Drug Diversion in the Workplace

Kimberly Miller, RN, BSN, MCOctober 4, 2014

Definition of Drug Diversion

Diversion - “Any criminal actinvolving a prescription drug.”

Uniform Controlled Substances Act (1994)

What to Expect

• Historical Overview of Diversion by Nurses• Factors Associated with Diversion• Preventing, Identifying, and Investigating

Diversion• Impact on Patients• What’s on the Horizon• Nursing Community Response

Diversion: Then to Now

• Historical– Moral behavior– Studies of addiction in nurses– Alternative to discipline programs– Automated systems to manage medications– Pain as the sixth vital sign– Expanding RN controlled substance administration – Media– State and Federal laws

Scope of the Issue

• Opioid Use– Use of opioids in the US– Use of opioids by nurses– Recreational use of opioids

• Frequency of Diversion

• Practice after Diversion

Why Divert?

• Addiction• Pain Management• Mental Illness• Personal Issues• Provide to Others• Barter or Sell

Addiction

• Chronic illness–Diagnosed by a cluster of behaviors

and physical symptoms–Evidence of biochemical brain

alterations

Brain Neurobiology

In the Ventral Tegmental Area of the mid-brain, neural circuits and neurochemicals create a mechanism to enhance brain plasticity related to reward, motivation, and learned behavior.Examples: quenching thirst, satisfying hunger, sex, sleep

Activation of Dopaminergic System

Sex Increased dopamine level

Pleasurable reinforcement

Repeat

Reinforcement of survival activity

Neurobiology of Addiction

• Chronic exposure to addictive drugs results in neurochemical changes in the brain that hi-jack the intended function and reinforces further drug use.

Use drug Increase synaptic dopamine level

Euphoria and sense of well-

being

Volitional behaviors become habits, which become compulsions through Pavlovian learning.

Other Illnesses Associated with Diversion

• Chronic PainExtended opioid useNo or failed tapersFear

• Mental IllnessUndiagnosed or treated

Self-medicating

Personal Issues Associated with Diversion

• Personal management– Stress management– Sleep disturbance

• Recreational use• Provide to others• Barter or sell

Preventing, Identifying, and Investigating Drug Diversion

• Develop Controlled Substance Management Systems (CSMS)

• Periodic Review of the CSMS• Monitor Controlled Substance Data• Educate Staff/Communicate Expectations• Investigate Suspected Diversion and

Tampering• Develop an investigations team

Controlled Substance Management System

• Determine an Organizational Team to Develop the System and Determine Protocols

• Determine a Multi-Disciplinary Team for System Oversight and Diversion Investigation

• Determine Overall Organization Communication and Policies

Pharmacy to Unit: Maintaining Chain of Custody

• Enter Available Drugs Into Electronic System• Secure Storage and Transfer• Customize Drug and Dose Supplies to Unit

Needs• Periodic Monitoring of Supplies

On the Unit: Maintaining Chain of Custody

• Controlled Access– Bio-identifiers v passcodes– Overrides, Cancelled Remove– Blind Counts/Count Backs

• Drug Handling by Nurse– Selecting appropriate dose– Congruent assessment and dose– Timely administration– Accurate and timely documentation– Timely waste of excess dose – witnessed

Communicating Expectations

• Clear policies with nurse involvement in development

• Consequences for failing to follow policies• Review of handling issues with staff• Stop work around practices and short cuts

Identifying Possible Diversion: Nurse Behaviors

• Repeatedly withdraws large doses or multiple doses at one time

• Volunteers to medicate other patients• Misused automated system functions• Keeps medications for greater than 30

minutes – or leaves med for others to use• Frequent “mishaps” when handling drugs• Frequently requests drug order changes

Suspected Drug Use Behavior

• Change in attitude and/or behavior• Change in personal appearance• Frequent illness or tardiness• Frequently takes on extra shifts• Slurred speech, drowsiness, constricted pupils• Poor organization and documentation• Frequently off the unit/missing

Investigation

• Consult with drug diversion team – remove access

• Review withdrawal, administration, and waste documentation – discrepancies or patterns

• Compare drug administration with that of other nurses – typical patient use

• Review automated system functions use• Interview and toxicology screen

Tampering & False Prescriptions

• Replace medication with another drug or substance

• Dilute injectable medications• Altered or false prescription submitted• Filling prescriptions for patients

Risks to Patients

• Inadequate pain management• Nurse inattentive or impaired• Other providers are working with inaccurate

information• Patients develop fear or mistrust of healthcare

Nursing Community Responsibility

• Opioid use by nursing students• Inadequate availability of addiction treatment

focused on the specific issues facing nurses seeking rehabilitation

• Minimize risks to patients• Better management of re-entry into practice• Need for research

Resources• American Association of Colleges of Nursing. (2012). Policy and guidelines for prevention and management

of substance abuse in the nursing education community (Updated 1998). Washington, D.C.• Angres, D.H., Bettinardi-Angres, K., & Cross, W. (2010). Nurses with chemical dependency: Promoting

successful treatment and reentry. Journal of Nursing Regulation, 1(1), 16-20.• Bell, D., McDonough, J., Ellison, J., & Fitzhugh, E. (1999). Controlled drug misuse by certified registered

nurse anesthetists. American Association of Nurse Anesthetists, 67(2), 133-140.• Bettinardi-Angres, K., & Bologeorges, S. (2011). Addressing chemically dependent colleagues. Journal of

Nursing Regulation, 2(2), 10-15.• Crowley, K., & Morgan, C. (2014). Re/entry: A guide for nurses dealing with substance use disorder.

Indianapolis, IN. Sigma Theta Tau International. • Health Professionals Assistance Program – South Dakota. http://doh.sd.gov/boards/nursing/healthpro.aspx• Health Professionals Services Program – Minnesota. www.hpsp.state.mn.us• K.H. Berge, K.R. Dillon, K.M. Sikkink, T.K. Taylor, &W.L. Lanier (2012). Diversion of drugs within health care

facilities, a multiple-victim crime: Patterns of diversion, scope, consequences, detection, and prevention. Mayo Clinical Procedures, 87(7), 674-682 http://dx.doi.org/10.1016/j.mayocp.2012.03.013

• Road Map to Controlled Substance Diversion Prevention. www.health.state.mn.us/.../drugdiversion/divroadmap041812.pdf

• What You Need to Know About Substance Use Disorder in Nursing (brochure). communications@ncsbn.org