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How big is the drug diversion problem? Nobody knows!

BD Institute for Medication Management Excellence

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How big is the drug diversion problem? Nobody knows!


PUBLISHED: Dec 2, 2019

Dennis A. Tribble, PharmD, FASHP, Director, Clinical Innovation, Medical Affairs at BD


Introduction

Unlike the opioid crisis in the U.S. which has widespread reporting and for which the numbers seem fairly clear, finding information about the incidence of hospital drug diversion seems much more difficult to discern.

Hospital drug diversion has been going on a long time. I was involved in diversion investigations regularly during my early years of practice; my first case was in 1977 and I was involved in at least four others that I recall during the ensuing two years.

The Cincinnati Experience

Commander John Burke (retired) of the Cincinnati Police Department and now President and Founder of the International Healthcare Facility Diversion Association (IHFDA) has presented on multiple occasions about the problem of underreporting. During a conversation, Commander Burke reported to me that he had led a task force formed specifically to investigate diversion of controlled substances in hospitals. Formed in 1992, the task force operated for 10 years. Based on that experience, he described that significant numbers of healthcare facilities do not report diversion; that most frequently the offender is terminated or permitted to quit, primarily out of concern about media attention.1 In a recent presentation, he reviewed his own statistics for Cincinnati, apportioned them across the US population, and concluded that the number of arrests for diversion in the US per year is the number that should be occurring per day.

There is a publication by Inciardi et al2 that describes these numbers more precisely. In an 11-year period, from 1992 through 2002, there were 423 documented cases of drug diversion involving healthcare professionals—an average of 38.4 cases per year. The population of Cincinnati declined over that time, starting at 359,433 in 19923, and falling to 322,644 in 20024 (resulting in an average population of 341,038). The United States population started at 256.9 million in 19925 and rose to 287.6 million in 20026 (an average of 272.3 million).

Presuming that Cincinnati is representative of diversion generally in the United States, this incidence computes to 30,656 documented cases per year across the United States in that same period, or 84 documented cases per day.

In that same presentation, Burke indicated that the number of arrests in such cases total less than 100 per year. There do not appear to be any references to validate that number. However, even if the number of arrests are ten times Burke’s number (1,000 arrests per year), they are nowhere near the numbers suggested as a result of the work of the Cincinnati task force.

Recent Data from the IHFDA

In a presentation at the recent meeting of the IHFDA (September 22-25, 2019 – Orlando FL), it was disclosed that the rate of diversion in healthcare facilities appears to be increasing, based on comparisons of 2017 and 2018 data. Specifically, research from publicly reported diversion incidents indicates that 21 million doses were diverted in 2017 and 47 million in 2018.7 Further, that same presentation asserted that a diversion investigation took (on average) 22 months to resolve in 2018.

Anesthesia Studies – Keith Berge, MD, Anesthesiologist, Mayo Clinic

At the same conference, Dr. Keith Berge presented a study in which he participated which evaluated the incidence and seriousness of substance use disorder among anesthesiologists.

  • Anesthesiologists represent 4.2% of physicians and 11.4% of physicians in treatment for substance use disorder8
  • Of 45,581 resident trainees from 1975-20098
    • The overall incidence of substance use disorder (SUD) was 2.2 per 1000 resident-years8
    • 896 had confirmed SUD at some time in their careers8
    • 384 had confirmed SUD while in training8
      • 338 detected in residency8
        • 28 died in residency8
        • 23 left residency before completion8
        • 12 transferred to a different program8
        • 173 completed residency8
        • 135 ABA Board Certified8
      • Of the 310 with SUD who survived residency8
        • 91 relapsed at least once8
          • 19 of these while still in training8
        • Estimated relapse rate at 30 years was 43%8
        • Median time to relapse 2.6 years8
        • 12 died during first relapse8
        • 12 had two or more relapses, of whom 2 died8
  • Only 56% of episodes were reported by program directors8
  • At least 1 in 9 residents who manifest SUD will die of this condition8
  • If one treats death by SUD as an “occupational hazard” then the death rate is 15.7 deaths per 100,000 FTE, a higher risk of death than for firefighters and policemen

BD Survey Results

In early 2019, BD commissioned a survey of more than 650 hospital executives and healthcare providers which echoed these anecdotes:

Of those surveyed, 85% expressed concern about diversion, but only 20% believe it is a problem in their own facility.9

  • 63% of executives and 54% of caregivers thought that diversion has probably happened in their facility in the past year9
  • 57% of executives and 64% of caregivers believed it goes undetected9

While those surveyed acknowledged that diversion management is difficult and that the tools they use may be less than effective, over half of each of the populations (executives and caregivers) felt they were spending the right amount on diversion management.9

This dissonance suggests rather significant amounts of denial.

