Home Health Care and the Opioid Epidemic

A few weeks ago, I addressed in my blog the headlines that have started to appear about elderly drug dealers.

Although such stories make for eye-catching headlines, the major problems continue to be the diversion of medications prescribed to seniors. This can occur with family members, neighbors and now increasingly, home health aides. In this blog, I will look at this issue.

Right now, home health care and hospice services are among the fastest growing industries in the elder care field. The current trend is to keep patients in their home whenever possible and provide them with home health aides and other medical professionals. Such services are much less expensive than nursing home placement and more comfortable for the patient.

For those with terminal illnesses, hospice care is becoming more and more popular. These services are available for people who are expected to pass within six months with a goal of keeping them as comfortable as possible.

Although both these options are desirable, a growing problem with them is the diversion and theft of medications that can be abused. So how prevalent is this problem?

Kaiser Health News recently did a report looking into the situation of missing medications in hospice care and found no national data available on the extent of drug diversion. What did alarm the report’s authors was the increasing number of the thefts of medications intended for these patients who were often in pain during the last weeks of their lives.

Kaiser found instances of adult children or hired caregivers stealing the drugs of hospice patients. It found a case of parents stealing the opioid painkillers of their child dying of brain cancer and neighbors of a man who was in great pain stealing his pain medications. In another case, a professional caregiver was caught stealing a hospice patient's opioid painkillers and replacing them with weaker, over-the-counter medications. There were also multiple cases of medical professionals stealing pain medications intended for patients in chronic pain.

Let’s look at some similar reports from the New England area;

  • A former registered nurse at the Providence, RI Veterans Administration Center was found guilty of stealing “approx. 240 oxycodone and morphine pills” from an automated medication dispensing system. This same nurse also failed to disclose being fired from an intensive care unit at another Rhode Island hospital years before.

  • A Providence, RI nurse was found guilty in federal court in Worcester, MA of four counts of stealing oxycodone and replacing them with another medication while working at a health care facility in Massachusetts

  • In Connecticut, Stratford police arrested a nurse for stealing oxycodone and diazepam from patients at a rehab center and substituting them with an over the counter medication

  • In Auburn, Massachusetts, a nurse working at a senior living center was arrested for switching pain medications with plain aspirin. This was discovered by the patient’s son when his mother was getting no relief for pain despite allegedly receiving the appropriate dose of medication

  • A Norwich, Vermont family found morphine missing from a hospice issued care kit. The theft was traced back to a home health aide.

But the problems don’t just occur locally. These issues are increasingly occurring across the country and are a much larger concern than senior drug dealers. The problems are also not confined to direct care employees;

  • In Iowa, a nursing director ordered excess pills for a patient and when the new ones were delivered, she stole the old ones after initially claiming to have destroyed them. She also stole Trazadone, a medication that is used as a sleep aid

  • In Madison, Wisconsin, a nurse, tampering with opioid-containing syringes introduced a bacterium called Serratia marcescens into the syringes which resulted in five illnesses and one death

  • A Minneapolis nurse was charged with five counts of theft by swindle for stealing opioids from a hospital machine at the Veteran's Affairs Medical Center and drinking them for his “mental health”

  • An NBC2 investigation revealed dozens of nurses in Southwest Florida have been referred to drug treatment after being accused of stealing pain medication from the hospitals they work in.

  • In July of this year, federal agents arrested an anesthesiologist on charges alleging that he stole drugs from the Muncie hospital in Illinois where he worked and treated patients while high.

Don Drake, a retired addictions clinician and administrator for drug treatment programs for over three decades and a presenter for some of my firm’s community education workshops, reports that such behaviors occur on an all too frequent basis in programs and centers that handle controlled medications and have been occurring long before the current opioid crisis.

“In my experience as an administrator, one of the first things I always did when taking over a program was to review the medication policies. Many of the policies were outdated and did not consider the ongoing problems with opioids, which, by the way, has been a problem in the healthcare setting long before it became a nationwide issue.”

Here’s the problem, hospices, healthcare settings and homes that provide care for elderly patients often have copious amounts of pain-killing and other medications like benzodiazepines on hand to be used as needed. In some cases, the patient doesn’t always receive the prescribed medications.

Home health nurse arrested for stealing pain medication from an 82 year old patient with cancer in an ongoing problem with opioids and those who are charged with administering them to patients with severe pain.

Drake experienced these problems in his own oversight of medical staff and medication administration in the healthcare setting.

“The theft of medications did not occur in just one place where I was the director but in nearly every program with those responsible always finding new ways to beat our policies and our counting systems”, he said.

“When I became the director at one location, the major problem I was faced with was a history of pain medications and benzodiazepines going missing. We had one medical professional who provided oversight of the direct care staff and aides who administered medications to the client. This person had total control of ordering, managing and packing these medications with little or no supervision. This was the problem.”

Drake says he set up a meeting with this person regarding implementing a new policy and supervision process with him that was met with anger and extreme resistance.

“This level of animosity immediately raised red flags and led me to look deeper into the problem of missing medications. It appeared to me that this was not just a series of mistakes and carelessness but an issue of diversion.”

He reports that within a week of this meeting, a patient on the unit who was diagnosed with a severe spinal disease and unable to participate in treatment activities due to intense pain had gotten worse despite an increase in pain medication.

“A fentanyl patch was added to his daily medication regimen but did not provide the expected relief we expected. It quickly became apparent that he was not at the appropriate level of care and was transferred to a medical facility for stabilization. Within a few days, I received a call from the medical director of the facility telling me that this patient was lethargic and blood work indicated that he was now being overdosed with pain medication. How was this possible when he was receiving the same amount of medication?”

