By Gary Evans, Medical Writer

While drug diversion experts draw a distinction between the national opioid epidemic and the longstanding problem of narcotics theft by addicted healthcare workers, it’s getting to the point where the lines may be blurring.

The CDC recently estimated1 that the U.S. saw more than 60,000 overdose deaths last year, which nearly doubles the 33,000 the CDC estimated for 2015.2 (For more information, see related story in this issue.)

A community opioid addiction problem of such staggering scale certainly adds another permutation to the hidden epidemic of drug diversion by healthcare workers.

“We need to look at the opioid crisis in this country and realize that healthcare personnel are not invulnerable to this,” says Kimberly New, RN, JD, a drug diversion specialist and executive director of the International Health Facility Diversion Association (IHFDA). “This is something that is growing. We are seeing more and more diversion by very alarming methods, like tampering with medications. The best place to start is to try to prevent it in the first place. I strongly recommend from an employee health standpoint that we inform [healthcare workers] who are coming back from a surgery or medical leave, for which they have been prescribed opioids, that they are at risk.”

It certainly doesn’t help that nurses are among the most often injured professions, a problem aggravated by increasing patient body weight.

“Another thing we are seeing is a sharp increase in the number of veterans that are coming back from combat and self-medicating for PTSD and physical injuries,” New says.

The IHFDA is a fledgling nonprofit that recently held its second annual conference. The group brings together stakeholders in the drug diversion crisis to raise awareness of the longstanding problem and urge hospitals to establish prevention programs.

Employee Health Perspective

Attending the recent IHFDA conference in St. Louis with several of her colleagues was JoAnn Shea, RN, director of employee health and wellness at Tampa (FL) General Hospital.

“People all over the country were there and a lot of them are from hospitals that went through some significant issues,” Shea says. “This is something hospitals are going to really have to take a look at. I think we are really missing the boat on detecting them all. There are machines now that measure [drug dilution]. If you have fentanyl waste, it will tell you if it is concentrated or diluted. If it is diluted, it may not be fentanyl.”

Shea attended the conference with hospital colleagues that represented pharmacy, security, and human resources. The group is forming a drug diversion prevention program at Tampa General in accordance with recommendations issued this year by the American Society of Health-System Pharmacists (ASHP).

“They put out a really good guideline, so many hospitals are going to diversion coordinators now,” she says. “That’s what we put in for this budget year: a drug diversion coordinator.”

The person taking on the role could have an employee health background or other healthcare experiences, New says.

“We see a number of people in this role,” New says. “It needs to be someone who is resilient, has a keen ability to conduct investigations and get to the heart of issues, and that can communicate with people in all different levels of the organization. They have to have the ability, the time, and the resources to address this issue.”

ASHP recommends that healthcare facilities create a diversion program that ensures training and competency of all healthcare workers authorized to handle controlled substances. In addition to a coordinator, the diversion program should include an interdisciplinary committee that reports at least quarterly to the hospital administration, the ASHP recommends.

“Diversion driven by addiction puts patients at risk of harm, including inadequate relief of pain, inaccurate documentation of their care in the medical record, exposure to infectious diseases from contaminated needles and drugs, and impaired healthcare worker performance,” according to ASHP.1 “In addition to patient harm, there are regulatory and legal risks to the organization, including fraudulent billing and liability for resulting damages, and decreased community confidence in the healthcare system.”

An initial step at Tampa General will be to conduct a gap analysis that will include assessing current practices and drug oversight, Shea says.

“I went to leadership and said, ‘we don’t know what we don’t know,’” she says. “If we don’t do a gap analysis we don’t know where our weaknesses are, where people could actually go in and steal — whether it’s receiving, ordering, or retail pharmacy.”

Though the issue appears to be finally gaining momentum, many hospitals currently do not have diversion prevention programs, New says.

“I would say less than 50% have proactive diversion programs, but I do think the number is increasing because we have had some unfortunate, high-profile cases,” New says. “Every hospital needs a proactive drug diversion program. Many hospitals don’t see this as an ongoing threat, so they treat these cases as isolated events. They are not equipped to deal with them appropriately if they are treating them as isolated.”

How common is healthcare drug diversion? Unfortunately, experts say that if hospitals look for it, they are likely to find it.

Far from being a rare phenomenon, healthcare drug diversion is rampant and largely undetected, says John Burke, president of the IHFDA. Burke began investigating incidents of drug diversion in healthcare as a Cincinnati police officer in the 1990s. A team of investigators began looking into the problem and found healthcare workers were frequently stealing opioids.

“We started that in 1990 and I was there for nine years, and at that time we averaged an arrest a week,” Burke says. “That was just the city of Cincinnati — at that time, a population of some 400,000.”

Since he is often asked to estimate the size of the healthcare drug diversion problem in the U.S., Burke crunched the Cincinnati arrest data and extrapolated it nationally.

