Drug Diversion Increasing Risk of Patient Outbreaks

By Gary Evans, Medical Writer

With experts warning drug diversion by healthcare workers has increased during the pandemic, infection preventionists should welcome the news that the medical tech who caused hepatitis C outbreaks in hospitals in eight states remains in a Florida prison.

A hepatitis C virus (HCV) carrier, David Kwiatkowski was sentenced to 39 years in prison in 2013 for infecting a string of victims with HCV as he diverted drugs from multiple hospitals and caused one outbreak after another.

Tracking back through this trail of tragedy, federal officials with the Department of Health and Human Services (HHS) tallied 45 HCV-infected patients, two of whom died.¹

Kwiatkowski’s modus operandi was to steal prepared fentanyl syringes intended for patients awaiting cardiac catheterizations, inject the drugs, and replace them with saline. The replaced syringes were contaminated with HCV from the cardiac medical technician’s blood.

“Kwiatkowski concealed his job history,” HHS officials wrote. “But regulations and procedures that differ from state to state, and even from institution to institution, enabled him to continue destroying lives. We know of only two instances when calls were made to law enforcement officials on suspicions that Kwiatkowski was stealing drugs. Both times, he left the state before any action was taken. Most hospitals didn’t call the police. They also didn’t communicate his job history to agencies and institutions to prevent his being hired again.”¹

Kwiatkowski entered a plea for early release in 2021, citing his HCV infection and the risk of COVID-19 in prison.

A district court judge in New Hampshire dismissed the plea out of hand, saying the crime committed was “extremely cruel and callous” and the perpetrator deserved no such mercy.²

In the years after this case, some states have tightened oversight over medical staffing agencies or discussed some version of granting immunity to those who report diverters. However, similar incidents — although on a smaller scale — have occurred since the landmark Kwiatkowski case.

The Centers for Disease Control and Prevention (CDC) investigated a 2017 outbreak of genetically similar HCV infections in 12 patients who all were linked to the same nurse. It was thought the nurse was HCV-positive, but her viral titers were too low to draw a definitive conclusion. However, a patient not in the cluster was diagnosed with chronic HCV and could have infected the nurse before she infected the other 12 patients, the CDC theorized.

“It is possible that nurse A acquired the virus from the patient with chronic HCV infection during the November 8 visit and was infectious during Nov. 22-Dec. 26, 2017, during which time at least 12 patients that she treated became infected,” the CDC concluded.³

That report underscores the challenge of determining routes of transmission and the behavior of individual pathogens with variable incubation periods. For example, HCV can appear relatively soon after an exposure as an acute infection or remain dormant for years.

“There is a ton of tampering going on,” says Kimberly New, JD, BSN, RN, principal consultant at Diversion Specialists. “I recently heard a facility say somebody tampered in the emergency room for eight months, but there was no patient harm. I don’t know how they can come to that conclusion. You are only going to find what you look for.”

Pandemic Hid Diversion

The resource reallocations required by the pandemic have made drug diversion investigations harder to fund, and the shortage of workers have made incidents harder to detect by colleagues, New says.

New has investigated hundreds of hospital diversion incidents and knows well the various tactics and methods employed to pilfer primarily opioid drugs.

“What I am seeing is that hospitals are desperate for staff, so they are using a lot of travelers and agency-type services,” she explains. “Although, by far, the majority of travel workers are great, many people who engage in diversion do prefer to work in that capacity because they can be in a facility for a short period of time, and then they can leave and go somewhere else. They stay under the radar — even if they are caught, they are already gone. They stay one step ahead.”

Oxycodone, fentanyl, morphine, and other medications derived from or synthetically designed to mimic the effects of the opium poppy plant are the main drugs diverted by healthcare workers. Some have suggested hospital drug diversion has contributed to the national opioid epidemic, which led to 107,000 overdose deaths in 2021, the CDC reported.⁴

“By far, the majority are both using while they are working and also taking it home,” New says. “If you are using hydromorphone at work and then you have a three-day break, you’re not going to do too well — you’re going to need it.”

In many cases, the healthcare worker may inject the drug in a bathroom on site and replace the drug with water or saline. If, according to the dosage, some medication is left, it should be discarded as “waste” with a witness present. This aspect often is manipulated, too.

“We see a lot of situations where people are delaying their drug waste,” New says.

“Say I have a 1 mg syringe of hydromorphone and I administer half of a milligram. But I don’t actually waste the other half of a milligram for several hours, which gives me an opportunity to go in the bathroom and inject it, fill the syringe back up with water, and then go waste it with a witness.”

Others like to save the waste drugs and take them home, which could be considerably easier if the witness is an accomplice. Healthcare workers scheming together is unusual, given the singular focus and secretive world of the individual addict.

“That is extremely rare, although it is not unheard of,” New says. “A case that comes to mind that I investigated was a husband and wife who were working as travel nurses. They were ‘witnessing’ each other’s waste. Of course, the wasting was not actually being done.”

REFERENCES

1. Levinson DR, Broadhurst ET. Why aren’t doctors drug tested? The New York Times. Published March 12, 2014. https://www.nytimes.com/2014/03/13/opinion/why-arent-doctors-drug-tested.html
2. Feely P. Judge rejects compassionate release request from man who infected 46 with hepatitis C. New Hampshire Union Leader. Updated July 2, 2021. https://www.unionleader.com/news/courts/judge-rejects-compassionate-release-request-from-man-who-infected-46-with-hepatitis-c/article_3551b7dd-b0b3-5126-bdad-b91f87c42889.html
3. Njuguna HN, Stinson D, Montgomery P, et al. Hepatitis C virus potentially transmitted by opioid drug diversion from a nurse — Washington, August 2017-March 2018. MMWR Morb Mortal Wkly Rep 2019;68:374-376.
4. Centers for Disease Control and Prevention. U.S. overdose deaths in 2021 increased half as much as in 2020 — but are still up 15%. Published May 11, 2022. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/202205.htm#:~:text=Provisional%20data%20from%20CDC's%20National,93%2C655%20deaths%20estimated%20in%202020