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VA hospitals see spike in opioid thefts


April 28, 2017

Drug diversion from federal hospitals part of nationwide epidemic of healthcare thefts

In what appears to be a continuing trend throughout U.S. hospitals, federal hospitals don’t seem to be able to escape an alarming spike in thefts of opioids and other medications.

According to a report in the March issue of Outpatient Surgery magazine, the incidence of opioids and other medications going missing from federal hospitals in more than a dozen states—most of them run by the Department of Veterans Affairs—has spiked more than 2,500 incidents since 2009.

The drug thefts—also known as “drug diversion”—are attributed mostly to thefts by doctors, nurses, or pharmacy staff who are suspected of keeping the drugs for their own use or selling them on the street.

According to the magazine’s report, incidents of drug losses at more than 1,100 facilities (which includes seven correctional hospitals and about 20 hospitals serving Indian tribes) jumped from 272 in 2009 to a high of 2,926 in 2015 before dropping to 2,457 last year, according to the Drug Enforcement Administration (DEA).

In light of such reports, Outpatient Surgery reported that the heads of two congressional committees—Rep. Phil Roe, MD (R-Tenn.), who chairs the House Veterans Affairs Committee, and Sen. Ron Johnson (R-Wis.), chairman of the Senate Homeland Security Committee— have ordered the VA to better explain its efforts to stem drug theft and loss in light of rising cases of missing prescriptions and other unauthorized use at VA hospitals.

“The fact that drugs are going missing from facilities further underscores the importance of oversight,” said Roe in an Associated Press (AP) report. “This is a serious issue, and it must be addressed quickly.”

Johnson also described incidents of rising drug loss and theft as concerning. Last year, he raised issues of possible unauthorized use at the Milwaukee VA Medical Center, involving allegations that drugs from the hospital's pharmacy were going to nonveterans, according to Outpatient Surgery.

According to data cited by the AP, doctors, nurses or pharmacy staff at federal hospitals—the vast majority within the VA system—siphoned away controlled substances for their own use or street sales, or drugs intended for patients disappeared.

Aggravating the problem is that some VA hospitals have been lax in tracking drug supplies, according to the reports. Congressional auditors said spot checks found four VA hospitals skipped monthly inspections of drug stocks or missed other requirements. Investigators said that signals problems for VA's entire network of more than 160 medical centers and 1,000 clinics, coming after auditor warnings about lax oversight dating back to at least 2009.

“Medical practitioners at the VA have a responsibility to provide the best care for the injured and ill veterans in their charge, and these actions are contradictory to the very nature of their professional obligations," said Garry Augustine, executive director of Disabled American Veterans' Washington headquarters.

The VA acknowledged it has had problems keeping up with monthly inspections. It said it was requiring hospitals to comply with inspection procedures and develop plans for improvement.

The thefts of drugs from VA hospitals are not limited to just a few facilities. According to a February report in the Press-Herald of Portland, Maine, some of the more notable thefts from hospitals include the following:

  • At the John L. McClellan Memorial Veterans Hospital in Little Rock, Arkansas, three VA employees were charged with the theft of more than $77,000 worth of drugs, including a pharmacy technician who used access to a medical supplier’s web portal to order and divert 4,000 oxycodone pills, 3,300 hydrocodone pills and other drugs; the total street value was more than $160,000.
  • A hospice nurse at the VA Medical Center in Albany, New York, was sentenced last year to more than six years in prison after admitting to stealing pain medication intended for patients. An investigation found that the employee stole the painkiller oxycodone hydrochloride from syringes for his own addictions, and replaced the contents with Haldol, an anti-psychotic medication.
  • In Providence, Rhode Island, a former nurse in   the intensive care unit of the VA Medical Center pleaded guilty last year to stealing prescription drugs on dozens of occasions over several months in 2015. She apparently had used an override feature of an automated medication dispensing system to obtain hundreds of controlled substance pills, such as oxycodone and morphine. According to the Press-Herald, the nurse had previously been fired from a private hospital for diverting controlled substances, but was hired at the VA after making false claims in her employment application.
  • An anesthesiologist at the VA Medical Center in Los Angeles pleaded guilty in 2015 to theft of public property and possession of a controlled substance while treating a veteran. Apparently, while providing anesthesia care to a veteran in surgery, the doctor passed out in the operating room after taking a sedative and injecting himself with several drugs, including fentanyl. The patient, who was fully conscious, reported he was initially frightened that the commotion was due to his own medical condition.

The incidents reported above are unfortunately just a few of what healthcare safety experts say is a growing epidemic in American hospitals.

“The problem is that (drug diversion is under-recognized and under-reported in many instances),” said Kimberly New, JD, a nurse, attorney, and consultant specializing in helping hospitals in the prevention, detection, and response to drug diversion by healthcare personnel, during an April 2016 webinar, “Drug Diversion in Healthcare.” “So many times facilities detect diversion, but they allow individuals to resign their position, move on, and they don’t necessarily do the appropriate external reporting.”

