Healthcare Facility Diversion Profiles of Diverters High Profile Cases. Charlie Cichon NADDI Executive Director

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1 Healthcare Facility Diversion Profiles of Diverters High Profile Cases Charlie Cichon NADDI Executive Director

2 Executive Director National Association of Drug Diversion Investigators (NADDI) Program Manager National Precursor Log Exchange (NPLEx) 15 years Baltimore City Police Department 15 years Maryland Department of Health Manager Investigations Maryland Medical Board Eli Lilly and Company Brand Protection Manager The Americas

3 How Big Is the Problem? Diversion is more widespread than is commonly recognized Drug diversion by health care providers is universal among institutions in the United States By its nature, diversion is a clandestine activity, and methods in place in many institutions leave cases undiscovered or unreported Most cases don t involve patient harm, but the potential for catastrophic harm exists the longer the diverter goes undetected

4 TOP Rx DRUGS OF ABUSE HYDROCODONE (Vicodin, Lortab, Lorcet) $6- $8 OXYCODONE (Percocet, Percodan, Tylox) $6 - $8 ALPRAZOLAM (Xanax) $3 METHADONE ($10-$40 per dose) OXYMORPHONE (Opana/Opana ER) $40+ METHYLPHENIDATE (Ritalin Adderall - Concerta) $10 - $12 Fentanly (Duragesic/Actiq) $8 - $40

5 Many Forms of Diversion MD, pharmacy staff diversion Doctor shoppers in ER Stolen script pads and forged prescriptions Patient s family Unauthorized drug cabinet access Sharps containers Theft of scripts for controlled substances Hospital Pharmacy

6 Methods of Diversion Failure to waste Unwasted medication kept for self Substitution in administration and wasting Substitution of look-alike pills Saline substituted for injectable medication Frequent null transactions, discrepancies and returns Removal of larger doses than necessary Withdrawal from PCA and drip lines Removal under sign-on of colleague Stolen password Left alone when colleague is signed in Removal of unspent syringes from sharps boxes Pilfering patient medications brought from home

7 Common Characteristics of Drug Diverters High achiever, potentially an award winner Very active in work activities Well-liked by peers and medical staff Works the night shift Comes to work early and stays late Volunteers for overtime, works when not scheduled Works in critical care or other high acuity enviornment Works for an agency Has a current or recent Rx for the suspected diverted drug

8 Considerations When Tampering Occurs Patient Safety Should be the Foremost Diversion Consideration In every case of drug diversion at a healthcare facility, the possibility of patient harm exists. Patients may receive substandard care from an impaired provider. Tampering and substitution may result in patient harm should any of the altered drug reach the patient. Patients may be exposed to bloodborne pathogens as a result of tampered injectable drugs. Tampering can be done artfully and it is not always readily apparent.

9 Make Diversion Difficult The best way to address tampering is to hinder the ability of staff to divert. Witness for all inventory counts. Limit the number of Patient Controlled Analgesia (PCA) keys Returns should be witnessed. The most basic preventive measure ensuring all medications are kept secure at all times from the moment they are removed from a secure area until they are administered.

10 A Clear Need for Prevention Traditionally healthcare institutions regarded incidents of drug diversion as isolated incidents Several highly publicized incidents have brought the issue of drug diversion in healthcare facilities to the public attention These have involved situations in which the diverting individual introduced pathogens into patient care

11 Doctors, medical staff on drugs put patients at risk. USA Today, April 17, 2014.) A USA TODAY review shows more than 100,000 doctors, nurses, medical technicians and health care aides are abusing or dependent on prescription drugs in a given year, putting patients at risk. USA TODAY reviewed more than 200 state and federal prosecutions completed since 2008 for drug diversion by health care providers; just 15% involved practitioners stealing drugs for personal use. Most involved doctors, nurses and others who diverted on a large scale for profit, often using prescription scams.

