Opioid misuse has again made headlines, this time in regard to the death of pop music sensation Prince from what was determined to be an accidental overdose of self-administered fentanyl. As you read the headlines, whether it is about a Prince or “a pauper” overdosing, consider the possibility that some of that fentanyl may be finding its way out of your hospital. While we do not yet know how Prince obtained the drug, fentanyl is the latest medication to gain notoriety as a cause of opioid addiction.
Fentanyl is a synthetic opioid that is almost 100 times more potent than morphine and up to 50 times more powerful than heroin and its misuse can lead to death. In the Cleveland area of Cuyahoga County, there have already been 140 fentanyl-related deaths in 2016.1 A Vail Colorado anesthesiologist overdosed on fentanyl in April of this year. In this case, both new and old puncture marks were found on the doctor’s legs indicating she had been using injectable drugs for some time.2
In addition to injectable fentanyl, we are also aware of the emergence of “super pills” in which oxycodone or Percocet® is laced with fentanyl. News reports from Florida to California tell of the growing number of deaths associated with these concoctions, more accurately named “death pills.” Some healthcare workers have confessed to abusing fentanyl because they find the “high” tends to last about as long as a lunch break. The results are increasingly deadly and put patients and staff in peril.
Since 2004, reports of fentanyl being illegally manufactured and imported from Mexico and other parts of the world have emerged. In May 2006, the U.S. shut down a manufacturing operation in Toluca, Mexico that had distribution ties to Chicago and Detroit.3 In April 2016, a dozen packages that shipped from China contained raw fentanyl powder and manufacturing presses were discovered in Southern California.4
While hospitals can’t prevent every illicit activity, we can combat the misuse of powerful painkillers by taking a more proactive approach to preventing drug diversion within our organizations. Clearly, drug diversion in the hospital by healthcare workers is of great concern for everyone. The continued challenge is how to prospectively detect and stop diversion before it happens. Our experience is that there are two important areas for continuous evaluation. These focus on finding every source of the drug in the hospital and how medication waste is handled.
Identifying sources of fentanyl
In the case of fentanyl diversion, we need to first identify all sources of the medication within our hospitals and health systems. For example, pharmacists often stock fentanyl in automated dispensing cabinets, create anesthesia “packs” or “kits” as a “grab and go” for procedural areas, and prepare fentanyl drips for epidurals or continuous infusion in the ICU. In addition to injectable fentanyl, we also have patches and, in some cases, anesthetic “lollipops” as among our internal sources. There are even more sources of the drug in the pharmacy vault as well as the receiving and ordering areas of the hospital. Once all sources are fully identified, the next step is to determine what procedures are being taken to secure fentanyl and then to note all risk points throughout the organization.
Consider these key risk points:
- Does your organization provide anesthesia “kits” of controlled substances? Are they standardized across all sites of care, regardless of clinical need?
- If you are using automated dispensing cabinets or anesthesia stations in your operating rooms, how have you configured the machine settings? Do you have blind counts and step-drawers?
- Do you allow anesthesia providers to pass controlled substances from one procedure to the next during cases where coverage is provided?
- Do anesthesia providers waste with a witness in the operating room, or do you require the return of waste with a random analysis?
There are many more risk points to consider on the patient care floors and other areas where controlled substances may be diverted.
Evaluating the pharmaceutical waste stream
The second big area for potential diversion of fentanyl is the pharmaceutical waste stream. While conducting facility audits, we have routinely encountered large, open waste containers that are ripe for the picking. Many hospitals spend a lot of time and effort to separate waste into yellow, black or red bins to comply with EPA regulations and yet often fail to consider diversion in the equation.
Ask yourself these questions:
- Have you taken the time to actually review how fentanyl is wasted in all areas where it is used legitimately? Are your processes secure?
- Do you have consistent practices for fentanyl patches to be folded onto themselves and cut?
- Does the patch go in the waste bucket or is it flushed?
In our experience auditing hospitals for drug diversion, we routinely encounter everything from partial sufentanyl epidural bags in open black waste buckets to labeled syringes in open waste containers, which expands the potential diverter pool far beyond direct care givers.
The time is NOW to put a stop to drug diversion in hospitals
The reality is that tomorrow’s headline might be about a prince, or a pauper overdosing on opioids. Hospitals nationwide must consider whether fentanyl or other opioids are finding their way out of their organizations and into the hands of abusers.
1. WKBN Staff Writers, “Fentanyl cases, deaths increase in Ohio,” WKBN Channel 27 News, June 3, 2016. http://wkbn.com/2016/06/03/fentanyl-cases-deaths-increase-in-ohio/
2. DOlinger and COshner, “Drug-addicted, dangerous and licensed for the operating room,” The Denver Post, April 23, 2016. http://www.denverpost.com/2016/04/23/drug-addicted-dangerous-and-licensed-for-the-operating-room/
3. JAker, “CDC: Street deaths tied to illegal fentanyl,” Injury Board National News Desk, July 25, 2008. http://news.legalexaminer.com/cdc-street-deaths-caused-by-illegal-fentanyl.aspx?googleid=244472
4. DArmstrong, “Truly terrifying: Chinese suppliers flood US and Canada with deadly fentanyl,” STAT News, April 5, 2016. https://www.statnews.com/2016/04/05/fentanyl-traced-to-china/