Our guest: Neil Braun, BSC (Pharm), BA (Hons), MPP, Director, PHSA Allied Health Professional Practice Provincial Health Services Authority
Drug diversion in healthcare settings is a challenge that crosses borders, affecting facilities worldwide. Today, we gain valuable insights into how our neighbors to the north approach this critical issue.
Our guest is Neil Braun, currently serving as the Senior Director of Provincial Health Services Authority Allied Health Professional Practice. Neil previously served as the Drug Diversion Lead for Fraser Health Authority, where he played a pivotal role in developing and implementing a comprehensive drug diversion program that has since become a model for other Canadian health systems.
In this episode, we’ll explore the evolution of drug diversion monitoring in Canadian healthcare, from a watershed moment in 2015 that catalyzed change, through the development of a multisectoral collaborative approach that Neil documented in his published article Establishing a Multisectoral Collaborative Drug Diversion Program in a Canadian Health System.
Through our conversation, we’ll discover both the similarities and unique differences between Canadian and U.S. approaches to diversion prevention, offering valuable perspectives for healthcare professionals on both sides of the border.
Join us as Neil shares his expertise and insights from building a diversion program within Canada’s publicly funded universal healthcare system, and learn how his team’s innovative approach has helped shape drug diversion prevention in Canadian healthcare.
Transcript
Terri
Welcome back, listeners. My guest today is Neil Braun. He is the senior director of Provincial Health Services Authority, Allied Health Professional Practice. That’s a long title and I’m going to ask you what’s involved in that. He was previously the drug diversion lead for Fraser Health Authority and it was while in this capacity that he wrote the now published article that establishing a multisectorial collaborative drug diversion program in a Canadian health system. We’re going to talk a little bit about the Canadian approach to drug diversion and I think we’re going to find that there are some similarities, but certainly a couple of differences too, on the way Canada approaches things versus the way the US Does. So welcome, Neal, to the podcast.
Neil Braun
Thanks for having me. Terry.
Terri
We’re gonna learn a lot about your role as the diversion lead when we talk about your article, but for now, let’s start by having you share. What do you do in your current role?
Neil Braun
In my current role, I almost sort of explain it as a bit of like a Price is Right example, is that you’re trying to do as much as you can without going over. So it’s really around. How are you leveraging the skills, abilities and competencies of folks that we would say are allied health professionals? So looking for a simpler definition, folks that aren’t physicians or nurses, so say social workers, occupational therapists. It’s a list of 70 different professions and disciplines. How do you get them to work up to the full ability of their skills, their competencies, their training and their knowledge without doing anything that exceeds what they’re allowed to do based on legislation or regulation from professional, say, boards or colleges?
Terri
Okay. Stay within their scope.
Neil Braun
That’s another way of putting it for the folks that are regulated is exactly. Stay within their scope, but get them to work within the full range of work to the full limit of their abilities and their scope.
Terri
Sure. Yeah. Well, that sounds like a pretty interesting, diverse job. You’ve got to know a lot about a lot.
Neil Braun
It’s. And you know, there’s, as I say, there’s 70 different disciplines that fall under that definition of allied health. And we as individuals only typically will come from one of them. So there’s a lot of listening, a lot of connection, and a lot of working with folks who are experts in their field to do work that will do well by them and do by. Well by the patients they serve.
Terri
Right, right. Okay. And your background is a pharmacist, correct?
Neil Braun
I am a pharmacist. It’s been some time since I’ve worked Frontline. But that is my professional designation.
Terri
Yeah. Okay. All right. When we spoke earlier, you shared with me an event that happened in 2015, I believe it was, that kind of precipitated the start of conversations surrounding diversion mitigation in Canada. So I’d like you to start by sharing that with the listeners to give us that background.
Neil Braun
Yeah, thanks, Terry. And that’s what led me to that event, is what led me to the previous, my now previous role as a drug diversion lead. So in 2015, there was. There was a tragic incident. There was a death of a health care aide that occurred in the emergency department of Vancouver General Hospital. So that’s the biggest hospital in the province of British Columbia, which is on Canada’s west coast. So in the city of Vancouver, that death happened as a result of this health care aid, essentially emptying sharps containers from the emergency department, placing it in a suitcase, removing it from the emergency department, and then self administering any syringes that still had some, some medication in them. And almost all those cases that medication would be an opioid or controlled substance.
