Drug Diversion Counter
Did You Know?
With the adoption of artificial intelligence (AI) driven technology to support drug diversion detection efforts, organizations often uncover significantly more medication handling practice concerns than anticipated. Trends such as unaccounted for controlled substances, manipulated documentation, and medication handling delays force drug diversion programs to determine how to confront the unexpected and overwhelming amount of mishandled controlled substances being received on a daily basis. Organizations may receive hundreds, if not thousands, of these alerts on any given week. And now that these deviations from standard practice are made visible, healthcare leaders may feel obligated to triage each and every alert as quickly as possible to minimize any downstream effects on patient care. As if that isn’t challenging enough, pharmacy leaders have regulatory obligations to maintain controlled substance inventory and report and theft or significant loss. This leaves healthcare leaders in a tough predicament, asking questions like ‘How can we possibly keep up with all of these alerts?’. As a result, some organizations may choose to distribute this work to employees managers or supervisors for them to address the concerns among their staff.
The purpose of this blog is to discuss the pros and cons of distributing drug diversion investigative responsibilities to department managers or other stakeholders.
Before we dive in, it’s important to make a distinction between what is meant by ‘alerts’ and an investigation. Alerts or incidents, as we refer to them at Protenus, are singular events that deviated from standard practice which may also be a concern for drug diversion. However, an incident does not mean there is reason to believe the activity was a result of drug diversion or nefarious activity. Sometimes the actions that led to the creation of an incident is completely justifiable for the sake of providing the best patient care. For example, it might make sense to have a delayed controlled substance waste disposal if the nurse is partaking in a rapid response event, in which the demand for patient care trumps the need for timely waste disposal. It’s also worth mentioning that healthcare providers are human too and are likely to make mistakes from time to time. These mistakes may lead to an alert being generated because the mistake resulted in a deviation from standard practice. With that in mind, consider the ultimate purpose of drug diversion programs; it is not to demonize or reprimand the inevitable human error, it is to detect drug diversion.
Distributing the Work
A previous post discusses the different investigative philosophies for mitigating the threats of drug diversion (The Philosophy of Drug Diversion Programs). Today’s focus is solely on the incident management methodology used to investigate and detect diversion. As previously noted, incident management is an overwhelming task that cannot be accomplished solely by the drug diversion program. As such, diversion programs may distribute these alerts to the employee’s department supervisor for them to assess and address any concerns for drug diversion. Even if your drug diversion program does not distribute alerts external to the program, inherently there is some degree of triaging or distributing certain aspects of the investigation to other stakeholders, so there is still value in understanding the impact that has on the investigation outcomes.
The primary advantage of distributing the work of incident management to other department managers is to reduce the burden on the drug diversion program - and identify diversion more efficiently. With many hospitals facing labor and staffing challenges, organizations may not have dedicated drug diversion program personnel and thus, have no choice but to distribute this work. Those organizations who are fortunate enough to have dedicated resources may choose to distribute the work to allow the diversion program to focus on other surveillance activities. Regardless of the resources on hand, it’s fair to say that distributing the work allows for a broader range of controlled substance monitoring across the organization.
Before embarking on a distributive approach to incidents and investigations, one must first consider what exactly is being asked of the department or unit leader. Is the local leader being asked to simply validate whether or not the incident actually occurred or is justifiable on its surface? Or are they being asked to assess and investigate the incident as a potential drug diversion related evidence?
Even when non-compliance of controlled substance accountability is the primary concern of the alert (i.e. missing or undocumented controlled substances), is the ask of the local leader to validate with the employee if they just made an error in documentation that needs to be corrected? Among the countless other responsibilities placed upon nurse managers and department leaders, incident investigations can quickly turn into a ‘check the box’ task, which undermines the initial purpose of doing such activities in the first place, detecting diversion. This is a common occurrence due to the heap of other responsibilities these leaders are responsible for. When this happens, organizations increase the risk of non-compliance (in the form of falsified documentation), in their attempts to maintain compliance.
