The Uniform Controlled Substances Act of 1994 Section 309 defines “diversion” as “the transfer of a controlled substance from a lawful to an unlawful channel of distribution or use” (http://www.uniformlaws.org/shared/docs/controlled%20substances/UCSA_final%20_94%20with%2095amends.pdf). In 2012 Physicians at the Mayo Clinic examined diversion in health care organizations and recognized that all health care organizations are not exempt from diversion activities, even themselves. In this publication, diversion is recognized as a “multi-victim crime” and discussion ensued about the necessity for health care organizations to develop systems that not only detect and prevent issues but to identify and respond to current ones (Berge, et.al. 2012). The United States Drug Enforcement Administration (DEA) communicate that “Diversion investigations involve, but are not limited to, physicians who sell prescriptions to drug dealers or abusers; pharmacists who falsify records and subsequently sell the drugs; employees who steal from inventory and falsify orders to cover illicit sales; prescription forgers; and individuals who commit armed robbery of pharmacies and drug distributors” (https://www.dea.gov/ops/diversion.shtml).
Berg, et. al. 2012, also identified that anesthesia personnel, which includes both physicians and nurses, are at the greatest risk for diversion activity due to their direct access to necessary anesthetic medications. It is also noted by the Premier Safety Institute that outpatient settings are where most diversion activity occurs (http://www.premiersafetyinstitute.org/safety-topics-az/opioids/drug-diversion/). As noted above however, the DEA identifies that this risk involves many more health care professionals than anesthesia personnel and those in outpatient settings. In my opinion, it would be harmful to focus diversion proofing activities on only one or two health care professions or locations. Reality is that diversion proofing activities must address all professions within the health care system from Administration to bedside care providers and both inpatient and outpatient settings. Again, in my opinion, as health care providers we must assure that we do not contribute to the minimization of the problem by pointing fingers at each other, but rather solve the problem by considering all at risk, and strengthening our prevention strategies collaboratively in all areas of health care service.
At the end of this criminal activity it is the patient who suffers most. According to the Centers for Disease Control (CDC) this suffering includes but is not limited to denial of necessary treatment for pain, substandard care as a result of an impaired care provider, and increases in infection rates as a result of drug tampering (https://www.cdc.gov/injectionsafety/drugdiversion/index.html). Shafer & Perez, 2014 demonstrate the impact of diversion activity when they reported the results of their CDC records review, this is directly quoted,
“We identified 6 outbreaks over a 10-year period beginning in 2004; all occurred in hospital settings. Implicated health care professionals included 3 technicians and 3 nurses, one of whom was a nurse anesthetist. The mechanism by which infections were spread was tampering with injectable controlled substances. Two outbreaks involved tampering with opioids administered via patient-controlled analgesia pumps and resulted in gram-negative bacteremia in 34 patients. The remaining 4 outbreaks involved tampering with syringes or vials containing fentanyl; hepatitis C virus infection was transmitted to 84 patients. In each of these outbreaks, the implicated health care professional was infected with hepatitis C virus and served as the source; nearly 30,000 patients were potentially exposed to blood-borne pathogens and targeted for notification advising testing” (http://www.premiersafetyinstitute.org/wp-content/uploads/Schaeffer-Perz-Drug-Diversion-MayoClinProc-June-2014.pdf).
Health Care is a patient first culture and we must be able to treat pain effectively for patients to experience healing and quality of life. However, to assure patients are receiving the care they deserve, and are at reduced risk for harm, we must become more aggressive in our approaches to dealing with this diversion issue. Recognizing that there is a statistically high rate of narcotic use in our country, according to Premier Safety Institute, “In 2015, 97.5 million people age 12 or older were past year users of opioid prescriptions” (http://www.premiersafetyinstitute.org/safety-topics-az/opioids/drug-diversion/) we have our work cut out for us. Most of this usage may have been for legitimate reason and a necessary care need and it may be impossible to eliminate all diversion activity. We can however, improve our systems and do all we can to prevent it, identify it, respond to it, and strive for a zero tolerance culture.
What strategies are there for the prevention of diversion activities? There are many, as diversion is not a one-sided issue. These activities include but are not limited to:
- Monitoring for and reporting insurance fraud
- Monitoring for and reporting prescription abuse
- Assuring safe medication administration processes
- Assure strict medication disposal processes
- Educate all staff and health care providers
- Assuring the laws are followed
- Developing and supporting a “safe” reporting culture
- Performing thorough chart reviews to identify missing and inaccurate medication documentation practices
- Establishing and following “no tolerance” policies
- Lobbying for stronger licensing penalties
- Promptly respond to and investigate any reported concerns, such as patients un-relieved pain or missing prescriptions
- Setting automated systems on the strictest dispensing settings to assure accurate dose dispensing
- Collaborate with other organizations, professions, and associations to learn how to balance the legitimate use and need with reduction of diversion risk
I hope you have enjoyed this week’s Talk Tuesday and can find at least one take away or resource that you can employ to contribute to the reduction of diversion risk in your organization or individual practice.
If you are interested in seeking my services as a legal nurse consultant in the areas of nursing assessment, diagnosis, planning, implementation or evaluation of your care environment and practices, I would love the opportunity to talk with you. If you are an attorney in need of medical chart review, or expert opinion, I am available to discuss your needs. To review my services and to contact me please visit https://upvisionconsulting.com/
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The Legal Nurse
Berge, K.H., Dillon, K. R. , Sikkink, K. M., Taylor, T. K. , & Lanier, W.L. (2012). Diversion of Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention. Retrieved at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538481/pdf/main.pdf
Centers for Disease Control at https://www.cdc.gov/injectionsafety/drugdiversion/index.html
Premier Safety Institute at http://www.premiersafetyinstitute.org/safety-topics-az/opioids/drug-diversion/
Shafer, M.K., Perez, J.R. (2014). Outbreaks of Infections Associated With DrugDiversion by US Health Care Personnel. Retrieved at: http://www.premiersafetyinstitute.org/wp-content/uploads/Schaeffer-Perz-Drug-Diversion-MayoClinProc-June-2014.pdf
The Uniform Controlled Substances Act of 1994 Section 309 at http://www.uniformlaws.org/shared/docs/controlled%20substances/UCSA_final%20_94%20with%2095amends.pdf
The United States Drug Enforcement Administration at https://www.dea.gov/ops/diversion.shtml