Attempting to estimate the scope of professional drug diversion
Dr. Kenneth Mishark, a hospitalist and Vice-Chair for Diversion Prevention at Mayo Clinic in Phoenix, AZ, spoke on the devastating realties of drug diversion, the difficulties of trying to solve a crisis that’s not been thoroughly studied, and emerging solutions in the Scottsdale Institute webinar “Drug Diversion: The Never-ending Chase.” The presentation was sponsored by Wolters Kluwer Health.
Based on data published at the 2022 annual conference of the International Health Facility Diversion Association, Mishark noted in the webinar that a state with 90,000 registered nurses may have an estimated 9,000 with a substance use disorder, but only around 430 of them are likely being monitored. “It’s just another way of saying we’re way under-touching what’s really going on and that is a huge problem.”
Estimating and understanding diversion, Mishark says, “basically is like grabbing smoke.”
How does healthcare define drug diversion?
The National Association of Drug Diversion Investigators officially defines drug diversion as “a medical and legal concept involving the illegal movement, adulteration, marketing, or transfer of any legal controlled substance anywhere within the supply chain; from manufacturer to end user.”
But Mishark says it’s simpler to think of it as the theft of any medication for:
- Use by self
- Use by family or friends
- To sell for profit
“A very common misperception is diversion is only controlled substances, so things like narcotics. But really, we have every bit as big a problem with high-dollar [products] like Botox,” Mishark explains. He also notes that any habit-forming or psychogenic substance can be a temptation for diversion, including anti-anxiety medicines and sedatives, stimulants, sleep aids like Ambien, and even anesthetic gases.
Factors leading clinicians and professionals to divert medications
When it comes to drug diversion in hospitals, Mishark notes there are four key things administrators and those working on prevention strategies need to understand:
- The problem of drug diversion has suffered from a lack of formal study, and what literature there is “sloppy.”
- Most “facts” about the issue are actually expert opinion.
- Definitions surrounding diversion, what constitutes it, and related protocols are poorly standardized.
- Organizations tend to hide incidents of diversion rather than reporting it for analytics and study, perpetuating the above listed issues.
Because of this dearth of standardized reporting and literature, it is difficult to get a secure scientific handle on the depth, breadth, and roots of the problem. But, Mishark says, there are some perspectives about diversion that the industry can and does largely agree upon.
“Compassion fatigue is very real,” he says. Between the emotional burnout from the stress of healthcare work and the physical strain caused by long hours and the lifting and bending that care work often requires, “we all live with a certain amount of pain,” he explains. “Sometimes self-medicating that works. People have a false sense of control, thinking, I gave a little bit of morphine to my patient and look at how well they did with their pain. I can do this same thing” for me.
While alcoholism can also be common among stressed healthcare workers, Mishark says the growing frequency of diverting hospital medications occurs because, “quite frankly, the biggest problem is, it’s widely available.”
Who are the diverters?
Mishark says, when investigating diversion cases, one of the most “shocking” aspects is who the perpetrators often are.
“The number of times we’ve caught somebody, and the comment is, ‘This is the best nurse on the floor. They’re the preceptors, the award winners.’ They’re the hard workers,” he says. “Those are the people who are diverting, and that is not something you commonly expect.”
The reason why diverters frequently present not as visible addicts or troubled employees but star employees, he explains, is that they need the hospital to be their source for medication. “So, by helping nurses, by coming in early, by staying late, by offering to give other nurses’ medications to their patients, they’re staying near the source.”
How do we combat drug diversion?
In addition to standards in place regarding packaging, storage, and dispensing of controlled substances, there are simple protocols Mishark says facilities can put in place to monitor diversion:
Badges: A practice he recommends is badging restrooms to track how often, and more importantly when, employees visit them. “We had a diversion case where somebody went to a pill crusher and then immediately to the restroom and again and again and again. Patterns like that are what you look for.”
Cameras: Mishark advises cameras over all medication dispensing areas, but not for the reasons you might think. “The useful part about a camera is in the majority of cases of suspected diversion, it exonerates the people. If you miscount the narcotics and you’re on camera, it’s very easy to see how you [accidentally] miscounted.” Nonetheless, he says that cameras are often rejected from plans due to complaints about aesthetics or budgetary constraints.
Hotlines: “Most of our diversion cases come from people reporting other people,” Mishark says, “and you’ve got to make that as easy as possible.” Anonymous compliance hotlines with easily accessible 24-7 text or page options are helpful.
Advancing technology to reduce diversion risk
Technology-based diversion tracking programs, particularly newer AI-enabled software are becoming an essential part of the fight against diversion, Mishark notes.
“They all look for data and patterns. And they use those data and patterns to generate a risk score,” he explains. “What all of these programs try to do is follow the chain of custody of [a drug product] across its lifespan.” That can include analyzing waste from medication use.
Also important is documentation of controlled substances and medications within the electronic health record. Medi-Span from Wolters Kluwer offers controlled substances data solutions integrated into EHRs and other systems to support U.S. federal, state, and local verification, monitoring, and reporting requirements.
Although there is no ideal solution, technology is getting better at tracking signs of diversion, Mishark says. “It’s very helpful for being able to say, ‘We have a clue. Let’s track it.’”
While fighting diversion feels like an insurmountable challenge at times, Mishark concludes, “Our goal is to get smarter and smarter and try to do better and better.”
To learn more, watch the webinar, “Drug Diversion: The Never-ending Chase.” This webinar was first presented to the Scottsdale Institute Members.