In terms of availability, access, and cruel temptation, healthcare workers are on the front lines of addiction risk in a national opioid epidemic that has reached epic proportions.

“Today and every day this year, more than 40 Americans will die from a prescription opioid overdose in this country,” CDC Director Tom Frieden, MD, said at a recent press conference. “We know of no other medication that’s routinely used for a nonfatal condition that kills patients so frequently. … Almost all the opioids on the market are just as addictive as heroin.”

According to public health officials, the number of accidental overdose deaths from prescription opioids has nearly quadrupled from 1999 to 2013. More than 29,000 deaths in 2014 were due to opioids. While the CDC tries to rein in opioid pain treatment misuse and overuse in the public health arena, recurrent cases of drug diversion, patient exposures, and outbreaks underscore that addicted healthcare workers are putting themselves and certainly their patients at risk. In an all-too-familiar scenario, a surgical technician who was recently charged with diverting drugs in Colorado had a history of moving from hospital to hospital, prompting several other facilities to advise thousands of patients to get tested for bloodborne pathogens. (See related story in this issue.)

“Travelers and agency workers do tend to be at higher risk,” says Kimberly New, RN, JD, founder of Diversion Specialists in Knoxville, TN. “We know that based on what we see across the country. It’s not that travelers and agency workers are bad — it’s just that people who are intent on diverting get drawn to that type of work because they can hit and run. They can come in and move on.”

Indeed, many of the recent diversion events identified by the CDC have involved “technicians — not doctors and nurses,” says Joseph Perz, PhD, team leader of quality and safety at the CDC’s Division of Healthcare Quality Promotion (DHQP).

“Perhaps there are ways to better evaluate these types of healthcare professions when they are applying for work, and be mindful that people who don’t have direct access to the medications may resort to more dangerous practices to obtain them,” he says. “As with this recent Colorado case, the [2012] case in New Hampshire and in several others people are resorting to swapping a ‘decoy’ syringe for a real syringe of fentanyl.”

DIVERSION INCREASING?

This type of diversion appears to be increasing as hospitals adopt more oversight on drug supplies, meaning in part that something cannot be taken without being replaced.

“I am onsite at hospitals almost every week of the year and I think it is unrecognized and underreported,” New says. “I think that the [overall diversion] incidence is increasing, I really do. Also [increasing is] the incidence of diversion by tampering and substitution. Perhaps one of the reasons why more providers are turning to tampering and substitution is that they know that we have sophisticated analytics and can monitor what is what is taken out of a drug cabinet, so they look for other methods to divert that will remain undetected.”

More than 100 patient infections and nearly 30,000 potentially exposed patients via drug diversion have been reported in U.S. healthcare facilities over the last decade, according to the CDC.1 Most of the infections in these cases involve HCV, but a variety of bacterial infections have also occurred. (See timeline in this issue.) Regardless of subsequent infection, the patient suffers harm when their medication is stolen and then put at further risk by whatever contagion may be in the dummy syringe. Due to a history of drug use, the diverter is often infected with HCV or other bloodborne pathogens, which may contaminate syringes and solutions and lead to an outbreak among patients.

Disturbingly, the reported outbreaks of infections related to drug diversion by healthcare workers represent only a portion of the actual infections occurring. In the absence of an outbreak and subsequent lookback investigations, many patient infections are not likely to be linked to a drug diversion incident.

“I think that is unsettling and it is reasonable to conclude,” Perz says. “An infection like hepatitis C often has mild or no symptoms during the initial phase, so those are not diagnosed and reported and they are not investigated.”

Compounding the problem, hospitals fearing liability in drug diversion incidents may be reluctant to report and prosecute diverters. Typically, diverters have been fired or allowed to resign — which could leave them free to find work in another facility if their history is not detected.

“I think [failure to report] is a big contributor to some of these more devastating patient harm cases,” New says. “Facilities are worried about their reputation, so they don’t report these cases to law enforcement. This is motivated by the fear that there will be negative publicity and regulatory authorities will come in and raise hell. So facilities don’t want to go that route.”

The CDC hopes that by highlighting the threat of drug diversion and the infection risks to patients, healthcare facilities will realize they have a “moral responsibility” to protect patients, Perz says.

