Effectively addressing drug diversion is a challenging pursuit for hospitals throughout the United States, but failure to do so can easily jeopardize patient safety. Although it is common to believe that one’s own hospital is an exception—since diversion could never happen here—this is certainly a misconception. The exact prevalence of drug diversion is unknown, because the deceptive and secretive nature of the problem, as well as health care institutions’ reluctance to acknowledge lapses in medication security, makes quantifying its pervasiveness difficult. However, recognizing that drug diversion is occurring at your hospital is the first step toward preventing it. 

To develop an effective diversion-prevention program, one must gain an understanding of who diverts, what drugs are the most common targets, which areas of the hospital are most likely to be targeted, and when and why diverters misdirect drugs. A program that addresses all of these points is most likely to be successful. At the Ohio State University (OSU) Wexner Medical Center, our diversion-prevention program—named Code N (for narcotics)—emphasizes the urgency of combating diversion. The key functions of the Code N program are enabled via a team of practitioners that quickly convene if evidence indicates a diversion scenario is in progress. The team comprises the director of pharmacy, the director of nursing, and representatives from risk management (the department responsible for calling the code), human resources, hospital security, hospital administration, as well as the manager of the discipline or patient care area under review. This team will meet within 24-48 hours of the discovery of potential diversion to review evidence and determine if a course of intervention is necessary. The success of this program is highly dependent on the multidisciplinary nature of our team and the rapid rate of response.

Who May Become a Diverter?
Anyone with access to desirable drugs—controlled substances, high-cost medications, and other drugs deemed valuable—may become a diverter. In any case of diversion, patients, their families, physicians, pharmacists, nurses, technical staff, and others are put at risk. In health care settings that comply with secure medication storage requirements, diversion detection and prevention efforts focus primarily on staff with access to that storage. 

CASE REPORT: The Unexplained Empty Vial
While cleaning under the bed of a discharged patient in the medical/surgical unit, housekeeping found an empty sufentanil vial. The director of pharmacy was perplexed as to why this medication was found in this location, as it is never stocked or dispensed outside of the pharmacy and was not administered to the discharged patient. Suspecting diversion, she began an internal investigation and found no anomalies, despite careful review of administration records for the patient’s medical/surgical unit nurses, the anesthesiologist, and the operating room and post-anesthesia care unit nurses.

Three weeks later, hospital security requested a review and identification of medications found in the belongings of Jane Doe, an employee being terminated for performance issues. The director of pharmacy identified several tablets and nearly empty vials of controlled substances in her possession. Jane Doe also tested positive for several controlled substances in a urine toxicology screen.

Five years prior, Jane Doe was hired as a third-shift pharmacy technician. After exemplary performance in that role, she obtained a nursing position in the medical/surgical department. However, after changing positions, her pharmacy access was not revoked, an oversight that Jane Doe eventually discovered. She began entering the satellite pharmacies after hours to remove used controlled substance vials from hazardous waste receptacles and obtained sufficient medication to inject herself by pooling multiple vials. Jane Doe was working in the unit the night before the empty sufentanil vial was discovered. Had Jane Doe’s diversion been discovered prior to (or in absence of) her termination proceedings pursuant to her performance, she would have been offered treatment through the hospital. In this case, her diversion was reported to the police as well as the state board of nursing. Jane Doe was subjected to criminal charges and her license was suspended pending successful completion of a rehab treatment program.

Access to Medications
A comprehensive diversion-prevention program should focus on nurses, pharmacists, anesthesiologists, and pharmacy technicians—practitioners who regularly access medications as a function of their job duties. Many hospitals design their diversion-prevention programs to address the nursing staff first because of the sheer size of this workforce. Nurses who administer drugs daily, and may perceive drug availability due to poor or nonexistent workplace controls, have twice the normal rates of drug misuse.¹ Knowledge of drugs has not been shown to prevent addiction among nurses, but rather to promote self-medication. Nurses who are abusing drugs often cite the nature of their work as a component driving their addiction. Contributing factors include²:

