Hospice providers are paying closer attention to the issue of drug diversion, as the opioid crisis continues and a rising number of prescription drugs finding their way to street dealers and black market internet sites. Consequently, pain management, one of hospices’ most essential priorities, has become more complicated.

Hospice providers are seeking new ways to balance patients’ need for controlled substances, opioids, and anxiety medications for symptom management with changing regulatory requirements and potential risks to the patient, family, or community.

Drug diversion—the transfer of a prescription medication from a lawful to an unlawful channel of distribution or use—is a prevalent issue throughout the health care continuum. Hospice providers and other organizations that provide care in the home face unique challenges due to the potential easy access to the patients’ medications.

A study published in the February issue of the Journal of Pain and Symptom Management indicated that prescription medications in the home are a “well-known entry point” for family members or visitors to access potentially addictive substances. The risk is particularly high if people in the home have a history of substance abuse.

“In my clinical practice as a hospice medical director I have always been concerned about prescribing controlled substances in all settings, but particularly in the home,” Todd Cote, MD, chief medical officer for Bluegrass Care Navigators, told Hospice News. “The hospice community has been trying to educate ourselves on patient safety issues including diversion. It’s more on the radar because of the opioid epidemic, which is very real.”

The scope of the issue is difficult to calculate. A 2017 report from Baltimore-based compliance analytics firm Protenus estimated that the annual cost of drug diversion for health care providers and payors exceeds $301 million. The report acknowledged that this was likely a low-ball estimate because the data was gathered through media reports. Costs include the lost medication themselves, as well as the time involved in developing prevention processes and the costs of regulatory compliance.

Opioids are among the most commonly diverted drugs, as are other pain medications, psychoactive drugs such as ketamine or benzodiazepines, and numerous others.

Any number of parties can be responsible for the diversion, in any given situation a patient, a family member, friend, or neighbor can divert a drug. In some cases, the health care providers themselves have taken medications intended for patients, either to traffic or to for their own use. In some instances, family members struggling with poverty have sold medications in order to buy groceries and other necessities, Cote told Hospice News.

“Some organizations simply say ‘We don’t have that problem in our community,’” Cote said. “My answer is that you may not be looking hard enough, and not thinking enough about how you develop a culture of responsibility in the hospice—a culture of monitoring, safety, education, screening, and a culture of support to patients and families.”

Cote’s hospice nearly seven years ago began to take a hard look at this issue. The first alarms were raised by the organization’s nurses who expressed concerns about diversion risk in the community. They brought the issue to the organization’s leaders, who determined that they needed to review their processes for assessing and supporting patients and families with a history of substance abuse, as well as potentially at-risk staff.

“I really think every hospice, whether large or small, has to do this kind of work and really look at the issue of diversion,” Cote told Hospice News. “We need to educate staff, patients, and families about risks and warning signs and develop processes for how we are going to handle it. We can’t just assume that it doesn’t happen.”

An important first step is to educate staff about the potential risk of prescription drug abuse as well as diversion. Staff also should be trained to have potentially delicate conversations about patient and family history regarding addiction, drug use, and associated factors.

Resources are available to guide these screenings. The Opioid Risk Tool, for example, is one evidence-based method of performing substance abuse screenings. The brief questionaire is designed to evaluate substance abuse risk factors such as prior history, mental health conditions, history of abuse, history of alcoholism and other considerations. Research has indicated that standardized evidence-based tools can make a difference in identifying substance abuse and diversion risk.

Careful background checks are important during the hiring process for staff who have access to medications or perform home visits. Hospices should also review the effectiveness of their medication surveillance efforts, including routine pill counts, and drug disposal procedures.

Coordinating with regional regulators and law enforcement agencies is also a key strategy. The hospice is not in a position to police substance abuse, but they can benefit from hearing the perspective of law enforcement.

“It helps to have an open dialogue with your local agencies to get information and have a clear understanding of what they are seeing in the field. Everyone involved in this issue is a little frustrated, and they can really help each other by staying in communication,” Cote explained.