In the first season of True Detective, detective Rust Cohle (Matthew McConaughey) enters a police evidence room in the 1990s and walks out with a brick of cocaine, saying, “They really need a better system for this.” While law enforcement has done a better job in this area of drug diversion by employees since then, healthcare practices are also implementing stronger measures to catch thefts of opioids and other drugs, with some using artificial intelligence (AI).

“Unfortunately, drug diversion is something that can go undetected for months or even years without technology that can spot patterns of risky behavior as early as possible,” said Karen Kobelski, vice president and general manager of clinical surveillance compliance and data solutions with Wolters Kluwer, Health. “Recovering from the fallout of undetected drug diversion can be expensive and the reputational harm to the healthcare organization can be tough to overcome – not to mention the increased risks to patient safety that come from delayed identification of diversion.”

The Cost of Drug Diversion

The US Department of Justice National Drug Intelligence Center (NDIC) estimates that the cost of drug diversion to public and private medical insurers is more than $72 billion per year. While estimates vary on how many healthcare workers steal drugs, the healthcare compliance and risk consulting firm Protenus conservatively projects that at least 1% will do so at some point in their career, making it a consistent challenge for medical practices.

Eilon Caspi, PhD, an assistant research professor at the University of Connecticut’s Institute for Collaboration on Health, Intervention, and Policy, said there is a relationship between the misuse of controlled substances and theft that is also compounded by the opioid epidemic and a historic workforce crisis facing medicine that can result in high turnover and inadequate training.

“With the opioid epidemic, it’s one of the components of a perfect storm that created the conditions for those opportunities for theft,” he said.

Dr. Caspi was the lead author of a 2023 study published in the Journal of Applied Gerontology that analyzed theft in long-term care homes using 107 Minnesota Department of Health drug diversion investigation reports substantiated between 2013 and 2021. Researchers found that 11,328.5 tablets were stolen from 368 residents with over 30 tablets stolen per resident. Of the tablets stolen, 97.5% were controlled substances and 94% were opioid pain medications.

“The vast majority was for personal use. Some employees who stole it ingested it while working their shift. There was one nurse that was so chemically impaired that she was almost falling asleep during the shift,” said Dr. Caspi.

Inventory Monitoring Programs

To monitor this type of theft, Wolters Kluwer’s Sentri7 Drug Diversion system receives data from healthcare organizations that includes electronic health records, drug wholesalers’ ordering platforms, employee timekeeping software, inventory tracking systems, and medication dispensing cabinets. The AI in this application then analyzes this data to uncover individual healthcare workers who are at high risk for stealing medications. Research published in the American Journal of Health-System Pharmacy in 2022 showed that Sentri7 was at least 95% accurate in identifying transactions involving a high risk of medication diversion.

“The system can identify medications that were taken out of the supply chain by a healthcare worker but [that] cannot be reconciled by direct administration to patients, the return of unused doses, or witnessed wasting by a peer,” said Kobelski.

More than 700 US hospitals currently use Sentri7, and administrators can use its dashboard to review at-risk behavior within their practice. Once an individual is identified, “Typically, we have seen clients review the underlying transactions that triggered the system, as well as other evidence such as video footage or ID badge logs, and interview the concerned individuals as part of their investigation process,” Kobelski said,

“They may also perform drug tests on suspected individuals or analyze any medications wasted by them if the organization’s policies permit this,” she added.

Kobelski also said that “People who divert medication consistently find new ways to divert,” and that Wolters Kluwer is looking at new ways to enhance the model. Dr. Caspi also cautioned that there are thefts of opioid pain medications that “don’t make it into a dataset of a healthcare system.” Some examples he cited include medications arriving at an assisted living residence and being placed on the nurse’s desk without being logged in, and opioid tablets being replaced by Tylenol that have been shaved to the size and shape of the opioid.

The National Institute on Drug Abuse (NIDA) has provided research funding to support the development and enhancement of Sentri7. In addition, NIDA has awarded grants to research the of use of AI in preventing opioid theft. Projects include an effort to use machine learning and blockchain technology to prevent drug diversion in hospitals, while another assesses clinical data intelligence and advanced analytics in reducing theft across the care delivery system.

Other In-House Tools for Risk Assessment

Additional measures are underway to lower opioid theft that do not involve AI. For example, the University of Toronto and the Institute for Safe Medication Practices Canada have developed a free, online tool to help hospitals identify and address the risk of drugs being stolen. The Pan-Canadian Diversion Risk Assessment Tool differs from other efforts in that it focuses on findings hospitals’ vulnerabilities instead of individuals who steal drugs.

“Unlike the person approach, which seeks to identify who is responsible for the loss or theft, our system approach investigates the conditions under which individuals work. By understanding these conditions, we can build safeguards to prevent losses or theft,” said Patricia Trbovich, PhD, an associate professor at University of Toronto’s Dalla Lana School of Public Health.

Dr. Trbovich also holds the Badeau Family Research Chair in Patient Safety and Quality Improvement at North York General Hospital in Toronto and noted that the hospital has implemented an electronic system that links the inpatient pharmacy’s narcotics vault with automated dispensing cabinets in clinical areas. “This system ensures secure documentation of controlled substances from removal to arrival, verified by independent counts by two staff members at each end,” she said.

However, both Dr. Trbovich and Mark Fan, manager of her research group HumanEra at the Centre for Global eHealth Innovation, noted that recent data from hospitals using the tool showed a need to improve safeguards against drug diversion. Much of these challenges center around organizational decisions on awareness and data stewardship.

“Auditing procedures are weak in some hospitals, such that excessive prescribing or drug wastage is not monitored on a quarterly basis,” said Fan. “Many of our respondents do not have an interprofessional committee to quickly respond to or investigate diversion when it is suspected.”

While Fan and Dr. Trbovich take a different approach than Kobelski and Wolters Kluwer, they all agree that improving monitoring of drug diversion will not only improve practice operations and the lives of patients, but it also can help the clinician who has a substance use disorder. Some researchers estimate that 10 to 15% of all healthcare professionals will misuse drugs or alcohol during their career.

“Helping an employee who has substance use disorder to get treatment for their condition before it escalates can change their lives and decrease risk in environments where high volumes of medications are dispensed daily,” said Kobelski.