A Systematized Approach to Combat Drug Diversion


January 2012 - Vol. 9 No. 1

It has been well publicized in recent news reports that prescription drug abuse is a major and growing problem in the United States. For the first time, deaths from overdoses of prescription opioid pain relievers have exceeded deaths from heroin and cocaine combined.1 Data shows that rates of drug abuse among health care workers are comparable to the general population, and thus remain a significant issue for health care facilities. The major difference between the general public and medical professionals is the accessibility of a large source of controlled substances, leading to illegal removal from the health system for the purposes of self-administration, selling, or supplying to others. To combat this national crisis, a systematic, collaborative process to manage drug diversion is a necessity in every health system.

In an effort to ensure patient safety and reduce the likelihood of drug diversion, Northeast Georgia Medical Center in Gainesville adopted its current drug diversion policy and procedure (P&P) in 2006, and made additional modifications in 2010. Our goals were simple: To ensure patient safety and improve the security of our facility and its employees by preventing the abuse and diversion of controlled substances.

Institute a Diversion Policy and Procedure
Just as local municipalities may not place a traffic light at a dangerous intersection until an accident occurs, some health care facilities may not see the need to adopt an institution-wide, comprehensive drug diversion P&P until a dangerous incident transpires. However, it is important to have a policy in place prior to having a problem, as neglecting to institute a P&P leaves hospitals vulnerable. Pharmacy leaders must be knowledgeable about all suspected diversion cases in their facilities and must be active participants in the collaborative process to detect, confirm, and address diversion.

While fitness-for-duty policies—including drug and alcohol policies—are fairly standard in most organizations, drug diversion policies are not as common. When developing a P&P, involve a multidisciplinary team from all affected departments, including pharmacy, security, human resources, employee health, EAP, and administration. Effective drug diversion policies must define the methods used in the investigation of suspected diversion. In addition, a drug diversion policy should contain the following elements:

  • The definition of drug diversion
  • Fitness-for-duty policy
  • An appropriate chain of contact when diversion is suspected
  • A system that facilitates timely recognition of any diversion of controlled substances, as well as a procedure to quickly identify the individual responsible for diversion
  • Requirement of staff to report suspected drug diversion immediately to his or her department director or manager, as well as a requirement to treat such information as confidential and take all responsible steps to protect the confidentiality of the information and the identity of the individual furnishing information, to the extent allowed by law
  • Chain of command for reporting drug diversion, both within the institution and to the appropriate local and federal authorities, if necessary
  • Involvement of facility security and police, if necessary

Any member of the team should be able to get the group together to discuss an instance of suspected diversion. Our team, nicknamed Code D, is led by the director of pharmacy. It is important to identify and document the responsibilities of each member. As the team is being formed, each participant needs to understand and agree on his or her individual responsibilities, as well as the procedures of the team as a whole. For example, the team members responsible for conducting interviews of suspected diverters, as well as where and when these interviews will typically take place, should be predefined and delineated in the P&P.

Develop Monitoring Methods
Automated reports are an excellent method of using technology to document cases of suspected diversion. As such, automated dispensing cabinets (ADCs) are a common means of securing controlled substances and oftentimes are capable of using software to analyze usage patterns for diversion. Data extraction software is available that works with any manufacturer that analyzes usage and presents anomalies up to 0.5 standard deviations from the mean (see Figure 1). The data extraction software can be used both as a screening tool and as a confirming tool.

In addition, a well-defined process that identifies weekly counts and reviews all discrepancies, PCA and epidural usage, and OR processes should be developed. Additional security measures, such as the placement of cameras in strategic locations, should be considered as well.

Click here to view a larger version of this Table


Interview Process
In many cases the suspicion of drug diversion may only be supported by statistical analysis and circumstantial facts such as observed behaviors and personal life challenges (for signs and symptoms of drug addiction, see Table 1). Although this information is very important to support an internal investigation, there is nothing more concrete than a confession.

Click here to view a larger version of this Figure


When an interview is warranted, a few essential factors must be considered: preservation of evidence, creating an environment where truth barriers are removed, asking questions to determine truth or deception, and balancing employee relations when asking hard questions. The interview should be a complete surprise to the employee and start with a supervisor escorting the employee from their department to the site of the interview. Because the employee will ask where they are going, be honest and state that the pharmacy department needs to speak with them regarding some medication practices. The location of the interview should be someplace unfamiliar to the employee, quiet, and void of distractions. It is vital during this first step that the supervisor escorting the employee go directly to the interview room and not allow for unobserved stops in locker rooms and/or bathrooms. If the employee is in possession of diverted medications, he or she will likely try to get to a private location to discard the evidence.

Upon their arrival at the interview room, the employee should be handed off to one or two interviewers who are unfamiliar to the employee. Experience has shown that it is easier for people to tell the truth to those they do not know than to someone they have a prior relationship with. To preserve transparency in the process, we recommend video recording the interviews, with the employee’s consent, so that what transpires is not misrepresented later. 

