1. health and fitness
2. drugs

Drug
Diversion
A collaborative processdriven approach to
managing diversion in
the healthcare setting
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Steve Carlson- Northeast Georgia Health System
Director of Pharmacy
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Disclosure
Steve Carlson- Has nothing to disclose
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Objectives
• Discuss the prevalence of drug abuse in
healthcare
• Describe how to develop a drug diversion
program
• Explain how to detect drug diversion
• Describe helpful interviewing methodology
• Discuss reporting requirements
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Definitions
• Drug Abuse: The misuse of legal or illegal
substances with the intent to alter some
aspect of the user’s experience
• Drug Diversion: The theft of controlled
substances from the health system for the
purpose of self administration, selling, or
other use
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Drug Abuse in Healthcare
• Drug abuse among healthcare workers is
comparable to the general population
• Data from National Center of Substance
Abuse Columbia (CASA) 2005 is 15% for
the general population
• 30% of addiction problems begin with
prescription drugs
• 14 of the 20 most abused substances in
the US are prescription drugs.
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Drug Abuse in Healthcare Con’t.
• Substance abuse among nurses ranges
from 2% to 18%
• Prevalence of diversion in the operating
room shows 9.8% in CRNAs
• 12 anesthesiologists die from overdoses of
fentanyl per year. The rate of abuse is 3
times the general population
Sullivan and Decker, 2001 Diversion in the Operating Room 2007, M Sobel 2006
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Drug Abuse in Healthcare Con’t.
• Drug diversion is a $25 billion a year
industry
• A “doctor shopper” can earn a living by
obtaining and selling controlled substances
US Pharmacist 2006
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Drug Abuse in Healthcare Con’t.
• A surgery tech in Denver, CO was found
guilty of infecting 17 patients with Hepatitis
C from syringes she used to inject herself
Hospital Compliance Services 2010
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Drug Abuse in Healthcare Con’t.
• The North Carolina State Bureau of
Investigation is investigating how nine of 29
residents of the Alzheimer’s unit of a Chapel
Hill nursing home, including one resident who
died, tested positive for opiate pain control
medication that was not prescribed for them
Kinston.com 2010
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Drug Abuse in Healthcare Con’t.
• A registered nurse in Iowa is charged with
stealing prescription dugs from the nursing
home where she worked and with falsifying
names on prescriptions in order to receive
the medications or to cover up her repeated
thefts
Muscatine Journal 2009
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Drug Abuse in Healthcare Con’t.
• A Pennsylvania nurse pleaded guilty to
stealing painkillers meant for patients at the
nursing home where she worked
The Patriot-News 2009
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Drug Abuse in Healthcare Con’t.
• The former director of a Georgia assisted
living facility was sentenced to one year in
prison for stealing a resident’s prescription
medications. A federal investigation linked her
to the theft of nearly 4000 prescription
painkillers prescribed for the facility’s
residents
The Florida Times-Union 2009
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Drug Abuse in Healthcare Con’t.
• Overdose deaths from opioid pain relievers
have now exceeded deaths involving Heroin
and Cocaine combined
CDC November 2011
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Most Commonly Diverted
Prescription Medications
• Hydrocodone
• Alprazolam
• Acetaminophen with
codeine
• Butalbital with
codeine
• Propoxyphene
• Methylphenidate
• Diazepam
•
•
•
•
•
•
•
Meperidine
Oxycodone
Hydromorphone
Carisoprodol
Butorphanol
Morphine
Fentanyl
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Minnesota Controlled Substance Diversion
Prevention Coalition: March 2012
Time Line: May 2011 – March 2012
• Reason- High Profile cases of Diversion
• Prescription Drug Abuse- A National
Epidemic
• Controlled Substances are more available
• Developed a road map for healthcare
systems
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Minnesota Controlled Substance Diversion
Prevention Coalition: March 2012
Best Practice Principles
– Storage and Security
– Procurement
– Prescribing
– Preparation and Dispensing
– Administration
– Waste
– Follow up of diversion
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Minnesota Controlled Substance Diversion
Prevention Coalition: March 2012
Best Practice Principles
– Storage and Security
• E box management- controlled substance?
• Counts-who, frequency, double check, discrepancies
– Procurement
• Chain of Custody
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Minnesota Controlled Substance Diversion
Prevention Coalition: March 2012
Best Practice Principles
– Prescribing
• Reduce resident controlled substances
• Assess resident pain
– Preparation and Dispensing
• Automation
– Administration
• Standardize Work
• Pattern Review
• Identify who can administer
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Minnesota Controlled Substance Diversion
Prevention Coalition: March 2012
Best Practice Principles
– Waste
• Disposal System
– Follow up of diversion
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•
•
•
Random observations
Random drug screen
Chart review
Review “phone orders”- nights, weekends, and holidays
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Minnesota Controlled Substance Diversion
Prevention Coalition: March 2012
Prevention Road Map – “SAFE”
“S” - Safety teams-structure
“A” - Access to Information
“F” - Facility Expectations
“E” - Education
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Minnesota CS Diversion Con’t.
