Technologies in preventing_diversion-ne_wweb
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The document discusses the challenges of preventing drug diversion in hospital and retail pharmacy settings, emphasizing the impact of controlled substance misuse and the strategies for tackling employee and patient-related diversion behaviors. It highlights the need for advanced technologies and analytical approaches to monitor and identify suspicious activities, including the implementation of proper protocols and surveillance measures. The document also addresses the rising incidents of pharmacy robberies and the importance of employee training for safety and prevention.
Technologies in preventing_diversion-ne_wweb
- 1. Technologies in Preven/ng Diversion April 2 – 4, 2013 Omni Orlando Resort at ChampionsGate
- 2. Technologies in Preven@ng Diversion Moderator: Dr. Sarah Melton, Associate Professor of Pharmacy Prac@ce, GaHon College of Pharmacy Prac@ce Presenters: Janet Hart, Director, Government Affairs, Rite Aid Dr. Michael O’Neil, Drug Diversion Consultant DEA /BCI Professor, Dept. of Pharmacy Prac@ce, South College School of Pharmacy
- 3. Learning Objec@ves 1. Evaluate the impact of controlled substance diversion in the hospital seVng. 2. Iden@fy primary methods of diversion in the pharmacy and on nursing units. 3. Iden@fy processes to maximize the use of technology in diversion preven@on, detec@on, and management.
- 4. Disclosure Statement • Dr. ONeil is a consultant for the DEA, WV-‐bureau of criminal Inves@ga@on, The US AHorneys Office, Na@onal Associa@on of Dental Boards and has provided con@nuing educa@on for in chronic pain management and prescrip@on drug diversion for Endo Pharmaceu@cals. • Janet Hart has no relevant financial rela@onships with commercial interests to disclose
- 5. Overview • Ini@al overview of employee behaviors and tac@cs in community and hospital sites • Overview of technologies used to combat diversion behaviors • Physician Driven Diversion • “Customer” oriented diversion: focus on robberies and burglaries
- 6. Impact of Drug Diversion in Hospital Pharmacies and Nursing Units • Absolute inventory $ costs -‐controls v. non-‐controls • Costs of impairment -‐pharmacist / techs -‐nurses -‐management • Cost to the pa@ent -‐injury, death
- 7. Counterfeit Drugs • Actual TRUE incidence and cost is unknown • Can be a major contributor in community and hospital pharmacy Bevacizumab (for cancer treatment) United States of America, 2012 Affected 19 medical prac@ces in the USA. The drug lacked ac@ve ingredient 1 Sildenasil (for erec/le dysfunc/on) United Kingdom, 2012 Smuggled into the UK. Contained undeclared ac@ve ingredients with possible serious health risks to the consumer (Source -‐ WHO Fact Sheet)
- 8. Counterfeit Drugs • Accounts for about 1% of total market sales of medica@ons • One of the primary reasons corporate pharmacies do not allow ‘drug take-‐backs’
- 9. “Grazing”
- 10. Grazing “Behaviors” • Overt self-‐medica@ng • Staff diagnosing / “encouraging” each other “Knowledge does not grant privilege!” • Blatant theh for $, sex
- 11. Medica@on Sources • BoHles in the pharmacy • Pa@ent boHles • Pa@ent carts • Medica@on drawers • Stock • Automated dispensing machines • Trash (broken, spilled medica@ons)
- 12. Grazing • sexual enhancers • an@depressants • an@psycho@cs • butalbital • an@eme@cs (promethazine)) • tramadol • muscle relaxants • aspirin, ibuprofen
- 13. Pharmacy Community • Trash • Inventory altera@ons • Overt Theh 1. individual pills v. boHles 2. dilu@ons • Inten@onal miscounts • Dropped meds / broken meds • Forged prescrip@ons • Adding “false” refills to old prescrip@ons • Sharing / Borrowing passwords
- 14. Hospital Pharmacy • Grazing • Overfill • Waste • returns
- 15. Nursing • Pa@ent complains of lack of pain relief • Highly suspicious behavior by the staff in ques@on sugges@ng impairment. Increased tardys, change in appearance, worsening behavior, increased errors • The nurse in ques@on was "too busy or forgot" to secure a witness for a waste • The controlled substance count is incorrect when the nurse in ques@on works, ohen repe@@vely • Suspected forged signatures • The nurse in ques@on states "gave access code" to another nurse • The frequently forgets to document in the pa@ent’s record
- 16. Nursing Techniques / Solu@ons Stealing pa@ent dose • Order is for hydrocodone/APAP 1-‐2 tablets Q4-‐6Hr Prn Pain Over IM/IV administra@on • Subs@tu@ng a dose 1. oral (capsule, liquid) 2. IV • Falsifying waste • New and used patches 1. replace new with old 2. reuse old patches • WriHen -‐Verbal / telephone orders that are false
- 17. Other Sites within the Ins@tu@on • OR / OR satellites anesthesiologist, anesthe@sts • ERs
- 18. The Technology -‐ Basics • Do official background checks regardless if you know the candidate or their families • Call at least 2 previous employers • Random drug tes@ng (for the right drugs) • Do not allow people to be alone in pharmacy • Double sign off inventories • No coats, purses, backpacks, etc. in pharmacy area • LIMIT ACCESS!