Shared Responsibility
That said, distributing the investigative responsibilities can very well lead to a shared sense of responsibility among local leaders and the staff they oversee. After all, no one wants to think that drug diversion is occurring in their department. Local leaders are closer to the action and are more attuned to the medication handling practices in their area. They are familiar with their team, their behaviors, and how to navigate and address challenges that may arise in their department. The theory is that investigating and addressing alerts as soon as possible can prevent the activity from reoccurring, ultimately reducing the risk of drug diversion. This shared sense of accountability helps reinforce a culture of medication and patient safety.
Although a distributive approach may allow for a quicker response to the incident, we want to give the charitable assumption to employees that their actions that led to the creation of the alert were well intentioned and they are not diverting drugs. This needs to be balanced with a healthy degree of skepticism that drug diversion may be occurring. This balancing act becomes a real challenge for department or unit leaders because they have closer relationships and a vested interest in their staff. Whether those relationships are good or bad, undoubtedly these leaders have a heightened degree of bias towards their employees which can dramatically impact their ability to investigate the alert. Bias is not right or wrong per se, but it’s existence cannot be ignored; it’s human nature. I have personally seen this bias go both ways. For example:
- ‘Positively’ influenced bias: “They are such a good person, everyone loves working with them, there is no way they would ever divert.”
- ‘Negatively’ influenced bias: “I knew something was up with them, they are so unpleasant to work with, go figure they created an alert.”
As a result of the bias, the unit leader may be more dismissive of legitimate concerns, when potentially the employee is diverting, leading to overlooked diversion and potentially patient (and employee) harm. On the other hand, if there is a negatively leaning bias towards an employee, the leader may be quick to justify the alert as a legitimate concern for diversion, prompting unwarranted corrective action or even wrongful termination. The investigator must take a neutral, non-bias stance when investigating and assessing incidents. The identified concerns should not be assumed to be diversion until there is concrete evidence to support that verdict. Similarly, the concerns should not be assumed to be accidental errors until there is evidence to support that conclusion.
Lastly, drug diversion mitigation efforts are not revenue generating activities for a healthcare organization, making it difficult to justify the need for additional resource support. By distributing some of the investigative work to local leaders, drug diversion programs can reduce the need to hire additional personnel that are otherwise necessary to effectively prevent and detect drug diversion.
Consistency (and Proper Training) is Key
Distributing investigative responsibilities allows for significant variance in the efforts applied investigating the incident. ‘Following-up’ on alerts is not well defined and can lead to drastically different results. The more operators doing the work, the greater opportunity for inconsistent practices. And even if the outcomes produced are reliably consistent, it does not mean they are accurate! Much like barcode medication administration compliance, in which there is a known goal to maintain 100%, there are concerning workarounds to reach that goal (i.e. accessing the automated dispensing system via a canceled transaction to ‘scan’ the barcode after the fact). Investigating alerts, especially those related to unaccounted for controlled substances, are no different. Documentation of administrations and waste transactions are easily edited after the fact to ‘reconcile’ the entirety of the dose, oftentimes with no way of verifying whether the transaction actually occurred.
This is not intended to be a slant toward the efforts of local leaders, it’s merely to say that they are not often equipped with the time, expert knowledge, or skills necessary to conduct an investigation. Similar to the consequences of bias, unreliable investigations can also lead to overlooked diversion or even wrongful termination of an employee.
Conclusion
Organizations need to be thoughtful and deliberate when considering their strategy to prevent, investigate, and detect diversion. There will always be trade-offs in the activities performed to monitor for drug diversion and the desired outcomes of detecting drug diversion. Doing something to protect against drug diversion is better than nothing. When determining what work will be done to mitigate and prevent drug diversion and who is responsible for the work, carefully consider the advantages as well as potential consequences of each approach and ultimately they contribute to your ability to detect drug diversion while continuing to provide exceptional patient care. Providing stakeholders with the necessary education, training and processes can help.
Cyber attacks have become a considerable threat to the solvency of healthcare organizations, causing massive disruptions to every aspect of patient care. Mitigating security breaches and cyber attacks typically involves system downtimes to the electronic medical record, automated dispensing cabinets, and other systems to prevent further damage. In response, organizations develop system downtime protocols to maintain patient care during such events. With the increasing risk of cyber attacks making the threat of prolonged downtimes a reality, organizations must develop a contingency plan to prevent and monitor for drug diversion during such events.
