Monitoring Hospice Medications

By Mike Bassett

It's not uncommon in hospice settings for medications to be diverted from patients for whom they're prescribed. Providers must be alert for diversion and abuse related to opioids and other drugs.

This past summer a former pharmacy technician in Alabama was charged with stealing drugs meant for a dying cancer patient and replacing them with saline or sterile water.

And in July a registered nurse in New Mexico pled guilty to diverting oxycodone by ordering medications for patients who didn't need them and then retrieving them from a Federal Express office rather than having them delivered to patients.

These are just a couple of the recent documented cases in which medications meant for sick patients have ended up in the wrong hands—and examples of why the issue of drug diversion has become particularly relevant for health care professionals involved in hospice care.

The problem of drug diversion in hospice care has two basic elements, says Joseph Rotella, MD, chief medical officer of the American Academy of Hospice and Palliative Medicine. First of all, according to Rotella, the population is aging and the elder demographic includes a substantial number of older adults—many in hospice care—who have serious illnesses in which pain is a significant problem. "It's common and really contributes to a poor quality of life," Rotella says. "Recognizing chronic pain and managing it is really a public health imperative."

Challenges of Pain Management
At the same time, the country is experiencing an opioid addiction crisis of epic proportions, which means it is becoming increasingly important for hospice staff to ensure that the opioids being prescribed for their patients are not being abused or stolen. Clinicians who care for sicker older adults must be prepared to recognize and manage chronic pain and do it in a way that is safe and doesn't contribute to the opioid crisis, Rotella says.

"But it isn't a trivial thing to address and manage pain," he says. "A good pain assessment needs to be very detailed and take into account not just what the patient reports his pain level to be, but also the quality of the pain; what makes it better or worse; the history behind the pain; the effect it has on ability to function, sleep, or take care of themselves; and on relationships with others."

It's also clear, he adds, that physicians managing pain must be able to identify signs of drug abuse disorder and signs of diversion, as well as being able to prescribe in a way that's safe not only for patients but also for their communities. He points out that drug abuse or diversion is in many cases not difficult to spot if clinicians are alert to potential problems.

Part of the solution, Rotella says, involves education. For example, he notes that he is seeing more specialists in the field of hospice palliative care obtain additional training in areas like addiction medicine. More importantly, Rotella believes that managing pain has to be an "engaged, continuous process.

"What I've found is that for sicker older adults under palliative or hospice care, one of the best things we can do is actually care for them in their homes," he says. "For example, if a patient comes to our clinic and we hand them a prescription, we might not have any contact with them again until they come back maybe three months later. We really have no idea what happened with that prescription."

But if a team of providers is handling that particular patient in her house on a regular basis and can coordinate care, then that team knows whether the patient has filled a prescription, where the pills are, how many pills are present at a given moment, and whether they are disappearing at an inappropriate pace.

Recognizing Signs of Diversion
Any signs indicating that medications are being abused or diverted "shouldn't be that hard to spot," Rotella says. For example, if a physician has a patient asking for early refills on a Saturday night when that physician has another doctor covering for him—that could be a red flag.

"Or [if] you start hearing stories like, 'I dropped the pills down the toilet,'" Rotella says, "that's a sign there could be a problem."

Rotella suggests that clinicians should also take advantage of state prescription drug monitoring programs—an electronic database that tracks controlled substance prescriptions and provides timely information about patients' prescribing histories—to make sure their patients aren't receiving prescriptions from other physicians or having prescriptions filled by multiple pharmacies.

Bernice Burkarth, MD, senior director of palliative care at Treasure Health in Stuart, Florida, says she believes the hospice industry is "taking a serious look at our role in drug diversion.

"From our end we have to make sure we are educated about identifying people who are at risk for abuse, look at their surroundings, and institute processes that mitigate the risks of having those medications out in the community," Burkarth says.

One step hospice workers can take is to be more meticulous about drug and pill counts, Burkarth says. "I've seen situations in the home where a patient dies and there are multiple bottles of Percocet and liquid morphine that are extra," she says, explaining that this is because hospice workers want to ensure they don't end up in a situation in which a patient is in pain and can't be palliated.

"If someone is prescribed a medication they have to take six times a day and has a month-long prescription, that's a lot of pills in volume," Burkarth says. "So if we start prescribing smaller amounts we can have better control over the number of pills going out and coming in."

Families of hospice patients may not be happy with smaller dosing frequencies, but Burkarth believes they will understand why it's necessary if it is explained that hospice workers not only need to care for their patients, but must also protect the safety of the community at large.

Hospice workers can develop relationships with their local pharmacies in order to ensure that the right person is picking up a patient's medication. "I've had the good fortune of having a pharmacist call me and tell me they had a person they didn't recognize picking up a prescription," Burkarth recalls. "I checked the electronic medical record and found out that person wasn't labeled as a caregiver for the patient."

Specialized Tools Can Help
Like Rotella, Burkarth notes that state drug prescription monitoring programs should be utilized and adds that hospice professionals should be proactive in ensuring that unused medications are disposed of properly.

"At this time if I prescribe medications and the patient dies, the medications belong to the family," Burkarth says. "And they have no obligation to give them to me or destroy them."

And while hospices may have policies to help families dispose of leftover medications, most forbid their employees from destroying those medications unless state law allows it.

The problem is that most states have no laws on the books giving hospices the authority to destroy leftover medications after the death of a patient. That situation is slowly changing—Ohio, Illinois, Wisconsin, and Georgia have recently passed legislation giving hospices the authority to destroy unused drugs—but for many hospices, encouraging families to destroy these drugs remains a matter of persuasion.

Burkarth says that hospices can be proactive by incorporating language into patient medication safety agreements related to the disposal of leftover medications. Families need to understand the depth of the opioid addiction crisis, she says. "And once you explain the role they could possibly play in it, then they're going to be more open to being part of the solution."

— Mike Bassett is a freelance writer based in Holliston, Massachusetts.