Drug Diversion in Healthcare Settings

Joseph Perz, DrPH, MA


June 02, 2014

Editorial Collaboration

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Hi. I'm Dr. Joe Perz, a healthcare epidemiologist at the Centers for Disease Control and Prevention (CDC). I'm pleased to be speaking with you today as part of the CDC Expert Video Commentary series on Medscape. I will be addressing the issue of drug diversion.

Drug diversion can be defined as any act or deviation that removes a prescription drug from its intended path from the manufacturer to the patient. Prescription opioid addiction, which has reached epidemic proportions in some areas of the United States, is a major driver of drug diversion.

This commentary will focus on diversion involving healthcare personnel who steal controlled substances for their personal use. Under these circumstances, patient harm can take many forms, including substandard care delivered by an impaired provider, denial of appropriate therapy or pain control, and even infection risks stemming from tampering with injectable drugs. Healthcare professionals who divert drugs risk losing their licenses, credentials, and employment; they even risk losing their lives if they overdose. Consequences may also include litigation or imprisonment.

At CDC, I lead a group that monitors outbreaks of healthcare-associated infections. We recently published a manuscript in the journal Mayo Clinic Proceedings.[1] In that article, we describe 6 outbreak investigations over the past 10 years in which diversion -- specifically tampering with controlled substances -- resulted in the transmission of infections. Two outbreaks involved tampering with opioids administered by patient-controlled analgesia pumps, which introduced contaminants and resulted in gram-negative bacteremia in 34 patients. The remaining outbreaks involved personnel who tampered with syringes or vials containing fentanyl. This involved, for example, self-injecting fentanyl from a syringe, replacing the contents with a clear solution such as saline, and returning the syringe to the procedure area or anesthesia cart. In these 4 outbreaks, hepatitis C virus (HCV) infection was transmitted to at least 84 patients. In each of these 4 outbreaks, the implicated professional was HCV-infected and served as the source. Nearly 30,000 patients were potentially exposed to bloodborne pathogens and targeted for notification advising testing.

Our review probably underestimates the burden of infections resulting from diversion. Making the connection between unexplained or difficult-to-detect infections on the one hand, and illicit, concealed drug diversion activities on the other hand, is extremely difficult. Our review also does not in any way adequately reflect the frequency of diversion by healthcare personnel in the United States. It has been reported that more than 100,000 US doctors, nurses, technicians, and other health professionals struggle with abuse or addiction.[2] Prescription drugs and controlled substances such as oxycodone and fentanyl are often involved. A manager of controlled substance surveillance at one hospital recently reported identifying at least 1 healthcare provider each month stealing medication from the facility.[3] What sets this institution apart from others? Perhaps nothing more than the fact that it has a program to actively monitor for diversion activity.

Patient safety and professional safety all demand effective, reliable safeguards to maintain the integrity of prescription drugs and controlled substances. Here are 3 things that you can do, whether your role is that of a manager or healthcare professional: Prevent, detect, and respond.

Prevent. Prevention always comes first. Healthcare facilities are required to have systems in place to guard against theft and diversion of controlled substances. It is important that all staff understand and comply with these protocols, acting in ways to minimize unauthorized access or opportunities for tampering and misuse.

Detect. Even with such prevention safeguards, healthcare facilities must have systems to facilitate early detection. These systems can include active monitoring of pharmacy and dispensing record data, as well as having staff who are aware of and alert for behaviors and other signs of potential diversion activity.

Respond. This leads to the third action: response. For staff, this can be summarized as "see something, say something." Appropriate response at the institutional level includes assessment of harm to patients, consultation with public health officials when tampering with injectable medication is suspected, and prompt reporting to enforcement agencies.

In closing, consider the ubiquitous nature of controlled substances in many healthcare environments -- settings where you provide care or help to manage. Access to these drugs must be tightly managed and monitored for the good of your fellow staff and your patients. Maintaining the security of controlled substances is a shared responsibility. Working together, we can raise awareness and strengthen protections in this area.

Web Resources

CDC: Injection Safety

CDC: Risks of Healthcare-Associated Infections From Drug Diversion

CDC: One and Only Campaign

CDC: Impacts Related to Unsafe Injection Practices

Minnesota Hospital Association Drug Diversion Prevention Toolkit

Premier Drug Diversion

Dr. Joseph Perz is the Ambulatory and Long Term Care Team Leader for the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention in Atlanta, Georgia. Dr. Perz entered the field of public health after training as an engineer and environmental scientist. After receiving a doctorate in public health from Columbia University, he served as an epidemic intelligence service officer with the Tennessee Department of Health. During his 15 years with the CDC, Dr. Perz has guided dozens of outbreak investigations and special studies, drawing attention to the need for injection safety and other basic infection control. He has authored or coauthored over 50 peer-reviewed journal articles, Morbidity and Mortality Weekly Report articles, and book chapters. His team's activities are currently focused on interagency collaboration, support to health departments, and partnership efforts to expand prevention activities to ambulatory and long-term care settings.


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