Unplanned system downtimes not only impact a drug diversion program's ability to efficiently monitor and audit for diversion, but it also can introduce new diversion related risks. System downtimes require considerable changes to workflows to maintain patient care. When developing contingency plans for system downtimes, two critical components need to be considered for drug diversion prevention and monitoring:
- What new risks to drug diversion accompanying the workflow changes?
- How can drug diversion be prevented in the new workflows and how can the new workflows be monitored/audited?
Not only do system downtimes introduce new threats for drug diversion, they present significant challenges to prevent and monitor for drug diversion with the same level of efficiency prior to the system downtime. System downtime is a drug diverter’s dream scenario! Downtime means a lack of data (or access to data), which is instrumental for identifying patterns and trends of suspicious medication handling activity. Downtime workflows often necessitate manual documentation of activity that would otherwise be captured electronically. Even if that data is still captured electronically, data feeds to third party vendors such as diversion monitoring software are temporarily severed, meaning diversion programs cannot investigate drug diversion the same either. But even when data feeds go back online, the data is often incomplete or inaccurate due to manual documentation and changes to workflows. This creates a real challenge for diversion programs to accurately identify legitimate concerns.
Example: System Downtime and ADCs
System downtime leads to ADC being on critical override. To limit access to ADC, the organization determines they will assign a dedicated nurse to dispense medications, followed by cycle counts at the end of each shift. If/when the organizations drug diversion software feed comes back online, this person will likely be seen as a user of high concern due to the frequency of dispenses compared to peers.
For all the reasons mentioned in this post, system downtimes act as a signal for drug diverters. The infrequent nature of downtimes, coupled with the introduction of unfamiliar workflows, create built-in excuses for employees to deny the possibility of diversion.
Drug diversion programs must also consider how to proceed after the system downtime is over. Will manually logged data be documented electronically, and will it be accessible for diversion monitoring purposes (and who is responsible for that work)? As a precautionary measure, organizations should perform a complete cycle count of all controlled substances post downtime to ensure the inventory counts are correct going forward. Workflows during downtime may cause discrepancies or lead to confusion in the expected inventory counts after the downtime is lifted. The inventory count acts as a new ‘trusted’ data point and can be used to audit activity that was said to have occurred during the downtime. Additionally, diversion programs need to determine when and how they plan to re-initiate their standard monitoring and investigative efforts, while simultaneously auditing the activity that occurred during the downtime. Lastly, a diversion program should consider how to maintain controlled substance records during downtime. In addition to storing all manual records accordingly, it would be wise for diversion programs to write an internal memo to be stored with the controlled substance records, explaining the downtime, the diversion prevention & monitoring response plan, and when normal activities will resume. It could prove beneficial if regulators or accreditors ever question any lapses in monitoring efforts.
In conclusion, diversion programs must proactively develop comprehensive strategies to prevent and monitor drug diversion during system downtimes. This includes creating auditable workflows that minimize new risks associated with workforce changes and enhancing awareness of potential vulnerabilities. Acknowledging the significant inefficiencies that arise during these periods, it becomes crucial to focus on meticulously auditing the movement of large quantities of controlled substances—such as ordering, receiving, restocking, expiring, and transferring drugs between sites. By implementing these tailored approaches, healthcare organizations can better safeguard against diversion while maintaining a high standard of patient care. Ultimately, embracing a culture of vigilance and adaptability will not only enhance operational resilience but also ensure that the safety and well-being of patients remain at the forefront of care delivery.
The purpose of most drug diversion programs is to prevent, monitor, and ultimately detect diversion. However, the responsibilities bestowed upon drug diversion programs have grown to encompass any activity involving controlled substances. This concept is not new to pharmacy; the words ‘medication’ and ‘drug’ have become synonymous with ‘pharmacy’s responsibility’ regardless of the context. The same holds true for drug diversion. As a result, drug diversion programs are asked to become experts in State and Federal Regulations, opioid stewardship, palliative care, substance use disorders, and so much more than its initial intent.
Yes, some auditing and monitoring practices can address both diversion and compliance, but this is not always the case. The purpose of this blog post is to set the record straight on the purpose of drug waste reconciliation and the unexpected impact it has on detecting drug diversion.