New said that it’s estimated that about one in every 15 healthcare employees may have some sort of addiction, whether it be to alcohol or drugs, and the healthcare environment often offers them the perfect opportunity to get the drugs they need for free. And in many cases, the patients that these employees are supposed to be caring for are put in harm’s way. In some situations, such as the one in Providence and Albany, the diverter will use medicine intended for the patient, and either replace it with another medication for paperwork purposes, or simply inject themselves with an IV of medication previously injected into a patient. This practice, obviously, can leave both patient and practitioner at serious risk of diseases. In 2016, for instance, New said that at least 12,000 patients in the U.S. had to be notified by hospitals that they may have been exposed to bloodborne pathogens as a result of tampering or substitution.

“What we do know is that this is universal among institutions in the U.S.,” she said. “It happens at all facilities. It doesn’t matter how high-tech a facility is. It doesn’t matter how great their patient safety initiatives are.  So the best we can do is prevent what we can, detect it quickly, and respond appropriately.”

In addition to the inherent health-related ramifications of the practices related to drug diversion, New said that the thefts open hospitals up to class action lawsuits, lots of negative publicity, and ongoing DEA investigations that can be very expensive for institutions and very disruptive, including increased scrutiny by accreditation organizations. 

So what can be done about the problem of the drug diversion? There are many signs of the problem occurring in your facility, and experts say there are many components of a drug diversion control program that should be in place. At the very least, keep in mind the following things.

Diverters are the best employees. In many cases, drug diversion thefts were conducted by some of the most model employees. New pointed out that diverters don’t fit commonly held perceptions or stereotypes of individuals who are stealing and abusing drugs and so it’s important for staff to understand that these may often be the person that they would least expect to be involved in this type of activity.

“Many times they are top performers, award winners, very hard working,” she said. “They’re always ready to help. They come in early and they stay late. They prefer a fast-paced critical care environment. They’re popular with medical staff. They often have a compelling personal story.” 

Ease of obtaining medications. Honestly, how easy is it to get prescription medications on your patient treatment areas in your facility? In many cases, diversions happened in places with little supervision of nurses, or on odd shifts such as overnights where nurses knew no one would be holding them accountable for the medications they were dispensing to patients.

“We tend to use some very, very powerful and dangerous medications, but we see them work well,” said New. “We use them day in and day out and we can become desensitized to the dangers associated with the medications that we’re using. In one instance, a nurse informed me that the medication that she gave as a preop medication was basically treated like water on her unit, because it was just used so commonly.”

Beware of agency nurses or temps. Many hospitals employ nurses contracted by outside agencies, many of whom work in several hospitals at once. This not only gives diverters more access to the drugs of their choice, but it also makes it harder to get caught, and in some cases, agency nurses are not held to the same employee standards as hospital employees would.

“If I work for an agency, I can divert small amounts of opioids or whatever my drug of choice is from various facilities in a geographic area and I can stay under the statistical radar, but also some agencies may not vet their employees as well as many hospitals and other healthcare facilities do,” New said.

Have sufficient auditing, surveillance, and reporting systems in place. Healthcare security experts say that many diversion incidents occur in healthcare facilities that don’t:

  • have an accountability program
  • properly secure and inventory their drug stock
  • hold employees accountable for the drugs they acquire for patients
  • have a system in place to report suspicions of drug diversion

“Many times I find in institutions where they’ve had, for instance, a lack of auditing for a period of time, that diverters will test the system and when they find that they can divert undetected, they can become very, very bold,” New said.

In addition, a general lack of a reporting system, and inconsistent practices from one hospital to another make it very difficult to accurately screen employment candidates. So many times a drug diverter who gets caught in one facility can simply go to another hospital and lie on applications in order to get hired.

“That comes primarily from lack of reporting of diversion because as I mentioned, sometimes facilities don’t report diversion,” New said. “Non-meaningful references, and really what that means is that the common practice for healthcare facilities is to report dates of employment. Many times facilities don’t even comment on whether someone is eligible for rehire. So it can be difficult to know what really happened while they were employed at a previous job.”

A healthy culture to institute, she said, is that of an accountable workplace where anonymous reporting is encouraged.

“A little known fact is that employers actually, under the Controlled Substances Act, have a responsibility to report drug diversion within their facility,” she said. “If they have a suspicion of diversion, they need to report it to a responsible individual within the institution, a supervisor, who can address the situation. So the two key terms here are that employees are obligated to report and also that employers shall inform all employees concerning this policy. So it’s important to make sure, as healthcare facilities, that we have notified employees that they have this responsibility to come forward and report.”

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