• Stress
• Access to controlled substances
• Belief that medications are safe, efficacious, and helpful 
• Caregiver burnout
• Belief that their training and knowledge of controlled substances can protect them from addiction 

Some hospitals and risk managers are wary of sharing cases of confirmed diversion, as they can create a negative perception of the hospital. Regardless, it is essential that drug abuse education be emphasized in the training of all health care practitioners and that all employees be made fully aware that a stringent diversion program is in place at the institution and that it will be strictly enforced. Knowledge about addiction does not prevent the pharmacologic action of the agents. Thus, from a management standpoint, we have to temper staff from working excessive overtime and beware of proffering rewards and accolades for doing so. Working long hours may be a root cause of diversion as long hours ensure continuous access to drugs.

Controlling Access
When medication access is no longer appropriate for a given employee, for whatever reason, procedures must be in place to remove that person’s access to the electronic medical record, ADCs, and any form of electronic security (such as badge readers) that grant physical access to a restricted space. To enable this, establish a process whereby departments notify the information technology (IT) data security group (or its equivalent) of upcoming employment transfers or terminations daily or whenever they occur; immediate or urgent terminations should be communicated rapidly as well. Moreover, the IT department must notify the department requesting an access change after the user’s access has been revoked. Implementing enhanced technology to coordinate and synchronize these notifications with minimal human intervention is key. Integrating ADC systems into the institution’s user database can increase control and decrease the risk of invalid users retaining access to controlled substances. However, even advanced systems cannot prevent all instances of unauthorized access, so continuous vigilance is required. 

When an employee transfers from one position to another within the hospital, medication access must be re-evaluated prior to the move. Because the human resources department often manages transfers, rather than IT data security staff, coordination and early warning can be challenging. Our hospital requires a background check for all employees before initial hire and at the time of each transfer. Coupling an access review with a background check is an effective method to formalize a systematic procedure for medication security.

The pharmacy department also must conduct a regular audit of all pharmacy users’ access to secured medication storage areas. Ensure that support and ancillary employees (such as office assistants or clerks) whose job descriptions do not include medication handling do not have access to medication storage areas.

What Drugs are Targeted for Diversion?
Opioids are the most commonly diverted medications in the health care setting by far, but narcotics are not the only drugs at risk of diversion. The choice to divert one drug over another is contingent on the goal of the diverter, as well as whether the drug is stolen for personal use or to sell to others. 

Diversion for Personal Use
Diverters who redirect products for personal use tend to begin with less potent oral agents, such as acetaminophen with codeine or acetaminophen with hydrocodone, as access and inventory of these DEA Schedule III drugs is often less restricted compared with Schedule II drugs. As the diverter’s tolerance to the narcotic grows, the diversion pattern is likely to intensify. Schedule II and injectable opioids may become the next target. 

In an anonymous study of drug misuse among nurses, 20% of those surveyed admitted to misusing one or more prescription substances. Easy access was highly correlated with drug misuse. Among these practitioners¹: 

• 60% used an opioid
• 45% used a tranquilizer
• 11% used sedatives
• 3.5% used amphetamines
• 1.9% used inhalants 

Diversion for Sale
An individual who is diverting opioids for sale typically focuses on oral, brand name medications with the highest street value, such as OxyContin and Percocet, or their generic equivalents. Controlled non-opioid medications that may be diverted for sale include the sedatives ketamine and midazolam (see SIDEBAR).

CASE REPORT: No Perceived Problem
An inpatient charge nurse called the pharmacy ADC manager to report that furosemide 20 mg tablets were out of stock twice in one week. ADC records indicated that an inventory of 15 tablets should have been in the machine, but the pocket was empty. The ADC manager refilled the pocket and reviewed the usage reports, finding that the furosemide pocket had been refilled six times in the last three months. One particular nurse had been working every day that the furosemide stock had been refilled. Upon questioning, the nurse admitted that she had an eating disorder and had been taking the furosemide to assist with weight loss. She did not think that taking the diuretic would be a problem because, in her words, it was just furosemide, not a narcotic. In this institution, all diversion was treated equally, regardless of the substance being diverted. The hospital reported the nurse to the police for theft, as well as the state board of nursing. She had to appear before the board and ultimately had action against her license, which remained a permanent part of her professional record.

