drug diversion

Uniform Controlled Substances Act

"Diversion means the transfer of a controlled substance from a lawful to an unlawful channel of distribution or use."

Centers for Medicare and Medicaid Services

"Drug Diversion is defined as the diversion of drugs from legal and medically necessary uses towards uses that are illegal and typically not medically authorized or necessary."

National Association of Drug Diversion Investigators (NADDI)

"Drug diversion is any criminal act or deviation that removes a prescription drug from its intended path from the manufacturer to the patient. This can include the outright theft of the drugs, or it can take the form of a variety of deceptions such as doctor shopping, forged prescriptions, counterfeit drugs and international smuggling."

potential consequences of diversion 4

- substandard patient care. inadequate or absent pain control for the patient - spread of hepatitis or other blood borne pathogens -reputational and financial harm to institutions - potentially lethal overdose by diverter

Drug thefts at U-M hospital

.....DelVecchio was found dead around 9:15 a.m. Dec. 6, 2013 in a locked bathroom at the Neuroscience Hospital, the former location of the old Mott Hospital, located at 1500 East Medical Center Drive in Ann Arbor. According to the autopsy, a syringe was also found in the bathroom and there were multiple needle marks on various parts of the body. Around 12:50 p.m. that same day, Sutton was found in a locked bathroom in the Cardiovascular Center, 1425 Ann St. in Ann Arbor, in cardiac arrest with a syringe and his doctor's kit of pain medications....

well over 50% of diverters start with...

...injectable opioids

drug abuse in general population, health care workers

10% 10-15%

Kristen Parker

2008-2009: Swapped syringes of drug for used syringes refilled with saline or water Needles were contaminated with HCV Over 6000 patients at two hospitals were called back for testing At least 18 patients were infected Sentenced to 30 years

CODE N Team

A small, "rapid response" investigative team acting on behalf of the DDPC Code N Team reviews audits and evaluates evidence using a scorecard If reasonable suspicion exists, the suspected diverter will be called in for an interview The individual will have an opportunity to explain discrepancies or other evidence The individual may be sent for a fitness for duty exam, including a drug screen

What to watch for in the patient care areas

Any medication being stored outside of the medication cabinet Any unmarked syringes in the medication room Dispensing and wasting practices of staff

What to watch for in COWORKERS or in the PHARMACY

Any misuse of modify bin or other functions to remove or tamper with medications Controlled substances left where they do not belong Coworker accessing controlled substance cabinet unnecessarily or excessively Any of the previously listed behavioral signs of drug abuse or diversion

Reporting Requirement

Any unaccounted controlled substance must be reported to the DEA in 24 hours Significant loss ALL theft must be reported DEA 106 form

General Recordkeeping Guidelines

CII: DEA 222 form. must be stored in secure location CIII-CV: can be dispersed with other medications separating inventory, and keeping track of inventory (initially, biannually)

Sarah May Casareto

CRNA 2010: Prosecuted for stealing surgical patient's fentanyl Told patient with kidney stone: "Man up!" Patient endured 57 minute procedure without analgesics Casareto: struggling to stay awake and rocking back and forth No conviction Agreed to stop practicing

Changing Appearance (later signs) 4

Decline in grooming Weight gain or loss Skin changes in tone and integrity Blood-shot eyes

deteriorating job performance (later signs) 4

Decreased responsibilities Withdrawal from committees and activities Forgetfulness in routine duties Cuts corners, dismisses details

4 drugs to ease withdrawal and enhance the impact of opiod

Diphenhydramine Ondansetron Promethazine Naloxone (for self-rescue)

DDPC

Drug Diversion Prevention Committee A leadership level, multidisciplinary committee which reports to Hospital Leadership develops policy, reviews data/trends, etc.

chain of custody

Empty return bins daily and return promptly to Central Pharmacy Inspect returned drugs for evidence of tampering Maintain security of drugs

The Role of Pharmacy in Drug Diversion

Failure to report and failure to maintain records are the most common reasons why institutions get fined with DEA audits! The department of pharmacy is required to maintain accurate Controlled Substance records.

David Kwiatkowski

Fired from the Arizona Heart Hospital in 2010 Injected narcotics, replaced with saline 32 patients diagnosed with HCV Additional cases in other states, 46 to date Sentenced to 30 years - plea bargain

pre-employement indicators 4

Frequent relocations Frequent hospitalization or accidents Working jobs lower than education Reluctance to undergo physical exam

2 pills and liquids

Hydrocodone Oxycodone

injectable drugs 4

Hydromorphone* Morphine* Fentanyl Propofol (anesthesia)

Psychological indicators 3

Irritability Social isolation Challenges department policies and procedures

wisconsin nurse

Jones arrested for stealing syringes of morphine and hydromorphine more than 40 times between Oct 2013 and March 2014

3 benzodiazepines

Lorazepam Alprazolam Clonazepam

Jamie Fitcher

Nurse at Lord Chamberlain Rehab Facility in Stratford, CT 2015: Facing charges for theft and misuse of prescription drugs from healthcare facility Switched out patient's opiates with OTC medications When arrested, she was in possession of several oxycodone and diazepam tablets

Mark Graziano

Owner of a pharmacy in Des Moines, Iowa 700,000 doses of painkillers missing from his pharmacy in 2014 Was ordering hydrocodone containing products from several different wholesalers Sentenced to federal prison in 2015

Automated dispensing cabinets

Passwords Default sign off Reports Procedure to inactivate access with terminated employees

watch for (providers/witnesses)

Providers wasting a large amount at one time Providers looking for a specific person to waste with Witnesses not observing the actual wasting of the medication Witness signing into the ADC then walking away

schedules for controlled substance management

Schedule I (CI): no currently accepted medical use in the US Schedule II (CII): approved for medical use, high potential for abuse Schedule III-V (CIII-V): lower abuse potential, less stringent requirements

methods of diversion

medication no longer necessary, discharged patient, duplkicate dose, no order for medication (lying saying it was verbally ordered). removing fentanyl from its patch, or giving the patient a used patch and keeping the new one

The Role of Pharmacy in Controlled Substance Management

segregating duties Ordering controlled substances Purchasing controlled substances Receiving reports Invoice processing Physical inventories No one person should be given control of these duties

Rocky Allen

surgical tech sentenced to 6.5 years in prison, Nov 2016 swapped out fentanyl in syringes of surgical patients with saline. found passed out, also rummaging through a sharp's container 5000+ offered testing for HIV and hepatitis B/C

4 physical signs

sweating/chills constricted pupils energetic/lethargic behavior itching/scratching

drug diversion

when prescription medications are obtained illegally