Drug Diversion

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Drug Diversion

• A collaborative process-driven approach to
  managing diversion in the healthcare setting

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• Steve Carlson- Northeast Georgia Health System
  Director of
  Pharmacy

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Disclosure

• Steve Carlson- Has nothing to disclose

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Objectives

• Discuss the prevalence of drug abuse in
  healthcare
• Describe how to develop a drug diversion program
• Explain how to detect drug diversion
• Describe helpful interviewing methodology
• Discuss reporting requirements

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Definitions

• Drug Abuse The misuse of legal or illegal
  substances with the intent to alter some aspect
  of the users experience
• Drug Diversion The theft of controlled
  substances from the health system for the purpose
  of self administration, selling, or other use

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Drug Abuse in Healthcare

• Drug abuse among healthcare workers is comparable
  to the general population
• Data from National Center of Substance Abuse
  Columbia (CASA) 2005 is 15 for the general
  population
• 30 of addiction problems begin with prescription
  drugs
• 14 of the 20 most abused substances in the US are
  prescription drugs.

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Drug Abuse in Healthcare Cont.

• Substance abuse among nurses ranges from 2 to
  18
• Prevalence of diversion in the operating room
  shows 9.8 in CRNAs
• 12 anesthesiologists die from overdoses of
  fentanyl per year. The rate of abuse is 3 times
  the general population
• Sullivan and Decker, 2001 Diversion in the
  Operating Room 2007, M Sobel 2006

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Drug Abuse in Healthcare Cont.

• Drug diversion is a 25 billion a year industry
• A doctor shopper can earn a living by obtaining
  and selling controlled substances
• US Pharmacist 2006

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Drug Abuse in Healthcare Cont.

• A surgery tech in Denver, CO was found guilty of
  infecting 17 patients with Hepatitis C from
  syringes she used to inject herself
• Hospital Compliance Services 2010

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Drug Abuse in Healthcare Cont.

• The North Carolina State Bureau of Investigation
  is investigating how nine of 29 residents of the
  Alzheimers unit of a Chapel Hill nursing home,
  including one resident who died, tested positive
  for opiate pain control medication that was not
  prescribed for them

Kinston.com 2010
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Drug Abuse in Healthcare Cont.

• A registered nurse in Iowa is charged with
  stealing prescription dugs from the nursing home
  where she worked and with falsifying names on
  prescriptions in order to receive the medications
  or to cover up her repeated thefts

Muscatine Journal 2009
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Drug Abuse in Healthcare Cont.

• A Pennsylvania nurse pleaded guilty to stealing
  painkillers meant for patients at the nursing
  home where she worked

The Patriot-News 2009
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Drug Abuse in Healthcare Cont.

• The former director of a Georgia assisted living
  facility was sentenced to one year in prison for
  stealing a residents prescription medications. A
  federal investigation linked her to the theft of
  nearly 4000 prescription painkillers prescribed
  for the facilitys residents

The Florida Times-Union 2009
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Drug Abuse in Healthcare Cont.

• Overdose deaths from opioid pain relievers have
  now exceeded deaths involving Heroin and Cocaine
  combined
• CDC November 2011

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Most Commonly Diverted Prescription Medications

• Hydrocodone
• Alprazolam
• Acetaminophen with codeine
• Butalbital with codeine
• Propoxyphene
• Methylphenidate
• Diazepam

• Meperidine
• Oxycodone
• Hydromorphone
• Carisoprodol
• Butorphanol
• Morphine
• Fentanyl

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Minnesota Controlled Substance Diversion
Prevention Coalition March 2012

• Time Line May 2011 March 2012
• Reason- High Profile cases of Diversion
• Prescription Drug Abuse- A National Epidemic
• Controlled Substances are more available
• Developed a road map for healthcare systems

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Minnesota Controlled Substance Diversion
Prevention Coalition March 2012

• Best Practice Principles
• Storage and Security
• Procurement
• Prescribing
• Preparation and Dispensing
• Administration
• Waste
• Follow up of diversion

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Minnesota Controlled Substance Diversion
Prevention Coalition March 2012

• Best Practice Principles
• Storage and Security
• E box management- controlled substance?
• Counts-who, frequency, double check,
  discrepancies
• Procurement
• Chain of Custody

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Minnesota Controlled Substance Diversion
Prevention Coalition March 2012

• Best Practice Principles
• Prescribing
• Reduce resident controlled substances
• Assess resident pain
• Preparation and Dispensing
• Automation
• Administration
• Standardize Work
• Pattern Review
• Identify who can administer

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Minnesota Controlled Substance Diversion
Prevention Coalition March 2012

• Best Practice Principles
• Waste
• Disposal System
• Follow up of diversion
• Random observations
• Random drug screen
• Chart review
• Review phone orders- nights, weekends, and
  holidays

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Minnesota Controlled Substance Diversion
Prevention Coalition March 2012

• Prevention Road Map SAFE
• S - Safety teams-structure
• A - Access to Information
• F - Facility Expectations
• E - Education

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Minnesota CS Diversion Cont.

