EDITORIAL

Bloodstream Infection Outbreaks Related to
Opioid-Diverting Health Care Workers: A
Cost-Benefit Analysis of Prevention and Detection
Programs

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n this issue of Mayo Clinic Proceedings,
Schaefer and Perz,1 representing the Centers for Disease Control and Prevention’s
(CDC’s) Division of Healthcare Quality Promotion, provide a unique and frightening look
at the harm that can be inflicted by a drugdiverting health care worker (HCW). With
access to heretofore-unpublished data gleaned
from multiple CDC investigations, these authors use the data to define the risks to patients,
health care institutions, and insurers created by
the criminal actions of those willing to tamper
with patients’ drugs to obtain controlled substances by diversion. They identified 6 US outbreaks of drug diversionerelated bloodstream
infections that occurred from 2003 through
2013. In every circumstance, the drugs stolen
were injectable opioids, and the manner in
which they were diverted (stolen) resulted in
bloodstream infections in innocent patients for
whom the drugs were intended. In 2 outbreaks,
the exposure resulted in gram-negative bacteremia and sepsis in 34 patients. In 4 other outbreaks, the diversions involved 4 different
hepatitis C virus (HCV)epositive HCWs who
infected 84 patients with the identical strain of
the virus each HCW carried. Several of the
aforementioned patients have died as a consequence of the bacterial or viral infections, and
all have been subjected to unnecessary illness,
expense, and debility.
What may be less appreciated is the collateral damage caused by the criminal actions of
these HCWs. Schaefer and Perz state that the 4
HCV-infected HCWs described in their report
potentially exposed nearly 30,000 patients to
HCV during the patients’ health care experiences, and each potential exposure required
notifying these patients that they should undergo
testing for bloodborne pathogens. Certainly,
such notification of the need for testing brings
with it heightened patient anxiety, at least until
test results prove negative. As well, lawsuits

resulting from the infliction of physical and
psychological trauma on the infected or potentially infected people have been filed, and some
of these suits have already been settled for undisclosed amounts.2 In the case of the most
recent outbreak in Exeter, New Hampshire, the
involved hospital is in turn suing individuals and
organizations that they allege failed to intervene
earlier when faced with evidence of opioid
diversion by that HCW. This inaction allegedly
allowed the offending HCWs to subsequently
gain employment in positions that allowed them
to divert additional drugs and infect additional
people.3
Aside from the aforementioned personal
harm to people that these outbreaks represent,
it is useful to explore the potential financial
implications for present and future health care
facilities and insurers affected by an infection
outbreak associated with inadequate infection
prevention practices and improper intravenous
drug administration practices. A jury in Nevada
recently awarded $524 million in combined
compensatory and punitive damages to 2 patients (one of whose husbands also collected a
portion of these damages for loss of consortium). These patients contracted HCV as a
result of the improper handling and administration of an intravenous sedative or hypnotic
drug (ie, dosing multiple patients out of a vial
intended for use in a single patient) by licensed
HCWs within an accredited health care environment.4 A plaintiff’s attorney, commenting
on culpability in the aforementioned case, not
only alleged responsibility on the part of the
HCWs to whom the infections were attributed
but also accused the health care services company and health insurance plan with whom
those HCWs were affiliated of “blatant disregard for patients’ health and safety.”5 Although
neither of these 2 patients was infected as a
consequence of drug diversion, the Nevada
example highlights the public’s intolerance for

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 MAYO CLINIC PROCEEDINGS

preventable patient harm related to allegations
of improper actions by HCWs and alleged
inadequate oversight by the health care organizations and insurers. Because drug-diverting
personnel have repeatedly been identified as a
source of hospital-associated transmission of
hepatitis, when taken in aggregate these experiences hint at the magnitude of potential hazards that disease transmission by drug diverters
within a health care facility creates for not only
the patients but also the financial survival of
the health care facility at which the infection
occurred. If one assumes that a financial award
associated with the harming of a single patient
(as a result of downstream effects of drug diversion) is potentially a large number and a single
health care institution, employer, or referral
service may lie at the crossroads of a massive
outbreak involving many patients, then the sum
of awards against a given entity can potentially be
an immense sum of money. Further, when we
consider that every health care facility that handles divertible drugs is at risk for an unscrupulous HCW not only diverting drugs but doing so
in a manner that could harm patients and
others,6 then the question becomes not “How
can we afford a program to prevent and detect
drug diversion by HCWs?” but instead “How can
we afford to not have such a program?”
Schaefer and Perz nicely review and provide references on how health care institutions
can develop comprehensive programs to prevent and identify drug diversion and how they
should respond when an episode of potential
drug diversion is suspected or proven.6,7 (Their
recommendations reinforce some of our own
writings,1,6 published previously in the Proceedings.) As well, they emphasize the importance of early engagement of outside resources
(eg, state departments of health and the CDC)
to assist in an investigation if there is concern
that drug tampering or patient harm has
occurred. Just as important, they emphasize
the critical urgency of involving law enforcement to assist in these investigations. Available
resources may include local law enforcement,
the US Drug Enforcement Agency, and the US
Food and Drug Administration’s Office of
Criminal Investigations (whose officers are
specifically tasked with investigating drug
tampering).
In our real-life experiences with investigating similar cases, we have repeatedly
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discovered that combining the resources of
the health care team with law enforcement
resources (eg, search warrants) has proven
critical to the successful resolution of those
cases.6 Any time tampering is suspected, such
cooperation among groups and agencies is
critical.
Schaefer and Perz point out that the incidence of drug diversionerelated infection
outbreaks is increasing. In the 20 years preceding the decade of their study, only 3 such
outbreaks were documented, a figure that
increased to 6 in the study decade (ie, a
4-fold increase). As well, recent data from the
Minnesota Department of Health, using
mandatory reports to the Drug Enforcement
Agency of thefts or loss of controlled substances from health care facilities, revealed an
increase from 1.3 reports per month in 2006
to 4.3 reports per month in 2010.8 Supporting the concept that drug diversion is a
common occurrence, the hospital manager
of controlled substance surveillance at the
University of Tennessee Medical Center in
Knoxville was recently quoted as saying, “I
was catching at least one health care provider
every month stealing medication.”9 Our experience at Mayo Clinic, an organization of
more than 55,000 employees, supports the
need for unceasing vigilance in identifying
and dealing with drug diverters because we
continue to identify drug-diverting HCWs
despite our ongoing education and prevention efforts.6
During the study decade analyzed in the
report by Schaefer and Perz, it also appears
that a more robust criminal prosecution of
diversion-related drug tampering has evolved.
The earlier (2006) gram-negative bacteremia
outbreak reported by Schaefer and Perz resulted in no criminal prosecution or licensing
board action (eg, revocation of a HCW’s license
or privileges), whereas the latter (2011) outbreak resulted in a 2-year prison sentence for
the perpetrator. The earliest HCV outbreak of
the study decade (2004) resulted in a 41month prison sentence for the HCW, the
second (2008) and third (2009) in 30-year
sentences, and the most recent (2012) in a
39-year sentence.1 This trend is apparently
being driven by increasing recognition of the
severity of patient danger that can be created by
drug diversion.