12 Surgical Nurse Ashton Paul Daigle Boulder Community Hospital 108 counts of tampering with a consumer product 67 counts of creating a counterfeit controlled substance for allegedly stealing fentanyl Over 300 potential victims Sentenced to 54 months in federal prison followed by 3 years supervised release

13 Tampering Kristen Parker Rose Medical Center Took pain medication from people going into surgery Used syringes replaced with tap water or saline Dirty needles placed back on the surgical trays for usetainted by hepatitis Over 20 patients infected Plea bargain rejected Sentence 30 years Kristen D Parker

14 Radiology Technologist Steven Larry Beumel Employee at Mayo Clinic Jacksonville. Addicted to Fentanyl since patients tested -5- Hep C infections 1 death Plead guilty to one count of tampering with a consumer product resulting in death, four counts of tampering with a consumer product resulting in serious bodily injury and five counts of stealing a synthetic narcotic by deception Sentenced to 30 years in federal prison

15 Tampering Sentenced to 39 Years Exeter Hospital 8 states 3,798 tested from Exeter alone 44 cases of hepatitis C St Cloud Hospital - Siphoned fentanyl from IV bags Replaced fentanyl with saline 24 patients infected with bacteria David Kwiatkowski

16 Drug Thefts Turn Up Big in State Report on Abuse and neglect of Vulnerable Minnesotans. Dec. 28, Dec. 28, 2015: Drug theft by health care workers has become so common that it accounts for nearly one-fifth of all abuse cases affecting elderly Minnesotans, the state Department of health reported Monday.State investigators examined 192 allegations of drug theft during the 12 months ending in June 2014; they substantiated 27 cases perpetrated by 14 health care workers.

17 Mass. General to pay $2.3 million over drug thefts. The Boston Globe, September 28, Massachusetts General Hospital will pay a record $2.3 million settlement to the federal government to resolve allegations that its lax control over the facility s drug supply allowed employees to steal thousands of pain pills, authorities said on Monday. According to the settlement agreement, one nurse identified as J.S. stole 14,492 pills, and a second nurse, identified as J.Z. 1, pilfered 1,429 tablets. Additional instances of drug misconduct cited in court papers included a doctor, identified as E.P., repeatedly prescribing medications to patients without seeing them or maintaining medical records, and nurses identified as M.B., M.M., and R.C., who stole substances.

18 Feds arrest Swedish Medical surgical tech accused of stealing drugs. (The Denver Post, February 15, 2016.) Rocky Allen, the surgical technologist accused of stealing a powerful narcotic drug at Swedish Medical Center, prompting wide-scale testing of thousands of patients for HIV and hepatitis, was arrested Tuesday. The hospital has not released any results, but a Denver attorney claimed Tuesday night that two people had tested positive for hepatitis B.

19 Several Hospitals Sued after Former Employee Accused of Drug Diversion May 3, 2016 Swedish Medical Center, Englewood, CO sued in March by former patients, claiming Swedish was negligent in hiring and improperly supervising Mr. Allen because drug diversion can put patients at risk for bloodborne infections. Banner Thunderbird Medical Center, Glendale, AZ HonorHealth John C. Lincoln Medical Center, Phoenix, AZ Scripps Green Hospital, La Jolla, CA

20 How Theft Ring Stole Millions of Drugs from Emory March 10, 2016 The criminal drug scheme that ran from Emory University Hospital Midtown s pharmacy was the biggest that state investigators had ever seen at a hospital. Technicians ordered prometh by the pint for the recreational drug concoction purple drank Security video shows them rolling cardboard cases on carts down Peachtree Street The five-year operation put an estimated $20-$40 million of addictive drugs on the street

21 Conclusion As is obvious from this brief listing of recent cases, drug diversion via healthcare workers has occurred at some of our nation s most prestigious medical centers, as well as some small community hospitals. Many of the above-described cases have resulted in class action suits against the hospitals involved for exposing patients to potential health risks. In more than a handful of the above cases, published information suggests that hospital officials were aware of certain risks and behaviors by employees and did too little or nothing to address them. It was found in some cases, for example, that addicted healthcare workers whose impaired behavior was discovered and documented by supervisors and/or coworkers nonetheless were permitted by their employers to resign in lieu of being fired.

22 Conclusion Although fines and insurance settlements in the millions of dollars may seem like an effective remedy, one wonders if these costs will simply be passed along to patients and third-party payers of health benefits at the institutions in question. Section 1128 of 42 USC 1320a-7 ( Exclusion of certain individuals and entities from participation in Medicare and State Health Care programs ) The Secretary of DHHS is empowered under this statute to bar those in violation for up to 20 years from participating in any Federal or State health care program. In practical terms, this means that such a person would be unable to work in this field for the stated period. The full statute referred to can be found here:

23 QUESTIONS? Charlie Cichon Thank You!