Identifying and Dealing with Drug Abuse and Diversion

1. Identifying and Dealing with Drug Abuse and Diversion Webinar May 25, 2010 Presented by Linda L James

2. Drug Abuse and Drug Diversion drug abuse:habitual use of drugs to alter one's mood, emotion, or state of consciousness. diversion: licit drugs for illicit purposes.

3. Objectives • Recognize scope and associated risks of drug diversion in the healthcare organization. • Identify behaviors commonly seen in an impaired worker. • Identify system failures related to diversion. • Determine best practices for preventing and addressing drug abuse and diversion in your setting.  

4. Where Does Diversion Occur? • Theft from manufacturing to distribution. • Receiving and accounting fraud. • Storage and access. • Prescribing. • Dispensing. • Medication administration. • Wasting and destruction. • Documentation in all phases.

6. Following the March $75 Million drug heist at an Eli Lilly pharmaceutical warehouse in Connecticut….growing phenomenon: Thieves are stealing large quantities of prescription drugs for resale on the black market. Pharmaceutical heists in the U.S. have quadrupled since 2006, a coalition of industry and law enforcement estimates. And experts say the reasons include spotty security and high drug prices that can make such thefts extremely lucrative.

7. Medical and Non-Medical Use of Drugs • Demand for drugs • Each year 1.5 billion prescriptions (AVG 6.7/person). • Common Supply Tactics • Illegal importation. • Theft: warehouse, in-transit, pharmacy, diversion tactics. • Prescription forgery. • Dishonest doctors, pharmacists, and healthcare personnel.

8. Costs of Drug Abuse and Diversion • Substance abuse costs businesses $100 billion annually due to productivity, absenteeism, and insurance premiums. • Drug users: • Consume almost twice benefits. • Absent 1.5 times more often. • More than twice workers’ compensation claims. SAMHSA.gov

9. Organizations - National Institute on Drug Abuse • Formed in 1974 • Goal to gather accurate data • NSHDA National Household Survey on Drug Abuse (since 1989) • DAWN Drug Abuse Warning Network (Emergency Department data collection since 1985) • High School Seniors Survey (since 1975)

10. Drug Abuse Warning Network (DAWN) 1. Cocaine 2. Marijuana 3. Heroin 4. Benzodiazepine 5. Xanax 6. Klonopin 7. Hydrocodone 8. Amphetamine 9. Diazepam (Valium) 10. Ativan 11. Methamphetamine 12. Trazodone (Desyrel) 13. Prozac 14. Carisprodol 15. Oxycodone 16. Valproic acid 17. Darvocet N, Darvon 18. Elavil 19. Methadone 20. LSD

11. The Substance Abuse and Mental Health Services Administration • SAMHSA 5 • Required testing for designated organizations. • Marijuana • Cocaine • Amphetamines • Opiates • Phencyclidine (PCP)

12. Why is it so difficult to control? • Drug Diversion • Prescription drug use: • Accounts for about 30% of overall drug problem in US. • Majority average citizens become addicted after a legitimate medical reason. • Often not reported to law enforcement or regulatory boards. • Fear of publicity. • Fear of lawsuits. • Resulting issue: free to repeat behavior.

13. Drug Abuse and Diversion Tactics • Doctor shopping. • Internet pharmacies. • Phone solicitation. • Employee theft. • Non-employee theft. • In-transit. • Prescription forgery. • Illicit prescribing.

14. Workers and Drugs • 15% professionals struggle with drug dependence at some point in their careers. • One in 10 workers has a problem with drugs. • More than 70% of drug users work full-time. • Failure to control a controlled-substance and falsification of records is a felony. • Did you know? • Approx 33% of nurses who are given an opportunity to report an impaired co-worker will do so.

15. Workers and Alcohol • Alcohol is a drug. • Over 7% of Americans drink during the workday, mostly at lunch. • Hangovers account for many workplace productivity losses. • Addictions of family members can affect productivity of the worker.

16. Behaviors Leading to Impairment at Work • Binge drinking night before working. • Recreational drugs on weekends (days off). • Prescription medications at work. • Working overly-tired or ill. • Passive attitude of managers.

17. Rates of substance abuse among different types of personnel within the health care industry are as follows:

18. Addiction • Working Partners for an Alcohol and drug free workplace. US Department of Labor. • Addiction is the irresistible compulsion to use alcohol and other drugs despite adverse consequences. • On the job indicators of Addiction: early, middle, late-middle, late phases.

