Best practice controlled substance tracking

[deleted126335]

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I am looking for some data on what constitutes "best practice" for controlled substance accounting/monitoring for anesthesia personnel. We use a controlled substance log that is randomly reviewed with the anesthesia record coupled with "witness wasting". This is obviously easily defeatable. Turning in drawn up but unused narcotics to pharmacy personnel for random assay has been suggested. 99% of the discrepancies between controlled substances logs and anesthesia records are sloppy accounting or *****s who just can't add. I have little doubt that those who are diverting make doubly sure that the paperwork is correct. What are folks who are confident in their process doing?

 

[urge]

The people diverting get very sloppy very soon. Check their waste. You will catch of them that way.

 

[pgg]

I think maybe the best way to catch diversion early is to track usage levels per person.

This graph is the Dilaudid usage of a diverting CRNA at my hospital a couple years ago. He started diverting in late August, and we caught him in early February the next year. Never missed a day of work, no flags re: quality of care or charting. He would've been caught during his next chart peer review anyway ... pharmacy didn't know enough to care that he was checking out Dilaudid for colonoscopies, but we would've.

If anyone had been looking at usage patterns (even just from-a-distance eyeballing of trends), diversion would have been obvious in September. His usage skyrocketed quickly, but outwardly he was totally symptom free for months, including the day he was caught.

This was from one facility. The dip in use over the holidays was because this facility was mostly closed and he was working elsewhere.

 

[jwk]

I think maybe the best way to catch diversion early is to track usage levels per person.

He would've been caught during his next chart peer review anyway ... pharmacy didn't know enough to care that he was checking out Dilaudid for colonoscopies, but we would've.

I agree this can help early on IF somebody with some common sense that is familiar with anesthesia narcotic use is looking at the data. We had a person years ago that was signing out large quantities of demerol for D&C's. Never mind that NOBODY in the anesthesia department ever gives demerol and that even if they did NOBODY would sign out 500mg for a D&C. Yet our pharmacy/pharmacist never noticed it.

 

[pgg]

I agree this can help early on IF somebody with some common sense that is familiar with anesthesia narcotic use is looking at the data. We had a person years ago that was signing out large quantities of demerol for D&C's. Never mind that NOBODY in the anesthesia department ever gives demerol and that even if they did NOBODY would sign out 500mg for a D&C. Yet our pharmacy/pharmacist never noticed it.

Right, I'm still a little miffed that our pharmacy didn't utter one single peep about Dilaudid use in the OR going up 50- or 100-fold. They just kept stocking the Pyxis. You don't need to know a thing about anesthesia to see that huge spike in Dilaudid usage in Sep 2010 ... if you're keeping track of schedule 2 drug usage stats. But no one was looking.

Since then our controlled substance audit #s go through the anesthesia department for a quick review. It's not perfect, but a trend like the graph I posted won't slip through again.

 

[nap$ter]

I am looking for some data on what constitutes "best practice" for controlled substance accounting/monitoring for anesthesia personnel. We use a controlled substance log that is randomly reviewed with the anesthesia record coupled with "witness wasting". This is obviously easily defeatable. Turning in drawn up but unused narcotics to pharmacy personnel for random assay has been suggested. 99% of the discrepancies between controlled substances logs and anesthesia records are sloppy accounting or *****s who just can't add. I have little doubt that those who are diverting make doubly sure that the paperwork is correct. What are folks who are confident in their process doing?

the cheapest and most effective method by far would be random drug testing.

all this "accounting, wasting, witnessing etc.." is easily defeated for up to years, until real trouble starts. and it's a pain in the arse and interferes with turnover and patient care. random drug testing can be defeated also, but it is more difficult (ie hair testing) etc.

why haven't we learned from the aviation industry?

 

[deleted126335]

the cheapest and most effective method by far would be random drug testing.

all this "accounting, wasting, witnessing etc.." is easily defeated for up to years, until real trouble starts. and it's a pain in the arse and interferes with turnover and patient care. random drug testing can be defeated also, but it is more difficult (ie hair testing) etc.

why haven't we learned from the aviation industry?

Anybody actually doing this? Can't imagine that it would go over well.

 

[IlDestriero]

Anybody actually doing this? Can't imagine that it would go over well.

The .mil does it every month.

 

[imfrankie]

The .mil does it every month.

I sure would rather pee in a cup every so often than horse around with the witnessing, wasting and micro-accounting that's become so prevalent.
I have to agree with P however; a close friend passed and his/her problem was so obvious in retrospect with the escalating pixis withdrawals. Can't imagine a narcotic abuser can subsist for long on a few hundred mcgs here and there.

 

[nap$ter]

Anybody actually doing this? Can't imagine that it would go over well.

a few residency programs are doing it. no private practice or hospital that i'm aware of is though.

i am curious why this is the norm for pilots but doesn't "go over" for anesthesia providers (or nurses, for that matter)

 

[Monty Python]

I am looking for some data on what constitutes "best practice" for controlled substance accounting/monitoring for anesthesia personnel. We use a controlled substance log that is randomly reviewed with the anesthesia record coupled with "witness wasting". This is obviously easily defeatable. Turning in drawn up but unused narcotics to pharmacy personnel for random assay has been suggested. 99% of the discrepancies between controlled substances logs and anesthesia records are sloppy accounting or *****s who just can't add. I have little doubt that those who are diverting make doubly sure that the paperwork is correct. What are folks who are confident in their process doing?

