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.
Despite the seriousness of the issue, identified instances among hospices may be rare. A study published earlier this month in the Journal of the American Medical Association found that among 371 hospices that participated in a phone survey, nearly two-thirds had not found an incident of diversion in the previous 90 days.
Nevertheless, these incidents do occur, and hospices should be on the alert.
“It’s a good first step for people to recognize that it’s a real problem that is affecting hospice and palliative care, and that we need to take it seriously,” said Mary McPherson, a professor of pharmacy who specializes in palliative care at the University of Maryland and co-author of the JAMA study. “It certainly is happening. I think that frontline practitioners, such as nurse case managers, are certainly considering this more thoughtfully, but there’s not a huge amount of consistency in practices that hospices are using in terms of how to screen for abuse and diversion.”
Hospices can look for a few red flags that could indicate that diversion may be occurring. These can include a history of substance abuse among the patient’s family members, medications that are missing during routine pill counts, unusually frequent requests for drug refills, according to John Cagle, associate professor of social work at the University of Maryland and co-author of the JAMA study. In some cases, the patient or a family member may report instances of diversion, or hospice staff may observe family members who appear to be under the influence.
Local media outlets in a number of states, including Massachusetts, Indiana and North Dakota, in recent weeks have reported several arrests of hospice nurses who had stolen patient medications, particularly opioids, subjecting patients to a devastating amount of suffering. However, the recent JAMA study found that family members, as opposed to hospice employees, are by far the greater threat in terms of diversion. Among the incidents discussed in the study, only 5% involved hospice staff.
Organization size seems to have an impact on the identification, and perhaps the incidence, of drug diversion in hospice.
“We did see an expected association between the number of cases of confirmed diversion and size of the hospice. That’s not unexpected; the more patients that you have the more likely it’s going to be that you have cases of diversion,” Cagle told Hospice News. “We did see that smaller hospices were much more likely to identify cases of confirmed diversion. It could be that larger hospice providers maybe have better policies or more resources that can prevent these kinds of things, or it could be that smaller providers are simply more in touch with their patient population and are more aware of when these kinds of things happen.”