Over the past decade, the opioid crisis in the United States has reached a fever pitch. The sharp increase in opioid pain reliever prescriptions has correlated with a significant increase in prescription and non-prescription opioid related deaths. The rise of opioid overdose related emergencies has put an increased strain on already overloaded public safety resources as well as hospital systems. Additionally, the problem of drug addicted healthcare workers has presented healthcare administration with a formidable threat to the organization from within its own workforce. Adding to the human cost of the opioid crisis, the financial aspect has had a major impact as well. Healthcare payers, both public and private, have been subject to increased financial pressure due to the costs of emergency department visits and hospital admissions. This research paper seeks to explore the origins of the opioid crisis, analyze its cascading effects on American healthcare systems, scrutinize the role of healthcare providers and pharmaceutical companies as causal factors, discuss current efforts being taken healthcare systems to increase patient safety with a specific focus on preventing and detecting drug diversion (which are typically opioids) within healthcare facilities. Further steps the healthcare administrator can take to lessen the financial and human impact on healthcare systems are discussed.
opioid, prescriptions, Purdue Pharma, diversion, administrator
The Opioid Crisis and Its Implications on Healthcare Administration
Opioid pain relievers have an extensive history of prescription worldwide, and are widely known as safe and effective methods to relieve severe chronic and acute pain when taken with proper purpose and competent physician oversight (O’Brien, et al., 2016). However, opioid prescriptions do not come without their risks. Bollinger and Stevens (2019) report that opioids have a propensity to lead to addiction and abuse by the patients they are prescribed to. Additionally, opioid overdoses have a high degree of lethality even with a relatively minor overdose. Factoring both legal and illegal opioids, the United States averages a death toll of 91 people per day due to the result of opioid overdose (Mack, Jones, & McClure, 2017).
The Timeline of the Opioid Crisis
Bollinger and Stevens (2019) note three major “waves” in opioid overdose related deaths noting 1999, 2010, and 2013 as beginnings of statistically significant increases in deaths. They point out each wave to be more fatal than the previous. The causes of each wave are subject to debate, although typically a new, major factor is in play during each year. It is reported by Van Zee (2009) that prescription opioids were being fiercely marketed during the year 1999 and that the treatment of chronic pain had become a large, lucrative industry by this time (Dasgupta, Beletsky, & Ciccarone, 2018). The year 2010, not long after the last economic recession, saw a sharp increase in heroin deaths (Bolliger & Stevens, 2019) correlated with slow economic recovery (Dasgupta et al., 2018). Scholl, Seth, Kariisa, Wilson, & Baldwin (2019) note a significant rise in the proliferation of powerful, easy to produce, illicit synthetic opioids such as Fentanyl in 2013.
From 1999-2017, there have been 399,230 recorded drug overdose deaths involving opioids (Scholl et al., 2019). It has been suggested that deceptive marketing practices by large pharmaceutical companies (specifically Purdue Pharma), illicit synthetic opioids, and economic downturns, have been key players in the rise of opioid addiction and death (Van Zee, 2009; Schatman and Webster, 2015; Dasgupta et al., 2018).
Individuals who become addicted through iatrogenic or illicit means are not the only victims of the opioid crisis. Drug theft by healthcare workers has also become a major issue. There are a myriad of documented cases of healthcare workers diverting medically necessary doses of opioid pain medications away from patients who are undergoing painful procedures or experiencing painful conditions in order to satisfy their own needs (Berge, Dillon, Sikkink, Taylor, & Lanier, 2012; Inciardi, Surratt, Kurtz, & Cicero, 2007).
In addition to the loss of life by fatal overdoses, hospital systems have experienced intense strain on resources due to opioid related emergency department (ED) visits. The rising rate of opioid related emergencies contributes to ED and hospital overcrowding, which consequently increases overall patient mortality (Jeanmonod & Jeanmonod, 2017). Between 2001 and 2012 opioid related overdoses caused an estimated 663,715 hospital admissions in the United States (Hsu, McCarthy, Stevens, & Mukamal, 2017).
Understanding the root causes and key factors in opioid proliferation is essential for the healthcare manager to mitigate the effects of the crisis on both patients and staff members. One cannot solve a problem they do not understand. “Know your enemy” should be a mantra adhered to when developing a strategy to respond to the issues caused by opioids.