Neil Braun
But she passed away as a result of injecting rokuronium, which is a paralytic. So she essentially has a very tragic circumstance. This all became public because there was a coroner’s report in doing an investigation into this death that found what the circumstances of it were and her, the. The family of the person who passed away, they reached out to media in the Vancouver area and there were a series of articles in the local newspaper here that published on this person and the circumstances leading up to her death that she was experiencing substance use disorder, had gone for treatment a couple of times and was. It was known that this was a, this was a challenge, this was a struggle for her by her colleagues in the time leading up to her death.
Neil Braun
So that led to then some more discussions from both within the health system where she passed away, but also the provincial government here in British Columbia that has some level of. Because they fund the hospitals and acute services in this province that gives them some degree of leverage in terms of directing the health systems here to take certain actions. So that led to them taking some of that initiative to ask the health systems here to do more around preventing and mitigating drug diversion from happening in our health system. And that led to the role of drug diversion lead getting created. And I was the first person to take that role in this province would have been in 2017.
Terri
Okay. So prior to that time, how was diversion mitigation or monitoring handled or was at all. Was it just kind of one of those things that nobody really thought about it?
Neil Braun
I think it was a very, I think it was a very ad hoc method of handling it. Is that depending on which hospital within the province it happened, which unit it happened, what the relationships say were between say the operations leaders on a particular unit that might have encountered drug diversion, what the relationships they were to their human resources counterparts or their risk or legal counterparts or potentially professional practice counterparts who they would have then engaged in terms of doing work on whatever was observed or seen. And so you would have a. I think you’d have a very varied response in terms of how drug diversion was dealt with. It was a very ad hoc thing. Would very much depend on the individuals involved in either investigating or looking into it.
Neil Braun
But there was nothing in terms of a consistent standard or transparent process that existed within our health systems here in this province before I came into the drug diversion lead role.
Terri
Yeah, that makes sense. I mean, very similar to what you would have in the US Then. It’s just. It kind of depends on your. What has happened at your facility. Right. If you’ve become aware that you have a problem probably because of an event, I mean, I think that’s what a lot of it. And then as the person with experience with an event goes to some other location, then it’s like, hey, we gotta look for this here, because it definitely happens. So with Canada’s healthcare system being publicly funded and a universal system after this event in 2015 and then rolling into a couple years later, when things are kind of getting up and running, does that mean that every facility started and was mandated to do the same thing or how did it work than with a diversion program implementation?
Neil Braun
What I’m aware of is that following that death is that there was communication from what’s called here a Ministry of Health, so it’d be its name as like a department of health for the province to the different health systems that operate the hospitals and other healthcare, publicly funded healthcare services in mostly within the geographical regions of this province to essentially say that more needed to be done to prevent or mitigate circumstances like what happened with the individual from happening again. So there was a little bit of guidance around, I think there was initial focus at that time around destroying pharmaceutical waste, because that’s how this person passed away. But other.
Neil Braun
The different health systems receiving that communication in that direction from the Ministry of Health, I think they then took Slightly different approaches in terms of what they wanted to lean into, in terms of preventing or mitigating drug diversion from happening. And with the role I had, I was essentially supporting four different health systems, primarily based within the metro Vancouver area. That’s where they made the decision that they wanted to lean in and create this drug diversion lead role. And so I was the first, to my knowledge, the first drug diversion lead in this province. But I, I didn’t stay that way. Even though I was created in 2017. Other Other regional health systems within this province created also their drug diversion lead roles as well.
Neil Braun
So by the time I left the role around a year ago, all but one health system in this province had drug diversion leads. So it wasn’t, I don’t think it was officially mandated from the province to create these drug diversion lead roles, but these health systems, seeing some of the direction that was coming and recognizing the issue and the scope of the challenges, and then seeing some of the work potentially that I and others in the area that I, the regional area I was working in, had some success in doing the work that were doing took that as a sign or as an indication that they could create similar roles as well.
Terri
Sure. Okay, so walk us through the program then, that you were a part of launching and how much of that was your own research and what you had thought would work well and what could be implemented versus maybe what they told you if it was just the waste part that they told you. The rest they left up to you to kind of figure out and learn on the fly.
Neil Braun
Walk us through was a lot of learning on the fly. Looking back at it, there was certainly that focus around pharmaceutical waste, but I think there was a recognition from, you know, from myself and from my leaders that we needed to think a little bit bigger picture around this. So we always focused around this notion, around thinking about the work in sort of three buckets that there’s detection. So identifying that signs of drug diversion are being observed or being identified through auditing or other means, investigations. So once signs of diversion are identified, what is our consistent, standard, transparent process for then looking into investigating those signs or doing any of the responses that we would need to do to make sure we’re aligning with legislation, with regulation, with any other needs that there may be, and then mitigation.
