Hospital Pharmacy

Volume 42, Number 3, pp 200–208, 225 2007

Wolters Kluwer Health, Inc.

FEATURED ARTICLE

A Novel Approach to Monitoring the

Diversion of Controlled Substances: The
Role of the Pharmacy Compliance Officer
Kent Fleming RPh,* Deborah Boyle RN, MSN, AOCN, FAAN,† W.J. Billie Lent RN, BSN, MBA,‡
Jesse Carpenter RPh,§ and Connie Linck RN, MN, CNAA, BC¶

Abstract Hosp Pharm — 2007;42:200–

Purpose: The true extent of drug diversion practices in acute 208
health care settings is unknown. Drug abuse by professional staff
may result in jeopardized patient safety, discredited organizational
reputations, compromised financial outcomes, and endangered

“S
community trust. Yet, limitations in reporting drug diversion
behaviors by health care professionals precludes quantification of
the scope of these practices in nurses, physicians, and pharmacists. your turn to run into
This manuscript describes one institution’s efforts to monitor drug
diversion with the implementation of a novel pharmacybased role, the being stolen from legal
the Pharmacy Compliance Officer (PCO). sources and ooner or later it will
Methods: Nearly 5 years of PCO experience will be identified and be America, controlled
organizational drug diversion methods will be delineated. substances are problem. All
Common profiles of professional drug diverters in acute care will across nearly half of the time,
be depicted with a review of the literature on pharmacist, nurse, health practitioners of one sort
and physician drug dependency characteristics. The collaborative or another are involved.” 1
process between the PCO and Nursing Directors will be described
with particular emphasis on options for validating drug diversion Psychoactive substances are
and confronting employees with evidence. Exemplars of drug abused primarily to depress,
diversion by professional staff will be highlighted with the use of stimulate, or distort brain
two case studies. Cost implications will be discussed as well. activity.2 Mind-altering drugs
Results: The PCO has assisted with the identification of staff at create dependence and a desire
risk, and responsible for, drug diversion. Implementation of this to engage in habitual
novel role has facilitated the early recognition of staff with active consumption in the absence of,
substance abuse disorders. Our relationship with the State Boards and in excess of, a legitimate
of Pharmacy and Nursing has been enhanced due to this proactive medical need resulting in both
approach to recognizing drug diversion practices in professional
injury and costs to society and
staff.
Conclusion: This contemporary strategy has the potential for the individual.3 The unlawful
replication, particularly in large, diverse, urban, acute care settings, use of drugs by health
where drug volume is high, information systems are frequently professionals is particularly
complex; hence, identification of drug-diverting professionals is disconcerting as patient safety
circuitous. may become jeopardized. Yet,
recent health care literature has
Key Words — Diversion; drug abuse; controlled substances; been characterized by the
impaired staff absence of focus on this major
public health concern.
Various methods to
evaluate drug diversion in
hospital settings have been
proposed. The evolving growth
of pharmacy data technology

200 Volume 42, March 2007

 Monitoring the Diversion of Controlled Substances: The Role of the Pharmacy Compliance
Officer
has created the ability to limit access to drugs through automated oversight and consistently
dispensing systems.4 Additionally, computerized audit trails can be evaluate the sequelae of this
produced and customized by specific query data points. 5,6 However, technology. The responsibility
technology can lull the user into a false sense of security. 7 Similar to oversee this monitoring is
to banking automation, someone must assume responsibility for usually assigned to

