Is Your Doctor Addicted to Drugs?
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Imagine going in for a routine kidney stone removal. The surgery goes as expected, and all seems well, until several weeks later you start feeling so ill that you rush to the emergency room, where you discover that you’ve caught the potentially deadly liver disease Hepatitis C.
This was Lauren Lollini’s terrifying reality in 2009. “I had no idea what Hepatitis C was. When I saw a specialist a few days later, we went over the risk factors and it just didn’t make sense. I had gotten a tattoo years before but had given blood many times since then so it was kind of a mystery how I could have gotten it,” said Lollini. “The only thing that seemed like a possibility was that I had surgery a few weeks before. I asked the doctor if I could have caught it then. He said ‘maybe’ and just kind of dismissed the notion.”
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But several weeks later, Lollini’s suspicion was confirmed when the Colorado Health Department informed her that an addicted surgical technician, Kristen Parker, who worked at Rose Medical Center in Denver where Lollini received surgery, was arrested for stealing fentanyl laid out in operating rooms in preparation for surgery. Despite having Hepatitis C, Parker would inject herself with the fentanyl that was intended for patients and then refill the same syringes with water or saline solution, leaving the patients without the intended medication and exposed to Hepatitis C. Parker infected 24 people with Hepatitis C between the Fall of 2008 through the Spring of 2009.
Parker’s act of stealing drugs is called “drug diversion,” and it's an issue that’s happening more than you might think. Alarming research revealed by USA Today in April 2014 stated that more than 100,000 doctors, nurses, technicians and other health professionals struggle with substance abuse or addiction.
WHY IS DRUG DIVERSION SUCH A PROBLEM?
Kimberly New, JD, BSN, RN, president of the Tennessee chapter of the National Association of Drug Diversion Investigators, which aims to educate healthcare providers and law enforcement on investigation, prevention, detection and resolution of drug diversion cases, says the nature of the job plays a part. “Healthcare providers have a high stress profession whether they’re a physician, nurse, radiology technician, lab technician or other provider. They see patients die and experience a lot of vicarious trauma. Many have compassion fatigue, and physical injuries because of the actions that they go through in the course of their job - lifting patients, turning patients, etcetera,” she explained. “A recent nurse I found diverting said he started using because the medication he was taking for back pain from lifting patients wasn’t cutting it anymore.”
Still, New says the number one factor in healthcare diversion is access and availability. “Controlled substances are right there at their fingertips. People find ways to access these drugs that are in the facility where they work. If they have access to the medicine cabinet, that makes it easier, but we find other providers who figure out ways to divert even if they don’t have that access,” said New.
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HOW ARE PATIENTS HARMED?
Cases like Lollini’s are the most dangerous instances of drug diversion and the hardest for the patient to detect in the situation. “Since Lauren was unconscious, there was no way for her to suspect something was wrong. Becoming educated on the topic is patients’ first line of defense,” said New.
The first thing to know is that nurses are the number one healthcare provider population who have regular access to controlled substances and who have a job responsibility to administer controlled substances. New says patients can be harmed in the following three ways by an impaired nurse or other healthcare provider in a similar role:
Tampering and substitution. Like Lollini’s experience, this is when a provider will remove a controlled substance from a syringe or vial, inject themselves with the substance, and then replace it with water or saline. “The patient doesn’t get the medication they were supposed to, and is also potentially exposed to blood borne pathogens that the diverter has. It’s like sharing needles,” stated New.
Delivery of care in an impaired state. Nurses who divert are often times in intensive care or emergency care settings. “These are critical care environments where they need to be making succinct decisions and may not be capable of doing that if they’re impaired. This really puts patients at risk when they need immediate and attentive care,” New said.
Withholding medication from patients in need. In these instances, the provider simply doesn’t give a patient the medication they need and instead steals the medication or takes the medication for themselves. “They place their addictive needs above those of the patient, leaving the patient untreated and possibly in pain,” stated New.
HOW CAN PATIENTS PROTECT THEMSELVES?
Prior to seeing a provider, New suggests checking with his or her state medical board (for physicians) and licensing boards (for nurses) to find information regarding any recorded disciplinary issues against the provider. “Also visit social media sites that offer reviews of providers. And if you’re having surgery, ask who is going to be involved with your care,” she said. “Patient care in an institutional environment has changed a lot. Years ago there was this blind faith in physicians, and patients just trusted them to do the right thing. Patient care has become much more consumer-based and really it’s the patients that are advocates for themselves, and are empowered to ask questions.”
If having a procedure, New says always have an advocate with you. “During recovery, this person can watch as medication is administered and can be a presence so the provider knows you’re not alone,” she said.