Origins of the Opioid Crisis in the United States
In 1986, the World Health Organization (WHO) issued a three-level flow chart to guide the treatment of pain. They suggested that the treatment of pain should start with non-narcotic analgesics and should only progress to weak, followed by strong opioids only as needed based on the relief of pain (Bolliger & Stevens, 2019). Despite this recommendation, throughout the next 20 years, opioid prescriptions became increasingly common. Drug companies like Purdue Pharma downplaying the addiction risks of their opioids and promising miraculous pain relief (Van Zee, 2009), emerging studies warning of cardiovascular and gastrointestinal risks among popular non-steroidal anti-inflammatory drugs (NSAIDs) (Conaghan, 2012), an increasingly consumerist view of healthcare by the public (Makary, Overton, & Wang, 2017), and the socioeconomic downturns of the late 2000s (Dasgupta et al., 2018), have set the stage for a national health crisis.
Schatman and Webster (2015) argue that unethical marketing practices by Purdue Pharma regarding the addictive properties of OxyContin ® have contributed to the opioid crisis. Hailed as a “miracle drug” upon launch due to its ability for those with chronic pain to continue to lead a normal life (Jayawant & Balkrishnan, 2005), Purdue Pharma claimed that addiction occurs in only 1% of patients prescribed the drug. This conclusion was based on a study of 11,882 burn patients using the opioid for pain. The study’s results noted that only 4 of the participants developed an iatrogenic addiction. Furthermore, another study of 10,000 burn patients resulted in no documented cases of addiction (Van Zee, 2009). Van Zee (2009) points out the usefulness of this drug in severe, acute pain, however it is unwise to use the results of these studies to determine the efficacy and safety of its use in treating patients’ chronic pain.
Van Zee (2009) reports that upon the launch of OxyContin in 1996, Purdue Pharma marketing teams were offered enticing incentives for selling the new drug and were tasked with aggressive promotion. Sales of the drug increased from $48 million upon its launch to over $1 billion in 2000.
By 2004, OxyContin became one of the most abused drugs in the United States (Van Zee, 2009). Patients who were addicted to the drug often presented to their care providers with fake complaints in order to get prescribed the drug. “Doctor shopping” had become a new trend where addicted individuals would travel from doctor to doctor seeking opioid prescriptions (Jayawant & Balkrishnan, 2005). Another term, “pill mill” had also been introduced into the public’s vocabulary. A “pill mill” doctor would prescribe high volumes of opioids such as OxyContin to patients with either no medical need or in amounts outside accepted medical practice (Mack et al., 2017).
Addicted patients had discovered ways to increase the euphoric “heroin like” sensation of OxyContin through different routes of absorption such as grinding up the tablets to “snort” them and dissolving ground tablets in water and injecting the liquid intravenously. Robberies of pharmacies with intent to steal narcotics and prescription forgery had also been increasingly common at this time (Jayawant & Balkrishnan, 2005).
Pain as the Fifth Vital Sign
Makary et al., (2017) point out that the introduction of “pain as the fifth vital sign”, proposed in the mid-1990s and commonly accepted in the mid-2000s, has likely been a factor in the overprescribing of opioid pain medications. They note that the evolving consumerist mentality of healthcare and the patient’s expectation of healthcare as a “pain-free experience”. The patient’s view of how well their pain has been treated became a benchmark on hospital performance and patient satisfaction, putting pressure on physicians to give in to the patient’s expectations.
Dasgupta et al., (2018) caution observers of the opioid crisis not to view it solely as an iatrogenic disease process that has resulted from overprescribing. They argue that a major cause of opioid abuse has been its application of a coping method for individuals to deal with social and economic downturns. The slow recovery of The Great Recession of 2008 coincides with a 3-fold increase in heroin deaths between 2010 and 2015 compared to previous years (Rudd, et al., 2014).
The Specific Impact of the Opioid Crisis on the Healthcare Management
The opioid crisis has proliferated the rise of additional challenges to the healthcare manager. It is administration’s responsibility to mitigate and overcome these challenges and assure the safety of staff, patients, and the organization as a whole through effective personnel and financial management skills (McClure et al., 2017). With no end to the opioid crisis forecasted for the near future, it is imperative that administration adapts to handle the challenges created by patient and staff opioid addiction.