“S”- Safety Teams
• Develop an interdisciplinary team
• Develop organization structure
• Develop connections with law enforcement
and reporting
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Minnesota CS Diversion Con’t.
“A”- Access to Information
• Review data and audits
• Track and measure
• Share findings
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Minnesota CS Diversion Con’t.
“F”- Facility Expectations
•
•
•
•
Communicate expectations to staff
Full disclosure policy
HR policies are in line
No sharing of pass codes
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Minnesota CS Diversion Con’t.
“E” - Education
• Comprehensive education and training
for all staff
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Culture Assessment
• Is your culture ready for change?
• Know your culture
– Patient
– Health System
– Employee
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Develop a Policy
• Drug and Alcohol Policy
• Fitness for Duty Policy
• Drug Diversion Policy
− Identify internal reporting responsibilities
− Identify external reporting responsibilities
− Identify the disposition of the employee
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Develop a Team
• ID who should be on your team
– Pharmacy
– Security
– Human Resources
– EAP/Employee Health
– Administration (Note TJC requirements)
• ID the team leader
• Identify the responsibilities of each member
• Understand the departmental requirements
of each member
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Develop Monitoring Methods
• Automated processes that help identify
potential diversions
• Automated storage for controlled substances
• OR processes
• Weekly counts
• Review PCA and Infusions/Epidurals
• Minimize exceptions
• Frequency of reports
• Security System Technology
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Data Extraction Software
• Software analyzes usage patterns from
automated dosing cabinets
• Identifies anomalous usage up to 0.5
standard deviations from the mean
• Identifies potential diversion activity
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Data Extraction Software
Case Study 1-Diversion of a Single Medication
• Patient complains of pain. Nurse notices on MAR that
patient had been given hydrocodone/apap 5mg/500
mg tab one hour prior
• When asked about receiving the medication, the
patient denied getting a dose
• This raised suspicion of the nurse on the previous shift
who charted the dose as given
• Patient was drug screened, and no evidence of
narcotics were present
• Nurse manager notified pharmacy management
• Data analysis software used to screen for potential
diversion via automated dosing cabinets of nurse in
question
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Data Extraction Software
Data analysis revealed the nurse in question had
unusually high dispensing of hydrocodone/apap
5mg/500 mg compared to her peers
Anomalous Usage Indicator Data Analysis Report
(names obscured to protect identity)
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Data Extraction Software
• Nurse in question was brought in for
interview
• During the interview, the nurse
subsequently admitted to diverting the
dose that had been documented as given
for the patient
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Data Extraction Software
Case Study 2-Diversion of Multiple Medications
• Nurse manager receives reports of unusual
behavior of night shift nurse from staff coming
in for day shift
• Nurse in question had instances of
– unexplainable narcotic charting discrepancies in
MAR
– incidence of electronic charting of medications
under another user’s log in
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Data Extraction Software
• Nurse manager contacted pharmacy
management
• Pharmacy provided nurse manager with
dispensing reports for review of charting
trends
• Data analysis software used to screen for
potential diversion via automated dosing
cabinets of nurse in question
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Data Extraction Software
•Data analysis revealed nurse in
question had higher than normal
dispensing of 3 medications
compared to her peers
•Nurse in question was brought in
for interview and subsequently
admitted to diverting narcotics for
personal use
(names obscured to protect identity)
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Narcotics Diversion
Interview Process
“There is one way to find out if a man
is honest-ask him.” Groucho Marx
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Strategies for a Successful Interview
Standardization of process
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•
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•
•
Who does the interview
Location of interview
Video tape
Manager responsibility
Timing of interview
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Diverter Profile
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•
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Initial
Hard worker
Takes care of his/her
patients and helps
with others
Stays late
May come in on off
day
May have prior
injuries (back, etc.)
•
•
•
•
Later
Lapse in recall:
charting errors, may
be reported by peers
as “acting funny”
Often takes bathroom
breaks
Wears long sleeves
Keep to themselves
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Behavior Analysis Interview
• The behavioral analysis interview is
designed to elicit responses focusing on
the following areas to determine probable
truth or deception:
– Non-Verbal
– Verbal
– Paralinguistic
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Two Phases of Behavior Based
Diversion Interview
• Phase I
Ask a series of questions to evaluate the
subject’s truthfulness concerning the topic at
hand. If deceptive responses are observed,
move to phase II.
