Health Care Inves.ga.ons Karen Ma3hew Director of Inves.ga.ons and Inspec.ons, North Carolina Department of Pharmacy Agent Bruce DiVincenzo Delaware State Police Drug Diversion Unit
LEARNING OBJECTIVES – 1. List signs of diversion in a health care facility. 2. Outline how to collaborate with clinicians to prevent diversion. 3. Demonstrate eﬀec.ve use of PDMP by law enforcement within a pharmacy.
Disclosure Statement • Karen MaRhew has no ﬁnancial rela.onships with proprietary en..es that produce health care goods and services. • Bruce DiVincenzo has no ﬁnancial rela.onships with proprietary en..es that produce health care goods and services.
Health Care Facility Diversion Karen MaRhew April 2, 2013
WHAT IS DRUG DIVERSION? The channeling of controlled substances, which are legally manufactured & intended to be used legi.mately for medical & therapeu.c needs by a license prac..oner, pharmacist, hospital, nursing home or medical research center, to an illegal use, whether it be for personal use or for illegal distribu.on to another person.
IN OTHER WORDS…… Diver.ng legi.mate Drugs for illicit or illegal purposes.
WHAT DOES HEALTH CARE FACILITY MEAN? • Hospitals • Nursing Homes • Assisted Living Facili.es • Group Homes • Clinics • Physicians’ oﬃces, other facili.es.
MORE SPECIFICALLY: • PRESCRIBERS – MD, DO, DDS, DMD, Vet, DPM, NP, RN PA, CPP • DISPENSERS – RPh., Tech, Clerk, Other employees • ADMINISTRATORS – RN, LPN, NA, CMA, CNA, Med techs • OTHERS – who have access through employment or obtain access
WHAT IS DIVERTED? • High Priced Medica.ons such as Erec.le Dysfunc.on Drugs, Chemotherapy , etc. • Drugs Easily Abused – Oxycodone, Hydrocodone, Morphine, Fentanyl, Dextroamphetamines, Benzodiazepines • Any Type of Medica.on
THE “WHYS” OF DIVERSION • Addic.on • Facilitate the addic.on of others • Pseudoaddic.on • To sell for money • To provide to others, par.es, etc. • Cost of prescrip.on drugs • To facilitate sexual acts, assaults, etc. • Every reason one can think of
DRUG FLOW INTO HEALTH CARE FACILITIES CRADLE TO GRAVE APPROACH
DRUG FLOW • Manufacturer – Wholesaler (Pharmaceu.cal Company) Broker Distributor • Courier Service – Delivery to the Health Care Facility
DRUG FLOW • Health Care Facility – Pharmacy Materials Management • Closed Door Pharmacy – Directly into ins.tu.on
DRUG FLOW Once in a Hospital : -‐ Inventoried & Stocked in Pharmacy -‐ Placed onto shelves/cabinets, etc. -‐ Automated Dispensing Units/robots -‐ Vaults
DRUG FLOW Drugs are sent out of the pharmacy -‐ Based on Dr. Order -‐ to Basic stock -‐ Nursing Units -‐ Pa.ent Areas -‐Specialty Areas (surgery, CT labs, ED) -‐Outpa.ent -‐oﬀ-‐site areas
DRUG FLOW Once a drug is sent out of the pharmacy, It is administered according to the Policy/procedure of the ins.tu.on. Example – Automated Dispensing Machines Medica.on Administra.on Record (MAR)
DRUG FLOW • Waste – pa.ent refusal, leh over, expired, contaminated. • Legally, if a drug is signed out, it must be administered or wasted. May be returned to stock under ins.tu.onal Policy, state law, etc.
DRUG FLOW INTO OTHER FACILITIES Nursing Home ﬂow is similar to hospitals except they Contract with LTC pharmacies or retail pharmacies to Provide drugs – normally pa.ent speciﬁc
DRUG FLOW • Some nursing homes & other facili.es now u.lize automated dispensing machines. (If controlled substances are administered, need DEA registra.on & Board permit). • Other nursing homes u.lize medica.on carts • Some use unit dose carts, pa.ent speciﬁc • Medica.ons administered to pa.ents by RNS, LPNS, med techs, CNAs, etc.