- 19. The Technology • Hospital Pharmacy -‐ Point of entry to controlled substances -‐ ID badge swipes -‐ refractometer drug tes@ng -‐ IV product / waste tes@ng and QA
- 20. Refractometer • Very accurate tes@ng • Provides a sense of “surveillance” as a deterrent • IV rooms, nursing units, ORs, satellite pharmacies
- 21. Tracking doses, nurses, tendencies Automated dispensing machines • drug, unit, formula@on, person, place, @me
- 22. Tracking doses, nurses, tendencies • PaHerns -‐on floor sta@s@cal comparisons, signs out more than other nurses -‐excessive documen@ng waste -‐uses larger vials for smaller doses -‐mul@ple breaks • Medica@on changes • Doses given -‐range doses -‐range schedule (Q4-‐6) -‐PRNS • Shih / nurse comparisons • Witness end of shih counts
- 23. Counterfeit – Shipment Tracking • RFID / GPS tracking of full shipments • RFID /GPS tracking of single boHles “NYPD Will Implant GPS Chips Into Pill Bo>les To Combat PrescripBon Drug Abuse”
- 24. Employee Diversion(retail) • Hydrocodone is the number 1 prescribed item in the US • Also a highly diverted item • Abusers typically take 15 to 20 tablets a day • Reports have shown abusers taking in excess of 100 tablets a day for personal use • Most employee diversion is for self use and profit
- 25. Automated Dispensing Cabinets • Strict control to inventory access • Records individual operator’s access to system • Daily discrepancy reports generated
- 26. Biometric Safe • Bolted to the floor • Controlled access with biometric scan
- 27. Analy@cs Predic/ve indicators • Cycle count adjustments • Overriding replenishment orders • Ordering from the outside vendor • Purchases do not balance dispensing
- 28. Point of Sale with Remote Monitoring • Remote video monitoring • Point of sale data is available • Transac@on analysis by individual user • Excep@on based reports automa@cally generated with video back up
- 29. Remote Monitoring Incident Report
- 30. Policies and Procedures Zero tolerance on employee pilferage for controlled substances
- 31. Prescrip@on Drug Abuse Epidemic 25 22.5 20 Millions 15 10 5 0.6 1 1.4 0.3 0 Heroin Inhalants Hallucinogens Cocaine Legend Drugs
- 32. Drug Fact Over 100 People die from drug overdoses every day in the United States. Many of the individuals started therapy with a valid prescrip/on for pain.
- 33. Drug Fact • For every death there are: – 10 treatment admissions for abuse – 32 emergency department visits for misuse or abuse – 130 people who abuse or are dependent – 825 non-‐medical users • An epidemic
- 34. Drug Fact • Most prescrip@on pain killers are prescribed by primary care and internal medicine prescribers – Not specialists • Roughly 20% of prescribers prescribe 80% of ALL prescrip@on pain killers
- 35. Drug Fact • Enough prescrip@on pain killers were prescribed in 2011 to medicate every American adult around the clock for a month • ¾ of all drug overdose deaths in the US are due to prescrip@on drugs
- 36. Analy@cs Suspicious Ac@vity Prac@ce of pharmacy is changing and pharmacists must be more aware of the poten@al diversion of controlled substances • Prescriber • Pa@ent • Pharmacy
- 37. Pharmacist’s Corresponding Responsibili@es (CSA) • Must consider the geographical distance PATIENT between the doctor, the pa@ent and the pharmacy – Would you fill a prescrip@on for a pa@ent that resides in Ohio, prescribed by a physician PHARMACY PRESCRIBER in Florida at a pharmacy in MassachuseHs? – NO
- 38. Pill Mill Clinics • Escalated from Florida • LiHle state regulatory oversight – Doctor dispensing – Ques@onable wholesalers
- 39. Ten Arrested In Strike Against Florida “Pill Mill”
- 40. The Migra@on
- 41. Suspicious Ac/vity • Pharmacists play an important role in the diversion of controlled substances – Pharmacist can iden@fy suspicious prescribers (trends) – Pharmacist can iden@fy suspicious pa@ents (PDMP) – Pharmacist can iden@fy abuse trends – Pharmacists are not licensed by the DEA/ pharmacies are – Pharmacists need help and guidance
- 42. Report Suspicious Ac@vity • Pharmacist should – Gather informa@on • Prescriber name – Address – DEA – Descrip@on of suspicious ac@vity • Pharmacist should report trends or suspicious ac@vity
- 43. Pharmacy Systemic Approach Chain data Top Oxycodone Pharmacy generated data Stores Prescriber data Reported Top Oxycodone Prescribers suspicious Trends Store/Site visit ac@vity Pa@ent is Distribu@on Cash vs. TP Clinical Protocol Edits iden@fied from threshold Oxy vs. CIIs completed by dispensing data increase requests member of field LeHer to CII’s vs. all RX’s management or Prescriber corporate Edit in dispensing system to prevent control prescrip@on dispensing for select prescribers
- 44. Analysis (Corporate) • Top oxycodone and hydrocodone dispensing pharmacies • Top oxycodone and hydrocodone prescribers • Reported suspicious ac@vity of prescribers • Requests for distribu@on threshold increases • Percentage of cash versus third party payer for controlled substance prescrip@ons for an individual prescriber • Percentage of controlled versus non-‐controlled prescrip@ons wriHen by a prescriber