*Pharmacy Compliance Officer; †Practice Outcomes Nurse Specialist; ‡Director, Clinical Care Operations; §Manager,
Pharmacy Services; and ¶formerly Director, Medical/Surgical Services, Banner Good Samaritan Medical Center,
Phoenix, AZ, at time of publication, Chemically Addicted Nurses Diversion Option (CANDO) Consultant, Arizona
State Board of Nursing, Phoenix, AZ.
individuals in conjunction with,
and secondary to, other job
obligations. Hence, relevant
findings may be missed and
possibilities for casespecific
tracking ignored. This article
will describe our institution’s
5year experience with the
implementation of a systematic
drug diversion monitoring
program overseen by a novel
pharmacybased compliance
officer role.
SCOPE OF DRUG DIVERSION IN
HEALTH CARE
Drug diversion is defined as
the unlawful taking of a
patient’s medication by a health
care professional for personal
use.8 Access to a variety of
drugs in the hospital setting
enables the addicted or
potentially addicted employee
to work in close proximity to
medications associated with
dependence.
The scope of drug abuse in
health care professionals is
comparable with the general
public. However, professional
drug abusers’ drug of choice
differs from that of the lay
consumer. Controlled
substances are the principal
drugs consumed by hospital
professionals.9 Fentanyl is being
diverted in record numbers for
personal use in acute care
settings.10 Other commonly
hospital-based abused drugs
include morphine,
hydrocodone/ acetaminophen
(Vicodin), and
oxycodone/acetaminophen
(Percocet). Despite cocaine’s
reputation as one of the most
addictive drugs, its limited
availability in the hospital
setting precludes its
exploitation.11 Of note is that the
street value of controlled
substances is greater than both
marijuana and heroin, and is
second only to cocaine.12
Underreporting minimizes
the true magnitude of drug
diversion. Drug abuse by health
care professionals can publicly
embarrass, financially impact,
and governmentally restrict
hospital operations.13 Considered
a ‘closet crime,’ staff abuse of
drugs is often not
acknowledged by hospitals as it
effects business, patient
satisfaction, community trust,
and the perception of the
institution being a safe place to
receive care. Yet, no hospital
escapes the problem of drug
diversion.
DRUG DIVERSION METHODS
There are three major types
of diversion practices in
hospital settings. Straight theft
generally refers to removal of
controlled substances directly
from narcotic supply
containers.14 This is a frequent
mode of pharmacy personnel
diversion as large quantities of
drugs can then be sold to buyers
outside the hospital setting. A
more recent version of this
phenomenon is the removal of
partially-used fentanyl patches
from sharps receptacles for
personal use.4 Theft by under-
dosing can occur in several
ways; it is manifested by the
practice of ‘phony wasting’
whereby the excess is used by
the diverter.15 It may also
transpire by substitution, where
the drug is replaced with saline
or other solutions which allows
for consumption by the
diverter.16 This variant is often
seen in critical care settings
where patients are intubated
and/or comatose and unable to
communicate their subsequent
lack of pain relief. Infection
also may be a problem due to
contamination. Under-dosing
can also occur by withholding
portions of the drug for self-
administration by the health
care professional. This is often
referred to as ‘short shotting.’17
Other recent evidence of this
phenomenon involves the
application of used fentanyl
patches on patients while the
diverter saves the new patch for
themselves
(ie, applying it transdermally or
sublingually, or boiling the
patch in water for oral
consumption).10 Theft charting is
the third type of diversion
activity. This encompasses
chart forgery such as signing
out and documenting narcotic
administration or wastage while
stealing the drug for personal
use; as needed (PRN) controlled
substances can be pilfered in
these instances. The following
case study offers testimony to
this phenomenon.

