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Building a stronger opioid stewardship program that includes drug diversion prevention | Tom Knight


The AHA’s Opioid Stewardship Measurement Guide, considered the 'gold standard' for opioid measurement for hospitals, misses a critical opportunity: measurement of opioid diversion.

In early 2020, the American Hospital Association (AHA) updated its guide for opioid stewardship measurement, which highlights best practices for hospital tracking of opioid stewardship, including acute pain management, harm reduction, and identification and treatment of opioid use disorder.

The AHA guide is seen as a totem of patient safety — ensuring clinicians, administrators, care partners, patients and communities are on the same page, and that opioids are distributed in the right way, for the right length of time, to the right patients, minimizing potential harmful effects.

That was early in the pandemic days, before the opioid crisis went into overdrive, fueled by multiple economic, social, and healthcare stressors.

An estimated 53,000 people died of opioid overdoses in the first six months of 2021, which, the Commonwealth Fund noted, was higher than any continuous six-month period in 2020.

Data published by the Centers for Disease Control and Prevention (CDC) in April reveals that 106,854 people died of drug overdoses in the 12-month period ending November 2021.

Two years later, many rightly consider the AHA’s Opioid Stewardship Measurement Guide to be the “gold standard” for opioid stewardship measurement. The guide offers a wealth of best practices on prescribing patterns and preventing drug-seeking behaviors such as doctor shopping.

However, the Guide misses one key area of opportunity for offering comprehensive guidance: preventing drug diversion by healthcare workers.

Drug diversion — the illegal movement, adulteration, marketing, or transfer of any legal controlled substance anywhere within the supply chain — impacts thousands of patients, healthcare workers, and communities. Even worse, drug diversion can spread infections such as Hepatitis C, for example, if an infected healthcare worker injects a patient’s syringe for self-use.

Unfortunately, drug diversion in healthcare is common.

As many as 82% of healthcare executives polled for the 2021 Porter Research on diversion have met at least one healthcare worker who has diverted drugs, and 73% agreed that most drug diversion goes undetected.

However, the issue of diversion is often weakly addressed in hospitals and clinics not only because of the bigger concerns around managing patients with substance-use disorders, but because of lingering stigmas. Few health systems want to openly acknowledge that it’s a risk.

Moving forward, giving attention to the growing risk of opioid diversion in hospitals and clinics is critical to deploying a truly comprehensive strategy to addressing the opioid crisis amid heightened stress induced by the Covid-19 pandemic.

The under-tapped potential of evolving technologies

The AHA Guide does include a short section on the prevention of drug diversion as part of a comprehensive opioid stewardship strategy.

In addition, the authors highlight and link to studies that feature best practices surrounding diversion. These include the 2016 document, “6 Steps for Hospitals to Take to Prevent Prescription Drug Abuse, Diversion,” as well as the 2017 American Society of Health System Pharmacists’ “Guidelines on Preventing Diversion of Controlled Substances.”

However, the guide misses the opportunity to include recommendations of specific measures related to opioid diversion, likely due to a lack of available literature at that time. In recent years, there have been significant healthcare technology advances, expertise, and data that bolster our defenses against drug diversion.

We’ve come a long way in the area of technology used to detect diversion beyond the most widely-accepted method of monitoring medication access through automated medication dispensing cabinets.

Advances in analytics and machine learning/artificial intelligence have made it possible to comb through multiple data sources for the purposes of synthesizing information, isolating patterns associated with diversion, and predicting risk.

For example, if a patient’s pain scores don’t align with the dosage administered by a clinician, and that pattern is seen across multiple patients for this clinician, this information would trigger an alert to investigate.

Use of analytics and machine learning has led to diversion being detected earlier, and faster follow-up investigations. This is an important point to emphasize, since many clinicians who divert opioids for personal use have later said they wish they were caught sooner, before they had become addicted, and their patients had suffered consequences. Some of these healthcare workers are serving jail time, while hospitals have been forced to pay steep fines.

Yet fewer than half of the respondents to the 2021 Porter Research (44%) said they used machine learning software or applications to detect drug diversion, and just 43% indicated they used advanced analytics. As such, they’re missing a crucial chance to address the opioid crisis by more rapidly identifying health care workers who may be diverting drugs and need help quickly.

Evolving best practices in drug diversion

As they work to enhance opioid stewardship programs, healthcare leaders should pay special attention to the following:

Recommendations pertaining to advanced technologies

Use of machine learning and advanced analytics software for identifying and reducing drug diversion is much higher than it was in 2019.

However, it’s not as universal as, say, the use of automated dispensing cabinets or internal audits, or anonymous tips from healthcare workers. All of these tools need to be used together to obtain the most accurate insights.

A recent NIH-funded study, “Detecting Drug Diversion in Health System Data using Machine Learning and Advanced Analytics,” published by the American Journal of Health-System Pharmacy, showed that advanced analytics and machine learning technologies detected known diversion cases an average of 160 days faster than existing, non-machine learning detection methods. Additionally, the machine learning model demonstrated 96.3% accuracy.

Staffing needs

Cutbacks have increased since 2020 and healthcare organizations have fewer people dedicated to their drug diversion programs and investigations, according to the Porter Research survey. Just 45% reported one or more fulltime, dedicated drug diversion employees, compared with 58% in 2019.

Without at least one worker who knows how to use technology to capture information that warrants further investigation, healthcare systems aren’t leveraging their tech to its fullest extent – and incidents of diversion are likely being missed.

Healthcare worker training

One of the longest-standing recommendations for combating diversion is to enhance education and training. This hasn’t changed.

In addition to training clinical workers on the signs of opioid use disorder and teaching them to search for utilization patterns indicative of substance use disorders, workers should be trained on the signs of diversion as well as the importance of communication.

If workers feel uncomfortable with reporting something to their supervisor, then they should be directed to submit tips anonymously (for example, through HealthcareDiversion.org). The impact of diversion on employment, the hospital, and patients themselves should also be emphasized, as well as any behavioral health or other resources for clinicians experiencing burnout.

Lowering the risks

Opioid stewardship is a critical aspect of hospital operations, given the scope and magnitude of the ongoing opioid crisis among Americans.

Then challenge them to look not only at the patient and preventing substance use disorder among patients. We must look at ourselves, and our co-workers, and our healthcare organizations and facilities to reduce the risk of SUD by ourselves and our colleagues.

As such, in order to be comprehensive, opioid stewardship programs must address not only over-prescribing and drug-seeking behaviors, but also include preventing drug diversion by healthcare workers themselves, through the use of technology, processes, and staffing considerations.

With this expanded scope, the opioid stewardship programs in hospitals and clinics will lower opioid risks— and the consequences that it brings to their patients, workers, and communities.

Tom Knight is the CEO and Founder of Invistics.

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