Tom Knight, MBA, MS

Health care systems have spent the bulk of 2020 and 2021 adapting to new norms in workplace safety and patient care to minimize transmission of COVID-19, while effectively rolling out vaccines. It hasn’t been easy, given the economic tolls of the past year and a half, including high rates of clinical staff turnover at some facilities.

But amid this evolving post-pandemic “recovery,” health care leaders have devoted fewer dollars, and less attention, to drug diversion, according to a newly released report by 

. As many as 38% of health care and diversion professionals surveyed in early 2021 said resources for drug diversion investigations were reallocated due to budget cuts because of the pandemic, whereas 47% said drug diversion became more difficult to track due to staff turnover.

Also, only 45% of percent of health care organizations said they have at least 1 full-time employee (FTE) dedicated to drug diversion. This is a substantial drop from the 2019 report, which showed that 58% of organizations employed at least 1 dedicated FTE.

But with the risk of diversion potentially greater than it was before the pandemic, these data should be viewed as a warning sign.

Cases of drug diversion have steep financial, clinical, and legal consequences. Recent incidents of health care diversion have culminated in 

, the spread of healthcare-acquired infections (HAI) including 

 said they strongly agree that most drug diversion goes undetected, a number that has increased compared with previous surveys. And 86% said they personally know someone that has diverted medications.

Yet there is the tendency to ignore what’s not in front of us and hyper-focus on only the immediate problems we can see. For the last 18 months, COVID-19 concerns have understandably eclipsed nearly everything else.

But multiple circumstances are, nevertheless, building up to a perfect storm. Between October 2019 and October 2020, drug overdose deaths among the general population increased by about 30% over a 1-year period, amid the larger mental health crisis. Meanwhile, health care workers are exhausted: 

 polled recently noted that the pandemic increased their feelings of burnout.

Also, hospitals nationwide must still focus on COVID-19-related priorities, such as overseeing vaccine distribution. But this, too, has raised ancillary concerns around drug diversion: One in 3 surveyed by Porter Research said they are more concerned about drug diversion given the distribution of the COVID-19 vaccine.

One silver lining in the data is the increased use of technologies that can identify drug diversion, and, in doing so, save organizations time and money.

Machine learning software, for example, enables technology providers to train machine learning systems to recognize known patterns of drug diversion in healthcare facilities. If, say, a hospital nurse dispensed 2 hydrocodone tablets from an automated dispensing machine but an hour later, the nurse reports in her electronic medical record (EMR) that she administered only 1 tablet, computer technologies would detect that the other tablet is missing.

More than 4 in 10 survey respondents (42%) said they use machine learning technologies to address drug diversion, up from 29% in 2019. Among those whose health systems use machine learning technology, 73% rated it favorably in effectively preventing diversion.

However, although the implementation of advanced technologies is encouraging, it’s only one solution. The issue of drug diversion is comprehensive and multifaceted. To successfully prevent diversion, or lower the risk, a health system needs leadership buy-in, staff cooperation, and potentially changes to hiring, education, and training practices.

Given the ongoing risk of diversion, health care organizations would benefit from strengthening the following areas:

 Having a dedicated professional to oversee systemwide initiatives around drug diversion — supply chain, investigations, reporting, IT purchases — is one of the best ways to bolster internal defenses. The fact that fewer health care organizations employed at least 1 full-time drug diversion professional may be to blame for a low level of investigations. In 2021, nearly 1 in five respondents (18%) respondents said they didn’t investigate any cases.

 Health care organizations need systems in place to ensure that packages and goods are tracked from the moment they’re taken off the loading dock to their ultimate destination.

 Every health care facility should ensure its educational programming goes beyond informational sessions on substance-use disorders (SUDs). Educators must specifically address the risks and consequences of both drug abuse and drug diversion, including addiction, job loss, and legal ramifications.

 Most clinicians and pharmaceutical workers are trained on what to do when they encounter patients with SUDs. Ensure clinicians and staff also understand the process of reporting a suspected incident of diversion, or suspicious activity. Organizations like 

National Association of Drug Diversion Investigators

 (NADDI), and the International Health Facility Diversion Association (IHFDA) offer resources to educate and train staff on drug diversion prevention best practices.

 Eighty-six percent of health care leaders already utilize automated dispensing cabinets. But for maximum benefits, the data derived from technology solutions like automated dispensing cabinets (ADCs) should be integrated with other data sets. For example, machine learning software can synchronize multiple sources of information — electronic health records, patient pain ratings, pharmaceutical records — from disparate sources, and dispatch alerts when patterns associated with diversion are detected.

Although health care organizations need to keep their focus on patient care and safety amid the ongoing pandemic, they also need to prepare for increased risks of medication theft and misuse. With the current state of declining hospitalizations of patients with COVID-19, now is the time to take another look at the protocols, policies, and technology used to reduce drug diversion.

Articles

With the risk of diversion potentially greater than it was before the pandemic, these data should be viewed as a warning sign.