Hospital Pharmacy 201

Monitoring the Diversion of Controlled Substances: The Role of the Pharmacy Compliance
Officer
Case Study #1
On a surgical unit within a
large hospital using automated
dispensing systems, Nurse G
would routinely ask a coworker
to witness narcotic wastage.
After doing this several times,
Nurse G memorized the
coworker’s user ID and
password. From that point on,
the coworker’s user ID and
password was used to document
wastage. During routine audits,
the Pharmacy Compliance
Officer (PCO) was alerted to a
significant increase in the
amounts of morphine 10 mg
and meperidine 100 mg
withdrawn. An Activity Report
was generated that revealed
Nurse G’s consistent
withdrawal of larger sizes of the
doses available (ie, morphine
10 mg for a morphine 4 mg
dose). The audit also revealed
that the same coworker
witnessed the wastage over
time. Time sheets were
reviewed by the nurse manager
to validate the coworker’s
presence on the days and shifts
the wastage occurred. This
revealed discrepancies that
were brought to the attention of
Nurse G along with evidence of
narcotic wastage patterns over
time. Nurse G confessed to the
theft of narcotics and the
fraudulent use of the
coworker’s user ID and
password.
PROFILES OF STAFF DRUG
DIVERTERS
The degree to which
physicians, nurses, and
pharmacists contribute to the
pool of illicitly used
prescription drugs is uncertain.9
In a breakdown of 100
documented drug diversion
cases; however, it is estimated
that 70 would be nursing
personnel, 20 would be
pharmacists, and 10 would be
202 Volume 42, March 2007
anesthesiologists or other
physicians.8
There is no uniform profile
of drug diverters. When the
health care professional is the
drug abuser, behavioral
presentations are highly
correlated with addiction
severity. A list of clues that
characterize drug addiction in
health professionals is provided
in Table 1.1,10,18 Yet, it also must
be noted that those who divert
drugs to sell outside the hospital
setting, or for use by a family
member, will not exhibit the
demeanor frequently associated
with drug dependence.
Nurses
Nurses are the most
frequently reported drug
diverters.19 Nearly two-thirds of
all disciplinary actions taken by
state boards of nursing in the
US are due to drugrelated
charges. Risk indices for
nurses’ abuse of drugs have
been the topic of investigation.
Trinkoff, Storr, and Wall20
addressed three dimensions of
workplace access that
influenced diversion behaviors.
These included perceived
availability of controlled
substances, frequency of
administration, and the degree
of workplace control. Nurses
who reported easy access and
daily contact with drugs, and
cited minimal workplace
control measures, had higher
odds of prescription-type drug
abuse. Varying rates of
substance abuse by nursing
specialty have also been noted.
In one report, nurses who
practiced in critical care,
oncology, psychiatry, and the
emergency room tended to
abuse controlled substances
with greater frequency.21
Employees early in their
drugseeking trajectory may
exhibit behaviors rarely
considered indicative of drug
dependence. In fact, they often
are perceived as the antithesis
of the stereotypical drug abuser.
In these scenarios, when
suspicion is demonstrated from
audit results, the employee’s
manager is frequently
astonished by the findings.
Characterized by their high-
performing, high-energy nature,
these nurses frequently offer to
work extra shifts and are highly
functional on the job. Yet other
clusters of behaviors are
concurrently evidenced. These
nurses tend to administer more
medications than their
colleagues, frequently volunteer
to give pain and sedative
medications to patients, have
more breakage and waste
reported, and often can be
observed going to the rest room
or lounge soon after medicating
patients.18 Additionally, patients
they care for complain of
inadequate pain relief despite
charting evidence that reflects
optimum medication
management. Even when the
effects of the drugs do not
directly affect the professional’s
practice capability, their
thinking is frequently distracted
by the need to identify, and act
on, opportunities to steal drugs
for personal use.1
Pharmacists
One-quarter of pharmacist
records reviewed for
disciplinary actions by the
National Association of Boards
of Pharmacy
(NABP) involve drug-related
allegations. Pharmacists’ direct
contact with potentially
addictive prescription drugs
offers them continuous
exposure that requires
deliberative constraint
regarding potential personal
use. Results of a written survey
 Monitoring the Diversion of Controlled Substances: The Role of the Pharmacy Compliance
Officer
randomly mailed to licensed Administration (DEA) requires • Narcotic solution for
practicing pharmacists who pharmacies, manufacturers, and patientcontrolled anesthesia
were members of the American distributors to report significant pumps is diluted after
Pharmaceutical Association, thefts and losses. Pharmacists diversion;
revealed that a considerable and pharmacy technicians are • Member of the pharmacy
percentage (40%) had on at often responsible for the staff removes narcotics
least one occasion, used some diversion of large quantities of from the vault room without
form of controlled substance drugs due to their proximity to authorization;
without first obtaining a storage sites.14,17 They may order, • Small amounts of scheduled
physician’s authorizing receive, and/or divert narcotics narcotics in tablet or capsule
prescription.22 Additionally, for street sale. Between 2000 form are taken from large-
69% directly violated their and 2003, nearly 90% of major lot containers;
professional code of ethics and drug thefts and losses occurred • Theft of excess fentanyl in
state and/or federal laws by in pharmacy settings.23 10 and 20 mL ampules;
either stealing drugs from their Other examples of pharmacy • Pharmacist drinks directly
place of employment (61%) or department diversion practices from cough syrup bottle
forging prescriptions to obtain include: containing
them(8%). • Pharmacist breaks bottle of Schedule III narcotics.10
The Drug Enforcement narcotic tablets, and
removes the glass pieces;

Hospital Pharmacy 203

Monitoring the Diversion of Controlled Substances: The Role of the Pharmacy Compliance
Officer
Table 1. Key Markers to Identify Drug Addiction in Health Professionals (adapted from
1,10,18)
DETERIORATING JOB PERFORMANCE
Assumes less responsibility and withdraws from committees and activities
Forgetfulness related to routine duties
Sleepiness at work
Cuts corners, dismisses details
Decline in quality and quantity of documentation
Ineffective use of work time
Increased number of errors
Increased absenteeism and tardiness
Frequent profile overrides in the automated dispensing system
PSYCHOLOGICAL INDICATORS
Mood swings with irritability
Attitude change with increased anxiety and paranoia
Social isolation
Inability to get along with colleagues
Challenges department policies and procedures
Rationalizes negative feedback
Defensive when questioned about errors or substandard patient care
PRE-EMPLOYMENT FACTORS
Frequent job changes and/or relocations
Frequent hospitalizations or accidents
Reluctance to undergo a physical exam
Unexplained gaps on resume
Working at a job lower than education level
Extensive travel or registry work experience
CHANGING PHYSICAL APPEARANCE
Decline in grooming and care of clothing
Weight gain or loss
Slight hand tremors
Pupillary size change and/or bloodshot eyes
Disorientation, unsteady gait, or slurred speech
OTHER BEHAVIORS
Preoccupied with medications and narcotics
Voices global concern about inadequate management of patient pain
Frequently checks narcotics supply and orders items from Pharmacy
Increased use of as needed (PRN) narcotics
Repeatedly uses inappropriately large syringes for small doses of controlled substance
Charting trends demonstrate more withdrawal of narcotics than coworkers
Waits for other colleagues to leave before accessing narcotics inventory
Disappears at work; takes a break or visits restroom after removing narcotics
Volunteers for extra shifts (particularly evenings and nights)
Rarely takes vacation
“RED FLAGS”
Pattern of heightened dispensing of more pain medications during a regular shift than coworkers
Trend noted in patient complaints of ineffective pain control