- 45. Analy@cs • Na@onal Controlled Substance Ra@ng Solu@on* – Na@onal database • Purchasing data • Prescrip@on data • Pa@ent data (de-‐iden@fied) • Prescriber reference data (specialty) – Guide to iden@fying suspicious prescriber ac@vity *Currently under development
- 46. Na@onal Dashboard • The Na@onal Dashboard will be color-‐coded based on the metric selected – Per Capita $ Spend for controlled substances – Rx Volume – Unit Volume (best analysis by dosage unit) – Change in Unit Volume (spike in dispensing CDS) – # of Outlets w/ High Overall Ra@ng – # of Prescribers w/ High Overall Ra@ng • Selec@ng a state will then drop color-‐code “pins” for each of the areas within a state where suspicious ac@vity may be iden@fied
- 48. Pharmacy Clinic Protocol • Checklist to review a prescriber’s office – Onsite visit (pictures or Google maps) – Review of opera@ng procedures (security guards) – Review staff and creden@als (sanc@ons) – Review the pa@ent base (similar age) – Review medica@ons prescribed (each pa@ent gets same medica@on in same strength and quan@ty) • Oxycodone 30mg #180 for all pa@ents
- 49. Clinic Protocol • The protocol is not only used for prescribers of opioids such as oxycodone and hydrocodone – Buprenorphine clinics • Review of DEA license to determine number of pa@ents prescriber can treat (30 versus 100 pa@ents) • Review the number pa@ents under treatment or care by the prescriber – Weight loss clinics – ADHD clinics
- 50. Poten@al Ac@on Edit in Computer • LeHer sent to the prescriber sta@ng this pharmacy will no longer dispense prescrip@ons for controlled substances under his/her DEA registra@on (2 days prior to edit in the dispensing system) – LeHer must be mailed via Cer@fied Mail, UPS, FedEx, or any other provider that has shipment tracking and signature required to assure delivery • “Corporate policy prohibits dispensing controlled substance prescrip4ons wri6en by this prescriber”
- 51. Suspicious Prescriber • Prescriber – Prescribed 695,811 total dosage units of oxycodone containing products in 12 months • Prescribed 460,806 dosage units of oxycodone 30 mg tablets in 12 months – Prescribed to several members of the same family at the same address with same diagnosis – Prescribed the same combina@on of drugs to the majority of pa@ents – Did not accept Medicaid pa@ents and did not accept insurance plans for office visits – Ini@al office visit per pa@ent was $250.00 cash only
- 52. Systemic Approach Store generated data Distribu@on • Pharmacy Manager requests a threshold threshold increase for oxycodone increase request 30mg – “Pharmacy 200 feet down the block is no longer stocking oxycodone 30mg. I’ve lost a ton of business so I try to fill in the gaps and aHract new business however I can”
- 53. Systemic Approach Prescriber Data Trends • Top 6 prescribers were prac@cing in Cash vs. TP Florida (Store is in New England) • Oxycodone 30mg was the primary Oxy vs. CIIs oxycodone product prescribed CII’s vs. all RX’s • 85% of these prescrip@ons were for cash payments • 67% of the CII prescrip@ons were for oxycodone 30mg • 78% of the prescrip@ons were for CIIs
- 54. Systemic Approach Store/Site Visit Clinic Protocol • Based on the informa@on from completed by member of the store generated data and field the prescriber data a Store/Site management or corporate. visit was not required • The request for a threshold increase was denied
- 55. Systemic Approach Edits LeHer to Prescriber. • Based on prescriber analysis a Edit in dispensing leHer was sent to suspicious system to prescribers prevent control prescrip@on • A message is ac@vated in the dispensing for dispensing system: “Corporate select prescribers. policy prohibits dispensing controlled substance prescrip@ons wriHen by this prescriber”
- 56. Addi@onal Technology Tools (under development) • Poten@al edit through “third party processor” to alert for suspicious ac@vity (may include) – Pa@ent demographic – Prescriber prac@ce loca@on – Prescriber’s scope of prac@ce – Medica@on and/or therapy prescribed – Prescribing paHerns • All pa@ents get the same combina@on of medica@ons with same diagnosis
- 57. Summary • Pharmacies should consider developing a comprehensive analy@cal approach to iden@fy suspicious prescriber ac@vity. – This approach cannot iden@fy all ac@vity and must be supplemented by the pharmacists in stores – Prescribers are reviewed on an individual basis with respect to their scope of prac@ce and pa@ent base – The analy@cs are simply an added tool. Pharmacists are a key part of the process Note: This list is not inclusive of all the inves@ga@ve techniques we rou@nely conduct, this is intended to highlight the major inves@ga@ve steps.
