Expert Discusses How Pharmacists Can Help Prevent Drug Diversion

Pharmacy Times®: How can institutions better approach and resolve drug diversion? What methods of intervention might be the most effective?

Jake Nichols: Great question. Initially, we thought technology would take care of this problem with the advent of systems like Pyxis, and so forth, which were instituted in a very large fashion, across institutions in throughout the country. And again, as substance users get more savvy, and they know the system, they've been able to subvert that. There’s definitely a role for improved technology in this as well, and has to go along with that is training around what those signs and symptoms are of substance use and an individual. Training around methods of how to, for lack of a better term, confront these individuals and expressing concern.

I think we do a very poor job in utilizing objective measures such as urine drug screens. I always give the example, in my 15 years of substance use, every job that I ever had had a clause in my contract that I could be randomly tested at any time. Never once was I asked to perform a urine drug screen. Again, there are issues around that. People don’t want to be confrontational, feel that they’re accusatory, but if we are able to institute a system whereby this is done for everybody randomly, we can hopefully head some of this off. Then finally, again, as I mentioned, institutions, organizations have to have resources to be able to refer people into. We need to do a good job at taking care of our own, whether that’s physicians, pharmacists, or nurses, or any other health care providers for that matter, and see that they have a disease that is very treatable. Outcomes are actually very good for health care providers when they go into substance use treatment.

Pharmacy Times®: What can pharmacists do to help prevent drug diversion?

Jake Nichols: As a profession, we have suffered from lack of education around what addiction is and what the signs and symptoms are. And that’s not unique to our profession by any means. If you ask any physicians or nurses, even dentists, physical therapists, none of us have had a lot of education around substance use, especially around detecting the signs and symptoms, and how to confront somebody, for lack of a better term, and express your concerns around that. That’s what I usually will suggest to pharmacists. Do not take a confrontational approach. If you have a concern about one of your peers, express that concern, don’t be accusatory. Literally state, “something is different about you, I’m not sure what it is, and I don’t want to make any assumptions, but if I can help you in any way, please let me know, and I’m willing to do that,” and ensure that you’ll keep that confidential. Again, there’s a tremendous fear of consequences, repercussions, and loss of license when somebody is dealing with this, and that’s completely understandable, especially if you’re supporting a family, and that’s your income stream. But again, if we’re able to have those conversations, be better trained in how to detect this, and find ways to creatively and efficiently address this and have conversations with our peers, hopefully, we can head these things off before they become too destructive.

Pharmacy Times®: What is the stigma around drug diversion? And what are the best ways to address and fight that stigma?

Jake Nichols:That’s a great question, and it is a distinct issue. I mean, drug diversion, as it remains, is very stigmatized, because again, as a health care provider having privileged access to those substances, when you are found to have diverted substances, it is almost seen by folks as a betrayal—as a theft. And again, a lot of that is not understanding the disease. I have never seen a case that I’ve been personally consulted on in my 12 years where a healthcare provider which diverting substances to sell to somebody else. It’s almost exclusively for personal use to support their own addiction. And again, people get to the point where they’re not getting high. It’s really a matter of just maintaining this kind of plateau state, so you don’t get sick from withdrawal. When it’s found that you’ve kind of crossed that line, and again, people see it as a betrayal of trust that you’ve been given from the public, there’s a stigma that’s associated with that, and it becomes very offensive to certain individuals.

Pharmacy Times®: In addressing that stigma, what impacts can initiatives such as education programs have on that stigma?

Jake Nichols: I think so. Stigma, as we look at substance use disorders as a whole, is our primary issue that’s really preventing us from getting a lot of traction and really helping people. What I have seen is the reactions of those individuals, like I described, are usually the result of lack of education. So, would it solve everything? Absolutely not. But I think it would make a giant impact on people’s perceptions and understanding of the reasons behind drug diversion. Again, it’s a survival mechanism is part of this disease where your brain is telling you, you need to do this.

Pharmacy Times®: How does the institutional setting, for example, a hospital compared to a retail pharmacy setting, affect how drug diversion occurs?

Jake Nichols: Another great question. In the hospital settings, in the institutional settings, there tends to be more, I guess, what we call passive observers. The system itself is observed and accessed by a variety of different health care providers: pharmacists, nurses, administrators, and so forth. You have more opportunity to identify potential issues and dig into them. Whereby in a community setting, in the traditional community setting, the pharmacist is really the one who’s maintaining the inventory of controlled substances. They’re usually the ones counting, dispensing, verifying. And the less folks that are looking into that—because this isn’t typically something that supervisors will come in to the store and open the inventory and go through it unless there’s an issue—I think provides a higher potential for diversion with also the fact that you have less staff and again, less of those passive observers around you, that it seems to be easier to get away with, at least in the short term.

Pharmacy Times®: Any closing thoughts?

Jake Nichols: If I had to leave with one thought it would be, remember, these are individuals. These are not folks that are looking to betray you through drug diversion. They truly have a sickness, a disease that is scientifically established and proven. This is not a matter of will or choice for individuals. We as pharmacists encounter folks with this disease state every day, and I think we do a great job, for the most part, in managing those folks and helping them in facilitating their recovery. And I hope that we can do the same for our peers, because there's a lot of us out there that need that help. Numbers have actually reported that rates of substance use are similar in healthcare populations as they are to the general population. My experience has been very different. I feel that it's underreported, for obvious reasons, fear of punitive action and legal ramifications. I would say it's probably a few percentage points higher. But if we can do a better job at identifying diversion early, and concurrently facilitating folks getting into treatment, I think we can do a pretty good job of managing this issue.