Increased Strain on Hospital Resources
From 2005 to 2014, a per capita analysis shows that nationally, opioid related inpatient hospital stays increased yearly by 5.7 percent from 136.8 per 100,000 in 2004 to 224.6 per 100,000 in 2014 (Weiss et al., 2017), during this same time period, opioid related emergencies increasingly contributed to emergency department overcrowding. Emergency department visits related to opioids increased by 99.4 percent from 89.1 per 100,000 in 2004 to 177.7 in 2014, an annual growth rate of 8 percent (Weiss, et al., 2017). The increased traffic the opioid crisis presents to hospitals have a rippling effect onto other patients. Emergency department overcrowding is noted to be a significant problem in healthcare and is correlated with increased mortality, increased time stroke patients wait for a computed tomography (CT) scan, and generally poorer outcomes across a broad spectrum of patient populations (Jeanmonod & Jeanmonod, 2017).
Financial Cost of Opioid Related Illnesses
Hsu et al., (2017) analyzed the financial cost of opioid related hospitalizations from 2001 to 2012. They noted that the cost of hospitalizations from opioid related illnesses rose from $179.2 million in 2001 to $727.3 million in 2012. Overall during their study period, the total cost of hospitalizations related to opioids was $5.5 billion dollars. Hsu et al., (2017) distinguish opioid related hospital admission patients two separate groups: heroin overdose associated admissions (HOD) and prescription opioid overdose related admissions (POD). HOD patients were noted to generally be covered by Medicaid or no insurance, while POD patients (typically older) were more likely to have Medicare as their primary insurance. Larger hospitals in urban settings were subject to the most financial pressure by opioid related admissions.
Mitigating Strain on Hospital Resources
Jeanmonod & Jeanmonod (2017) suggest healthcare administration implement strategies to reduce emergency department presentations and improve throughput. They note the most effective strategy to reduce emergency department overcrowding is to reduce time spent in the ED and streamline admission to inpatient floors. Hospitals have studied innovative solutions to address this issue. A study using telemedicine by healthcare providers in an ED triage demonstrated the same level of effectiveness as an in-person assessment, allowing care to begin sooner after registration (Rademacher, et al., 2019).
Another effective way to decreasing wait times and ED overcrowding can be accomplished by utilizing the Lean Method, as demonstrated by the ED staff at Hôtel-Dieu Grace Hospital. By applying Lean principles, the emergency department at this hospital was able to decrease average time from when the patient is first registered to physician assessment from 111 minutes to 78 minutes as well as decrease length of ED stay from an average of 3.6 down to 2.8 hours without adding additional beds. The authors note that in addition to decreasing wait times, patient satisfaction also increased (Ng, Vail, Thomas, & Schmidt, 2010).
Narcotics Diversion by Healthcare Workers
Prescription drug diversion is described as unlawful movement of regulated drugs from their intended, legal sources to the illegal marketplace (Inciardi et al., 2007). Diversion by healthcare workers produces a cascade of negative events which affects the patient, the person themselves, other healthcare workers, the healthcare organization, and the community as a whole (New, 2015). Institutional management has duty to ensure the safety of all within the organization. Opioid diversion within a facility presents a major threat to the wellbeing of all involved. Management must ensure all staff members are vigilant regarding the safety of opioids and all safety policies and procedures are followed meticulously (Berge et al., 2012).
Prevalence of drug and narcotics diversion by healthcare workers.
The most commonly diverted drugs in healthcare facilities are opiates, and most often, the culprits are healthcare workers themselves. The typical location for these thefts to occur is in the outpatient setting, where drugs are most often prescribed. (Berge et al., 2012). Typically, the motivation behind these thefts are to sell on the streets for cash (Chandra & Ozturk, 2010) or to feed their own addiction (Berge et al., 2012).
Although there are estimations about the prevalence of narcotics diversion by healthcare workers, the true number will likely never be known due to the inherently surreptitious nature of the activity (New, 2015). The Mayo Clinic has examined this issue thoroughly and notes that although it is a major issue that can directly affect patient and staff safety, the true scope of prevalence cannot be accurately estimated. The addicted healthcare worker becomes extremely adept at feeding their addiction without drawing suspicion from their coworkers or management. Constant vigilance is recommended for the healthcare manager to effectively mitigate, and ideally eliminate drug diversion by healthcare workers (Berge et al., 2012).
Methods of drug and narcotics diversion by healthcare workers.
