Diversion - MNDAKSPAN

Drug Diversion in the Workplace
Kimberly Miller, RN, BSN, MC
October 4, 2014
Definition of Drug Diversion
Diversion - “Any criminal act
involving a prescription drug.”
Uniform Controlled Substances Act (1994)
What to Expect
• Historical Overview of Diversion by Nurses
• Factors Associated with Diversion
• Preventing, Identifying, and Investigating
• Impact on Patients
• What’s on the Horizon
• Nursing Community Response
Diversion: Then to Now
• Historical
– Moral behavior
– Studies of addiction in nurses
– Alternative to discipline programs
– Automated systems to manage medications
– Pain as the sixth vital sign
– Expanding RN controlled substance administration
– Media
– State and Federal laws
Scope of the Issue
• Opioid Use
– Use of opioids in the US
– Use of opioids by nurses
– Recreational use of opioids
• Frequency of Diversion
• Practice after Diversion
Why Divert?
Pain Management
Mental Illness
Personal Issues
Provide to Others
Barter or Sell
• Chronic illness
–Diagnosed by a cluster of behaviors
and physical symptoms
–Evidence of biochemical brain
Brain Neurobiology
In the Ventral Tegmental Area of the midbrain, neural circuits and neurochemicals
create a mechanism to enhance brain
plasticity related to reward, motivation,
and learned behavior.
Examples: quenching thirst, satisfying
hunger, sex, sleep
Activation of Dopaminergic System
dopamine level
Reinforcement of survival
Neurobiology of Addiction
• Chronic exposure to addictive drugs results in
neurochemical changes in the brain that hijack the intended function and reinforces
further drug use.
Use drug
Increase synaptic
dopamine level
Euphoria and
sense of wellbeing
Volitional behaviors become habits, which become compulsions through
Pavlovian learning.
Other Illnesses Associated with
• Chronic Pain
Extended opioid use
No or failed tapers
• Mental Illness
Undiagnosed or treated
Personal Issues Associated with
• Personal management
– Stress management
– Sleep disturbance
• Recreational use
• Provide to others
• Barter or sell
Preventing, Identifying, and
Investigating Drug Diversion
• Develop Controlled Substance Management
Systems (CSMS)
• Periodic Review of the CSMS
• Monitor Controlled Substance Data
• Educate Staff/Communicate Expectations
• Investigate Suspected Diversion and
• Develop an investigations team
Controlled Substance Management
• Determine an Organizational Team to Develop
the System and Determine Protocols
• Determine a Multi-Disciplinary Team for
System Oversight and Diversion Investigation
• Determine Overall Organization
Communication and Policies
Pharmacy to Unit: Maintaining Chain
of Custody
• Enter Available Drugs Into Electronic System
• Secure Storage and Transfer
• Customize Drug and Dose Supplies to Unit
• Periodic Monitoring of Supplies
On the Unit: Maintaining Chain of
• Controlled Access
– Bio-identifiers v passcodes
– Overrides, Cancelled Remove
– Blind Counts/Count Backs
• Drug Handling by Nurse
Selecting appropriate dose
Congruent assessment and dose
Timely administration
Accurate and timely documentation
Timely waste of excess dose – witnessed
Communicating Expectations
• Clear policies with nurse involvement in
• Consequences for failing to follow policies
• Review of handling issues with staff
• Stop work around practices and short cuts
Identifying Possible Diversion: Nurse
• Repeatedly withdraws large doses or multiple
doses at one time
• Volunteers to medicate other patients
• Misused automated system functions
• Keeps medications for greater than 30
minutes – or leaves med for others to use
• Frequent “mishaps” when handling drugs
• Frequently requests drug order changes
Suspected Drug Use Behavior
Change in attitude and/or behavior
Change in personal appearance
Frequent illness or tardiness
Frequently takes on extra shifts
Slurred speech, drowsiness, constricted pupils
Poor organization and documentation
Frequently off the unit/missing
• Consult with drug diversion team – remove
• Review withdrawal, administration, and waste
documentation – discrepancies or patterns
• Compare drug administration with that of
other nurses – typical patient use
• Review automated system functions use
• Interview and toxicology screen
Tampering & False Prescriptions
• Replace medication with another drug or
• Dilute injectable medications
• Altered or false prescription submitted
• Filling prescriptions for patients
Risks to Patients
• Inadequate pain management
• Nurse inattentive or impaired
• Other providers are working with inaccurate
• Patients develop fear or mistrust of healthcare
Nursing Community Responsibility
• Opioid use by nursing students
• Inadequate availability of addiction treatment
focused on the specific issues facing nurses
seeking rehabilitation
• Minimize risks to patients
• Better management of re-entry into practice
• Need for research
American Association of Colleges of Nursing. (2012). Policy and guidelines for prevention and management
of substance abuse in the nursing education community (Updated 1998). Washington, D.C.
Angres, D.H., Bettinardi-Angres, K., & Cross, W. (2010). Nurses with chemical dependency: Promoting
successful treatment and reentry. Journal of Nursing Regulation, 1(1), 16-20.
Bell, D., McDonough, J., Ellison, J., & Fitzhugh, E. (1999). Controlled drug misuse by certified registered
nurse anesthetists. American Association of Nurse Anesthetists, 67(2), 133-140.
Bettinardi-Angres, K., & Bologeorges, S. (2011). Addressing chemically dependent colleagues. Journal of
Nursing Regulation, 2(2), 10-15.
Crowley, K., & Morgan, C. (2014). Re/entry: A guide for nurses dealing with substance use disorder.
Indianapolis, IN. Sigma Theta Tau International.
Health Professionals Assistance Program – South Dakota. http://doh.sd.gov/boards/nursing/healthpro.aspx
Health Professionals Services Program – Minnesota. www.hpsp.state.mn.us
K.H. Berge, K.R. Dillon, K.M. Sikkink, T.K. Taylor, &W.L. Lanier (2012). Diversion of drugs within health care
facilities, a multiple-victim crime: Patterns of diversion, scope, consequences, detection, and prevention.
Mayo Clinical Procedures, 87(7), 674-682 http://dx.doi.org/10.1016/j.mayocp.2012.03.013
Road Map to Controlled Substance Diversion Prevention.
What You Need to Know About Substance Use Disorder in Nursing (brochure). [email protected]

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