Neil Braun
So what are we learning as a result of doing those investigations? What do we think potentially could be put in place to mitigate future instances of whatever signs of diversion that we investigated from occurring again? And I think just over the Years then of me being in the role was then establishing, well, what could we do around each of those three buckets? And, and so what we eventually set up was using some, what’s I think commonly referred to as first generation drug diversion detection software. So this would be software that pulls data from automated dispensing cabinets and tries to apply a little bit of an algorithm to give some sense about individuals, staff, individuals that may be withdrawing more of a particular controlled substance than their peers.
Neil Braun
So there was again some trial and error in terms of taking what that software would generate in terms of data to then work with that to see, well, who do we want to spend some time looking into to see if there may be signs of diversion? There might be something going on here that’s not explained by just general practice or say specific or unique patients that those staff may have been serving. So there was work done to set up. How would we go about using that software? There was then work around setting up what are our policies and protocols for doing investigations. So who would we engage in terms of doing an investigation? What would be the roles and responsibilities of different members in conducting an investigation?
Neil Braun
How do we leverage, say collective and collective union agreements with staff in terms of how we can investigate staff while making sure they’re being treated accordingly, provided whatever resources or rights according to the collective agreement and then mitigation. So making sure that we had an oversight committee made up of fairly senior leaders within some different departments to say nursing, professional practice, pharmacy, risk security, to make sure that whatever were finding investigations, were then saying, well, what system level improvements or changes would we make to hopefully mitigate what we’ve seen happen in particular investigations from occurring again? So making sure that we have leadership on board to make those systemic changes that would need to happen. And that again was all done over the course of, again kind of a constant quality improvement process of reviewing and refining and improving the processes that we have.
Neil Braun
And so that was done over a few years and was also done, as I say, in the role I had. I served four different health systems here in the province. So it was really starting in the Fraser Health Authority, which is the published article, really talks about their experience, but then taking it to the other three health systems as well and establishing those same processes in those health systems.
Terri
Okay, so serving four locations, how did that work with using that first generation software, which really is a very manual. I mean it kind of tells you where to look, right? But then the review itself is extremely manual. How, what was the process for that did you have?
Neil Braun
It was, it was extremely manual. And I, I tried to, I was the, I was essentially a team of one in my role serving these four, these health systems. And I think what at least worked in my favor was that we, and I did not try to implement that software in terms of using it in all four health systems all at once. I mean, we’re talking around maybe two dozen acute care hospitals that I would be serving on my own, which I don’t think is possible. So we at least had the chance to work with just a few hospitals in the Fraser Health Authority to start and then again refining the processes before then spreading and sharing and getting more hospitals to use it.
Neil Braun
But essentially the process that we laid out was it was sort of a four step process that would happen over a four month period where the software would generate reports at the start of whatever month. I would then connect, I would send these reports to a contact at each hospital. So these reports would run for groupings of units within a particular hospital.
Neil Braun
The reports would get sent by me to somebody with particularly somebody with a nursing background at each hospital so that they would know their hospital, they would know kind of the practice that different units would be doing within their hospital and would also have maybe a sense too about maybe some of the individuals and some of the roles so that if they could see somebody on a report who is withdrawing more of a particular controlled substance than their peers, they might have a sense about, you know, as this person, say a leader who might, should only be withdrawing a particular controlled substance once or twice in a few months, or somebody who you would expect to be withdrawing more often.
Neil Braun
What they would then do is they would flag from reviewing those reports, flag a few names to a maximum of say five, who they wanted to potentially review a little bit more deeply, do a deeper dive into. At which point I would then take data directly out of the software, put it into Excel, do some cleaning on it to suggest, well, here’s the patient charts associated with that staff that you’ve identified. Here’s maybe some patient charts you want to review to get a bit of a clear picture in terms of whether there might be some anomalous activity or withdrawals happening that aren’t explained by normal practice.
Neil Braun
Those contacts at each hospital would then review those patient charts to see again, are we seeing patterns here or other things that are concerning, say that there’s not documentation in the medication administration record that any charting data doesn’t Reflect that there should have been withdrawals, to say there’s no pain assessments done or something of that nature, then looking for a pattern over time. If we’re seeing the same pattern over multiple patient charts, that again would be an indication that we have something that’s not being explained by regular practice and that potentially there would be a need for a drug diversion investigation.
