1. Drug Diversion in the Workplace Kimberly Miller, RN, BSN, MC October 4, 2014

2. Definition of Drug Diversion Diversion - “Any criminal act involving a prescription drug.” Uniform Controlled Substances Act (1994)

3. What to Expect Historical Overview of Diversion by Nurses Factors Associated with Diversion Preventing, Identifying, and Investigating Diversion Impact on Patients What’s on the Horizon Nursing Community Response

4. 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

5. 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

6. Why Divert? Addiction Pain Management Mental Illness Personal Issues Provide to Others Barter or Sell

7. Addiction Chronic illness – Diagnosed by a cluster of behaviors and physical symptoms – Evidence of biochemical brain alterations

8. Brain Neurobiology In the Ventral Tegmental Area of the mid- brain, 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

9. Activation of Dopaminergic System Sex Increased dopamine level Pleasurable reinforcement Repeat Reinforcement of survival activity

10. Neurobiology of Addiction Chronic exposure to addictive drugs results in neurochemical changes in the brain that hi- jack the intended function and reinforces further drug use. Use drug Increase synaptic dopamine level Euphoria and sense of well- being Volitional behaviors become habits, which become compulsions through Pavlovian learning.

11. Other Illnesses Associated with Diversion Chronic Pain Extended opioid use No or failed tapers Fear Mental Illness Undiagnosed or treated Self-medicating

12. Personal Issues Associated with Diversion Personal management – Stress management – Sleep disturbance Recreational use Provide to others Barter or sell

13. 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 Tampering Develop an investigations team

14. Controlled Substance Management System 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

15. Pharmacy to Unit: Maintaining Chain of Custody Enter Available Drugs Into Electronic System Secure Storage and Transfer Customize Drug and Dose Supplies to Unit Needs Periodic Monitoring of Supplies

16. On the Unit: Maintaining Chain of Custody 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

17. Communicating Expectations Clear policies with nurse involvement in development Consequences for failing to follow policies Review of handling issues with staff Stop work around practices and short cuts

18. Identifying Possible Diversion: Nurse Behaviors 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

19. 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

20. Investigation Consult with drug diversion team – remove access 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

21. Tampering & False Prescriptions Replace medication with another drug or substance Dilute injectable medications Altered or false prescription submitted Filling prescriptions for patients

22. Risks to Patients Inadequate pain management Nurse inattentive or impaired Other providers are working with inaccurate information Patients develop fear or mistrust of healthcare

23. 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

24. Resources 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.aspxhttp://doh.sd.gov/boards/nursing/healthpro.aspx Health Professionals Services Program – Minnesota. www.hpsp.state.mn.uswww.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.2012.03.013http://dx.doi.org/10.1016/j.mayocp.2012.03.013 Road Map to Controlled Substance Diversion Prevention. www.health.state.mn.us/.../drugdiversion/divroadmap041812.pdf www.health.state.mn.us/.../drugdiversion/divroadmap041812.pdf What You Need to Know About Substance Use Disorder in Nursing (brochure). communications@ncsbn.org