Health care investigations_final

Health  Care  Inves.ga.ons  

Karen  Ma3hew  Director  of  Inves.ga.ons  and  Inspec.ons,  North  Carolina    Department  of  Pharmacy    

Agent  Bruce  DiVincenzo  Delaware  State  Police  Drug  Diversion  

Unit  

LEARNING  OBJECTIVES  –  

1.  List  signs  of  diversion  in  a  health  care  facility.  2.  Outline  how  to  collaborate  with  clinicians  to  

prevent  diversion.  3.  Demonstrate  effec.ve  use  of  PDMP  by  law  

enforcement  within  a  pharmacy.  

Disclosure  Statement  

•  Karen  MaRhew  has  no  financial  rela.onships  with  proprietary  en..es  that  produce  health  care  goods  and  services.    

•  Bruce  DiVincenzo  has  no  financial  rela.onships  with  proprietary  en..es  that  produce  health  care  goods  and  services.    

Health  Care  Facility  Diversion    

Karen  MaRhew  April  2,  2013  

WHAT  IS  DRUG  DIVERSION?  

The  channeling  of  controlled  substances,  which  are  legally  manufactured  &  intended  to  be  used  legi.mately  for  medical  &  therapeu.c  needs  by  a  license  prac..oner,  pharmacist,  hospital,  nursing  home  or  medical  research  center,  to  an  illegal  use,  whether  it  be  for  personal  use  or  for  illegal  distribu.on  to  another  person.  

IN  OTHER  WORDS……  

Diver.ng  legi.mate  Drugs  for  illicit  or  illegal  purposes.  

WHAT  DOES  HEALTH  CARE  FACILITY  MEAN?  •  Hospitals  •  Nursing  Homes  •  Assisted  Living  Facili.es  •  Group  Homes  •  Clinics  •  Physicians’  offices,  other  facili.es.  

WHO  COMMITS  DIVERSION?  

ANYONE!!  

MORE  SPECIFICALLY:  •  PRESCRIBERS  –  MD,  DO,  DDS,  DMD,  Vet,  DPM,  NP,  RN  

PA,  CPP  •  DISPENSERS  –  RPh.,  Tech,  Clerk,  Other  employees  •  ADMINISTRATORS  –  RN,  LPN,  NA,  CMA,  CNA,  Med  

techs  •  OTHERS  –  who  have  access  through  employment  or  

obtain  access  

WHAT  IS  DIVERTED?  •  High  Priced  Medica.ons  such  as  Erec.le  

Dysfunc.on  Drugs,  Chemotherapy  ,  etc.  •  Drugs  Easily  Abused  –  Oxycodone,  Hydrocodone,  

Morphine,  Fentanyl,  Dextroamphetamines,  Benzodiazepines  

•  Any  Type  of  Medica.on  

THE  “WHYS”  OF  DIVERSION  

•  Addic.on  •  Facilitate  the  addic.on  of  others  •  Pseudoaddic.on  •  To  sell  for  money  •  To  provide  to  others,  par.es,  etc.  •  Cost  of  prescrip.on  drugs  •  To  facilitate  sexual  acts,  assaults,  etc.  •  Every  reason  one  can  think  of  

DRUG  FLOW  INTO  HEALTH  CARE  FACILITIES  

CRADLE  TO  GRAVE  APPROACH  

DRUG  FLOW  

•  Manufacturer  –      Wholesaler  (Pharmaceu.cal  Company)    Broker    Distributor  

•  Courier  Service  –    Delivery  to  the  Health  Care  Facility  

DRUG  FLOW  

•  Health  Care  Facility  –    Pharmacy    Materials  Management  

•  Closed  Door  Pharmacy  –    Directly  into  ins.tu.on  

DRUG  FLOW  

Once  in  a  Hospital  :    -­‐  Inventoried  &  Stocked  in  Pharmacy    -­‐  Placed  onto  shelves/cabinets,  etc.    -­‐  Automated  Dispensing  Units/robots    -­‐  Vaults  

DRUG  FLOW  

Drugs  are  sent  out  of  the  pharmacy    -­‐  Based  on  Dr.  Order    -­‐  to  Basic  stock    -­‐  Nursing  Units    -­‐  Pa.ent  Areas    -­‐Specialty  Areas  (surgery,  CT      labs,  ED)    -­‐Outpa.ent    -­‐off-­‐site  areas  

DRUG  FLOW  

Once  a  drug  is  sent  out  of  the  pharmacy,  It  is  administered  according  to  the  Policy/procedure  of  the  ins.tu.on.  

