Ten thousand pain pills. That is what authorities estimated were once contained in the stacks of blister packs found at the residence of a 33-year-old nurse recently arrested in Spring Hill, FL.

The nurse is charged with diverting opioids such as hydrocodone, morphine, and hydromorphone from a health and rehabilitation center where she worked. She reported “battling an extensive drug addiction for many years, after suffering an injury,” the Hernando County Sheriff’s office said in statement.1

It was not clear if the injury was occupational, but nurses in all types of healthcare settings certainly run that risk. Nurses face a confluence of risk factors for addiction, including long hours, risk of injury, and access to powerful medications, says Indra Cidambi, MD, an addiction specialist and medical director for Center for Network Therapy treatment centers in Middlesex, NJ.

“Nurses are hands-on, and it could be that lifting a patient could cause them to have a herniated disc or some kind of other injury,” she says. Minor injuries can become aggravated, as nurses may not have time off due to lack of coverage by other staff, and must adhere to a schedule that requires long hours, she says.

“They may just pull a muscle, but they have to go back to work and deliver patient care,” she says. “It becomes a chronic issue. They are working with slight pain, and eventually it becomes a chronic injury. They end up taking pain medication.”

Eventually, if their primary care provider will no longer prescribe opioids — which is becoming more likely under stricter guidelines — nurses may be tempted to divert.

“There is an assumption that nurses wouldn’t have drug problems and commit diversion, but the literature shows that their problems with addiction are the same as the general population — about 10%,” says Linda Good, PhD, RN, COHN-S, manager of occupational health services at Scripps Health in La Jolla, CA. “Nurses have opportunities to self-medicate — they are in contact with pharmaceutical-grade drugs on a frequent basis.”

Once the downward spiral of addiction starts, nurses and other healthcare workers may become overconfident in their ability to handle opioids, notes Kimberly New, JD, BSN, RN, executive director of the International Health Facility Diversion Association.

Nurses and other clinicians can become “desensitized” to the danger of the drugs, she said recently in Minneapolis at the annual conference of the Association for Professionals in Infection Control and Epidemiology.

“I see a lot of nurses who are actually diverting an opioid and something like naloxone — a rescue drug,” she said. “They feel they are so in control that they can inject themselves with the opioid and then rescue themselves.”

They are not always successful, as some diversion investigations begin with the overdose death of a healthcare worker, she added. Another impact beyond patients is that addicted healthcare workers are driving.

“These people come to work impaired and leave impaired,” New said. “I’m aware of one case in Florida where an entire family was killed by an impaired provider driving home.”

Threat to Patients

Of course, patients are the primary risk group. Drug diversion by addicted healthcare workers has resulted in recurrent outbreaks of hepatitis and resulted in tens of thousands of patients being advised to seek testing for bloodborne pathogens. For example, a hospital in Puyallup, WA, recently contacted some 2,800 patients and advised them to be tested for hepatitis C virus (HCV).

“We believe that a healthcare worker was taking part of doses of pain medications that were meant to be given to patients,” the hospital said in a statement on its website.2

The hospital said that six patients tested positive for HCV that was genetically matched to two initial cases that triggered the investigation. A nurse was initially arrested but was released, and the case remains under investigation.

Too often in these cases a fired healthcare worker may end up in another facility, as healthcare employers fearing negative publicity may simply terminate the worker rather than reporting him or her to health officials.

Because of these continuing incidents and outbreaks, many hospitals are setting up drug diversion programs to detect and prevent theft of narcotics. “You need to make sure employees are not under the influence of anything that could jeopardize themselves and the patients,” Cidambi says.

It is critical to develop a proactive diversion prevention program, and many employee health professionals are playing key roles in these efforts.

Seek and Find

As experts have emphasized, if you look for drug diversion, you probably will find it.

In ramping up a prevention program and hiring a full-time diversion specialist, a monthly audit of the frequency of medication use on hospital units picked up suspicious activity, says JoAnn Shea, ARNP, MS, COHN-S, director of employee health and wellness at Tampa General Hospital. Shea also co-chairs the hospital’s Controlled Substance Diversion Prevention Committee.

“We look at who is taking the most drugs out,” she says. “When we see outliers, the diversion specialist does some chart audits. We saw some issues of [a nurse] giving drugs too close together, or she would sign them out and not administer them.”