“There is never ‘no harm’ in this context,” he says. “If the drug that was intended for the patient did not reach the patient, then they were harmed. But for whatever reason, healthcare facilities — I’m speculating here — [may have] a sense that they don’t have hard evidence, that patients were not harmed in a substantial way or in a way that they can prove, so they kick the can down the road. The easiest course of action may be to fire the person and the healthcare worker may also quit and walk out the door after being identified.”

If diverters are identified they should be removed from the clinical environment, barred access to controlled substances pending further investigation, and tested for bloodborne pathogens, the CDC recommends. The U.S. Drug Enforcement Agency requires healthcare facilities to report theft or loss of a controlled substance within one business day of the incident using DEA Form 106.

“The medical community and public health at large have work to do to educate institutions about their responsibilities for not just reporting but for managing these incidents and assessing potential risks to patients including infection risks,” Perz says. “We have been advocating communication from the health departments to the communicable disease programs if there has been tampering with injectable drugs. We really wish we could move the prevention activities upstream to be less reactive.”

That would require, in part, prosecuting identified diverters or at least making it clear to future employers that a firing was a result of drug diversion. Without proper reporting, diverters may move from facility to facility, continuing to harm patients, New emphasizes.

“Regarding background checks: If cases are reported to law enforcement, and they take some action, that can assist subsequent employers,” she says. “Diversion of any amount of a controlled drug is a felony.”

OUTREACH TO WORKERS

Employee health professionals can play a role in identifying addicted workers and even possibly getting them into treatment before a drug diversion incident results in an outbreak, New says.

“We need to be letting nurses and other healthcare workers know that they are at risk,” she says. “Tell them that there are resources to help them if they find they are getting into trouble. It is so important to seek help and self-report before you cross that line and commit a felony.”

In addition to drug access and availability, there are more subtle occupational issues that may contribute to a diversion incident.

“Certainly, access and availability are really the biggies, but I think there are other things that come into play,” New says. “The fact that I am a nurse and I see the medication being used day in and day out. I see how effective it is and I can become desensitized to the risks associated with it. So I may be more inclined to abuse drugs I find at work — drugs I’m familiar with, I understand, and I consider to be relatively benign substances”

Of course that is profound error in judgement, as the little data available on the subject shows that drug diverters are clearly at risk of fatal overdose. In a study of resident anesthesiologists, 44 (11%) of 384 clinicians with drug addiction to opioids or other substances died of drug-related causes.2 Most of the deaths occurred in residency training, but 14 anesthesiologists died later after suffering a relapse. The researchers found that just under 1% of the 44,612 residents in the study had drug use and addiction problems. The researchers note that there is no rigorous data showing anesthesiologists have more addiction problems than other health worker groups.

“We are seeing an increase in [drug diversion] in nurses who are coming back from medical leave or who have had a workers’ comp claim and had a legitimate prescription,” New says. “Many nurses start diverting after a legitimate prescription. They no longer have their prescription because their injury has passed, but they are coming back to work and they feel they can’t do without the medication. Then they are presented with access to that drug and they divert. That is something that employee health and occupational nurses can look at.”

While there may be opportunities to educate and intervene, there is also the fact that addicts can be very high functioning and have often developed behavior patterns designed to evade and elude oversight.

“As compassionate as it may seem to ‘reach out’ to addicted employees in healthcare, those who have such problems distrust anyone remotely connected with administration out of fear of reprisal, sanctions, and loss of job,” says William G. Buchta, MD, MPH, medical director of the Employee Occupational Health Service at the Mayo Clinic in Rochester, MN. “Someone prone to diversion, which is fortunately rare, is certainly not likely to be one to self-identify. We have found the best solution is to devise systems to disincentivize diversion.”

One such approach is to ban “wasting” of unused controlled medications, requiring that they all be returned to the pharmacy for random testing to detect substitution.

“We have seen a large drop in such cases after this administrative control measure,” he says. “The bigger challenge is with employees who inject themselves or swallow their patients’ medications while documenting administration to the patient. However, I do not advocate random urine drug testing as an effective deterrent as some of the most likely abused drugs are not likely to show up on a screen and the process is both costly and bad PR for the 99.9% of employees who don’t divert.”

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. Warner DO, Berge K, Sun H, et al. Substance use disorder among anesthesiology residents, 1975-2009. JAMA 2013;310(21):2289–96.