Medication Management: Countering Drug Diversion

Medication Management

Countering Drug Diversion

rescription drug abuse is one of the fastest growing heath care problems in the United States. It has affected so many

patients, families, health care workers, and hospitals across the nation that the US Centers for Disease Control and Prevention (CDC) has formally labeled the problem an “epidemic.”1

According to the CDC’s latest data, drug overdose was the leading cause of injury death in 2013. There were 43,982 drug overdose deaths in the United States in 2013. More than half of those deaths (22,767) were related to prescription drugs, and 71% involved opioid painkillers.2 (See figure 1 on page 8.)

A major driver of the prescription drug abuse crisis is drug diversion, which occurs when prescription medicines are obtained or used illegally. The problem of drug diversion is complex, often making it difficult to prevent. Patients can become addicted to medication, some people pose as patients

to obtain prescriptions drugs, and in many cases, health Health care organizations nationwide are struggling to prevent

medication diversion.

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care providers mastermind drug diversion schemes by writing unlawful prescriptions, falsifying documents, and mislabeling inventory. These providers can become addicted to the drugs they steal, or they end up selling them on the streets, or both.

Harmful Effects of Diversion

Jeannell Mansur, PharmD, practice leader, medication safety, Joint Commission Resources, says that there are not a lot of eyes on the medication distribution process, so

abuse doesn’t always become recognizable until a health care worker becomes addicted to drugs or to stealing them for illicit purposes.

“By the time someone recognizes the signs, diversion has probably gone on a while and the person has just gotten more desperate and sloppy,” she says.

When a health care provider reaches the desperation stage, it’s likely they have already done significant harm to patients. Substandard care, denial of essential pain medication for patients, and the risk of infection from injectable drugs that have been tampered with, are all possible effects of diversion.

Substandard care can include not giving prescribed

drugs to patients or giving them diluted versions of prescribed drugs. Both actions can result in unnecessary pain or anxiety for the patient. Contaminated substances that are used in place of a prescribed drug, such as unsterilized tap water or a different drug, can also increase patients’ risk for bloodborne infections, allergic reactions, and sepsis.

In addition to the effects of drug tampering, patients can be at risk when they are cared for by an impaired health care worker. Impairment could mean a health care worker who is addicted to drugs, or simply in a state of constant distraction. In other words, that provider will be more focused on getting his or her next hit or obtaining drugs

to sell, than on patients’ needs. Whether it’s addiction to a substance or to the continual crime, a health care worker who diverts drugs is much more likely to make bad decisions or medication errors, which will almost certainly lead to patient injury.

Diverting drugs can also harm the addicted health care worker both physically and emotionally. Along with the potential physical consequences of taking drugs improperly, the stress of obtaining drugs illegally, avoiding detection, and the huge risk to a health care worker’s professional career can cause emotional distress as well.

Figure 1. Drug Diversion

Preventing Diversion

Mansur says that many opportunities exist for health care workers to take and use medication for illicit purposes. Drug diversion can often be difficult to detect because the abusers know the systems they work in and are actively trying

to cover their tracks. Many hospitals do have controlled processes, so it’s unlikely you’ll find easy evidence of diversion, such as medication counts being off. Abusers will instead try other methods of diversion that are harder to discover, “Such as saving a portion of a dose that you might have squirted down the drain of a sink for yourself,” Mansur says. “Or, taking a dose that is intended for a patient and giving them a normal saline.”

Avoiding detection is also made easier because many health care workers are not even aware that drug diversion occurs in their workplace.

To prevent diversion, health care organizations should educate staff about what the problem is, how to identify signs of possible diversion and addiction, how to keep medication secure, and how to properly respond if they witness diversion.

Creating a comprehensive prevention program that provides clear procedures for tackling these diversion issues is a good way to start. “Policies should be developed that address all aspects of controlled substance process—from purchasing, distribution, removal, and administration, to wasting, policies on monitoring for diversion, reconciliation of discrepancies, to process for investigating suspected diversion to process for confirmed diversion to process for disclosing to patients and families if they have been affected by a diversion,” Mansur says.

A solid backbone for diversion policies can be found in The Joint Commission’s Comprehensive Accreditation Manual for Hospitals, which includes standards that specifically reference ways of storing medication and controlled substances to minimize diversion. Medication Management (MM) Standard MM.03.01.01, for example, addresses how a hospital should safely stores medications. “This standard

specifies that processes must be in place that minimize potential for diversion; making sure those who shouldn’t have access to medications don’t have access,” Mansur says. (See “Related Requirements,” below for a list of applicable standards.)

