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A Look at What 2023 Could Hold for Drug Diversion Prevention Programs
Adam Beeler, PharmD, MS, Director of Pharmacy Services at Protenus - December 23, 2022
A lot has changed in healthcare since the last time the ASHP Midyear Meeting was held in person in 2019. Aside from the obvious and ever-present COVID-19 pandemic, healthcare undergone a complete digital transformation. The industry has relied on technology to optimize and advance patient care during a period of unknown circumstances and restrained resources. The 2022 ASHP Midyear Meeting was a reminder of the unrelenting contributions the pharmacy profession continues to make to advance healthcare. As healthcare continues to forge into uncharted territory, here are three subjects to consider for your drug diversion prevention program for 2023.
Employee Support
The American Psychiatric Association defines substance use disorders (SUD) as a complex condition characterized by uncontrolled use of a substance (alcohol, opioids, illicit drugs, etc.) despite harmful consequences. Often synonymous with addiction, SUDs affect more than 20 million Americans, some of which are healthcare employees. The close proximity to medications may prove too tempting for healthcare workers looking to satisfy their addiction. Although there is no published data regarding the intentions of those who divert drugs, it is thought to be most commonly for self-use.
Healthcare facilities ordinarily have policies that speak to the employment status for those caught stealing hospital property. For some facilities, the act is seen as a terminable offense while others may decide on a case-by-case basis. Regardless of the policies in place, the first thing to consider for your drug diversion prevention program in 2023 is how to support employees with SUDs, including those who were caught diverting.
In collaboration with the drug diversion prevention program, healthcare facilities should have clearly defined policies that can answer the following the questions:
  • What should the employee’s status be after they are caught diverting?
    • Are all drug diversion cases subject to termination?
    • Are there alternatives to termination? If so, who is eligible for different course of corrective action?
  • How are employees supported if they admit to a substance use disorder?
  • How are employees with SUDs re-introduced into the workplace?
    • Where will they work?
    • Do they require additional monitoring?
    • What ongoing support is offered?
The literature suggests that substance use disorder is considered a mental illness, which infers that the person suffering is not functioning within their normal capacity. The word illness also infers the possibility of successful treatment. In fact, there are thousands of people who have fully recovered from a substance use disorder. However, those who have successfully recovered often keep quiet in fear of being labeled an addict and the stigma attached to it. The drug diversion prevention program should consider the risks and benefits of rehabilitating and reintroducing those employees who suffer from SUDs that were caught diverting drugs.
Drug Testing
In the advent of drug diversion becoming more complex, employee drug testing will become an even greater component of the drug diversion program. It will be essential to establish a well-defined policy that provides detail on how and when to conduct drug tests. The first aspect of this policy should determine when to issue a drug test. An increasing number of healthcare institutions are opting for random drug testing of those employees who have access to facility-supplied medications. The fear of randomly getting drug tested alone could be enough to deter drug diversion. However, one must also consider the consequences of random drug testing. For example, employees may lose trust in the organization and it’s possible that high quality employees may test positive for federally-listed controlled substances unrelated to drug diversion, such as THC.
Whether your program opts to conduct for-cause testing or random testing, consider which drugs will be included on the panel and what will happen if (or when) an employee tests positive. One cannot ignore the possibility of incidental findings in either scenario. Consider how your policy would address the following scenario:
A highly respected nurse takes a urine drug screen as part of the random drug test policy. The nurse test positive for THC, a cannabis derivative and schedule-1 controlled substance per federal regulations. The facility is in state that has de-criminalized marijuana, but the facility itself still follows federal protocols to participate in Medicaid and Medicare. The nurse has shown no signs of impairment at work but admits to occasionally using marijuana on their time off.
If the goal of drug testing is to prevent and deter drug diversion, the policy should specify which  drugs are included on the test panel. Regardless of the stance taken, consider the benefits and possible unintended consequences of your current drug test policy.
Controlled Substance Compliance
The emergence of AI-driven drug diversion surveillance software has increased the efficiency of monitoring and detecting diversion. As monitoring efforts become finely tuned, consider other aspects of the Controlled Substance Act (CSA) the drug diversion prevention program can engage in. When drug diversion is detected, there is a chance that the DEA or State licensing board opts to investigate further. To avoid hefty fines, it's critical to comply with all State and Federal regulations. For example, each record-keeping violation of the CSA could amount to a $15,040 fine. This includes prescription records, purchasing records, inventory records, and many more. Consider how your drug diversion program can help your institution remain in compliance with the CSA and State regulations.
The Case for Classifying Propofol as a Controlled Substance
Christy Rand, BSN, RN, Medication Diversion Prevention Professional - October 13, 2022

