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Considering healthcare workers’ broad access to addictive drugs, along with the rampant opioid epidemic that is sweeping the nation, The Joint Commission (TJC) is urging hospitals to develop a comprehensive approach to the prevention and detection of drug diversion. Experts note that the problem can be addressed in multiple ways, including direct prevention techniques and broader initiatives that focus on awareness of employee behaviors and workplace wellness. Professional organizations also are urging healthcare systems to move to alternative-to-discipline (ATD) approaches for employees identified with substance use problems.
Noting that roughly 10% of all healthcare workers abuse drugs, The Joint Commission (TJC) has issued an advisory, urging systems to develop a comprehensive approach to help detect and prevent the diversion of controlled substances.1
The issue is of particular concern in light of the opioid epidemic. TJC notes that the powerful drug fentanyl is the most commonly diverted drug and the leading culprit behind opioid overdose deaths. Further, experts suggest that only a small number of hospital employees who are diverting fentanyl or other illicit drugs are identified, adding more urgency.
Diversion is not just a safety issue for hospital employees. The methods used to acquire opioids subversively can come at the expense of patients, depriving them of needed pain relief or, in some cases, leading to hepatitis C or other bloodstream infections.
Although diversion is a difficult problem to address, there are some best practices health systems can implement not only to close the gaps that allow diversion to occur, but also help guide employees with substance use problems into treatment programs that will give them the opportunity to achieve wellness and return to their clinical careers.
“What hospitals in particular offer is access,” observes Elaine Cox, MD, FAAP, the chief medical officer at Riley Hospital for Children at IU Health and a professor of clinical pediatrics at Indiana University School of Medicine. “While there have been a lot of safety measures put into place, there are still opportunities for access.”
For instance, although investigators can monitor the use and amount of addictive medications that clinicians remove from medication-dispensing machines while caring for patients, it can take time to pick up on individuals who may be engaged in diversion, Cox observes. Typically, a clinician must enter his or her own identifying information and information about the patient requiring medication to open the drawer on a medication-dispensing machine. “That unlocks the drawer, and then [the clinician] can take the dose. In many cases, the patient doesn’t require the whole vial,” she says.
In such instances, the clinician would record the waste; however, the wasted medication often is not measured, leaving a loophole for potential diversion, Cox explains. “We have to look for patterns of lots of removals of those sorts of [addictive] medications in higher-than-the-average [doses] and large amounts of waste,” she says. “The medication-dispensing machines can run those reports of usage. Then, you have to go back through and ask whether [the patterns] make sense for each patient.”
There are other access points for drugs that have to be managed, too. Sometimes, there is a little bit of unused medication left in an IV bag that must be disposed. There also are the “sharps” boxes hospitals use to dispose of used syringes, some of which contain unused portions of opioids or other addictive medications. Administrators have to think about how such waste will be monitored and removed in a way that prevents potential diversion.
“Our [sharps] boxes are locked to the wall and they require a key to get into them,” Cox says. “You empty them when they get to a certain line, which is about two-thirds of the way up into the box so that not even a small hand can reach into the slot and get [to the disposed needles]. Now, [hospital employees] don’t even empty these boxes. They go to a central place where the process is managed and watched.”
Another diversion-preventing technique is installing a special sink where unused medication can be discarded. “We don’t want people disposing of drugs down the drain or in the toilet because you don’t want them to get into the water supply,” Cox says. “You put the unused medication into one of these sinks ... and there is a chemical or charcoal-like substance in the sink that deactivates the drugs so that you don’t then have active drugs anywhere in your labs.”
While such approaches are not entirely foolproof, they are considerably more effective than the way medications were handled long before the opioid crisis swept the nation. “In operating rooms or EDs, people would just get a box of drugs for their cases during that day,” Cox recalls. “Then, at the end of the day, they would turn their boxes back in, which wouldn’t [reveal] what happened with those medications over the course of the day.”
Generally, EDs and operating rooms are two of the highest-risk areas for diversion. “The rapidity with which patients turn over in those areas makes the patterns very hard to detect,” Cox says. “We can still see the [medication usage] patterns over time, but they are harder to see than on a med-surg floor because we don’t use as much medication up there, and the patients are there longer.”
From a physician’s standpoint, the literature has identified anesthesia as the practice most at risk for diversion, Cox notes. “Nursing across the board is high risk as well just because nurses have high access [to medications],” she says. “What we have found is that most diversion has been for personal use. While there are certainly lots of articles that talk about diversion for the purposes of distribution, in my experience, I haven’t seen that as much as when diversion is done for personal use or for close family members.”
In addition to the more direct methods for preventing diversion, hospitals also should consider what Cox refers to as adjuvant tactics. For example, consider the overall use and abuse of certain addictive medications and why healthcare professionals in certain specialties are turning to addiction. “I think you link this directly to people’s wellness and the environment in which they work,” Cox offers. “[Think about] how we can support people in different ways so that they do not turn to addiction.”
