Drug diversion: The crime that affects everybody
Drug diversion is defined as any transfer of a prescription drug from a lawful to an unlawful channel of distribution or use. Often thought of as occurring in the outpatient setting – with doctor-shopping, “pill mills,” and family or friends taking medications not prescribed to them – drug diversion can occur in hospitals and other inpatient facilities. It is a very real and costly problem, with far-reaching effects, often referred to as a “multiple-victim” crime.
The agents in hospital drug diversion may exist anywhere along the employee ladder – physicians, nurses, pharmacists, medical techs, custodians. They do it to serve their own addiction or for financial gain. Opioids are the most commonly diverted drug, but no drug is immune to being abused. In one case, oncology medication that cost $2600/dose was diverted long enough to total $14 million of diverted product.
There are many diversion methods. However, there is one overarching factor: a lack of supervision and oversight. Diverters target those facilities where it is known that: 1) controls are weak; and 2) violators face limited consequences.
The agents in hospital drug diversion may exist anywhere along the employee ladder – physicians, nurses, pharmacists, medical techs, custodians. They do it to serve their own addiction or for financial gain.
Common diversion approaches include:
- Taking medications from storage areas without documentation
- Taking medications and falsifying an order in order to “explain” the missing items – and possibly delaying requests for an MD signature on an order, taking advantage of the time lapse so that a provider may not recall that he/she never actually made that order
- Taking a medication meant for a patient and giving the patient something else (such as saline for IV medications)
- Falsifying waste records while taking the medication for oneself rather than disposing of it properly
- Taking the leftover remnants of medications from the sharps container
- Making pharmacy orders and then taking the delivered medications for personal use, perhaps adjusting inventory records so that inventory doesn’t align with what invoice reads
Consequences are extensive
Patient safety is affected, through medical errors stemming from an impaired employee and through the intentional acts necessary for the diversion – including under-treatment of pain and risk of infection. In one case, a healthcare provider with Hepatitis C who was diverting Fentanyl via syringes potentially exposed almost 30,000 patients to the hepatitis virus. The other staff, who may be working alongside an impaired provider, are at risk – including medico-legal risk if relying on that provider’s skill and judgment. The hospital’s reputation can suffer: falsifying records is a felony, and criminal records become public information. Such acts can jeopardize a facility’s licensure and drug registrations.
There are hefty financial consequences as well, beyond the costs of lost pharmaceuticals, such as accounting for billing errors due to falsified records. Investigation costs are significant, which include time spent by pharmacy and staff reviews, and administrative, HR, and risk management involvement, as well attorney fees. There are costs to the victims (as in the case of those exposed patients who needed to be traced, contacted, and sent for hepatitis testing). Indeed, one estimate is that the cost of controlled prescription drug diversion and abuse to both public and private medical insurers is $72.5 billion per year.
What’s to be done?
Measures can be taken. For example, insurers can advise contracted facilities to have policies and procedures, not only for the prevention of diversion, but also for the management of detected diversion practices. Preventative policies may include both scheduled and random audits of pharmaceuticals and charting; electronic monitoring; a checks-and-balances system surrounding controlled substances – including a required two-person sign-off when such substances are being administered or disposed of; and stricter standards for chart completion, including physician signatures on telephone orders. Facilities should perform drug-testing and background checks as part of the pre-employment process.
Further, hospital employees need to be educated on the risks of diversion; the systems that are in place to monitor and detect it; and their role in reporting suspected illicit practices. Continuing education can also include detecting and addressing impaired co-workers who are struggling with substance use.
If an employee is guilty of drug-diversion practices, there should be a clear plan as to how to address it. To start, facilities need to consult its state’s regulations and licensing boards. They have to be sure the employee can no longer access the hospital. Additionally, they need to submit the appropriate reports to prevent the offender from getting hired at another facility. It is important to note that HIPAA does not protect one’s confidentiality if fraud or other criminal acts have been committed.
In brief, hospitals need to develop and follow a drug-diversion protocol. Suspected prescription drug abuse incidents can be reported to the Drug Enforcement Agency’s online portal: https://apps.deadiversion.usdoj.gov/rxaor/spring/main?execution=e1s1.