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Drug Diversion: Understand Addiction and How It Unfolds

Rodrigo Garcia, MBA, MSN, APN-BC, CRNA, was thriving as a nurse in the late 1990s and into the 2000s in Indiana. Drug diversion wasn't even on his radar.

[caption id="attachment_56034" align="alignleft" width="238"]drug diversion Rodrigo Garcia, MBA, MSN, APN-BC, CRNA[/caption] He worked in all types of critical care areas and was eager to take his career to the next level by completing his education and training as a nurse anesthetist in 2004. Little did he know an ankle injury during a baseball game and subsequent reconstructive surgery a few years later would change the direction of his life. "I was probably 29 years old at the time," Garcia said. "That was the first time in my life that I had ever been prescribed or took an opioid. It was a legitimate prescription for the pain, for the surgery, for the post-op, the recovery and the rehab." The legitimate pain prescribing lasted for three months -- plenty of time for Garcia's body to become physically dependent on opioids. But even he didn't know what was happening at first. "I was never in a situation where there was this euphoria, or I liked getting high, or I was chasing the buzz," he said. "It started with the withdrawal symptoms, which are absolutely crushing and debilitating." Garcia thought he had the flu, then realized he needed to take more of the drug to stop the pain.

No one noticed the drug diversion for quite a while

In the years that followed, Garcia said he was the consummate "super nurse."

"I'd come in early," he said. "I'd stay late. I didn't take bathroom breaks. I didn't take lunch breaks. I took on more patients than I could handle. I'd miss my son's T-ball game."

In reality, Garcia wanted to work in order to get access to the medication. He was diverting meds from the hospital waste receptacle. Even his wife, who was the charge nurse in the surgery department from which her husband was diverting opioids, thought there might be something wrong but wasn't sure what it was. "There was suspicion especially toward the end, but everything that I was doing to sustain the addiction on paper looked like I was a super nurse," Garcia said. "I was winning awards during this whole time." Many of Garcia's colleagues tried to help but were unsuccessful. The interventions went from friendly to punitive. Garcia was fired, escorted off the facility and forced into a treatment center. It was then he realized he was dealing with something much bigger than taking a couple of pills or a few ccs of opioids, and he couldn't get through it alone.

Garcia had to deal with consequences from his state's attorney general and board of nursing. He had to take mandatory time off work, self-report and agree to be monitored. But after about a year, Garcia got back on his feet and under close monitoring, began practicing anesthesia.

He and his wife Claudia Garcia, MBA, BSN, RN, CADAC II, LAC, started speaking publicly about the experience. They returned to school to earn master's degrees and in 2015 opened the Parkdale Center, a treatment center focused on helping healthcare professionals get beyond addiction. Today, Garcia is CEO of Parkdale Center in Chesterton, Ind., and Parkdale Solutions, a consultative service for healthcare facilities to help identify and address diversion of controlled substances by employees. Garcia said he now also runs Indiana's monitoring program for impaired nurses, pharmacists and podiatrists -- the very program that once monitored him.

Drug diversion at U.S. hospitals

Drug diversion at hospitals occurs in different ways. Employees, including nurses, might be diverting from a hospital's waste receptacle to support their habits, which is what Garcia did.

The next level of diversion, according to Garcia, happens when employees divert opioids or controlled substances from patients. And in some cases, employees divert drugs from the hospital to distribute on the streets or to other people.

Garcia estimates 10% of the nursing workforce is battling issues with addiction. Hospital environments create the perfect storm to fuel addiction, according to Garcia, because they offer access to medications, high achievement and high stress.

Addiction signs and symptoms

Addiction is not always evident unless one knows where to look, according to Garcia. In its early stages, addiction is a physical dependency on a medication. Psychological addiction happens later. "The full-blown addiction is a psychological addiction," Garcia said. "That's when you start having the mental health contributing factors -- the depression, the anxiety, the trauma that has been unresolved, the high stress." Coworkers who better understand the problem might identify coworkers suffering earlier -- before it becomes a psychological addiction, Garcia said.

"By the time nurses and the administration can see the stereotypical signs of diversion and addiction, the addiction has progressed to later stages," Garcia said. "You'll see the disheveled nurse. Maybe you'll see some track marks. Maybe you'll see them nodding off, losing weight, irritability. When you see all those stereotypical things the addiction has already been going on for a very long time."

Ironically, the problem of addiction is happening where people expect it least -- among some of the most accomplished, highly educated nurses, physicians, pharmacists, etc., according to Garcia. "The addict, the impaired nurse, the impaired provider, they're intelligent," Garcia said. "They graduated in the top 25% of their class. They're often supervisors. They hold advanced degrees. They're well liked. They're charming. They come in early. They stay late. They offer to do all the cases."