A drug is considered unreconciled when the amount dispensed does not equal the documented administration, waste, and return amounts. For example, if one fentanyl 100mcg/2ml vial is dispensed and the only corresponding transaction is an administration of 50mcg, the drug is considered unreconciled. Meaning, 50mcg are still not accounted for in the documentation.
The question then becomes, are unreconciled drugs a diversion issue, a compliance issue, or both?
Although an unreconciled drug is a compliance issue, it’s not always diversion related. Unreconciled drug can be the result of user error, poor documentation practices, and system failures. Even though the act of reconciling unaccounted-for controlled substances may address compliance concerns, in most cases it does not help detect diversion. In fact, one may argue that the pursuit of waste reconciliation makes it even more difficult to detect drug diversion. Here’s why:
The typical waste reconciliation process looks something like this:
This model of waste reconciliation provides an opportunity for diverters to take advantage of those who make honest mistakes, while simultaneously causing the diversion program to overlook legitimate diversion related events. Put yourself in the shoes of someone who is diverting drug waste and not reconciling their dispenses.
What is your immediate reaction when you receive an email stating you have unreconciled drug?
Knowing the repercussions of stealing narcotics, those who are diverting will likely lie, making it appear as if it were an honest mistake. It also provides warning to the diverter that they need to do a better job covering their tracks. The next time they divert, they will be more careful to falsify the administration or waste documentation so that the drug is reconciled. And since it is near impossible to validate the employee’s claim that the drug is accounted for, the reconciliation audit becomes a ‘check the box’ compliance activity without properly addressing the root of the problem.
This is not to downplay the importance of controlled substance compliance. This is to say that the typical method of waste reconciliation should not be considered a diversion monitoring tactic, as it does not help detect or prevent diversion.
Policies and prevention tactics alone will not eliminate the diversion of controlled substance waste. Waste disposal should still be audited, especially in high-use and complex care settings. Depending on the resources available, there are several different ways to monitor for drug waste diversion.
Surveillance Camera Audits
If time and resources allow, the diversion program can conduct random audits of waste transactions to review via the surveillance cameras.
Pros:
- Can see if employees are following the policies and procedures. For example, did the witness fulfill their responsibilities to validate the drug or did they just document their presence at the automated dispensing cabinet and not visualize the disposal.
- Provides undeniable evidence of the events that took place compared to what was documented.
Cons:
- Requires surveillance cameras and resources to conduct the audits.
- Audit process can be time-intensive and requires manual documentation.
- Can only validate the waste disposal if the waste occurs at the time of dispense. As soon as the employee leaves the view of the camera without wasting, it is impossible to know whether the substance being wasted truly is the controlled substance.
Drug Waste Assay
There are several devices available that assay drug waste. Capabilities for drug waste testing will be determined by the device itself. With newer drug waste technologies emerging onto the marketplace, consider the value such devices may bring to your drug diversion program. The pros and cons of such audit will vary depending on the device and the workflow developed to test drug waste.
Pros:
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Cons:
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Drug Handling Patterns
The most effective and productive way to monitor controlled substance waste is to review drug handling patterns. If someone is diverting drug waste, they will go out of their way to create drug waste or come in contact with it. Most of these patterns would be difficult to identify by reviewing transaction logs or reports. However, an AI-driven monitoring software that reviews 100% of medication handling transactions can spot these patterns and bring them to the investigator’s attention for further review.
Here are some waste related patterns to consider monitoring as part of an investigation.
- Repetitive wasters:
- Individuals who purposefully dispense more than needed to create unnecessary waste. These individuals may also favor certain medication orders over others. For example, if there are multiple medications for pain management, they may opt for the medication that produces waste. Furthermore, if there are range orders, they may opt to administer a particular dose that creates waste.
- Time to waste:
- It’s not just delayed waste transactions that are concerning for drug diversion. Rather, look for patterns of when the waste occurs in relation to other activities. For example, does the waste disposal occur before or after the administration? When does the drug waste disposal occur in relation to when the administration was charted? Patterns that deviate from standard practice could indicate that the user is looking for a workaround to cover their tracks, while diverting the controlled substance waste.
