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Drug diversion in health care settings

What is drug diversion?

Drug diversion occurs when a medication is taken for use by someone other than whom it is prescribed or for an indication other than what is prescribed. In a healthcare setting, this can involve staff, patients, or visitors, who take medication for themselves, someone they know, or to sell to others. Additionally, tampering (altering or substituting) with medication can be a method of diversion.

Healthcare professionals who divert medications put patients at risk either because they are caring for patients while impaired or needles and injectable medications are contaminated with bacteria, bloodborne pathogens, or other organisms during the diversion process.

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Easy access to medications without appropriate restrictions or documentation creates the opportunity for diversion. Diversion often involves use of readily available medical supplies. Example opportunities for diversion include:

  • Medications left unattended on carts
  • Medications inappropriately disposed of in sharps containers
  • Automated dispensing systems without adequate security settings
  • Medications stored in offices or workstations where personal belongings are stored
  • Medications left unattended during surgical procedures

Bags, flushes, or vials of saline are commonly used to replace diverted medications. However, other clear solutions and medications have been used to replace controlled substances, including tap water.

This article from Mayo Clinic highlights that access is a critical component of drug diversion (Berge et al., 2012). Securing supplies and/or limiting their access to select health care personnel can reduce the risk.

Resources:

The Council of State and Territorial Epidemiologists’ (CSTE) Drug Diversion Toolkit (also available on Centers for Disease Control and Prevention’s (CDC) Drug Diversion webpage) lists signs of diversion and opioid use.

Behavioral patterns that may be associated with drug diversion by a health care personnelSigns of opioid use and withdrawal
  • Unscheduled absences, sick days, and tardy arrivals
  • Frequent disappearance from the worksite, such as frequent long trips to the bathroom or medication storeroom
  • Appearance at work when not scheduled to be there, and volunteering for overtime
  • Arrival at work early and staying late
  • A pattern of removal of controlled substances near or at the end of a shift
  • Alternating between periods of high and low productivity
  • Having poor interpersonal relations with colleagues
  • Insistence upon personal administration of injected medications to patients
  • Heavy or no “wastage” of medications
  • A pattern of holding waste until oncoming shift or wanting to waste with a variety of health care partners
  • Offering to help in non-assigned areas or with patients prescribed opioid medications
  • Preference to work with new health care personnel or orientees
  • Patients not responding as expected to pain medications
  • Replacing or under-dosing patient medication
  • Creating false orders or “prefill” orders prior to approval
  • Constricted pupils
  • Itching or scratching
  • Sweating and/or chills
  • Runny nose
  • Shaking of hands, feet, or head
  • Vomiting and/or diarrhea
  • Stomach camps
  • Anorexia
  • Needle track marks
  • Malaise and/or fatigue
  • Anxiety
  • Insomnia
  • “Nodding Out” or semi-consciousness
  • Depression
  • Apathy
  • Paranoia

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According to CDC, addiction to prescription narcotics has reached epidemic proportions and is a major driver of drug diversion. Health care facilities with opioid pain relievers and other drugs of abuse are at risk for diversion. The Drug Enforcement Administration (DEA) and Centers for Medicare and Medicaid (CMS) have a list of drugs commonly associated with drug diversion, which includes the following:

  • Opioid pain relievers are the most commonly diverted drugs:
    • Codeine
    • Fentanyl (Duragesic®, Actiq®)
    • Hydromorphone (Dilaudid®)
    • Meperidine (Demerol®)
    • Morphine (MS Contin®)
    • Oxycodone (OxyContin®)
    • Pentazocine (Talwin®)
    • Dextropropoxyphene (Darvon)
    • Methadone (Dolophine®)
    • Hydrocodone combinations (Vicodin, Lortab, and Lorcet)
  • Increases in diversion using high-cost antipsychotic and mental health drugs have been reported:
    • Aripiprazole (Abilify®)
    • Ziprasidone (Geodon®)
    • Risperidone (Risperdal®)
    • Quetiapine (Seroquel®)
    • Olanzapine (Zyprexa®)
    • Benzodiazepines (Alprazolam (Xanax®)
    • Clonazepam (Klonopin®)
    • Lorazepam (Ativan®)
    • Additional medication considerations:
    • Anti-nausea drugs, such as ondansetron (Zofran®), might be used to relieve symptoms of withdrawal.
    • Diphenhydramine (Benadryl®) might be used to supplement an opioid given its ability to make the user drowsy and help reduce withdrawal symptoms.
    • Gabapentin (Neurontin®) might be used to enhance the euphoria caused by an opioid, or to stave off withdrawals.
    • Propofol (Diprivan®) may be used because of its impact on levels of consciousness and memory.