First step is admitting the problem exists

Drug diversion by hospital employees is a hidden epidemic feeding into the nation's opioid crisis, according to the report Health Care's Hidden Epidemic: A Call to Action on Hospital Drug Diversion released in 2019 by medical technology company BD. But there's an element of denial. Based on the report's survey of 650 healthcare professionals about drug diversion in U.S. hospitals, 85% of providers surveyed are concerned about drug diversion but only one in five thinks it's cause for concern where they work. [caption id="attachment_56035" align="alignright" width="300"]drug diversion Kelly Robke, MBA, MS, RN[/caption] There are ways in which nurses become proactive, getting involved with and leading efforts to monitor for and address drug diversion, according to Kelly Robke, MBA, MS, RN, vice president of clinical thought leadership at BD.

  • Communicate. "Narcotic diversion by healthcare providers in the inpatient care setting can be a taboo subject, allowing this phenomenon to fly under the radar," Robke said. "Peer-to-peer conversations and other open communications can help nurses understand the risks they face. Statements, such as 'I'm concerned about you. I want to help you' or 'I don't know what is going on, but I think you need to get help,' are good ways to express concern for colleagues and show support to a colleague who may be at risk."
  • Pay close attention to injuries. "In addition to the role nurses play as leaders in care delivery and advocates for patients, the profession can be physically demanding," Robke said. "Through the delivery of patient care, nurses can periodically sustain physical injuries related to their duties. Sometimes injured nurses may return to work before they are fully healed, making opiates available for patient administration particularly tempting to take for their own pain control. Nurses coming back from an injury can be supportively monitored to ensure they are ready to return."
  • Take advantage of support systems. "Nursing can be quite stressful," Robke said. "While most nurses employed in the inpatient setting are generally aware of employee assistance and other programs that can help them manage their stress, many do not take advantage of programs that can assist with substance use disorder, or subsequent opiate diversion from inpatient care medication supplies. Encouraging colleagues to access their hospital's emotional support programs can ease the pressure and potentially prevent diversion."

Garcia's message to nurses? There is help.

"There's a way to preserve your license. There's a way to preserve your integrity. There's a way to preserve your ability to work and support your family, and there's a way to get better," Garcia said. "You just have to take the first step and ask for help."

Nurses can contact a center like Garcia's or contact their state board monitoring program. If nurses reach out before punitive action happens, they can get help without going through what Garcia did. "If I would have known that there was a way to get help without getting in trouble, I would have asked for help many, many months earlier," he said.

Take these courses about drug diversion:

  • Prescription Drug Abuse (1 contact hr) Most people take prescribed medications properly, but many obtain drugs fraudulently, use medications that are not prescribed to them, or use more than prescribed or take them for reasons other than medically indicated. The nonmedical use of prescription drugs has been increasing rapidly in recent years. The most commonly abused prescription drug categories include pain relievers, stimulants, sedatives, and tranquilizers. Drug overdose deaths more than tripled from 1999 to 2015. Through 2015, drug overdose remained a large and growing public health crisis in the United States. This CE module provides nurses with information about prescription drug abuse, high-risk groups, factors related to misuse, and assessment/treatment strategies. 
  • Recognizing Drug-Seeking Behavior (1 contact hr) The 2016 National Survey on Drug Use and Health estimated that 6.2 million Americans ages 12 and older misused psychotherapeutic drugs in the previous month. Of those, 3.3 million were misusers of pain relievers, 2 million of tranquilizers, 1.7 million of stimulants, and 497,000 of sedatives (totals exceed 6.2 million because some of those surveyed misused more than one type of drug). The increased emphasis on pain management to improve quality of life and functionality of people who live with chronic pain has contributed to more than a twofold increase in the number of opioid prescriptions being written in the U.S. The ethical need to adequately treat pain must be balanced with a responsibility to minimize misuse and abuse of medications that treat pain. We are in the midst of an opioid abuse epidemic, and drug seeking is especially problematic. 
  • Controlled Substances Prescribing Practices (2 contact hr) Healthcare providers face many difficulties when prescribing controlled substances for pain control, anxiety disorder, and attention deficit hyperactivity disorder. The pressure to aggressively treat patients' symptoms, coupled with current public health problems such as rising drug overdose rates, creates a major dilemma for healthcare providers. Determining which patients could benefit from prescribed controlled substances and which patients could be harmed by taking these medications is not always easy. Discussing recent guidelines and evidence-based literature evaluating safe prescribing practices can be beneficial to both healthcare providers and patients. Completion of this module will satisfy one hour continuing medical education for states that require specific continuing medical education for prescribing controlled substances.