1. Diversion of Controlled Substance: Crossing the Line Kimberly Miller December 5, 2008

2. Diversion: Issues to Consider Addiction is a deadly disease Impairment while on the job puts everyone at risk Patient’s pain may be undertreated Patient Care Record may contain false information $$

3. What do we know about diversion? Hard to identify Risky behavior It persists even with better safeguards in place It may be overlooked by co-workers When is the nurse impaired?

4. Search Strategies Keywords – Diversion, theft, controlled substances, narcotics, drugs, addiction, substance dependence, nurse, healthcare provider Databases – MEDLINE, CINAHL, PsychINFO, Google Scholar Scope – Inclusion: English language, nurses, research, drug use, diversion, deviant behavior – Exclusion: editorials, legal briefs, opinion papers

5. Comparison of Drugs Used by Nursing Specialty Trinkoff, A., et al. (1998) SpecialtyMarijuana /Cocaine % Prescription –Type % Binge Drinking % Adult critical care6.2*7.222.2* Pediatric critical care 6.8*5.920.8* Emergency7.3*7.824.5* OR/PACU4.6*7.316.5* Medical/Surgical3.07.9*14.9* Home/Public Health 3.06.015.7* Oncology3.68.825.5* Psychiatry4.4*8.314.4 Other/Non-clinical4.4*4.813.9

6. Impact of Job Issues on Substance Use in Nurses Trinkoff, et al. (2000) Factors associated with depression symptoms – Job demands Reciprocal relationship – depression and use Indirect pathway to increased use – job demands Factors with direct effect on past year use – Increased workplace access to substances – Less religiosity – More substance users in social network

7. Effect on Behavior of Nurses Related to Work Group Norms Dabney, D. (1995) BehaviorFinding Theft of general suppliesOK Theft of OTC medicationsOK Theft of Non-Narcotic medicationsOK Theft of Narcotic medicationsNot OK

8. Finding Drug Diversion in Operating Rooms Epstein, et al. (2007) High use of opiates for a case High wastage of controlled substances Drugs signed out for cancelled cases Sign out of drugs late in the day Location of access to the drug doesn’t match with the location of the patient

9. Comparison of Nurses in an Alternative to Discipline Program (New Mexico) Dabro, N. (2005) Nurses who completed the program – Dual diagnosed with MH or Pain – Typically work in ICU/OR/ER/Oncology – Seven of the eight diverted – Strong desire to keep nursing license – Positive response to coercion to obtain treatment – Values participation in support groups – Strong affiliation with other nurses with addiction Nurses who did not complete the program – Dual diagnosed with MH or Pain – Typically work in ICU/OR/ER/Oncology – Five of the eight diverted – Planning to change careers – Values participation in support groups – Saw no value in monitoring

10. Alternative to Discipline Program (Idaho) Referral Reasons Clark, et al. (2006) Reasons for ReferralNumberPercentage Diverting drugs9948 Inappropriate behavior178 Passing fraudulent Rx3517 Positive drug screen2311 “Doctor shopping”189 “Pharmacy shopping”189 Intoxication on the job157 Reported for unsafe practice 115 Drug-related legal issues94

11. Ethical Considerations Harm to Patients Violation of ethics codes Multiple levels of deception Negative effect on other healthcare providers Moral distress versus illness related behavior

12. Gaps in Research/Literature Most studies on factors date to the 1980s Very little information specific to nurses Very limited information specific to diversion No information related to the impact of diversion on patients Just beginning to see review of effectiveness of alternative monitoring programs

13. Suggestions?