Data released in 2007 by the U.S. Substance Abuse and Mental Health Services Administration estimated that an average of 103,000 doctors, nurses, medical technicians, and healthcare aides a year were abusing or dependent on drugs. Most drug diversion by HCWs is not discovered, and when it is discovered it is often not reported or prosecuted. Precise data on drug diversion in individual hospitals is difficult to obtain due to the clandestine nature of diversion and the culture in place in many healthcare institutions that leave diversion undiscovered and unreported.
The estimated cost of just Controlled Substance drug diversion and abuse to public and private medical insurers is $72.5 billion a year, much of which is passed to consumers through higher health insurance premiums (National Drug Intelligence Center, 2009). The overall economic cost of drug abuse in the United States was estimated at $193 billion in 2007 (Office of National Drug Control Policy, 2016).
Drug diversion is a significant crime with multiple victims – patients, HCWs, hospitals, and communities
- For patients, diversion can lead to them receiving substandard care from an HCW with a substance abuse disorder whose job function is impaired by drugs. The HCW might also divert prescribed pain medication away from patients who require them. Also, there have been multiple documented cases of diverting HCWs infecting dozens of patients with Hepatitis, HIV, or other blood-borne infections when the HCW uses a shared syringe to divert the drug.
- For healthcare workers, nearly every hospital has employed people with a substance use disorder, and many facilities have dealt with the overdose death of an HCW, often on hospital premises. Beyond general risks to health, drug diversion often ends with civil malpractice actions, loss of professional licenses, and/or felony criminal prosecution for theft and fraud. Annually, hundreds of HCWs forfeit their training and medical license following diversion and subsequent abuse.
- For hospitals, there is significant financial damage when drug diversion occurs. Stolen drugs must be replaced without reimbursement, with additional costs due to absenteeism and turnover by addicted HCWs. When drug diversion stories hit the press, hospitals see millions of dollars in lost revenue and fines. For example, Massachusetts General Hospital paid the DEA a $2.3 million settlement when its employees stole thousands of pain pills. These stories also damage the hospital’s reputation in the community and harm employee morale. In cases where HCWs have entered falsified administration data, and payers were charged for diverted drugs, these fines can involve the False Claims Act or Medicaid fraud, with triple damages.
- For communities fighting drug abuse, healthcare workers could divert drugs for personal use or provide for others. In 2014, a review of more than 200 prosecutions since 2008 for drug diversion by HCWs discovered just 15% of the prosecuted HCWs were stealing drugs for personal use. Shockingly, many involved doctors, nurses, and other HCWs were diverting on a large scale, for profit, sending thousands of unprescribed pills to drug abusers in the community.
Problems with current methods to detect drug diversion
Current approaches to preventing drug diversion in hospitals include three complementary techniques:
- 89% of U.S. hospitals lock up narcotics and other addictive drugs in Automated Dispensing Machines (ADM) like Pyxis and Omnicell machines.
- Most hospitals run “Anomalous Usage” reports that compile ADM data to flag HCWs with unusually high Controlled Substance usage, using commercial off-the-shelf software (COTS) like Pandora or RxAuditor. Unfortunately, these reports contain significant errors, both Type II “false negative” errors, in that they fail to detect actual drug diversion cases, and Type I “false positive” errors, in that the reports flag normal events as possible drug diversion. Type II false negatives let diverters getaway, while Type I false positives rob hospital staff and supervision of precious time investigating innocent people.
Hospitals typically set an arbitrary threshold of 2-3 standard deviations to define “anomalous” usage, and this arbitrary approach guarantees 0.3-4.5% of HCWs are flagged as potential diverters, most of which is Type I error.
- Many hospitals implement Controlled Substance Diversion Prevention Programs (CSDDP) to limit diversion, with investigation teams, training, and other administrative approaches.
Drug diversion continues despite these activities and the investment of significant time and money. Leading healthcare institutions admit that new approaches are required. Recognizing the ongoing problem, the American Society of Health-System Pharmacists (ASHP) has updated Controlled Substance procedures for all hospitals. Hospitals broadly agree that current methods to detect drug diversion have two main weaknesses:
- Data in the ADM only show part of the equation: dispensing the drug from the locked cabinet. Detecting diversion also requires drug administration data in the Electronic Medical Record (EMR) and data from other systems such as Wholesaler Purchasing Systems, Internal Inventory System(s), or Employee Time Clocks.
- Motivated diverters can game the system with falsified data entries to avoid detection. Moreover, historical anomalous usage reports contain so many “false positives” that overworked supervisors must comb through haystacks of false positives to find a true diversion. More advanced algorithms are required to reliably detect diversion without excessive false alarms.
Recognizing these two weaknesses, Invistics is working with the support of the National Institute of Health to develop a solution that can fill the gaps in current Drug Diversion technology to improve patient and healthcare worker safety.