Berge et al., (2012) highlight typical ways the healthcare worker engages in drug theft. Some methods include: purposefully underdosing a patient with the drug the provider intends to covet and taking the unused portion for themselves, taking vials or syringes that still contain the drug from a “sharps” disposal container, and tampering with unopened vials or syringes.
In addition to the aforementioned, Inciardi et al., (2007) note another practice of diversion includes intentionally miscounting drugs to obfuscate theft. Berge et al., (2012) advise that although most healthcare facilities have policies in pale requiring a witness or co-signer for opioid uses or transactions, an unsuspecting “witness” could potentially be subverted by the diverter. This introduces several new factors into the theft. The witness, with no ill intent of their own, may not only be subject to disciplinary action but potentially criminal and civil prosecution. These factors may increase the difficulty of tracking down the source of diversion.
Potential harm Caused by Drug and Narcotics Diversion
Drug diversion caused by addiction is not a victimless crime. Diversion has numerous deleterious effects on all parties involved, specifically patients, other staff members, employers, and themselves. Potentially adverse patient outcomes secondary to drug theft, multimillion dollar lawsuits, and potential public relations crises due to the high profile nature of nosocomial and iatrogenic disease outbreaks secondary to drug tampering by staff, make this an extremely high risk problem that the healthcare manager must mitigate. (Berge et al., 2012).
Harm to the patient.
It is arguable that the patient is the one most affected by drug diversion. Patients subject to the care of the cognitively impaired healthcare provider who is under the influence of mind-altering substances are potentially at risk for life threatening medical errors. The patient may go through undue pain and anxiety due to being underdosed, or not dosed at all with drugs such as procedural sedatives, anxiolytics, or analgesics. The danger of the “substitute” substance administered to the patient can also be called into question. There have been cases of unsterile substances such as tap water being administered to patients, which have the potential to result in negative outcomes (Berge et al., 2012).
In addition to the prospect of patients not receiving their prescribed medications, the contraction of bloodborne illnesses from an infected, addicted healthcare worker is a potential secondary effect to the diversion. There have been six documented outbreaks of these secondary diseases from 2004-2014 in healthcare facilities. Four cases involve Hepatitis-C transmission via opioid vials and syringes that had been tampered with by a healthcare worker. In these cases, eighty-four patients total contracted the virus. In the other 2 cases, 34 patients contracted septicemia through their patient-controlled analgesia pumps due to drug diversion by healthcare workers. In these 6 cases, approximately 30,000 patients were potentially exposed to pathogens secondary to drug theft and were advised to receive testing for bloodborne diseases (Schaefer & Perz, 2017).
Harm to the diverter.
Healthcare workers who divert drugs to satisfy their addictions bring immense risk upon themselves and are subject to potentially permanent disability and death (Berge, Seppala, & Lanier, 2008). Abuse of diverted opioids and anesthetics are subject to the same risks as drugs acquired through other means including anoxic brain injury, trauma associated with altered mental status, and bloodborne pathogen infection (Berge et al., 2012). New (2015) notes a unique danger of drug diversion by healthcare workers, reporting most diverted opioids include acetaminophen compounds. In addition to the other dangers of opioid abuse, the addicted healthcare worker can be subject to acetaminophen toxicity caused by potentially lethal levels building up within the body due to repeat use.
Along with the biological dangers that drug diversion and abuse entails, there is also significant legal and professional risk. Diverters of controlled substances from healthcare facilities can have their professional licenses suspended or revoked and may be subject to criminal and civil prosecution (Berge et al., 2012), although the aggressiveness of pursuing prosecution has some variance depending on the facility and situation (New, 2015).
Harm to other healthcare workers.
Berge et al., (2012) note several risks to other healthcare workers. They note the prospect of the diverter’s coworkers being at an increased of injury contracting bloodborne pathogens due to the diverters attempts to shroud their actions, specifically an unwitting staff member finding “sharps” in areas where they are not expected to be. Staff members working with an impaired employee are subject to increased legal liability due to potentially dangerous actions committed in the course of patient care by the impaired individual.
Harm to the healthcare organization.
The organization’s investigation and mitigation of consequences of drug diversion involves significant investment of time, money, and resources. (Berge et al., 2012). There are also major financial and regulatory penalties that may be incurred by accrediting and federal agencies such as a facilities termination from the Medicare and Medicaid programs if patient harm occurs (New, 2015). An organization’s public image and employee morale can potentially suffer greatly due to mandated reporting, which can be widely broadcast by media (Berge et al., 2012).