Looking Ahead

It appears to be axiomatic in management circles that things that are not measured cannot be managed. This quote, falsely attributed to Peter Drucker, nonetheless appears to serve as a foundation for modern management science. Since things that are not measured cannot be managed,10 it seems that we have a long way to go to know how big our healthcare diversion problem is, much less to be able to measure the effectiveness of any of our remedies.

One possible solution has been proposed by a coalition of vendors and stakeholders in the healthcare diversion space, HealthCareDiversion.org.* This organization has introduced a website on which individuals and agencies can report diversion cases that are promised to be appropriately anonymized. It will be interesting to see how this effort pans out.

*This is a new attempt to deal with diversion and it is too soon to know if will work.

Learn more

Each month on the BD Institute for Medication Management Excellence blog, thought leaders explore topics of critical importance to medication management, and provide additional ways to learn.

Deepen your understanding of the opioid crisis in healthcare by reading our two-part series in which pharmacy and nursing thought leaders first compare perspectives on diversion, then discuss a framework for getting ahead of the problem via early intervention.

 

References

  1. Burke, J. Role of Security and Law Enforcement In Diversion Investigations, presented to the International Healthcare Diversion Association First Annual Meeting, 2016.
  2. Inciardi et al. The Diversion of Prescription Drugs by Health Care Workers in Cincinnati, Ohio. Substance Use & Misuse 41:255-264 (2006).
  3. Population of Cincinnati in 1992 - Google Search. Google.com https://www.google.com/search?q=Population+of+Cincinnati+in+1992&rlz=1C1OKWM_enUS775US775&oq=Population+of+Cincinnati+in+1992&aqs=chrome..69i57.9951j1j7&sourceid=chrome&ie=UTF-8 Published 2019. Accessed October 2, 2019.
  4. Population of Cincinnati in 2002 - Google Search. Google.com. https://www.google.com/search?rlz=1C1OKWM_enUS775US775&ei=aOdeXY7iLYS0sQWsrLn4Dw&q=Population+of+Cincinnati+in+2002&oq=Population+of+Cincinnati+in+2002&gs_l=psy-ab.3...336291.338591..339240...1.2..0.452.1105.0j2j1j0j1......0....1..gws-wiz.......0i71.0cHh5jc0Hpg&ved=0ahUKEwiOtpj0lZfkAhUEWqwKHSxWDv8Q4dUDCAo&uact=5 Published 2019. Accessed October 2, 2019.
  5. Population of the United States in 1992 - Google Search. Google.com. https://www.google.com/search?rlz=1C1OKWM_enUS775US775&ei=veheXbPuGom2tQXr-YXYCQ&q=Population+of+United+States+in+1992&oq=Population+of+United+States+in+1992&gs_l=psy-ab.3...228522.234277..234826...0.2..1.536.4474.0j19j2j5-1......0....1..gws-wiz.......0i71j0i67j0j0i22i30.gjUwRx_YhWg&ved=0ahUKEwjzwNKWl5fkAhUJW60KHet8AZsQ4dUDCAo&uact=5 Published 2019. Accessed October 2, 2019.
  6. Population of United States in 2002 - Google Search. Google.com. https://www.google.com/search?rlz=1C1OKWM_enUS775US775&ei=qeleXe2_L4HWtQWA26-YDw&q=Population+of+United+States+in+2002&oq=Population+of+United+States+in+2002&gs_l=psy-ab.3...26765.28796..31825...1.2..0.203.755.0j3j1......0....1..gws-wiz.......0i71.rtGwy9QnDtM&ved=0ahUKEwituKuHmJfkAhUBa60KHYDtC_MQ4dUDCAo&uact=5 Published 2019. Accessed October 2, 2019.
  7. Protenus, Inc. 47.2 Million Doses Lost Due To Healthcare Employee Misuse And Theft In 2018. Protenus, Inc.; 2019.
  8. Berge K. Chemical Abuse in Anesthesia Personnel: An Occupational Hazard, presented to the International Healthcare Diversion Association First Annual Meeting, 2016.
  9. BD Institute For Medication Management Excellence. Health Care's Hidden Epidemic: A Call To Action On Hospital Drug Diversion. BD; 2019.
  10. Zak P. Measurement Myopia. Drucker Institute. https://www.drucker.institute/thedx/measurement-myopia/. Published 2019. Accessed October 22, 2019.
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