WASHINGTON—In the past two years, the VA has implemented a nine-step process to minimize drug diversion, but cases continue to slip through.
In December 2018, the VA’s Office of the Inspector General reported two instances of healthcare workers diverting drugs for personal use. In one instance, an intensive care unit nurse in the Providence VAMC withdrew medication from prepackaged fentanyl and hydromorphone syringes. After refilling the devices with saline solution, the nurse returned the tampered drug back in the Pyxis automated medication dispensing machine for later patient use.
In the other case, for more than two years, a nurse at the Denver VAMC used a syringe to withdraw liquid fentanyl and hydromorphone that remained in dispensing containers after administration to a patient. He would then replace the liquid with saline and throw out the container in the presence of a witness.
Drug diversion increases the risk of harm to patients in three ways, according to the national Centers for Disease Control and Prevention. Tampering with an injectable medication as seen in the Providence example risks spreading pathogens to patients. The CDC found five outbreaks of hepatitis C affecting 129 individuals as a result of healthcare providers diverting drugs between 1983 and 2013. The diversions also led to four other outbreaks affecting 63 additional patients.
As seen in both VA reports, pain medications are frequent targets of diversion. Replacing those medications with saline solution leads to patients being denied essential pain medication. Even when patients receive their full dose of the prescribed medication, drugs diverted for personal use lead to substandard care being delivered by an impaired healthcare provider, the CDC notes.
In 2017, the Government Accountability Office found that four VA facilities failed to ensure monthly inspections, update procedures and properly train controlled-substance coordinators. The GAO report came on the heels of a number of reported cases of drug diversion within the VA and determined that the VA needed to provide greater oversight of facility and VISN level efforts to minimize diversion.
By the end of 2017, the VA had complied with all the GAO recommendations and instituted additional safeguards.
Today, “VA takes a systems-level process improvement approach when reviewing controlled substance loss and diversion,” according to Michael A. Valentino, RPh, MHSA, chief consultant, pharmacy benefits management, at the VA.
“Oversight of controlled substances is multi-faceted,” he told U.S. Medicine. Current practices include:
- Ensuring VA lists all controlled substances that have evidence of safety and effectiveness on its national formulary.
- Providing evidence-based prescribing criteria for controlled substances.
- Developing internal controls for physical drug security.
- Using electronic prescribing to prevent forgery.
- Monitoring suspected cases of theft or diversion and taking appropriate actions for follow-up.
- Addressing any controlled substance prescribing that does not align with evidence-based criteria.
- Implementing patient-focused initiatives such as medication take-back programs.
- Overdose education and naloxone distribution.
- Ensuring the availability of complementary and integrative medicine therapies to improve wellness and whole health.
Internal controls and monitoring pick up the majority of cases of internal drug diversion. Discrepancies may be identified through the inspection program, reports of suspicious behavior by staff members, use of software surveillance programs, and data review of overrides of automated dispensing cabinets, discrepancy reports, null transactions and other indicators of unusual activity, Valentino said.
‘Robust’ Processes at VA
“Most importantly, VA encourages robust processes to prevent, detect, report and remediate controlled-substance diversion. Without it, it’s likely that healthcare systems have undetected diversion occurring,” he noted.
Undetected and unreported diversion plagues the healthcare industry nationwide. An estimate by John Burke, the past president of the National Association of Drug Diversion Investigators and the president and cofounder of the International Health Facility Diversion Association puts the rate of diversion by healthcare workers at 102 cases per day, though he noted that most of those are not prosecuted or reported as organizations often allow diverters to quit or fire them.
The VA takes a strict stand on reporting diversion. “All cases are reported to both VA police and the OIG,” Valentino said. Those organizations make the determination on any prosecution.
NADDI and Protenus Inc. identified 179 cases of reported diversion by healthcare workers in the U.S. in the first six months of 2018. Of those, 31.88% occurred in a hospital or medical center setting. Nearly all cases involved opioids (94.87%) and almost one in five (19.65%) involved one or more type of benzodiazepine.
While the VA does not track which drugs are diverted, “the opiate analgesic drug class is commonly involved,” Valentino said.
The VA does not track the cost of diverted drugs, but the Protenus report provides an indication of the impact of diversion. While reports did not include the cost and quantities diverted for most of the instances in the Protenus report, 32 incidents with quantity data accounted for the loss of 18.7 million pills or dosages, and 23 incidents with cost information had medication losses that totaled more than $162 million. Physicians accounted for 42.6% of all diversions, with nurses involved in 28.49% of cases and pharmacists in 13.41%. Other healthcare workers were responsible for the balance.
The VA’s unusual reliance on its mail order pharmacy makes it an outlier in the area of drug diversion. A study conducted between Jan. 2, 2014, and March 11, 2016 found that 92% of controlled substances lost or diverted by the VA system occurred during shipment to veterans, and just 1.5% of reported incidents represented diversion by VA staff.
Few healthcare systems disclose cases of drug diversion, leading to a perception that reports indicate poor management of medications. The opposite is likely true.
“Transparency creates a culture of accountability and encourages an environment of robust processes and controls,” said Valentino. “When compared to other healthcare entities, some may erroneously conclude that VA has significant problems in this area. Many health care systems don’t have the same controls and processes as VA and may not know the magnitude of the problem that almost certainly exists.”