The fight against the diversion of opioids and other controlled substances is heating up in the nation’s health systems, according to experts at a packed session at the 2016 annual meeting of the American Society of Consultant Pharmacists (ASCP). Two major factors are providing the wake-up call for more diversion oversight: the nation’s opioid crisis and the $2.3 million Massachusetts General Hospital fine imposed in 2015 by federal officials. The fine followed an audit into the hospital’s controlled substances practices, after hospital officials reported that two nurses had stolen nearly 16,000 pills, mostly oxycodone, due in part to breakdowns in automated drug cabinet (ADC) security.
More recently, the Georgia State Board of Pharmacy levied a $200,000 fine against Atlanta’s Emory University Hospital Midtown. The board found that the hospital did not have sufficient controls in place to prevent the diversion of more than a million doses of controlled substances by two pharmacy technicians, including a combination of alprazolam, hydrocodone and codeine products, according to the consent order, issued Feb. 22, 2016.
Kimberly New, JD, BSN, RN, the executive director of the recently created International Health Facility Diversion Association, and the featured speaker during the ASCP session, said that diversion doesn’t just pose a threat to an affected hospital’s finances and reputation. Along with siphoning off drugs needed for patient care, clinicians covering their thefts might tamper with the medications, boosting patients’ vulnerability to hepatitis C virus (HCV) and other infections, she noted. Moreover, on-the-job impairment is a very real issue. “People who are diverting are not waiting to use their drugs some other time,” Ms. New explained. During her talk and in a subsequent interview with Pharmacy Practice News, Ms. New said it has been difficult to track down reliable data on the still somewhat hidden problem of clinician diversion. Her Bethel, Ohio–based association, which she co-founded in early 2016, keeps track of a litany of media coverage on its website (https://ihfda.org ) detailing diversion-related fallout for clinicians, patients and hospitals.
Consistency in detection and investigation of potential cases—whether it is missing drugs or a possibly impaired clinician—is key, said Ms. New, who has consulted with many health facilities seeking to improve their diversion control systems. To that end, she recommends to hospital leaders that they create several layers of accountability, ranging from a diversion oversight committee to spot checks of clinical areas via drug diversion risk rounds. “If you have a formal process, then everyone is in the loop that needs to be in the loop,” she said. “Many times I’ve seen directors of pharmacy blindsided because the DEA [Drug Enforcement Administration] has come in and says, ‘What about this big diversion?’”
One blind spot in terms of catching the clinicians involved is human nature, because the culprits might not be those who perform poorly or fall asleep on the job, Ms. New noted. In fact, they might take on extra shifts or work less desirable hours to boost their access to controlled substances. She recounted how one nurse came in to distribute medication in the predawn hours, saying she wanted to help out because she was having difficulty sleeping anyway.
Rick Couldry, MS, BSPharm, FASHP, can vouch for the lack of a consistent pattern, except for one: “In my experience, they’re all very, very sad stories,” said Mr. Couldry, the executive director of pharmacy services at the University of Kansas Health System (UKHS), in Kansas City, which recently hired Ms. New as a consultant. “They almost always have someone who is a very good person who falls upon a difficult time in their life for some reason or another, and they make a bad choice,” he said. “And then they roll downhill, and they make more and more bad choices. And then they are in trouble, and they don’t know how to get out.”
To be effective, drug diversion prevention must be a partnership between pharmacy and nursing, rather than pharmacy leaders attempting to shoulder the entire effort themselves, Ms. New pointed out. In addition, education must extend to non-clinicians, according to UMass Memorial’s Mr. Bercume. It might be someone on the cleaning staff, for example, who is the first to notice that a patient is routinely complaining of unrelieved pain, he said.
Admitting that diversion occurred within one’s own facility is an awkward conversation for sure—one that has been kept under wraps too long by hospital pharmacists, said Mr. Couldry, who also was director-at-large (2013-2015) of the ASHP executive committee. But pharmacy leaders have a duty to lead this effort, not just internally but by exchanging stories and strategies with clinicians at other facilities, he said.
“One of the things that we can do better is have more open conversations about diversion issues, diversion detection and diversion cases, frankly, so that our individual institutions respond in appropriate ways,” Mr. Couldry said. “We can diminish that ‘oh, it can’t happen here’ mindset.”
Kimberly New, JD, BSN, RN, the executive director of the International Health Facility Diversion Association, described several ways that hospital leaders can discourage or detect diversion attempts.
- Procurement: Ensure that a different person in the pharmacy orders the controlled substances than receives and stocks them, Ms. New said. “You really need a good process where you have separated those duties,” she said, “and have different people involved, and then good reconciliation at the back end.”
- Wasting: Watch for time-related gaps, such as a nurse pulling a medication at 1 p.m., but not disposing of what’s left until 6:30 p.m. as the shift wraps up. “If it’s done repeatedly for a particular drug, that’s a big red flag,” Ms. New said. “It may be diversion, or it may be just a practice issue.”
- Cancellations: Pay attention to canceled transactions. For example, a nurse could open the drawer of an automated dispensing unit, switch out vials of fentanyl with water-filled vials from home, then cancel the entire transaction. Not all summary reports routinely include cancellations, so they may need to be searched for specifically, Ms. New said.
- Shift behaviors: Delve further if there are changes in behavior, such as a nurse charting well at the start of the shift but by the end there is a “major deterioration,” Ms. New said, or a clinician appears to use the restroom frequently. In some cases, clinicians might even concoct a medical condition, such as having irritable bowel syndrome, to explain frequent trips so they can use their drug of choice, she said.
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