When I started in a medication diversion prevention position, I remember hearing that any drug with a street name has the risk of being diverted. Although there are no street names listed on the DEA website, the short-acting, non-barbiturate sedative propofol (and its rapid, powerful high) is widely known to both healthcare workers and the public. Because it’s not classified as a controlled substance, despite the high potential for abuse and associated risk to workforce health and patient care, propofol’s dangerously easy accessibility makes it a prime target for diversion.

And propofol does, in fact, have street names — based on the milky white coloration of the medication it’s referred to as “Milk” or “Milk of Amnesia”, and also known as “Jackson Juice” following the pop star’s highly publicized 2009 overdose death. In 2007, prior to the increased street knowledge of the drug, it was reported that propofol abuse had risen fivefold over the 10 years prior based on email surveys sent to the 126 academic anesthesiology training programs in the United States. 

In the author’s opinion, classifying propofol as a controlled substance would help healthcare organizations greatly reduce risk to their workforces, patients, and communities at large.

Propofol’s Abuse Potential

To understand why propofol is so dangerous, it’s important to know its abuse potential. Users are drawn to the easy access and hard-hitting, quick high. "It's like three drugs rolled into one. It's like marijuana, Valium and the club drug Ketamine. It creates a unique high like no other drug,” says Paul Wischmeyer, MD, Anesthesiologist.

Propofol produces rapid loss of consciousness within 40 seconds of an IV injection, with a short duration of action lasting 3-5 minutes following a single bolus dose. In low (subanesthetic doses), propofol has been shown to increase dopamine concentrations and produce feelings of euphoria, "being high", light-headed, and spaced out. Studies investigating the recovery profile of propofol have reported patients wake up elated, euphoric, and talkative. Cravings do occur with repeated use.

Heavy abusers may inject up to 50-100 times a day to maintain their high, and unfortunately one of the first symptoms of propofol abuse or addiction is death. 40% of anesthesia residents who reportedly abused propofol died as a result. Overuse and abuse of propofol can lead to propofol toxicity which in turn can lead to metabolic acidosis. Although metabolic acidosis can occur, the leading cause of death is respiratory depression followed by hypoxia that leads to cardiac arrest.

Rethinking the FDA’s 2010 Ruling 

So knowing all of this, why isn’t propofol classified as a controlled substance? In October of 2010 the DEA proposed that the FDA include propofol as a schedule IV medication, which was supported by the American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthesiology (AANA). The proposal was ultimately rejected by the FDA. Commonly cited rationale for the rejection includes:

  • Pain on injection and rapid onset: The pain on injection may be a deterrent for some, but inversely the pain followed by a rapid high may be a driving force for some abusers. The pain tells them the high is coming.
  • Not enough evidence of drug dependence: Propofol is not associated with physical dependency.  Yet, treatment centers have reported propofol withdrawal symptoms similar to withdrawal from benzodiazepines; including irregular or fast heartbeat, tremors, hallucinations, confusion, agitation, and fever.
  • Low risk to the public: It is true that the vast majority of reported propofol abuse has been among medical professionals, although reports indicate that the risk to the general population is increasing. Potentially, this is because controlled substances are under more harsh restrictions and propofol is not regulated under the same rules — it’s more easily accessible and poorly controlled in most healthcare facilities.

Yet the #1 reason I hear as to why propofol should not be scheduled is that making it a controlled substance is impossible and would negatively impact patient care and workflow. As someone who has worked as a registered nurse for the last 17 years and has firsthand experience conducting a propofol diversion investigation, I understand workflows and processes — I also understand when something isn’t right. I know the change won’t be easy but it’s far from impossible. At the state level, Alabama, Georgia, and North Dakota have already set the gold standard in requiring propofol to be treated as a controlled substance. 

Proactive Protection

For anyone working in a healthcare setting, I feel it is imperative that we, at a minimum, define expectations around wasting practices and a way to account for propofol within our organizations. 

In some organizations, propofol is treated as an antibiotic, with no true oversight around its dispense, waste, and administration. Defining expectations around the disposal of propofol (for example, prohibit in waste receptacles or garbage cans), working to limit access, and performing random audits around dispense compared to usage are all actions healthcare organizations can undertake proactively. 

