Refractory Pain in the Institutional Setting: Could Diversion be a Culprit?

Refractory Pain in the Institutional Setting: Could Diversion Be A Culprit?

Kimberly New, RN, BSN, JD

Disclosure Information

National Association of Drug Investigators (NADDI) Speaker’s Bureau

Learning Objectives Identify institutional diversion reporting requirements Recognize patient safety issues Examine methods of drug diversion List tools for diversion detection

Many Forms  MD, pharmacy staff diversion  Doctor shoppers in ER  Stolen script pads and forged prescriptions  Patient’s family  Unauthorized drug cabinet access (ie, unit secretary)  Sharps containers  Theft of scripts for controlled substances  Theft of shipment prior to delivery in pharmacy

Many Forms

Patients

MD

Contractors

Family Members

Discipline of Nurses Substance abuse is a primary reason for discipline of nurses across the country Drug diversion is the number one substance abuse-related infraction

Nursing Diversion in the News Nurse sentenced for stealing narcotics from patients: A 40-year-old nurse formerly employed at a senior care assisted living facility was sentenced for stealing Percocet by removing it from patient medication bottles and replacing it with acetaminophen Police say nurse took meds from patients: A now-former nurse at a Danvers assisted-living facility is facing charges that she stole pain medications from at least six residents for months, secretly replacing their Vicodin and oxycodone with a generic version of Tylenol

Nursing Diversion in the News (cont’d) Drug tampering cases by 3 Kansas nurses highlight gaps in state regulations: A nurse with a prior felony conviction for forging prescriptions diluted morphine solutions for five Halstead nursing home patients. Another nurse convicted of stealing drugs from patients secured another job, where she added tap water to a painkiller prescribed for a 105-year-old patient. Another nurse fired from her last job at a hospital over drug discrepancies secured a new job where she was later accused of taking home syringes full of morphine and replacing the medicine with a dangerous sodium chloride solution

Reporting is Essential “I am usually discussing not only the horrors that can occur in our nation’s health facilities, but the common practice of those criminal acts not being reported to law enforcement or even regulatory boards. Unfortunately, many times the practice is to dismiss or accept the resignation of the violating health professional. This opens the door for abuse at the employee’s next facility and fails to address the underlying cause: addiction” - Burke http://www.pharmacytimes.com/publications/issue/2009/July2009/

Reporting Requirements DEA (immediate reporting required) Upon discovery of theft or loss. Pharmacy Board Law Enforcement Issues of abuse/neglect/reckless endangerment, fraud State Licensure Board Incompetent, unethical or illegal practice FDA/OCI (tampering cases) State Department of Health, Health Facilities division

Why Don’t We Hear More?  Drug diversion by health care providers is universal among institutions in the US –Fear of negative publicity –Fear of State and Federal agency involvement –Justification that terminating the employee is enough

Impact on Diverting Employee Health care professionals who divert are at substantial risk for –Arrest and criminal prosecution –Loss of license and imposition of fines by the State Licensing Board –Loss of job/career –Placement on the Abuse Registry –Exclusion from health care by the federal government

Impact on Diverting Employee  Diverting professionals also risk: – Separation/divorce – Loss of custodial rights to children – Financial loss or ruin – Related criminal charges (DUI, possession) – Significant health problems - even death

Impact on Patients  Impairment and addiction put patients at risk (reckless endangerment)  Strong likelihood of denying patients appropriate pain relief (abuse of a vulnerable individual)  Falsification of records (fraud)  Theft

Our Experience  Approximately 1 nurse per month –Award winners –New Grads –Team Leaders –Pediatric and neonatal nurses –Pregnant nurses –Clusters of nurses

Recovery Room Nurse  Diversion over many years  Moved from state to state  Hydromorphone, fentanyl, ketamine  All patients “vulnerable”  Patients with painful procedures  Nurse’s needs came firstdocumentation reflected anger

Recovery Room Nurse (cont’d)  353 instances of diversion of a controlled substance in a 3 month period  Some patients did not receive any pain medication  Delay in administration of opiates between 10 minutes and 2 hours with average delay between 30 and 45 minutes  Method of diversion: documented appropriate administration of opiates but delayed removing any until the last possible moment  Destruction of records

Recovery Room Nurse (cont’d) Patient S/P MVA with intermedullary nail placement in femur

