http://www.ems1.com/ems-management/articles/820734-The-common-denominator-of-narcotic-diversion

By Aimin Alton

A week ago our industry learned once again — that one of our own has been accused of diverting narcotics. The individual at the center of this investigation is a 22-year veteran of the Camas, Wash., Fire Deptartment, a Captain in charge of their EMS program. From the news footage, a neighbor described him as, "A nice man who always helps others."

Bradley Allen was taken into custody following a police investigation into missing vials of fentanyl citrate. Officers said they believe Allen may have replaced the fentanyl with saline solution. Camas Fire Chief Leo Leon described the incident as "probably the worst thing to happen to this department in its history."

In our industry, we put safeguards in place to prevent narcotic diversion and narcotic tampering, yet it still happens at departments and agencies across the country. What more can we do to stop it? In a previous article, I 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. Records show me that both men and women divert, young and old, rookie and preceptor, firefighter and chief. The one common denominator here 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. But 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 two keys: one key for supervisors and another key for field personnel or administration, or some form of electronic lock that requires two 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 two hospitals.

Kristen Diane Parker infected about three dozen people with hepatitis C after she injected herself with painkiller-filled syringes and replaced them with ones filled with saline. Parker, who said she got hepatitis C from using heroin, acknowledged that she took syringes filled with the painkiller Fentanyl from operating carts at the hospitals, according to The Associated Press.

She said she injected herself and replaced the stolen syringes with ones filled with saline and that she meant to use clean replacement needles but got careless.

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 seven 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?

Put simply, be smarter than the addict, engineer systems that protect our narcotics from those who 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.

Finally, here's the basic terms and facts you need to be aware of:

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.

The 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 who 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.

Aimin Alton has more than 13 years experience in the field of EMS. He serves as a firefighter for the Ventura County, Calif., Fire Department and is licensed by the state of California as a Mobile Intensive Care Paramedic. Aimin is a strong advocate for EMS professionals, and for the patients they serve, by raising awareness and promoting solutions for narcotics diversion within the industry. Toward that goal, Aimin founded Alton & Associates and StopNarcoticTampering.org, for which he serves as the program director. Similarly, as a member of the California State Firefighters' Association's EMS Committee, Aimin formed and leads the CSFA Emergency Responder Substance Abuse Task Force. He has also recently provided his presentation, titled "Narcotic Tampering Awareness & Detection," at Firehouse World (San Diego), Fire-Rescue Med (Las Vegas) and CFEDWest (Palm Springs). He promotes vigilance and outlines the known methods of tampering with physical examples and directions on how to spot them. You can contact Aimin at aalton@alton-associates.com.