By Gary Evans, Medical Writer
The national shortage of opioid medications is contributing to drug diversion incidents by healthcare workers, as scarcity leads to hoarding of vials, and new and unfamiliar products make tampering less detectable, said Kimberly New, JD, BSN, RN, executive director of the International Health Facility Diversion Association.
“Be aware that the opioid shortage may be changing the [diversion] landscape,” she said recently in Minneapolis at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC).
Drug theft by addicted healthcare workers has given rise to recurrent outbreaks of hepatitis and resulted in tens of thousands of patients being advised to seek testing for bloodborne pathogens.
“The diverter will find a syringe that is prefilled with fentanyl and inject themselves,” said Jan Davidson, MSN, RN, CNOR, CASC, director of the Ambulatory Surgery Division of the Association of periOperative Registered Nurses (AORN). “Then they fill up the syringe again — often just with tap water or saline — and put it back for patient use.”
Diversion incidents have compounded the longstanding problem of unsafe injection practices by clinicians who should know better, she told APIC attendees. Data presented by Davidson showed unsafe practices, such as reusing needles, are still shockingly common.
While such practices may be the result of some combination of ignorance and apathy, workers involved in unsafe practices are typically not trying to steal drugs. The addicted healthcare worker, in contrast, may divert drugs and contaminate syringes and needles until an outbreak among patients reveals the behavior.
An Epidemic and a Shortage
Meanwhile, the national opioid epidemic has resulted in public health and regulatory actions that have reduced the availability of the drugs.
For example, hydrocodone has been reclassified as a Schedule II opioid, and many states have tightened requirements for physician review of prescription drug monitoring programs. As a result, shortages have been reported of common opioids such as morphine, hydromorphone, and fentanyl.
At the APIC conference, New described a similar situation, with the added twist that the shortage could actually contribute to more drug diversion by healthcare workers.
“Many facilities are having a lot of trouble now getting the opioids that they need,” New said. “One facility I worked with in Florida said we will be out of hydromorphone in the next two months if something doesn’t change. Many facilities have gone now from a 2 mm morphine syringe to a 10 mm.”
That can raise the temptation to preserve drugs that would normally be wasted, creating pockets of opioids for drug diverters.
“Multidosing — we are seeing people holding on to stuff as they conserve,” New said.
“People delay drug wasting. They try to hold on to it just in case something comes up and they may need to use a little more. People are carrying around opioids for extended periods of time.”
While this is being done to ensure pain medication is available for patients, these breaks in normal practice may be a temptation to divert drugs.
“At one facility I worked with, the nurses are required to walk down to the pharmacy to get a morphine syringe, and then they carry it back up,” New said. “That is a lot of time to be unsupervised with an injectable. A lot of things could happen in that time.”
As various manufacturers try to meet the opioid demand, new products are coming into clinical settings, she added. Healthcare workers may be unfamiliar with the tamper protections, which were actually removed by a nurse in one facility New investigated.
“A new syringe from a new manufacturer was given to a particular unit because they couldn’t get them from their regular manufacturer,” she said.
The new syringes had a tamper-evident feature, but nobody knew about it beforehand because they had not worked with the product.
“A charge nurse made sure she was right there when they were stocking it, and she pulled the tamper-evident feature off of every one of them,” New said.
Despite all the publicity drug diversion has received with high-profile arrests and outbreaks in recent years, it too often remains the unspoken elephant in the room at many facilities, she said. Having looked for diversion and consistently found it for years in all manner of settings, New still is often told that it is not a priority because the organization has never had any incidents.
“That couldn’t be further from the truth,” New said. “If you have controlled substances in your facility — it doesn’t matter where you are or whether it is an outpatient or inpatient setting — you will have drug diversion. It is a fact.”
The flagrant unsafe injection practices are perhaps more shocking than the theft of drugs by addicted clinicians. For example, in a 2017 study, 12% of physicians and 3% of nurses indicated reuse of syringes on more than one patient occurs in their workplace. “Nearly 5% of physicians indicated this practice usually or always occurs,” the researchers found.1
A survey of work practices by the Accreditation Association for Ambulatory Health Care (AAAHC) was similarly disturbing.
