Opioid – Drug diversion in healthcare
The epidemic of Opioid Use Disorder (OUD) and addiction to opioids are major drivers of drug diversion for improper use and can occur at any point along the supply chain. Misuse of prescription drugs, including opioids, is a national challenge. In 2017, an estimated 18 million people misused a prescription medication at least once in the prior year (NIDA) . All healthcare settings are vulnerable to diversion (Protenus, 2017).
As people use opioids repeatedly their tolerance increases which can lead to physical dependence and addiction and they may not be able to maintain the source for the drug and look for opportunities for drug diversion for their own use. Drug diversion in healthcare (employee stealing for their own use) results in care delivered by impaired provider, denial of essential pain therapy and outbreaks from hepatitis C virus or bacterial pathogens when tampering with injectable opioids.
Although most opioid prescriptions are for use in the outpatient setting and so most diversions of drugs occur there, there is a portion of these drugs are administered in a health care facility, such as a hospital or ambulatory surgery setting. The nature of the practices and ready access in some healthcare settings provide ample opportunity for drug diversion. Although there are no precise national data on the extent of drug diversion by healthcare workers from a healthcare facility, the most common drugs diverted are opioids.
The adverse consequences of diversion in healthcare include harm not only harm to the drug diverter, but also risk of harm for the patient. In addition to denial of essential drugs to treat patients in pain, outbreaks of hepatitis C virus (HCV) transmission from an infected healthcare worker to a patient have been reported in the setting of narcotic diversion when tampering with injectable opioids, as well as transmission of bacterial pathogens, with fentanyl being the most commonly implicated opioid.
Drugs stolen from health care facilities are commonly used to support an addiction of the health care worker (HCW). This theft can be of unopened vials; vials or syringes that have been tampered with, resulting in either substituted or diluted dosages being administered to the patient; or residual drug left in a syringe or vial after being administered to the patient. Theft has also been linked to discarded syringes or ampules with opioids that have been properly disposed of in a “sharps” safety container.
Outbreaks from drug diversion
A healthcare worker in Colorado infected with hepatitis C virus (HCV) infected 18 patients as a result of stealing fentanyl in the operating room intended for patients and injected herself and refilled the same syringes with water or saline. Another HCV-infected traveling radiology technician infected 45 patients in New Hampshire, Kansas and Maryland by stealing syringes with opioids, self-injecting and refilling with saline. Gram-negative bacteremia developed in 25 surgical patients at a Minnesota hospital that was linked to a nurse tampering with IV bags containing opioids used for patient- controlled analgesia (PCA) machines – using a syringe to remove opioids and replacing liquid with saline. CDC has investigated these, and many other outbreaks related to drug diversion activities that involved healthcare providers who tampered with injectable drugs. (Schaeffer and Perz 2014). CDC has compiled a summary of these outbreaks and timeline.
Efforts of healthcare organizations and state health departments
All health care facilities should have systems in place to deter controlled substance diversion to include methods to promptly identify and investigate possible diversion, intervene when it is occurring and follow up to deal with outcomes of confirmed diversion.
Many healthcare organizations and states actively address drug diversion and effective prevention methods for hospitals and healthcare providers. Some of the most comprehensive resources for developing programs to prevent and respond to drug diversion are available from the Mayo Clinic and the Minnesota Department of Health. Mayo Clinic has described the patterns of diversion, consequences, and strategies for detection, prevention and follow up (Berge 2012). The Minnesota Department of Health (MDH) developed a toolkit and resources as an outcome of the work of a coalition of the MDH and Minnesota Hospital Association along with hospitals, providers, law enforcement, licensing and other stakeholders.
- Mayo Clinic protocol – 77 best practices for storage, security, procurement, ordering, prescribing, preparation, dispensing, administration, inventory, recordkeeping, surveillance, investigation, education and quality improvement.
- Minnesota Department of Health campaign to respond to drug diversions
- Hellinger WC et. Al., Healthcare-associated hepatitis C virus infections attributed to narcotic diversion. Ann Intern Med. 2012;156:477-482.
- Berge KH et.al., Diversion of drugs within healthcare facilities, a multiple-victim crime: Patterns of diversion, scope, consequences, detection, and prevention. Mayo Clin Proc 2012; 87 (7):674-682
- Schaeffer MK and Perz JF Outbreaks of infections associated with drug diversion by US healthcare personnel. Mayo Clin Proc 2014; 1-10
Opioid drug diversion prevention resources
- ASHP Controlled Substances Drug Diversion Pharmacy Technician Toolkit
- Centers for Disease Control and Prevention CDC
- CDC Healthcare Drug Diversion website
- CDC One & Only Campaign Risks of Healthcare-associated Infections from Drug Diversion
- CDC Public health ethics case study, Unsafe Infections: Duty to Warn
- DEA Diversion Control Division
- Minnesota Hospital Association – Drug Diversion Prevention
- Missouri Department of Health – Drug Diversion in Hospitals: A Guide to Preventing and Investigating Diversion Issues
- National Association of Drug Diversion Investigators NADDI.
- New Hampshire Department of Health –New Hampshire Hepatitis C Outbreak Report
- Premier Advisor Live® webinar: Preventing theft of drug and controlled substances – a patient safety imperative. Faculty KH Berge, Mayo Clinic; KR Dillon, Mayo Clinic; JF Perz, CDC; G Pugliese. Slides