The Profile of A Nurse Drug Diverter
Brittany was a rising star on the MedSurg unit. She was hard working, bright and bubbly. Everyone loved her. Within two years of graduating, she became charge nurse. She was head of the unit’s self-governance committee and winner of the Daisy Award, a prestigious award given to outstanding nurses.
Everyone was shocked the afternoon she was escorted off the nursing unit for diverting drugs Brittany? Their top nurse?
Chances are you have worked with a nurse who diverts drugs. It’s estimated that roughly 6-10% of nurses abuse drugs. It’s a given that where there’s drugs, there’s substance abuse, and nurses have both availability and access.
An example of tampering discovered in a small hospital was when a nurse neatly removed the bottom of Valium ampules stored in a rarely used crash cart and diverted the Valium. Later it was discovered the same nurse had also injected PCA syringes with saline.
A nurse in Utah infected 16 patients with hepatitis C when she tampered with narcotics, injecting herself and her patients with the same syringes. Neither of these nurses was suspected by their coworkers.
Most nurses believe they would be able to recognize a colleague who is using drugs or alcohol. Unfortunately, this is not always true. This false belief places nurses at risk for enabling.
It is not unusual for the nurse diverter to be seen as the most competent and least likely to have problems. Yet problems do exist. Even though the rest of her life may be in chaos, she continues in her job and manages to appear in control.
She must be super efficient in order to both get her drugs and do her job - in essence, she is managing two jobs. She may receive glowing evaluations and be Employee of the Month.
But underneath the outer facade is a nurse who most likely prefers to work alone so mood swings will not be evident to others and communication with colleagues will be at a minimum. Inwardly, she may feel inadequate and socially uncomfortable.
Physical and Behavioral Indicators
Barbara, a traveler, injected herself while at work and developed a large infected boil on her thigh from skin-popping morphine. She would occasionally nod off at the nurses’ station but coworkers thought she was staying up too late or working too much. Looking back, her drug use seemed obvious, but she worked and functioned fairly well for months before getting caught and getting help.
Later, coworkers would recall that Barbara:
- Disappeared frequently
- Took multiple bathroom breaks and smoke breaks in her car
- Had mood swings- sporadic excessive talking followed by moody withdrawal
- Regularly offered to medicate other nurses’ patients
- Always had multiple physical complaints- back aches, stomach aches, headaches
- Sometimes appeared to have a flushed face and dilated pupils
But overall, Barbara was well liked. Her contract had been extended twice.
Overly helpful The nurse diverter is first to help cover another nurse’s patients, and especially to offer pain medication. The diverter becomes adept at identifying opportunity, such as the charge nurse who gets to work and immediately targets post-op patients likely to have narcotics ordered. She can then pro-actively offer the patients pain medication.
High performer/workaholic The nurse diverter works extra shifts. She may come in early or stay late. Overextending oneself at work can be an early indicator of weak boundaries and serve a secondary purpose of increased access to drugs.
Well liked The nurse diverter has an ability to make people like them, which allays suspicion. Addicts typically are good at manipulating people to met their needs.
Bright and smart Nurse diverters are smart and persuasive- they can quickly offer a plausible albeit elaborate explanation for discrepancies.
Work history Nurse diverters may jump from hospital to hospital to avoid being caught. They seek positions that give them access to patients and drugs- such as night house supervisor in a small hospital with pharmacy access, or staff RN in Interventional Radiology where there is greater autonomy and no automatic dispensing cabinet (ADC), Smaller hospitals are less apt to have diversion detection programs in place.
Diverters waste large amounts of narcotics, drawing up more than ordered to create waste. Most diverters have a preferred drug. Popular choices include fentanyl, propofol and hydromorphone (injectables) and hydrocodone, oxycodone and benzodiazepines (pills).
Wasting becomes an art- pills are documented as “dropped” and meds are “refused” by patients.
Reports show the diverting nurse will waste more of their preferred drug while showing normal waste patterns with other drugs.
Transaction reports show users who fail to waste, waste large amounts, and waste more than co-workers caring for the same patients. By the time reports show a noticeable pattern, the nurse has been diverting for a long time.
At first, the diverter is cautious. Over time, they become reckless and sloppy. Brittany started out by diverting one of two hydrocodone pills ordered for her patient. Later, she routinely diverted both pills and substituted look-alike pills.
When discharging patients, she would quickly pull their pain meds before they were discharged from the automatic dispensing cabinet (ADC). One of her patients was admitted with a fentanyl patch. Brittany removed it and applied it to herself.
Eventually she forgot to document a prn medication that was diverted, and neglected to have a waste witnessed. Another time, desperate, she falsified a doctor’s order, thinking he would just sign it without thinking. The order was refused.
Addiction is a progressive disease and as tolerance builds, usage increases. The user needs greater amounts of drug to chase the initial high and eventually to just not feel bad. Over time, the nurse becomes more and more like the stereotypical substance addict and less and less like her “pre-addict” self.
Ethical deterioration in the form of dishonesty, secrecy, manipulation, lying and stealing takes place. These behaviors cause great inner conflict, dissonance, and guilt - all of which increase mental distress and the need for chemical relief.
As the disease progresses, addict-nurses invariably manifest impairments in thinking, feeling, and actions. Intermittent confusion, memory loss, impaired judgment, personality change, emotional disturbance, social withdrawal, physical incoordination, and sluggishness leading to falls, accidents and injuries are common.
Reluctance to Report/Enablers
There is a reluctance to report by co-workers and institutions- no one wants to cause a coworker to lose their job and no hospital wants the negative publicity.
New nurses are naive to the problem and too focused on their own performance to pick up on warning behaviors. Other nurses may turn a blind eye, cover the nurse’s workload, and rationalize the behavior. “She has a bad back and needs meds”, and “She needs her job”.
A nurse who is diverting will casually ask a coworker to co-sign unwitnessed wastes, implying that it’s no big deal and relying on the coworker’s inclination to not make waves. Refrain from co-signing any unwitnessed waste. You could become the diverter’s “go-to” person and be complicit in their drug use.
Rehabilitation and Treatment
Once diversion is confirmed, the hospital has a responsibility to report to regulatory agencies is so that the diverter doesn’t simply practice elsewhere. DEA, State licensing board (BOB/BRN), at a minimum. Law enforcement and the Pharmacy Board and the Department of Health reported to all required agencies according to state law.
In many states, the BON/BRN offers diversion programs that can help get a nurse back to full practice. Rehabilitation and re-entry into practice are the goal of recovery.
How to Help
Nurses have an ethical duty to protect patients by reporting suspected diversion. The first goal is always patient safety. Signs of diversion should be reported so an investigation can occur. There doesn’t need to be proof, just suspicion. Turning a blind eye is enabling, but helping a nurse face her problem is the only meaningful way to help.
Related article: Read here about how pharmacy profits spawned the deadly opioid epidemic.