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Diversion of Controlled Substance: Crossing the Line Kimberly Miller December 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 Specialty Trinkoff, 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 Nurses Trinkoff, 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 Norms Dabney, 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 Rooms Epstein, 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?