–noted, “Cursing staff. Very rude. Hitting at staff when try to help reposition patient Complains of pain scale 9/10” –hydromorphone withdrawn 31 minutes after this note

Recovery Room Nurse (cont’d) Patient S/P assault with ORIF left parasymphysis fracture; closed reduction of left subcondylar fracture of mandible – noted pain of 5/10 to 8/10 and “increased pain, hitting side of rails” – first dose of hydromorphone administered 1 hr 30 min after first notation of pain • first notation pain at 23:20

• 00:27 first dose Dilaudid (4 mg) withdrawn • 00:50 first dose to pt-pt received 0.8 mg total

Recovery Room Nurse (cont’d)

 Trauma patient-ORIF humerus 3 fragments, ORIF right intra-articular distal radius fracture, ORI left distal radius fracture with 3 fragments, closed reduction w/pinning right fifth metacarpal, ORIF left distal radioulnar joint – Noted, “Yelling and thrashing about bed complaining of pain 10/10. Patient behaving belligerently”

pain control issue

Recovery Room Nurse (cont’d) 58 year old patient with repair of abdominal aortic aneurysm –Noted pain of 9/10 to 8/10 and “patient thrashing about complaining of severe pain. Blood pressure elevated. Patient crying and states ‘this is awful’”

Recovery Room Nurse (cont’d)  Health Related Boards-revoked license, fined nurse $185,000, placed nurse on the abuse registry  Nurse excluded by OIG  Pled guilty to acquisition of controlled substances through misrepresentation, deception, fraud and subterfuge  Sentencing July 2012

Reflection  OR records now online to view contemporaneously  All diversion cases taken through “critical event” review  Multidisciplinary core team determines when patient harm has occurred  Change from 2 mg to 1 mg hydromorphone syringes housewide

Daily Surveillance Report  All Issue/Waste transactions for each department/user  Discrepancies  Staff that are statistically significant in withdrawals for the day  Instances in which a drug was removed without a recognized order (medication override)  Drugs issued in large quantities  Drugs issued in close time proximity  Drugs issued to discharged patients

Monthly Report

Methods of Diversion  Removal of medication when not needed – Often initial method of diversion – Very difficult to detect – Falsification of records

 Removal for discharged patient  Removal of duplicate dose – May not be caring for patient – May be preceptor

 Removal of fentanyl patches

Methods of Diversion (cont’d) Removal too frequently Ordered q 4 hrs, removed q 2 hrs Removal of medication without order Medication override Falsification of “verbal order” Removal and use from inconspicuous vessel

Removal of Opiate When Not Needed

no order for morphine or hydromorphone

Failure to Document removed 2 tablets every 2 hours this shift

Withdrawal for Discharged Patient

no order for Dilaudid

discharged @ 0200

Removal of Duplicate Dose • legitimate dose

• duplicate dose • legitimate dose

• duplicate dose

Unordered Doses Too Close

first two doses too close even if an order existed

Medication Overrides

False Verbal Order

Ambulatory to checkout in care of responsible driver. Vicodin ii po per vo Dr. Oros

Methods of Diversion Failure to waste

–Unwasted medication kept for self

Substitution in administration and wasting –Substitution of look-alike pills –Saline substituted for injectable medication –Potential for tampering charges

Frequent null transactions, discrepancies and returns Removal of larger doses than necessary Withdrawal from PCA and drip lines Removal under sign-on of colleague Removal of unspent syringes from sharps boxes Pilfering patient medications brought from home

Failure to Waste ORDERS

versed 2 mg: 0.25 mg IV q 3 hr prn pain

morphine 2 mg inj: 0.25 mg IV q 3 hr prn

Recognition of Diversion/Impairment Staff are educated to look for the following signs:  Tardiness, unscheduled absences and an excessive number of sick days used  Frequent disappearances from the work site, having long unexplained absences, making improbable excuses and taking frequent or long trips to the bathroom or to the stockroom where drugs are kept  Volunteer for overtime and are at work when not scheduled to be there  Arrive at work early and stay late

Recognition of Diversion/Impairment  Pattern of removal of controlled substances near or at end of shift  Work performance which alternates between periods of high and low productivity and mistakes made due to inattention, poor judgment and bad decisions  Confusion, memory loss, and difficulty concentrating or recalling details and instructions. Ordinary tasks require greater effort and consume more time  Emotional breakdowns

