Just before the Independence Day holiday, I received an email from a colleague with a link to an article in Newsweek entitled HOSPITAL HORROR STORY: CONFESSIONS OF A NIGHT-SHIFT JUNKIE. As sensational as the title sounds, it is the true story of a man who is now in prison for the rest of his life for stealing narcotics, for substituting saline for the Fentanyl he injected into himself, and for giving over 40 patients Hepatitis C, of which at least one died from the disease.
As alarming as this personal case is, what seems more alarming to me was his persistent experience that he could find and exploit a subculture of diversion within hospitals.Time after time he describes how easy it was to find individuals within a healthcare organization who could, and would divert controlled substances for their own, or someone else's use.
The article is worth a read; I recommend it to your reading, and recommend that you circulate it to your patient care management team. It describes a problem I first encountered as a wet-behind-the-ears new pharmacy residency graduate in Chicago; a problem that doesn't appear to be going away any time soon.
There are some grim realities here:
- Patient Care Organizations operate on the basis of trust - whether in the pharmacy or on the floor, there is a general assumption of trust that the caregivers with whom I work have the patient's best interests at heart. That trust can be broken.
- Patient Care Providers have appropriate access to addictive drugs - diverters therefore attempt to masquerade their diversion as appropriate access and use of controlled substances.
- Patient Care Providers Self-Medicate - we all believe we know what we are doing with medications and that we are in charge of it. Sometimes we are wrong; sometimes we get addicted.
- Diverters are among those we least suspect - In Pharmacy Purchasing and Products, Kimberly New describes a list of attributes of a diverting caregiver. The list would surprise you. I have personal experience having said "anyone but him!" about a pharmacy technician who turned out to be the person stealing Demerol.
- Drug-Seeking behavior of addicts is compulsive and highly adaptive - diverters excel in identifying and exploiting situations in which policy enforcement is lax, or depend on the good will of the people involved. There is no known system that prevents diversion.
- Hospitals generally do not prosecute diverters - they are often released to work at other hospitals
So it is likely that if your institution does not seem to be experiencing drug diversion, it is because you are not looking for it.
The good news is that drug-seeking behavior eventually results in consumption well above the norm, and usage patterns are detectable. Working with your ADC vendor, you should be able to build up a surveillance system that helps you identify,track, investigate and manage diversion. The above-referenced article from Pharmacy Purchasing and Products is the first of two about setting up and operating a diversion prevention program that are worth reading.
But whatever you do, don't ignore this problem; deal with it, and make your hospital a place where it is much harder to divert.
Dennis A. Tribble, Pharm. D., FASHP
Ormond Beach, FL
The opinions expressed herein are my own, and not those of ASHP or my employer.