The Centers for Disease Control and Prevention’s Only One Campaign, which aims to educate on safe injections, suggests that patients (and advocates) ask healthcare providers the following questions before they receive an injection:
- Will there be a new needle, new syringe, and a new vial for this procedure or injection?
- Can you tell me how you prevent the spread of infections in your facility?
- What steps are you taking to keep me safe?
Speaking up about pain management is another way to protect yourself. “Sudden unrelieved pain from methods that previously worked is something to address right away. For instance, if a patient is getting morphine and it’s working great and then one particular day it’s suddenly not working, that’s when you need to tell someone,” said New, adding that you should tell a supervisor, not the nurse in case the nurse is diverting. “Pain during procedures should be expressed immediately. There was a case in Minnesota where a CRNA, who is usually the person delivering the anesthesia, told the patient that he needed to ‘man up’ prior to his procedure. He nearly jumped off the table as the surgeon made the incision. The CRNA was diverting the patient’s pain meds.”
When it comes to providers you already know, New says it can be difficult to notice if they’re using because often times providers who are diverting don’t always fit the stereotypical profile of somebody who’s a drug addict. “Many are very high achievers and enormously liked by everybody. Often times they’re even award winners, and receive many compliments from patients. The drugs they take can give them a state of euphoria, allowing them to super perform for a time. Over time, they will spiral downwards if they’re allowed to continue to divert,” she said.
So was the case with Stephen Loyd, MD, when he worked as a private practice internist, hospitalist, and assistant professor of medicine at Quillen College of Medicine East Tennessee State University. Although Loyd struggled with alcoholism as a young adult, he stopped drinking when his medical class nominated him as class president the first week of school, and he remained sober until his residency. To deal with the stress of residency, Loyd turned to pain pills. “I remember exactly where I was when I took my first one. I had some leftover hydrocodone from a dental procedure, and I was in my car at a red light when I took half of one. Within just a few minutes, I remember thinking, ‘this is alcohol nobody can smell.’ It relieved my stress and I was relaxed,” he said. For the next three years, Loyd’s intake reached 100 pills a day. He got prescription medication mainly from other doctors and by stealing them out of medicine cabinets from family and friends.
While using, Loyd says he didn’t think he was putting patients in danger. “The scary thing is that the drugs made me feel like I was more focused and better at my job, but that’s certainly not the reality. My decisions could have been way out of left field,” he said.
Looking back on his actions and behaviors, Loyd says the following could have been red flags to patients:
- Working at odd hours or unexpected times
- Producing sloppy medical records that were previously thorough
- Inattention to detail and making errors, such as having to rewrite prescriptions because of incorrect medications and doses
- Being extremely late for appointments
- Cancelling and rescheduling with patients several times
- Constantly moving clinics
- Arguing with other medical staff
- Undergoing physical changes like looking tired or losing weight
- Displaying personality changes
“I know I lost many patients. I remember one particular patient, who I was mad at for leaving, ran into my dad in town and he told him that he left my practice because I was never in the office. I was irritated at him at the time, but of course it makes sense he left,” said Loyd.
What should patients do if they suspect a physician is diverting or using a substance? “I would strongly encourage any patient who is concerned that their physician has a health problem to report it to their local medical board. The concerned patient has an opportunity to help the physician who may be impaired and also protect the public. Medical Boards generally refer a physician who may be impaired to a Physician Health Program [PHP] for evaluation,” said Doris C. Gundersen, MD, president of the Federation of State Physician Health Programs, a national organization that provides guidelines, education and support to local state PHPs about how best to serve physicians who are suffering from a variety of ailments including addiction, burn out, depression or medical conditions that require treatment.
WHERE CAN DOCTORS GET HELP?
If a physician is aware of his or her addiction and wants to find help, Gundersen says the provider should get in touch with their state PHP. “Physician Health Programs are designed to intervene early, when a physician has ANY health problem, inclusive of addiction. The advantage of a physician utilizing a PHP is that they can receive timely evaluation and treatment referrals before there is a complaint-driven referral. Generally, when the first awareness of a physician being ill is through a regulatory agency, harm has already occurred. When PHPs are involved, there is an opportunity to intervene early, before the physician is impaired which allows proper treatment for the physician while concurrently keeping the public safe.”
New adds that most medical boards will have some type of a physician and recovery assistance program. “With nurses, it’s not universal across all states, so they would need to find a recovery option right away,” she said.