WHERE DOES DIVERSION TAKE PLACE? ANYWHERE WHERE DRUGS ARE STORED
START AT THE BEGINNING Courier Service: Package Disappears Packages are not sealed completely (altered) Packing is diﬀerent than past deliveries Change in delivery schedules Personnel ac.ng diﬀerently
NOW WHAT? Couriers are aware they are delivering drugs. Ensure there are good tracking systems from wholesaler to facility. Once package is delivered, contents need to be inventoried immediately against invoice/manifest.
DRUGS ARRIVE IN THE FACILITY • Drugs should be inventoried & stocked as soon as soon as possible. • Whether placed in an automated dispensing machine, medica.on cart or vault, they should be stocked immediately to help cut down on diversion.
TYPES OF DIVERSION Diversion in a pharmacy of a health care facility is normally commiRed by pharmacists & technicians. Pharmacists will divert from automated dispensing machine, vault, when preparing or mixing medica.ons. Technicians ohen divert when checking in deliveries, stocking the pharmacy, coun.ng out meds, stocking ﬂoor units, taking return meds in the pharmacy.
WHO DIVERTS DRUGS ON FACILITY UNITS? • Nurses – RN, LPN • CNA, CMA • Physicians, although they do not have as much access as other staﬀ • Anesthesiologists, CRNAs • Therapists, surgery techs, others
NURSES Addicted Nurses are one of the Most widely diverters of medica7ons In health care facili7es. Few facili7es are exempt from this Problem. More cases since # of nurses are More than Rphs or techs.
DIVERSION BY NURSES • Trash • Sharps Containers • Destruc.on • Restocks • Signouts for Discharged Pa.ents • Documenta.on Issues • Stealing from Automated Dispensing machines • Pa.ent complaints – no relief for pain, etc.
ISSUES SPECIFIC TO NURSING HOMES • Storing of Delivered Medica.ons • Medica.on Counts at Change of Shih • Punch outs on Unit Dose cards • MAR changes • Expired medica.ons, leh-‐over pa.ent medica.ons • Falsifying orders • Subs.tu.on of medica.ons • Pa.ent complaints
CHARACTERISTICS Job Performance Employment History Changes in Behavior/Moods Appearance Quality of Employees Documenta.on Issues Working Over.me or Oﬀers to Do So Taking over others’ pa.ents Showing up when not on duty Check & Balance on medica.ons Policies/procedures
WHAT CAN BE DONE? • Collabora.on between health care professionals and law enforcement • Training for all staﬀ in health care facili.es on diversion & what to look for • Good policies & procedures in place • Zero tolerance for diversion in health care facility – Pa.ent Safety is Utmost! • Referral of employee to employee assistance program
WHAT CAN BE DONE? • Background Checks including criminal history • Verifying License Informa.on with Regulatory Boards • Checks & Balances of En.re Medica.on Flow • Inventorying of Drugs at all Levels • Use of Biometric measures on automated devices • Random Drug Tes.ng • Random Review of Drug ﬂow to determine weak points • Check of expired drugs, return to stock
WHAT CAN BE DONE? • Rigorous Security Measures • Think of Drugs as Money! • Close Observa.on/Supervision of Employees Handling Medica.ons • Training for all employees • Preven.on is best measure • Always look for new systems such as bar coding, etc.
USE OF PDMP • NC has had PMP (CSRS) for almost 4 years • Only @ 28% of all prescribers signed up • Less than 26% of Rphs signed up • Useful tool to check for doctor shoppers, forgers, etc. • Some pharmacies do not have internet access • Cannot provide to law enforcement in NC • Board has limited access
Limita.ons of PMP • Only as good as data sent in from pharmacies • In one review of pa.ent informa.on on prescrip.ons, 20% informa.on was incorrect prescriber, drug, etc. • In NC, limita.ons on info on prescribers who are “over-‐prescribing” • No access by local law enforcement • Changes being reviewed now • No mandatory use by prescribers
Contact Informa.on Karen MaRhew Director of Inves.ga.ons & Inspec.ons NC Board of Pharmacy 919-‐246-‐1050 kmaRhew@ncbop.org
Collabora.on with Pharmacists to Prevent Diversion Through Use of the PDMP April 2 – 4, 2013 Omni Orlando Resort at ChampionsGate
Learning Objec.ves • What law enforcement can do to encourage collabora.on with pharmacists to reduce diversion at the pharmacy counter. • Learn from several examples how the PDMP when used by pharmacists, can aid law enforcement in improving inves.ga.ve outcomes.
