Addressing the Effects of Drug Diversion in Health Care

Drug diversion (the transfer of a controlled substance from a lawful to an unlawful channel of distribution or use”—Uniform Drug Diversion Act of 1994) is a pervasive problem across health care environments, including inpatient and in-center dialysis settings. In July, 2012, the Mayo Clinic Proceedings published a groundbreaking article that provided education to health care workers related to diversion behaviors, consequences, scope, detection and prevention. The Mayo Clinic’s willingness to shine a bright light on diversion behaviors within its own system was unprecedented, and led to a robust collaboration on drug diversion within health care that continues today.

Impact

Over the years, drug diversion has become increasingly recognized as a multi-faceted problem. Diversion may harm the diverter in a multitude of ways, including a potential loss of professional licensure, health concerns related to the disease of addiction, and disruption of family and work relationships. Additionally, the largesse of patient safety concerns, liability, legal implications and financial losses are astronomical within inpatient and outpatient care settings.

Protenus, Inc was created to analyze diversion incidents within health care and use those analytics to develop an artificial intelligence system of oversight, data gathering and behavioral patterns related to diversion. The company publishes the annual Drug Diversion Digest, which reviews all aspects of diversion behavior, including financial losses and liabilities described in public disclosure cases. Protenus aims to share information and provide actionable recommendations for patient and provider safety.

According to Protenus, in 2018 alone, $301.1 million dollars was lost to hospital organizations and payors as a direct result of diversion behaviors. And it was not only hospitals and payors that were affected: The hospice and palliative care industry (which typically involve a home environment in which oversight and monitoring of drugs is difficult) was also negatively affected by drug diversion. However, with tracking mechanisms now in place for more-accurate reporting of aggregate data, the effects of drug diversion in hospice and palliative care will likely improve.

Prevalence

In 2014, it was estimated that more than 100,000 health care workers annually suffer from addiction and substance abuse. As many as 10 to 15 percent of nurses and physicians suffer from dependency on prescription medications and/or alcohol.

Nurses are involved in 41 percent of all publicly disclosed diversion incidents, whereas physicians are involved about 26 percent of the time. Of all diversion events publicly disclosed, nearly 92 percent involved opioids with the three most popular being Oxycodone, Hydrocodone and Fentanyl. Certainly this is not a complete list, with antidepressants and stimulants also in the mix (albeit less frequently).

Solutions

Vigilant efforts to prevent diversion involve the following:

• Robust and repetitive training for health care workers so there is better understanding and recognition of diversion behaviors in their work environment.
• Strict audit processes that capture unusual findings in drug dispensation and delivery of medicines to patients.

These processes are just the beginning of what is needed to design and build proactive measures in the hospital and clinic setting—whether it be dialysis or any other sector of health care. The most difficult step may be to start the conversation, admit the problem exists, leverage technologic capabilities and use statistical research and data to inform and educate the care team. Despite factors that can cause health care professionals to self-medicate (high stress, fatigue, burnout, depression, disrupted sleeping patterns and others), increased awareness and more-sophisticated tools (such as AI) and pharmacology auditing can be of tremendous benefit in curbing this behavior, improving patient safety and reducing costs.