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Health care providers who divert prescription medicines or controlled substances, such as opioids, for their own use put patients at risk for healthcare-associated infections. Not only does it result in substandard care delivered by an impaired health care provider, it can deny the patient essential pain medication or therapy. Tampering with injectable medications puts patients at risk for infections such as hepatitis B and C, HIV, or bacterial pathogens when needles and drugs get contaminated.

CDC and state and local public health departments investigate outbreaks of bloodborne pathogens, such as hepatitis C virus, and bacteria associated with drug diversion activities that involve injectable drugs. Articles published by Mayo Clinic in 2012 and 2014 highlight investigations which resulted in outbreaks.

Any patient believed to have been put at risk as a result of drug diversion should be notified promptly and offered bloodborne pathogen (BBP) testing. Health care providers who suspect drug diversion should notify the Colorado Department of Public Health and Environment’s (CDPHE) Healthcare-Associated Infections/Antimicrobial Resistance (HAI/AR) program by calling 303-692-2700 or emailing cdphe_hai_ar@state.co.us. CDPHE investigates the risk of infection associated with drug diversion reports and can assist with patient notification and testing. Additional reporting requirements and reporting forms are available below. Refer to CDC’s Patient Notification Toolkit for best practices.

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There are multiple processes that facilities can implement to help prevent drug diversion.

  • Pre-employment screening
    • Criminal background checks
    • Verification of licenses
    • Drug screening (upon hire and randomly during employment)
    • Written, signed response to the question: “Have you ever been disciplined, terminated, allowed to resign or denied employment because of mishandling a controlled substance or a drug diversion issue?”
    • Staff education, including what to do if they witness, and understanding the risks of drug diversion
  • Enhanced security measures which making diversion more difficult and easier to detect
    • Automated dispensing systems (ADS) are in a medication room with security cameras.
      • ADS cabinets have appropriate settings for timing out, require bio ID (fingerprint) or password, access is limited to staff that administer medications, and reports/data are routinely monitored on the cabinets and all activity occurring in the cabinet.
    • Implementing and enforcing the use of proper medication waste containers to avoid any medication being wasted in sharps containers.
  • Policies and procedures which make diversion more difficult
    • Strict policy not allowing storage or transport of medications in staff member pockets
    • Strict policy which prevents staff from bringing personal items/bags into medication areas
    • Policies dictating expectations for wasting and storage of controlled substances
  • Data review to identify unusual trends
    • Monitoring badge access and movement in the facility
    • Reviewing automated dispensing system records, including dispensing of commonly diverted medications and/or unusual trends such as canceled pulls, duplicated pulls, dispensing without orders, or false orders
    • Reviewing wasting practices and records
  • Encourage a culture of “if you see something, say something.”
    • Ensure staff know how to report and where to report any concerns.
    • Allow for easy and confidential reporting.

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The risk to patients greatly increases when intravenous medications are diverted. Appropriate response by health care facilities includes assessment of harm to patients, consultation with public health officials, and prompt reporting to law and other enforcement agencies.
Ensure that people suspected of diversion are promptly screened for bloodborne pathogens (HIV, Hep B, Hep C) and toxicology. Ideally, screening should occur immediately upon discovery, before the person suspected of diversion leaves the premises. Additional priorities include (but are not limited to):

