By Russ Nix
Since 2003, when I started working as an undercover narcotics agent for the Piedmont Multi-Agency Narcotics Squad (Piedmont MANS) in Georgia, law enforcement has come a long way in recognizing the magnitude of the current opioid crisis, keeping opioids off the street, helping those with substance-use disorders and ensuring illicit drug distributors are prosecuted.
We’re seeing more education throughout the ranks, as well as increased use of lifesaving tools like Narcan/naloxone to reverse opioid overdoses. We’re also seeing the introduction of programs that provide mental health interventions for officers affected by the stress of policing during the opioid crisis.
But while there’s a high level of awareness among law enforcement about opioid addiction, we could be doing more as a profession to address the drug diversion happening within our healthcare systems, which impacts patients, their loved ones and entire communities.
What is drug diversion?
Drug diversion is generally defined as any activity that removes a prescription medication from its intended patient use. Drug diversion-related activity may include addictive drug-seeking behaviors, over-prescribing practices and the theft of drugs by healthcare workers.
For years, drug diversion has grown quietly in the shadow of the larger opioid crisis, as noted by a 2019 report from the Office of the Inspector General (OIG), which cites the rise in investigations of diversion and other data. It’s also occurring among every rank of healthcare worker, from nurses and physicians to health aides and medical assistants, in every healthcare setting (hospital, nursing home and private practice).
The consequences are potentially life-threatening. According to the Centers for Disease Control and Prevention (CDC), between 2005 and 2015, there were more than twice as many healthcare-acquired infection (HAI) outbreaks than between 1985 and 2005, all stemming from incidents of drug diversion where infected healthcare workers used syringes intended for patients. Unfortunately, it often takes a big outbreak after a clinician infected with a bloodborne illness such as Hepatitis C swipes and injects medication from multiple patients’ clean syringes for drug diversion to be discovered. By then it is too late.
The rise of these incidents may also explain why just 36% of healthcare organizations are “very confident” in the effectiveness of their drug diversion program, according to a recent Porter Research survey commissioned by Invistics.
With the COVID-19 crisis in full swing, healthcare leaders have shifted their focus to mitigating the coronavirus. From what we’ve seen and heard, the sense of urgency about mitigating drug diversion is far behind the desire to keep healthcare workers and patients safe and protected. Yet it is while everyone is focused on the coronavirus that we fear clinicians who want to divert drugs might see a window of opportunity.
We need to, therefore, work harder to help keep our neighborhoods safe while enforcing the law. We can do this by improving our understanding and response to healthcare diversion.
The Challenges Ahead
There is no widespread, mandated law enforcement training for addressing drug diversion in healthcare settings. Instead, many law enforcement agencies rely on the officer on duty to decide, on a case-by-case basis, how to address a drug diversion incident reported at a particular facility or location.
This can be problematic. For example, if an officer has a good relationship with the doctors and nurses at a particular facility where drug diversion is being reported, there may be the tendency to give the healthcare workers the benefit of the doubt. Internal biases are strong, and it’s natural to want to extend a “professional courtesy” in certain situations.
While it is certainly important to recognize the service healthcare workers provide, such professional courtesies can undermine an officer’s ability to objectively analyze and investigate a person or situation.
Simultaneously, the lack of training and education on drug diversion in healthcare settings can limit officers’ knowledge of the signs of opioid use in clinicians and other healthcare workers, which is more insidious and harder to detect than the use of other substances, such as marijuana, cocaine or amphetamines. In my experience, most drug diversion occurs for personal use, although it can occur for other reasons, such as the desire to resell medications.
Steps for Success
Given that these unique challenges exist, here are some strategies for moving forward:
1. Improve education around drug diversion
Most police officers have encountered and/or responded to multiple incidents involving drugs like heroin, but not necessarily incidents pertaining to drug diversion in healthcare settings (which may be different than settings typically associated with the use and distribution of drugs). With more specific training (e.g., online classes focused on healthcare diversion), law enforcement will improve its ability to identify and investigate diversion, including the behaviors associated with opioid addiction among healthcare professionals.
2. Refine communications
One of the biggest challenges in investigating drug diversion boils down to communication. Law enforcement officers need to make fact-based investigations and ask certain questions to move forward, find answers and adjudicate in a timely way – but if they don’t ask the right questions in the right way, they will likely be met with a significant push-back.
Law enforcement teams should educate themselves on the Health Insurance Portability and Accountability Act (HIPAA) and refine their fact-finding queries accordingly. For example: If you’re an officer trying to look for background on a patient who allegedly stole from a facility, instead of asking a facility for all protected healthcare information about a patient – which may take a long time to obtain – ask only for the specific information relevant to the investigation. Remember that any attempt to extract patient data – particularly a record – requires a subpoena. However, the tone you use, and the specificity of the question, can make a huge difference.
3. Commit to collaboration
Instead of acting like you have a silo in healthcare and a silo in law enforcement, think of healthcare as an extension of the community served. Come together with healthcare leaders in your jurisdiction to discuss ideas for simplifying the way you work together. One of the things we did when I worked as a drug diversion specialist at a large health system in Georgia is bring in an investigator from the police department to hash out:
- How can we expand what we’re doing?
- How can we do more to support one another?
- What ways can we streamline communications?
All of our concerns were shared so we gained a better understanding of our respective roles and how we could support one another.
4. Utilize technological support
We’re seeing an increased use of technology, such as machine learning software, to help healthcare systems and law enforcement professionals gather multiple pieces of information and identify patterns associated with drug diversion (e.g., missing medication, patient pain reports and suspicious activities).
These advanced analytics systems provide greater visibility into the supply chain and extrapolate meaningful information and daily alerts based on the risk level of an incident or behavior pattern. Any technology that helps to improve transparency into the supply chain and broaden our understanding of drug diversion is an asset to all stakeholders.
While our attention is on COVID-19, drug diversion in healthcare settings remains a threat to our communities and institutions. It’s time to improve our understanding of this issue, as well as our commitment to working with healthcare professionals, so we can do a better job of enforcing the law and boosting public safety.
About the author
Russ Nix is the founder and a consultant at Aegis RX. He has over 20 years of investigations experience with 15 years of experience in criminal narcotics investigations. Russ serves on the board of advisors for the Healthcare Diversion Network, a nonprofit association dedicated to preventing drug diversion.