“It is mind-boggling to me that people would actually reuse a syringe and a needle when the cost is minimal to use a new one,” said Davidson, who is an AAAHC surveyor. Indeed, consider that public health and infection control groups have been emphasizing for years that needles and syringes are single-use devices and should never be reused on different patients. These often are underground outbreaks, which may go undetected unless a health department becomes aware of cases of, for example, hepatitis C infections in people with no risk factors.
Typically, these clusters are traced back to reuse of a needle after medication was administered to a hepatitis C virus (HCV) patient. Infected blood can aspirate into syringes and multidose vials, putting patients downstream at risk of cross-transmission.
“Between 1998 and 2014, more than 700 patients contracted hepatitis B virus or HCV, or were infected with bacterial pathogens due to unsafe injection practices,” Davidson said. “In an 11-year period between 2001 and 2012, 150,000 patients received notifications with recommendations that they undergo blood testing because of an exposure to a pathogen through unsafe injection practices.”
In 2017, the AAAHC conducted a safe injection practices study over a six-month period. Data were collected from 20 primary care organizations and 90 ambulatory surgery centers. Respondents reported compliance with national guidelines on safe injection practices, medication storage and preparation, and disposal of single-use medications.2
“Each organization voluntarily submitted about 3,300 routine uncomplicated injections,” she said. “So, any nonroutine or complex cases were excluded from their study.”
Of the 90 ambulatory surgery centers and office-based surgery organizations in the study, just over three-quarters reported that when withdrawing medication from a single- or multiuse vial, all three of these recommended measures were used:
- disinfect the rubber septum of the vial using 70% alcohol;
- use a new, sterile needle;
- use a new, sterile syringe.
In addition, the survey included 20 primary care facilities that scored higher, with 87% of respondents saying they performed all three of the measures.
“Most of the complaints and issues were failure to clean off the rubber septum prior to withdrawing the medication, and failure to clean off the hub of the IV tubing prior to injecting,” Davidson said. “The biggest one, I don’t know how many of you have an OR background, but anesthesiologists love to carry around in their pocket prefilled syringes without a label. That was probably one of the biggest ‘a-ha’ moments for us.”
While Davidson emphasized risk assessments and education, an infection preventionist in the audience said the longstanding problem speaks more specifically to the values and work culture of anesthesiologists.
“Most of the outbreaks really go back to anesthesia, and we talk about education,” said Jeanne Pfeiffer, DNP, MPH, RN, CIC, FAPIC, FAAN, a clinical professor in the University of Minnesota School of Nursing. “Education is only 50% effective in changing behavior.”
Saying she first noticed anesthesiologists predosing syringes — only some of which were labeled — when she became an IP in 1979, Pfeiffer said the problem needs to be addressed in a root cause analysis.
“Education is not going to change this,” she said in the discussion period after Davidson’s talk. “It is a value system in anesthesia that we have to get to. I don’t know if anybody has the answer to this.”
Davidson concurred, saying, “I don’t mean to throw anesthesia under the bus, but they really are the primary problem. It’s a little better now with the [dispensing machines] in the rooms, but they still like to prefill a syringe and carry it around it their pocket.”
“That’s not acceptable,” Pfeiffer answered. “We wouldn’t let anybody else stay in practice who did that.”
It has to be addressed at the peer review level, Davidson said.
“Two weeks ago, I did a survey in Syracuse, NY, and questioned an anesthesiologist who had a pocket full of fentanyl,” she said. “His response was, ‘Who are you to tell me how I can practice?’ So, they get a deficiency, but …”
Pfeiffer said anesthesia has to take on this issue at a professional level. Attempts to get a comment on this issue from the American Society of Anesthesiologists (ASA) were not successful as this story was filed.
However, the ASA guidelines for safe injection practices clearly state, “Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae, and syringes are sterile, single-use items. Do not reuse for another patient or to reaccess a medication or solution.”3
- Kossover-Smith RA, Coutts K, Hatfield KM, et al. One needle, one syringe, only one time? A survey of physician and nurse knowledge, attitudes, and practices around injection safety. Am J Infect Control. 2017;45(9):1018-23.
- AAAHC. Study Finds Compliance Concerns Remain with Safe Injection Practices. Oct. 18, 2017.
- ASA. Committee on Occupational Health Task Force on Infection Control. Recommendations for Infection Control for the Practice of Anesthesiology (Third Edition).