“It comes out to about 102 arrests a day in the country,” he says. “And you have to understand, we didn’t catch everybody, either. We weren’t 100% successful, but it kind of gives you a little bit of a sense of what the problem is in the United States. Cincinnati is not a hotbed for hospital diversions — it is as typical as any other community in the country.”

Currently, healthcare diverters primarily are caught when their activities trigger an outbreak of bloodborne infections, such as hepatitis C virus (HCV). Thus, patients may suffer a lifelong injury beyond the initial insult of stolen opioid pain medication.

Consider the case of a single mother of a one-year-old child who underwent emergency surgery for kidney stone complications. Upon discharge, she progressively succumbed to a jaundice-inducing illness. After weeks and months of turmoil and unanswered questions, she found out she was infected with HCV by a surgical tech who was stealing fentanyl and replacing it with saline. (For more information, see related story in this issue.)

While discovering the source of her misery was initially relieving, that feeling gave way to anger for patient Lauren Lollini when she realized she was not the victim of an isolated incident. She discovered that drug diversion by healthcare workers is a common problem, in part because diverters — including the one who infected her — may be fired or leave a job and have no record to warn the next hiring facility.

“When I dug deeper, I thought, 'How is an employee able to steal controlled substances?'” she tells Hospital Employee Health. “Then I got angry. I realized it wasn’t about one rogue employee, about her having an addiction and needing the drug — it was about a broken hospital system.”

Indeed, HCV and other bloodborne infections may have few symptoms initially, meaning those patients will be lost to follow-up and unlikely to be linked to receiving healthcare as a risk factor. Thus, the reported outbreaks of drug diversion-related infections by healthcare workers represent only a portion of the actual infections.

While state laws vary on this issue, Ohio laws favored Burke’s police enforcement and explain, in part, the success of his program.

“In Ohio, not only do you have the [federal] DEA regs, but you also have the Ohio Board of Pharmacy, which says you have to report the loss of any prescription drug — not just a controlled substance,” he says. “Also, it is a crime in Ohio to not report a felony. All of these [diversion] offenses are felonies.”

Diversion may come to light as a cluster of infections are identified and reported by public health officials, but the recurrent problem is that hospitals will too often let diverters leave without reporting them.

“Those [infected patients] ultimately get reported because they have to,” Burke says. “In the average healthcare diversion issue, unfortunately, the [diverter] is either fired or quits and goes on to another facility. Different states have differing requirements, but these are crimes that some hospitals have decided they are just not going to report. I’m sure they are concerned about the publicity that would follow.”

New argues for legislation mandating the reporting of suspected diversion.

“If you terminate somebody under suspicion for diversion, there should be mandatory reporting [of that] so subsequent institutions can at least have some idea,” she says. “There should be reporting to police authorities so it can become public record.”

Having looked at the issue for decades, Burke says the common misperception is that hospitals reporting diverters are facilities to be avoided.

“It’s exactly the opposite. These are people who are trying to do the right thing,” he says. “That’s where you want to be a patient. It’s something I have been battling since the 1990s — trying to get proper reporting.”

In addition to protecting downstream patients, the other reason to report is to get the addicted healthcare worker into treatment, he says.

“When you fire them or allow them to leave and don’t follow a process to get treatment, essentially their addiction gets worse,” Burke says. “More patients are in jeopardy and there is more liability for the healthcare facilities. It’s like a snowball that rolls down hill and gets worse and worse if you don’t take action.”

The message to diverters is to seek help before their addiction turns into patient harm and criminal proceedings.

“They need help. We are not looking to put these people in the penitentiary,” Burke says. “They have an addiction issue, but it is still against the law. Often times, the court system will work through mandatory treatment directives. I have seen that work tremendously, but it does not work when you fire them or they quit and go on to another facility. That is a recipe for disaster.”

Having seen both sides of the street, so to speak, Burke says healthcare diversion predates the current opioid epidemic and remains, in some ways, distinctly different.

“[Healthcare workers] have the drugs there available to them; they are diverting in the healthcare facility now,” he says. “I think the problem in the healthcare facilities has always been there. We don’t know if it has gotten worse, but there is a little more awareness.”

REFERENCES

1. CDC. O’Donnell JK, Halpin J, Mattson CL, et al. Deaths Involving Fentanyl, Fentanyl Analogs, and U-47700 — 10 States, July-December 2016. MMWR October 27, 2017. Available at: http://bit.ly/2idBfPT. Accessed Oct. 30, 2017.

2. CDC. Trends in Deaths Involving Heroin and Synthetic Opioids Excluding Methadone, and Law Enforcement Drug Product Reports, by Census Region — United States, 2006–2015. MMWR 2017;66(34):897-908.

3. Brummond PW, Chen DF, Churchill WW, et al. American Society of Health-System Pharmacists (ASHP). ASHP Guidelines on Preventing Diversion of Controlled Substances. American Journal of Health-System Pharmacy 2017; DOI: https://doi.org/10.2146/ajhp160919. Accessed Oct. 30, 2017.