Drug Diversion In Long Term Care - PowerPoint Presentation

Slide1

Drug Diversion In Long Term Care

G

Gara

Wilsie, D.Ph.

Remedi

SeniorCare

ROOkkla

G

Oklahoma City, Ok 73108Slide2

Learning Objectives

What is Diversion of drugs and why does it happen?

What are the signs to watch for?

What policy and procedures should be in place to decrease the risk of diversion?Checklist for investigation of diversion?Anticipated changes to prevent diversion?

2Slide3

Control Medication Diversion

Diversion

of

drugs: Unlawful channeling of regulated pharmaceuticals, including the misuse of prescription medicationsSymptom of the disease of addiction Addiction is a treatable diseaseSlide4

Reasons for Diversion?

Personal use by staff

90% of Americans struggling with addictions are not currently getting treatment

In 2016, 11.5 million persons misused prescription opioids and 116 persons died every day from opioid related drug overdosesUse by related person to staff

Sale of medications:

Hydrocodone $3-$7/tablet

Alprazolam $1-$5/tabletSlide5

Healthcare Professionals and Drug Abuse:

Types

of drugs preferred:

60% use an opiate45% use a benzodiazepine11% use sedatives3.5% use amphetamines1.9% use inhalants

Early Intervention

is vital for both patient care concerns and health care employee professional

recovery

A

visible program

is a major deterrent to diversion

(Lillibridge, Cox & Cross, 2002)Slide6

Drug Diversion Issues: Staff

10

–20% of nurses have substance abuse issues

ANA estimates approximately 6% to 8% of nurses are practicing while impaired

Substance

abuse is the number one reason named by state boards of nursing for disciplinary

action

Recidivism

rates by nurses from diversion and rehabilitation programs are lower when compared with the general population

(Griffith, 1999); (Trinkoff& Storr, 1998

)

(Sullivan & Decker, 2001).Slide7

Staff Risk Factors:In the workplace:

Stress

Belief in medications-back pain, headaches

Caregiver BurnoutAccess to control Substances

At high risk: Staff who administer drugs daily and perceive poor to non-existent workplace controls have 2 X the risk of drug misuse.Slide8

Physical Signs of Use/Withdraw

Physical signs of use or

withdrawal:

Hand tremorsHeadacheDiaphoresisAbdominal/muscle crampsNausea/ DiarrheaIrritability or RestlessnessSigns may disappear with use

Non-descript: can

also be signs of psychological

problems.

Behaviors

impair clinical judgment and put

residents at risk

(Smith et al., 1998).Slide9

Drug Diversion: Staff Indicators

Staff Behavioral

Indicators

:Frequently volunteers to work extra shifts “could be your best employee”Work the heavier care halls with the “better drugs”

Offer to work weekends, evening, nights when management is not around

Frequent, unexplained disappearances during shift

Feels the need to order the medication and go after the medication.Slide10

Drug Diversion: Staff Indicators Continued

Control medication only needed when that staff person works.

Often shows up on days off to finish work or retrieve forgotten items

Frequently spills or wastes narcotics

Chaotic home/personal life

Refuses to comply with narcotic diversion investigational procedures

Implausible excuses for behavior or become defensiveSlide11

Drug Diversion

Resident Care

Indicators

:Inconsistent or incorrect charting: Narcotic sheet documentation does not match PRN sheet documentation for number of doses administered.

Displays

inconsistent work quality with times of high and low

efficiency

Offers

to medicate other nurses’ patients on a regular basisSlide12

Drug DiversionResident Care Indicators

Care for specific residents

with cognitive impairment

His/her residents reveal consistent pain scale patterns or complain that narcotics are not effective on that shift.Slide13

Preventing Drug Diversion: Best Practices

Policies, Procedures and Controls

Procurement

Storage/SecurityPrescribingPreparation/Administration of CDSHandling WasteDocumentation

Followup

if diversion is suspected.Slide14

Procurement:

Prescriber or physician agent calls pharmacy with order

Hard copy of control drug is written

Electronic copy of control drug is sent to the pharmacyStorage/Security:

Control medications should be stored separately from other medications and under double lock

Access to medication carts/medication cabinets should be limited to person passing medication and wellness director. Don’t hand over medication keys to anyone during shift.

Where are medication carts kept when not in use?

Preventing Drug Diversion: Best PracticesSlide15

Preventing Drug Diversion: Best Practices

Handling Waste:

Waste should have a documented witness

Documentation:Documentation should occur when administering not at the end of a shift.

Documentation should occur on the MAR and medication count sheet

Document pain scores at the time of administration of pain medication

See it-report it!

Report discrepancies immediately

Report suspected diversion

Report inappropriate access to control medication areaSlide16

Preventing Drug Diversion: Best Practices

Managers

:

Use proactive approach for early detection/intervention- Be observed doing documentation audits Med pass observations

Med cart audits randomly

Are carts kept where they are supposed to be kept when not in use?