Example  –  Automated  Dispensing        Machines            Medica.on  Administra.on      Record      (MAR)  

DRUG  FLOW  

•  Waste  –  pa.ent  refusal,  leh  over,  expired,    contaminated.  

•  Legally,  if  a  drug  is  signed  out,  it  must  be      administered  or  wasted.  

May  be  returned  to  stock  under  ins.tu.onal  Policy,  state  law,  etc.  

DRUG  FLOW  INTO  OTHER  FACILITIES  

Nursing  Home  flow  is  similar  to  hospitals  except  they  Contract  with  LTC  pharmacies  or  retail  pharmacies  to  Provide  drugs  –  normally  pa.ent  specific  

DRUG  FLOW  

•  Some  nursing  homes  &  other  facili.es  now  u.lize      automated  dispensing  machines.    (If  controlled    substances  are  administered,  need  DEA    registra.on  &  Board  permit).  

•  Other  nursing  homes  u.lize  medica.on  carts  •  Some  use  unit  dose  carts,  pa.ent  specific  •  Medica.ons  administered  to  pa.ents  by  RNS,  LPNS,  

 med  techs,  CNAs,  etc.  

WHERE  DOES  DIVERSION  TAKE  PLACE?  

ANYWHERE  WHERE  DRUGS  ARE  STORED  

START  AT  THE  BEGINNING  

Courier  Service:    Package  Disappears    Packages  are  not  sealed  completely      (altered)    Packing  is  different  than  past  deliveries    Change  in  delivery  schedules    Personnel  ac.ng  differently  

NOW  WHAT?  

Couriers  are  aware  they  are  delivering    drugs.  

Ensure  there  are  good  tracking  systems    from  wholesaler  to  facility.  

Once  package  is  delivered,  contents  need    to  be  inventoried  immediately    against  invoice/manifest.  

DRUGS  ARRIVE  IN  THE  FACILITY  

•  Drugs  should  be  inventoried  &  stocked  as  soon    as  soon  as  possible.  

•  Whether  placed  in  an  automated  dispensing    machine,  medica.on  cart  or  vault,  they    should  be  stocked  immediately  to  help  cut  down    on  diversion.  

TYPES  OF  DIVERSION  

Diversion  in  a  pharmacy  of  a  health  care  facility    is  normally  commiRed  by    pharmacists  &  technicians.  

Pharmacists  will  divert  from  automated    dispensing  machine,  vault,  when    preparing  or  mixing  medica.ons.  

Technicians  ohen  divert  when  checking  in    deliveries,  stocking  the  pharmacy,    coun.ng  out  meds,  stocking  floor  units,    taking  return  meds  in  the  pharmacy.  

WHO  DIVERTS  DRUGS  ON  FACILITY  UNITS?  

•  Nurses  –  RN,  LPN  •  CNA,  CMA  •  Physicians,  although  they  do  not  have  as  much  

access  as  other  staff  •  Anesthesiologists,  CRNAs  •  Therapists,  surgery  techs,  others  

NURSES  

Addicted  Nurses  are  one  of  the  Most  widely  diverters  of  medica7ons  In  health  care  facili7es.  

Few  facili7es  are  exempt  from  this  Problem.  

More  cases  since  #  of  nurses  are    More  than  Rphs  or  techs.  

DIVERSION  BY  NURSES  

•  Frequent  sign  outs      •  Frequent  was.ng  •  Subs.tu.on  •  Dilu.on  •  PCA  –  PT  Controlled  Administra.on  •  IV  Drips  •  Fentanyl  patches  

DIVERSION  BY  NURSES  

•  Trash  •  Sharps  Containers  •  Destruc.on  •  Restocks  •  Signouts  for  Discharged  Pa.ents  •  Documenta.on  Issues  •  Stealing  from  Automated  Dispensing  machines  •  Pa.ent  complaints  –  no  relief  for  pain,  etc.  