Recognition of Diversion/Impairment  Heavy or no “wastage” of drugs  Pattern of holding waste until oncoming shift  Insistence on personal administration of injected narcotics to patients  Personality change - mood swings, anxiety, depression, lack of impulse control, suicidal thoughts or gestures  Patient and staff complaints about health care provider’s changing attitude/behavior  Increasing personal and professional isolation

Tools for Detection  Drug cabinet Transaction reports (User, Witness, Patient, Item reports)  Dispensing Practices Report  Refused order reports  MD interviews (verbal orders)  Patient complaints and survey results relating to pain management  Urine drug screen  Interview with patients  PSN or “incident” reports  Locator reports

Locator Reports

Excerpt from Locator Report Case  Ms. Jones documented administration of a dose of Ativan at 3:50 am on February 11, but was not in the patient’s room between 11:28 pm on February 10 and 6:19 am on February 11  Another patient (RE) complained that Ms. Jones didn’t show up in the room until around 11:00 pm to administer pain medication. The patient record reflected that Ms. Jones had documented administration of Roxicodone and morphine for this patient at 8:10 pm. The locator report reflected that Ms. Jones did not enter this patient’s room until 11:11 pm on the evening of February 10

When Diversion Suspected  Verification of data/analysis with Pharmacy and Nurse Manager  Nurse immediately removed from patient contact or intercepted when coming in for next shift  Drug cabinet access discontinued  Initial interview of nurse including review of medical and drug cabinet records  Urine drug screen  Suspension pending conclusion of investigation  Initial contact made with LE if appropriate

No Tolerance When diversion is confirmed:  Termination for gross misconduct  Reporting to all relevant state and federal agencies  Referral to TNPAP  Rebill  Work with LE and other agencies involved in investigating or prosecuting case  Notification of patients if applicable

Our Efforts at Prevention  Surveillance by neutral examiner  Treatment of high abuse risk non-controlled substances as controlled substances (cyclobenzaprine, carisoprodol, tramadol)  Policy of wasting prior to administration where possible  All partially used controlled substance doses from surgery submitted to OR Pharmacy for wasting  OR pharmacist does random refractometry on 10% or more of all surgery waste; focused refractometry when indicated  All orders for controlled substances which are not accepted by the physician are reviewed by Pharmacy and Compliance

Our Efforts at Prevention  Nurse Managers make daily “pain” rounds to ensure pain management concerns are promptly addressed  Liberal “reasonable suspicion” policy  Review of drugs used to ease withdrawal symptoms (promethazine, ondansetron, diphenhydramine)  Diversion training for all new nursing staff and annually thereafter for nursing staff  Education of all staff (not just clinical)  Regular training for nursing leadership  All patient complaints and survey responses relating to unrelieved pain reviewed by Compliance and Nurse Managers

Our Efforts at Prevention  Educational outreach at nursing schools statewide  CEO Summit monitoring for and addressing failure to properly waste (injectables, pills, fentanyl patches)  Identifying and addressing medication handling issues (early removal)  Reducing number of individuals handling sharps containers  Increased used of surveillance in high risk areas such as pharmacy

Patient Harm and Tampering Patient Harm  Diversion of scheduled (non prn) doses  Documentation of pain in face of diversion  Impairment resulting in patient harm or reckless endangerment  Confession Tampering In most cases proof limited to:  Confession  Covert surveillance

Surgical Nurse Boulder Community Hospital Ashton Paul Daigle  108 counts of tampering with a consumer product  67 counts of creating a counterfeit controlled substance for allegedly stealing fentanyl  Over 300 potential victims  Sentenced to 54 months in federal prison followed by 3 years supervised release

Tampering  Took pain medication from people going into surgery  Used syringes replaced with tap water or saline  Dirty needles placed back on the surgical trays for use-tainted by hepatitis  Over 20 patients infected  Plea bargain rejected  Sentence-30 years

Kristen D Parker

Links Minnesota Controlled Substance Diversion Prevention Coalition Final Report and Road Map to Controlled Substance Diversion Prevention http://www.health.state.mn.us/patientsafety/drugdiversion/index.html Minnesota Hospital Association-Controlled Substance Diversion Toolkit http://www.mnhospitals.org/index/tools-app/tool.438?view=detail National Association of Drug Diversion Investigators http://www.naddi.org/aws/NADDI/pt/sp/home_page

Questions?

Kimberly New RN BSN JD NADDI, TN Chapter President (865) 305-9116 Knew@utmck.edu