After Loyd’s father spotted him taking 15 pills at once, he convinced Loyd he needed help. Loyd turned to a physician friend who suggested he go to Vanderbilt Institute for Treatment of Addiction, where he went through five days of detox. Then he spent 90 days at the Center for Professional Excellence, which treats addicted medical professionals. He’s been sober since, and giving back in various ways. “When I got out of treatment, I knew what I was going to do for the rest of my career,” Loyd said. As an associate professor of medicine, Loyd lectures students on identifying addicted colleagues who have access to narcotics. “Nobody teaches MDs about these topics, and as physicians it can be hard and very stressful to call out another doctor, but I teach students that we have a moral and ethical responsibility in our profession to watch each other for the patients’ sake and for the sake of each other,” said Loyd.
Loyd also works as an internist in a private practice where, after hours, he helps addicted and poverty-stricken teens and pregnant women seek treatment. “We lose about three Tennesseans a day from drug overdose and many of these people don’t have access to treatment so I see them based on ability to pay,” he stated. “As hard as it was for me to hurt so many people while I using along the way, I wouldn’t change the experience because now it helps me to connect with patients who really need my help. I’ve literally gained thousands of patients.”
Despite Lollini’s tragic story, she applauds providers like Loyd who seek treatment and go on to make a difference. “Maybe it’s my career as a therapist that gives me this perspective, but it’s just as important to get these professionals the help they need as it is to stop this from happening again,” she said.
HOW CAN DRUG DIVERSION BE STOPPED?
While patients can report suspicious behavior to facility managers or medical boards, New says colleagues of healthcare providers are in the best position to detect diversion. “I give talks all around the country about how to recognize the signs and about how important it is to report instances of suspected diversion. One provider may report something that is the last piece of the puzzle. For instance, a provider could have found there was an issue with drug cabinet transactions, and someone else may have reported that there was an issue with a doctor’s clinical practice or that the doctor seemed impaired. All that together could be enough to warrant action,” New noted.
While Gundersen agrees, she backs Loyd’s concern that it’s not always easy to report a colleague. “Most physicians have no training in this area. It is extremely stressful for a physician to confront another physician who may be impaired by addiction or other illnesses. Physicians have an ethical duty to intervene when they suspect that a colleague is impaired. The best way to intervene is to help a physician get connected to a Physician Health Program, where they can get their illness assessed, receive appropriate treatment referrals and be monitored to make sure the treatment is in fact efficacious. PHPs can help workplaces recognize when a physician is ready to return to work and also offer recommendations about any needed accommodations for that physician,” said Gundersen.
Lollini is doing her best as a patient advocate to encourage providers to have a watchful eye. She joined forces with the organization HONOReform, in order to spread word about the dangers of spreading Hepatitis C. “Since I was lucky to gain my health back, I couldn’t be silent. I needed people to hear that this happens to real people. I talk to different groups and my hope is to not only let patients be aware that drug diversion happens, but also to show providers that they are in the best position to protect patients and stop this from happening when they suspect a colleague might be diverting or using,” she said.
Federal agencies like the Department of Health and Human Services (DHHS) are bringing attention to the matter too. For instance, the renewed Viral Hepatitis Action Plan created by the DHHS includes goals specific to diversion, including the following:
- Educating providers and communities to reduce health disparities
- Improving testing, care, and treatment to prevent liver disease and cancer
- Strengthening surveillance to detect viral hepatitis transmission and disease
- Eliminating transmission of vaccine-preventable viral hepatitis
- Reducing viral hepatitis caused by drug use behaviors
- Protecting patients and workers from health care-associated viral hepatitis
WHAT CONSEQUENCES DO PROVIDERS FACE?
In Parker’s case, she was sentenced to 30 years in prison. This isn’t always the case though. While it’s a felony in every state to divert drugs, New says there’s a disconnect with who is in charge of the issue and how it is enforced. “Is it the healthcare facility, DEA, or local police? Law enforcement does have a legitimate role in these types of situations. There are a lot of experienced law enforcement investigators who can take advantage of programs that will hold the healthcare provider accountable, but at the same time enforce them getting into treatment. In some states there are drug courts and treatment in lieu of conviction programs, in which the provider will have their license revoked or suspended at the time and then will have a felony charge. But if they’re cooperative with a treatment program, then they will have their record expunged and can return to practice at some point,” explained New.
If the diversion is reported, then the respective medical, nursing or other professional board will address a disciplinary action and in the case of physicians, most likely contact the Physician Health Program in their state for assistance. “The reality is that there is little consistency from state to state in how the boards respond to these cases. For instance, in some states, if I’m a nurse or physician diverting, I may get my license revoked or suspended, but in other states there may be no action taken,” said New. “There isn’t a uniform approach across the country in the consequences of this type of activity and in the support that’s offered to medical professionals who are diverting,” said New.
Getting the word out that drug diversion is indeed a public health issue will hopefully prevent further tragedies such as Lollini's and get providers the treatment they need.
Cathy Cassata is a regular contributor to The Fix. She last wrote about video game addiction.