• S- Safety Teams
• Develop an interdisciplinary team
• Develop organization structure
• Develop connections with law enforcement and
  reporting

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Minnesota CS Diversion Cont.

• A- Access to Information
• Review data and audits
• Track and measure
• Share findings

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Minnesota CS Diversion Cont.

• F- Facility Expectations
• Communicate expectations to staff
• Full disclosure policy
• HR policies are in line
• No sharing of pass codes

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Minnesota CS Diversion Cont.

• E - Education
• Comprehensive education and training for all
  staff

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Culture Assessment

• Is your culture ready for change?
• Know your culture
• Patient
• Health System
• Employee

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Develop a Policy

• Drug and Alcohol Policy
• Fitness for Duty Policy
• Drug Diversion Policy
• Identify internal reporting responsibilities
• Identify external reporting responsibilities
• Identify the disposition of the employee

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Develop a Team

• ID who should be on your team
• Pharmacy
• Security
• Human Resources
• EAP/Employee Health
• Administration (Note TJC requirements)
• ID the team leader
• Identify the responsibilities of each member
• Understand the departmental requirements of each
  member

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Develop Monitoring Methods

• Automated processes that help identify potential
  diversions
• Automated storage for controlled substances
• OR processes
• Weekly counts
• Review PCA and Infusions/Epidurals
• Minimize exceptions
• Frequency of reports
• Security System Technology

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Data Extraction Software

• Software analyzes usage patterns from automated
  dosing cabinets
• Identifies anomalous usage up to 0.5 standard
  deviations from the mean
• Identifies potential diversion activity

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Data Extraction Software
Case Study 1-Diversion of a Single Medication

• Patient complains of pain. Nurse notices on MAR
  that patient had been given hydrocodone/apap
  5mg/500 mg tab one hour prior
• When asked about receiving the medication, the
  patient denied getting a dose
• This raised suspicion of the nurse on the
  previous shift who charted the dose as given
• Patient was drug screened, and no evidence of
  narcotics were present
• Nurse manager notified pharmacy management
• Data analysis software used to screen for
  potential diversion via automated dosing cabinets
  of nurse in question

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Data Extraction Software
Data analysis revealed the nurse in question had
unusually high dispensing of hydrocodone/apap
5mg/500 mg compared to her peers
(names obscured to protect identity)
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Data Extraction Software

• Nurse in question was brought in for interview
• During the interview, the nurse subsequently
  admitted to diverting the dose that had been
  documented as given for the patient

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Data Extraction Software

• Case Study 2-Diversion of Multiple Medications
• Nurse manager receives reports of unusual
  behavior of night shift nurse from staff coming
  in for day shift
• Nurse in question had instances of
• unexplainable narcotic charting discrepancies in
  MAR
• incidence of electronic charting of medications
  under another users log in

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Data Extraction Software

• Nurse manager contacted pharmacy management
• Pharmacy provided nurse manager with dispensing
  reports for review of charting trends
• Data analysis software used to screen for
  potential diversion via automated dosing cabinets
  of nurse in question

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Data Extraction Software

• Data analysis revealed nurse in question had
  higher than normal dispensing of 3 medications
  compared to her peers
• Nurse in question was brought in for interview
  and subsequently admitted to diverting narcotics
  for personal use

(names obscured to protect identity)
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Narcotics Diversion Interview Process

• There is one way to find out if a man is
  honest-ask him. Groucho Marx

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Strategies for a Successful Interview

• Standardization of process
• Who does the interview
• Location of interview
• Video tape
• Manager responsibility
• Timing of interview

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Diverter Profile

• Later
• Lapse in recall charting errors, may be reported
  by peers as acting funny
• Often takes bathroom breaks
• Wears long sleeves
• Keep to themselves

• Initial
• Hard worker
• Takes care of his/her patients and helps with
  others
• Stays late
• May come in on off day
• May have prior injuries (back, etc.)

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Behavior Analysis Interview

• The behavioral analysis interview is designed to
  elicit responses focusing on the following areas
  to determine probable truth or deception
• Non-Verbal
• Verbal
• Paralinguistic

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Two Phases of Behavior Based Diversion Interview

• Phase I
• Ask a series of questions to evaluate the
  subjects truthfulness concerning the topic at
  hand. If deceptive responses are observed, move
  to phase II.
• Phase II
• Using a direct positive confrontation approach,
  remove the barriers that are preventing them from
  telling the truth. The ultimate goal is to get a
  verbal confession and/or explanation of the
  variance.