19. Early Phase

20. Middle Phase

21. Late Middle Phase

22. Late Phase

23. Hot Spots for Closer Observation in Healthcare • Anesthesia • Emergency Department • Pharmacy • Drug storage /distribution areas • Technicians • Delivery personnel-drivers • Clerks and admin staff • Family member use • Contractors/temps

24. Anesthesia • High risk group due to high access and low control measures. • Solutions include accountability for controlled drugs. • Pharmacy checkout and check in. • Preparation and Labeling procedures. • Chain of custody. • Wasting procedures. • Credentialing and monitoring previous abusers.

25. OR and OB-subset of Anesthesia • Unattended and/or early set up drug on anesthesia tables. • Dosing epidurals. • Carrying syringes in lab coat. • Does not destroy or have excess narcotic witnessed in real time. • Does not document in real time. • Does not label syringes.

26. OR - Case Study • In June 2009, at a hospital in Colorado, 108 instances of theft and tampering with fentanyl vials from automated dispensing equipment. • 27 year old nurse had been replacing fentanyl with saline. • More than 350 patients were involved. • Patients reported pain. • Employee worked at facility for 4 months.

27. Emergency Department • Drug Seeking behaviors. • Patients request specific drugs. • Patients request ED physicians by name. • Frequent visitor to ED. • Prescribing practices of controlled drugs not monitored. • Easy access to prescription pads. • Direct calls to pharmacy by drug seeker with specific DES information. • Illegal drugs on person.

28. Pharmacy • Pattern of returning leaking IV bags containing drug additives for replacement. • Patterns of broken vials or ampoules. • Narcotic waste is thrown in general trash. • Changes in use quantities of a given area. • Returned capsules missing powder. • Returned broken tablets missing pieces. • Diluent is used instead of active injectable. • Substitution of look-alike drugs.

29. Pharmacy • Access not controlled. • No audit process for check-in of new drugs. • Non-monitored destruction of expired medications. • Limited pharmacy hours. • Access to pharmacy after hours.

30. All Clinical Areas • PRN drug orders that allow a range (nurse gives low dose and documents high dose). • Falsification of physician orders. • Replacing controlled drug with saline. • Excessive wastage (without actual witnessing). • Patient medications. • Actual vs. system counts. • Intentional miscounts.

31. Product Tampering • In 2001, nurse sanctioned for removing patient’s prescription for oxycodone and attempting to fill it. • In 2003, began work in Surgery Center. Was fired in 2008. Admitted stealing Demerol ampoules from a locked case and falsifying the records. As addiction worsened, she replaced Demerol with saline and secured ampoules with super-glue.

32. Behaviors of Impaired Workers • Offers to give PRN medication to patients other than assigned or selecting assignments for patients requesting pain medication. • Refuses to let others administer pain medications. • High use of PRN medication. • Offers to perform drug counts/accountability when working. • Heavy wastage of drugs.

33. Behaviors of Impaired Workers • Change jobs frequently. • Sloppy record keeping: alterations in documentation, suspect ledger entries, and drug shortages. • Inappropriate prescriptions for larger doses of narcotics. • Deterioration of appearance. • Personality changes – mood swings. • Complaints about attitude and behavior. • Increasing personal and professional isolation.

34. Behaviors of Impaired Workers • Brings purse/bag near drug administration area and makes frequent restroom breaks with purse/bag. • Wears inappropriate clothing for temperature. • Physical symptoms: sweating, chills, photophobia. • Work performance issues including poor judgment and bad decisions. • Higher rate of Workplace accidents and more likely to file workers’ comp claim. • Productivity: absenteeism, coming to work unscheduled, volunteering to complete drug inventories.

35. Handlingan Event: Assessment Behavior: describe visible or unusual. Involvement of one person or group? Witnesses. Physical dangers of action/inaction? Is security/law enforcement needed? Policy that applies? Consultation? (HR, EAP, MD, security) Suspicion testing needed? De-escalation techniques. Documentation.

36. How to Approach an Employee in Drug or Alcohol Crisis • Move to a private place with appropriate chaperone (supervisor, HR, security). • Ask questions. Stick to facts. Stay non-judgmental. Do not give any names of other employees. • Express concern about the specific behavior. • For a violation, notify department head or labor representative. • Suspicion of recent use; follow policy for handling.

37. Approaches During Evaluation/Investigation • Escort to lab for analysis. • Refer employee to EAP. • Physical or mental evaluation, if warranted, use workers comp policy guidelines. • Place on suspension pending investigation. • Provide an escort to employee’s home. • Call law enforcement, if needed.

