Cheshire Medical Center is still declining to answer basic questions about its policies to prevent drug diversion, as a federal investigation continues into the gallons of fentanyl solution stolen or lost from the Keene hospital.
National experts say these policies are key to avoiding the theft of controlled substances — though few hospitals have effective ones in place.
“Being proactive keeps patients and staff safer, and possibly saves lives ...,” said Russell Nix, founder and senior consultant for Aegis RX, a Georgia-based health care consulting company specializing in preventing drug diversion. “Being proactive has become basically paramount in what [hospitals] need to be doing right now.”’
Health care organizations carry the burden of liability regarding drug diversion, according to Nix, who has more than 15 years of experience in criminal narcotics investigation. This can be difficult, he noted, because the few federal regulations in place are often vague.
To help, hospitals can look to guidance from sources such as the Joint Commission — a national nonprofit that accredits hospitals and other health care facilities — and from societies for health care workers, including the American Society of Health-System Pharmacists.
But, Nix said it’s rare for hospitals to have a thorough prevention policy.
“Having a very robust, a very comprehensive program, that’s the unicorn,” he said. “We don’t see that very often at all, even in the states that have the more strenuous or rigid requirements.”
Diversion ‘seen across all levels’ of health care
Cheshire Medical reported that more than 7½ gallons of fentanyl solution went unaccounted for — much of it stolen — from the intensive care unit between September and May, according to documents on the drug loss from the N.H. Office of Professional Licensure and Certification (OPLC).
This has prompted emergency license suspensions for key hospital personnel, and the N.H. Board of Pharmacy has ordered a hearing on whether Cheshire Medical can keep its pharmacy permit.
A criminal investigation into the missing drugs is ongoing, a spokeswoman for the Drug Enforcement Administration said Wednesday.
Fentanyl is the most commonly diverted drug, and is the leading cause of death in opioid overdoses, according to a 2019 newsletter on preventing drug diversion from the Joint Commission.
Used by medical providers for sedation and pain relief, fentanyl is 50 to 100 times more potent than morphine and highly addictive and dangerous when used illicitly, according to the National Institute on Drug Abuse.
The Joint Commission says opioid diversion is seen across all levels within health care organizations, from chiefs to frontline staff, and that “only a fraction of those who are diverting drugs are ever caught, despite clear signals — such as abnormal behaviors, altered physical appearance, and poor job performance.”
Nurses diverted drugs in 31 percent of publicly reported incidents in the country in 2020, according to a report last year on drug diversion by Protenus, a health care compliance analytics firm.
At Cheshire Medical Center, Alexandra Towle, a nurse in the ICU, self-reported around Feb. 4 that she had stolen fentanyl from the Dartmouth Health affiliate.
Before her death the following month, she signed a preliminary agreement not to practice on Feb. 9 that states she stole 12 bags of fentanyl solution in October, 50 to 100 bags in November, about 100 bags in December and 200 bags in January.
Fentanyl solution also went unaccounted for between April and May, according to OPLC documents, although the hospital does not have reason to believe it was stolen.
Hospital staff said the drug loss was partially due to the winter surge of COVID-19 and a software transition affecting record-keeping related to fentanyl and other drugs, according to the documents.
Cheshire Medical has not answered questions from The Sentinel about what the fentanyl solution was used for and how much fentanyl it keeps on site.
Each 50 milliliter bag stolen from or lost at the Court Street hospital — 583 bags in total as of April — contained 2,500 micrograms of fentanyl, OPLC investigators said during testimony on one of the practitioner’s licenses, according to the documents.
“When I think of grams, milligrams, of fentanyl being diverted, it’s frightening. So when we start to talk about gallons [of fentanyl solution], it’s absolutely terrifying,” Nix said.
The OPLC documents state that Cheshire Medical implemented remedial measures in February and March aimed at preventing further losses, such as permanently locking the medication room, training nursing and pharmacy staff to prevent and detect theft and implementing a daily accounting of controlled substances.
The drug losses in April and May occurred after these measures were in place, the documents state.
Prevention requirements slim, thorough protocols needed
The Sentinel requested interviews with 10 hospitals within the state and beyond about their diversion-prevention protocols. Aside from one hospital — which outlined its policy via email — officials either declined or were not reachable for comment.
Under federal law, organizations must orally report the loss or theft of a controlled substance to the DEA at the “earliest practicable opportunity” after becoming aware of it. The health care facility must then file a written report to the DEA within 15 days of finding out about the drug loss.
In New Hampshire, hospitals must have a policy outlining procedures for preventing, detecting and resolving drug diversion.
The policy must include, among other components, staff education; procedures for monitoring storage, distribution and procurement of drugs; and a process for investigating, reporting and resolving drug misuse or diversion.
Speare Memorial Hospital in Plymouth, the sole facility to send The Sentinel its diversion policy, meets these state requirements.
In Nix’s experience, he said hospitals often have only a few of these proactive approaches in place. Though hospitals tend to recognize drug diversion as a national issue within the ongoing opioid crisis, he said, “there’s typically some illusion that the issue isn’t in their system as much.”
And with limited resources and staff already stretched thin, he added, hospitals often put drug-diversion prevention on the back burner.
Charlie Cichon, executive director of the National Association of Drug Diversion Investigators (NADDI), agreed that most hospitals have only reactive policies in place.
The organization — where Nix serves as the health care drug-diversion adviser — trains and educates people whose jobs touch the abuse or diversion of pharmaceutical drugs on how to prevent it.
Cichon said effective measures include developing a team of staff members from various departments to look specifically at drug diversion.
Additionally, he said, hospitals can use artificial-intelligence programs to produce daily reports of drug inventory, rather than relying on someone to do so manually. Those reports should be checked each day by a designated employee for any red flags.
“In [Cheshire Medical’s] case, it doesn’t appear that anything was looked at on a daily basis or weekly basis or monthly basis ...,” said Cichon, who hasn’t worked with the Keene hospital but read The Sentinel’s first article on the drug loss. “This was something that, in a health facility that was being proactive, it would’ve been found almost immediately.”
Nix echoed Cichon’s advice for hospitals, while adding that there needs to be a philosophical shift within health care facilities across the country to prioritize prevention.
Until then, he said these problems will likely continue.
“There’s just this huge overarching risk and vulnerability in health care when medication is going where it’s not supposed to,” Nix said. “If we only react, typically patient harm is occurring before we find it.”
Despite the drug losses at Cheshire Medical, the OPLC documents say patients still got their medications. The hospital hasn’t answered The Sentinel’s question about how they can be sure of that.
Cheshire Medical has not answered any of The Sentinel’s questions regarding the incident since the newspaper obtained the OPLC documents June 2, aside from clarifying that it operates both a retail and hospital pharmacy.
That includes questions this week about what drug-diversion prevention policies the hospital had in place before and after this months-long incident.
“We are unable to comment, as this relates to an ongoing investigation,” spokesman Matthew Barone said via email.