Removing the mask of drug diversion

June 26, 2019
Healthcare professionals currently suffer from substance use disorder at a significantly higher rate than that of the general public.

In the August 2019 issue of Healthcare Purchasing News, experts discussed the many things that can go wrong in the operating room human error, equipment malfunction, poor process as well the many solutions readily available to ensure those mistakes don't happen again.

But there’s another safety issue that doesn’t get nearly the amount of attention or resolve, yet is as unsafe and scary as any other OR hazard – nurses and surgeons with substance use disorders (SUDs), including those who engage in drug diversion (stealing controlled substances reserved for patients). It’s more common than people might think, and as the nation battles the deadliest opioid crisis on record, hospital drug diversion is also beginning to receive the meaningful attention it deserves.

“Most of what we know about hospital drug diversion is anecdotal, and much of the work that has been done is quite dated,” said Ranjeet Banerjee, Worldwide President, Medication Management Solutions, BD. “In fact, when BD hosted a Diversion Summit in 2018 with pharmacy, nursing and anesthesiology executives from across the U.S., they told us they were concerned with the lack of data on diversion and said research was needed to bring attention to the issue.” Rodrigo Garcia, APN-BC, MSN, CRNA, MBA, is CEO of Parkdale Center for Professionals and Parkdale Solutions, a recovery organization with programs tailored specifically to healthcare professionals with SUDs. He added, “Diversion is a significant problem anywhere the providers have unique access to these powerful medications, they have increased knowledge and expertise on how to use the medications, and their occupational risk factors include high levels of stress, sleep deprivation, anxiety, and isolation,” said Garcia. “By those standards, nearly every healthcare professional is at risk. In fact, healthcare professionals currently suffer from substance use disorder at a significantly higher rate (15 percent) than that of the general public (10 percent) for those exact reasons.”

The BD Institute for Medication Management Excellence commissioned an independent national survey of more than 650 hospital executives and providers to better understand hospital diversion perceptions, behaviors and solutions. The resulting report, Health Care’s Hidden Epidemic: A Call to Action on Hospital Drug Diversion, released in early June, reveals some thought-provoking beliefs among its respondents.

“Four out of five providers who were surveyed are concerned about drug diversion in U.S hospitals, but only 20 percent believe diversion is cause for concern in their own facility,” said Banerjee. “Despite this, half of respondents say they have observed suspicious activity in their hospitals that may have been evidence of diversion.”

Tricky, delicate situation 

“Diversion can occur many different ways, hence the difficulty in catching it,” Garcia added. “It can be in the form of falsifying charts and diverting it from the patient; it can occur when ‘extra’ is taken out, so the patient gets their does and the provider gets the extra. Oftentimes partial doses are ordered, and the extra medication should be properly wasted. However, this is an ideal opportunity for diversion of the waste to occur. Tampering and substituting out medication has also been known to occur. A very important point to consider is that the impaired provider is always ‘one step ahead.’ There is always going to be a new diversion technique, a new medication of abuse, and a new way to circumvent the revised policy.”

Diversion is also difficult to address because of a lack of uniformity in reporting, not identifying cases early and lack of effective, unvarying intervention protocols. As for those who are secretly struggling with a SUD, he says very few – between four and five percent – ever self-report the problem even when they want help, which isn’t surprising since the stigma of addiction is pervasive in this country. To make matters worse, someone struggling with addiction and feeding it with drugs that are meant for patients is likely to be stigmatized on a grander scale.

Garcia says opiates have always been the No.1 drug that hospital workers divert, followed by benzodiazepines, but now it seems a few others are gaining popularity. “As diversion identifying techniques improve and drug testing becomes more specific, increases of non-controlled substances like propofol and ketamine and are on the sharp rise. They are difficult to track, difficult to test for, and with the small margin of error with these medications, increasing accidental overdoses are expected to increase as well,” Garcia warned. “It is also important to keep in mind that ‘impairment’ takes many forms. The surgeon need not be ‘shooting up’ before a case to be impaired nor does a nurse need to ingest medications while on shift to be impaired.

"Impairment, secondary to substance use disorder, presents itself in the provider that is going through withdraw and not able to render safe care," he continued. "It shows up as the provider’s preoccupation with how to get the next fix so that the debilitating withdrawal symptoms might subside, distracting them from providing quality care. Impairment is evident in the hungover provider who was up late and not well rested for the surgery case or the critical ICU patient that awaits them. Prevention, education, and early identification are the optimal formula for getting a hold of the impaired provider, otherwise they will usually be discovered when the actions and or errors can no longer be ignored.”

After the BD Institute for Medication Management Excellence reviewed the results of its survey, Banerjee said the organization come up with some recommendations for mitigating drug diversion. They include:

Data and technology. Healthcare facilities need more accurate data and reporting technology to identify suspected diverters without generating false positives. Specifically, 59 percent of healthcare executives want more accurate data to reduce false positives and 54 percent would like artificial intelligence (AI) or machine learning technologies and advanced analytics.

Education and training. Formal training, diversion-focused materials, team meetings, and lifelong learning approaches can improve controlled substances handling and documentation. Only 30 percent of respondents reported receiving mandatory diversion training at their facility.

Staffing and enforcement. Most survey respondents reported their hospitals had between one and five staffers focused on diversion oversight, monitoring and detection, even in large hospitals with more than 450 beds. Additional staff could be a sound investment in quality and safety, to help improve surveillance and detection.

Culture of support and open communication. Hospitals also have an opportunity to offer and encourage frontline-staff to engage with the programs that provide support and rehabilitation for diverters. Providing an obvious path for people to self-report could bring more forward to get the help they need.

“Hospital executives and providers said they believe that, if given the appropriate resources, diversion can be significantly reduced,” Banerjee noted. “Ultimately, we hope this report sparks a national conversation, spurs much-needed research, and leads hospitals and health systems to adopt comprehensive diversion programs. A relevant analogy is medication errors, which were a significant problem in U.S. hospitals but largely under-discussed until 20 years ago, when new research and resulting data dramatically reduced the problem. Rather than place blame on individuals, a new approach was adopted by hospitals that identified and addressed medication error system faults. We believe this model could offer a way forward against drug diversion, as well.”

As for medication and the multitude of other errors that occur in the surgical environment, until the data arrives, nobody knows for sure just how many of those mistakes may have been made by individuals secretly struggling with a SUD. 

About the Author

Valerie J. Dimond | Managing Editor

Valerie J. Dimond was previously Managing Editor of Healthcare Purchasing News.