Start the interview by introducing the interviewers and asking the employee some general questions about themselves, ie, name, department, and phone number. This is where the analysis of their behaviors will start and the signs of truth and/or deception will present themselves. For example, most people will be nervous during this initial phase of the interview process. You may notice them sitting with their arms and legs crossed in a barrier posture, or sweating and shaking with heavy respiration. A person who is being honest and truthful will show a decrease of these symptoms as the interview progresses. On the other hand, someone who is lying will become more nervous and display continued symptoms over the course of the interview.

Asking specific questions will allow you to gauge how honest the person is willing to be with you. Try to focus on their verbal (speech), nonverbal (body language), and paralinguistic (how fast they answer, is their behavior consistent with their response) behavior. The following questions are commonly asked during the interview process:

  • Why do you think you are being interviewed today?
  • How do you feel about being interviewed on this topic?
  • The reason for the interview is to find out why you are pulling an unusually high volume of narcotics, which to us is an indication of diversion (describe diversion). Are you taking these narcotics for yourself and not giving them to the patients? If you are, it is important that you tell us that now.
  • Can you give us an explanation as to why your usage is significantly higher than others on your floor?
  • Do you have coworkers who can vouch for the rationale behind the high volume of drugs that you are pulling? 
  • Is there any reason why another employee would name you as someone who would divert drugs?
  • When we complete this investigation, and pull all the necessary data and interviews together, how do you feel this investigation will be resolved?
  • Are you taking any prescription medications? Is there any reason that a fitness-for-duty test performed after this meeting would show a scheduled narcotic in your system? 
  • What do you think should happen to an employee who is caught diverting narcotics?
  • Do you think the police should get involved with internal drug diversion in our organization?
  • Do you think that someone found diverting drugs deserves a second chance under any circumstances?

To determine whether someone is being truthful or deceptive requires much more than simply relying on common sense or an understanding of normal and abnormal human behavior. Uncovering deception often takes training and repetition to master. Many companies offer this kind of training for a wide array of industries. To effectively use this interview approach it is highly recommended that an investment be made in training programs for pharmacy and security leaders who are responsible for uncovering diversion.

Follow-up Steps
If the employee confesses to diversion, certain steps must be taken. Have the employee complete a written statement at the conclusion of the interview, detailing the nature and scope of the diversion. Conduct a search of the employee’s belongings as defined by organizational policy, and have the employee escorted to employee health or the ER for a drug screen panel. Inform the employee that he or she is now on administrative leave without pay until the screen returns and the team meets to reviews the case findings.

Different facilities will have various perspectives on the rehiring of employees who have completed a program and can prove they are no longer using and diverting medications. Although some facilities may hire back these employees, Northeast Georgia Medical Center has adopted a zero tolerance policy, meaning that we do not hire these employees back. We regard our commitment to safe patient care our top priority.

Reporting Requirements
Depending on your state’s requirements, reporting to the state licensure board may be required, in addition to both state narcotics agents and local authorities. If there is a substantial loss, the DEA must be notified.3 It is also a requirement to report any diversion to the CEO of the health system.

Conclusion
Drug abuse is a significant problem in the United States. With the comparable rates of addiction among health care workers, the potential of drug diversion occurring in our health systems is a constant issue. A vigilant approach is required to help prevent, monitor for, and investigate drug diversion. The ideal method is multidimensional, and includes explicit policies, detection methods, investigation processes, and an organizational culture of readiness. Without a systematized approach, hospitals are vulnerable to major drug diversion and subsequent public and legal repercussions.

References

  1. Paulozzi LJ, Jones CM, Mack KA, Rudd RA, Div of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC. Morbidity and Mortality Weekly Report. Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999-2008 (November 4, 2011). http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm?s_cid=mm6043a4_w Accessed December 12, 2011.
  2. US Department of Justice, Drug Enforcement Administration, Office of Diversion Control Web site. Drug Addiction in Health Care Professionals. http://www.deadiversion.usdoj.gov/pubs/brochures/drug_hc.htm#how Accessed December 22, 2011.
  3. US Department of Justice, Drug Enforcement Administration, Office of Diversion Control Web site. Theft or Loss of Controlled Substances, DEA Form 106. www.deadiversion.usdoj.gov/21cfr_reports/theft/index.html Accessed December 12, 2011.

Steve Carlson, RPh, MHA is the director of pharmacy services at Northeast Georgia Medical Center (NGMC), Gainesville, Georgia. He received his pharmacy degree from Philadelphia College of Pharmacy and Science (USP) and his masters in health care administration from St. Joseph’s University in Philadelphia.

Andrew F. Corsaro is the director of corporate security and emergency management for NGMC. He joined NGMC in March 2008, after serving for over ten years with the Baltimore City Police Department. Andrew holds a BS in criminal justice from Northeastern University in Boston and is a current law enforcement officer in the state of Georgia, serving as a reserve deputy with Hall County Sheriff’s Office.

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