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Behavior Symptom Analysis

• Non-Verbal Behavior Accounts for 55 of
  communication and is more reliable than verbal
  behaviors. Non-verbal responses will either
  support or contradict the verbal responses given.
• Behavior symptoms become more clear as the stress
  and anxiety of the interviewee increases.

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Nonverbal Behavior Symptoms

• Posture - It reveals level of interest, emotional
  involvement and confidence.
• Truthful- Upright, open and relaxed, leaning
  forward, frontally aligned, casual.
• Deceptive- Retreating from interviewer,
  slouching, frozen, non-frontal alignment, barrier
  posture, erratic and rapid posture changes, head
  and body slump.

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Nonverbal Behavior Symptoms Cont.

• Personal Gestures
• Truthful- Use of hands to illustrate what they
  are talking about.
• Deception- Grooming, scratching, picking, licking
  lips, difficulty swallowing, sighs and yawns, leg
  bouncing, knuckle popping, pulling and twirling
  of hair, spinning rings, adjustment of clothing,
  fixing hair, nail inspection.

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Nonverbal Behavior Symptoms Cont.

• Facial Expressions
• Truthful- anger, defiance, surprise
• Deceptive- fear, acceptance, smile or smirk
• Eye Contact
• Truthful- normal eye contact is maintained 30-60
  percent of the time.
• Deception- hard gazing or challenging the
  interviewer

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Verbal Behavior Symptoms

• A person will choose to engage in deception only
  when they perceive no other response option.
• Question Did you divert narcotics from your
  department?
• Truthful Response- No I didnt or No
  Deceptive Response- No I did not(ramble),
  Why would I risk doing that?

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Evaluating Paralinguistic Behavior

• Paralinguistic evaluation will focus on verbal
  responses and timing
• Truthful- Truthful responses will be to direct
  questions and on time.
• Deceptive- Early or delayed responses to
  questions, rate, pitch and volume changes,
  stopping and starting.

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Phase I Interview Questions

• General Control Questions
• Introduction of Interviewers
• Name
• Work Title and Description
• Tenure
• Previous jobs (recall question, note eye movement
  and direction) Most of the population look up to
  the right when fabricating or editing and up to
  the left when giving a factual recall.

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Phase I Interview Questions Cont.

• Attitude
• Do you like your job here?
• If you could rate job satisfaction on a 1-10
  scale, what would it be?
• How are your performance evaluations?
• Honesty Scale On a scale of 1-10, 10 being a
  person who never lies and a 1 being a person who
  lies often where do you place yourself (Nobody is
  a 10)?

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Phase I Interview Questions Cont.

• What is your understanding about why you are
  being interviewed with us today?
• How do you feel about being interviewed on this
  topic?
• The reason for the interview is to find out why
  you are (Give little detail on diversion case),
  which to us is an indication of diversion
  (describe diversion), so I am just going to ask
  you if youre taking these narcotics for yourself
  and not giving them to the patients. If you are,
  its important that you tell us that now.
• Is there any reason why they would name you as
  someone who would divert drugs?
• When we complete this investigation, and pull all
  the necessary data and interviews together, how
  do you feel this investigation will come out on
  you?

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Phase I Interview Questions Cont.

• What do you think should happen to an employee
  who is caught diverting narcotics?
• Do you think the police should get involved with
  internal drug diversion in our organization?
• Do you think that someone found doing this
  deserves a second chance under any circumstance?
• Are you taking any prescription medications? Is
  there any reason that if a fitness for duty test
  was performed after this meeting that they would
  find a scheduled narcotic in your system?

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Phase II Interview Positive Confrontation

• Begin interview with
• I have in this file the results of our
  investigation which clearly indicates that you
  are the one who (did issue).
• A diverter will be persuaded to tell the truth if
  the internal anxiety associated with deception
  outweighs his/her perception of the consequence
  associated with their crime.

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Phase II Interview Positive Confrontation

• Using a theme reinforces the diverters existing
  justifications and rationalizations for their
  crime to create an environment where the person
  feels more comfortable telling the truth.
• Themes to Consider Poor security, nature of job
  makes it easy, lack of controls, exaggerate the
  amount, blame employer for not paying enough

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Phase I

• Direct Positive Confrontation

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Narcotics Diversion

• Truthful
• or
• Deceptive

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Phase II

• Direct Positive Confrontation

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Dont Stop at Confession

• Follow up to confession
• Determine reason for Diversion (Personal use or
  sale)
• Get a written statement of facts from them
• Conduct a search of their person, bags and locker
  (Need organizational policy to support)
• Conduct fitness for duty screening
• Report findings to appropriate licensure board
  and Law Enforcement authorities

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Conclusion

• Questions/Comments
• Email Contact
• steve.carlson_at_nghs.com