Detecting and Preventing Drug Diversion in Healthcare

When prescription medicines are obtained or used illegally, it is known as drug diversion. (1) The impact of drug diversion on healthcare organizations can be devastating in multiple ways—from a financial, operational, and patient outcomes perspective.

The American Journal on Addictions estimates that medical professionals are more likely to abuse prescription medications, with higher rates of abuse frequently seen with benzodiazepines and opioid narcotics. (2) This presents a variety of complex challenges to healthcare organizations as they attempt to juggle compliance risks, patient safety, and the financial losses associated with drug diversion.

In 2019 alone, the U.S. healthcare system lost roughly $183 million due to the diversion of drugs from patient care. (3)

A Closer Look at Drug Diversion in Healthcare

Historically, drug diversion has been viewed as taking a patient’s medication for personal or someone else’s use by stealing partial drug doses; stealing full drug doses; diluting a medication; substituting for a real drug; stealing general stock; or even armed robbery and forging prescriptions. (4) The Drug Enforcement Agency (DEA) has recently redefined the definition of drug diversion as the “loss of chain of custody”. This means that healthcare organizations must be able to account for every controlled substance from the time it arrives until the time it is administered or wasted. (4) Organizations who fail to do so may be at a heightened legal and/ or compliance risk.

Drug diversion negatively impacts multiple facets of a healthcare organization, from adverse patient outcomes to the organization’s financial bottom line. Any type of drug is considered to be at risk of diversion; however, the National Institute on Drug Abuse (NIDA) and the U.S. Drug Enforcement Administration (DEA) have identified the following classes of prescription drugs as having the highest potential for diversion and abuse (5):

• Anabolic steroids
• Central nervous system depressants
• Hallucinogens
• Opioids
• Stimulants

Studies show that approximately 15% of pharmacists are confronted with alcohol and/or drug dependency, 10% of nurses struggle with addiction, and 8% of physicians are dependent on drugs. (6)

Healthcare workers who suffer from addiction represent not only an increased risk of errors in patient care, but also an indirect risk of damaging the physician-patient relationship. A Public Library of Science (PLOS) study established a correlation between how patients perceive the wellness of their physicians—through factors such as demeanor and physical appearance—and the quality of the care that they received. (7) A negative view of a physician can be damaging to the physician-patient relationship as well as hinder patient actions such as following care plans. (7)

How to Detect and Prevent Drug Diversion

With a multitude of negative outcomes associated with drug diversion, the importance of prevention is clear. How can healthcare organizations establish programs to effectively detect and prevent drug diversion from occurring?

1. Implement an Incident Reporting System

It’s very difficult for organizations to prevent drug diversion if they aren’t aware that it’s happening in the first place. That’s why incident reporting is one of the most critical components of an effective drug diversion prevention program. Incident reporting allows healthcare organizations to become aware of any incidents, events, or near misses that are occurring across the organization – all in real-time. For instance, if a healthcare worker becomes aware of a shortage in drug doses, they can immediately report the shortage through an electronic reporting form to their department supervisor or risk manager to initiate further investigation.

An electronic incident reporting system allows supervisors to easily keep track of the follow-up management of incidents, including peer review, root cause analysis, and mortality review. Real-time dashboards and analytics can provide deeper insights into exactly where drug diversions are occurring, down to the location, department, and even time of day. The goal is for healthcare organizations to be able to identify areas of risk and get in front of it before a drug diversion event results in patient harm.

2. Establish Written Policies and Procedures for Drug Diversion Response

Beyond establishing an incident reporting process, it’s also important for organizations to address the fundamental elements of a drug diversion prevention program through written policies and procedures. For instance (4):

1. 1. Who will participate on the drug diversion response team?
   2. How will falsification of clinical or inventory documentation be addressed?
   3. How will failure to maintain physical security of medications be addressed? (i.e. unauthorized access and/or unsupervised storage)
   4. Are all stages of the medication use process fully addressed in the drug diversion prevention protocol? (procurement, storage, prescribing, preparation, dispensing, administration, waste/ disposal)

Thinking through these types of questions upfront will help the drug diversion response team be prepared to act appropriately if and when drug diversion occurs within the organization.

3. Form a Drug Diversion Response Team

If your organization does not currently have a drug diversion response team in place, think about establishing a team sooner rather than later. If drug diversion does occur within your organization, you’ll want to have a team that is prepared to respond both quickly and efficiently.

Commonly, either the nursing, pharmacy, employee relations, or risk department will lead the drug diversion response team. (4) It’s recommended to have a multidisciplinary team that includes members from nursing, pharmacy, anesthesia, risk/legal, employee relations, compliance, and security in order to approach drug diversion response with a holistic, comprehensive view of the organization in mind. The response team should also appoint a drug diversion team lead to be the main point-person for decision-making and communication. (4)

By implementing an incident reporting system, establishing policies and procedures for drug diversion response, and forming a drug diversion response team, healthcare organizations can begin to mitigate the impact of drug diversion and improve both patient and employee outcomes to create a safer, more trustworthy environment of care.

References:

1. https://www.cdc.gov/injectionsafety/drugdiversion/index.html
2. Merlo, L. J., Trejo-Lopez, J., Conwell, T., & Rivenbark, J. (2013). Patterns of substance abuse initiation among healthcare professionals in recovery. The American Journal on Addictions, 22, 605–612.
3. https://www.prnewswire.com/news-releases/183m-lost-due-to-healthcare-workforce-diverting-drugs-from-patient-care-in-2019-301131566.html
4. Alexandre Raymond, 2021 Ochsner Health Webinar, Demystifying Detecting Drug Diversion – A Compliance Professional’s Perspective
5. https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/DrugDiversionFS022316.pdf
6. Baldisseri MR. Crit Care Med. 2007 Feb;35(2 Suppl):S106-16 Burke J. Pharmacy Products and Purchasing, May 2019
7. Lemaire, J.B., Ewashina, D., Polachek, A.J., Dixit, J., & Yiu, V. (2018). Understanding how patients perceive physician wellness and its links to patient care: A qualitative study. PLoS One, 13(5), e0196888.