Pay attention to behavior of family members, friends

Lockboxes, limited drug supply discourage theft

A family member's statement that "Dad's pain is really helped by methadone rather than hydrocodone," should serve as a red flag for any hospice nurse, says Debbie Williams, RN, CHPC, administrator of Agape Hospice in Minden, LA. Any time a family member or friend of the patient is naming specific drugs to bring into the house, you should be suspicious of drug diversion, she says.

This suspicion doesn't mean a nurse should report the family member immediately, but it does mean the nurse should pay careful attention to what is happening in the home, says Williams. "Give them the benefit of the doubt, but ask questions about medication, be sure to count pills and patches in view of the family member, and talk to the patient about effectiveness of pain control," she says. "Make it obvious that medication is carefully monitored, especially if there are always a lot of family members and friends hanging around."

Jane Garrett, RN, MHSA, director of consulting services for Weatherbee Resources, a hospice consulting firm in Hyannis, MA, says, "It is usually not the primary caregiver who steals medication but other family members or friends who are at the house are more likely to be the suspects if medications are missing."

If the nurse suspects that medication is being diverted from the patient because the number of pills is decreasing but the patient is in pain, a drug test of the patient can be ordered, says Garrett. "You can get a physician's order to test the patient to see if the proper level of medication is in the bloodstream," she explains. "This will give you more proof that the patient isn't receiving the medication."

Williams says, "In one case, the patient was using a lot of narcotics between visits but was still complaining of pain. The nurse suspected theft by a family member but knew the patient would not say anything about the theft." The nurse explained to the patient that because he was using such a high dose of narcotic with no relief, the best way to keep him comfortable would be to admit him to an inpatient unit for intravenous medication. "If possible, we move the patient to a nursing home or inpatient unit if we see signs that the patient is not getting medication, proper food, or appropriate care, and sometimes that is the only way to help," Williams says.

Although her agency only delivers two weeks of medication at a time, there are some patients who receive only one week at a time, Williams says. "If there are fewer pills or patches, it is much easier to monitor and control diversion," she says.

Nurses should know what different medications look like, says Williams. "I've seen family members take a narcotic and substitute with a different pill," she explains. "Nurses should know what color, consistency, size, and smell different medications have." A pharmacist can be helpful in staff education and identification of medications that nurses don't recognize, Williams says.

At the time of death, it is important that nurses count and document all remaining medications and dispose of them according to guidelines from the Food and Drug Administration (FDA), says Garrett. Narcotics can be mixed with kitty litter or coffee grounds and put into the garbage, or medication can be flushed down the toilet if the label allows, she says. The nurse should have another person witness the disposal and sign the documentation, Garrett says. "This ensures that the hospice accounts for all medication," she says.