An increase in discussions on diversion, and on what has been characterized as the opioid crisis has kindled my thoughts on controlled substances and diversion. I know that I have written a lot about aspects of this recently, but looking specifically at the opioid crisis got me thinking about whether or not we really pay attention on a day-to-day basis to the controlled substances we handle.
There is little question that the opioid crisis is real. A 2016 report by the CDC identifies that the number of opioid prescriptions has quadrupled and the number of opioid-related deaths has doubled since 2000.
Some of this rise would appear to be associated with our aging population and with health issued associated with unhealthy lifestyles. For example, the National Cancer Institute estimates that there will be nearly 1.7 million new cases of cancer diagnosed in 2016 and that trends associated with cancer risk (such as obesity and age) are increasing as well. So some increase might be expected.
Having said that however, it does not explain the dramatic rise in both opioid prescriptions and opioid deaths, much less the fact that these deaths are attributed to prescription opioids, not street heroin or other street drugs.
The real problem we have, of course, is that there are legitimate uses for prescription opioid drugs, and some of those uses require large quantities of them. That just makes it all the harder to tell when usage is appropriate and when it is not. Our problem is known to include "pill mills"; outpatient clinics whose parking lots hold buses and that see and dispense to large numbers of patients without real examination or justification for use. Of course, these operations are all cash. But there are also patients who start with a real need for pain medication and become addicted, and there are patients with real need whose medication supplies may be stolen from them, including being stolen by members of their families or by their caregivers.
We have seen some positive effect from clamping down on providers who seem to over-prescribe opioids, but those efforts have penalized patients with real need in some cases, and have resulted in secondary increased in street heroin use, which is now known to be cheaper (on the street) than prescription drugs. The problem, of course, is that we have also seen the advent to heroin laced with synthetic opiates, such as carfentanil (100 times more powerful than fentanyl and only approved for use in large animals), which also contributes to the opioid death toll.
That being said, eventually outpatient prescriptions are pretty easily tracked (through claims data) and prescription drug monitoring programs are being shown to be effective in identifying primary care providers, pharmacies and patients who are abusing the system.
We would probably help with the prescription opioid problem by encouraging physicians discharging patients to limit the amount of opioids they prescribe at discharge to the amount needed until their next appointment, but other than that, we likely will not influence this part of the problem.
The problem we have is that once someone is addicted, the need for more is compulsive, and leads to drug-seeking behaviors that are nothing if not clever and adaptive. And nowhere is that problem more difficult to detect and manage than among highly educated caregivers in the acute care environment. Indeed, while we have some pretty solid statistics on prescription opioid use in the general population (and in the resultant deaths), our ability to detect and quantify that same behavior among healthcare providers has proven to be significantly more elusive. The American Nurse's Association estimates that 10% of nurses are drug-dependent, a number not significantly different than the general population. In a presentation given to the newly-founded International Health Facility Diversion Association this year, it was estimated that we should be identifying the number of nurses each month that we ordinarily identify in a year in the United States.
Note that nurses are not alone, or even necessarily the worst of diverters of controlled substances; physicians, pharmacists, and pharmacy technicians are also known to be involved. Additionally, there have been some highly publicized cases involving radiology technicians, and surgical technicians, whose access was limited to the few seconds that it took to substitute a syringe filled with saline for a syringe filled with fentanyl and left in a relatively unsecured place.
Again, the key features in all these cases are similar to the outpatient cases in that the medications are available because they are legitimately needed (or may be legitimately needed) and the diversion can masquerade as such legitimate use. Unlike the outpatient arena, however, there is very little visibility into the problem; indeed what we know tends to be more anecdotal than statistical.
The problem is not new. Although diversion by nurses was not officially acknowledged as a problem until 1984, I actually was involved in my first diversion investigations in the late 1970's. Way back then our problems were much the same as they are now; the people we eventually caught had all been dismissed from other area hospitals under suspicion of theft of narcotics.
