The Case of the Missing
Morphine:
Next Steps for Compassionate Care with a Plan
Jessica Fishman, MSW, LCSW and Katie Fallon, MSW, LCSW
Providence Hospice
Learning Objectives
• Identify potential medication diversion situations
• Obtain collaborative strategies for team response and
patient communication
• Documentation recommendations
• Not intended to be legal advice
What is medication diversion?
Common Definition:
Prescription medications illegally diverted for use by someone other than the
patient for whom they are prescribed.
Plenty of motivators for this:
Addiction or abuse by other family members or caregivers
Financial gain for patient or caregiver
Theft; unsafe environment
Team Response: Initial Assessment Goals
• Gather as much information as possible with all team
members
• Identify risk factors, red flags and concerns
• Assess willingness of patient or caregiver to discuss
concerns directly
Initial Assessment: Common “Red Flag” Areas
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Patient’s descriptions of their pain
Patient’s relationship to their medications or medication plan
Psychosocial history; risk factors
Current environmental and behavioral cues
System information
*Looking for a constellation of these clues and patterns of behavior*
Team Response: Assessment cont’d…
• Determine the patient’s decision making capacity and/or legal surrogate or healthcare
decision-maker.
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Identify potential patient abuse/vulnerability/risk/safety issues
Identify potential staff safety issues
Identify possible diversion by patient vs diversion by other
Assess for other contributing barriers or causes (difficulty learning or tracking meds)
Identify interventions already implemented
Team Response: Internal Communication
• Team conference to review observations and assessment, determine plan,
create safety plan as appropriate. Identify external communication and
coordination needs.
• Update and coordinate with all prescribers involved
• Determine if it is appropriate to involve Adult Protective Services or law
enforcement.
• Document clearly in chart, title note so concerns and plan easily identified
by “after-hours” staff and others not regularly involved.
Communicating with Patients & Caregivers:
First Steps
• Communicate early and often
• Make a joint visit with another member of your team to have these conversations: Importantly, reinforces
that we work as a team; Offers support for you and the patient with a potentially challenging conversation;
Provides witnesses.
• Involve family or caregivers who have a positive & trusting relationship with the patient. Involve legal
representative.
• Watch for any signs of fear or coercion in the relationship between the patient and the caregiver.
• Sit down with the patient and caregiver at a time of day when they are most likely to be alert and open to
talking.
• Begin with the least restrictive option appropriate to your assessment of current risk.
• Document all conversations and interventions
Patient Care Planning and Discussion Points
• Note primary goal to honor patient goals and ensure safe pain management for patient but also
obligated to ensure medication is delivered safely and as reported.
• Emphasize importance of taking medication as prescribed, and logging accurately, in order to evaluate
its effectiveness against the pain.
• Explain that the doctor can not replace the medication without knowing exactly how much medication
is being used.
• Reassess patient’s/caregiver’s understanding of prescription and any barriers to learning. Review pain
log teaching.
• Review any pertinent patient rights and responsibilities signed at admission.
• Review and introduce concrete interventions and the follow-up actions or consequences related to the
intervention.
• Discuss risk for discharge if plan of care is not followed.
Care Planning: Additional Concrete Tools
• Narcotics Contract: Consider implementing this early as a tool for communicating
and tracking the agreements you and the patient/caregiver discuss, as well as the
potential consequences rather than later as a “line in the sand.”
• Medication count parameters or other medication changes.
• Explore caregiving plan, options and support needs as appropriate. In some
cases, a higher level of care such as ICF may be needed for an MD to continue
prescribing.
• Consider implementing a lock box, keys held by trusted person. Identify and
review plan for how patient will receive medications as prescribed.
Medication Care Planning
• Decrease quantity of medication dispense and/or reduce dispense periods (3 days vs 2
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weeks)
Change to medication less easily or likely used for diversion
Refills managed by primary team only
Medication Count each visit in the presence of the patient & caregiver. Document
count in care plan. Compare to pain log. Document discrepancy. Place communication
alerts in the chart.
