Drug Diversion Q&A | John Burke, President, International Health Facility Diversion Association

Q. Do you think that the incidents of drug diversion within healthcare facilities have called off since the advent of the pandemic?

Definitely not. Most healthcare facilities diverted personnel from the jobs of monitoring and detecting drug diversion in their facility to address the urgent needs of the COVID problem.

This means that whatever was in place, a diversion specialist, and/or a diversion team, etc., has likely been either temporarily eliminated or at the very least diluted. So, with monitoring likely next to non-existent, it allows the diverting employee even more latitude to divert medication.

The mere added stress of the COVID pandemic can cause those with the tendency of diverting or prior addictions, the temptation of stealing medications.

Q. Do you think that the mandatory reporting of theft/loss of a controlled substance is being documented to DEA and state authorities?

No, I do not. First, as mentioned above I don’t think adequately trained personnel that are familiar with diversion inside healthcare facilities would recognize the signs of diversion and report the incident/s, since many of those people have been reassigned.

Q. What is a drug diversion specialist, and how does he/she operate within the healthcare facility?

A diversion specialist is someone whose job is to monitor daily, the administration of controlled substances by the institution’s healthcare employees. This is typically augmented by various software programs that can assist in pinpointing a drug diversion problem within the healthcare facility.

The diversion specialist is also responsible for identifying potential diversion trends, notifying the drug diversion team, if applicable, and conducting the investigation with the assistance of nursing and pharmacy, which includes conducting interviews of drug diverters and anyone who can provide insight into the incident. They are the primary person tasked with resolving discrepancies involving medication administrations.

Q. What is the best background for a person to be a diversion specialist?

Typically, most diversion specialists are a nurse, pharmacist, and in some cases a pharmacy technician. I have seen several pharmacy technicians in this role who do an outstanding job.

Q. What exactly is a diversion team and how do they function?

A diversion team is very important to the level of addressing the drug diversion problem within a healthcare facility.  The team is at the very least made up of pharmacy and nursing personnel. Others such as risk management, legal, or human resources can also be a part of the team, but if a diversion specialist exists, this person is obviously a team member also. The diversion specialist will oftentimes be the one to call the meeting. 

Diversion team participants need to be able to assemble within a very short time frame and are typically called together when there is an obvious diversion or unresolved medication error. This meeting is designed to notify the team in a timely manner and for the team to discuss the next steps in resolving the potential drug diversion. The diversion team should debrief after each incident of a bona fide diversion to examine the entire incident, critiquing both the good decisions and where improvement is warranted.

Q. What else should be done when a diverter is identified?

Healthcare facilities need to make sure that in each incident of a bona fide diversion within their facility, they make sure to test the diverter for blood-borne pathogens.  This is oftentimes overlooked, and yet may be very important. Protecting patients that have been in contact with a diverter who has a communicable disease as quickly as possible is crucial.

Q. Why is detecting and reporting drug diversion within a healthcare facility so important? When detected why not just fire the offender and move on?

There are many valid and important reasons.

As mentioned above, there is little chance of testing the diverter for blood-borne pathogens, thus the inability to protect your own patients.

A. Diverters will likely move on to the next facility, endangering the lives of their patients and the welfare of the next institution.

B. The diverter themselves, are very unlikely to overcome their addiction without assistance and mandatory discipline. You may very well be attributing to the overdose death of this employee or damage to a patient by doing nothing.

C. It can be illegal! Some states, like Ohio, require reporting to law enforcement and the regulatory board involved or you can be prosecuted criminally.

D. Failure to report to DEA Diversion can result in serious sanctions on your facility, both monetary and the dispensing of controlled substances, or both.

E. Large scale legal action can be taken against your facility for not reporting properly when a significant diversion problem occurs in another facility that could have been avoided if your institution had taken the proper action.

Q. Is drug diversion in the operating room a real problem?

Absolutely. The diversion of drugs inside healthcare facilities operating rooms has always been commonplace. First, the drugs are some of the most powerful and addicting drugs that exist anywhere, and those who work in the OR are specialists in administering them to patients. Those employees in the OR that have addiction issues are experts in the administering of these dangerous drugs to themselves, most of the time, however overdose deaths do occur. 

Pharmacy is key here, as they need to closely monitor the administration of controlled substances in the OR. Ideally, any wastage needs to be returned to the pharmacy where random or for-cause sampling can be done. Employees in the OR need to know this is an option that the pharmacy can invoke at will. 

In recent years, some of the most egregious OR diversions have taken place, not by those authorized to administer controlled substances, but those with a valid reason to be in the OR but not authorized to administer drugs of any kind. They were able to access their drugs of choice by diverting medication that was left unattended by a person that was authorized to possess and administer the drug.  In those instances, the diverter injected themselves and then refilled the syringe with saline or tap water. Therefore, the authorized healthcare professional was unaware of the tampering and the diversions continued. 

In these cases, it is essential that all authorized administers of these drugs keep strict control of their medications and not leave them anywhere that others can access. It is possible that some training by looking at the case of David Kwiatkowski might stir awareness as to how important securing their medications can be, and thus avoiding a tragedy at your institution. 

John Burke, President, International Health Facility Diversion Association

Mr. Burke has been in law enforcement for almost 50 years, with 32 years with the Cincinnati Police Department, where he formed and commanded the Pharmaceutical Diversion Unit. He has a background in all facets of drug diversion and previously wrote a monthly article in an industry publication on prescription drug abuse for over 15 years. He is the past president of the National Association of Drug Diversion Investigators (NADDI).

He is the owner and president of Pharmaceutical Diversion Education Inc., which provides education, expert witness, and consulting to healthcare facilities and law enforcement. He is also the co-founder of the International Health Facility Diversion Association (IHFDA) and serves as its president.