Drug diversion in nursing puts patients, staff, and communities at risk. With 18% of nurses showing signs of substance use disorders, supporting nurses to prevent drug diversion is essential.
A nurse working in the Cardiovascular Stepdown Unit was flagged with medication management issues, specifically high dispenses of controlled medications, late or delayed wasting, and missing medications. The nurse is new to the unit and has little connection with the other staff in the department. The investigation was initiated quickly, with cooperation from nursing leadership. During the interview, the nurse in question admits to diverting medication and requests assistance finding a recovery program. The early detection of drug diversion and buy-in from leadership meant that time lapsed from incident discovery to interview was 2 days.
A nurse working in the General Surgery Unit was also flagged for medication management issues. However, this nurse worked in the same unit for almost 20 years and has close personal relationships with other staff in the department, including the nurse manager. The investigation was delayed when the nurse manager pushed back on the process and refused to believe this nurse was diverting medications. Three attempts were made to interview the nurse in question, ultimately ending with the nurse manager warning the nurse that there would be a drug screen. The nurse fled the facility, admitting, "I can't do that. I took it". The time between incident discovery and the nurse leaving to avoid the interview was over 90 days.
Drug diversion in nursing: Understanding the scope and impact
While these situations are similar in terms of avenues of discovery and activities, the outcomes of these investigations were completely different. Ultimately, the less assertive approach resulted in three months of additional risk of further diversion and potential patient harm. It also lets the nurse continue to self-harm despite their cry for help. These outcome differences highlight why you can't delay conducting drug diversion investigations. Apathy does not equal empathy. You must approach the investigation with the understanding that it benefits the nursing professional more than it hurts them and will require more engagement, not less. Regardless of the reason, the dismissal of flags or indicators often leads to more vulnerability and risk.
Causes of addiction
Nurses are particularly vulnerable to opioid addiction due to the intense physical and emotional demands of their profession. They face long hours, high-stakes decision-making, emotional exhaustion, and frequent exposure to trauma, which can lead to chronic stress and burnout. The accessibility of controlled substances leads many nurses to opioids to manage pain, both physical and psychological, not realizing how easy it can be to fall into dependency. According to the American Journal of Psychiatry, opioid use disorder (OUD) often begins with attempts to self-medicate stress or pain, eventually impairing function and leading to addiction.
We must recognize the significance and severity of the issue and make sure our efforts to prevent it match the priorities. We talk a lot about patient harm, but there are two people getting harmed: the patient and the nurse who is about to be a patient themselves.
Implications of underreporting
In our State of Drug Diversion survey, 80% of respondents believe that most drug diversion in hospitals goes undetected, and the majority are not confident in the effectiveness of their current drug diversion program. The combination of the highly addictive nature of the drugs and the lack of detection leads to issues with patient safety, workplace integrity, and raises costs.
In 2023, Wolters Kluwer spoke with nursing professionals about their experience with drug diversion in nursing. Ann Marie, a nurse in recovery from substance abuse, commented on the reality of this issue. "Even at 10%, that means in an average surgical team, at least one nurse could be struggling with substance use disorder."
The role of stigma in underreporting and delayed intervention
As portrayed in the second story about the nurse from the General Surgery Unit, there is a desire to protect the nurse by shielding them from reporting. There is a stigma around reporting where no nurse wants to blow the whistle on their friends and coworkers. In addition, the nurses themselves don't want to lose a career they may be passionate about. There needs to be a concerted effort to remove barriers to help through an effective drug diversion program that detects issues quickly and adds employee assistance programs that lend support to the nurses. As Anne Marie goes on to say, "Programs must eliminate stigma and show nurses that asking for help won't end their careers." Deborah Koivula, who also joined our conversation in 2023 and is part of the state peer assistance for nurses program with the New York State Nurses Association, stated, "Many nurses later say they're grateful diversion was spotted because it brought them the help they didn't know how to ask for."
Understanding accountability and immediate risks
Healthcare drug diversion programs are often faced with an interesting obstacle: maintaining a balance between accepting accountability and recognizing risk. Due to DEA registration, the organization must accept that significant accountability rests within the pharmacy department. On the other hand, a large portion of the risk exists in the nursing department. Direct patient care conducted by nursing requires medications to be dispensed, opened, administered, and wasted. By its very nature of patient care, this stage in the medication management process contains an elevated level of vulnerability.
Best practices in prevention and education
As a result, the question remains for many healthcare systems: how does an organization build a program that enables the pharmacy to stay accountable while simultaneously creating a culture that doesn't make nursing feel targeted? The answer rests in the spirit of the approach, keeping healing as the primary goal.
The healthcare industry is built on a culture of healing. Healthcare professionals are trained to recognize the signs of disease or illness and then rush to the individual's needs to help start the healing process. Most nurses take their work home with them, fielding questions from family and friends regarding fevers, scrapes, ailments, and new diagnoses. These nurses jump at the opportunity to help those they care about because it is in their blood. It is why they chose the field they are in.
Unfortunately, this culture comes to a halt when a nursing professional is suspected of drug diversion. Suddenly, the culture of healing transitions to a punitive culture set on “getting the bad guy.” When you remove empathy from the process, the sterile act of trying to identify the individual who is diverting and removing them from patient care can feel unsupportive. How can the healthcare industry create an environment that encourages engagement and transparency? How can an organization build a program that focuses on identifying the individual diverting to help them in the same way other diseases are addressed, through resources that heal and restore? Education and awareness play a crucial role in cultural change, acting as the foundation or cornerstone.