Detection of Drug and Narcotics Diversion.
New (2015) reports “red flag” behaviors that should raise the suspicion of the healthcare manager that an employee may be diverting drugs. Some common behaviors include: Frequent lateness, prolonged or frequent trips to the restroom, “wasting” entire doses of drugs, erratic behavior on the job, patients complaining of pain despite analgesic administration, and discrepancies in medication par levels. Providers working with a degree of autonomy, traveling nurses, and night shift workers have a tendency to be at a higher risk to divert drugs than average. New (2015) cautions managers to perform an unbiased assessment when suspicious of diversion. She suggests that diverters are not always sub-par employees, and they can be top performers with years of experience. New summarizes her advice by telling managers it is impossible to identify diverters by their surface level appearance.
Prevention of Drug and Narcotics Diversion.
Although increased access to opioid treatment programs is an integral part of combating the rise of opioid addiction, the most effective action is to prevent addiction in the first place (Makary et al., 2017).There is evidence to suggests that ease of access to commonly abused drugs is directly correlated with diversion prevalence (Trinkoff, Storr, & Wall, 1999). Berge et al., (2012) observe that programs designed to prevent drug diversion have a wide degree of variation across healthcare setting, noting the stark contrast between reactionary and proactive prevention programs. Larger hospitals tend to have more advanced and rigorous prevention strategies than smaller hospitals (McClure, O’Neal, Grauer, Couldry, & King, 2011). Berge et al., (2012) postulate that an ideal diversion prevention program should be developed while drawing input from behavioral science, law enforcement, pharmacy sciences, credentialing agencies, and information technology. They report although efforts to prevent diversion are becoming more advanced, the problem still overshadows even the most progressive systems.
New (2015) informs the problem of drug diversion is impossible to prevent entirely, however it is possible to decrease the likelihood of it occurring. She reports prevention begins in the pre-employment evaluation. Managers should check for “red flags” when evaluating an applicant’s employment history. She notes that applicants to a clinical position who do not provide clinical references should draw the most amount of suspicion. New (2015) advises management should clearly and thoroughly explain drug security and diversion policies to new applicants, including (if applicable) self-reporting programs in which, if an employee admits to diverting drugs to feed their addiction, they could potentially keep their jobs providing they seek rehabilitative services. Berge et al., (2012) add continuing education of employees regarding drug diversion policy should be utilized and administration should assure all relevant staff members should be competent with the procedures to report suspected drug diversion.
McClure et al., (2011) promote the use of advanced technologies to prevent diversion. In a survey of 135 pharmacy directors, they note 94% of respondents utilize automated dispensing machines (ADMs), however only 61% of the facilities utilize fingerprint access to ADMs. Additionally, 16% of ADM utilizing facilities do not utilize a automated controlled substance vault, which has software that automatically audits narcotic access and can detect potential diversion in real time. They argue expanded use of biometrics for pharmaceutical access, use of diversion detecting software, regular audits, camera systems and a ban of personal belongings in narcotic access areas are all potentially effective methods to reduce diversion.
The studies presented in this research paper illustrate the root causes and current significance the opioid crisis has on healthcare administration from the provider to patient level, up to the organization as a whole. Opioid addiction is a preventable ailment. This disease generally stems from iatrogenic or societal causes that has been catalyzed by dishonest marketing by drug companies, socioeconomic downturns, and overprescribing by physicians. It is also important to realize the secondary victims of the opioid crisis: patients otherwise unrelated to opioids. Whether being subject to increased ED wait times or being subject to the potentially deadly actions of a drug addicted healthcare worker, this population is subject to the opioid epidemic despite otherwise having no involvement. The paramount duty the healthcare administer has to assures the safety of all staff, patients, and the organization, cannot be overstated.
Future research into alternatives to opioid prescriptions, advanced technologies to prevent drug diversion, and investigation into methods to reduce ED overcrowding (which opioid related emergencies contribute to), would likely be beneficial. Studies and policies aimed at reducing opioid addiction, increasing patient safety, and drug diversion should have multidisciplinary input, as evidenced by the studies done at Mayo Clinic. Until the root causes can been resolved, the opioid crisis remains a major challenge for the healthcare administrator.
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