Prevention of drug diversion and substance use disorders among anesthesiologists: a narrative review

Fitzsimons, Michael G.; Sousa, Gabriel Soares de; Galstyan, Arpine; Quintão, Vinícius Caldeira; Simões, Cláudia Marquez

doi:10.1016/j.bjane.2023.07.008

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Brazilian Journal of Anesthesiology

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REVIEW ARTICLE • para Braz. J. Anesthesiol. 73 (6) • Nov-Dec 2023 • https://doi.org/10.1016/j.bjane.2023.07.008 copy

Prevention of drug diversion and substance use disorders among anesthesiologists: a narrative review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Diversion of substances from the care of the intended patient is a significant problem in healthcare. Patients are harmed by the undertreatment of pain and suffering, transmission of disease, as well as the risk associated with impaired vigilance. Healthcare providers may be harmed by the physical and mental impact of their addictions. Healthcare systems are placed in jeopardy by the legal impact associated with illegal routes of drug release including sanction and financial liability and loss of public trust. Healthcare institutions have implemented many measures to reduce diversion from the perioperative area. These efforts include education, medical record surveillance, automated medication dispensing systems, urine drug testing, substance waste management systems, and drug diversion prevention teams. This narrative review evaluates strengths, weaknesses, and effectiveness of these systems and provides recommendations for leaders and care providers.

KEYWORDS
Drug diversion; Substance abuse; Substance use disorders; Drug testing; Healthcare professionals; Anesthesiology

Diversion weak point	Potential fix
False documentation of complete use of a substance with	Return of all full and empty vials.
False documentation of full use with partial diversion of remaining substance	Video recording of operating room practices.
Return of substituted fluid (saline)	Qualitative analysis of returned substances
Return of diluted substance	Quantitative analysis of returned substance
False documentation of waste observation	Formal sanction of individuals falsely documenting observation. Requirement for all waste observation to occur in pharmacy. Video recording of waste.
Collaboration by witnessing and wasting individual	Video recording of waste.

Focus	Recommendations
Education	Program should institute mandatory substance use disorders and drug diversion prevention education sessions. Such sessions should address indicators of diversion, impairment, and impact as well as protocols for management of substances abuse, record surveillance, and means to report concerns.
Medical record surveillance	Programs should establish ongoing surveillance of medication records and include controlled substance between drug transactions. The effectiveness of automated information management systems should be harnessed to estabish unbiased daily reports. Indicators of diversion including mismatch between drug transactions and location of care, transactions after hours, and frequent errant documentation should trigger local investigation.
Urine drug screening	Programs should consider development of urine drug screening programs which include pre-placement, random, and “reasonable suspicion” components. Drug screening should meet regulatory standards including strict chain-of-custody, testing through credentialed laboratories, and review of results through a certified review officer (MRO). Drug screening must be accompanied by a formal system to adress results with the healthcare provider in the form of a formal intervention.
Substance waste management	Programs should establish formal policies which address medication return, wastage, and disposal. Waste practices should include verification and documentation. Controlled substance waste systems should include security that renders substances irretrevable and inactive. Return and waste policies should define management of drug discrepancies, a clear time frame, and penalty for violation.
Drug diversion prevention team (DDPT)	Institutions should estabilish drug diversion prevention teams, which are responsible for investigation of any suspected drug diversion. Teams assess medical records, interview individuals, perform additional surveillance, and enforce event specific drug testing if indicated.
Controlled Substances Diversion Prevention Committee	Hospitals should establish a multidisciplinary controlled substance diversion prevention committee to establish policy, assure compliance with regulations, oversee DDPTs, and assess the impact of interventions focused on reduction for drug diversion.

Sociedade Brasileira de Anestesiologia (SBA) Rua Professor Alfredo Gomes, 36, Botafogo , cep: 22251-080 - Rio de Janeiro - RJ / Brasil , tel: +55 (21) 97977-0024 - Rio de Janeiro - RJ - Brazil
E-mail: editor.bjan@sbahq.org

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[1] * Corresponding author: E-mail: vinicius.quintao@hc.fm.usp.br (V.C. Quintão).

Pharmacy
Procurement (ordering, purchasing, receiving)	Unauthorized orders Packaging slips removed from records
Storage	Replacement of substances with similar appearing medications, liquids
Preparation	Product switch (saline for medication) Substance dilution Removing small volumes of substance “Accidental” product damage or discard
Prescribing Wastage	Verbal orders Expired substances diverted Returned substances retained for personal use False documentation of wastage
Operating room
Preparation	Theft Dilution Saline substitution Obtaining substances under another providers credentialing or name Unsecured substances switched by another individual
Administration	Lack of administration to patient Documentation False documentation of usage or amount administered
Wastage	Substance switch or dilution prior to disposal Substance removed from waste containers Theft of biohazard boxes Collaboration between providers to divert drugs