Controlled substance diversion is a major challenge for hospitals across the country. The problem is being fueled, in part, by the power of addiction: It is estimated that 10% to 15% of health professionals will develop serious substance abuse/addiction problems during their career (Crit Care Med 2007;35:S106-S116). Experts warned during a recent webinar that vigilance by all hospital staff—those in pharmacy, nursing, security, human resources and administration—is required to address this looming problem.

Accrediting and regulating agencies have responded by requiring pharmacy departments to secure all controlled substances and identify the diversion of drugs in a timely manner. Advanced monitoring and dispensing systems, such as anesthesia dispensing carts, are helping hospitals better control their medication inventories, but diversion detection still remains a daunting task.

Pharmacy Practice News spoke with Deborah Riffel, RN, MS, a senior clinical sales consultant for CareFusion’s Pyxis Technologies, in Kansas City, Miss., about diversion prevention and detection in the hospital setting, the focus of the webinar sponsored by the company. Ms. Riffel recommended that hospitals take a systemized, multidimensional approach.

“Hospitals must have explicit policies, detection methods, investigation processes and an organizational culture of readiness,” she said. “Without a systemized approach, hospitals are vulnerable to major drug diversion and subsequent public and legal repercussions. Pharmacy, nursing and anesthesia are the main players, but when developing policies and procedures we also recommend including human resources, security, risk management [and] administration—all of those people potentially can be involved.”

Technology Can Be a Potent Weapon …

Technology upgrades are an important weapon in the fight against drug diversion, Ms. Riffel noted. She cited, as an example, moving from hospital narcotic storage boxes to automated controlled substance cabinets. One study showed a 321% increase in diversion detection rates after the installation of automated cabinets in the controlled substance vault in central pharmacy (0.36 diversions detected per 100 beds per year before installation vs. 1.12 diversions detected per 100 beds per year after installation; Hosp Pharm 2005;40:977-983).

Table 1. Practical Tips To Secure Your Pharmacy Unit
Have two employees to place and receive orders.
Have rotating personnel perform inventory in the controlled substance vault in central pharmacy.
Keep keys to the controlled substance vault and automated dispensing cabinets in a secure place. Number the keys and have one set locked in the vault and give another set to the director of pharmacy.
Create an automated or paper audit trail for any movement of controlled substances. There must be a reconciliation system of what was purchased versus what was received in the vault. Audits should be completed by a person who does not handle controlled substances.
All controlled substances in automated dispensing cabinets on the floor should be in single-jar or single-dose access pockets. Keep controlled substances in a drawer separate from noncontrolled substances.
Require a witness to return bins.
Source: Deborah Riffel, RN, MS

The monitoring and reporting tools built into many technology systems also can be invaluable in fighting diversion. Such tools “[enable] us to look at behavior patterns,” Ms. Riffel said. One productive strategy is to closely examine data on two employees who always seem to waste drugs together or employees who are canceling a lot of medication transactions, both of which can be mechanisms for drug diversion. “Having usable data is really the key to curbing diversion and allowing hospitals to have better means for detection,” she said. In addition to any reports generated from advanced monitoring technology, there also needs to be internal reporting to provide checks and balances, Ms. Riffel added.

Tricia Meyer, PharmD, an associate vice president of pharmacy at Scott & White Memorial Hospital, and an associate professor of anesthesiology in the Department of Anesthesiology at the Texas A&M University College of Medicine, in Temple, echoed Ms. Riffel’s sentiments of how timely reports generated by technological advances result in improved detection rates. However, Dr. Meyer said that she strongly believes in implementing checks and balances as well. “The information in the reports needs to be confirmed or validated by manual chart auditing, and inconsistencies or irregularities ... found in the automated reports must be checked,” she said. Additionally, she said, a representative from the department with the team member involved in the discrepancy should be involved in conducting the verifying audits along with a representative from pharmacy.

Ms. Riffel also suggested including a pharmacy presence by having pharmacy participation in the nursing orientation and being very clear about expectations for controlled substance management. “One of the first steps pharmacy can take is to look at privileges and see who has access to the controlled substance vault and the automated dispensing cabinets on each floor. Make sure employees have enough privileges to perform their job but not excess privileges to inappropriately access the system.”

Ms. Riffel noted that because technology has moved into the operating room (OR) suite to specifically handle anesthesia medications, this may be a big change for anesthesia providers. “Nurses may be used to having this oversight but many anesthesiologists may not, and it is a change in their practice to get used to technology in each individual OR suite.” (For more practical strategies for reducing drug diversion, see Table 1.)

… But It’s Not a Cure-All

Table 2. Signs and Symptoms of Substance Abuse in the Workplace
Frequent absences from work without reasonable explanations
Consistently late arrivals
Missed appointments with patients
Inaccessibility to patients and staff
Inappropriate behavior with colleagues, staff and patients
Conflicts with colleagues, staff and patients
Avoidance of a supervisor or other colleagues
Rounding on patients at odd hours
Large quantities of drugs ordered
Inappropriate orders and forgotten verbal orders
A disorganized schedule and missed deadlines
Heavy drinking at hospital functions
Vague letters of reference
Multiple prescriptions for family members
Long lunches or unnecessary breaks
Decreased chart and work performance
Source: Crit Care Med. 2007;35:S106-S116.

Even with the most advanced technology and monitoring systems in place, diverters who are familiar with a system still can find creative ways to divert medication. Hospitals, therefore, should seek to incorporate a human component that may be absent from monitoring technology. “Nurse managers can be helpful in diversion prevention because they perform patient interviews asking about pain control,” Ms. Riffel said. “We discovered a case where a patient reported only receiving one pill, but it was documented that the nurse was removing two pills from the dispensing machine.”

Observing unusual employee behavior is another way hospitals can be vigilant for controlled substance abuse in the health care setting. Key behaviors to look for when trying to identify diverters include work absenteeism, excessive time spent near drug supply, confusion, memory loss, deterioration in personal appearance, personality change, denial and trying to deflect attention. For more information, visit the Drug Enforcement Administration’s Office of Diversion Control (http://www.deadiversion.​usdoj.gov/​pubs/​brochures/​drug_hc.htm).

Dr. Meyer stressed the importance of educational programming for hospital employees so that they can recognize the signs and warnings of impaired colleagues (Table 2). “The substance abuser rarely reports his or her addiction, and coworkers are hesitant to become involved or [divulge their concerns],” she said. “Staff must be informed that the consequences of not reporting the individual in question can be significantly worse than reporting him or her. Addicted health care workers who are not discovered ... are in danger of hurting themselves, patients, the workplace and their profession,” Dr. Meyer cautioned.

How can hospitals enforce controlled substance policies without making employees feel like they are constantly being watched by Big Brother? It can require walking a fine line. “Establish a culture of diversion prevention and detection overall in the hospital and emphasize that it is every hospital employee’s responsibility,” Ms. Riffel said. “If employees know that there is a zero tolerance policy for medication diversion, they will be held accountable for their actions. For new employees, hospitals might emphasize controlled substance management and detection and the possibility of drug testing.”