Diversion Is Occurring in Your Organization.
Drug diversion is a universal problem that occurs regularly in hospitals throughout the country. If you think diversion is not a concern in your organization, you are simply not looking hard enough.
In 2012, it was estimated that 2.1 million Americans suffered from prescription opioid abuse with an additional 467,000 addicted to its illicit cousin, heroin. Health care professionals are not immune to this problem; an estimated 10% to 20% of nurses have substance abuse problems,2,3 and they tend to abuse prescription drugs rather than street drugs.4 Although health care professions are among the most rewarding careers, they can also be incredibly demanding. Nurses who abuse drugs often cite the nature of their work as a component contributing to their addiction; for example, stress, access to controlled substances, a belief that medications are safe, caregiver burnout, and the belief that their training and knowledge of controlled substances will protect them from addiction often are described as contributing to drug abuse among nurses.
Anyone can become a diverter, and diversion puts patients, their families, physicians, pharmacists, and nurses at risk. Although it is easy to understand why health care professionals are reluctant to believe that their coworkers could divert medications, this does not mean it is not occurring. Believing that diversion could never happen here is a dangerous misconception.
Be Aware of the Two Faces of Diversion.
Diversion by a health care professional for personal use is a serious situation that has ruined countless lives. Years of effort to create a career are knowingly risked the moment the choice to divert is made. Individuals who divert narcotics for personal use will go to great lengths to hide their secret and can be extremely clever at remaining undetected. When suspected diverters are asked to take a drug test, many quit immediately under the guise of being offended at the suggestion that they are diverting. Likewise, these individuals will not hesitate to quickly relocate so that their behaviors can continue if they are at risk of being discovered. Reporting drug test refusals to the state board is warranted, provided the hospital’s HR department approves.
Although diversion for personal use is more common, diversion for resale also occurs. Cases of diversion for distribution tend to occur when life circumstances change: after a divorce, during a chronic illness in the family, or in the event of financial problems. These challenges can cause otherwise stalwart professionals to lose perspective and then justify to themselves that it is acceptable to steal narcotics and use them for personal reasons, be that selling them on the street for monetary gain or medicating a loved one or friend.
Recognize the Warning Signs.
Diverters will seek out opportunities to administer narcotics, so be aware of individuals who administer a significantly greater number of narcotics compared with their peers in the same area. These administrations will most likely occur near the beginning or ending of a shift, as it is easier for diverters to hide extra doses in their dispensing profiles at these times. Moreover, diverters are creatures of habit, and rely on organized patterns to keep their master plan intact; be sure to investigate suspicious patterns to determine whether they are linked to a plan to divert. Compare medication administrations with patient pain scale measurements; these should correspond with other shifts and similar patient conditions. For example, does one nurse document the administration of narcotics despite a patient reporting a low pain score, when other nurses document administering a non-narcotic in similar circumstances?
Invest in Diversion-Detection Software.
The only consistently effective means of identifying patterns of possible diversion in automated dispensing cabinet (ADC) transactions is the employment of diversion-detection software. Most ADC manufacturers provide access to such programs, and purchasing them is well worth the investment. Without software, the sheer volume of data that must be evaluated via a manual sort in order to identify patterns and trends is practically impossible on a large scale.
When selecting diversion-detection software, look for software packages that facilitate robust data manipulation—for example, the ability to compare medication use by peer groups. Drug surveillance packages should be used regularly, and reviewing reports to identify outliers must be a multidisciplinary pursuit that includes pharmacy, nursing, and the human resources department. Scheduling monthly diversion meetings with the multidisciplinary group to discuss ADC data and identify trends is critical to an effective diversion-detection program. The Drug Enforcement Agency (DEA) and other government agencies expect that this practice will be maintained over time. As such, this practice must be afforded the same consideration as any Joint Commission standard. Moreover, policies and procedures should be in place to ensure uniform interpretation of data, hierarchies of investigation, and clearly define the steps to be taken once diversion is confirmed.
Diversion Prevention Is Pharmacy’s Responsibility.
The DEA has imposed enormous financial penalties on organizations that fail to protect the public trust by not implementing effective documentation practices and prudent diversion-surveillance processes. For example, in 2013 CVS pharmacies were fined $11 million for poor recordkeeping practices related to narcotics, and multiple hospital pharmacies also have had financial penalties levied for having inadequate diversion-detection programs (see the DEA Web site for instances of diversion and the resultant financial penalties, available at: www.dea.gov/pr/top-story/Prescription.shtml.)
Beyond the threat of penalties is the even more important ethical mandate to prevent diversion. The highest calling of any health care professional is to protect the public trust. For pharmacists, this means serving as the last line of defense between an institution’s narcotic inventory and the collateral damage those medications can cause when diverted. As the medication experts, preventing and addressing diversion is pharmacy’s responsibility, and thus pharmacy must ensure a robust diversion-prevention plan is in place. Fortunately, a variety of tools and expertise are available to assist in this endeavor and protect health care professionals and the communities we care for (see SIDEBAR for recent PP&P articles discussing diversion-related topics).
Moreover, continued collaboration between institutions and government agencies is vital and must continue to evolve, as law enforcement and health care seek to stem the epidemic of narcotic diversion and abuse. Additional guidance from the DEA and law enforcement on how organizations should optimize their diversion-prevention efforts would be especially useful.
L. David Harlow III, BS, PharmD, is the assistant vice president for professional services, clinical laboratory, clinical imaging, clinical pharmacy, and disease management at Martin Health System in Stuart, Florida. He received a BS in pharmacy at VCU/Medical College of Virginia in 1992 and a PharmD at the University of Florida in 2012. Dave is a national speaker on the importance of pharmacy on health care reform and population health.
Recent PP&P Diversion Articles
Resources for Standardizing Diversion Management
Avoid Diversion Practices that Prompt DEA Investigations
Preventing Diversion in the ED
Detecting and Responding to Drug Diversion
Develop a Drug Diversion Prevention Program
Controlling Diversion Risk
Addressing Substance Abuse in the Pharmacy
Four Case Studies on Diversion Prevention
The Legal Ramifications of Diversion Prevention