DRUG DIVERSION TRAINING Jassin M. Jouria, MD Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. ABSTRACT As prescription drug misuse becomes more common, medical professionals are being forced into the role of detective, evaluating every patient — and coworker — for their potential for drug diversion. Clinicians must be able to identify characteristics of drug diverters and provided with tools to help them prevent diversion. Strategies to address the problem of drug diversion are discussed. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 3 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Statement of Learning Need Increasingly, health team members are required to update their knowledge and practices to recognize and prevent drug diversion. The rise in public access to information about disease cures and, in particular, by drug diverters, has led to heightened challenges and surveillance measures. Current federal and state laws require health administrators to develop drug diversion prevention programs that include mandatory training by all employees to recognize and report a substance use disorder in the workplace. Course Purpose To provide knowledge for clinicians expected to be compliant with the regulation of controlled substances, and to recognize and report the signs of drug diversion. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC - all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 1. Most drug diverters will divert drugs from some of the following categories: a. Opiates b. Stimulants, Pseudoephedrine and Ephedrine c. Central Nervous System Depressants d. All of the above 2. True or False: Dextromethorphan is part of a classification of drugs called antitussives that are found in less than 10 products. a. True b. False 3. Prescription Drug Monitoring Programs utilize databases that do the following except: a. collect and store information regarding the prescription, dispensing, and use of prescription drugs b. collect information regarding the patient, practitioner, and pharmacy used c. consistently collect information from prescribers d. include gaps in process that can cause drug diversion to go undetected 4. A prescription for a controlled substance must: a. be dated and signed by the prescriber on the date issued b. include one patient identifier c. include only the drug name, strength and number prescribed d. none of the above 5. In the past decade, there has been an increase of _____ in the number of cases related to prescription painkillers. a. 40% b. 200% c. 400% d. 100% nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 Introduction As prescription drug misuse becomes more common, medical professionals are being forced into the role of detective, evaluating every patient - and co- worker - for their potential for drug diversion. Drug diversion can take many forms, but the most common types of drug diversion include theft from family and friends, doctor shopping, and theft from healthcare facilities.1 It is important for medical clinicians and pharmacists to be aware of the different strategies for drug diversion as well as the common characteristics of individuals with a substance use disorder, as this information will help reduce the incidence of drug diversion. Drug Diversion And Scope Of The Problem The National Association of Drug Diversion Investigators provides the following definition for drug diversion:2 Drug diversion can be defined as any criminal act or deviation that removes a prescription drug from its intended path from the manufacturer to the patient. This can include the outright theft of the drugs, or it can take the form of a variety of deceptions such as doctor shopping, forged prescriptions, counterfeit drugs and international smuggling. Prescription drug misuse and drug diversion is a significant problem that affects numerous individuals. As the availability and scope of prescription drugs have expanded to include a range of opiates, non-opiate depressants, stimulants, and potent cold medicines, so too have the misuse of these substances and the tendency to use them recreationally. Prescription drug use is a growing problem that can be difficult to identify. In the past decade, there has been an increase of 400% in the number of treatment admissions nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 related to prescription painkillers, and a significant number or prescription drug related deaths.3 Approximately seven million Americans misuse prescription drugs, which is more than the number of individuals addicted to all forms of illegal drugs.4 This study focuses on the jurisdiction of West Virginia as an example of regional efforts to improve regulation of controlled substances. In West Virginia, it is reported that the number of individuals that died from overdosing on prescription drugs is higher than the number of individuals who have died from overdosing on illicit drugs.5 In fact, prescription drug misuse is considered a significant problem in West Virginia, as a large percentage of the population is affected.6 Other state jurisdictions report outcomes, which more or less compare with those of West Virginia and may be found at the U.S. department of Substance Abuse and Mental Health Services Administration (SAMHSA) website: http://www.samhsa.gov/data/2k12/NSDUH115/sr115-nonmedical- use-pain-relievers.htm. For the purposes of this brief self-study, the focus will be on West Virginia as a case example within a much broader and growing national concern about the problem of drug diversion within and across state borders. While any type of prescription drug can be diverted, it is most common for individuals to divert those that are classified as controlled substances as they tend to have a physical or psychological effect on the body.7 Drug diversion occurs when patients are addicted to the drugs, which is most common with those classified as controlled substances. Most drug diverters will divert drugs from the following categories:8 Opiates nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 Pseudoephedrine and Ephedrine Dextromethorphan Central Nervous System Depressants Stimulants Drug diverters do not fall into one specific category. In fact, drug diverters are categorized based upon the ways in which they divert drugs. The following is a list of the different types of drug diverters.9 Individual Drug Diverters Patients Healthcare workers Drug Dealers Drug Addicts Organizational Drug Diverters An Organization with a defined hierarchy (Managers, Supervisors, Recruiters, Runners) Pharmacy Employee Pharmacist Pharmacy Technicians Physicians Wholesale Distributors The list above provides examples of all the types of drug diverters. However, the most common drug diverters are individuals, healthcare nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7 workers and pharmacy technicians.10 Therefore, this course will focus primarily on those