State pharmacy boards statistics on the prevalence of to resultant licensing

usually have the most accurate pharmacist drug diversion due

204 Volume 42, March 2007

 Monitoring the Diversion of Controlled Substances: The Role of the Pharmacy Compliance
restrictions and referral to
pharmacist assistance programs.
Physicians
No repository of physician
drug offender cases exists to
approximate the extent of this
problem. Hence, quantifying
the degree of drug diversion
among physicians is difficult.
Physician autonomy and the
absence of peer pressure to
monitor diversion practices
preclude accurate reporting.
Self medication is common.24
Instances of drug abuse are
often addressed in an
environment of secrecy in the
administrative medical staff
service domain.25 Yet despite
these difficulties, it is estimated
that 10% to 14% of physicians
demonstrate chemical
dependence; namely, they use
opiates and sedatives.26 This
projection is derived from
physician recovery program
figures.
Although professional
medical organizations
infrequently collect statistics on
the numbers of drugdependent
members, anesthesiologists are
overrepresented in disciplinary
and treatment program data.27
Despite their relatively low
number (ie, representing only
4% of all physicians), it is
estimated that 12% of
substance-abusing physicians
are anesthesiologists and
constitute the largest group of
physicians who abuse drugs.28
They have a three times higher
risk for developing chemical
dependency than other
physician specialists.29 Drug
availability and accessibility,
ability to circumvent traditional
drug usage limitations, and a
control-oriented personality
profile, have been associated
with greater risk with this
physician cohort.30,31 However,
some contest that physicians in
psychiatry and emergency
medicine may have equal or
higher prevalence of substance
dependence.15
METHODS
Integration of corporate
compliance programs into
hospital settings has increased
nationally.32 Such health care
programs create and oversee
internal controls that promote
adherence to federal and state
laws and programmatic
requirements of governmental
and private health plans.33 As
investigation and prosecution of
fraud and abuse in health care
has increased, so has interest in
establishing these programs.
The Joint Commission on
Accreditation of Healthcare
Organization (JCAHO), in
particular, now inquires about
the existence of institutional
practices in place that reduce
the likelihood of criminal
behaviors in hospital settings.
In an effort to address the
prevalence of drug diversion in
a large tertiary care referral
teaching institution, the
pharmacy director at our 638-
bed tertiary care medical center
created a full-time position to
enhance the organization’s drug
surveillance and diversion
detection capability.
The PCO position was
developed with basic role
eligibility inclusive of a
pharmacy degree. A pharmacist
was identified as having more
advanced critical thinking skills
than that of a pharmacy
technician. Additionally, the
pharmacists’ knowledge of
psychoactive substances,
specifically dose ranges,
scheduling norms, and suspect
patterns of inappropriate drug
use, were pharmacist-specific
competencies required for
optimum role functioning. Two
Officer
primary job responsibilities
were delineated (see Table 2).
Most of the PCO’s time (95%)
is dominated by the assumption
of accountability for
maintaining federal, state, and
JCAHO requirements related to
controlled substance drug
distribution. The PCO ensures
that internal policies and
procedures related to controlled
substance prescribing and
administration are consistently
followed.13 Monthly audits are
performed on DEA 222 forms,
data entry of Class III-V
narcotics into the Class II safe,
transaction alterations,
medications pending
destruction, and open
discrepancy documentation. By
performing and monitoring
regularly scheduled audits,
trend analyses, and database
assessments, drug diversion
activities can be identified
early. The secondary role
responsibility of the PCO is to
ensure accurate and timely
billing for pharmacyrelated
services. This component of the
role accounts for approximately
5% of the PCO’s time.
Ongoing monitoring is
performed on all staff nurses,
nurse anesthetists, and
physicians. Narcotic audits are
performed on nurses whose
usage extends beyond the norm.
These staff are identified
through reports produced from
the automatic dispensing
machines. Additionally, a nurse
manager can request an audit
based on questionable nurse
behavior or other indices of
suspicion (see Figure 1).
Quarterly reports are generated
on anesthesiologists and nurses
practicing in the cath lab,
endoscopy, radiology, and the
post-anesthesia care unit.
Verification that the nursing
staff in these areas are properly
documenting the withdrawal,
Hospital Pharmacy 205
Monitoring the Diversion of Controlled Substances: The Role of the Pharmacy Compliance
Officer
return, and waste of narcotics is data can heighten suspicion and management, the staffing
analyzed. Case Study #2 prompt a more detailed audit. office, human resources, risk
reflects how the use of these Lastly, the PCO works management, medical staff
closely with nursing
Table 2. Major Components of the Pharmacy Compliance Dilaudid was in fact ordered for
Officer's Auditing Responsibilities these patients. Only two of the
15 patients had Dilaudid orders
MONITOR POTENTIAL DRUG DIVERSION PRACTICES: on their medication profile.
Monitor the disposition of all controlled substances and validate
Patient charts were subsequently
compliance with Federal and State regulatory requirements reviewed. For the two patients
Routinely evaluate trends in narcotic dispensing by staff nurses,
with Dilaudid orders, only four
nurse anesthetists, physicians, and pharmacists Perform of the 40 Dilaudid 4 mg
individual investigative audits as required injections were documented as
ENSURE ACCURATE AND TIMELY BILLING: given to the patient. Nurse B
was confronted and admitted to
Capture pharmacy services’ costs and charges
diverting injectable Dilaudid.
Assess unusual prescriptive patterns for potential Medicare fraud
RESULTS
services, and the patient safety this report are displayed in
The PCO role has helped to
director to foster a work spreadsheet format, so the PCO can categories of staff at
identify
environment where employees feel monitor these users over time.heightened
The risk for drug
they can raise concerns without fear report lists job title (ie, core nursing
diversion. Our experience has
of retribution. staff, nurse traveler, physician), unit
documented an unusually high
of employment, and controlled prevalence of traveler and daily
Case Study #2 registry nurses that have
substance usage by individual
A proactive drug diversion patients. Nurse Traveler B showed ultimately
a required termination
search is generated monthly to high amount of narcotic withdrawal(see Table 3). The mobility of
determine which automated these
over a period of 1 month. An activity staff allows exposure to a
dispensing users are withdrawing variety of health care settings
report was generated for Nurse B,
controlled substances more over a short period of time. This
which revealed that the only narcotic
work
frequently than their peers. Data the nurse
from
withdrew was Dilaudid injection. The PCO reviewed 15
patient orders in the pharmacy’s computer to determine if