- Waste the full amount dispensed:
- The idea here is that the user is intentionally producing an opportunity to create drug waste. Perhaps they had no intention of ever giving the medication, but dispensed it knowing they would have to dispose of the drug as soon as they opened the vial or unit dose.
- Pull-Waste-Pull:
- This occurs when an individual dispenses a dose, wastes the entire dose, then proceeds to dispense the dose again for administration. Sure, sometimes the dose that was initially dispensed is compromised (i.e., damaged package, dropped on the floor, etc.), but this should be a rare exception. Look for patterns in which the individual is performing this activity more so than their peers. Also note the time between the dispense and re-dispense. If the patient truly did need the medication, you would expect to see an immediate re-dispense and administration.
- Accessing the dispensing cabinet for a single waste transaction:
- Healthcare requires an extreme amount of efficiency to keep up with the demands of patient care. This translates to maximizing the time spent away from the patient bedside. Therefore, it wouldn’t make sense to consistently go to the med room or automated dispensing machine just to document a single waste transaction. Sure, every now and then that may make sense, but pay close attention to this particular pattern. No one purposefully makes more work for themselves unless they have an ulterior motive for doing so.
- Wasting multiple as one transaction:
- This pattern involves disposing the contents from multiple dispenses as a single waste transaction. Some may do this for convenience, but others do this purposefully as a tactic to create confusion, making it more difficult to reconcile the dispense and corresponding waste.
- Change in custody:
- The person who dispenses the narcotic should be responsible for the entirety of the amount dispensed, including any drug waste. Look for patterns where one employee is disposing of drug that was dispensed by someone else. It may seem like a friendly gesture, but the person volunteering to dispose of drug waste may also be using it as an opportunity to divert.
Stay tuned for the final post in our Controlled Substance Waste series where we’ll be sharing information and guidance on Waste Compliance and Diversion Detection.
Controlled substance waste is often a primary target for drug diversion. Waste is challenging to validate and has no direct impact on patient care. And although the amount available to divert is relatively small, the quantities can add up quickly. In any given shift, a nurse may have 20+ waste transactions. Over the course of a year, there are tens of thousands of waste transactions, providing numerous opportunities to divert. This blog will highlight some tactics to help prevent and monitor for controlled substance waste related diversion.
Prevention of Controlled Substance Waste Diversion
Diversion of drug waste can only happen if there is drug waste. Reducing the total number of waste transactions required not only limits the opportunities to divert, but also eliminates one more task taking up precious time that could be spent caring for patients. To eliminate controlled substance waste transactions, there needs to be an alignment between the order sets and inventory management.
- Order Sets:
- When possible, avoid range orders.
- Indicate specific criteria for when to administer certain medications and certain doses.
- The electronic medical record dispense logic needs to align with what is available in the dispensing cabinet. The dispense logic should be built to avoid unnecessary drug waste.
- Inventory Management:
- Where possible, several different vial and tablet sizes should be made available.
- Evaluate opportunities to stock drug options that align with what is typically administered. For example, instead of only having a 100mcg/2ml vial available, consider stocking a 50mcg/ml vial.
- Even if the size available does not align perfectly with the dose needed, it will reduce the amount of waste available to divert.
- For example, if only a 100mcg/2ml vial is available, but the dose is 25mcg, there will be 75 mcg of drug waste. Whereas, if a 50mcg/ml vial is available, it would produce only 25mcg of drug waste.
- Even if the size available does not align perfectly with the dose needed, it will reduce the amount of waste available to divert.
Check back for the next part of the series to learn more about Monitoring of Controlled Substance Waste Diversion.
As technology improves the ability to secure and account for medication inventory, drug diverters have relied upon drug waste disposal (among other methods) to steal their drug of choice. To reduce the opportunity of diversion and remain compliant with Drug Enforcement Administration (DEA) and Environmental Protection Agency (EPA) regulations, healthcare institutions should have policies and procedures in place to address drug waste disposal.
