Story Time: A Tale of Fentanyl Diversions

Drug diversion in hospitals is an unfortunate fact. Although no one likes to think about it, drug abuse by hospital staff is a reality that I’ve dealt with all too frequently. In nursing units, especially, easy access to strong medications like morphine, Dilaudid, and fentanyl make diversion unnervingly simple.

Fentanyl is an extremely potent, highly addictive synthetic opiate. The number of recent fentanyl-related overdoses and deaths speaks volumes about how dangerous this drug can be. In intensive care, we use fentanyl for conscious sedation, breakthrough pain control, and as an additional sedative for ventilated patients.

Unfortunately, in one year, a single nursing unit where I worked experienced three separate, devastating cases of IV fentanyl diversion by nursing staff.

Type-A Diversion Disbelief

In my ICU, we had an exceptionally busy nurse who ran circles around her coworkers. She was noticeably hyperactive, but worked hard and seemed to love her job. Every month when a report on narcotic pulls was presented to management, her fentanyl pulls were 50-100 times higher than anyone else. Because of her good work, the excess was attributed to the countless patients she treated and medicated.

One day, after an exhaustive drill-down of missing narcotics on her shift, this nurse was called into the office to account for a missing fentanyl dose. She reluctantly confessed to stealing it and gave up the missing vial. Over two years, this busy, hard-working nurse had been diverting fentanyl. Although her drug test came back negative, she admitted to using fentanyl at work and was let go.

The Night Nurse

In another case that happened around that same time, we had a bright, dedicated male nurse who had been newly promoted to the nightshift. Soon after, he started sleeping through his alarms and would come in late to work. During one shift, he arrived visibly impaired and was hallucinating. At three AM, he left the unit to go to a store and crashed his truck, eventually returning to the hospital on foot. His supervisor ordered a drug test and sent him home. He claimed exhaustion.

Although his test came back negative, an investigation of his pulls found that Ativan, hydromorphone, and fentanyl doses were missing. He was placed on medical leave but returned two months later. One night, he came to work visibly impaired and was again sent home.

Eventually, he was terminated, and another nurse was promoted to charge nurse in his place, but this too went downhill.

A New Charge Nurse

After only a month, the new charge nurse’s fentanyl pulls skyrocketed. The first time he was asked about it, he played it off. The second time, he couldn’t. A temp ICU doctor noted that his ventilated patient was still mostly awake when she should not have been. Her urinalysis test was negative for fentanyl, and the doctor became concerned. After a thorough investigation, the charge nurse was called into the office and admitted that he had been diverting fentanyl for personal use. He was placed on medical leave until he resigned after only three months on the job.

The loss of three adept nurses in such rapid-fire succession was demoralizing for our unit. We were shocked and saddened. Team morale plummeted.

The Paper-Thin Silver Lining

Although the whole ordeal was difficult, I now know how to recognize the warning signs of drug diversion:

· Nurses removing narcotics without an order

· Excessive overriding

· Medicating other nurse’s patients

· Multiple verbal orders for fentanyl

· Not following strict narcotic-wasting protocols

Drug diversion can be devastating for care teams and patients alike, and it is an experience that I hope others can now recognize and cope with in the future.