An Informatics Approach to Preventing Diversion of Controlled Substances

Tragically, deaths due to drug overdoses have escalated in recent years to more than 100,000 annually.¹ While many people associate narcotic abuse to be driven by drug cartels, opiates and other controlled substances are also diverted from medical waste at hospitals. According to the American Society of Health-System Pharmacists (ASHP), diversion of medical waste creates “serious patient safety issues, harm to the diverter, and significant liability risk to the organization.”²

Yet, in my experience as a hospital pharmacist, many hospitals do not fully understand the volume of waste generated during patient care. Through a simple analysis of data, hospitals can find solutions for reducing waste to address drug diversion and wasted money and staff time.

Through a simple analysis of data, hospitals can find solutions for reducing waste to address drug diversion and wasted money and staff time. Image Credit: © praewpailyn - stock.adobe.com

Drug Diversion: A Widespread Problem

Wasted controlled substances are commonly diverted in several ways, according to ASHP.² For instance, excess drug may be withdrawn and replaced with saline. Expired controlled substances may be diverted from holding areas or taken from unsecured waste containers.

A variety of studies and reports document the scale of the problem:

• Nearly all participating health care executives in a recent survey agreed that drug diversion is occurring, and about two-thirds are “not confident” or only “somewhat confident” that drug diversion programs are effective.³
• About 10% of American health care workers abuse controlled substances, a rate that matches abuse in the general US, according to The Joint Commission.⁴

The Costs of Medical Waste

Addressing medical waste can also help reduce costs both in terms of unused drugs and staff time required to document waste, according to a recent study.⁵ Each time a dosage is only partially used, nurses must log into a reporting system to enter the drug wasted. This requires getting another nurse to witness the disposal, then to validate the disposal. The drug is put into a receptacle for controlled substances, which also has associated costs. The study found that “there are financially significant costs associated with wasting both the product and the valuable time of a skilled workforce.”

Quantifying Medical Waste

Despite this thorough documentation process, in our experience many hospitals underestimate the volume of waste that can be generated. Our team of pharmacists has developed a data-focused method to help hospitals quantify medical waste of controlled substances and calculate the cost of discarded drugs and staff time for documentation. Many of the hospitals we work think they do not have much waste—until they see the data.

The process starts with accessing data from the hospital’s waste reporting system (typically an automated dispensing system). This report provides detailed information about each incident in which nurses documented waste of controlled drugs, including the medication, the dosage, and the cabinet location from which it was dispensed. For instance, this granular detail might show a nurse administered a 0.2 mg dose from a 1 mg vial, meaning 0.8 mg were wasted.

A Solution: Right-Sizing Vials

The analysis often points to a basic problem: Controlled substances are typically packaged in vials with more drug than is commonly needed. For instance, a common opiate is typically available in 100 microgram (mcg) vials. However, the typical starting dose, our analysis shows, is more commonly 25 to 50 mcg. As a result, the remaining medication is wasted—and available for diversion—while adding cost from unused product and staff time for documentation.

This is a common issue because product size is traditionally selected by a pharmaceutical company in order to maximize flexibility in potential dosing needs, which is set when any new drug comes to market, including controlled substances. After patents expire, manufacturers of generic versions adopt the same dosing standards used with the branded product along with presentation, concentration, and other factors. While that approach makes sense for most drugs, dosage is an important consideration with some controlled substances because wasted medications can be illicitly diverted.

At Fresenius Kabi, we assess packaging size when launching products. For example, we offer a 50 mcg prefilled syringe of a common opiate, which helps provide the right amount of drug for many patients while helping reduce or eliminate medication waste—and potential opportunities for diversion.

Our data analytics validate this approach. At one hospital, we found that over a 90-day period there were more than 3700 instances in which a nurse documented waste of a common pain medication. About half of those waste instances could have been avoided by using a right-sized product, which would have saved 128 hours of staff time.

At one hospital, we found that nearly 13,000 vials of narcotics were wasted on an annual basis. That translated into about 450 hours of staff time wasted at a total cost of more than $71,000.

When reviewing the results, hospital leaders can be surprised by the volume of waste of controlled substances their hospital can generate, as well as the financial costs of diversion risks. Through careful data analysis, hospitals can reduce costs, simplify documentation demands for staff, and play an important role in addressing drug diversion.

About the Author

Matthew Farley, PharmD, is an informatics pharmacist and serves as Director, Medication Technology & Analytics at Fresenius Kabi USA, a leader specializing in lifesaving generic medicines and technologies for infusion and clinical nutrition.

REFERENCES

1. National Center for Health Statistics, Provisional Drug Overdose Death Counts. Updated January 7, 2024. Accessed May 30, 2024.https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
2. ASHP Guidelines on Preventing Diversion of Controlled Substances. 2022. Accessed May 30, 2024.https://www.ashp.org/-/media/assets/policy-guidelines/docs/guidelines/preventing-diversion-of-controlled-substances.ashx
3. Wolters Kluwer. The State of Drug Diversion 2023 Report. September 2023. Accessed May 30, 2024.https://www.wolterskluwer.com/en/expert-insights/the-state-of-drug-diversion-2023-report
4. The Joint Commission, Drug diversion and impaired health care workers. April 2019. Accessed May 30, 2024.https://www.jointcommission.org/-/media/tjc/newsletters/quick_safety_drug_diversion_final2pdf.pdf
5. Hertig J, Jarrell K, Arora P, et al. A Continuous Observation Workflow Time Study to Assess Intravenous Push Waste. Hosp Pharm. 2021;56(5):584-591. doi:10.1177/0018578720931754