Is an employee at your facility diverting opioids or other drugs for personal use? If so, not only are they risking their own life, they are putting patients at risk of suffering in the absence of pain medication and outbreaks due to contaminated medications.

Somewhat surprisingly, drug-diverting health care workers are not easy to spot by outward mannerisms, as most can appear perfectly collected and professional even under the influence of opioids, says Kim New, RN, JD, an independent drug diversion consultant in Knoxville, TN.

“When I work with institutions my first question is how many diversions have you uncovered in the last year and what method did you use,” she says. “I feel very uncomfortable when I hear that hospitals are only picking up diversion through reports of behavioral issues. The reason for that is that behavioral manifestations are typically a late sign. Usually these folks are very high achievers. They are able to do a number of things and they are very well respected. They are top performers and continue to be that way even when they are diverting and using large amounts of opioids. So we need to be able to have a mechanism to pick up diversion before there are behavioral manifestations.”

Drug diversion typically involves theft of an injectable opioid drug intended for a patient. As addicted health care workers try to cover their tracks by replacing the targeted drug with saline, for example, medications can become contaminated and infect subsequent patients. In other cases, workers already infected with hepatitis C virus pilfer drugs from vials and syringes, transmitting the virus to unsuspecting patients through contaminated equipment and solutions. It is particularly shocking to see how many patients can be endangered by a single health care worker. Over the past decade, outbreak investigations have documented more than 100 infections and nearly 30,000 potentially exposed patients stemming from drug diversion in U.S. health care facilities, a Centers for Disease Control and Prevention study reveals.1

As disturbing as those numbers are, it should be noted that while protecting patients is paramount, there is an employee health issue: the addicted health care worker. For example, nurses emphasize the ethical obligation to try to get their addicted colleagues into treatment: “Drug diversion is a symptom of the disease of addiction …a treatable disease.”2 Encouraging health care workers with an addiction problem to seek treatment may be one of the best ways to save a caregiver’s career before the disaster of an outbreak — the event that typically reveals the diverter.

To catch a thief

Many facilities have automated dispensing cabinets with sophisticated data analytics programs, which will highlight suspicious transactions that occur and will also do statistical comparisons of individuals on a particular unit against each other based on dose per transaction day, New explains.

“That’s where you really want to be finding signs of diversion and doing focused auditing based on those analytics,” New says. “Because you will find diverters much more quickly using data analytics than you will just waiting for someone to report something unusual.”

A case in point was a new graduate in nursing, beginning her first days of unsupervised care at the University of Tennessee in Knoxville, where New previously ran a drug diversion program.

“On that first night that she worked independently she started diverting,” New said. “Three days after she started diverting, I was able to pick it up based on some statistical comparisons I was doing on a regular basis. She went from being totally normal among her peers to being an extreme outlier in a matter of days.”

The nurse was simply taking out duplicate doses, giving one to the patient and taking one herself. In this case, the stress of taking on the responsibility of being a nurse likely triggered the drug seeking behavior, New says.

“I’ve caught a number of new grads and there are different things that may lead to this type of activity,” she says. “Some of them have told me that they [previously] had legitimate prescriptions for opioids that they were simply not able to get off of — when the prescription ran out they started diverting. But of course working in nursing, particularly as a new graduate, can be extremely stressful. Diversion may occur at that point because they are trying to cope with the stresses of their job.”

While hospital oversight is one issue, regulations and even the threat of criminal charges may not be enough to deter a health care worker who is already ready to risk their job and livelihood by stealing drugs, New says. Nor are diverters like recreational drug users who may only indulge themselves occasionally, she adds.

“In my experience in talking to a number of diverters — and I’ve spoken to many — what they say is once they cross the line and divert there is no going back,” New says.

“I have yet to speak to anyone that told me it was just occasional,” she says. “This is a situation where someone knows that they are risking the loss of their job, the loss of their license, potentially the loss of custody rights to children and the deterioration of their marriage. This is not something that folks engage in casually.”

New finds that diverters are typically nurses, which is probably because “they are the number one health care provider and they have regular access to controlled medications,” she says.

References

  1. Schaefer, M.K., Perz, J.F. Outbreaks of infections associated with drug diversion by US health care personnel. Mayo Clin Proc 2014;89: 878–887
  2. Tanga HY. Nurse Drug Diversion and Nursing Leader’s Responsibilities: Legal, Regulatory, Ethical, Humanistic, and Practical Considerations. JONA’s Healthcare Law, Ethics, and Regulation 2011;13:13-16.