Challenges of Drug Diversion in Health Care Settings Amid High Staff Turnover, Budget Cuts

In the US, health care leaders are so overwhelmed by the clinical, operational, and financial aspects of managing coronavirus disease 2019 (COVID-19) that they may be less focused on stopping drug diversion. But it is still happening. In many parts of the country, opioid-related overdoses are rising while health care workers on the front lines are reporting higher levels of mental health issues. Meanwhile, the supply of coronavirus treatments, within a strained economy, could increase their black market value.

Yet the biggest signs of the potential for drug diversion to skyrocket in health care environments may be within the hospitals themselves, which have been forced to quickly adapt to the COVID-19 era.

Since March, the spread of COVID- 19 has fueled a higher sense of urgency in health care centers, from the movement of nurses from one hotspot area to the next to related increases in patients with high-acuity needs. This has led to the implementation of new rules, workflows, and guidelines, to ensure that contact with high-risk individuals is minimized, personal protective equipment is appropriately rationed, and frontline workers receive the support they need. Although these operational shifts were necessary, they have exposed new vulnerabilities in care settings.

Here are 5 tactics health care leaders can employ to improve their efforts in stopping drug diversion:

Clinical leaders are already having conversations about drug diversion, but it is important to keep the issue top of mind among clinicians.Sharing news of recent incidents highlights not only the theft of COVID-19–associated supplies,but also the criminal consequences.

 If the physical layout of a health facility was modified in response to COVID-19, clinicians may need to be retrained on adapting medication management practices to a new environment. For example, Drug Enforcement Agency guidelines require that unused controlled substances must be destroyed following strict rules, so clinical supervisors may need to take extra steps to ensure compliance.

Discrepancies in data,such as patient pain scores,
may indicate the need for a diversion investigation. Case in point: In May, an Iowa nurse anesthesiologist was sentenced to 34 months in prison for tampering with vials of fentanyl in a hospital’s surgery
and birthing center. But the nurse’s drug problem was only discovered by accident when a hospital visitor caught him sleeping. Only when authorities reviewed his obstetrics patients did they learn that
1 in 4 of the nurse’s spinal anesthesia patients had received narcotics that were insufficient to reduce labor pain. Had a red flag been raised sooner, the perpetrator would have potentially been investigated more quickly.

 A dedicated drug diversion professional, used
on a part-time or full-time basis, can assess a health care facility’s current approach and solutions to mitigating drug diversion and identify gaps. Yet according to a 2020 study conducted by Porter Research and Invistics, just 41% of health care organizations have at least 1 dedicated diversion professional on site.

 Considering that only 36% of workers surveyed said they are confident in their organization’s drug diversion program, having an expert available to support efforts to improve drug diversion could be a game changer.

 In addition to having visibility into the supply chain, it is important to have visibility into other areas, including health care workers’ experience and background, adjustments in the workflow, and so on. A health care organization may want to consider using technology (eg, track and trace software) or increasing the number of audits it performs on a regular basis.

, the leading provider of inventory visibility and analytics software solutions. Prior to founding Invistics, Tom spent 10 years improving supply chains as a manufacturing manager at Alcoa and Siemens. Tom has a B.S. and M.S. in Mechanical Engineering and an MBA from Massachusetts Institute of Technology (MIT).

Issue brief: reports of increases in opioid- and other drug-related overdose and other concerns during COVID pandemic. American Medical Association. Updated October 31, 2020. Accessed November 9, 2020. 

https://www.ama-assn.org/system/files/2020-11/issue-brief-increases-in-opioid-related-overdose.pdf

Spoorthy MS, Pratapa SK, Mahant S. Mental health problems faced by healthcare workers due to the COVID-19 pandemic: a review. 

 2020;51:102119. doi:10.1016/j.ajp.2020.102119

Drug disposal information. US Department of Justice, Drug Enforcement Administration Diversion Control Division. Accessed November 9, 2020. 

https://www.deadiversion.usdoj.gov/drug_disposal/index.html

Charles City nurse anesthetist sentenced to nearly three years in federal prison for drug tampering and diversion scheme. News release. The United States Attorney’s Office Northern District of Iowa. May 29, 2020. Updated June 1, 2020. Accessed November 9, 2020. 

https://www.justice.gov/usao-ndia/pr/charles-city-nurse-anesthetist-sentenced-nearly-three-years-federal-prison-drug#:~:text=West%20was%20sentenced%20in%20Cedar,%243%2C158.18%20in%20costs%20of%20prosecution

Porter Research Study 2020: A Comprehensive Look at Drug Diversion from the View of Healthcare Executives. Porter Research. Accessed November 9, 2020. http://porterresearch.com/wordpress/wp-content/uploads/2020/05/Invistics_Diversion-Report-2020-Porter_Research.pdf

Incidents of medication theft, including theft of COVID-19 treatments, could jeopardize operations and hurt patients.