Expert Discusses Drug Diversion in the Pharmacy

Pharmacy Times®: Could you explain your experience with drug diversion and what drug diversion is?

Jake Nichols: My personal experience with drug diversion is just that—it’s personal. I am a pharmacist in long term recovery. I've been working in the addiction field for over 12 years, which also correlates to the amount of time I've been in long term recovery. My path, like many healthcare professionals, involved drug diversion, which is using substances, usually pharmaceutical-grade prescription substances, without a prescription that you have access to through your employer. In my case, being a pharmacist, there was obviously ready access to a variety of different controlled substances. I was taking them without authorization, obviously, illegally and consuming them for my own use.

Pharmacy Times®:Can you describe your path since you entered recovery?

Jake Nichols: Sure. I entered recovery in July of 2010. As a pharmacist, I found my options very limited. And at the encouragement of a peer and a very close friend, I started going out and sharing my experience and talking to my peers to other pharmacists about this disease and found that it had quite an impact on individuals. I was perceived as somebody who was well known and respected as an educator, especially in Massachusetts. It was really earth shattering to a lot of people that I came forward with this and that I was found to have this issue and was charged with multiple issues relating to drug diversion. It was a wakeup call for a lot of my friends, my peers, my classmates, in terms of what this disease truly was.

That openness and honesty actually opened a lot of doors for me, where I started in early career working in pharma as a medical science liaison. I did that for multiple different addiction-focused companies. The network that I built up through that, as well as me going out and continuously speaking and sharing my stories at pharmacy schools across the country, opened up a lot of additional doors, and I formed my own consulting group in 2017. Since then, I've been involved in a variety of different things from having my own clinics, to working with digital companies that have apps, for lack of a better term, for addiction treatment support, working with health plans, working with correctional systems. There's a lot of opportunity for pharmacists in this field, as obviously, this is a medication, a drug related issue. I found once I started working in the field, that there was this tremendous knowledge gap, related to pharmacology and how these substances work in individuals. It's been great to see more of my peers and recent graduates get into this field as they get out and do residencies in either psychiatry or directly in addiction and get more involved in treatment and more involved in the communities I've done. I’ve been very lucky.

Pharmacy Times®: Can you speak to what it’s like experiencing addiction as a healthcare worker?

Jake Nichols: Experiencing addiction as a healthcare worker is very hard. It's obviously very hard for anybody, but there are some unique facets to being a health care provider with a substance use issue. The first is the shame that comes along with it. You are judged, by many of your peers, to be inferior. In fact, a statement was made by a member of the board of pharmacy that said I had betrayed our profession and I had betrayed the public trust. And that's a reflection of the stigma that goes along with addiction and substance use issues. It's usually lack of education or even personal issues and experiences as this has touched so many. Many have had very negative experiences with friends and family members, and that's what they carried with them and that's completely understandable.

Pharmacy Times®: Why are addiction and drug diversion sometimes hidden or ignored by institutions?

Jake Nichols: When you're in the throes of addiction, obtaining your substance literally becomes a survival mechanism. You become quite adept at hiding your tracks, if you will. Knowing the system of drug distribution throughout an institution or even in a community pharmacy gives you, for lack of a better term, an advantage in being able to secure those substances, but also for many long periods, being able to hide that substance use from others or make convincing excuses as to why substances may be missing. In many cases, especially in institutional settings, it involves removing medication that was supposed to go to a patient and replacing it with something like saline or sterile water for injection. That is really undetectable. In many cases—and obviously, they look very similar, they're both colorless—unless somebody was to randomly test that compounded IV solution or whatever substance or prescription that we were making our order. It's very hard to detect that. And again, knowing those systems, they can be manipulated as well.

Pharmacy Times®: How can institutions and employees, specifically pharmacists, spot drug diversion?

Jake Nichols: There's some really standard, almost, signs and symptoms of substance use disorder, especially in health care providers, that's somewhat unique. Varied work schedules, meaning people are showing up late or volunteering to stay later than their shift even when they're not being paid overtime, or wanting to work shifts that there are less individuals around to observe them. Overnights are an example. Erratic behaviors, disappearing for long periods of time—and that may be because they're so intoxicated that they don't feel comfortable being around others. Sometimes they'll have to go and basically take a nap because certain substances have really drained them, and they have to kind of reenergize. And, what we see a lot in practices is these things are observed. There may be suspicions about substance use or maybe even behavioral health issues, and we don't confront those individuals for fear of confrontation. In addition, in many cases, we don't know what to do with that individual. We don't have the resources to be able to help them. Again, dealing with a legal system and it being punitive and being involved with, that is very daunting for people.

Pharmacy Times®: What issues exist with current methods of addressing drug diversion?

Jake Nichols: I think the primary issue we're dealing with when it relates to drug diversion, especially with healthcare providers, is again, not knowing what to do with these individuals. What I've seen in my 12 years of working in the field and consulting with various institutions, specifically around diversion, is that the signs and symptoms are there, but folks are ignoring them for fear of having to deal with it and the ramifications and consequences of dealing with it. That can be concerns about institutional exposure. It can be concerns about ruining an individual's life, having to report this to their licensing boards and to law enforcement. Probably most common is not having the resources to be able to facilitate a transition into treatment. So, they're left with really one option, and that's to dismiss the individual and report them to the licensing boards. We have a large educational gap around what addiction is, as well. And again, as I mentioned previously, stigma is a big part of it. But all these contribute to a perpetuation of these situations where healthcare providers are diverting substances usually for personal use, almost primarily for personal use.