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The painful problem of drug diversion and what you can do


Controlled substance (CS) abuse and addiction is debilitating for those who suffer from it and devastating to those with whom they interact. Yet, some healthcare professionals, including nurses, become involved with drug diversion of controlled substances in their workplace. In 2011, Thomas and Siela reported that approximately one in ten nurses “may be impaired or in recovery from alcohol or drug addiction.” The stress of the profession, long shifts, fatigue, insomnia, physical and psychic pain, along with fairly easy access to controlled substances contribute to drug diversion by nurses. Additionally, the number of CS prescriptions continue to grow. In 2010 alone, hydrocodone with acetaminophen was prescribed 131.2 million times.

Theft of controlled substances usually occurs for personal use, to supply the drug to another user, or for financial gain. Theft can occur wherever controlled substances are found. In addition to theft from a medication dispensary, narcotic cabinet, or pharmacy, drug diversion can include removing a pain patch directly from a patient’s body for personal use or even rifling through medical or hazardous waste for CS remnants and residue.

Drug diversion in health care harms addicts, fellow employees, employers, and patients. Patients may not be receiving the prescribed amount of the correct CS as frequently as needed, or none at all. If so, patients will suffer needless pain. In a few documented cases, the healthcare worker injected herself or himself, then injected the patient, passing on chronic bloodborne illnesses. If the nurse is using a CS on duty, his or her judgment and responses will be impaired. Higher rates of error can occur, and all of the impaired nurse’s patients will receive a decreased level of care, not just the one whose drugs were diverted. (See Signs and symptoms of drug diversion.)

Signs and symptoms of drug diversion

The National Council of State Boards of Nursing, in its brochure, “What You Need to Know about Substance Use Disorder in Nursing,” offers the following signs to look for if you suspect a nurse of drug diversion:

• Changes in job performance;
• Absences from the unit for long periods;
• Multiple restroom breaks;
• Arriving late/leaving early;
• Excessive errors, including medication errors;
• Subtle changes in appearance that may escalate over time;
• Increasing isolation from colleagues;
• Inappropriate verbal or emotional responses;
• Diminished alertness, confusion, or memory lapses;
• Incorrect narcotic counts;
• Large amounts of narcotic wastage;
• Numerous corrections of medication records;
• Frequent reports of ineffective pain relief from patients;
• Offers to medicate co-workers’ patients for pain;
• Altered verbal or phone medication orders; and
• Variations in controlled substance discrepancies among shifts or days of the week.

©2014 The National Council of State Boards of Nursing (NCSBN®).

Consequences, actions, and resources

Drug diversion of CS damages the reputations of the employer and employee, often destroying the employee’s career. The impaired nurse, when caught, can face criminal prosecution, civil malpractice actions, and actions against his or her RN license. He or she may be fired. However, there are also non-punitive approaches in certain states. These may come in the form of various alternatives to discipline programs: random monitoring, Employee Assistance Programs (EAP), education programs, peer assistance programs, recovery programs and substance abuse treatment programs. Many state nurses associations and nursing specialty organizations offer peer assistance programs.

Healthcare employers should offer their employees education regarding the dangers of drug addiction and diversion; meticulous monitoring, documentation, and tracking of CS; assistance for addicted employees; and employee surveillance programs that monitor behavior changes and patients appearing undermedicated. Any CS diversion and drug abuse or addiction must be identified quickly and stopped immediately to provide a safe healthcare environment for patients and employees. Contact your state’s Board of Nursing for information on how to get assistance for a drug (or alcohol) impaired nurse, as well as consult your employer’s policies and procedures for the impaired employee. State and local regulations may vary.

Holly Carpenter is senior staff specialist in Nursing Practice and Work Environment at ANA.

Selected references and resources

Berge KH, Dillon KR, Sikkink KM, et al. Diversion of drugs within health care facilities, a multiple-victim crime: patterns of diversion, scope, consequences, detection, and prevention. Mayo Clin Proc. 2012;87(7):674–82.

National Council of State Boards of Nursing. (2014). What You Need to Know about Substance Use Disorder in Nursing. Accessed November 25, 2014.

Thomas CM, Siela D. The impaired nurse: Would you know what to do if you suspected substance abuse? Am Nurse Today. 2011;6(8) Accessed November 25, 2014.

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