ISSUES  SPECIFIC  TO  NURSING  HOMES  

•  Storing  of  Delivered  Medica.ons  •  Medica.on  Counts  at  Change  of  Shih  •  Punch  outs  on  Unit  Dose  cards  •  MAR  changes  •  Expired  medica.ons,  leh-­‐over  pa.ent  medica.ons  •  Falsifying  orders  •  Subs.tu.on  of  medica.ons  •  Pa.ent  complaints  

CHARACTERISTICS  

Job  Performance  Employment  History  Changes  in  Behavior/Moods  Appearance  Quality  of  Employees  Documenta.on  Issues  Working  Over.me  or  Offers  to  Do  So  Taking  over  others’  pa.ents  Showing  up  when  not  on  duty  Check  &  Balance  on  medica.ons  Policies/procedures  

WHAT  CAN  BE  DONE?  

•  Collabora.on  between  health  care  professionals        and  law  enforcement  

•  Training  for  all  staff  in  health  care  facili.es  on    diversion  &  what  to  look  for  

•  Good  policies  &  procedures  in  place    •  Zero  tolerance  for  diversion  in  health  care  facility  –    

 Pa.ent  Safety  is  Utmost!  •  Referral  of  employee  to  employee  assistance  

 program  

WHAT  CAN  BE  DONE?  

•  Background  Checks  including  criminal  history  •  Verifying  License  Informa.on  with  Regulatory  

Boards  •  Checks  &  Balances  of  En.re  Medica.on  Flow  •  Inventorying  of  Drugs  at  all  Levels  •  Use  of  Biometric  measures  on  automated  devices  •  Random  Drug  Tes.ng  •  Random  Review  of  Drug  flow  to  determine  weak  

points  •  Check  of  expired  drugs,  return  to  stock  

WHAT  CAN  BE  DONE?  

•  Rigorous  Security  Measures  •  Think  of  Drugs  as  Money!  •  Close  Observa.on/Supervision  of  

 Employees  Handling  Medica.ons  •  Training  for  all  employees  •  Preven.on  is  best  measure  •  Always  look  for  new  systems  such  as  

 bar  coding,  etc.  

USE  OF  PDMP  

•  NC  has  had  PMP  (CSRS)  for  almost  4  years  •  Only  @  28%  of  all  prescribers  signed  up  •  Less  than  26%  of  Rphs  signed  up  •  Useful  tool  to  check  for  doctor  shoppers,  

forgers,  etc.  •  Some  pharmacies  do  not  have  internet  access  •  Cannot  provide  to  law  enforcement  in  NC  •  Board  has  limited  access  

Limita.ons  of  PMP  

•  Only  as  good  as  data  sent  in  from  pharmacies  •  In  one  review  of  pa.ent  informa.on  on  

 prescrip.ons,  20%  informa.on  was    incorrect  prescriber,  drug,  etc.  

•  In  NC,  limita.ons  on  info  on  prescribers  who    are  “over-­‐prescribing”  

•  No  access  by  local  law  enforcement  •  Changes  being  reviewed  now  •  No  mandatory  use  by  prescribers  

Contact  Informa.on  

Karen  MaRhew  Director  of  Inves.ga.ons  &  Inspec.ons  NC  Board  of  Pharmacy  919-­‐246-­‐1050  [email protected]  

QUESTIONS?  

Collabora.on  with  Pharmacists  to  Prevent  Diversion  Through  Use  of  

the  PDMP  

April  2  –  4,  2013  Omni  Orlando  Resort    

at  ChampionsGate  

Learning  Objec.ves  

•  What  law  enforcement  can  do  to  encourage  collabora.on  with  pharmacists  to  reduce  diversion  at  the  pharmacy  counter.  

•  Learn  from  several  examples  how  the  PDMP  when  used  by  pharmacists,  can  aid  law  enforcement  in  improving  inves.ga.ve  outcomes.    

Disclosure  Statement  

       Agent  Bruce  DiVincenzo    has  no  disclosed  no  relevant,  real  or  apparent  personal  or  professional  financial  rela.onships.  

•  Review  nine  (9)  minute  video  concerning  crimes  occurring  at  the  pharmacy  counter  and  how  the  ac.ons  taken  by  pharmacy  staff  can  aid  law  enforcement  in  the  reduc.on  of  diversion.  

