We all have a story to tell.
I clearly remember the client who presented his two cockers to our practice for chronic coughing. Upon examination, our doctors determined that both dogs had collapsing trachea and the drug hycodan was prescribed. We all thought – how unusual that two dogs in one home had the same issue. Then the frequent visits began. The client “dropped” his pet’s pills. The one dog got worse and he gave more doses. He was going out of town and needed his refills early. This started to become suspicious yet not enough to really red flag the client.
In a local managers group, someone happened to mention this client who had two coughing cockers. Several of us perked our ears up and then began to compare notes. This client was having his dogs treated by no less than 5 practices represented in that room! We called the police and reported our suspicions and found out he was taking his pets medications.
In this story, the client was found out because of networking between the area managers. That is not always going to be the case. What do we do to put systems in place to avoid drug diversion?
I have walked in practices with the controlled drugs in a fire safe box open on the practice owner’s floor…next to the hall all the clients walked through. The DEA has a guideline for controlled drug use and storage on their website. The list on page 15 of this document gives excellent rules we should follow. However, these systems still are of no use if the team is not on constant alert. Some of the basics for good controlled drug monitoring are as follows.
First of all, limit staff access – One person or two highly trusted people can be designated the inventory manager(s) and have access to the stock. The advantage of this is that the inventory manager will quickly notice an increase in the number of controlled drugs being used and then begin an investigation as to where the medications are going. If they discover most of the stock going to one client – red flag.
Perform frequent cycle counts– controlled substances need to be counted weekly and randomly spot checked by the thepractice manager or owner for accuracy. It is unfortunate that diversion can also be a staff member problem and not just a client problem.
Do not allow staff to invoice their personal purchases –this includes DVM owners and managers. Again, some pet drug diversion is found in team members – particularly veterinarians with a problem who prescribe medications for their own pets. Not allowing staff to invoice their own purchases will help discourage this deception. Watch for unusual or erratic behavior. Perform random drug screening of the team.
Count and confirm– when clients drugs one “trick” is claiming they were not given a full prescription but were shorted medications. Count the pills with the client before they leave the practice. This confirms they received an accurate count.
Software will create a controlled drug log if the drugs are marked as such in the inventory management system. Frequently review the software log and look for unusual purchases or too frequent purchases by the same client.
Read client body language – Odd nervous behavior when requesting refills, deceptive lack of eye contact, stress actions in person or panicked voice tones on the phone all should make us pay close attention to this client. (Suggested reading: Navarro, Joe 2008 What Every Body Is Saying: An Ex FBI agents guide to speedreading people Harper Collins Publishers NY, NY)
Watch for odd medical cases – one client was caught cutting her dog to obtain drugs. If the wounds or symptoms are illogical to the client’s story – be cautious of intentional harm.
Finally, the most important aspect is team awareness and communication among departments. The CSR’s will get the calls or texts for refills and should notice if this client is a frequent visitor for these drug purchases. If technicians are responsible for refills, then they perform a medical chart review to see not only if the refill is approved but how frequently is the client requesting refills ahead of the dosing schedule. Team huddles are also helpful when sending patients home on drugs likely to be misused. Everyone is aware, and everyone can be on the lookout.
Take advantage of technology like the VitusVet app that can allow veterinarians in ER, Specialty and General Practices to cross-reference medical charts so medications can be reviewed before dispensing. If you would like to learn more about VitusVet, schedule a demo with their team and see how they can help you improve your practice.
I reached out to veterinarians and managers to see what systems they had implemented because of the diversion dilemma. Dr. Maureen Noftsinger, an ER veterinarian said they limit the number of controlled medications dispensed to 2- or 3-days’ supply. Others are following the same path. Yet others are writing prescriptions for these drugs so pharmacies with more advanced tracking and flagging systems are involved. Many are utilizing other options for pain management outside of the hospital setting, such as NSAIDs.
What do we do if we suspect diversion?
Call law enforcement. In an interview with John Burke the former Commander of the Warren County Ohio Drug Task Force and the owner of the consulting company PDE (Pharmaceutic Diversion Education), Mr. Burke recommended that veterinarians who suspect a client of diversion call their local State Veterinary Board, the State DEA office or local law enforcement’s detective division to report the client.
None of us wants to be in this position. Candidly, our intervention could improve the quality of care our patient receives if a prescribed drug is not being administered or even worse, a client is intentionally harming their pet.