Erica Lindsay, PharmD, MBA, Esq.
Erica Lindsay, PharmD, MBA, Esq., is a healthcare attorney practicing in the greater Chicagoland area. Dr. Lindsay is active in various organizations including the American Bar Association, where she is chairwoman of the Nursing and Allied Healthcare Professionals Task Force, Illinois State Bar Association, Health Care Compliance Association, American Society of Pharmacy Law, American Intellectual Property Law Association and the Chicago Bar Association. She has recently published Protect and Empower: The Career Survival Guide for Healthcare Professionals. Dr. Lindsay can be contacted at firstname.lastname@example.org
Drug diversion is the transfer of a prescription drug from a lawful to an unlawful channel of distribution or use. It is a significant problem that has a direct impact on drug spending.
The estimated cost of controlled prescription drug diversion and abuse to both public and private medical insurers is approximately $72.5 billion a year. In 2007 alone, the economic cost related to drug abuse in the United States was estimated at $193 billion.
This includes $120 billion in lost productivity mainly due to labor participation costs, drug abuse treatment, incarceration, and premature death, as well as $11 billion in health care costs for drug treatment and drug-related medical consequences, and another $61 billion in criminal justice costs primarily stemming from criminal investigations, prosecutions, incarceration, and victim costs.
In 1992, federal and state governments bore about $45.1 billion (46.2%) of the total $97.7 billion in drug abuse costs. Meanwhile, private insurance bore $3.1 billion, victims bore about $6.5 billion, and drug abusers and members of their households bore $42.9 billion.
These costs are imposed on society in a number of ways, which include drug-related crimes and trauma (eg, motor vehicle crashes); government services, such as criminal justice and highway safety; and various social insurance mechanisms, such as private and public health insurance, life insurance, tax payments, pensions, and social welfare insurance.
Approximately 100 individuals die from drug overdose daily, with opioids accounting for 75% of these overdoses.
Medicaid patients are prescribed opioids at twice the rate of non-Medicaid patients, leading to more unnecessary visits and services provided. This has a direct effect on Medicaid spending.
Among health care providers, it is estimated that 15% of pharmacists, 10% of nurses, and 8% of physicians are challenged with alcohol and/or drug dependency.
According to the US Bureau of Labor Statistics’ May 2013 report, there are 287,420 pharmacists in the United States, meaning that 43,113 of them could be potential substance abusers.
Of the top 17 abused prescriptions in 2013, 16 (94%) were classified as Schedule II, III, or IV medications, including Ritalin, oxycodone, Ativan, Vicodin, and Percocet.
Some providers are victims of drug abuse and divert drugs to maintain their habit.
At a facility in Tennessee, a physician was abusing narcotic pain relievers. There were no complaints from patients or staff, even though the physician demonstrated behavioral changes such as dressing poorly, rounding at abnormal hours, and not handling administrative duties.
The physician’s father intervened and sought help for his son. Since then, he has returned to practice successfully while staying drug-free.
Mayo Clinic reported the following examples where drug diversion was discovered at its facilities:
- A procedural sedation nurse assigned to administer opioids and sedatives to patients during colonoscopy was found to have a secret pocket sewn inside her uniform top into which she dropped syringes of the potent opioid fentanyl and substituted them with syringes containing saline solution.
- A radiology technician with hepatitis C diverted unused fentanyl syringes intended for administration to patients, and 5 patients became infected with the virus.
- While rummaging through sharps waste containers, a night custodian had been withdrawing and consolidating the miniscule remaining fentanyl vials, which he later used.
An instance of non-narcotic diversion was seen when a nurse was discovered diverting furosemide from the automatic dispensing cabinet because she had an eating disorder and took the drug to assist with weight loss. The facility reported the nurse to the police and the state board of nursing for theft. The action became a permanent mark on the nurse’s professional record.
In August 2012, a pharmacy technician at the University of Miami Sylvester Comprehensive Cancer Center stole non-narcotic medications including Neulasta and Aloxi over a 3-year period. The technician would steal 4 Neulasta doses at a time, at a cost of $2600 per dose. The lack of monitoring of high-cost medications led the cancer center to lose more than $14 million.
In 2014, the Drug Enforcement Administration (DEA) rescheduled hydrocodone combination products from Schedule III to Schedule II. Prior to this, hydrocodone combination products could be refilled as much as 5 times in a 6-month period.
The common thread among these cases is the lack of controls for prescription drugs within the high-risk areas of a health care facility, including pharmacy storage, administration by staff, and disposal.
Any drug can be abused or used for economic gain. Therefore, selective monitoring by drug type would not be effective.
Capital limitations may inhibit electronic surveillance of all drugs. Still, there should be random audits of purchases compared with drugs administered to potentially identify instances of diversion.
Facilities should have policies and procedures in place for handling controlled substances, and these procedures should be updated regularly.
Areas to address include orders of controlled substances for a pharmacy or facility with DEA Form 222 and the Controlled Substance Ordering System; reconciliation of drugs from wholesalers; audits of drugs in automated controlled drug cabinets; and distribution of drugs, including controls throughout the facility (eg, operating rooms, outpatient facilities, and patient care areas).
Compounding records and documentation of waste are 2 other important areas to consider, as well as performing ongoing surveillance through constant monitoring of the following reports: automated dispensing cabinet activity, anesthesia flow, operating room waste, abnormal usage, and transaction.This is a sample of reports that can provide valuable information on users and usage of medications throughout the hospital. Scheduled and random audits of these and other reports can allow administrators to identify potential drug diversion in a more proactive manner.