To help reduce diversion risk, healthcare organizations should consider developing a controlled substance waste disposal policy with the following elements:
Who:
Consider who is responsible for the disposal of the drug waste, as this may vary depending on where the drug is dispensed from. The policy may call attention to specific scenarios in which there is a change in custody of the controlled substance. For example, controlled substances dispensed from the central pharmacy, or those dispensed during a long procedural case. In any scenario, drug waste disposal should be witnessed by another licensed health care employee to ensure the drug and quantity disposed of corresponds with the documentation.
What:
The controlled substance waste disposal policy should define what drug waste is. The DEA has strict record keeping regulations regarding drug disposal. Keep in mind that expired or recalled inventory must be disposed of differently than drug waste. Although all unusable/unwanted drug is often deemed drug waste, the DEA has more specific classifications. The most common use of the term drug waste refers to controlled substances dispensed by a practitioner for immediate administration at the practitioner's registered location, when the substance is not fully exhausted (e.g., some of the substance remains in a vial, tube, or syringe after administration but cannot or may not be further utilized). Per the DEA, this type of drug waste does not require a DEA Form 41 but still does require record keeping (21 CFR 1304.21(e)). The policy should clearly define what needs to be documented and any corresponding exceptions to the rule. To avoid any record keeping confusion, consider including verbiage so that each medication dispense has a corresponding waste transaction. In other words, waste from multiple dispenses should not be combined and wasted as a single transaction.
Side note: consider creating a separate policy for medication destruction and the management of recalled, expired, and unwanted (unused) controlled substances, including those from ultimate users (i.e. prescriptions left behind by patients). |
Where:
To comply with DEA and EPA standards, controlled substance waste must be disposed of into a waste container that renders the drug ‘non-retrievable’. To also limit the possibility of drug diversion, these containers should be strategically placed in areas with surveillance camera coverage. Since the drug waste should be disposed of at the time of dispense (more on that to come), the ideal location for controlled substance waste containers is in medication rooms or near the automated dispensing machines. The policy should also speak to other unique areas such as procedural areas, operating rooms, and pharmacies. Unless conducting random drug waste assays, controlled substance drug waste should never be returned to the pharmacy for the pharmacy team to dispose of. Not only does this create a massive burden for the pharmacy team, it also creates unnecessary safety and diversion related risks.
When:
To reduce the risk of drug diversion, controlled substance waste disposal should occur at the time of dispense, or as close to the time of dispense as possible. In a perfect world, the dose needed would be known before dispensing the drug and any unneeded portion could be disposed of at that time. However, this is not always the case in healthcare. If the waste cannot be disposed of immediately, the policy should set a time threshold for when to dispose of waste, given the situation. For example, in procedural areas, the policy may indicate that the waste must be disposed of before the end of the procedure (or before starting the next procedure).
A well thought out policy allows the diversion investigation team to hold employees accountable for their actions and serves as the first line of defense against poor practice behaviors and potential diversion. If all personnel adhere to the policy, it is easier to identify those who deviate from the standard practice. Even if an employee does not intend to divert, improper handling of controlled substance waste creates opportunities for employee and patient safety risks as well as non-compliance.
The next installment of this blog series will discuss methods to prevent and monitor for drug waste related diversion.
As technology improves the ability to secure and account for medication inventory, drug diverters have relied upon drug waste disposal (among other methods) to steal their drug of choice. To reduce the opportunity of diversion and remain compliant with Drug Enforcement Administration (DEA) and Environmental Protection Agency (EPA) regulations, health care institutions should have policies and procedures in place to address drug waste disposal.
Consider developing a controlled substance waste disposal policy with the following key elements.
Who:
Consider who is responsible for the disposal of the drug waste, as this may vary depending on where the drug is dispensed from. The policy may call attention to specific scenarios in which there is a change in custody of the controlled substance. For example, controlled substances dispensed from the central pharmacy, or those dispensed during a long procedural case. In any scenario, drug waste disposal should be witnessed by another licensed health care employee to ensure the drug and quantity disposed of corresponds with the documentation.
