing in modern technology that reduces the risk of drug diversion and increases their ability to support proper medication management. Hospitals must establish strict operating protocols, secure medications, and track access to those medications. A simple lock and key cabinet is not enough. Leveraging technology capabilities, authorization, accessibility, tracking, and reporting is all automated. By removing the manual touches and risk for human error from the equation, automated technology increases efficiencies, productivity, accuracy, and security.

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