  • Interview people suspected of diversion and other staff to determine diversion opportunities and methods (e.g., tampering, failure to waste, etc.). An example interview can be found in the CSTE Toolkit.
  • Refer people to Peer Assistance, Colorado Physician Health Program (CPHP), or facility-specific Employee Assistance Programs.
  • Review available camera/video footage.
  • Review available data.
    • Identify shifts/units worked and any visit outside of work hours.
    • Review badge access within the facility, including medication rooms.
    • Review automated dispensing system logs. Consider risks such as:
      • Delayed wastes, missing wastes, overrides, full vial or package wastes, null or canceled transactions, frequency of access, or patterns in access
      • Discrepancies between dispensing records and what was ordered or documented in the health record
  • Report to State and Federal agencies (see below).
  • State regulations
    • Colorado Revised Statute § 25-1-124 requires each licensed health care facility to report “any occurrence in which drugs intended for use by patients or residents are diverted to use by other person” to the Colorado Department of Public Health and the Environment.
    • Colorado Revised Statute §18-8-115 states, “It is the duty of every corporation or person who has reasonable grounds to believe that a crime has been committed to report promptly the suspected crime to law enforcement authorities.”
  • Federal regulations
    • Federal regulations require that registrants notify the Drug Enforcement Agency (DEA) Field Division in their area in writing of the theft or significant loss of any controlled substance within one business day of discovery of such loss or theft.
    • Food and Drug Administration – Office of Criminal Investigations (FDA-OCI) has federal jurisdiction and the expertise to assist facilities when drug tampering occurs.
  • List of enforcement agencies

Drug diversions (suspected or confirmed) must be reported to State and Federal agencies as outlined above. A list of State and Federal agencies and information for reporting are available online.

Below are some resources to help develop a program or form a team to focus on diversion prevention in healthcare settings.

  • Program development: Considerations for a successful program
    • Dedicated personnel for diversion program
      • When possible, establish a dedicated position or program with multiple people to focus solely on drug diversion prevention, monitoring, and investigations. It can be overwhelming to a staff member in an existing role to merge diversion prevention work into their current roles and responsibilities.
    • Determine reporting structure
      • Many health care organizations maintain this program within their pharmacy structure. However, other options include moving the program into a location with more organizational oversight and a structure of reporting directly to senior leaders or the board of the organization. Programs may be placed under Compliance, Risk Management, Legal, Pharmacy, Nursing, or a combination of any of the above. The program lead needs to have access to senior level leaders to have support for the program and be able to escalate events quickly and seamlessly. Often, the program manager is someone with clinical experience in disciplines like nursing or pharmacy. This person may provide awareness about clinical workflows, medication management, and handling that a non-clinical leader may not have.
  • Diversion program development/fundamentals
    • Committee structure
      • An oversight committee for the diversion prevention program is recommended and should be made up of representatives from various areas. Senior level leaders or managers with the authority to make decisions and understand risk and benefits for the organization are most appropriate for this work. Consider representatives from any or all the following groups: Pharmacy, Nursing, Anesthesiology, Medical Directors, Security, Risk Management, Compliance, Legal, Human Resources, Occupational Health, and Employee Assistance Programs.
      • Just like other organizational committees or steering groups, it may be helpful to develop by-laws or a charter to guide and define the work of the committee(s).
      • Many organizations have a Drug Diversion Steering Committee in addition to a smaller subset of this group that is responsible for responding to diversion or suspected diversion incidents called a Response Team. The Response Team should be made up of leaders who can quickly investigate, review information and data, and provide guidance to the diversion program lead on next steps, as well as engage additional support and resources as necessary.
  • Guidance documents: Below are samples of documents that can be used as a starting template for a new program. These documents were developed by collaborative participants representing various health care facilities across Colorado:

Colorado Healthcare Drug Diversion Prevention Collaborative 

This is a group of professionals who focus on diversion prevention and response for health care entities in Colorado or those that have the responsibility for medication security and accounting within their organization. Current members include representatives from various hospital systems, individual hospitals, ambulatory surgery centers, and rural health partners.  Additional participants represent agencies such as public health, drug enforcement, law enforcement, and they are involved as important partners in the larger scope of drug diversion prevention and response in the state.

The group shares knowledge and expertise with others to help address diversion across the state. Participants may share recent cases or trends they are seeing, ask about best practices, or share resources, such as education and training opportunities. The agenda is decided upon by the team and often guest speakers are invited to attend to discuss topics related to drug diversion prevention, monitoring, investigating, and reporting.

The networking group meets quarterly via a virtual meeting platform or in a hybrid setting.

Anyone working in a health care facility in Colorado interested in discussing and improving their practices around drug diversion prevention and response is welcome to join. You do not need to have a formal diversion program established at your facility to participate.

For more information or to be added to the meeting invitations, fill out this online form and a member of the collaborative will be in contact with you.