Disclosure Statement Agent Bruce DiVincenzo has no disclosed no relevant, real or apparent personal or professional ﬁnancial rela.onships.
• Review nine (9) minute video concerning crimes occurring at the pharmacy counter and how the ac.ons taken by pharmacy staﬀ can aid law enforcement in the reduc.on of diversion. • Diversion which occurs at the pharmacy counter is vastly underreported. Law enforcement can aid in improving this outcome. My PERSONAL belief is that the problem is HUGE. Unless an agency becomes involved on a regular basis in the inves.ga.on and prosecu.on of these crimes, the amount of drug diversion occurring at the pharmacy counter will remain a signiﬁcant source of diverted controlled drugs which con.nue to devastate our communi.es. You just don’t know un.l you look!!
• Pharmacy crimes – Forgery, Doctor and Pharmacy shopping. These crimes are underreported, and in many metropolitan areas not inves.gated at all. Signiﬁcant amounts of diverted drugs are the result. • Educate the clinicians about the law (code and statute ) that governs your jurisdic.on. Assist them and work together for the reduc.on of diverted drugs in your community. Work to increase repor.ng! Examples from experience – 3 Friday nights in a row!
• The video is our eﬀort in DE to let the clinician know what evidence is used by prosecutors. Discuss trial probability -‐ minimal. Pharmacists provide many, if not most of the leads provided to law enforcement in DE. Pharmacists working together with law enforcement can make a diﬀerence. Example – we don’t have that. • Climate Change – What I have learned from pharmacists about the change resul.ng from the increase in drug seeking crimes and the eﬀect this has on medical prac..oners. Never experienced such behavior by alleged pa.ents.
• The amount of drugs diverted by a single defendant – Delaware County PA and New Castle County DE 2010 to 2012 -‐ 25,000 dosage units Percocet 10/325. • A pre-‐PDMP inves.ga.on. Discuss M/O. Ini.ally report to us by a dedicated pharmacist
• Use of PDMP -‐ Examples of actual cases where the PDMP is eﬀec.ve in providing leads to law enforcement: • 1. Aids in determining the extent of the forgeries occurring. Recent – Dr S….. • 2. Iden.fy the ac.vity of a doctor shopper. Reported by another dedicated pharmacist. Involved doctors in two states. Ongoing case….
• 3. Counterfeit scripts -‐ Phila Hospital -‐ PDMP Administrator checked further aher viewing writer’s alert and provided other leads based on address of hospital. Ongoing case…… 4. Extent of damage -‐ NY script case. Crime occurs in DE, scripts ﬁlled also in NJ and PA and North Carolina. PDMP aided in determining where the suspects had been. Also Brooklyn suspects in DE and Pocono area of PA. Ongoing case…..
• The PDMP is a valuable aid in the prosecu.on of criminals involved in the diversion of controlled substances. • It is the presenter’s hope that government issued photo ID will be a required part of the data captured in every transac.on involving the dispensing of a controlled substance. Prosecu.ons are made possible and some.mes enhanced by the inclusion of this ID informa.on as part of the PDMP data and most diﬃcult to begin without this ID informa.on. • The PDMP remains a work in progress. For addi.onal reading on where this process is heading, please review the wri.ngs from Brandeis University on this topic. Excellent source.
• Thank you for your aRen.on. I do hope that I provided informa.on you ﬁnd helpful in your work in your jurisdic.on. • If there are any ques.ons here or even later, I am always glad to discuss any ques.ons you may have. • Thank you to Opera.on Unite for invi.ng me to speak. I am thankful for your good work and learn a great deal from my .me here.