There are many lights shining today on the health care industry. One illuminates a corner that until recently was largely hidden from public view: the issue of drug diversion in hospitals and other facilities and provider impairment and addiction.
The attention comes in the wake of highly publicized instances of health care workers stealing drugs and putting patients at risk. One such case, in Colorado, also exposed the problem of monitoring individuals who continue to secure hospital jobs even after being dismissed for diverting drugs.
Add to that a mountain of publicity about soaring rates of addiction to and deaths from opioid painkillers, and it is little wonder that the public worries about the sobriety of the physicians and other health care workers who treat them.
Against this backdrop, UCHealth and others in the health care industry are working toward improving systems that protect both patients and the rights of providers and other employees – all the while recognizing that addiction is a treatable disease that pays no heed to the professions of the individuals it strikes.
Putting commitment to the test
These and other issues were brought to the forefront last week by Michael Fitzsimons, MD, director of the Division of Cardiac Anesthesiology at Massachusetts General Hospital. Fitzsimons visited the Anschutz Medical Campus at the invitation of Jean Kutner, MD, MSPH, chief medical officer for University of Colorado Hospital.
Fitzsimons heads the Substance Use Disorder Prevention program in Mass General’s Department of Anesthesiology, Critical Care and Pain Medicine. The program, launched in 2004, includes mandatory pre-placement and random urine drug testing for all members of the department, including attending physicians, certified registered nurse anesthesiologists, residents and fellows.
In a presentation at the Bruce Schroffel Conference Center at UCH May 18, Fitzsimons said that prior to the testing program, the department identified drug abuse in 2.2 percent of first-year anesthesiology residents. It’s now zero for that group – significant not only for public safety but also because research has shown that substance use disorders among anesthesiologists generally increase their risk of death from suicide, drug overdose and other causes.
“Their drug-related death risk remains higher through the remainder of their careers,” Fitzsimons said. “The stresses never go away.”
Mandatory drug testing has long been in place for federal workers in areas such as transportation, but the health care industry generally, and physicians specifically, have historically been self-regulated, Fitzsimons said.
“As physicians we’ve said, ‘We’re different. [Addiction] doesn’t happen to me,’” he said. “But that’s wrong.” The problem can’t be kept under wraps, he added. “With the dawn of the internet, people doctor shop. Society is paying more attention, and no one can argue that we aren’t tasked with the safety of the public.”
Untangling the truth
But Fitzsimons emphasized that random drug testing is not a panacea for a complex societal problem. The Mass General program includes not only a stringent testing system designed to ensure accurate results, but also an “intervention” for individuals who have a positive test. The process involves the provider meeting with Fitzsimons, the department chair, the vice president of education, and a psychiatrist.
“We’re there to ask tough questions,” Fitzsimons said. “It’s important to remember that the test shows only the presence of drugs, not necessarily abuse, misuse or dependence. Each situation is different, and there is always an element of judgment. Random testing is only one component of an effective program.” For example, he said, all anesthesiology residents get education on substance control, including lectures and videos, an important element of prevention.
Kutner noted that the School of Medicine – like UCH – already drug-tests individuals “for cause.” She said the recent spate of highly visible diversion cases and the harm inflicted on patients convinced her and other faculty and hospital leaders of the need to scrutinize the processes in place.
“As a hospital, school and system, we have a number of programs already that relate to mitigating drug diversion, assuring patient safety and protecting the health of faculty and staff as it relates to substance use disorders,” Kutner said. “However, we have been reminded of the need to look at our policies and procedures and ask ourselves what we can be doing better,” Kutner said.
Balancing obligations
At the May 17 meeting of the Medical Board, UCH Pharmacy Director Nancy Stolpman, PharmD, PhD, presented an overview of the systems the hospital currently uses to detect and prevent drug diversion. She identified a handful of diversion cases since 2013 but acknowledged that there very likely have been more.
Medical Board President Ethan Cumbler, MD, showed the group a list of hospitals in Colorado that appeared in a recent Denver Post story on provider drug diversion and addiction. “It’s probably the tip of the iceberg,” Cumbler said. He noted the article’s point that in a large number of drug-theft cases, patients and other hospitals did not learn the identities of the providers involved.
“It contributes to the perception that organized medicine favors providers at the expense of patients,” Cumbler said. “We have a moral obligation to keep patients safe from harm by impaired clinicians.”
The observations of Stolpman and Cumbler strike at the heart of the dilemma facing hospitals and physicians, said Carolyn Sanders, RN, PhD, chief nursing executive for UCHealth and chief nursing officer for UCH.
“There is no doubt that drug diversion is underreported in our industry,” Sanders said. The difficulty of an institution monitoring thousands of doses of highly addictive drugs is illustrated by the fact that UCH alone has more than 2,000 nurses, she said. “What worries me the most is the risk to our patients and our providers.”
Sanders noted that UCHealth terminates any employee who diverts drugs. “But addiction is obviously a disease,” she added. “The question of how we can support our own providers who are in recovery is causing us to put a bigger spotlight on our policies and practices around drug diversion and tampering. We don’t want to jeopardize a career because of the disease, but we also must protect our patients.”
Bolstering defenses
The hospital is looking at bolstering or implementing a number of steps to decrease the risk of drug diversion, Sanders said. They include close monitoring of the “chain of custody” when addictive drugs like fentanyl are involved, monitoring the amounts of drugs used on units, performing random refractometry tests of syringes in the Pyxis system to test their contents, and administering pre-employment drug screens.
On tap for fiscal year 2017, which begins July 1, is badge access for anesthesia medication carts, she added. Also in the works are new steps designed to guard against prospective employees with drug-diversion dismissals on their records from gaining employment at UCHealth or other hospitals.
“As employers, we’re trying not to hire those individuals so they won’t continue to put others at risk, and as a health care community, we must work together to accomplish this,” Sanders said.
Julie Lonborg, vice president of communications and media relations for the Colorado Hospital Association, noted in an email that a Colorado law enacted in 2010 protects hospitals that share information with other hospitals about an employee seeking work “who has been terminated due to drug diversion, drug tampering, patient abuse, violation of drug or alcohol policies of the employer, or crimes of violence.”
Random drug testing is among the topics under discussion at UCHealth.
Kutner said she is continuing to explore strategies to address the problem with Sanders, Cumbler, UCHealth Chief Human Resources Officer Dallis Howard-Crow, and UCHealth Chief Medical Officer Bill Neff, MD. She also plans to contact the Cleveland Clinic and Mayo Clinic. Those institutions have system-wide drug testing, while Mass General’s program covers only anesthesiology.
“It is our responsibility as a self-regulating profession and as an institution to make sure we have all procedures in place for keeping patients safe,” Kutner said. “At the same time, we must design a program that does not put careers at risk and is transparent, with controls in place.”