By Gary Evans, Medical Writer
On Sept 16, 2022, an emergency nurse was arrested and charged with diverting drugs from a hospital in Jacksonville, FL. In a development that says more about the problem of drug diversion than any scholarly study, the nurse already was out on bond after similar charges of diversion were filed against her two months earlier by another hospital 30 minutes away.1
That is how fast drug diversion can happen as healthcare workers move from one facility to another, enabled by lax reporting systems and hospital disincentives to alert patients and raise liability issues. Diverters may slip through cracks in oversight by medical and nursing boards as they move to other facilities and are lost to follow-up.
This longstanding problem — often a multivictim crime after an outbreak — has worsened, according to an expert investigator in the field. 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, says Kimberly New, JD, BSN, RN, principal consultant at Diversion Specialists.
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. “Though 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.”
The COVID-19 pandemic has been cited as a contributing factor by both diverters and hospitals responsible for drug oversight. For example, a Waterloo, IA, nursing home worker admitted in 2021 to stealing a resident’s painkillers because she was traumatized by watching 14 residents die alone.2
“We hear that from a lot of nurses — they are burned out, they are using [drugs] to go to sleep, to keep up with the rigorous work schedule,” New says. “I think the primary reason people divert is to self-medicate for stress or some of kind of trauma they are going through.”
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.
Part of the Opioid Epidemic?
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.3
Evidence shows hospital diverters hoard drugs at home, ostensibly for their own use, but nevertheless bringing narcotics into the community where they could be sold or shared.
Indications were found after two nurses who worked at the same Dallas hospital died of fentanyl overdoses within 16 months of each other in 2016 and 2017. Both were found lying in bathroom stalls, a syringe beside one and a needle still in the arm of the other. Considering these unrelated cases, a Dallas newspaper requested records from the state pharmaceutical board. Among the findings were records of a nurse who stole more than a half-gallon of fentanyl, and a technician at another Texas facility who stole 16 gallons of codeine cough syrup.4
Last year, a nurse admitted to stealing hundreds of bags of fentanyl from a hospital ICU in Keene, NH, after it was discovered a staggering 7.5 gallons of the narcotic was missing. Investigators reported “staff explained that the spike in critically ill COVID-19 patients during the winter surge resulted in controlled-substance procedures not being enforced.”5
The nurse died about month after her admission, but the cause of death had not been revealed as of this report. Adding to the intrigue, the nurse told different versions of her story in two emails, one of which ascribed the theft for personal use and another message noting she gave 12 bags of the fentanyl to a friend. State and federal investigations are ongoing.
Taking stolen drugs home is common, so diverters have access if they must be away from work.
“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 to good — you’re going to need it.”
Analytics Reveal Diversion Patterns
The nurse in Jacksonville drew suspicion for frequent use of controlled medication dispensers, using her status as an emergency nurse to override the machine safeguards.
“That’s when the drug cabinet analytics that we use really make a difference because we can see patterns,” New says.
For example, New recalls an investigation into cabinet analytics revealed a nurse was consistently dosing patients earlier than the medication was indicated.
“If something was ordered every six hours, she would give it every three hours so she could divert several times during a shift without signs of impairment,” New explains. “But looking at her transaction data, she was over twice the number of doses compared to her peers. We saw this pattern of dosing way too early. That was enough to bring up reasonable suspicion without any overt signs of impairment.”
In such 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 milligram 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.”
Nightmare Surgery
As this report was filed, an unusual case of possible drug diversion was playing out in a San Diego courtroom. After undergoing neck surgery in 2017, a patient said he awoke during the four-hour procedure in a dream-like state and has been experiencing nightmares ever since. Lawyers for the hospital say the medical records show he was unconscious. However, a surgical employee later revealed the anesthesiologist’s medical license was suspended for diversion-related activities.
The lawsuit contends the hospital covered up the incident. Depositions and other evidence revealed the anesthesiologist previously was confronted by the hospital about drug diversion, and he underwent a four-month rehabilitation before returning to work under supervision. This lasted more than five years before he allegedly relapsed.
Under deposition, the anesthesiologist admitted using drugs and treating patients. In an unusual tactic, his lawyers said the anesthesiologist was a “high-functioning addict” who could take drugs and keep working. In the kind of “microdosing” that New describes in other cases, the anesthesiologist allegedly injected himself with small amounts of diverted drugs throughout the workday. This brings up the elusive issue of “impairment,” which can be hard to determine when clinicians are under the influence of certain drugs, possibly in smaller amounts.
“The problem is that many times, people who are diverting don’t show overt signs of impairment,” New says. “They become acclimated to using the medications, and they may perform quite well.”
Second Chances
While conceding he has seen anesthesiologists “go rogue” in hospitals where he worked, occupational health expert William Buchta, MD, MS, MPH, FACOEM, said those caught diverting should be given a second chance on a case-by-case basis to undergo treatment for addiction and return to work under scrutiny. Buchta spoke at a recent webinar held by the Association of Occupational Health Professionals in Healthcare (AOHP).
“I was working this job where people were surfing needle boxes,” Buchta recalled. “It’s pretty hard to stop that if someone is willing to stick their hand in a sharps box and pull needles up. Almost every year, one of our anesthesiologists would overdose on medication. [The unnamed hospital] wanted a one-strike policy — the first time you are caught using the drugs inappropriately, you can’t do this job anymore. Pretty harsh. I’ve seen a lot of physicians and nurses rehabilitated and be better workers than their peers.”
However, New warns it is a long road back. Some former diverters find they can resist everything but temptation. “We have seen it time and again,” she says. “Sometimes, people do really well for a period of time, and then something triggers them.”
