Let me state up front that this is going to be a bit of a rant. I believe firmly that diversion is a problem, and that it is first and foremost a patient-safety problem. I also believe it is a problem that we can manage, but never solve, because its sources are beyond our control.
First, addiction is not a matter of morals or will-power[1]. Addiction occurs because of a combination of psychological, physiological, and physical changes in the brain induced by these drugs that tends to enable and perpetuate addictive behavior.
Addiction occurs as the result of a variety of factors that include environment, genetics, and development. Once it occurs, it becomes a chronic disease that must be managed1. Whatever else might be true, it is hard to envision control processes within healthcare institutions preventing substance use disorder in the population.
The NIDA article previously mentions prevention, but it goes on to talk about prevention in terms of programs that inform individuals about the hazards of drug abuse, claiming that prevention programs are shown to be “effective in reducing drug use and addiction”. Reducing is not eliminating; it is not preventing.
What got me started down this path was something I saw on-line about an institution creating a “diversion prevention committee”. That aspiration caused me to reflect on the fact that I saw my first diversion case in the late 1970’s and have seen very little to indicate that the problem of diversion has waned in any way more than 40 years later. So, while ASHP Guidelines[2] call out a Controlled Substances Diversion Prevention Program, it seems that the best we can do in reality is make it harder to do and try to intervene more quickly when a caregiver starts to divert controlled substances.
To prevent something, one must first detect it. At the 2019 International Healthcare Facility Diversion Association (IHFDA) Annual meeting, four different facilities presented about their efforts to use currently available diversion monitoring tools to catch diverters. All four asserted that it was very difficult to differentiate between diversion and poor practice.[3]
John Burke, the President and Founder of IHFDA describes operating a task force that concentrated on health-system diversion and notes that, based on the number of cases they found in the Cincinnati area, we should be seeing reports of more diversions in a month than we are seeing in a year[4].
Further, we in healthcare operate under a fundamental assumption of trust. That level of trust is necessary to the smooth patient care handoffs that must occur every day for a variety of causes. As a result, it is extremely difficult for the co-workers of a diverter to conclude that they may be working with someone who may be placing patients in harm’s way until their behavior becomes overt. Kim New[5] points out that the diverter is often the person everyone least suspects. If the culture around controlled substances management is lax, there are no control measures that will reliably prevent diversion. As said in the quote sometimes attributed to Peter Drucker, “Culture Eats Strategy for Breakfast[6].”
It is important to note that maintaining a culture of awareness is hard work. As I have noted in other blogs, we are learning machines, and learn even that we do not intend to learn. In that culture of trust, we quickly “learn” that our co-workers are trustworthy, and it becomes easy to drop one’s guard.
While it is true that personal use is not the only reason caregivers may divert controlled substances, most cases of which I am aware, and certainly those that have been highly publicized[7], started elsewhere and those caregivers who diverted controlled substances were addicted before they began diverting. When their behavior rises to the level of direct visibility, they may be well-advanced in their substance use disorder.
We must remember that one of the hallmarks of addiction is compulsion[8]; the individual with a substance use disorder feels compelled to seek out the drugs, above all other considerations. The result is that they can be truly ingenious in finding ways to trick the system so that they can divert medications. Control measures may impede diversion, but diverters will find other ways.
So, we should not be talking about preventing diversion, because we cannot. Dr. Keith Berge, from Mayo Clinic, cites “Berge’ Law[9]” which, simply stated is:
- Addicts are smart people
- We are smart people
- Addicts are desperate
- We are not
- Therefore: They are going to outsmart us every time
Rather we must be willing to recognize that there likely are individuals with a substance abuse disorder among our caregivers who may be diverting controlled substances and that the methods used to divert are subtle simulations of normal patient care3. The goal must be to identify and intervene on behalf of these caregivers before they harm our patients and, eventually, themselves.
This also means that both we, and any of our analytics, must constantly watch for new patterns of diversion. Management that focuses only on practices that have already been observed is sooner or later doomed to fail.
Since, as previously noted, the differences between diversion and poor caregiver practice are often hard to discern, this means we must be willing to investigate a lot of cases to locate a few true diverters. It must be remembered that the traditional diversion tools (e.g., standard deviation reports) required a lot of investigative “legwork” before a case is referred for active investigation, which results in a relatively light load of cases being so referred. Newer analytics approaches, which automate some, or all of the previously manual investigative activities will result in larger numbers of cases, and more work for the investigators. Given John Burke’s estimates for actual occurrence, this should mean these systems are working.
Control systems are needed; that is beyond question. Proper documentation of the chain of custody not only discourages diversion; it also meets state and federal law. But we must remember that diversion today simulates normal medication administration, and is thus fare more subtle, and difficult to demonstrate.
We can hope that, if our control measures and our culture shifts make it hard enough for someone to successfully divert controlled substances, that they look elsewhere for opportunity, but that simply kicks the proverbial can down the street. Rather, in my opinion, we owe it to ourselves, our colleagues, and our patients, to be diligent in finding diversion when it occurs, and intervening in a compassionate way before it generates harm to our patients.
What do you think?
The opinions expressed in this blog are my own, and not necessarily those of ASHP, or my employer, BD.
Dennis A. Tribble, PharmD, FASHP
Ormond Beach, FL
datdoc@aol.com
[1] NIDA. 2018, June 6. Understanding Drug Use and Addiction DrugFacts. Retrieved from https://nida.nih.gov/publications/drugfacts/understanding-drug-use-addiction on 2022, March 31.
[2] ASHP Guidelines on Preventing Diversion of Controlled Substances viewed at https://www.ashp.org/-/media/assets/policy-guidelines/docs/guidelines/preventing-diversion-of-controlled-substances.ashx on 4-8-2022
[3] The following presentations discussed implementations of advanced analytics but asserted that “cleaning up caregiver practice” was a prerequisite to success:
- Siska M et al, Mayo Clinic Diversion Management Solution and Results
- Patel-House S Testing the Value of Intelligent Analytics for Drug Diversion
- Harper T Integrating Technology to Improve Drug Diversion Auditing within the Operating Room
- Hickey D and Rainey R Establishing Surveillance Reports to Gauge Practices Susceptible to Drug Diversion
[4] Burke J Health Facility Diversion: Our Nation’s Secret presented at the 4th Annual IHFDA Conference, September 26, 2019, copy on file
[5] New K Investigating Institutional Drug Diversion Journal of Legal Nurse Consulting 26(4):15-18 Winter 2015
[6] “Culture Eats Strategy for Breakfast” What Does it Mean? The Alternative Board 2/26/2020 viewed at https://www.thealternativeboard.com/blog/culture-eats-strategy on 4-7-2022.
[7] Eichenwald K When Drug Addicts Work in Hospitals, No One is Safe Newsweek June, 2015 viewed at https://www.newsweek.com/2015/06/26/traveler-one-junkies-harrowing-journey-across-america-344125.html on 4/7/2022
[8] Archives, National Institutes of Health; The Science of Drug Use and Addiction: The Basics NIDA. (2018, July 2). Media Guide. Retrieved from https://archives.drugabuse.gov/publications/media-guide on 2022, April 7
[9] Berge K Chemical Abuse in Anesthesia Personnel: An Occupational Hazard viewed at https://www.yumpu.com/en/document/read/21973693/keith-h-berge-md on 4-7-2022 presented at the 2016 IHFDA Annual Conference by Dr. Keith Berge (copy on file)