There are several sources for this relative opacity in the problem, only one of which is a reluctance on the part of the institution to acknowledge that diversion might be happening at their facility. Other issues include:
- A reluctance on the part of caregivers to believe that a member of their team is diverting - healthcare teams operate on a fundamental and unspoken assumption of trust. The loss of that trust can be devastating to the remainder of the team. As a result, caregivers ignore, or excuse behaviors that should signal danger until the signs and symptoms are undeniable.
- A lack of good education of caregivers on those signs and symptoms.
- A lack of process and well-trained personnel to manage diversion investigations.
- Diverting caregivers who are both well-trained in both policy and practice and who are driven by drug-seeking behaviors to exploit the holes in the process, including the very trust that their co-workers extend to them.
- The fact that most acute care diversion occurs for personal use, and therefore does not become apparent on the street.
- Diverting caregivers are often those who one would least expect. They are often overly helpful, especially in handling tasks surrounding controlled substances that most caregivers find burdensome. They are the highest performers, those who come in during off hours apparently out of concern for their patients. They often volunteer to take undesirable shifts.
- A tendency to exert poor control over the systems that store and dispense controlled substances. A report from the University of Michigan described two caregivers who overdosed while on duty in two completely separate parts of the campus. A subsequent audit of the system found nine users of their automated dispensing system who should not have had access to the system.
Having said that, acute care diversion carries its own peculiar and devastating public health risks:
- Diversion activities may result in compromising the integrity, and/or sterility of sterile injectable medications creating both treatment failures and nosocomial infections.
- Compromised caregivers have compromised medical judgement, may demonstrate poor technique, inadequate documentation causing subsequent medical error, and failure to perform essential tasks.
- Diversion activities may result in under-treatment of pain
- Diversion activities place additional workload burdens on caregiver teammates, increasing their likelihood of error
The environment has changed recently, with the advent and publication of multi-million-dollar fines for failure to manage diversion and report its occurrence to the Drug Enforcement Agency. These reports highlight the need for vigilance in management of controlled substances inventory, and what could likely be characterized as our having allowed familiarity to become contempt around our regulatory responsibilities for managing these substances.
The bottom line appears to be that if you think your institution doesn't have a diversion problem, you aren't looking very hard.
It also may mean that you lack the tools you need, in terms of automation, training, and process, to ensure that you have a robust process in place to manage diversion.
- We likely need better analytics to help us identify professional diverters. I was at a meeting recently where the participants indicated that their biggest problem was the number of false positives delivered by their diversion analytics. I would estimate that most current analytics process automate less than 50% of the information gathering that represents the forensic process. We should be able to do better than that.
- We likely need better training of those involved with the forensic process both in terms of what to look for, and how to actually conduct the investigation
- We likely need to remove the managers of the suspected individual from the forensic process. I know from painful experience that I was not part of the solution when one of my more valued employees was caught diverting drugs. I was fortunate to have internal security people who knew how to do it, and how badly I would want not to believe what turned out to be the truth of the matter.
What it clearly means to me is that we have a problem, and that, until we are ready to shine a light on that problem, measure it, and deal with it, we won't be able to manage it. In the nearly 40 years since my first diversion investigation, I have come to the conclusion that we will not likely prevent it. None of the cases with which I have been involved started out intending to be an addict. If anything, it started with the "I'm a professional... I know what I am doing.. I can quit any time" attitude, until, of course, the day that they couldn't. When you pile the stress, fatigue, and emotional toll that caregivers experience onto what Hamlet describes as "the thousand natural shocks that flesh is heir to" it is no surprise that some of us fall prey to that syndrome.
I have also come to conclude that part of our responsibility in being prepared to deal with diversion is being prepared to both manage the disease that is afflicting the diverter, and to manage the inevitable damage that the discovery of the diverter will have on their co-workers. That's something else we likely don't do exceptionally well.
But we have to, because it is part of our responsibility for the medication use process, and because we are called to compassion both for our patients, and those who care for them.
What do you think?
Dennis A. Tribble, PharmD, FASHP
Ormond Beach, FL
The opinions expressed in this blog are my own, and do not necessarily reflect the opinions of my employer, or of ASHP