38. Preventing Diversion • Drug detection and mitigation systems led by pharmacy director and supported by managers, chief risk officer. • Employee background checks and drug testing prior to hire/contracting. • Review of medication distribution and investigations of all discrepancies. • Vigilance: unusual in appearance, chances are something is wrong.

39. Preventing Diversion • System to track: order vs. sales variances. • Locked dumpsters. • Limited access. • Monitor removal and destruction of damaged, outdates, other. • Reconciliation processes: track and trend. • Blister packaging (LTC). • E-kits (emergency kits LTC).

40. OSHA Comprehensive Drug-Free Workforce Approach OSHA recognizes that impairment by drug or alcohol use can constitute an avoidable workplace hazard…. Policy Supervisor training Employee education Employee assistance Drug testing

41. Policy • Purpose • Who, when, what is covered? • Searches, drug testing. • Consequences for violations. • Return-to-Work. • Assistance. • Confidentiality. • Enforcement and communication to employees.

42. Supervisor Annual Training • Responsibilities. • Identify performance problems. • Recognize problems. • Intervention and referral. • Protecting confidentiality. • Continued supervision. • Enabling. • Dos and Don’ts.

43. Employee Education • Policy review and sign off by employee. • Impact of substance abuse in the workplace. • Ways that people use alcohol and other drugs: • Specific drugs of abuse. • Understanding addiction: • Signs and symptoms of substance abuse. • Family and coworker impact. • Types of assistance available. • Confidentiality.

44. Employee Assistance Programs • Refer employee to the EAP. • Emphasize the confidential nature of the EAP. • Be clear about your expectations of the employee’s performance and his/her participation in the program. • Continue to monitor job performance. • Apply progressive discipline as needed. • Notify the EAP if performance continues to decline.

45. Drug Testing • Pre-employment screening * • Following accidents • For cause/ reasonable suspicion * • Return to work * • Random testing • Follow up • * most commonly done in healthcare

46. Return to Work • Return to work certification. • Drug screening upon return. • Random drug screening.

47. Questions? Thank you for attending

48. References • http://www.drugtestinfo.com/documents/EmployeeGuidetoaDrugFreeWorkplace.pdf • http://www.osha.gov/SLTC/substanceabuse/index.html • http://www.aishealth.com/Compliance/ResearchTools/RMC_Drug_Diversion.html • http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/PubsNewsArticle/data/2006March/060321HHN_Online_Yarin&domain=HHNMAG • http://oem.bmj.com/content/61/4/318.abstract?related-urls=yes&legid=oemed;61/4/318 • http://www.dol.gov/elaws/asp/drugfree/drugs/screen92.asp • http://www.workplace.samhsa.gov/wpworkit/pdf/components_of_a_drug_free_workplace_br.pdf • http://www.qsl.net/w5www/diversion.html • http://www.pharmacytimes.com/issue/pharmacy/2009/July2009/drugdiversionandabuse-0709 • http://drugtopics.modernmedicine.com/drugtopics/article/articleDetail.jsp?id=405412 • http://www.msnbc.msn.com/id/35917590/ns/us_news-crime_and_courts/ • http://archives.drugabuse.gov/pdf/monographs/131.pdf • http://www.samhsa.gov/ • http://www.dol.gov/asp/programs/drugs/workingpartners/materials/materials.asp • http://www.dol.gov/elaws/asp/drugfree/drugs/screen28.asp

49. Linda L James RN, MSN, HRMbio notes Ms James has more than 25 years of healthcare experience. She holds a Master of Science in Nursing degree from University of Evansville and a current NC nursing license. She has past certification as a CCRN and Nursing Administrator, Advanced. While working for a national medical malpractice insurer, she acquired the HRM designation. In addition to chairing and participating in national ASHRM committees, Ms James has given presentations relating to risk management and nursing topics. She has provided healthcare risk consulting services for over 100 entities. Other risk management projects included development of clinical risk modification programs; a risk management program for a hospital captive system; and coordination of a Duke Endowment Grant project. Ms James has been published in journal articles addressing risk management and patient safety topics. In addition to her risk management background, Ms James has performed monitoring and project management in Phase III clinical drug trials. Her administrative and clinical nursing experiences include senior vice president of patient care services in a community hospital; director of critical care services in a tertiary hospital; head nurse of a post bypass unit; and staff nurse in a surgical ICU.