• Phase II
Using a direct positive confrontation
approach, remove the barriers that are
preventing them from telling the truth. The
ultimate goal is to get a verbal confession
and/or explanation of the variance.
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Behavior Symptom Analysis
Non-Verbal Behavior – Accounts for 55% of
communication and is more reliable than
verbal behaviors. Non-verbal responses
will either support or contradict the verbal
responses given.
• Behavior symptoms become more clear as
the stress and anxiety of the interviewee
increases.
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Nonverbal Behavior Symptoms
Posture - It reveals level of interest,
emotional involvement and confidence.
Truthful- Upright, open and relaxed,
leaning forward, frontally aligned, casual.
Deceptive- Retreating from interviewer,
slouching, frozen, non-frontal alignment,
barrier posture, erratic and rapid posture
changes, head and body slump.
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Nonverbal Behavior Symptoms Cont.
Personal Gestures
Truthful- Use of hands to illustrate what they
are talking about.
Deception- Grooming, scratching, picking,
licking lips, difficulty swallowing, sighs and
yawns, leg bouncing, knuckle popping,
pulling and twirling of hair, spinning rings,
adjustment of clothing, fixing hair, nail
inspection.
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Nonverbal Behavior Symptoms Cont.
Facial Expressions
Truthful- anger, defiance, surprise
Deceptive- fear, acceptance, smile or smirk
Eye Contact
Truthful- normal eye contact is maintained
30-60 percent of the time.
Deception- hard gazing or challenging the
interviewer
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Verbal Behavior Symptoms
A person will choose to engage in deception only
when they perceive no other response option.
Question: “Did you divert narcotics from your
department?”
Truthful Response- “No I didn’t” or “No”
Deceptive Response- “No I did not”(ramble),
“Why would I risk doing that?”
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Evaluating Paralinguistic Behavior
Paralinguistic evaluation will focus on verbal
responses and timing:
Truthful- Truthful responses will be to direct
questions and “on time.”
Deceptive- Early or delayed responses to
questions, rate, pitch and volume changes,
stopping and starting.
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Phase I Interview Questions
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•
•
•
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General Control Questions
Introduction of Interviewers
Name
Work Title and Description
Tenure
Previous jobs (recall question, note eye
movement and direction) Most of the
population look up to the right when
fabricating or editing and up to the left when
giving a factual recall.
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Phase I Interview Questions Cont.
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•
•
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Attitude
Do you like your job here?
If you could rate job satisfaction on a 1-10
scale, what would it be?
How are your performance evaluations?
Honesty Scale: On a scale of 1-10, 10
being a person who never lies and a 1
being a person who lies often where do
you place yourself (Nobody is a 10)?
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Phase I Interview Questions Cont.
• What is your understanding about why you are being interviewed with
us today?
• How do you feel about being interviewed on this topic?
• The reason for the interview is to find out why you are (Give little
detail on diversion case), which to us is an indication of diversion
(describe diversion), so I am just going to ask you if you’re taking
these narcotics for yourself and not giving them to the patients. If you
are, it’s important that you tell us that now.
• Is there any reason why they would name you as someone who
would divert drugs?
• When we complete this investigation, and pull all the necessary data
and interviews together, how do you feel this investigation will come
out on you?
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Phase I Interview Questions Cont.
• What do you think should happen to an employee who is
caught diverting narcotics?
• Do you think the police should get involved with internal
drug diversion in our organization?
• Do you think that someone found doing this deserves a
second chance under any circumstance?
• Are you taking any prescription medications? Is there any
reason that if a fitness for duty test was performed after
this meeting that they would find a scheduled narcotic in
your system?
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Phase II Interview Positive Confrontation
Begin interview with:
• “I have in this file the results of our
investigation which clearly indicates that
you are the one who (did issue).”
• A diverter will be persuaded to tell the truth
if the internal anxiety associated with
deception outweighs his/her perception of
the consequence associated with their
crime.
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Phase II Interview Positive Confrontation
• Using a theme reinforces the diverter’s
existing justifications and rationalizations
for their crime to create an environment
where the person feels more comfortable
telling the truth.
• Themes to Consider: Poor security, nature
of job makes it easy, lack of controls,
exaggerate the amount, blame employer
for not paying enough
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Phase I
Direct Positive
Confrontation
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Narcotics Diversion
Truthful
or
Deceptive
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Phase II
Direct Positive
Confrontation
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Don’t Stop at Confession
Follow up to confession
• Determine reason for Diversion (Personal use
or sale)
• Get a written statement of facts from them
• Conduct a search of their person, bags and
locker (Need organizational policy to support)
• Conduct fitness for duty screening
• Report findings to appropriate licensure board
and Law Enforcement authorities
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Conclusion
Questions/Comments
Email Contact
[email protected]
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