Diversion Podcast Transcript
(Music)
Dr. Howard Zucker:
I’m Dr. Howard Zucker, Commissioner of the New York State Department of Health.
Today I’m hosting this podcast to discuss a difficult topic: provider drug diversion.
What exactly is provider drug diversion?
The issue centers on healthcare providers who divert injectable drugs away from their
legitimate use as medications for patients and instead, self-inject the drug to get a
“high”.
To cover their tracks, they sometimes substitute saline, water or other liquids in the
syringe. Then they place the used syringe back on the cart for use on patients.
Returning the used syringe not only denies patients the pain medications they need but
the tainted needle and syringe could also expose them to bloodborne pathogens like
hepatitis B virus, hepatitis C virus and HIV, the virus that causes AIDS.
This is disturbing and distressing.
Today we are joined by one of the leading voices in the country on drug diversion
prevention, Kimberly New, who is both an attorney and a registered nurse. Kimberly is a
controlled substance security consultant to healthcare facilities across the country. She
has extensive experience assisting facilities with starting and refining their drug
diversion detection program. Kim is past president of the Tennessee chapter of the
National Association of Drug Diversion Investigators. She is a frequent author and
speaker on the subject of provider drug diversion
Dr. Zucker: Kim, I was shocked by a comment you made in the past. You had said that
in your former job at the University of Tennessee Medical Center when you initially
started the program, you found that three to four providers were diverting each month.
That seems like a lot. After the program was well established, you were still finding one
or two providers each month either taking pills or using injectables every month. That
also seems like a lot.
Kimberly New: Most facilities have some processes in place to detect diversion, but
they don’t recognize that it happens in facilities across the US where controlled
substances are found and there really is no way to stop it entirely. So shortly after I
started working at my former job, we had a diversion case that I started investigating .It
became apparent that we had good processes in place in some areas to address
diversion, but our program certainly did need a lot of work. So once I began the formal
program with regular auditing and surveillance for diversion, I started catching three to
four nurses per month. That’s three to four per month out of a staff of around 1,000
nurses. Although a lot of people think that diverting healthcare personnel start with pills
and only a small number use injectables, I found that well over 50 % of the people I was
catching were diverting injectables and starting with injectables. So even when word got
out that we had a robust program, I was still catching one to two nurses per month, but I
was able to catch them much more quickly. In fact in one case I caught a nurse three
days after the diversion started happening.
Dr. Zucker: So, that’s, that’s critically important because if you catch them early on,
potentially you’ll be able to change habits, stop them, clearly. I think this is something
which really important, to be sure, that we identify problems quickly.
Kimberly New: Absolutely, it also protects patients from potential harm.
Dr. Zucker: Right, exactly, I think that’s another key point even if it’s three or four
nurses you know, out of 1,000 imagine how many patients they have interacted with in
the course of, let’s say a month or two.
Kimberly New: Absolutely.
Dr. Zucker: And obviously the impact it has on their lives and the lives of their families.
How widespread do you think the problem is?
Kimberly New: Well, that’s a good question. It is universal among institutions there’s no
question about that. Many institutions however, don’t have adequate processes in place
to detect it and once they do detect it, they’re not inclined to report it because of
concerns about civil and regulatory liability and negative publicity. Because it’s underdetected and under-reported, we really don’t have reliable data on how common it is.
Some will say maybe one in ten nurses, but that’s just a guess. When looking at the
frequency of diversion, though, we do need to look at the fact that although we catch a
lot of nurses, all types of personnel are involved. More nurses are caught because
they’re the number one patient care profession that has regular access to controlled
medications. Because we don’t know how common this issue is, what I tell facilities is: if
they are not detecting diversion they certainly need to take a closer look
Dr. Zucker: I agree with what you’re saying about the nurses and as an
anesthesiologist I’m familiar with this as well because what often happens is, that when
a nurse or an anesthesiologist is doing patient care they really do understand the
amount of medication to give in order to get an effect, and we’re very concerned about
that in anesthesiology. A couple of years ago there was a high profile case in New
Hampshire that involved a radiology technician who practiced in eight states including
New York, right here, he was ultimately sentenced to over 30 years in prison for
tampering with a consumer product and obtaining a controlled substance by fraud. Yet
many practitioners who divert aren’t brought to justice; they just simply change their jobs
and move somewhere else. So how did the New Hampshire episode raise the
awareness about this problem?
Kimberly New: Well, the New Hampshire case demonstrated how much harm can be
done by one diverting healthcare worker. As you mentioned, patients across the country
were harmed and facilities were impacted as well. In that case, patients likely received
care delivered by an impaired provider but they were clearly harmed by being denied
pain medication and by exposure to hepatitis C. This caught the attention of public
health, law enforcement, regulatory agencies and healthcare facilities because it was so
egregious. It became clear that this was a widely underestimated patient safety risk.