•  Diversion  which  occurs  at  the  pharmacy  counter  is  vastly  underreported.    Law  enforcement  can  aid  in  improving  this  outcome.    My  PERSONAL  belief  is  that  the  problem  is  HUGE.    Unless  an  agency  becomes  involved  on  a  regular  basis  in  the  inves.ga.on  and  prosecu.on  of  these  crimes,    the  amount  of  drug  diversion  occurring  at  the  pharmacy  counter  will  remain  a  significant  source  of  diverted  controlled  drugs  which  con.nue  to  devastate  our  communi.es.  You  just  don’t  know  un.l  you  look!!  

•  Pharmacy  crimes  –  Forgery,  Doctor  and  Pharmacy  shopping.    These  crimes  are  underreported,  and  in  many  metropolitan  areas  not  inves.gated  at  all.    Significant  amounts  of  diverted  drugs  are  the  result.  

•  Educate  the  clinicians  about  the  law  (code  and  statute  )  that  governs  your  jurisdic.on.    Assist  them  and  work  together  for  the  reduc.on  of  diverted  drugs  in  your  community.  Work  to  increase  repor.ng!    Examples  from  experience  –  3  Friday  nights  in  a  row!  

•  The  video  is  our  effort  in  DE  to  let  the  clinician  know  what  evidence  is  used  by  prosecutors.    Discuss  trial  probability  -­‐  minimal.    Pharmacists  provide  many,  if  not  most  of  the  leads  provided  to  law  enforcement  in  DE.    Pharmacists  working  together  with  law  enforcement  can  make  a  difference.  Example  –  we  don’t  have  that.    

•  Climate  Change  –  What  I  have  learned  from  pharmacists  about  the  change  resul.ng  from  the  increase  in  drug  seeking  crimes  and  the  effect  this  has  on  medical  prac..oners.    Never  experienced  such  behavior  by  alleged  pa.ents.  

•  The  amount  of  drugs  diverted    by  a  single  defendant  –  Delaware  County  PA  and  New  Castle  County  DE  2010  to  2012    -­‐    25,000  dosage  units  Percocet  10/325.    

•  A  pre-­‐PDMP  inves.ga.on.    Discuss  M/O.    Ini.ally  report  to  us  by  a  dedicated  pharmacist    

•  Use  of  PDMP  -­‐    Examples  of  actual  cases  where  the  PDMP  is  effec.ve  in  providing  leads  to  law  enforcement:  

•  1.    Aids  in  determining    the  extent  of  the  forgeries  occurring.  Recent  –  Dr  S…..  

•  2.  Iden.fy  the  ac.vity  of  a  doctor  shopper.    Reported  by  another  dedicated  pharmacist.      Involved  doctors  in  two  states.    Ongoing  case….  

•  3.    Counterfeit  scripts  -­‐    Phila  Hospital  -­‐    PDMP  Administrator  checked  further  aher  viewing  writer’s  alert  and  provided  other  leads  based  on  address  of  hospital.    Ongoing  case……  

4.  Extent  of  damage  -­‐    NY  script  case.    Crime  occurs  in  DE,  scripts  filled  also  in  NJ  and  PA  and  North  Carolina.    PDMP  aided  in  determining  where  the  suspects  had  been.    Also  Brooklyn  suspects  in  DE  and  Pocono  area  of  PA.      Ongoing  case…..        

•  The  PDMP  is  a  valuable  aid  in  the  prosecu.on  of  criminals  involved  in  the  diversion  of  controlled  substances.      

•  It  is  the  presenter’s  hope  that  government  issued  photo  ID  will  be  a  required  part  of  the  data  captured  in  every  transac.on  involving  the  dispensing  of  a  controlled  substance.    Prosecu.ons  are  made  possible  and  some.mes  enhanced  by  the  inclusion  of  this  ID  informa.on  as  part  of  the  PDMP  data  and  most  difficult  to  begin  without  this  ID  informa.on.    

•  The  PDMP  remains  a  work  in  progress.    For  addi.onal  reading  on  where  this  process  is  heading,  please  review  the  wri.ngs  from  Brandeis  University  on  this  topic.    Excellent  source.  

•  Thank  you  for  your  aRen.on.    I  do  hope  that  I  provided  informa.on  you  find  helpful  in  your  work  in  your  jurisdic.on.  

•  If  there  are  any  ques.ons  here  or  even  later,  I  am  always  glad  to  discuss  any  ques.ons  you  may  have.  

•  Thank  you  to  Opera.on  Unite  for  invi.ng  me  to  speak.    I  am  thankful  for  your  good  work  and  learn  a  great  deal  from  my  .me  here.