For example, a nurse who worked in a hospital recovery room was caught diverting drugs and was fired. She entered a rehabilitation program and eventually restored her nursing license.
“She returned to work, and everything was going fine,” New says. “Then, she started working in the OR and noticed anesthesiologists were throwing intact syringes into the [sharps] container. She kept seeing that, and eventually succumbed, and started taking waste out of the container. These [recovering] people are at very high risk, and some make the decision not to work in an environment where controlled substances are used.”
Although generally against random drug testing in healthcare, Buchta said a rehabilitated drug divertor returning to work would be an exception.
“If someone has been caught diverting [and returns to work], you really want a very strong post-rehab testing program,” Buchta said. “Some of them won’t be returning to work because what they did was a crime. Drug diversion is one of the biggest issues in healthcare. It may be overkill, but we need to show them it won’t be tolerated.”
New agrees a well-designed random drug screening program could be a good deterrent for rehabilitated staff returning to work. “Hospitals may put restrictions on them, they may not be able to pull certain medications, or no working on the weekends and nights, nor floating to other units,” she says. “They should have truly random testing where they are given very little notice to go to employee health and be tested under very tight conditions.”
Evading Detection
That said, implementing random drug testing programs hospitalwide can be problematic and ineffective. “I’ve worked with many hospitals who have attempted it unsuccessfully, and a few that have done it successfully,” New notes. “In order for it to really be effective, it has to be a very strictly defined program.”
For example, in some lax programs, workers may be given a 24-hour notice about a “random” test or told when they come in for work it will be given at the end of the work shift.
“Dilution is an option,” New says. “If your test is at the end of the day, you can drink water all day and the specimen may come back as inconclusive. Frequently, they will say ‘Come back tomorrow,’ and that buys you more time. There are ways to evade a drug screen.”
Another common tactic by diverters is to carry a container of urine from a patient or some other source. “A lot of the facilities I have worked with don’t physically witness the collection of urine,” New says. “There was a case just last year where somebody was diverting, and they just kept patient urine in their backpack. If they get into a situation, they slip that out of their backpack, go into to the bathroom, and then come out and present that clean specimen.”
Noting routine random drug testing programs can be counterproductive, Buchta said new devices to detect impairment are under development. Primarily, these detect impairment due to alcohol, marijuana, poor sleep, and fatigue. However, there is an ongoing line of research on devices to detect opiate-induced effects in the pupils of the eyes. Similar devices might be tested and proven reliable enough to detect opioid impairment.
“Of course, there is not a lot of efficacy data, but I think that is going in the right direction,” Buchta said. “Focus on impairment first, testing later. Finding a real impairment tool is kind of the Holy Grail of [occupational] medicine. Diversion is mostly an engineering problem; the system needs to be ironclad.”
A thorough literature review shows little benefit to random drug testing programs in general, Buchta said. There is a paucity of evidence and research, but what is available shows little reduction in patient harms or worker accidents with random drug testing.7
The Cannabis Conundrum
Hospitals also may be reticent to implement random drug screening because state laws ranging from complete legality, decriminalization, or medicinal use of marijuana are all over the map.
“A lot of facilities fear they would pick up a lot of positives on marijuana, and that could further deplete their staff,” New says. “In many of my investigations, THC does come up positive on drug screens. If the facility has a policy against illegal substances — and federally, it is still not a valid substance to have in your urine — workers could be terminated.”
It is a murky area that is in total flux. “Again, I think we need to get away from testing and focus more on impairment,” Buchta emphasized. “Just because they have marijuana in their system doesn’t necessarily mean that they are impaired. Testing for marijuana is a very slippery slope.”
Indeed, if employee health professionals work in a hospital with an entrenched random drug screening program, ask to look at data showing its effectiveness, Buchta advised. “Show me the money,” he said. “Where is the evidence that this is effective? Ask them what data they have that show that since we started this program, we have a reduction in injuries and errors. I’m trying to cast doubt on some of the costly, worthless, or even harmful practices that are used under the auspice of safety.”
Buchta recommended old-fashioned supervisor and employee engagement that could form bonds and reveal problems. “Nursing managers should get to know their staff, know about their families — just getting to know them is what good supervision is all about,” he said. “If there is some suspicion, have a chat with them. But having them show up for a drug test every couple of months doesn’t foster a lot of trust.”
REFERENCES
- Avanier E. UF Health nurse arrested for 2nd time following accusations of stealing medication. New4JAX. Sept. 16, 2022.
- Kauffman C. Nurse admits stealing patient’s drugs, citing stress from COVID-19 deaths. Iowa Capital Dispatch. June 9, 2022.
- Centers for Disease Control and Prevention. U.S. overdose deaths in 2021 increased half as much as in 2020 — but are still up 15%. May 11, 2022.
- Ambrose S, Hacker HK. Two nurses died of overdoses inside a Dallas hospital. What went wrong? Dallas Morning News. Dec. 2, 2018.
- Spencer R. Stolen, lost fentanyl prompts license suspensions at Cheshire Medical. Keene Sentinel. Jun 4, 2022.
- Moran G. Truth or a simple dream? Lawsuit by man claiming he awoke during surgery at UCSD goes to trial. San Diego Union-Tribune. Jan. 17, 2023.
- Els C, Jackson TD, Milen MT, et al. Random drug and alcohol testing for preventing injury in workers. Cochrane Database Syst Rev 2020;12:CD012921.
Drug diversion can happen quickly as healthcare workers move from one facility to another, enabled by lax reporting systems and hospital disincentives to alert patients and raise liability issues. Diverters may slip through cracks in oversight by medical and nursing boards as they move to other facilities and are lost to follow-up.
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