206 Volume 42, March 2007

 Monitoring the Diversion of Controlled Substances: The Role of the Pharmacy Compliance
Officer

Pharmacy Nurse Manager

Compliance
Officer Suspicious behavior noted
Employee
identified Substandard documentation
Ongoing audit
of narcotic
withdrawals Employee
Activity report Complaints
caught
generated
diverting
Results generate
high user report Patients selected
for audit

Charts ordered

Audit reveals compliance Results compiled Audit reveals noncompliance

and reported

Employee terminated Reported to

Employee counseled
Board

Figure 1. Process options for drug diversion audit of nursing staff.

Table 3. Analysis of Hospital Personnel Terminations Due to Drug Diversion
from January 2000 to December 2005
Type of Employment # Audits # Terminations % Terminated

RN hospital employee 280 12 4.3%

RN traveler
RN registry/pool
RN anesthetist
Physician
Total
style often precludes trend
documentation related to drug
diversion. Due to this finding,
our nursing management
maintains vigilance in
evaluating the performance of
nurse travelers and registry staff
in this regard.
An additional outcome to
the identification of drug-
diverting colleagues has been
the PCO’s education role both
within and external to our
organization. Housewide
knowledge about the PCO role
in the institution reiterates the
message that we are serious
about this problem and have a
zero tolerance for its practice
due to overwhelming patient
118 15 12.7%
37 4 10.8%
4 0 0
4 0 0
443 31 7%
safety concerns. The PCO pharmacists, and physicians.
offers inservices to nurse New information about the
managers, participates in neurobiology of addiction has
nursing leadership forums, and proposed that the brain’s reward
has ongoing dialogue with circuitry is composed of
hospital management. Our pathways that prompt the
reputation has been enhanced reinforcement of both natural
by a proactive approach to and pharmacologic rewards.
identify drug dependence in Chronic use of addictive drugs
health professionals and by our promotes changes in this reward
discovery of new diversion circuitry by activating the
practices. The PCO role has mesolimbic dopamine system,
caused our relationship with the which in turn contributes to
State Board of Nursing to excel. behavioral disinhibition (ie,
impulsivity).34 Additionally,
DISCUSSION incentive learning is
Chemical dependency has subsequently facilitated
historically been considered an prompting motivational
occupational hazard for nurses, responses to the
relapseinducing stimuli.

