Drug Diversion in Health Care Settings Can Put Patients At Risk for Viral Hepatitis

Kimberly New

I do healthcare facility drug diversion education, program development, and investigations for a living. Drug diversion involves the diversion of drugs from legal and medically necessary uses towards uses that are illegal and typically not medically authorized or necessary. Many people find it difficult to believe that drug diversion can occur in a health care setting nor do they fully appreciate how often this activity occurs or how much it can harm patients.

Healthcare workers who divert drugs for their own use can harm patients in several ways:

1. Delivering care in an impaired state,
2. Failing to administer adequate pain relief to patients in need, and
3. Exposing patients to bloodborne pathogens, including hepatitis C or unsafe substances as a result of tampering and substitution.

Tampering involves removing medication from a syringe or vial and replacing it with saline, water, or other substances. Tampering is the most serious type of drug diversion because it is most likely to result in patient harm.

Healthcare workers who divert drugs intended for patients for their own use are struggling with an addiction that has escalated out of control. Tampering is a sign of true desperation. In order to obtain the drugs they need without being detected, the tampering and substitution must occur quickly. As a result, sterile technique is seldom used, the needle used to inject drugs is rarely replaced, and if the healthcare worker happens to be infected with a bloodborne pathogen (for example, undiagnosed hepatitis C) that means that the exposed patients are at very high risk of developing infection.

The patient who receives the adulterated medication is, in essence, “sharing needles” with the person who diverted the drug. . There have been several publicized cases in which patients have been exposed to and contracted hepatitis C due to drug diversion in health care settings.

According to the Centers for Disease Control and Prevention (CDC), 9 percent (or 120 out of 1,229) of hepatitis C cases reported in 2011 (the most recent year for which surveillance data are available), involved any type of healthcare-related exposure such as dialysis, surgery, or accidental needlestick. Further, CDC reports that a total of 18 healthcare-associated hepatitis C outbreaks occurred in the U.S. between 2008 and 2013 with causes including misuse of medical devices, lapses in infection control procedures, and exposure due to drug diversion (A case refers to a person diagnosed with a disease or condition, and an outbreak refers to a larger than usual group of people who acquire a disease or condition at the same location and within the same period of time). Since 2008, there have been three reported hepatitis C outbreaks in the U.S. due to drug diversion – in 2009, 2010, and 2012.

A 2012 outbreak resulted in a Public Report by the New Hampshire Department of Health and Human Services (NH, DHHS), which described their investigation and subsequent recommendations. The NH DHHS noted that, “Since drug diversion is a real and constant threat in healthcare settings, the approach to prevention and early detection should be one of active planning, implementation, and oversight rather than being reactive to an event.”

In its report on drug diversion the Maryland Department of Health and Mental Hygiene asserted, “Hospitals and healthcare facilities must change their view of drug diversion and elevate it to the level of both a patient safety violation and an infection prevention event…Healthcare culture must change for hospital staff to accept and understand that the patient is the primary victim of diversion.”

Several organizations and groups of public health advocates are addressing the important topic of drug diversion in health care facilities. HONOReformExit Disclaimer (Hepatitis Outbreaks National Organization for Reform) has established a Drug Diversion Prevention Committee that includes patient advocates, health professional organizations, and health department representatives working to strengthen programs designed to prevent hepatitis outbreaks associated with drug diversion in health care settings The National Association of Drug Diversion InvestigatorsExit Disclaimer promotes awareness among healthcare personnel in several annual Healthcare Facility Diversion Training Conferences across the country.

Recently, I attended the launch of the updated Action Plan for the Prevention, Care and Treatment of Viral Hepatitis and participated in a subsequent consultation about how nonfederal stakeholders can be further engaged in implementing the plan. I am pleased to note that in the section “Opportunities for Nonfederal Stakeholders” in Priority Area 6 (“Protecting Patients and Workers from Health Care-Associated Viral Hepatitis”) the updated Action Plan calls for the implementation of measures to prevent opioid diversion. And in the subsequent consultation held following the launch, stakeholders agreed upon the importance of identifying best practices for investigation and management when diversion is suspected. Also, I’ve shared with federal colleagues working to implement the Viral Hepatitis Action Plan information about ongoing efforts among health care workers, advocacy and treatment professionals, regulatory agents, law enforcement personnel, health care fraud investigators, and the pharmaceutical industry to advance awareness of and response to the issue of drug diversion in health care settings.

We may not be able to completely eliminate the problem of drug diversion in health care settings, but through education and the implementation of quality standards, we can limit its impact, including the risk of contracting viral hepatitis.Editor's Note: A recent USA Today articleExit Disclaimer discusses this issue.