What:
The controlled substance waste disposal policy should define what drug waste is. The DEA has strict record keeping regulations regarding drug disposal. Keep in mind, that expired or recalled inventory must be disposed of differently than drug waste. Although all unusable/unwanted drug is often deemed drug waste, the DEA has more specific classifications. The most common use of the term drug waste refers to controlled substances dispensed by a practitioner for immediate administration at the practitioner's registered location, when the substance is not fully exhausted (e.g., some of the substance remains in a vial, tube, or syringe after administration but cannot or may not be further utilized). Per the DEA, this type of drug waste does not require a DEA Form 41 but still does require record keeping (21 CFR 1304.21(e)). The policy should clearly define what needs to be documented and any corresponding exceptions to the rule. To avoid any record keeping confusion, consider including verbiage so that each medication dispense has a corresponding waste transaction. In other words, waste from multiple dispenses should not be combined and wasted as a single transaction.
Side note: consider creating a separate policy for medication destruction and the management of recalled, expired, and unwanted (unused) controlled substance, including those from ultimate users (i.e. prescriptions left behind by patients).
Where:
To comply with DEA and EPA standards, controlled substance waste must be disposed of into a waste container that renders the drug ‘non-retrievable’. To also limit the possibility of drug diversion, these containers should be strategically placed in areas with surveillance camera coverage. Since the drug waste should be disposed of at the time of dispense (more on that to come), the ideal location for controlled substance waste containers is in medication rooms or near the automated dispensing machines. The policy should also speak to other unique areas such as procedural areas, operating rooms, and pharmacies. Unless conducting random drug waste assays, controlled substance drug waste should never be returned to the pharmacy for the pharmacy team to dispose of. Not only does this create a massive burden for the pharmacy team, it also creates unnecessary safety and diversion related risks.
When:
To reduce the risk of drug diversion, controlled substance waste disposal should occur at the time of dispense, or as close to the time of dispense as possible. In a perfect world, the dose needed would be known before dispensing the drug and any unneeded portion could be disposed of at that time. However, this is not always the case in healthcare. If the waste cannot be disposed of immediately, the policy should set a time threshold for when to dispose of waste, given the situation. For example, in procedural areas, the policy may indicate that the waste must be disposed of before the end of the procedure (or before starting the next procedure).
A well-thought-out policy allows the diversion investigation team to hold employees accountable for their actions and serves as the first line of defense against poor practice behaviors and potentially diversion. If everyone adheres to the policy, it will be easy to identify those who deviate from the standard practice. Even if an employee does not intend to divert, improper handling of controlled substance waste creates opportunities for employee and patient safety risks as well as non-compliance.
The next installment of this blog series will discuss methods to prevent and monitor for drug waste related diversion.
Nursing strikes continue to make headlines, exacerbating staffing shortages at hospitals and health systems. But they can also wreak havoc on your drug diversion prevention efforts — here's how.
These strikes not only create more potential for clinical drug diversion, but also make it more difficult to detect. Augmenting RN staff with travel or contract nurses poses a risk as they're less familiar with your organization's workflows, procedures, and policies. Naturally, they're going to make more mistakes. However, detection of actual diversion becomes more difficult as these mistakes lead to an increase in false positives for activity that may look like diversion but is strictly a result of not knowing protocols.
Aside from that, nursing strikes mean departments are working short-staffed, which inevitably leads to more errors, which then lead to more false positives. Due to the increased workload, RNs may change their workflows in an effort to maintain the level of patient care being provided. Changes in workflows may make it easier for the RN team, but also may amplify the risk of diversion.
Consider this example seen during COVID: one RN would dispense meds for patients assigned to all RNs on the unit so they didn't have to leave the bedside, resulting in:
- Increased suspicion as the RN dispensing looked like an outlier for dispenses compared to peers
- Increased number of false positive incidents (change in custody, delays in administration, delays in waste, backcharted administrations, etc.)
- Increased opportunity to divert as the RN has more times in the dispensing cabinet
If your health system or hospital experiences nursing strikes or frequent short-staffing, or relies on travel nurses to fill the gaps, it pays to be aware of the increased risk of drug diversion and the detection difficulties that may arise.
- 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?
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.
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:
- Different backgrounds are being requested — some organizations want pharmaceutical experience, but more are open to nurses with clinical backgrounds who understand medication movement.
- 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.
- 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.
- 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.
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.
- 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.
- 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.
- 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?
- Policies and procedures: Having these in place gives organizations a baseline to hold people accountable and enhances security around controlled substances.
- 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.