Hospital Pharmacy 207

Monitoring the Diversion of Controlled Substances: The Role of the Pharmacy Compliance
Officer
Escalating drug intake, implementation, nearly 500 resources to staff this position,
increased drug craving, individuals have been audited the salary costs must be
tolerance, dependence, with a 7% termination rate. weighed against the benefits
withdrawal symptoms Elimination of lost drug costs derived, such as enhanced
following drug cessation, and due to PCO’s intervention can patient and employee safety.35
relapse characterize addiction. be considered along with the
This scenario has profound reduction of hidden costs. TEAM APPROACH TO
implications when the addicted These include professional CONFRONTATION
professional works in an implications of lost employee
Nurse and pharmacy
environment surrounded by productivity, accidents, and
managers must remain vigilant
drugs while caring for medication errors. Additionally,
in monitoring for drug
vulnerable patients. reduced unit morale can evolve
diversion on patient care units
Overall, addiction’s toll on as colleagues voice concern
and in pharmacy departments.
health and productivity in the about the perception of
Unusual staff behaviors,
US has been estimated as more decreased quality of patient care
inadequate pain control voiced
than $300 billion annually, where an impaired colleagues
repeatedly by patients, and
making it one of the most practices. Patients may be
unexplained narcotic variances
serious problems facing exposed to added and
Table 4. Signs of Acute Intoxication and Withdrawal36
Substance Examples Signs of Intoxication Signs of Withdrawal

Opiates Morphine, heroin, Anxiety, impaired cognition,
codeine, Dilaudid, delirium, euphoria, flushing,
fentanyl sense of floating, pinpoint
pupils, skin picking, sleepiness,
anorexia
CNS stimulants Amphetamines, Labile affect, anxiety,
cocaine, crack anorexia, arrhythmia,
restlessness, tremors,
delirium, dizziness,
euphoria, skin picking,
violence, halucinations,
irritability, tonic-
clonic seizures, dry
mouth, sleep disturbance,
paresthesia, dilated pupils,
hyperactive reflexes,
tachycardia
Barbiturates Diazepam, Drowsiness, euphoria,
and Anxiolytics pentobarbital fatigue, sense of floating,
orthostatic hypertension,
irritability, anorexia,
anxiety, slurred speech,
ataxia, poor memory
and comprehension,
seizures, delirium,
depressed mood,
diplopia, dizziness,
nystagmus, violence
society.11 Due to the absence of unnecessary diagnostic tests,
historical data by which to require prolonged lengths of
measure role outcomes, we can stay, and increased injury
only project the financial accompanied by enhanced risk
impact of the PCO role. Over for liability.2,14 Hence, in
the 5-year timeframe of role considering allocating human
Tearing, runny nose, excessive
sweating, yawning, tachycardia,
fever, insomnia, muscle aches,
craving, nausea, vomiting,
dilated pupils, chills, abdominal
cramps, diarrhea, salivation, pain
(bone, joint, lower back, headache),
muscle twitching, sneezing, sniffling
Depression, fatigue, agitation,
suicidal thoughts, paranoia,
insomnia or hypersomnia,
disorientation (with amphetamines)
Nausea, vomiting, generalized
malaise, tachycardia, excessive
sweating, anxiety, irritability,
orthostatic hypotension, coarse
hand, tongue or eyelid tremors,
insomnia, tonic-clonic seizures
must be investigated.
Knowledge of signs of acute
intoxication and withdrawal
related to the abused substance
also helps heighten the index of
suspicion (see Table 4).36