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 INFECTIONS CAUSED BY OPIOID-DIVERTING HCWs

Schaefer and Perz are to be congratulated
for bringing their message to publication, in
part because their reporting elucidates the
multiple dangers that drug diversion creates
within health care systems. The vast numbers
of potential exposures (n¼30,000) created by
4 drug-diverting HCWs serve notice that all
health care facilities that house controlled
substances or other drugs of abuse must have
effective systems in place that deter drug
diversion. Further, those facilities must be able
to quickly and effectively investigate when a
drug diversion is suspected in an effort to limit
the number of patients potentially exposed to
harm. Although effective systematic improvements in pharmacy handling and distribution
of controlled substances have inherent costs
(eg, labor expenses, costs of camera surveillance, automated delivery machines, and
toxicology testing of waste), the increasing
incidence of drug diversion makes it mandatory that drug control be improved. Unfortunately, the plague of drug diversions cannot be
fully exterminated because highly intelligent,
desperate, and motivated addicts (eg, addicted nurses and physicians training in or
working in drug-rich environments) will
continue to seek ways to obtain the highly
desirable and abusable drugs housed within
health care settings.10,11 Thus, it is mandatory that health care facilities have effective
control and surveillance programs in place
in an effort to prevent drug theft and that
they have a plan for enlisting the aid of and
cooperating with law enforcement and appropriate state and federal investigatory authorities when confronted with a suspected
drug tampering.

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Keith H. Berge, MD
William L. Lanier, MD
Department of Anesthesiology
Mayo Clinic
Rochester, MN
Dr Berge currently serves as President of the Minnesota
Board of Medical Practice.
Correspondence: Address to Keith H. Berge, MD, Department of Anesthesiology, Mayo Clinic, 200 First St SW,
Rochester, MN 55905 (berge.keith@mayo.edu).

REFERENCES
1. Schaefer MK, Perz JF. Outbreaks of infections associated with
drug diversion by health care personnel, United States. Mayo
Clin Proc. 2014;89(7):XXX-XXX.
2. Sanborn A. Exeter Hospital Settles 6 Hepatitis C Lawsuits.
http://www.seacoastonline.com/articles/20130802-NEWS-30
8020338. Accessed April 8, 2014.
3. Sanborn A. Exeter Hospital Spreads Blame for Hepatitis
Outbreak. http://www.seacoastonline.com/articles/20131126NEWS-311260341. Accessed April 8, 2014
4. Miller V, Feeley J. UnitedHealth Units Ordered to Pay $500M
Over Hepatitis Cases. http://www.startribune.com/business/
202236131.html. Accessed April 8, 2014.
5. Ritter K. Jury: HMO Liable for $24M in Vegas Hep C Outbreak.
http://bigstory.ap.org/article/jury-hmo-liable-24m-vegas-hep-coutbreak. Accessed April 16, 2014.
6. Berge KH, Dillon KR, Sikkink KM, Taylor TK, Lanier WL. Diversion of drugs within health care facilities, a multiple-victim
crime: patterns of diversion, scope, consequences, detection,
and prevention. Mayo Clin Proc. 2012;87(7):674-682.
7. Minnesota Department of Health. Drug Diversion. http://www.
health.state.mn.us/patientsafety/drugdiversion/. Accessed April
8, 2014.
8. Minnesota Controlled Substance Diversion Prevention Coalition. Final Report. http://www.health.state.mn.us/patientsafety/
drugdiversion/divreport041812.pdf. Accessed April 8, 2014.
9. Eisler P. Doctors, Medical Staff on Drugs Puts Patients at Risk.
http://www.usatoday.com/story/news/nation/2014/04/15/doctorsaddicted-drugs-health-care-diversion/7588401/. Accessed April
16, 2014.
10. Warner DO, Berge K, Sun H, Harman A, Hanson A,
Schroeder DR. Substance use disorder among anesthesiology
residents, 1975-2009. JAMA. 2013;310(21):2289-2296.
11. Berge KH, Seppala MD, Schipper AM. Chemical dependency
and the physician. Mayo Clin Proc. 2009;84:625-631.

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