Where Does Diversion Occur?
Diversion can occur in numerous areas of the hospital; consequently, more than one approach is required for prevention. Quite often, diversion occurs at the patient’s bedside.

• Substitution: A common method of drug substitution is to replace a patient’s prescribed opioid with another agent, such as saline or sterile water. An injection of sterile water will provide a sting (a feeling similar to an injection of the medication), but no therapeutic effects, so the diverter may sedate the patient with diphenhydramine or lorazepam to mask the lack of analgesia. Sometimes the diverter will not remove all of the opioid but dilute it so the patient receives partial pain relief. In one instance, the antipsychotic medication haloperidol was substituted for a diverted opioid. 
• Improper Charting: Diverters will often put forth considerable effort to identify patients who can be used to cover for their diversion. Non-verbal patients, or those whose reports are considered unreliable, may have difficulty reporting inadequately controlled pain. For patients who are able to respond to a simple pain scale, improper charting may be used to obfuscate the reason for a dosage increase. The diverter will then administer the original dose to the patient, while keeping the remainder for personal use (see TABLE 1).  

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CASE REPORT: Too Much Information
The pharmacy department set up a phone hotline to enable anonymous reporting of suspicious behavior. The call is recorded and will trigger a page to the narcotics manager. The manager can then alert the pharmacy manager on-call for review and potential action. The intent of the hotline is for immediate reporting of a caregiver impaired while on duty or in the act of diversion. 

The hotline received a tip that a nursing unit manager had improperly removed a controlled medication from an ADC that was intended for a patient who had been discharged that day. The ADC had been set to automatically remove patients from the profile eight hours after discharge. When questioned, the manager stated that the patient was coming back to the hospital to pick up the medication. An inventory of the ADC revealed that the manager removed numerous 4 mg syringes of hydromorphone, which is not a medication that would be given to a discharged patient. A search of her office and locker found no evidence of the diverted medication. Further investigation revealed that she had been injecting diverted opioids into grapes and eating them in plain sight of her staff. 

The manager had received diversion prevention training, and therefore knew how to run reports and determine if certain activities would be detected. As a manager, she had access to four ADC units. She deduced that if she removed opioids from more than one unit, the standard deviation (SD) report would not compile all of her activity, but instead compare activity on each unit separately. By keeping her activity on each unit less than 2 standard deviations (SD), she could stay below the 4+ SD that would have triggered an investigation. This incident drove home the fact that no one is above suspicion and that caution must be applied in how we train and how much we train. The facility should be cognizant of not providing the means by which to divert.

Be aware that while training personnel in how to identify diversion, you could be inadvertently providing information that teaches methods for successful diversion. Interestingly, in this instance, the pharmacy department’s training program provided the nurse manager with the information that allowed her to divert, while the hospital’s anonymous diversion hotline assisted in uncovering her diversion. Nevertheless, educating staff to be observant and vigilant will improve diversion detection and prevention.  

Why Do Medical Professionals Divert? 
It can be difficult to understand why medical professionals would risk their years of training, professional reputations, and personal livelihoods to engage in drug diversion. However, addiction knows no bounds, and anyone can develop a substance use disorder. Among all drug users, most are functioning in the community and nearly 66% are employed.³ Furthermore, an estimated 10% to 20% of nurses have substance abuse problems,^4,5 and they tend to abuse prescription drugs instead of street drugs.⁶

CASE REPORT: The Supernurse
Monthly reports from the controlled substances vault showed that a registered nurse on one of our patient care units had a 3+ SD use of controlled substances compared with fellow nurses in the same time frame. Further investigation revealed that this nurse was the only one who gave several patients acetaminophen with oxycodone after charting their pain scales. Review of the charts showed that the highest doses were always removed, and no doses were wasted. The unit’s head nurse vouched for the nurse in question, saying he was one of the most well-respected and reputable nurses in the department. She insisted that this nurse was beyond reproach—never taking vacation, always volunteering to work overtime, and available whenever someone called in sick.