- 58. Pa@ent Diversion Behavior • Armed Robberies rose 81% from 2006 to 2010 • The number of dosage units stolen grew from 706,000 to 1.3 million • Haven Drugs – Medford, NY a pharmacist, a clerk and two customers killed in the robbery • Charlie’s Family Pharmacy – Seaford, NY an ATF agent and robbery suspect shot and killed
- 59. Reason Pharmacies are Targeted • Easy to find and easy access • Open extended hours • Typically carry larger inventory to sa@sfy demand • Open floor design to facilitate pa@ent interac@on • Limited barriers • Limited training for employees on robbery events • Sa@sfy addic@on and some converted to cash – $80/tablet of oxycodone in certain markets
- 60. Preven@on Tips -‐ Training • Understand and observe behaviors of poten@al robber 1. Purposely wearing mul@ple layers to cover their face 2. Do not directly look at cashier or other associate 3. They do not acknowledge your gree@ng or comply with request to show their face 4. They walk directly and with purpose to the pharmacy counter • Be aware of your surroundings • Controlled safes/cabinets must be locked when not in use • Keep pharmacy doors locked at all @mes • Never leave the pharmacy area unaHended
- 61. Preven@on Tips -‐ Training • Wipe counters and front doors – Finger prints • Stage par@ally filled boHles for a robbery event • Mark your boHles – Provides a link for law enforcement – Iden@fies point of origin
- 62. During an Event • Primary concern – Safety of coworkers and customers • Do not resist • Remain calm – no sudden movements • Cooperate and follow instruc@ons given by the robber – Do exactly what you are told, nothing more, nothing less, do not argue • Make mental notes of the robber – hair, clothing, shoes, taHoos, scars, etc. • Do not aHempt to apprehend the criminal • Goal is to get the robber out of the building quickly
- 63. For@fica@on Sugges@ons Based on Risk Level • Height Strip Cameras • Public view monitor • Capture’s height of at the pharmacy robbery suspect drop off window • BeHer facial image • In@mida@on
- 64. Exterior Ligh@ng and Cameras • Increasing the foot candles of exterior ligh@ng • Exterior cameras for parking lots and store entrance – Some suspects do not wear their disguise in the car or parking lots – Capture car make and model, may capture license plates – Direc@on the suspected headed
- 65. Robbery Poster • Overt warning to the suspect and customers for awareness • Trained associates
- 66. Reward Offers Asking concerned ci@zens for their help to resolve a crime.
- 67. “Bait BoHles”
- 68. Tracking Devices • GPS tracking system • Law Enforcement Tool • Immediate no@fica@on of robbery events to a mobile device and law enforcement • Provides law enforcement accurate loca@on data on the suspect • Aids in the apprehension of the robbery suspect and recovery of stolen drugs
- 69. Tracking Devices • Hidden within the inventory • Fully automa@c • Updates GPS loca@on every 6 to 8 seconds • Track via secured website (law enforcement) • Device is silent • Seamless to day to day pharmacy opera@ons • Tip: Give staged par@ally filled boHles with the tracker
- 70. Tracking Points • 9:27 PM – Device ac@ve on Server • 9:29 PM – Unit gains GPS and is SW on Roosevelt Blvd • 9:33 PM – Subject turns leh traveling SE on Tyson Ave • 9:34 PM – Vehicle crosses over Frankford Ave s@ll moving SE • 9:36 PM – Subject turns right on to Torresdale Ave traveling SW • 9:39 PM – Subject’s vehicle is stopped by Police
- 71. Outcome • Police arrested 2 subjects at the scene • Recovered weapons and evidence of the event – Clothing and drugs • They were connected to 20+ open cases against chain and independent pharmacy robberies This list of suggested tac@cs is not all inclusive. All factors should be considered when implemen@ng any tac@c or combina@on of tac@cs including threat level, design of building, method of robbers in the geographic area, etc.
- 72. QUESTIONS • Thank you • Dr. Michael O’Neil • Janet Hart R.Ph.