Norris Cunningham

Drug diversion occurs when prescription medicines are obtained or used illegally. While diversion has always been a concern, without question, COVID-19 certainly increased personal stress and pressure on workers in long-term care, potentially leading to increased diversion.  Further, COVID-19 disrupted facility management, including diversion control programs. 

This column is the first in a two-part series that will discuss how to prevent diversion, spot diversion, and deal with diversion.  This first column focuses on the first two pieces of the puzzle: prevention and spotting.

How to prevent diversion

At the outset, it is essential for facilities to screen potential employees to prevent the risk of diversion.  In fact, the Drug Enforcement Administration considers such screening essential to controlled substance security.  See 21 C.F.R. § 1301.90.  Screening should include criminal background checks, verification of licenses, drug screening and perhaps even written signed acknowledgments related to any history of mishandling a controlled substance or involvement in a drug diversion issue.  

Security measures are also vital in preventing diversion.  Develop an interdisciplinary team responsible for maintaining the organization’s Control Substance Diversion Prevention Program (CSDPP).  According to the ASHP Guideline on Preventing Diversion of Controlled Substances, this team should be led by a “designated diversion officer”. 

Committee membership should include staff from medicine, pharmacy, nursing, security, human resources, compliance, administration, legal and more. Also, build in tight control through process checks and balances, diligent surveillance and prompt interventions to prevent, promptly identify and investigate suspected diversion.  

For example, medication room access should be limited to authorized individuals only.  Medication carts should be locked and secured when not in use.  Discontinued medications should be removed from the medication cart/room as soon as possible and destroyed or returned per individual State requirements.  All multi-dose vials should be dated when opened and discarded within 28 days or according to the manufacturers’ instructions.  All collection receptacles shall be located in a secured area and either locked or regularly monitored by employees. See 21 C.F.R. § 1317.75

Staff should be educated upon hire and regularly thereafter about the risks of diversion, reporting protocols and proper documentation. Several states have specific laws and rules that regulate reporting of drug diversion.  In addition, facilities must comply with several federal regulations pertaining to drug diversion.  Employees have an obligation to report drug diversion under federal law. “It is… the position of DEA that an employee who has knowledge of drug diversion from his employer by a fellow employee has an obligation to report such information to a responsible security official of the employer.” 21 C.F.R. §1301.91.  

Further, drug diversion events are typically reportable to law enforcement agencies and licensing organizations for healthcare professionals. Depending on local requirements, they may also be reportable to public health authorities and licensing agencies.

Angela Rinehart

What does it look like?

Knowing how to spot drug diversion is crucial in allowing facilities to be proactive, rather than reactive, to incidents of diversion.  Unfortunately, public health agencies sometimes learn of drug diversion events from the media or after a larger issue is identified.  It is much preferred and safer for the facility to be able to spot drug diversion so that prompt reporting can occur.

As such, the need arises to monitor for signs and behavior patterns of facility employees such as signs and symptoms of impairment, work absenteeism (e.g., absences without notification and an excessive number of sick days, frequent disappearances from the work site or long unexplained absences), excessive amounts of time spent near drug supply, sloppy recordkeeping or uncharacteristic deterioration of handwriting or charting, intermittent work performance of high/low productivity, progressive deterioration in personal appearance and hygiene, increasing personal or professional isolation or receipt of information that an employee is arrested for illicit use of controlled substances.

Signs of diversion can include unexpected complaints from residents of increased pain or that their regular medication is not working.  This could be a sign of medication substitution or dilution.  Anomalies in documentation should be investigated, such as an unexpected increase in medication orders.  This could reveal record tampering to conceal diversion.  Lastly, irreconcilable numbers of medications could likely be a sign of simple theft from stock medication.

Facilities should routinely evaluate their employees, systems and patient care environments to remain mindful of patient care and safety.  Look for the next column in this series, which will discuss how to deal with and investigate diversion once it is spotted.

Norris Cunningham is a founding shareholder and leads the Health Care Practice Group at Katz Korin Cunningham PC (KKC) in Indianapolis. Contact him at [email protected] Angela Rinehart is an associate attorney in the Health Care Practice Group at KKC and focuses her practice on the defense of long-term care providers. Contact her at [email protected].

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.