Additionally, organizations can revamp the access to anesthesia carts to eliminate policy violations, like the wide use of common codes. Implementing automated dispensing carts in all procedural areas also has a huge impact. 

The risk to those in healthcare abusing propofol is grave. And after the extensive reading I have done on the topic, I also believe the risk to the public regarding propofol abuse does exist — whether it be through the risk of receiving care from an impaired provider or experimenting personally with the readily available drug.

Christy Rand, BSN, RN, is an independent Diversion Prevention Professional with 17 years experience as a registered nurse.

Interested in more drug diversion content? Read this short blog post to learn how and why an Academic Medical Center (AMC) switched to a proactive approach to drug diversion prevention.

4 Emerging Staffing Trends In Drug Diversion Monitoring
Russell Dorsey, CPhT, Sr. Customer Success Manager at Protenus - September 30, 2022

As with all other healthcare-related departments, clinical drug diversion monitoring is facing challenges in filling open positions. However, due to recent regulatory sanctions there’s a renewed focus on dedicating resources to bring diversion monitoring programs up to parity with industry best practices. Here are four trends I’m seeing:

  1. Different backgrounds are being requested — some organizations want pharmaceutical experience, but more are open to nurses with clinical backgrounds who understand medication movement.

  2. Organizations who are creating positions that do not have qualified internal candidates are finding it harder to fill these specialist jobs when looking outside the organization. This is in part due to the lack of foundational education or certifications for diversion — it doesn’t allow for large-scale growth of these positions. Some industry associations like American Society of Health System Pharmacists (ASHP) and International Health Facility Diversion Association (IHFDA) are creating educational series to centralize some of that knowledge, but there is currently no formal training.

  3. Thought leaders who do have full time employees in place have measurable outcomes in terms of productivity and effectiveness and are requesting more FTEs for further specialization and program expansion. An optimal diversion monitoring department encompasses three personas: an analyst using diversion tools daily and requesting follow up investigations; an operations manager overseeing the program and measuring outcomes; and a compliance specialist who is not just diversion monitoring but is responsible for patient and medication safety — they’re an additional check to ensure processes are being followed and sit outside the day-to-day operations of a compliance team, acting more as an auditor.

  4. Community engagement in the form of requests to connect with other organizations — healthcare organizations and their stakeholders are all striving to improve their knowledge. Healthcare organizations and their stakeholders don’t have diversion prevention or monitoring totally figured out, so we’re all striving to improve our knowledge. There’s a desire to network and share best practices with peers through groups like IHFDA, National Association of Drug Diversion Investigators (NADDI), and PANDAS.

For more, read key takeaways from Protenus’ Special Report: State of Drug Diversion in America.

5 Key Elements of an Optimal Drug Diversion Prevention Program
Russell Dorsey, CPhT, Sr. Customer Success Manager at Protenus - September 19, 2022

When you’re building a clinical drug diversion prevention program at your organization, or are ready to elevate your existing program, it can be overwhelming to know where to start. As outlined in this Controlled Substance Diversion Monitoring Playbook, these key elements of an optimal program can provide a solid foundation.

  1. Executive buy-in: This is critical to get the necessary resources to execute your program. Because pharmacy is not a revenue generating department, executives want to reduce expenses to as little as possible.

  2. Resource allocation: Technology identifies areas of risk much more efficiently than humans, but it isn’t the silver bullet. Build a good team, add in technology, and leverage your people, processes, and technology to scale.

  3. Education: One of the most important components of a diversion prevention program. Frontline staff need to be informed about policies and procedures on engagement with controlled substances and how they’re held responsible. Education should go beyond clinical staff to all staff, even if they’re not handling controlled substances to cover questions like:
  • What is diversion and why is it important?
  • What are the federal and state regulations?
  • If you have a substance use disorder, how do you engage with employee assistance to get help so you have a better chance of recovering and keeping your license?
  •  What are the pathways and mechanisms to report suspicious behavior?
  1. Policies and procedures: Having these in place gives organizations a baseline to hold people accountable and enhances security around controlled substances.

  2. Measuring effectiveness: This is important to make sure your program is constantly improving in identifying gaps and keeping pace with regulations. Reporting on ROI helps prove the worth of your program to upper management in terms of how your team is reducing risk for the organization.

Read 9 critical steps for building or leveling up a robust, proactive diversion monitoring program.

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