Drug Diversion in Health Care Facilities: Should Testing Be Required?

Drug DiversionThe Uniform Controlled Substances Act defines drug diversion as the “transfer of a controlled substance from a lawful to an unlawful channel of distribution or use.” Reports of diversion of prescription drugs by health care workers is increasingly in the media, raising questions as to why drug testing is not required in health care facilities.

Medical technologist David Kwiatkowski, a prescription-drug addict, for years stole the painkiller fentanyl intended for patients from the facilities where he worked. Kwiatkowski injected himself and then refilled the used syringes with saline, which was then injected into the patients. Kwiatkowski has hepatitis C, a virus that causes liver disease and is usually transmitted through contact with infected blood. He transmitted the virus to 46 people in four states over a 10-year period.

Kwiatkowski worked at 18 hospitals in seven states, despite being fired at least four times over allegations of drug use and theft. In December, 2013, he pleaded guilty to 16 federal charges and was sentenced to 39 years.

Although drug controls are extensive in the outpatient setting, within inpatient healthcare facilities like hospitals or nursing homes it is easy for workers to get drugs from central stores, during preparation, during administration to patients, and during disposal of waste.

Health care worker drug abuse puts patients, health care workers, and employers all at risk.

Patients may receive substandard care, such as not receiving all the drugs they need that have been prescribed to them. They may suffer great pain due to receiving either no medicine or a diluted form so that results in a dosage far less than what was intended. They may get a contaminated drug and risk infection or receive an alternative drug they may be allergic to. There is also risk to the patient by care from an impaired worker.

The health care workers themselves may be at risk from unintentional overdose, infection from unsanitary needles or injection techniques, or transmission of blood borne pathogens. They also have legal risks, such as felony charges for criminal possession, civil malpractice cases, and actions against professional licenses.

If harm befalls a patient while under the care of a drug-impaired worker, both the worker and the employer are vulnerable to civil litigation.

The most commonly diverted drugs in health care facilities are opioids, medications used to relieve pain. The diversion usually occurs to support the addiction of a health care worker or associate, or for resale. The stolen medication may be in the form of unopened vials, vials and syringes that have been tampered with, or leftover drugs in syringes or vials after only part of the drug ordered was administered.

drug diversion
Fentanyl is one of the common opioids that are diverted by health care workers

Many health care workers are not even aware that drug diversion is a serious problem. Detection can be a problem because the compromised worker may not be visibly impaired. The diversion is often not discovered until the abuser reaches extremely large doses of controlled substance.

Regular monitoring in health care facilities is standard for the prevention of drug diversion, but typically only includes watching for red flags, such as a nurse who documents administering more “as needed” meds than others. Drug testing is not commonly found in health care facilities except for workers with known substance abuse problems.

Easier access to drugs may put health care workers at an increased risk for substance abuse. A 1986 survey of 500 physicians regarding illegal drug use was published in the New England Journal of Medicine. Out of the 70 percent of physicians who responded to the survey, 10 percent reported at least once-per-month drug use.

The American Hospital Association’s (AHA) 1992 drug screening policy for hospital employees recommends that a rule that includes pre-employment, for-cause, and post-accident testing be adopted by health care institutions, but there are currently no regulations requiring it. The majority of employers in the U.S. are not required to drug test even though are federal regulations requiring drug tests for certain jobs, such as those requiring operation of a commercial motor vehicle on public roads.

Drug testing detractors refer to the lack of scientific data proving that drug testing is effective in achieving its goals, which may not be clearly defined. The immense task of drug testing, it is argued, is of potentially bigger legal and public relations disadvantages than is the benefit to patient safety. Detractors also say that it has not yet been shown that pre-employment drug testing of health care workers actually improve safety.

According to a 2004 article in Occupational & Environmental Medicine, the goals of drug testing should be clearly stated so that their effectiveness in accomplishing their designed purposes can be studied, since at this time it is not clear whether patient safety is actually improved by pre-employment drug testing by hospitals.

Hire Right says among the common reasons facilities do not drug test is the complexity of properly administering the tests, concerns about the legal rights of the individual, and the time it takes to get results when competing for scarce talent.

There are reporting requirements for drug diversion. Federal regulations require that the Drug Enforcement Administration (DEA) be notified in writing of the theft or loss of any controlled substance within one business day of discovery. It is also typical for the health care facility to require internal reporting. But most reporting is confidential, as is referral to a professional addiction program. Often the abuser is fired from the facility when mishandling is suspected. Or they may quit when the supervisor becomes suspicious and move on to another location.

There is an increasing push for a requirement for drug testing for medical professionals, and many lab facilities now offer medical professional testing programs. However, the debate will most likely continue for some time as to whether mandatory testing should be required, and whether it will actually reduce the problem of drug diversion in health care facilities.

By Beth A. Balen

NY Times
Mayo Clinic
International Business Times
National Council of State Boards of Nursing

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