When I began my career as a pharmacist, I knew drug diversion was a problem but was astonished when I learned its true scope within healthcare settings.
It’s estimated that roughly 10% to 15% of all healthcare workers will misuse substances at some point in their career. While this statistic mirrors that of the general population, it’s a hard figure to accept, given that the general population trusts healthcare professionals with their lives.
Yet it’s also unsurprising, as the ease of access to opioids and other controlled substances within the healthcare environment likely has fueled the decision by some professionals to steal medication from their workplace. More than 8 out of 10 healthcare executives say they’ve met at least one healthcare worker who has diverted drugs, and 73% agreed that most drug diversion goes undetected.
Drug diversion professionals encounter clinicians who divert narcotics with the intent to resell them, as well as those who are struggling with substance use disorders. We are also aware of the customary efforts that healthcare organizations put into preventing drug diversion, from complying with credentialing organizations’ medication management standards to providing staff education and training programs to implementing sophisticated automated medication dispensing cabinets.
But exactly what health leaders should do isn’t always clear. Most organizations already have some type of drug-safety program in place and may believe this preparation alone is sufficient.
Nevertheless, health leaders must recognize diverters are exploiting gaps in the medication distribution process that may not be intuitive or apparent. Patient-safety risks, such as the potential exposure to diseases from contaminated needles, and financial risks, including regulatory fines and the loss of revenue from diverted drugs or reputational harm,are too significant to ignore.
Who’s at Risk?
Nearly every healthcare organization is vulnerable to drug diversion, yet there are certain risk factors that can increase the odds of it becoming a reality.
One example of such a risk factor: the lack of transparency around a new hire’s background. Without visibility into a clinician’s work history, including former employer-led investigations, it’s possible that hiring managers will miss key information. This happened to Lauren Lollini, who contracted Hepatis C in a Colorado hospital because a clinician was diverting pain medication. Lollini noted in a recent essay that if there were more transparency around her clinician’s dismissal from a previous job, both Lollini and the clinician would have avoided their respective outcomes.
Regulatory investigations and legal hearings surrounding a suspected diversion incident may take upwards of 18 months. During this time, clinicians often remain in practice. Incidentally, those seeking new employment after a termination based on suspicious activity or poor practice inspired the passage of a New Jersey Act known as the “Cullen Law.” Named after a nurse who killed dozens of patients at a series of hospitals over the course of 16 years, the law supports information sharing between healthcare entities. However, many states still lack this type of reporting legislation.
Another risk factor is the lack of dedicated drug diversion professionals. A 2021 survey of healthcare leaders revealed that just 45% of healthcare organizations employed one or more fulltime dedicated drug diversion employees, down from 58% in 2019.
A health system’s culture can compound these issues.For example, in some hospitals coworkers may be very hesitant to tell their supervisor if they see a colleague diverting medications or showing signs of impairment because they are afraid of retribution. Their manager may not make a point of encouraging them to share or ensuring their feedback will remain anonymous.
Five Meaningful Actions
No singular solution will eliminate risks, but there are several best practices organizations can adopt to strengthen their drug-diversion mitigation programs, including:
1. Staff training and education. The most critical step in developing a diversion prevention program is equipping staff and managers with the skills they need to recognize drug diversion and the expectation of how to respond. Best practices suggest health systems provide annual training which may include broad discussions topics, such as common red flags associated with diversion, a review of unconscious bias, and a list of resources for additional information and guidance.
2. Compassionate responses. Often times healthcare systems’ strict termination policies leave staff who divert medication feeling like there are no options to seek help. They are afraid if they say something, they’ll lose their job and sabotage their career. Leaders need to be mindful that health care professionals don’t seek out their respective careers with the express intention of developing a substance use disorder and diverting medication. While there are legal obligations to report theft to federal and state regulators and diverters face legal consequences, employee assistance programs and professional assistance programs can provide a kinder, more effective, and compassionate response to offer hope to clinicians who want treatment but don’t want to be fired and barred from professional practice. Studies show alternative to discipline programs are 60% to 90% effective, Pharmacy Times noted recently.
3. Enhancing diversion-detection technologies. Hospitals have become technological hubs, between the wide use of tools such as electronic health records and clinical-decision support applications. These tools should be supplemented by machine learning and/or advanced analytics programs that can pull and distill data from multiple sources (e.g., patient pain scores, employee timecards and aberrant practice reports) and shed light on patterns associated with incidents of diversion. A study published by the American Journal of Health-System Pharmacy showed that advanced analytics and machine learning technologies detected known diversion cases (n=22) in blinded data an average of 160 days faster than existing, non-machine learning detection methods. Decreasing the time to detect diversion offers hospitals a better chance to identify healthcare workers before grave scenarios transpire.
4. Bringing all stakeholders to the table. Drugdiversion does not exist in a vacuum. New or revised policies and procedures aimed at prevention need buy in from all stakeholders — physician leaders, pharmacy leaders, clinical supervisors, legal/compliance teams and other patient-facing staff. Creating a drug diversion prevention and intervention committee comprised of multiple department leaders that meet with a regular cadence can ensure that everyone is aware, engaged, and poised to spread consistent messaging. Healthcare leaders should also partner with their state licensure boards and relevant law enforcement agencies; non-profits such as HealthcareDiversion.org can provide guidance through its unique public-private partnership allowing these diverse stakeholders to collaborate and jointly address the problem.
5. Use of anonymous reporting. Healthcare workers may be more likely to report suspected incidents of diversion if they know they won’t face personal or professional repercussions, particularly if an alternative to disciple program is in place to assist the coworker in question. Healthcare facilities should provide methods for reporting suspected diversion, such as anonymous ombudsman phone numbers. Organizations like HealthcareDiversion.org allow individuals to remain anonymous and report concerns that may not be receiving internal attention at their facility in order to get help for their coworkers.
While none of these five best practices can singlehandedly stop drug diversion, using all of them can significantly curb an organization’s risk. By adopting proactive measures to prevent and address drug diversion, we’re elevating a culture of safety and quality of care within our most trusted healthcare institutions.