Midwinter Meeting February 29, 2020
What’s Mine is Yours Mine: Controlled Substance Diversion in Health System Pharmacy Megan Evans, PharmD, BCPS Director of Pharmacy St. Mark’s Hospital
Disclosure and Disclaimer The presenter has no conflicts of interest and no off label uses of medications will be discussed. Details of nationally publicized healthcare worker diversion events as well as other de- identified events will be shared. The disease of substance abuse disorder is not taken lightly by the presenter and it is the intent to convey respect toward the persons named herein while discussing the dangerous reality this disorder may present when affecting healthcare workers.
Learning Objectives At the conclusion of this activity, pharmacists should be able to successfully: 1. Appraise known indicators of substance abuse disorder in healthcare workers 2. Describe a strategy for identifying diversion in a health ‐ system pharmacy 3. Comply with state and federal requirements for timely reporting of confirmed controlled substance diversion 4. Identify at least one program that offers anonymous assistance to healthcare workers with substance abuse disorder
Learning Objectives At the conclusion of this activity, pharmacy technicians should be able to successfully: 1. Analyze the role of pharmacy technicians in the timely reporting of confirmed controlled substance diversion per state and federal requirements 2. Describe a strategy for identifying diversion in a health ‐ system pharmacy 3. Identify at least one program that offers anonymous assistance to healthcare workers with substance abuse disorder
Reward System Simplified: Go for a natural high! Prefrontal Cortex: Area of the brain uses these rewarding signals to drive decisions toward what is best for individual or group survival Nucleus Accumbens: Area of the brain that releases rewarding signals (e.g. dopamine) for making choices that are good for individual or group survival “If you want to be happy… then you should keep doing those things”
Reward System Simplified: Go for an unnatural high – because can be even better! Prefrontal Cortex: Interprets these signals as evidence that actions to create access to the addictive substance are the very most Nucleus Accumbens: important things that can Triggered by addictive substances be done to release rewarding signals (e.g. dopamine) “WHOA!!!! If you want to be happy… then you must do whatever it takes to be able to do THAT thing”
Survey 1: True or False A healthcare worker with substance abuse disorder is motivated at work to… o Ask lots of good questions – do things “right” o Know the department policies and adhere to them o Complete excellent documentation o Volunteer for extra shifts o Assist peers o Anticipate the needs of patients o Act charismatically o Take actions that result in being well ‐ liked
You Cannot Tell Just By Looking At Them
Simplified Addicted Brain Checklist Does this action give me immediate access to my drug of choice? Does this action ensure continued or future access to my drug of choice? If yes: Do it! x Does this action impede immediate access to my drug of choice? x Does this action restrict continued or future access to my drug of choice? If yes: Do not do it!
Progression of Addiction: Role of Preoccupation 1 Preoccupation Preoccupation serves to stop Preoccupation the suffering serves to create caused by euphoria withdrawal Withdrawal Euphoria
Signs of Addiction in Healthcare Workers 2 Spends excessive time around Appears to require more effort Excuses do not seem to be storage location of controlled than required previously for motivated by providing excellent substances similar task completion patient care Leaving work location Lacks attention or makes inferior Inconsistent work effort unexpectedly and frequently decisions Attendance issues Seeks isolation Blames others for issues Documentation is generally bad Appears at work when not Peers complain about changes in except for controlled substance scheduled nor expected behavior documentation Wears long sleeves at Becomes angry when work Seeks to care for specific types of inappropriate times assignments change patients that increase access Unexplained, excessive waste Errors in documentation/records Diminished self ‐ care
Group Discussion
Survey 2: Is substance abuse disorder in healthcare workers…. A problem in the United States? A problem in Utah? A problem in your organization? A problem in your department? A problem with your closest colleagues?