208 Volume 42, March 2007

 Monitoring the Diversion of Controlled Substances: The Role of the Pharmacy Compliance
Clinical observation must be
substantiated by the results of
computerized audits and other
forms of documentation.
Reports from automated
dispensing systems,
documentation in the patient
record, and review of employee
attendance patterns are
required. Additionally,
conducting pain rounds by the
nurse manager and interviewing
patients, helps validate clinical
impressions. Drug screening is
an option when behaviors
warrant immediate assessment.
Routine drug screening of
hospital staff is a controversial
subject yet its implementation
would be another vehicle to
proactively identify drug
dependent staff.
While monitoring for drug
diversion is an important
component of the nurse
manager’s role, confronting an
employee suspected of drug
diversion can be most difficult.
The focus must be on protecting
patients and obtaining help for
an impaired employee. Nursing,
pharmacy, and human resources
work collaboratively to
investigate individual cases.
Unless there is an event that
warrants immediate
intervention, it is important to
have all documentation
organized prior to speaking
with the employee. The meeting
between the manager and the
staff member should be planned
to provide sufficient discussion
time. It should be held in a
location that allows maximum
privacy for the employee.
During the meeting, facts are
presented and the employee is
provided the opportunity to
explain the findings. Common
emotional reactions include
anger, denial, or tearfulness. It
is imperative that the nurse
manager remain objective in
evaluating the evidence as well
as considering the employee’s
explanations. Regardless of
admitting to drug diversion or
not, the employee is given the
option to initiate a self-report to
their respective professional
state board. The manager also
submits a report. While this is
the usual scenario for both
nursing and pharmacy,
confrontation and validation of
medical staff drug diverters is
usually managed in isolation by
medical staff leadership.
Most state boards of
nursing, pharmacy, and
medicine offer professional
assistance programs that
promote rehabilitation to
counter addiction. Recovery is a
major emphasis rather than
punishment. States such as
California have enacted
legislation that created an
independent program outside of
usual disciplinary paths to
rehabilitate impaired
physicians.29 Expectations for,
and timing of, return to work
possibilities are both stateand
institution-driven. One
recommendation emanating
from our experience with
employee re-entry is that
focused communication be in
place with the PCO to ensure
the absence of illicit behavior is
maintained.
An interesting retrospective
review of physician and nurse
substance abuse disorders
revealed that following index
hospitalization, nurses received
less primary treatment, were
more symptomatic than
physicians, and worked longer
hours.31 Additionally, as a group,
nurses reported more frequent
and severe work-related
sanctions as a consequence of
their impairment. Investigation
of risk factors for health
professionals’ relapse requires
further study. A recent
communication cited abuse of a
Officer
major opioid, presence of
coexisting psychiatric illness, or
family history of a substance
abuse disorder, as risk factors
for relapse in health
professionals.37 Subsequent
validation of these findings
could influence the duration of
therapy interventions and the
intensity of recovery
monitoring.
CONCLUSION
Despite the American
closed distribution system of
licensing, security, and record-
keeping, drug diversion is
evidenced nationally.23 Early
recognition of staff diverting
drugs is critically important as
it increases their chance for
recovery and patient safety
becomes less jeopardized. The
designation of a pharmacy-
based colleague to proactively
oversee drug diversion practices
has benefited impaired staff and
our organization as a whole.
This role has become
indispensable with well-
documented outcomes that
foster an environment of patient
safety and employee support.
As part of a large organizational
health care network, other acute
care facilities within our system
are currently in varying stages
of PCO role integration in their
respective operations.
The creation of a full-time
pharmacist to scrutinize drug
diversion practices in our
hospital has also enhanced our
community recognition as an
innovative facility and has
cultivated a more formal
partnership with our
professional state licensing
boards. Lastly, our professional
staff are astutely aware of our
utmost concern for patient
safety and hence our zero
tolerance for any employee
behavior that could jeopardize
patients’ well-being. We
Hospital Pharmacy 209
Monitoring the Diversion of Controlled Substances: The Role of the Pharmacy Compliance
Officer
believe this program control and medical practice. 23. Joranson DE, Gilson AM.
exemplifies timely, insightful JAMA. 1992;268:1306-1310. Drugcrime is a source of abused
