Transcript Diversion_ppt

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?
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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)
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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
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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
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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
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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
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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?