When the nurse declined testing, the health department was contacted, and somewhat surprisingly, public health officials asked to see the minutes of the hospital’s diversion prevention committee meetings.

“We have never been asked that before,” says Shea, who was told by the health department that “‘the district attorney really wants us to make sure hospitals have these programs in place now.’ That was interesting, because there are still a lot of healthcare organizations that don’t have these committees.”

While healthcare drug diversion is a longstanding problem, these latest incidents are occurring amid a national opioid epidemic. The CDC recently reported that synthetic opioids like fentanyl drove a record 72,000 overdose deaths estimated for 2017.3

The 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. The crackdown has led to shortages of common opioids like morphine, hydromorphone, and fentanyl.

The efforts to stem the flow of these opioids is in sharp contrast to years past when the focus was on relieving patient pain, Good says.

“In my opinion, it has swung far in the other direction,” she says. “I think there are people with chronic pain problems who are having more difficulty accessing medication because their doctors are under pressure to prescribe less opiates.”

Shea concurred, saying, “I think sometimes, yes, doctors overordered a long time ago, but that was because we were told we weren’t relieving pain adequately,” she says. “People were not being relieved. Now [the message] is people are getting addicted because of the pain meds.”

Fewer Drugs, More Diversion?

Ironically, the shortage of drugs could contribute to drug diversion incidents by healthcare workers, as scarcity leads to hoarding of vials. Unfamiliar products also make tampering less detectable, New reports.

“Be aware that the opioid shortage may be changing the [diversion] landscape,” she said. “Many facilities are having a lot of trouble now getting the opioids that they need. 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 create the temptation to divert drugs.

For example, if such hoarding and scavenging become accepted practice on a given unit, workers found with opioids could claim they were saving them for patients, Good says.

“I haven’t experienced this, but I also could see healthcare workers who, in the past, have had legitimate prescriptions for opioids but are no longer getting them in the amount they feel they need and may be more desperate to meet their need in illegitimate ways, including diversion,” Good says.

While another department performs pre-employment drug testing, employee health becomes involved if a healthcare worker is tested based on a for-cause incident at her facility, she says.

“Our process is that if someone’s behavior indicated that they may be under the influence or diverting, the manager would contact HR,” Good says. “HR contacts us to do the collection with the chain-of-custody form and send it out, and then the results go to HR.”

Having researched drug diversion as part of her academic training, Good says some of the common warning signs of addicted healthcare workers include rapid mood swings, suspicious behavior around controlled substances, volunteering to give meds for others, a lot of wasted medications, and uneven fluid levels in vials or predrawn syringes.

Once they have gone down this road, diverters rarely turn back until their activities are detected or unsafe use of needles and vials results in a patient outbreak. New is wary of moments of temptation created by the current drug shortage.

“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 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 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 every one of them,” New said.

Diverters seem to favor tampering to outright theft, refilling syringes with water or saline after injecting the opioid. “Tampering is happening at an alarming rate,” New said. “It continues to increase. I am seeing cases every single week — just right and left. Many times these cases are not handled appropriately.”

For example, healthcare workers seeing something different about a syringe may assume it was a manufacturing defect and discard it without reporting suspected tampering. Although tampering can be done with sufficient skill to pass for the original medication, it is also a “desperate activity” where safeguards will often be bypassed, New said.

“Often they are doing this in a staff bathroom, trying to tamper quickly before anybody becomes suspicious,” New said. “One nurse who confessed to tampering actually had open lesions on her arms from injecting.”

The diverter may take the drugs home for use, filling empty syringes with water or saline and replacing them the following day.

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,” she 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.”

REFERENCES

1. Hernando County Sheriff’s Office. Detectives Arrest Nurse for Stealing Medication, July 25, 2018. Available at: https://bit.ly/2F92lXq.

2. Committee on Energy and Commerce. CDC Estimates a Record-Breaking 72,000 Overdose Deaths Last Year. Aug. 16, 2018. Available at: https://bit.ly/2N0NoWI.

3. MultiCare Safety Alert. Potential Hepatitis C Exposure for Some Good Samaritan Emergency Department Patients. June 7, 2018. Available at: https://bit.ly/2wfhxKJ.