Maintaining Vigilance for Diversion during the COVID-19 Pandemic

BD Institute for Medication Management Excellence

Maintaining Vigilance for Diversion during the COVID-19 Pandemic

PUBLISHED: Sep 18, 2020

Dennis A. Tribble, Pharm.D, FASHP, Director, MMS Medical Affairs
Doina Dumitru, Pharm.D. FASHP, Senior Director, MMS Medical Affairs
Kelly Robke, RN, BSN, MBA, MS, Vice President, Clinical Thought Leadership, MMS Medical Affairs
Christopher Urbanski, B.S.Pharm., R.Ph. M.S., FASHP, Director, MMS Medical Affairs

Introduction

In the midst of the COVID crisis, it is easy to let the urgent take our eyes off matters that will eventually demand our attention. One of those matters is the ongoing risk of drug diversion. If anything, the current COVID pandemic may increase opportunities for diversion within health systems.

Operational Issues

Many of us are undertaking challenges that will strain the safeguards we ordinarily have in place.¹

Especially in our hardest-hit environments, we may be dealing with a lot of temporary or repurposed caregivers. While this help is well-intentioned and welcome, it does offer opportunities to the individuals impacted with substance abuse disorder.
Our need to conserve personal protective equipment (PPE) may have us making a number of changes to preserve it, including moving away from the use of BIO ID in favor of logins with passwords, which can make diversion easier. Additionally, PPE conservation may complicate required witnessing of controlled substance waste.
Our desire to minimize the number of pharmacy delivery trips to areas where contact with the COVID virus is more likely has led many of us to overstock automated dispensing cabinets. While appropriate, this will reduce our presence in those areas, leading to longer times between refill visits, and concurrent abandonment of certain functions (e.g. inventory counting).

Our front-line staffs are stretched to the limit; there will be the temptation to skip steps and it will be easier for suspicious activities to go undetected.

Many facilities operating have decided to operate their ADCs without order verification, especially in temporary facilities like hotels and field hospitals. There will be no orders to limit what someone pulls for any patient.

Additional Stress

In addition to the challenges presented by relaxed access to opioid medications necessitated by the COVID crisis, the added stress of managing the crisis may contribute to increased vulnerability among clinicians to diversion. Clinicians may be under greater stress due to:

Higher caseloads, especially if their peers become ill and must take time off from work
The emotional toll of losing patients to the disease
Working outside their normal areas and responsibilities
Worry about availability and efficacy of PPE
Worry about child care or the wellbeing of other family members

Increased vulnerability combined with increased access to controlled substances can result in increased diversion and the multitude of risks that come with it.

Relaxation of State and Federal Mandates

The Drug Enforcement Agency (DEA) has relaxed several policies²
List of states with licensure actions³

The tyranny of the urgent will undoubtedly pull us in many directions, highlighting the importance of having to keep track of our controlled substances through whatever means we can. Failing to do so could haunt us when this crisis resolves.

Much of what follows comes from our combined experience as healthcare providers and administrators, as well as from the myriad publications and list serves that address the needs of pharmacists responding to the COVID crisis. It is ultimately your responsibility to decide which of these recommendations, if any, you choose to follow.

The following steps are therefore suggested to increase oversight and security of controlled substances, based on our experience and information gleaned from pharmacies on the front lines of the epidemic:⁴

In general, maintain frequent and clear communications within the organization, especially regarding procedural changes.
Create a mini-orientation for new or relocated staff on how the dispensing systems are expected to be used. Such an orientation should be short (5-10 minutes) but sufficient to ensure that new staff know all the rules of the road. There may also be benefit for just-in-time reinforcement of this training when pharmacy personnel are present on the unit.
Carefully determine role-based permissions for new, temporary or student resources.
Resist the temptation to ease off in blind counts and other control procedures in the workflow of acquiring controlled substances.
Set up and maintain a schedule of controlled substances inventories at remote locations. This helps ensure that those inventories remain under appropriate control and visibly reinforces that those inventories are under observation. Such checks should be performed 2-3 times per week.
Plan to audit transactions from ADC’s in remote areas. Follow up on any perceived issues immediately.
Follow up immediately on discrepancies.
Use of certain opioids (notably fentanyl and its derivatives) has escalated with the use of ventilators to treat COVID patients. It is probably worth the effort to establish a baseline of usage and look for increases.
Plan for your State Board of Pharmacy wanting to conduct an audit of the remote system when the pandemic has resolved. If you are capturing the information for that audit prospectively, you will be prepared for it.
You may want to consider adopting one of the Diversion Analytics packages available on the market to help you more rapidly identify abnormalities in practice.

Coe E and Enomoto K Returning to resilience: The impact of COVID-19 on mental health and substance abuse McKinsey & Company Healthcare Systems and Services 4/3/2020 (viewed at https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/returning-to-resilience-the-impact-of-covid-19-on-behavioral-health on 4/16/2020)
https://www.deadiversion.usdoj.gov/faq/coronavirus_faq.htm (viewed 11/16/2023)
https://www.ncsl.org/research/labor-and-employment/covid-19-occupational-licensing-in-public-emergencies.aspx
COVID-19 Pharmacy Response in Southeastern Michigan: Lessons Learned in Managing the Supply Chain and Pharmacy Operations, Webinar delivered through ASHP Webinars. https://www.ashp.org/Professional-Development/Live-Webinars/Free-Live-Webinars/COVID19-SE-Michigan?loginreturnUrl=SSOCheckOnly Slides/recording not available.

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