Use of lockbox
Use of contract as a communication tool and for limit-setting
MEDICATION CONTRACT (Example)
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Our goal is to provide safe pain control for________________, to support his/her comfort and quality of life. We also hope to support
___________________ in the role as caregiver. We understand that this requires patience and trust. We will work hard to offer you the
support and resources you will need.
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I agree only to take medications that have been prescribed to me. I will not sell or trade medications that have been prescribed to me.
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I will not seek prescription medication from any other doctor than my hospice doctor or _______________.
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(Specific medication direction): Eg; If I experience pain after applying the Fentanyl patch, I will take the prescribed amount of Oxycodone for
“breakthrough” pain. If I take more than 3 “as needed” doses in 24/hrs I will call contact hospice. I understand that doing this helps hospice
figure out how much medication I need to manage my pain.
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I will write down when I take my “as needed” medication (list medication names here) in the journal provided. I will allow the hospice nurse to
review this at his/her visit.
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All of my “controlled” medications will be kept in a lock box, including narcotics.
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Refills of my “controlled” medications may be limited to a few days or a week at a time. Any refills before the agreed date must be reviewed by
hospice. If any medications are missing, hospice will review them to see if changes need to be made.
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Successful treatment for your pain and other symptoms requires open and respectful communication. You can expect this of your hospice team
and we will expect this from you.
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If your hospice plan does not meet your needs we will work with you to develop a safe plan that does. If this is not possible, you may choose to cancel hospice or transfer to
another hospice. If these agreements are not kept, you may be discharged from ________ Hospice.
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Signatures and Dates: Patient, Caregiver, Hospice Staff members
Discharging for Cause
• Review plan of care with team to determine whether all options/alternatives
have been shared with patient/caregiver
• Ensure documentation of ongoing concerns, observations, and failure of
patient/caregiver to follow plan of care, or of imminent staff safety
concerns is thorough & complete
• Team to create/discuss plan for discharge with patient or caregiver &
appropriate physicians
Documentation
• Consider titling clinical notes with Diversion title. This allows discussions
and interventions to be easily located and referenced in patient chart.
• Patient and caregiver should have a copy of the written agreement and a
copy should be kept in patient medical records/chart for consistent reference
by team.
• Pertinent plan info should be communicated to other covering non-primary
team members to support continuity of plan.
QUESTIONS? REFLECTIONS?
Resources
• Collier, K, Kimbreal, J., McCrate B. Medication Appropriateness at End of Life; A New Tool for Balancing
Medicine and Communication for Optimal Outcomes; Home Health Care Nurse; October 2013; Vol 31, No 9
• Collins, C. The Dog Ate My Morphine: An Interdisciplinary Model for In-home Medication Diversion; Joint
Clinical Conference April 9-12, 2003; JCC reporter Vol 1 Issue 1
• Giles, C, St Clair T. 4th Joint Clinical Conference. April 10-12, 2003. Denver, CO.
• Holle, L., Chamberlin, K. Regulatory and Ethical issues in Pain Management. Drug Topics; July 2013, p58-60.
• Jewell, C., Tomlinson, J., and Weaver, M. Identification and Management of Prescription Opioid Abuse in
Hospitalized patients; Journal of Addictions Nursing, 2011; 22: 32-38
• Sehgal, N., Laxmaiah, M., and Smith, H. Prescription Opioid Abuse in Chronic Pain: A Review of Opioid Abuse
Predictors and Strategies to Curb Opioid Abuse; Pain Physician; July 2012; 15: ES67-ES92
• US Department of Justice. Drug Enforcement agency; Office of Diversion Control. http://www.deadiversion.usdoj.gov/
• Weinstein, S. Managing Controlled Substance in the Home Hospice Setting. Huntsman Cancer Institute.