Because never wanting to be away from work—where there is access to narcotics—is a potential red flag for diversion (see TABLE 2), the decision was made to interview this nurse and ask for an explanation for why his utilization patterns were notably different than his peers. For confidentiality, we interviewed him in a conference room outside his own unit. The nurse denied any wrongdoing and was insulted that we were questioning him. (That reaction was not surprising, as denial is common in substance use interventions.) After he regained his composure, we again asked him to explain the high volume of use and the unusual usage pattern. He emphasized how concerned he was for his patients and that he did not want to see them suffer, unlike some of his colleagues who encouraged patients not to use narcotic pain medication.

When the head nurse questioned his judgment in always offering patients the highest dose, the nurse said that he always removed the highest dose, and if all tablets were not used he would save them for later. We then inquired why he did not follow policy and waste the medication per protocol, and the nurse replied that he did not want to waste other nurses’ time and throw away viable medication. The next question was whether or not he sometimes forgot he had the drugs and accidentally took them home after his shift, which he strongly denied. As he became increasingly upset, he was asked how long had he been taking medications from the unit and why he was taking them. At this time, the nurse finally confessed to diverting the drugs. He said he had received prescription pain medications several years ago for a work-related back injury, but that his doctor had refused to prescribe additional narcotics when he would not take time off from work for physical therapy. One day a patient only wanted one of the two tablets offered, so he took the other tablet. Because no one seemed to notice, this became his method for diversion. He apologized profusely, but explained that using the pain medication was the only way he could get through a shift. As his addiction increased, he volunteered to work more often. He rationalized that his ability to keep working was in the best interest of the hospital. This nurse was placed in a rehabilitation program.

Technology to Monitor for Diversion
In our experience, automated surveillance programs detect about one-half of diversions that are discovered; the other 50% are revealed through direct observation and tips reported to the pharmacy. Although not a substitute for human instinct and evaluation, technology is a vital component of any diversion-prevention program. 

Automated Dispensing Cabinets (ADCs): To prevent diversion in the operating suite, accountability requires accurate record keeping for dispensing and waste. The use of ADCs may assist with dispensing accountability, but reconciliation of the inventory is essential. 

Spectrophotometry: Some institutions use spectrophotometers to perform a qualitative assay of returned narcotics, as these devices can detect a wrong drug, diluted drug, or missing drug. It is important to be aware of the limitations of these devices, as they cannot detect all types of drugs. When staff is aware that a spectrophotometer is being used, this may deter diversion, but spectrophotometry is only one tool in a comprehensive diversion-prevention program. Keep in mind that a diverter may research which narcotics the spectrophotometer cannot detect. To increase the odds of detection, run random, unpredictable sample assays, and also assay all suspicious returns, whether late, left behind, or returned with missing information. 

High-performance liquid chromatography (HPLC) is required to do a quantitative analysis of returned narcotics, but HPLC is beyond the scope of many pharmacies. Waste samples for HPLC must be sent to a toxicology laboratory for evaluation, a process that can be time-consuming and costly.

Diversion Monitoring Software: Diversion-monitoring systems can be useful to screen for variations in utilization. However, for this software to be effective, the pharmacist or technician must be trained to accurately interpret the results. For example, screens set to detect all users at 1+ SD of variance from the mean will return hundreds of false-positive reports, making follow-up impossible. We have found the monthly reports of all users with a threshold of 3+ SD narrows the reports to a more manageable sample group. Each user with 3+ SDs then must be investigated to determine if a reasonable explanation exists for the higher utilization. Although this report works for unit-based users, float nurses may avoid accurate screening unless they themselves are compared as a user group.

