A week ago our industry learned that one of our own diverted narcotics...again.  This time in the Pacific North West in the town of Camas Washington, population about 20,000.  The individual at the center of this case is a 22 year veteran of the Camas Fire Dept., a Captain in charge of their EMS program.  From the news footage, a neighbor described him as “A nice man who always helps others.”  

I feel for his family, his agency and his community.  This is a tough time for those that know this man, one day-considered a pillar of the community, the next-revealed to be a thief and drug addict.  It can be hard to digest for those closet to him.  I hope they understand that he is still the same person they knew and cared about.  They now know he undoubtedly suffers from the disease of addiction and chemical dependency.  The alternative is that he stole and tampered-with narcotics for a reason other than to self medicate his pain and addiction.  Those other reasons may be to treat the pain or addiction of a friend or family member (possible), for profit (doubtful), or out of anger (possible, especially if he developed a victim mindset). My guess is that he stole the narcotics to feed his addiction, to medicate a pain, be it a result of a workplace injury or post traumatic stress.

In our industry, we put safeguards in place to prevent Narcotic Diversion and Narcotic Tampering, yet it still happens.  What more can we do to stop it?  In another article we wrote about safeguarding our medications, briefly discussed were Reverse Distribution, Stronger Containers, Tracking, QI, CQI, and TQM.  This time, I’d like to discuss one of the few common denominators found in cases of Narcotic Diversion in Prehospital Care.  It isn’t gender, age, experience or rank.  How ever much I’d like to say it’s only men of a certain background, age, experience and rank that commit diversion, the records show me, that both men and women divert, young and old, rookie and preceptor, firefighter and chief.  The common denominator I’m speaking of is - Access.  

Those that divert narcotics often have nearly unconstrained access to them or know how to get access.  Many times, narcotic control and accountability systems are built that prevent field personnel from having direct physical access to narcotics except for times they are needed by a patient.  Otherwise, they are inside some (hopefully) tamper evident lock box.  What maybe overlooked is the access a supervisor has to them.  Narcotics restock stored in a locked cabinet behind closed doors, where a single person can access them, at any time, is a system asking for trouble.  A more secure approach would be to have our narcotic drug cabinets utilize 2 keys.  Perhaps 1 key for supervisors and another key for field personnel, or administration, or some form of electronic lock that requires 2 separate combinations, codes, or electronic key card.  No supervisor, for their own sake, should ever have single person, unrestricted access to Narcotics restock.  While the vast majority of people that work in EMS are good and ethical people, we are all susceptible to injury and temptation.  Our narcotic control and accountability systems need to be built stronger, more secure, not because we don’t trust individuals, but because we know the fallibility of human nature.     

The phenomena of Narcotic Diversion and Narcotic Tampering isn't restricted to Prehospital care, not by a long shot.  In February a surgical tech from Colorado was given a 30 year sentence for diverting Narcotics at 2 hospitals and possibly exposing 6000 patients to hepatitis C.  At least 3 dozen patients did get hepatitis C as a result of her not utilizing clean needles and aseptic technique.  If this doesn’t frighten the medical profession, I’m not sure what will.  One of the patients that received the gift of hepatitis C is suing the medical center and the anesthesiologist, claiming they failed to adequately supervise, administer and manage their fentanyl supplies.  They offer as proof that 7 other employees were reported to have diverted drugs, and that they failed to take reasonable action to detect and stop patterns of drug diversion by its employees.

What message does this send to our industry?

Be smarter than the addict, engineer systems that protect our Narcotics from those that may want to tamper with them.  No one should be forced to be trusted with single person access to these drugs.  We treat these drugs like gold, not because they are expensive, but because of the harm they can cause us.  

FAQ’s

Q: What does Diversion Mean?

A: Misappropriation of DEA Scheduled medications from approved and/or legitimate patient usage, through doctor shopping, prescription forgery, outright theft or substitution.

Q: What does Substitution/Tampering Mean?

A: Tampering is the diversion of narcotics done in such a way that makes it look like it was never stolen.  To be left in the system, to be used by an unsuspecting health care Professional (Paramedic, RN, RT, MD) on an unsuspecting Patient.

Q: What are our responsibilities?

A: Code of Federal Regulations - Section 1301.91 Employee responsibility to report drug diversion.

    Reports of drug diversion by fellow employees is not only    a necessary part of an overall employee security program but also serves the public interest at large.

    It is, therefore, the position of DEA that an employee who has knowledge of drug diversion from his employer by a fellow employee has an obligation to report such information to a responsible security official of the employer.

    The employer shall treat such information as confidential and shall take all reasonable steps to protect the confidentiality of the information and the identity of the employee furnishing information.

    A failure to report information of drug diversion will be considered in determining the feasibility of continuing to allow an employee to work in a drug security area.  The employer shall inform all employees concerning this policy.

See additional here.

Texas state health department suspended a Blanco paramedic’s license for 18 months after finding that she aided or at the least didn’t stop Drug Diversion.

Q: What can someone that Tampers with Narcotics be charged with?

A: Among others, the Federal Anti-Tampering Act

   

    The penalties range from a maximum of $25,000 and 10 years imprisonment in the case of an attempt to tamper, to a maximum of $100,000 and life imprisonment, in a case where death results from the tampering.

See additional here.

Sources:

http://www.latimes.com/news/nationworld/nation/wire/sns-ap-us-surgery-tech-hepatitis,0,1679089.story

http://www.outpatientsurgery.net/news/2010/05/5

Camas PD Press Release, copy found http://www.stopnarcotictampering.org/main/Paramedic_Articles/Entries/

2010/5/9_Camas_Fire_Department_Employee_Charged_with_Misappropriation_of_Narcotics.html

http://www.columbian.com/news/2010/may/10/camas-fire-captain-arrested-for-misappropriating-n/

http://youtube.com/watch?v=lRv-eyVwtgY

http://www.kptv.com/news/23524081/detail.html

http://www.kptv.com/video/23523961/index.html

Narcotic diversion and tampering by healthcare  professionals is a complex subject matter being studied from the perspectives of Addiction Medicine, EAP, EMS Regulatory Authority, Organizational Psychology, Criminalistics and Criminology.  Formed under the Auspices of the California State Firefighters’ Association, our Emergency Responder Substance Abuse Task Force and associated colleagues are working toward our mission to “Stop Narcotic Tampering Through Awareness & Prevention.”

This brief overview was written by Aimin Alton, BA, MICP, CSFA EMS Committee Member, Team Lead with the Emergency Responder Substance Abuse Task Force, CE Program Director at Alton & Associates, Fire Fighter with the Ventura County Fire Department and Founder of StopNarcoticTampering.org. 

He has recently delivered his presentation “Narcotic Tampering Awareness & Detection” at the combined Firehouse World / CSFA Annual Conference in San Diego, Fire-Rescue Med in Las Vegas and CFEDWest in Palm Springs.  This hands-on workshop not only stresses the importance of vigilance but shows the audience several types of (what can be) easily detectable tampered-with medication containers.  His presentation is an “ounce of prevention” for our industry.

Questions and comments can be sent to aalton@alton-associates.com