10. Bogardus D. Drug Diversion in pain medications in the United
collaboration, and professional States. J Pain Symptom Manage.
advocacy at its best. Health Care: A Guide to
Identification and Prevention. 2005;30:299-301.
Marblehead, MA: Opus 24. Joranson DE, Ryan KM, Gilson
ACKNOWLEDGMENTS Communications; 2002. AM,Dahl JL. Trends in medical
The authors would like to 11. Nestler EJ, Malenka RC. The use and abuse of opioid
recognize the contributions of addicted brain. Sci Am. analgesics. JAMA.
2004;290:78-85. 2000;283:1710-1714.
colleagues Linda McCoy,
Chuck Berry, Herb Geary, and 12. Parran T. Prescription drug 25. Bennett J, O’Donovan D.
abuse: aquestion of balance. Med Substancemisuse by doctors,
Selma Kendrick in the nurses and other healthcare
development of this manuscript. Clin North Am. 1997;81:967-
978. workers. Curr Opin Psychiatry.
2001;14:195-199.
REFERENCES 13. Van Dusen V. The compliance
liaison: preventive medicine for 26. Hughes PH, Brandenburg N,
1. Bracelin FJ. An experienced the pharmacy department. US Baldwin DC Jr. et al. Prevalence
investigator reveals drug Pharmacist. of substance use among US
diversion tip-offs. RN. 2003;28:HS34,HS36,HS38. physicians. JAMA.
1982;45:61-63. 1992;267:2333-2339.
14. Carlson GM, Castile JA,
2. American Society of Health- Janousek JP.Guidelines for the 27. Storr CL, Trinkoff AM, Hughes
System Pharmacy. ASHP prevention and detection of P.
statement on the pharmacist’s controlled substance diversion. Similarities of substance use between
role in substance abuse Hosp Pharm. 1988;23:1057- medical and nursing specialties.
prevention, education and 1059. Subst Use Misuse. 2000;35:1443-
assistance. Am J Health Syst
15. Myers CE, Buttaro M. 1469.
Pharm. 2003;60:1995-1998.
Preventingdrug diversions. 28. Nemes J. Fighting drug abuse
3. Haislip GR. Drug diversion Nursing. 1994;24:74. inoperating rooms. Mod Healthc.
control systems, medical
16. Castledine G. Staff nurse who 1991;21:60,62.
practice, and patient care. N IDA
Res Monogr. stolefentanyl from a syringe and 29. Pelton C, Ikeda RM. The
1993;131:1120-1313. replaced it with saline. Br J CaliforniaPhysician’s Diversion
Nurs. 2005;14:385. program’s experience with
4. Bogardus D. Dangerous new
17. Jaspan N. The drug problem. recovering anesthesiologists. J
trends in drug diversion. Hosp
Top Health Care Financ. Psychoactive Drugs.
Secur Saf Manage. 1997;18:12-
1988;15:46-50. 1991;23:427-431.
14.
18. Anonymous. How to spot drug 30. Gallegos KV, Browne CH, Veit
5. Pizzi LT, Howell JB, Deshmukh
theftand abuse by staffers. RN. FW,Talbot GD. Addiction in
A, Cohen H, Nash DB. Clinical
1998;61:20I20J. anesthesiologists: drug access
information management
and patterns of substance abuse.
systems: an emerging data 19. Incardi JA, Surratt HL, Kurtz QRB Quart Rev Bull.
technology for inpatient SP,Burke JJ. The diversion of 1988;14:116-122.
pharmacies. Am J Health Syst prescription drugs by health care
Pharm. 2004;61:76-81. workers in Cincinatti, Ohio. 31. Shaw MF, McGovern MD,
Subst Use Misuse. 2006;41:255– AngresDH, Rawal P. Physician
6. Ervin KC, Skledar S, Hess MM,
264. and nurses with substance abuse
Ryan M. Data analyst technician:
disorders. J Adv Nurs.
an innovative role for the 20. Trinkoff AM, Storr CL, Wall 2004;47:561-571.
pharmacy technician. Am J MP.Prescription-type drug
Health Syst Pharm. misuse and workplace access 32. Doody MF. Corporate
2001;58:1815-1818. among nurses. J Addict Dis. complianceofficer role is
1999;18:9-17. emerging. Healthc Financ
7. Anonymous. How to monitor
Manage. 1998;52:78.
drug diversion from automated 21. Trinkoff AM, Storr CL.
dispensing cabinets. Healthc Substanceuse among nurses: 33. Spooner JJ, Peterson AM.
Hazard Manage Monit. differences between specialties. Corporatecompliance: an
2002;15:6-7. Am J Public Health. emerging issue for pharmacists.
1998;88:581-585. Am J Health Syst Pharm.
8. Sells D. On drug diversion in
2002;59:1874-1881.
health care. Hosp Secur Saf 22. Dabney DA. Onset of illegal use
Manage. ofmind-altering or potentially 34. Tamminga CA. Drug
1995;15:11-13. addictive prescription drugs dependenceand addiction. Am J
9. Cooper JR, Czechowicz DJ, among pharmacists. J Am Pharm Psychiatry. 2004;161:223.
Petersen RC, Molinari SP. Assoc. 2001;41:392-400.
Prescription drug diversion

210 Volume 42, March 2007

 Monitoring the Diversion of Controlled Substances: The Role of the Pharmacy Compliance
Officer
35. Horgan C, Prottas J, Tompkins
C,Wastila L, Bowden M.
Summary and conclusions of a
review of prescription drug
diversion methods. N IDA Res
Monogr. 1993;131:206-223.

36. Project SAEL (Substance Abuse

Education Liaisons). Substance
Abuse Resource Manual for N
urses 2002. Houston, TX:
University Texas-Houston,
School of Nursing; 2002.

37. Domino KB, Hornbein TF,

PolissarNL, Renner G, Johnson
J, Alberti S, Hankes L. Risk
factors for relapse in health care
professionals with substance use
disorders. J Am Med Assoc.
2005;293:1453-1460. ■

Hospital Pharmacy 211