Are they locked at all times when out of eyesight of the person passing medications?Slide17

Preventing Drug Diversion: Best Practices

Disposing of control substances:

Controlled substance receipt/reconciliation

Timely identification and removal of medicationIdentification of storage method for medication awaiting final disposition

Control and accountability of medications awaiting final disposition

Documentation of actual disposition of medication

Method of destruction consistent with community policy

Procedures for discrepancies, theft/lossSlide18

When Diversion Occurs…CREATE A CHECKLIST TO INCLUDE:

1. Date/Time/Brief description of the event

2. Who is notified-Administrator/DON? What is policy for

timely notification? At that time or Monday AM?Discrepancy report-what is missing? Medication supply/cart inspection. Suggest not only cart that count is off but all controlled

drug storage areas including discontinued medications.

Review documentation of administration vs. count sheetSlide19

CHECKLIST FOR INVESTIGATIONCREATE A CHECKLIST TO INCLUDE:

Review of pain monitor documentation

Review of ordered CDS for trends in frequency and

quantities. Multiple incidents of same person ordering/receiving?8. Are there missing count sheets?

9. Were the controls in refrigerator checked?

10. Are there VA medications not counted every shift?

11. Camera documentation? Blind spots?Slide20

CHECKLIST FOR INVESTIGATION

You should consider contacting the Pharmacy

-

Records of dispensing new and refill control substances for designated time frameCopies of refill requests-who is requesting refills?Delivery manifest of narcotics-who signed for the control medicationsSlide21

CHECKLIST FOR INVESTIGATION

WHO DO WE NOTIFY?

Administrator/Director of Nurses

PoliceOSDH-misappropriation of resident propertyOSDH-Neglect/AbuseNurse Aide Registry (CMAs)Board of Nursing (RN,LPN)

OSDH will notify the Attorney General’s officeSlide22

PROPOSED CHANGES TO PREVENT DIVERSION

Control

substance

medications are required to be ordered electronically January 1, 2020. Many of physicians serving our communities are currently using a software called Sure Scripts to do this.Possible limits to days supply of control medications by insurance companies.Possible early refill limits-90% used prior refill Slide23

PROPOSED CHANGES TO PREVENT DIVERSION

Oklahoma Health Care Authority is looking at incorporating

MME (Morphine Equivalents) for all opioids into the OK Medicaid Management System. Members aggregate MME/day will be included in claims. The CDC encourages caution in doses exceeding 50MME/day.

Some states have changed the requirements for drug disposition to occur within 5 days after drug is discontinued to help prevent diversion (Ohio). Suggest look at what your community policy for destruction is and determine if adequate.Slide24

Medical MarijuanaSlide25

Classification of Schedule I Drugs

Schedule I Controlled Substances

Federal Level:

No currently accepted medical use in the United States

Lack

of accepted safety for use under medical

supervision

High

potential for

abuse

Schedule

I

: heroin, LSD, marijuana, peyote, ecstasy

State Level: Varies by state, 30 states have approved to date

Physicians cannot ‘prescribe’ medical cannabis because prescriptions are regulated under the CSA

Physicians can ‘recommend’ or ‘certify’Slide26

Maryland Health Dept Action April 2018 Slide27

New York Department of Health Oct 2017Emergency Regulations allow Nursing

H

omes and Assisted Living Residences to be among the “designated caregiver facilities” under the state medical marijuana program.

Such facilities may see DOH approval to become a registered designated caregiver for a certified patient in the medical marijuana program.Finally, the regulation also clarified that designated caregivers, including employees of designated caregiver facilities, are protected against arrest, prosecution, penalty, or disciplinary action by professional licensing board or bureau.Slide28

Medical Cannabanoids Legal Under Federal Law

FDA Approved

Marinol (Dronabinol)- THC (N/V, Anorexia)

Cesamet (Nabilone)- THC analog (N/V)Awaiting NDA SubmissionEpidiolex (Cannabidiol)-

Cannabidiol/CBD (Seizures)

Sativex (Nabiximols)- THC+

CBD (Pain, spasms in MS)Slide29

CBD Oil?

OK Health Department Comments

DEA 21 CFR Part 1308 Federal Register/Volume 81, No 240/90194-12/14/16Slide30

REASONS TO ADDRESS DIVERSION NOW

Security of our facilities, staff

and residents!Our residents deserve to receive their prescribed medications and have their health conditions treated appropriately. Slide31

Thank You Slide32

References1.

Narcotic

Use and Diversion in Nursing

Mandy L. Hrobak, University of Arizona College of Nursinghttp://juns.nursing.arizona.edu/articles/Fall%202002/hrobak.htm.2. Nurse Drug Diversion and Nursing Leader's Responsibilities: Legal, Regulatory, Ethical, Humanistic, and Practical Considerations. Tanga, H. JONA's

Healthcare Law, Ethics, and

Regulation Jan 2011 Vol 13(1) pg 13 –16.

http://www.nursingcenter.com/lnc/static?pageid=1193263

.

3.

Impaired healthcare

professional

Marie R. Baldisseri, MD, FCCM

. Crit Care Med 2007 Vol. 35, No. 2 (Suppl.) http://www.csam-asam.org/sites/default/files/pdf/misc/16_article_Baldisseri_Impaired_healthcare_prof_2007.pdf.4.

A Multidisciplinary Approach to Proactive Drug Diversion Prevention. Jerry Siegel Pharm.D. FASHP The Ohio State University Medical

Center Columbus

,

Ohio, 2009.