Diversion of Controlled Substance:Crossing the Line

Kimberly MillerDecember 5, 2008

Diversion: Issues to Consider

• Addiction is a deadly disease• Impairment while on the job puts everyone at

risk• Patient’s pain may be undertreated• Patient Care Record may contain false

information• $$

What do we know about diversion?

• Hard to identify• Risky behavior• It persists even with better safeguards in place• It may be overlooked by co-workers• When is the nurse impaired?

Search Strategies

• Keywords– Diversion, theft, controlled substances, narcotics,

drugs, addiction, substance dependence, nurse, healthcare provider

• Databases– MEDLINE, CINAHL, PsychINFO, Google Scholar

• Scope– Inclusion: English language, nurses, research, drug use,

diversion, deviant behavior– Exclusion: editorials, legal briefs, opinion papers

Comparison of Drugs Used by Nursing SpecialtyTrinkoff, A., et al. (1998)

Specialty Marijuana /Cocaine%

Prescription –Type%

Binge Drinking%

Adult critical care 6.2* 7.2 22.2*

Pediatric critical care

6.8* 5.9 20.8*

Emergency 7.3* 7.8 24.5*

OR/PACU 4.6* 7.3 16.5*

Medical/Surgical 3.0 7.9* 14.9*

Home/Public Health 3.0 6.0 15.7*

Oncology 3.6 8.8 25.5*

Psychiatry 4.4* 8.3 14.4

Other/Non-clinical 4.4* 4.8 13.9

Impact of Job Issues on Substance Use in NursesTrinkoff, et al. (2000)

• Factors associated with depression symptoms– Job demands

• Reciprocal relationship – depression and use• Indirect pathway to increased use – job

demands• Factors with direct effect on past year use– Increased workplace access to substances– Less religiosity – More substance users in social network

Effect on Behavior of Nurses Related to Work Group NormsDabney, D. (1995)

Behavior Finding

Theft of general supplies OK

Theft of OTC medications OK

Theft of Non-Narcotic medications OK

Theft of Narcotic medications Not OK

Finding Drug Diversion in Operating RoomsEpstein, et al. (2007)

• High use of opiates for a case• High wastage of controlled substances• Drugs signed out for cancelled cases• Sign out of drugs late in the day• Location of access to the drug doesn’t match

with the location of the patient

Comparison of Nurses in an Alternative to Discipline Program (New Mexico)

Dabro, N. (2005)• Nurses who completed the program

– Dual diagnosed with MH or Pain– Typically work in ICU/OR/ER/Oncology– Seven of the eight diverted– Strong desire to keep nursing license– Positive response to coercion to obtain treatment– Values participation in support groups– Strong affiliation with other nurses with addiction

• Nurses who did not complete the program– Dual diagnosed with MH or Pain– Typically work in ICU/OR/ER/Oncology– Five of the eight diverted– Planning to change careers– Values participation in support groups– Saw no value in monitoring

Alternative to Discipline Program (Idaho)Referral Reasons

Clark, et al. (2006)

Reasons for Referral Number Percentage

Diverting drugs 99 48

Inappropriate behavior 17 8

Passing fraudulent Rx 35 17

Positive drug screen 23 11

“Doctor shopping” 18 9

“Pharmacy shopping” 18 9

Intoxication on the job 15 7

Reported for unsafe practice

11 5

Drug-related legal issues 9 4

Ethical Considerations

• Harm to Patients• Violation of ethics codes• Multiple levels of deception• Negative effect on other healthcare providers• Moral distress versus illness related behavior

Gaps in Research/Literature

• Most studies on factors date to the 1980s• Very little information specific to nurses• Very limited information specific to diversion• No information related to the impact of

diversion on patients• Just beginning to see review of effectiveness

of alternative monitoring programs

Suggestions?