Prior to that case, the focus was typically on the diverter and these cases were treated
as isolated by institutions, but now public health officials, law enforcement, regulatory
agencies and healthcare facilities, have begun working together toward the common
goal of preventing, detecting and properly responding to diversion. So to answer your
question, if there was any silver lining that came out of the New Hampshire case it was
increased awareness and increased diligence.
Dr. Zucker: So you just mentioned the word prevention and in a lot of ways this is all
about prevention. So the key thing is to pick up the warning signs ahead of time, so
what do you think a healthcare provider could do, what should they be looking for, so
that they could prevent an individual, a nurse, a doctor, anyone in the health profession
for that matter, from diverting?
Kimberly New: Well oftentimes, preventing diversion isn’t as easy as maybe early
detection. Some of the signs that we see in individuals who are diverting include:
volunteering for overtime, coming to work when not scheduled to be there, coming to
work early and staying late. They may make frequent trips to the staff bathroom
because that’s the best place to tamper with medications and inject. They may
repeatedly check the controlled substance inventory because that allows a diverter to
swap out tampered-with syringes for unaltered syringes. They may choose submissive
or less experienced staff to waste narcotics with because they are less likely to insist on
complying with proper procedure and they may delay waste so that they can inject the
waste and replace it with water. It’s important for individuals who work in healthcare
facilities to know that individuals that divert are oftentimes high achievers and that they
don’t fit the stereotype of someone who is stealing and abusing drugs
Dr. Zucker: So I think that you bring up another key point here regarding the fact that
syringes can be swapped and sometimes doctors label things with one name and that
could be a variant of a type of narcotic that is less potent--the name on the syringe
could be less potent than name of the drug actually in the syringe and they subject
themselves to great risk if they start to switch out syringes obviously in general it’s a risk
but there’s always the risk that they will overdose themselves.
Many in the healthcare profession think that provider drug diversion is an issue for law
enforcement, and you touched upon this a little bit, and that it’s not an issue for
healthcare administration but as a lawyer and as a nurse and I am a lawyer and a
doctor, I’ve thought about this a lot. What do you think about that, regarding law
enforcement versus healthcare administration?
Kimberly New: Well, I think they both need to be involved. There are certainly differing
opinions on who should ultimately be involved. But it’s important to keep in mind that
diversion of controlled medications is a felony, so law enforcement clearly has a role.
Healthcare facilities need to reach out proactively to external authorities and develop
good working relationships with them preferably prior to having an issue. That’s
essential to addressing the issue effectively. It’s also important to know that patient
harm can be reduced by involving law enforcement, because an arrest and criminal
disposition may be apparent to a subsequent employer much sooner than a protracted
professional board investigation. Even when law enforcement is involved, there are drug
courts and other programs that support recovery and can expunge criminal convictions
once the program is successfully completed so those programs encourage recovery.
Dr. Zucker: Who needs to come to the table to fight injectable drug diversion? From the
hospital perspective, we have risk management, we have pharmacies, we have
administration we have our colleagues as well. Who should be there?
Kimberly New: Well, in the hospital the key players would be nursing, pharmacy,
compliance, security, risk management, human resources, occupational health and then
a relatively new development is including infection prevention. I think it’s important to
include infection prevention, because they need to be equipped to fully assess and fully
respond to cases in which patients develop infection. In the past infection prevention
has been kept out of this entire process but I think it’s an important thing to include them
at this point.
Dr. Zucker: So, with regards to that, do you think that the practitioners who are found
diverting injectable drugs—should they be tested for bloodborne pathogens, like HIV
and hepatitis?
Kimberly New: I absolutely do think that they should be tested. Now,of course,
compelling testing is not generally feasible and it’s been extremely rare that anyone
tested for bloodborne pathogens but it is becoming more common after the New
Hampshire case. At UT Medical Center, I developed a process where suspected
diverters were asked to consent to bloodborne pathogen testing and we did that at the
time of the drug screen. It was treated as voluntary, and if the individual decided they
didn’t want to do it, that was fine. They weren’t punished or treated differently. We
ensured that the testing process and the result were handled in a confidential manner
because we treated it like an occupational exposure. So we did it under that protocol.
Nearly every suspected diverter that I had agreed to testing. So now, some institutions
that I work with do undertake bloodborne pathogen testing as part of each diversion
investigation. Again, it’s not overly common but I think that more and more facilities are
considering doing this and they understand the value of doing so.
Dr. Zucker: I want to jump back for a second to what we were speaking about regarding
hospital roles. What administrative controls do you feel can be put in place by the
hospitals, by the pharmacies, to make sure that diversion is much harder and is easier
to detect.