Further, when healthcare workers become addicted, it is important for health systems to support them in the same way they would support individuals with other health conditions so employees do not turn to diversion. “It used to be if you were a physician and you had any kind of addiction problem ... your career was over,” Cox shares. “This, as opposed to recognizing that addiction is a health condition, and that perhaps the intense work environment and responsibility contribute to the problem.”
It is not an easy area for hospitals to navigate, Cox acknowledges. “Society is just beginning to understand this [issue]. Many hospital systems, including my own, have recently redesigned their policies on employees who are addicted, including physicians,” she says.
How can hospitals most effectively identify employees with this problem, and then support them through treatment and monitoring after they return to work so they do not relapse? “We use our state medical society now to help us. State nursing societies all have programs for this as well,” Cox says. “I think a lot of entities are moving toward that sort of management.”
In May 2017, the Emergency Nurses Association and the International Nurses Society on Addictions (IntNSA) issued a position statement in favor of an alternative-to-discipline (ATD) approach that includes specialized treatment and a pathway for a return to practice.2
Since its release, several other professional organizations have endorsed the position paper, including the American Nurses Association, the American Association of Nurse Anesthetists, and the Association of periOperative Registered Nurses. Also, the paper has been distributed broadly to state boards of nursing, explains Stephen Strobbe, PhD, RN, PMHCNS-BC, CARN-AP, FIAAN, FAAN, a statement co-author, a clinical professor at the University of Michigan School of Nursing, and past president of IntNSA.
“The prevalence of substance use among nurses and other health professionals is generally comparable to that of the general population, but healthcare professionals have a higher probability of misusing opioids with serious consequences,” Strobbe says. “The ways the issue has been addressed ... have not only perpetuated but exacerbated the problem.”
Strobbe notes that from a disciplinary standpoint, a substance use problem has either been ignored or treated harshly and punitively. “People may have been fired, but without treatment and recovery,” he says. “As a result, many have simply started working at another facility, still placing patients and themselves at risk.”
Why should hospitals consider a nonpunitive approach even in cases in which health professionals have engaged in diversion? Because it is more likely to promote transparency, consistency, and fairness, with far more positive outcomes, according to Strobbe. “There is a preponderance of evidence to demonstrate that not only is ATD a more humane approach, but it is also the approach that is more likely to lead to increased patient safety,” he shares.
The University of Michigan Health System was jolted into action on diversion when two separate incidents occurred on the same day in December 2013. A nurse and a physician were both found in hospital bathrooms after they overdosed on stolen injected drugs. The nurse died, while the physician, an anesthesiology resident, was revived. A Drug Enforcement Administration investigation followed, and the health system faced stiff penalties related to diversion.3 The health system has revamped its policies completely, making the prevention of drug diversion a top priority.
“We have a director of diversion prevention ... who works closely with pharmacy, leadership, security, and managers to consistently address problems,” Strobbe notes. “We have also developed a highly sophisticated software program that helps to identify outliers in terms of documentation in the dispensing of opioids. That has resulted in the successful identification and movement into treatment [of employees with substance use problems], utilizing an ATD approach.”
Putting such a system in place has been a process with many layers. “We had some tragic events that involved staff members here, and that shocked people into an awareness of the need to do things differently,” Strobbe explains. “By this time, any institution that is willing to take a clear-eyed view of this probably has similar stories or good reasons to show that things need to be done differently.”
An effective ATD program must be structured around compassion, consistency, and accountability, Strobbe notes. “There needs to be a structure in place that treats substance use problems as medical disorders. Historically, that has not been the case,” he says. “That has contributed to stigma and discrimination.”
Strobbe acknowledges that many organizations will require education at all levels to make the cultural shift necessary to implement a successful ATD program. “The perspective that a healthcare facility, department, or leadership team takes in even viewing the problem will contribute to the way in which it is identified and addressed,” he says.
Often, healthcare professionals with substance use problems will need a period away from the jobs to undergo treatment and recovery. “This may include residential treatment or intensive outpatient treatment. During this time, the individual is generally removed from the clinical setting to attend to the disorder the same way a person might take medical leave for other illnesses or diseases, and then return,” Strobbe shares. Another important component of an ATD approach includes the involvement of a professional monitoring program, followed by a return to the practice setting. This can take place in several different ways, Strobbe observes. Individuals may return to a job in which they have no access to narcotics for a period.
“When they have successfully completed at least certain portions of their treatment program, some individuals may return to their previous roles, although during an interim period, no access to narcotics is more often the rule,” Strobbe adds.
Financial Disclosure: Physician Editor Robert Bitterman, MD, JD, FACEP, Nurse Planner Nicole Huff, MBA, MSN, RN, CEN, Author Dorothy Brooks, Editor Jonathan Springston, Executive Editor Shelly Morrow Mark, Accreditations Manager Amy M. Johnson, MSN, RN, CPN, and Editorial Group Manager Leslie Coplin report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.