Introduction

Research estimates that 10-15% of medical providers will abuse or misuse drugs or alcohol at some point in their career.¹ Some of these providers may obtain substances of abuse through drug diversion, which is defined as “when prescription medicines are obtained or used illegally” according to the CDC.² Such action places patients and health care providers at significant risk.³  Although the risk is clear, the methods by which health systems lower the risk and detect drug diversion are not so simple. For this reason, drug diversion in healthcare continues to be an area of focus for The Joint Commission, American Society of Health-System Pharmacists (ASHP), Anesthesia Patient Safety Foundation (APSF), American Association of Nurse Anesthesiology, and the Institute of Safe Medication Practices (ISMP).^3,4,5,6,7 Given that establishing a robust drug diversion surveillance program is a tall task for hospitals, a great place to start is surgical areas since they are considered at higher risk for diversion.³

Unique risks in the perioperative and procedural areas

There are several reasons why the perioperative space is a high-risk area for drug diversion, including:

Unique behaviors associated with drug diversion 

The uniqueness of the perioperative space coupled with creative techniques that healthcare workers employ when diverting controlled substances make it much harder for organizations to detect diversion. Therefore, it is important for leaders to be aware of behaviors associated with diversion. An article from Nursing Critical Care¹² and the “See Something, Say Something” campaign¹³ both provide several examples of ways that medications may diverted and behaviors that may be exhibited:

Recommended Practices for Drug Diversion Prevention and Detection

The ASHP Guidelines on Preventing Diversion of Controlled Substances provides a framework that organizations can use to develop controlled substance monitoring programs. These guidelines highlight the importance of implementing drug diversion detection and prevention through all aspects of medication use, with special attention to high-risk surgical settings.³

1. Use of automation and technology: The use of ADCs is recommended in all high-risk locations and access to controlled substances within the ADCs should be limited to specific providers.³  ADCs restrict access to medications, allow for auditing of medication dispenses and highlight when medications may be missing (e.g., discrepancies). Additionally, drug diversion monitoring software may utilize data from ADCs which can assist with monitoring chain of custody and inventory management for controlled substances. ISMP guidance for safe medication handling in the perioperative area also supports restricted and controlled access of preoperative medications and their storage in secured cabinets such as locked ADC pockets.⁷
   
   
2. Monitoring and surveillance: A Controlled Substance Diversion Prevention Program (CSDPP) should be implemented and include assigned committee members to determine the diversion data points necessary for review and audit. It is expected that the program be an ongoing, cyclical process to include review of controlled substance (CS) compliance, surveillance of trends identified during the review, investigation and reporting of the trends, a resolution of the investigation, and the implementation of continued systems improvements identified throughout the process. ³ It is recommended that surveillance activities are cross-collaborative efforts and performed at a regular cadence.  
   
   
3. Returns and waste: Given that drug diversion by means of the wasting process is a known issue, waste should be verified by another provider and documented. Facilities should also perform random waste testing in high-risk areas like the OR. ³ A facility may choose to purchase equipment to perform testing on-site or send samples to an outside lab for testing to avoid the upfront capital expense. Lastly, some facilities may initially perform “for cause” testing but then progress towards a more mature model of sampling various medications, providers, and including more patient care areas at a regular cadence.¹¹ Regardless of which method is chosen, it is crucial to follow chain of custody for waste samples to maintain integrity for investigations. 
   
   
4. Leadership support and multi-disciplinary collaboration: Establish resource allocation and accountability for all team members while also creating a speak-up culture (e.g., see something say something campaign). To best support compliance in the perioperative space, it is key to include an anesthesia leader as a program champion for program oversight.³
   
   
5. Ongoing education: To highlight the importance of drug diversion, education should be provided at a regular cadence to all team members. APSF has provided guidance for specific topics of focus and means of disseminating education.⁵

Conclusion

Drug diversion is multifaceted and difficult to address. Focusing on areas of high risk is a key step in the process; one such area is the perioperative space given the unique workflows and challenges. ASHP guidelines state that “ultimately, each organization is responsible for developing a CSDPP that complies with applicable federal and state laws and regulations and applies technology and diligent surveillance to proactively prevent or detect diversion”.³ In addition, health system leadership should educate staff regularly on diversion behaviors and encourage a speak-up culture that empowers staff to tackle this important issue together. Having a multidisciplinary team approach to ensure monitoring and surveillance at a regular cadence are important first steps. Developing a CSDPP is a journey that requires collaboration and a system of checks and balances.