A Novel Approach to Monitoring the Diversion of Controlled Substances: The Role of the Pharmacy Compliance Officer

Abstract

Purpose The true extent of drug diversion practices in acute health care settings is unknown. Drug abuse by professional staff may result in jeopardized patient safety discredited organizational reputations, compromised financial outcomes, and endangered community trust. Yet, limitations in reporting drug diversion behaviors by health care professionals precludes quantification of the scope of these practices in nurses, physicians, and pharmacists. This manuscript describes one institution's efforts to monitor drug diversion with the implementation of a novel pharmacy-based role, the Pharmacy Compliance Officer (PCO). Methods Nearly 5 years of PCO experience will be identified and organizational drug diversion methods will be delineated. Common profiles of professional drug diverters in acute care will be depicted with a review of the literature on pharmacist, nurse, and physician drug dependency characteristics. The collaborative process between the PCO and Nursing Directors will be described with particular emphasis on options for validating drug diversion and confronting employees with evidence. Exemplars of drug diversion by professional staff will be highlighted with the use of two case studies. Cost implications will be discussed as well. Results The PCO has assisted with the identification of staff at risk, and responsible for, drug diversion. Implementation of this novel role has facilitated the early recognition of staff with active substance abuse disorders. Our relationship with the State Boards of Pharmacy and Nursing has been enhanced due to this proactive approach to recognizing drug diversion practices in professional staff. Conclusion This contemporary strategy has the potential for replication, particularly in large, diverse, urban, acute care settings, where drug volume is high, information systems are frequently complex; hence, identification of drug-diverting professionals is circuitous.

Diversion of Controlled Drugs in Hospitals: A Scoping Review of Contributors and Safeguards

“…4,10,31,44,[46][47][48][49]56,74 Staff may monitor data from a variety of sources: ADCs and associated analytics, 10,12,21,37,57,[67][68][69]71,73,78,92,93 video surveillance 11,21 (while being mindful of patient privacy 94 ), drug assaying technologies (to verify the contents of wasted drugs), 4,35,49,69,76,77 and biometric access. 37,40,61,73,74 Diversion teams audit high-risk drugs (eg, narcotics, benzodiazepines, propofol, gabapentin) and follow-up on cues that may indicate potential diversion, such as reports of HCW behaviors, 10,12,22,34,56,79,81 patients' reports of untreated pain, 10,31 or outbreaks where multiple patients are infected with the exact same strain (an outcome consistent with a single infectious HCW who may be self-injecting in the course of their diversion). ...…”

“…4,42,50 A colleague's credentials can be used to document that wastage was witnessed, without their presence. 22,31 a For convenience, storage is placed after the procurement stage of the medication-use process because the largest storehouse of controlled drug likely exists in the hospital pharmacy. However, storage occurs elsewhere (eg, in patient areas, delivery trucks) and readers should be cognizant that storage risks occur at multiple stages of the medication-use process, rather than as a discrete step as it may appear in the table.…”

Comparison of 3 Surveillance Methods to Detect Potential Controlled Substance Diversion in an Academic Medical Center

“…Narcotic managers then meet with nurse managers to further review the high-risk users, which allows the nurse manager to provide insight regarding any suspicious behaviors that may indicate potential diversion (eg, cognitive dysfunction, preoccupation with opioid orders, volunteering for undesirable shifts, patient complaints). 9,28,31,32 Three potential outcomes may result: (1) practice issues will be addressed with the nurse, (2) they will be placed on an “active watch” list to review monthly, or (3) a “Code Narcotic” (also known as “Code N”) is initiated. 20,24 If a Code N occurs, the user is given the opportunity to discuss the identified diversion behaviors, which may result in resignation from the organization or rehabilitation with the potential opportunity to return with restricted job activities.…”

“…Substance use disorders afflict approximately 10% to 15% of health care professionals, 1-3 resulting in a 4-year loss of more than 19 million dosage units due to internal diversion of controlled substances (CS) by health care employees to supply an addiction of their own or a friend or family member. 4-7 Internal drug diversion includes any activity whereby regulated pharmaceuticals are unlawfully channeled away from intended use, 8 or more formally, “the unlawful taking of a patient’s medication by a healthcare professional for personal use.” 9 The clandestine nature of diversion complicates the procurement of accurate, contemporary statistics, and while professionals of any discipline may divert CS, multiple studies and case series highlight nursing as the discipline at highest risk, potentially due to perceived poor workplace controls, ease of availability, and frequent interaction with CS. 3,9-17 Recommendations for CS diversion prevention and detection have been provided, 18-25 including comprehensive guidelines from the American Society for Health-System Pharmacists (ASHP), 26 and in a national survey of pharmacy directors, compliance with recommendations was variable.…”

Preventing Large-Scale Controlled Substance Diversion from within the Pharmacy

“…1 The PIC's responsibility to prevent and detect small-scale diversion by hospital employees has received a lot of attention, and many recommendations have been published in the literature. [2][3][4][5][6][7][8] In our experience, most PICs are familiar with this area of concern and devote considerable time to this responsibility. Compared to small-scale diversions, largescale theft of CS from a hospital pharmacy is rare, but it is nonetheless extremely important for the PIC to take steps to prevent and detect large-scale diversion.…”