Medications must always be kept in secure areas, and controlled substances need to be locked up if they are not in the hands of a health care practitioner who is giving it to a patient. A good system should be in place for storing controlled substances when they aren’t being used.

“This is a big issue in the operating room,” Mansur says. “At the end of a case the anesthesiologist needs to be very careful that they take any unused substances and secure them in storage, or waste those that have already been open so they are not accessible to unauthorized individuals. You want to make sure that you don’t have controlled substances out.”

Mansur says that Joint Commission standards also direct organizations to set up a program that minimizes diversion. When Joint Commission surveyors visit accredited hospitals, they ask health care organizations how they monitor for diversion and what issues they might have. The surveyors will also look at how medication is dispensed

and stored at a hospital (Standards MM.03.01.01 and MM.05.01.11) and search for evidence of discrepancies. If discrepancies are found, they will ask about the correct procedure that should occur when that discrepancy is identified. It is important for hospitals to have proper procedures in place for handling those discrepancies.

“Our standards always allow hospitals to define their own ways of doing things,” Mansur says. “But in the end it is about steps to mitigate diversion and steps to keep controlled substances locked.”

Staff Education Is Critical

To comply with Joint Commission standards, ongoing education should be a big part of the prevention program

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Related Requirements

Ensuring compliance with the following Joint Commission standards can help organizations counter drug diversion:

Standard MM.01.01.03: The hospital safely manages high-alert and hazardous medications.
Standard MM.03.01.01: The hospital safely stores medications.
Standard MM.05.01.11: The hospital safely dispenses medications.
Standard MM.05.01.13: The hospital safely obtains medications when the pharmacy is closed.
Leadership (LD) Standard LD.03.01.01: Leaders create and maintain a culture of safety and quality throughout the hospital.
Standard LD.04.04.05: The hospital has an organizationwide, integrated patient safety program within its performance improvement activities.

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(continued from page 9) It’s also a good idea to let staff know just how vulnerable they

effort. After staff understand the problem, how serious it is, and the importance of keeping medications out of the wrong hands, they must be instructed on how to identify signs of possible diversion and addiction. Warning signs typically include a change in an employee’s behavior. In order to prevent harm to patients, it’s vital that all health care workers be vigilant for signs of possible diversion. They also need to know how to engage the appropriate authorities.

Mansur says that staff who work with someone abusing drugs are much more likely to notice that person acting oddly, than a manager is. It’s the staff who will witness the disposal of unused drugs, for example. So, it’s often up to staff to report any strange activity, even if it turns out to

be something other than diversion. “Odd behavior doesn’t necessarily mean they are diverting, but it’s an opportunity to assess someone,” Mansur says. “Reporting is important, so that investigation can occur. Information should be treated confidentially, and appropriate authorities should be involved, such as professional licensing boards, DEA [US Drug Enforcement Agency], and law enforcement in the event that diversion is found.”

It’s also a good idea to let staff know just how vulnerable they are to diversion and to give them information about

the consequences that drug diversion can have on their lives and careers. They should be aware that the procedures for mitigating diversion are in place for good reason—to prevent patient harm, illnesses, and death.

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are to diversion and to give them information about the consequences that drug diversion can have on their lives and careers.

Diversion is a serious, ongoing problem for the health care industry. Unfortunately, it’s a difficult battle because many offenders know how to manipulate the drug control systems and breach procedures to get what they want. “If you have access to controlled substances and you have a reason to be around them—taking care of patients who needs them, preparing controlled substance doses for patients, or administering them in an operating room—it is not difficult to divert,” Mansur says. “But, that sets up a whole chain of events. Abuse leads to addiction, and then you go down that very slippery path.”

Health care organizations need to make sure staff are educated on diversion and help raise awareness. Health care providers must be vigilant and report problems to make a difference in the lives of patients and their coworkers. “I think we have to emphasize that the sooner [diversion] is addressed, the sooner those addicted can get help. And certainly there is patient safety to be concerned about. That should always be our first responsibility.” TS

“It’s the elephant in the room, but it is one that needs to

be addressed,” says Mansur. “I worked with a chairman of anesthesia who recognized that in the operating room world there was a steady flow of controlled substances and a lot of potential for abuse. Every year he would talk to his residents about this and how vulnerable they were, how they should be watching for signs, how important it is to be meticulous with accounting, and perform a proper witnessing of people who ask you to witness their dose wastage. Those are all aspects of education that proved beneficial.”

References

.cdc.gov/drugoverdose/data/overdose.html.