I'll just repeat what others have said: random testing. Every month at drill the pay computer spits out a randomly-generated list of 10% of all reservists at my reserve center. You WILL pee in the cup or get handed your discharge papers.

The "witness" thing is a joke. Are your eyes mass spectrometers? In court the correct response would be that you watched "2 ml of a clear liquid, of unknown chemical structure, ejected from a clear syringe with a blue label stating "fentanyl" on it."

Anyone with insider (ie, anesthesia) access and knowledge can easily defeat anti-diversion systems for a while. They'll eventually get caught, hopefully before they and/or patients suffer harm. We need to have constant random testing, IMHO, as the best diversion prevention method.

 

[chocomorsel]

I sure would rather pee in a cup every so often than horse around with the witnessing, wasting and micro-accounting that's become so prevalent.
I have to agree with P however; a close friend passed and his/her problem was so obvious in retrospect with the escalating pixis withdrawals. Can't imagine a narcotic abuser can subsist for long on a few hundred mcgs here and there.

Passed a drug test or passed as in died? Sorry if he/she died. That's terrible especially if due to drugs.
I, however find it odd that a physician would use "passed" instead of "died" if that should be the case.

 

[chocomorsel]

a few residency programs are doing it. no private practice or hospital that i'm aware of is though.

i am curious why this is the norm for pilots but doesn't "go over" for anesthesia providers (or nurses, for that matter)

Because we have "integrity" and should be trusted.
Actually nurses have to pass a drug test at many if not most places before being hired. I used to be one, that's how I know. I don't recall having to pee in a cup for any of my physician jobs, i.e residency and current gig. Want to say I had to pee in a cup for a State license (TX) but could be mistaken.
I don't see the big deal myself being ex military and ex RN. Wouldn't make me no difference.

 

[pgg]

The .mil does it every month.

But it's random. Our diverter didn't get tested in that entire ~6 month period. But he'd have been spotted after just a month if anyone had been looking at the Pyxis pull trends.

 

[imfrankie]

Passed a drug test or passed as in died? Sorry if he/she died. That's terrible especially if due to drugs.
I, however find it odd that a physician would use "passed" instead of "died" if that should be the case.

He "died" from a fentanyl overdose--how's that?

 

[imfrankie]

He "died" from a fentanyl overdose--how's that?

Apologies for the harsh reply.

 

[chocomorsel]

No worries. No offense taken.

 

[geogil]

Random drug testing would be the answer if the lab tests were 100% sensitive and 100% specific, but they're not. They're good, but not perfect. Eventually, statistically, an innocent person will have a positive test, which could potentially be a career ruiner. We just had a lecture by one of our state medical board guys on diversion and recidivism after rehab. They just published the data in JAMA and it's pretty shocking. What was particularly interesting was that the mortality from addiction was high for all substances (i.e. cocaine, alcohol etc) not just fentanyl, sufenta, prop, and anesthesia specific drugs.

 

[nap$ter]

Random drug testing would be the answer if the lab tests were 100% sensitive and 100% specific, but they're not. They're good, but not perfect. Eventually, statistically, an innocent person will have a positive test, which could potentially be a career ruiner. We just had a lecture by one of our state medical board guys on diversion and recidivism after rehab. They just published the data in JAMA and it's pretty shocking. What was particularly interesting was that the mortality from addiction was high for all substances (i.e. cocaine, alcohol etc) not just fentanyl, sufenta, prop, and anesthesia specific drugs.

the sensitivity and specificity of toxicology is far higher than the sensitivity and specificity for witnessed wastage and pharmacy tracking, i assure you.

i am not aware of a single instance of a false positive drug test leading to ruination of an anesthesia provider's career. any positive result leads to referral to rehab for further evaluation.

 

[pgg]

Random drug testing would be the answer if the lab tests were 100% sensitive and 100% specific, but they're not. They're good, but not perfect. Eventually, statistically, an innocent person will have a positive test, which could potentially be a career ruiner.

The military does a mind-staggeringly large amount of random drug testing. It is a huge undertaking and I assume it's a huge expense. They have people on staff everywhere whose primary job seems to be managing the pee collection and custody and shipping. A positive test is a fast ticket out of service, and not an honorable discharge. Always at the back of my mind I wonder how often a series of false positives comes up and sink someone. But I guess it doesn't, because I've never ever heard of a credible claim for a faulty test.

The way the .mil does it is (IIRC) is by testing a pooled sample of many people. If the pooled sample is positive, every individual sample in the pool is tested. If one or more of those are positive again, it's tested again, and then eventually confirmed via mass spec. No test has a perfect 0 for false positives, but I don't lose any sleep over it.

Not that I'd trust some random hospital to get everything from collection to chain of custody to testing to reporting correct. And were I not in the military and voluntarily waived a civil right or two in return for that fat government paycheck, I'm not sure how I'd feel about my employer drug testing me.


Again, I think the solution is simple and essentially free: my reply #3 above. Diversion and addiction always leads to escalating use as the addict loses control. If someone is keeping track of what everyone checks out and claims to be giving to patients or wasting, diversion will be apparent very soon. No drug testing, no expense and man-hours spent mass spec'ing waste. Just a pharmacy tech who can be bothered to fire up Excel once a month.