Kimberly New: Well, there are several things hospitals can do but some of the key
things: Number one would be transparency. Historically these cases have been kept
under wraps. Staff within the facility never knew that diversion happened. But if you
expect staff to know that the issue is real, to appreciate that and to invest in the program
they have to know that it’s happening at their institution. So transparency is essential.
There needs to be ongoing education for all staff. They need to understand what the
risks are to patients and their colleagues. They need to know signs of diversion and
they need to understand reporting expectations and avenues. There needs to be regular
auditing of drug cabinet transactions, appropriate security within the institution, physical
security, and regular physical rounding within the institution to ensure that the policies
institutions have in place are being complied with and to identify areas of risk.
Dr. Zucker: I think your point here brings up an issue regarding colleagues. So, it’s
hard sometimes for someone to have to report on someone that may be a colleague
they’ve worked with for years and now suspect that they are involved in drug diversion.
I think we should try to figure out ways to tackle that. So I was wondering, are there
anonymous hotlines, or mechanisms to make that easier so people don’t end up having
to work with someone even for a short period of time while the investigation is going on?
Kimberly New: Sure, there are anonymous hotlines, and certainly all staff have a duty
to their patients, their colleagues and to the institution to report. As you mentioned ,
some may be reluctant because they don’t want to get a colleague in trouble, but they
need to be educated about the fact that failing to report is not a compassionate
approach. It’s not uncommon for diverters to overdose and die. They may crash a car
while driving impaired or they may even commit suicide. Fortunately, as I mentioned,
many institutions do have anonymous hotlines. And it’s important for those institutions
to know that if a hotline is used it has to be monitored around the clock. Because of the
patient safety risks involved the last thing we would want is for a case to be reported
Friday evening and not be discovered until Monday morning when someone took a
message off the machine. I think anonymous reporting is extremely valuable, I think all
institutions need to have it in place.
Dr. Zucker: Has anyone ever looked at someone who’s involved with drug diversion
who is also involved with sales of drugs, involved with you know, alcohol, other risky
behaviors?
Kimberly New: Yes there absolutely are, I’m glad you brought that up. We find that
many of individuals we catch diverting are using alcohol and have experimented with
illicit substances as well. On the topic of selling though, most healthcare personnel who
are direct care providers, who divert at healthcare facilities are not diverting to sell the
drugs, they are diverting for personal use. They are very secretive about what’s going
on, they oftentimes haven’t even been honest with themselves fully about what’s going
on. So they’re typically not out on the street selling the drugs. There are exceptions.
Certainly we see more pharmacists involved with the sale of drugs that have been
diverted than we do for instance, nurses or physicians. When we look at healthcare
personnel who are diverting drugs we’re typically looking at individuals who are not
selling them on the street.
Dr. Zucker: In New York, we have a strong Bureau of Narcotic Enforcement. I’m
curious as to what you think maybe governments should be doing in addition to what we
already are doing, to address this issue.
Kimberly New: I think one excellent state to look at is the state of New Hampshire.
After the New Hampshire incident occurred, the state of New Hampshire undertook
several different measures to ensure that controls were put in place to screen
healthcare personnel to ensure that hospitals had proper processes in place. And so I
think that looking to them is, would certainly be valuable to any state. In addition I think,
you know, the state of Maryland has some immunity provisions, relating to employment
references. I know in my own experience in working with institutions across the country,
particularly the references that are given are strictly dates of employment and nothing
further even if the individual has been terminated for diversion or some other serious
event. So I think increased immunity for employers to report is also something that is
really desperately needed. And finally I think that diversion cases should have a central
reporting location where cases can be reported with some protections afforded for
individuals who are reported, but also for facilities who are reporting like the National
Practitioner Databank.
Dr. Zucker: Thank you. One last question: is there data that tells us what percentage of
individuals who were involved in drug diversion return back to their job that they had
before?
Kimberly New: There are figures in various states, but of course that data only
encompasses individuals who go through a recovery program, oftentimes a formal
recovery program. I think that there are concerns in every institution about recidivism
and certainly any institution who has hired a prior diverter back has experienced at least
one individual who has gone back to diversion. I know there is data in the anesthesia
field.about recidivism and about how tremendously significant that can be because
many of those individuals die. I think that individuals who are involved in diversion
certainly need a chance to recover and a chance to return to safe practice but it’s
important once they’re back in a practice environment that they be supported and that
they be monitored very closely.
Dr. Zucker: I will say that in my orientation period when I started in my anesthesiology
residency— this was a while back— one of the initial presentations we had was about
this issue, it was something which was profiled pretty quickly when we were starting to
learn our specialty. Our thanks to Kimberly New for what has been a very enlightening
conversation. This is Dr. Howard Zucker, Commissioner of the New York State
Department of Health. Thanks for listening to this podcast.