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Drug Diversion in the Workplace

Drug Diversion in the Workplace. Kimberly Miller, RN, BSN, MC October 4, 2014. Definition of Drug Diversion. Diversion - “Any criminal act involving a prescription drug .” Uniform Controlled Substances Act (1994). What to Expect. Historical Overview of Diversion by Nurses

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Drug Diversion in the Workplace

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  1. Drug Diversion in the Workplace Kimberly Miller, RN, BSN, MC October 4, 2014

  2. Definition of Drug Diversion Diversion - “Any criminal act involving a prescription drug.” Uniform Controlled Substances Act (1994)

  3. What to Expect • Historical Overview of Diversion by Nurses • Factors Associated with Diversion • Preventing, Identifying, and Investigating Diversion • Impact on Patients • What’s on the Horizon • Nursing Community Response

  4. Diversion: Then to Now • Historical • Moral behavior • Studies of addiction in nurses • Alternative to discipline programs • Automated systems to manage medications • Pain as the sixth vital sign • Expanding RN controlled substance administration • Media • State and Federal laws

  5. Scope of the Issue • Opioid Use • Use of opioids in the US • Use of opioids by nurses • Recreational use of opioids • Frequency of Diversion • Practice after Diversion

  6. Why Divert? • Addiction • Pain Management • Mental Illness • Personal Issues • Provide to Others • Barter or Sell

  7. Addiction • Chronic illness • Diagnosed by a cluster of behaviors and physical symptoms • Evidence of biochemical brain alterations

  8. Brain Neurobiology In the Ventral Tegmental Area of the mid-brain, neural circuits and neurochemicals create a mechanism to enhance brain plasticity related to reward, motivation, and learned behavior. Examples: quenching thirst, satisfying hunger, sex, sleep

  9. Activation of Dopaminergic System Repeat Sex Increased dopamine level Pleasurable reinforcement Reinforcement of survival activity

  10. Neurobiology of Addiction • Chronic exposure to addictive drugs results in neurochemical changes in the brain that hi-jack the intended function and reinforces further drug use. Use drug Increase synaptic dopamine level Euphoria and sense of well-being Volitional behaviors become habits, which become compulsions through Pavlovian learning.

  11. Other Illnesses Associated with Diversion • Chronic Pain Extended opioid use No or failed tapers Fear • Mental Illness Undiagnosed or treated Self-medicating

  12. Personal Issues Associated with Diversion • Personal management • Stress management • Sleep disturbance • Recreational use • Provide to others • Barter or sell

  13. Preventing, Identifying, and Investigating Drug Diversion • Develop Controlled Substance Management Systems (CSMS) • Periodic Review of the CSMS • Monitor Controlled Substance Data • Educate Staff/Communicate Expectations • Investigate Suspected Diversion and Tampering • Develop an investigations team

  14. Controlled Substance Management System • Determine an Organizational Team to Develop the System and Determine Protocols • Determine a Multi-Disciplinary Team for System Oversight and Diversion Investigation • Determine Overall Organization Communication and Policies

  15. Pharmacy to Unit: Maintaining Chain of Custody • Enter Available Drugs Into Electronic System • Secure Storage and Transfer • Customize Drug and Dose Supplies to Unit Needs • Periodic Monitoring of Supplies

  16. On the Unit: Maintaining Chain of Custody • Controlled Access • Bio-identifiers v passcodes • Overrides, Cancelled Remove • Blind Counts/Count Backs • Drug Handling by Nurse • Selecting appropriate dose • Congruent assessment and dose • Timely administration • Accurate and timely documentation • Timely waste of excess dose – witnessed

  17. Communicating Expectations • Clear policies with nurse involvement in development • Consequences for failing to follow policies • Review of handling issues with staff • Stop work around practices and short cuts

  18. Identifying Possible Diversion: Nurse Behaviors • Repeatedly withdraws large doses or multiple doses at one time • Volunteers to medicate other patients • Misused automated system functions • Keeps medications for greater than 30 minutes – or leaves med for others to use • Frequent “mishaps” when handling drugs • Frequently requests drug order changes

  19. Suspected Drug Use Behavior • Change in attitude and/or behavior • Change in personal appearance • Frequent illness or tardiness • Frequently takes on extra shifts • Slurred speech, drowsiness, constricted pupils • Poor organization and documentation • Frequently off the unit/missing

  20. Investigation • Consult with drug diversion team – remove access • Review withdrawal, administration, and waste documentation – discrepancies or patterns • Compare drug administration with that of other nurses – typical patient use • Review automated system functions use • Interview and toxicology screen

  21. Tampering & False Prescriptions • Replace medication with another drug or substance • Dilute injectable medications • Altered or false prescription submitted • Filling prescriptions for patients

  22. Risks to Patients • Inadequate pain management • Nurse inattentive or impaired • Other providers are working with inaccurate information • Patients develop fear or mistrust of healthcare

  23. Nursing Community Responsibility • Opioid use by nursing students • Inadequate availability of addiction treatment focused on the specific issues facing nurses seeking rehabilitation • Minimize risks to patients • Better management of re-entry into practice • Need for research

  24. Resources • American Association of Colleges of Nursing. (2012). Policy and guidelines for prevention and management of substance abuse in the nursing education community (Updated 1998). Washington, D.C. • Angres, D.H., Bettinardi-Angres, K., & Cross, W. (2010). Nurses with chemical dependency: Promoting successful treatment and reentry. Journal of Nursing Regulation, 1(1), 16-20. • Bell, D., McDonough, J., Ellison, J., & Fitzhugh, E. (1999). Controlled drug misuse by certified registered nurse anesthetists. American Association of Nurse Anesthetists, 67(2), 133-140. • Bettinardi-Angres, K., & Bologeorges, S. (2011). Addressing chemically dependent colleagues. Journal of Nursing Regulation, 2(2), 10-15. • Crowley, K., & Morgan, C. (2014). Re/entry: A guide for nurses dealing with substance use disorder. Indianapolis, IN. Sigma Theta Tau International. • Health Professionals Assistance Program – South Dakota. http://doh.sd.gov/boards/nursing/healthpro.aspx • Health Professionals Services Program – Minnesota. www.hpsp.state.mn.us • K.H. Berge, K.R. Dillon, K.M. Sikkink, T.K. Taylor, &W.L. Lanier (2012). Diversion of drugs within health care facilities, a multiple-victim crime: Patterns of diversion, scope, consequences, detection, and prevention. Mayo Clinical Procedures, 87(7), 674-682 http://dx.doi.org/10.1016/j.mayocp.2012.03.013 • Road Map to Controlled Substance Diversion Prevention. www.health.state.mn.us/.../drugdiversion/divroadmap041812.pdf • What You Need to Know About Substance Use Disorder in Nursing (brochure). communications@ncsbn.org

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