This week I attended the first annual meeting of a newly formed organization, the International Health Facility Diversion Association (IHFDA). The meeting was sold out (200 attendees) and the agenda was packed.
For the first time, I heard someone put a size on the problem. John Burke, who operated a team on the Cincinnati Police Force specifically for health system diversion reported on the numbers of arrests this team made during its tenure. When that number is extended to the entire population of the United States, those numbers indicate we should be seeing about 100 healthcare providers arrested every day! Last year, the total reported number of arrests was 120. We are barely scratching the surface!.
We heard from a patient who contracted Hepatitis C from a surgical technician who took advantage of lapses in control in the OR to divert and use Fentanyl. We learned that this surgical technician, another surgical technician and a radiology technician were responsible for nearly 20,000 patients having to be tested for HIV and Hepatitis C. The radiology technician was responsible for over 40 confirmed cases of Hepatitis C, one of which resulted in death. This case alone was responsible for over 12,000 patients having to be tested. By the way, our typical controlled substances management tools wouldn't have caught these folks; they had no direct access to the medication storage system. Rather, they were able to take advantage of the lax procedures around handling those substances once they were removed for use.
We learned that addiction is truly a disease. Carl Christensen, MD, PhD, presented information on radiographic brain studies that demonstrate differences in the way the brains of addicts and the brains of non-addicts operate. We learned that everyone who takes opioids for a period of time becomes dependent, and must go through withdrawal. But not everyone who becomes dependent be comes an addict. Dr. Christensen indicated that addiction is functionally a genetic disease, somewhat like diabetes mellitus, the difference being that the differences do not become apparent until the addict brain is exposed to addictive substances. Because of the nature of this disease, we learned it is unlikely that it can be cured, and it is unlikely that we can ever prevent diversion. Like diabetes, it is a chronic problem that must be managed. Further, we learned that rehabilitation from substance abuse does not enable a healthcare worker to return to duty where that duty requires the use and handling of controlled substances.
We heard some truly disturbing statistics about substance abuse in anesthesiology from Dr. Keith Berghe from the Mayo Clinic.
Perhaps the most disturbing thing we learned was how easy it is for someone to simply move from one health system to another and continue diverting because health systems appear to be reluctant to take action other than to discharge the employee. This amounts to "kicking the can down the road", making the problem provider someone else's problem. We learned:
- Diversion is both a federal and a state crime. In addition to theft, it is also tampering and adulteration of a medication (which is a federal crime), and, to the extent that a patient does not get the prescribed medication, it may be considered healthcare fraud under CMS regulations.
- As a result, diverters will likely be incarcerated by the justice system. It was pointed out that court-mandated and court-supervised rehabilitation is more likely to be effective than voluntary rehabilitation, because it is supervised.
- It is also a crime not to report that crime. We heard from both Massachusetts General Hospital and Dignity Health on their million-dollar fines for failure to report missing or diverted controlled substances, along with the substantial amount of process improvement they had to put in place in order to avoid more fines.
- Catching and prosecuting a diverter will likely cause some adverse public relations for the institution, but nothing even approximating what will happen if the health-system becomes involved with a DEA investigation.
All this learning reminded me that there had been a blog in this forum nearly a year ago on this very subject. Oh yeah... it was one of mine.
Dave Swenson, a friend and colleague who attended this meeting with me commented "It's amazing. Anywhere you shine a light on this problem, you find diversion you didn't know you had!" Friends and colleagues, we aren't managing this problem, because we are not looking for it.
We learned that there are health-systems out there, such as the University of Michigan, Sarasota Health, and Allina Health, that have individuals tasked with managing the problem of diversion whose oversight reaches all the way to the C-Suite.
Did you know that the nurse manager is the wrong person to place in charge of a diversion investigation? Not only to they lack the necessary forensic training, they are too close to the diverters to handle the problem correctly. It is both kinder and more effective to have an independent team handling suspected diversions.
And, once having found it, our health systems appear to often sweep it under the rug, as if it were some dirty family secret of which we are ashamed. It should be of first importance to protect patients in general, which means getting that compromised provider out of the workforce where they cannot harm patients. It's not enough to have a zero-tolerance policy and fire the diverter; that just kicks the can down the road. Rehabilitation is a benign and appropriate response to the compromised caregiver, but that caregiver can never work where controlled substances are used again and must pay for the consequences of their crimes. That means being publicly reported.
I guess the bottom line is that we as a profession are not doing a very good job of managing this endemic problem in our workplace and, as those responsible for the medication use process, we are the very people who should be providing leadership in this area.
So what are we going to do about it?
Dennis A. Tribble, Pharm. D., FASHP
Ormond Beach, FL
The opinions expressed in this blog are my own, and not necessarily those of ASHP or of my employer.