“Not-In-My-Backyard Effect” 3 Substance Abuse disorder is a problem in: Respondent Type indicating “Yes” US Hospitals Respondent's Hospital Executive 89% 53% 17% Pharmacists 99% 59% 16% Nurses 97% 70% 13% Anesthesiologist 97% 48% 13% It is very or somewhat Current tools at their Respondent Type difficult to detect organization are very or indicating “Yes” diversion 7 somewhat effective Executives 80% 92% Providers 60% 90%
Healthcare Workers’ Responsibilities “You have a personal responsibility to protect your practice from becoming an easy target for drug diversion. You must become aware of the potential situations where drug diversion can occur and safeguards that can be enacted to prevent this diversion.” Drug Enforcement Agency 2
Identifying Diversion: Health-System Pharmacy This is an actual picture of me at work…
Stage of Medication System: Procurement Anthony D’Alessandro, Chief Hospital Pharmacist, stole 200,000 oxycodone tablets over ~ 5 years with a street value in New York of approximately $5.6 million by “selling” them to a falsified investigational study 4 Strategies to Detect and Prevent: 5,6 ◦ Audit the leaders – consider using financial auditors or controllers ◦ Mandate separation of purchasing, receiving, and auditing duties ◦ Trace inventory access and final disposition of medications ◦ Reconcile inventory ◦ Log movement of drug into and out of pharmacy
Stage of Medication System: Storage Thirty vials of fentanyl, hydromorphone, and morphine were adulterated in 9 hours at a community hospital. This occurred shortly after the facility increased accountability and documentation for transfers of custody Strategies to Detect and Prevent: 5,6 ◦ Monitor for delays between dispense, administration and return of controlled substances ◦ Track cancelled transactions ◦ Confirm inventory discrepancy resolutions ◦ Educate staff to detect and report signs of adulteration ◦ Increase individual surveillance after revealing new for ‐ cause audit procedures ◦ Maximize security/surveillance footage of storage locations ◦ Limit manipulation of commercial packaging to point ‐ of ‐ use ◦ Reduce quantities of accessible inventory on clinical units
Stage of Medication System: Prescribing Lori Hoskins, Medical Assistant at a clinic in Utah, stole ~260 prescriptions for oxycodone used to receive ~56,000 tablets billed to insurance for herself, family members and friends by using the clinic physician’s computer password 7 Strategies to Detect and Prevent: 5,6 ◦ Maintain confidentiality of passwords ◦ Review transactions at end of shift ◦ Secure prescription pads and track use ◦ Improve consistency of order interpretation ◦ Reduce use of range orders
Stage of Medication System: Administration University of Michigan Hospital fined $4.3 million for the overdose death of a nurse due to DEA findings of incomplete/inaccurate documentation and failure to follow ‐ through with reporting of loss and theft 8 Strategies to Detect and Prevent: 5,6 ◦ Complete internal audits to ensure compliance with legal requirements ◦ Retain records after periodic audits for completion ◦ Audit use of controlled substance overrides with corresponding orders and documentation of need for emergency access ◦ Investigate use patterns that deviate from expected practice ◦ Enforce change of custody documentation ◦ Consider use of software for statistical outlier review ◦ Report incidents of loss and theft
Stage of Medication System: Waste, Returns, and Expired Products Community hospital surveyed over 100 nurses – the most prevalent answer for how they believe diversion occurs is to swap waste ‐ stating “how do you know what clear liquid is in my syringe? It will not hurt the patient.” Strategies to Detect and Prevent: 5,6 ◦ Unannounced unused drug testing ◦ Encourage witnessed dispense transactions with immediate waste of remainder ◦ Review security footage to audit gaps in witness procedures ◦ Periodically inventory expired drugs prior to reverse distribution ◦ Audit and reconcile documentation to verify wastage
Stage of Medication System: Peer-Identified Changes in Behavior Two nurses died at hospital – 2 years apart – from use of controlled substances obtained from the hospital. One of the nurse’s brothers stated: “They knew she was a hard worker… and they covered for her.” 9 Strategies to Detect and Prevent: ◦ Consider substance abuse disorder as a contributor when investigating errors, patient falls, and patient code blue events ◦ Create a culture of open communication and awareness about substance abuse disorder ◦ Respond immediately and completely to peer complaints – recognize that voiced concerns are generally the tip of an iceberg ◦ Encourage self ‐ reporting and communicate resources for help
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