Drug Diversion

Drug Diversion – the act of illegally obtaining, using, or distributing prescription drugs – threatens the integrity of our healthcare system, and long-term care providers in particular.

Drug diversion can cause serious harm to residents. It can result in inadequate pain relief, exposure to infectious diseases like Hepatitis C or bacterial pathogens, and unsafe care from healthcare workers who are impaired. Healthcare workers who divert prescriptions put themselves at risk for addiction, overdose, death, criminal prosecution, and criminal malpractice suits. Care facilities as a whole face serious consequences such as fines for failed safeguards, loss of eligibility for Medicare or Medicaid reimbursement, and compromised public trust from the publicity of drug diversion cases.

One report found that long-term care facilities account for 18% of all drug diversion incidents. Another survey found that 11% of seniors experienced drug diversion issues with staff in their own facilities. A major driver of drug diversion is opioid abuse. The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) and the American Nurses Association (ANA) suggest that about 10 percent of healthcare workers are abusing drugs.

Drug diversion can be perpetrated by family members or friends of a resident, staff members, doctors, and pharmacy employees. Several factors that make long-term care settings particularly susceptible are the vulnerability of the populations they serve, the delegation of medication administration to trained but unlicensed staff, and the failure of some settings to have a clearly-defined policy and procedure in place in managing opioids and other controlled substances.

Long-term care facilities bear the responsibility of ensuring that drug diversion is not endangering their vulnerable clients, that they are not enabling the illicit use of controlled substances by staff or families, and that they maintain the integrity of our healthcare system.

Preventing and Minimizing Risk of Drug Diversion

Awareness and recognition of drug diversion are the first steps to prevention because “it’s happening in every organization,” says Ann Koeniguer, RPh, pharmacy operations manager at HCA Midwest in Kansas City, MO. Accepting the reality of the drug diversion and understanding it is a possibility in every facility makes it easier to counteract and prevent.

1. Be aware of medications in use at your facility, and set strict requirements for tracking any medications at risk for abuse. The Drug Enforcement Administration (DEA) recognizes five classes of drugs that are frequently abused: opioids, depressants, hallucinogens, stimulants,and anabolic steroids.
   Fentanyl—one of the most potent opioids—is the most commonly diverted drug, and is the lead opioid in causing deaths due to opioid overdoses.
2. Be alert to evidence of tampering in bubble-packed cards.
3. Limit the amount of controlled substances on hand – avoid overstocking.
4. Be attentive to staff behavior, appearance, and other key indicators. Experts believe that only a fraction of those who are diverting drugs are ever caught, despite clear signals such as abnormal behaviors, altered physical appearance, and poor job performance.
5. Resident reports of unrelieved pain need to be scrutinized. Staff diverting pain relieving drugs may substitute a non-narcotic and ‘pocket’ the controlled med. Review efficacy of pain relief and look for patterns if pain spikes occur under certain staff’s care.
6. Paper documentation systems leave room for staff to alter or forge data. Electronic health records with secure logins leave little if any room for altering health records.
7. The very nature and complexity of medication management and administration processes can make the detection of diversion of controlled substances difficult or nearly impossible without a comprehensive software management program. Meds charted in real-time allow nurses up-to-the minute accounting of medications and
   alerts to discrepancies.

• Comprehensive nursing assessment of resident medication needs
• Medication entry, including resident-specific, detailed instructions for staff to follow
• Links to the National Institute of Health database, giving staff up-to-date information on medications
• Pharmacy Connect integration with the pharmacy that serves as a periodic medication reconciliation
• Facility control over what meds are considered controlled
• A comprehensive system of pill counting that accounts for controlled medications at multiple points throughout the med process – from
  documenting receipt from the pharmacy, at med review, administration of scheduled or PRN doses, with shift counts, if sending medications out-of-facility with family, and at discharge or with the documented destruction of medications
• Witnessed pill counts at shift count or with receipt of controlled meds or destruction
• Declined medications require a note of explanation, and are easily reviewed by the nurse
• Required PRN follow-ups can alert nurses if an administered PRN med is not effective (as in the case of a pill substitution)
• Nurses or administrators can be notified of pill count discrepancies via a dashboard at login OR by text message or email alert
• Reports can show if any one staff person is administering markedly higher numbers of controlled medications
• Complete Pill Count History Reports can highlight where count discrepancies occurred

Sources

1. Gartley, C. E.(2021, November 29). Drug diversion in Healthcare. American Nurse.
   Retrieved July 28, 2022, from https://www.myamericannurse.com/drugdiversion-in-healthcare/
2. Elaine HowleyElaine K. Howley is a freelance journalist for various publications.
   An award-winning writer specializing in health.(2020, September 9). Curbing
   opioid abuse and diversion in long-term care facilities. I Advance Senior Care.
   Retrieved July 28, 2022, from https://www.iadvanceseniorcare.com/curbingopioid-abuse-and-diversion-in-long-term-care-facilities/
   #:~:text=Ninety%2Dfour%20percent%20of%20these,to%2017%25%20in%2
   02018.%E2%80%9D
3. Drug diversion in the Medicaid program. CMS.(n.d.). Retrieved July 29, 2022, from https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/
   Medicaid-Integrity-Program/Education/Resource-Library/drug-diversionmedicaid-program
4. Drug diversion and impaired health care workers – joint commission.(n.d.). Retrieved
   July 29, 2022, from https://www.jointcommission.org/-/media/tjc/newsletters/
   quick_safety_drug_diversion_final2pdf.pdf