Drake continued, “A review of his med charts and previous blood testing yielded no answers until another call from the medical director of the other facility suggested that he was may have been ‘shorted’ on his opiate medication while he was with us resulting in under-dosing and the addition of another narcotic along with the appropriate dosing was causing the problem.”

Drake immediately called the medical professional in to discuss the report.

“At first, he first blamed the patient, stating that the patient was a drug addict and

therefore untrustworthy, saying the patient was probably “cheeking” the medication (a behavior that patients do especially in drug treatment programs where they place the medication high inside their cheeks and pretend to take the med only to remove it later and save it to take a larger amount to get a high or sell it to others) and then he blamed direct care staff saying they ‘probably are not being very observant’.”

Then a call from human resources raised another red flag -- the medical professional had put off numerous requests to sign off on an annual criminal background check. After meeting with him and citing the policy that required a suspension until the check was conducted, he walked out in a huff only to call Drake later with a request.

“The employee wanted to discuss this background check with me”, Drake stated, “then he informed me that the reason he was avoiding this was two DUIs that he had recently incurred. He also stated that he was also charged with possession of another’s prescribed narcotic medication until the charges were dropped after he “explained” he was a medical professional helping a patient manage these medications. Now things were beginning to make sense. The employee resigned within a week and avoided any charges since it could not be proven that he did indeed take medications but the problems did stop. Draw your own conclusions”.

The issue of missing pain medications and substituting them with other drugs is not only uncomfortable for a patient in pain who needs them but can also have deadly consequences. Again, Drake saw this at another location.

“We had a patient on the unit who had a serious and painful condition requiring her to be on Vicodin. Although the medication had initially kept the pain in check, the patient began to report that the pain was returning and no longer controlled by the dosage she was receiving.”

“Then one morning, she presented with an outbreak of hives and complained of breathing problems. Rushing her to the emergency room, she was diagnosed with anaphylactic shock. A search of her medical records indicated an allergy to certain antibiotics however none were prescribed to her. Blood testing indicated that she had no level of opioids in her system despite being administered them several times daily. A search of her pre-packed medication box indicated that the Vicodin had been removed and substituted with an antibiotic that looked very similar to the pain killer”.

Drake states the stories of medication diversion and addiction among healthcare employees has been an ongoing problem and has gotten worse with the increased availability of opioids and benzodiazepines.

"It doesn’t matter if it is a homeless man who has been on the street for thirty years or the CEO of a Fortune 500 Company – the telltale behaviors are the same:

  1. They begin to weave a web of deceit and lies

  2. Manipulation becomes the center piece of their everyday functioning. They will apologize for their behavior (I’m sorry I called out sick on the day you really needed me) while planning their next manipulative act.

  3. They are masters of shifting blame and making others feel guilty.

  4. They very often engage in criminal behaviors including DUIs, shoplifting, stealing from the office to fund their growing addiction problem

  5. As their web starts to untangle, they will become physical, mentally and verbally abusive."

So how do you find a good home health aide or hospice program for your loved one? Drake recommends researching the many programs available to find out what policies and procedures they have in place for their employees;

  1. Does the agency or program do background checks on perspective employees before hiring them

  2. Do they have strong, no-nonsense policies around drug use in the workplace?

  3. Do they have a urine screening program? Although it is not foolproof, it sends a message that they value their employees and patients enough to keep everyone safe and healthy.

  4. Are all employees educated on the signs and symptoms of addiction and know what drug paraphernalia looks like?

  5. Do they do annual or bi-annual criminal background checks on employees. In many cases, addicts resort to criminal activity to pay for their supply (dealing, possession, shoplifting) or are involved in criminal activity as their addiction worsens (DUIs, public intoxication, disturbing the peace). A clean background check this year could drastically change as the addiction disorder deepens.

  6. Do they review their policies and procedures annually and update them as needed?

  7. Do they have a system of supervision that focuses on the job description and employee expectations? One of the earliest signs of addiction problems is a change in job performance.

  8. If medications are handled by non-medical staff, are medications ordered in blister packs which are much more difficult to tamper with than bottled medication?

Drake also suggests that more than one person have knowledge of the medications being used but access to them be as limited as possible.

“It’s a touchy situation, one person in control can be problematic and too many hands in the pot leads to chaos. A limited few can provide checks and balances to keep everyone safe. All involved, professionals and non-professionals, should know what the meds are, what they look like, what they do, where they are filled and when they should be taken. Any missing medications should be reported immediately to the agency providing the service.”

Even with the best policies and procedures in place, problems can still occur.

So, the issue in evaluating an agency is not whether someone has been caught diverting drugs but how they respond to the problem and what safeguards they have in place. Addiction is a difficult disorder to deal with and a person who was clean and sober six months ago could be deep in the throes of addiction today.

It’s also important not to paint the entire healthcare field with a broad brush as is being done so by many in the media today. The overwhelming majority of home health care and hospice programs and the medical professionals they employ are dedicated, caring, compassionate, hard-working people who uphold their oaths to do no harm and provide the very best care possible at a very difficult time.

Oversight, at all levels, can help keep medication diversion problems to a minimum.

Attorney Connelly practices in the area of elder law. This area of law involves Medicaid planning and asset protection advice for those individuals entering nursing homes, planning for the possibility of disability through the use of powers of attorney for the both health care and finances, guardianship, estate planning, probate and estate administration, preparation of wills, living trusts and special or supplemental needs trusts. He represents clients primarily in the states of Rhode Island, Connecticut and the Commonwealth of Massachusetts. He was certified as an Elder Law Attorney (CELA) by the National Elder Law Foundation (NELF) in 2008. Attorney Connelly is licensed to practice before the Rhode Island, Massachusetts, Connecticut, and Federal Bars.

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