Conclusion
Potential diversion opportunities in a health care setting are too numerous for any one individual or technology to monitor effectively. Successful prevention and detection must rely on multiple strategies, and the following have demonstrated effectiveness: 

• Incorporate dispensing by users within the pharmacy department in routine diversion-monitoring programs
• Connect time-keeping (clocking-in) devices with ADCs so that access to dispensing systems outside of an employee’s work hours can be prevented or more easily detected 
• Link pain scale charting to dispensing devices to better correlate higher doses of medication with the patient condition and nursing documentation
• Use bedside bar coding and bar code dispensing to facilitate tracking and detection of discrepancies 
• Retrieve data from the EHR on uncharted doses dispensed and review these unreconciled medication reports for trends 
• Work with IT data security to program financial/billing systems to identify cases of dispensed but uncharted controlled substances or other medications targeted for diversion

Utilizing multiple diversion-prevention strategies will best ensure diversion is effectively detected, addressed, and prevented at your hospital. While a percentage of hospital staff will always seek to divert drugs, developing and implementing a comprehensive, robust diversion-prevention program is the most effective tool to combat this ongoing challenge.

References

1. Trinkoff AM, Storr CL, Wall MP. Prescription-type drug misuse and workplace access among nurses. J Addict Dis. 1999;18(1):9-17. 
2. Lillibridge J, Cox M, Cross W. Uncovering the secret: giving voice to the experiences of nurses who misuse substances. J Adv Nurs. 2002;39(3):219-229.
3. Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHSPublication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011.
4. Griffith J. Substance abuse disorders in nurses. Nurs Forum. 1999;34(4):19-28.
5. Dunn D. Substance abuse among nurses—defining the issue. AORN J. 2006;82(4):573-582, 585-588, 592-596, quiz 599-602.
6. Trinkoff AM, Storr CL. Substance abuse among nurses: differences between specialties. Am J Public Health. 1998;88(4):581-585.

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Jerry Siegel, PharmD, FASHP, is the former senior director for pharmaceutical services at The Ohio State University Medical Center, where he worked for over 35 years. He graduated from The Ohio State University College of Pharmacy with both his BS and PharmD. Jerry also served as assistant dean of medical center affairs at The Ohio State University College of Pharmacy. He remains a clinical associate professor there. Prior to focusing on administration, Jerry worked as a clinical microbiologist and as a clinical pharmacist in transplantation and hematology/oncology. He has lectured extensively on immunology, infectious disease, and pharmacoeconomics, and is a Fellow of ASHP. 

Ryan A. Forrey, PharmD, MS, is an associate director in the department of pharmacy at The Ohio State University (OSU) Wexner Medical Center, and a clinical assistant professor at the OSU College of Pharmacy, Columbus, Ohio. In his position at OSU, Ryan is responsible for the pharmacy operations of the inpatient cancer hospital and five hospital-based ambulatory chemotherapy infusion clinics. He also teaches graduate-level lectures on pharmacy management at the OSU College of Pharmacy and serves as a preceptor for the Health-System Pharmacy Administration Residency Program at the OSU Wexner Medical Center. Ryan has presented on controlled substance diversion detection and prevention at numerous national and international meetings.

SIDEBAR
Diversion for Sale
Diversion of controlled substances for sale occurs in hospital settings, but is less common than diversion for personal use. Dealing in narcotics often requires large quantities of controlled substances to meet customers’ demands. In a patient care area, high-volume diversion should trigger even a basic surveillance system early on. 

Larger-scale diversion is more likely to occur in a hospital when the same person orders and receives the inventory. Other diversion-for-sale schemes involve robbery rather than passive diversion. Robberies have increased at outpatient and retail pharmacies as access to prescriptions for controlled substances has become more restricted. Therefore, outpatient pharmacies should be aware of this potential threat.

A proactive diversion program should not focus exclusively on controlled substances, because non-controlled medications of high value also may be diverted. Diversion may occur during shortages (eg, ciprofloxacin tablets during the anthrax scare of 2001) or where health care workers’ access make certain agents tempting (eg, fluconazole tablets or diuretics).