Terri
Yeah. So really a collaborative event or you started it, you made them pick, you know, you got to pick somebody and then you did a little bit more digging and then turned it back to them for a little bit more. Very collaborative. I want to know, did you ever do what I did one time and that is spend hours and hours on looking at somebody’s activity. And the very last transaction I saw in this manual review was a discrepancy where it looked like they took out, you know, 20, but it was really only two or something. And it was just a discrepancy. It’s like, oh my gosh, I just did spent hours on this audit for nothing. Because there was something that explained the numbers.
Neil Braun
And that shows the weakness of, or the weakness of say first, that first generation software. As you just see the aggregate amount that’s withdrawn of a particular controlled substance over a period of time. And were doing these audits over four month cycles. And you’re right, I would have exactly that scenario where a hospital would flag, you know, whatever number of people. I would look at one and I would see that almost all of their withdrawal, all the quantity withdrawn was just one patient, one time. And when you looked, you saw, it’s like, oh, there was this withdrawal for this large amount. And then it was, almost all of it was reversed or wasted right away.
Neil Braun
And so I would say, you know, to my counterparts at a hospital, well, you’re probably going to want to just validate just by looking at this chart, but I’m pretty sure I know what you’re going to find in that. This is all explained by just regular behavior and that drug diversion is not occurring. But yes, it very much speaks to the challenge of that first generation software and finding those type of scenarios.
Terri
I never made that mistake again. From that point on, I checked every single one very quickly, made sure it wasn’t a discrepancy. It’s like, okay, not gonna make that mistake again. That was, yeah, very frustrating. Absolutely. How did you go about getting your nursing counterparts for the most part up to speed on taking this seriously and what it is that they’re supposed to look for? Because that’s what we typically find, right, the people in the nursing roles, unless they’re dedicated to this kind of position, they don’t necessarily know what they’re looking for. They certainly don’t have the time to devote to looking for it. So how did you get that collaboration going and get that training done?
Neil Braun
It’s interesting. I think my experience may not be that much different than other colleagues working in other facilities across North America is that this isn’t sort of an overnight thing where, you know, a program is launched, there’s full buy in from all the different sectors within a health system and you’re off to the races. It’s, I’ve heard people talk around in terms of building their programs that this is something that takes years to get that full buy in from every, from all the different teams that need to be involved. And, and I was certainly no different in starting this work. It was very much localized to just a couple of units in a couple of hospitals seeing what was possible showing to people what the value and the potential to work.
Neil Braun
And really in a lot of cases I can think of actually one of the different health systems outside of the Fraser Health Authority, when we first took this work to them and said, well, let’s sit down with these audit reports and let’s just look at them together so you can get a sense in terms of what the software can show you. And right there you can see, you know, very plainly that somebody is doing something very different than their peers. And so I said, well, again, we haven’t done the chart review work or any of that deeper dive yet. But let’s start with this one.
Neil Braun
And when I’m wondering if we might find something knowing full well that having some experience looking at the reports that I’m pretty sure this person is diverting and then when they go through that process and say, oh, I didn’t have any idea that diversion was happening in my hospital or in my unit, you then got that buy in from your nurses for a very long time afterwards. And once you just again kind of build the sustained and regular process of doing the work and find whether it’s more diversion or other bad practice that gets identified just as a consequence of doing this work, you kind of reaffirm and reaffirm and re establish the value that this work has on multiple levels.
Neil Braun
So I guess my, my wisdom that I learned through this is that you know, buy in, doesn’t happen immediately or overnight, but once you get your hooks into folks, they will see it and they will also spread and share to their colleagues as well. Say if you have a health system with multiple sites or multiple hospitals, you know, those people talk to each other. So if one person is seeing it in one area, they will let their colleagues know and that will also help you as you spread and share the work around mitigating diversion.
Terri
Right? Yeah. And so this is probably a good point. Share with us some of your numbers. When you started your program, did you find people right away?
Neil Braun
Yeah. And that’s something that’s mentioned in the article, is that to the best of our knowledge, there was only one confirmed instance of drug diversion that had happened in the Fraser Health Authority. And so were talking about a region that has 12 or 13 acute care hospitals. It serves a little under, I believe the number was a little bit under 2 million people living within that region. So this is, you know, this is not a small area. But they were only able to confirm one instance of diversion and only did that one investigation the year before this program started in full flight. So 2018, only one case identified. The first year that I started doing this work with the Fraser health authority, in 2019, there was 13 investigations into drug diversion that were started.
Neil Braun
And eight of those 13 came back with a finding of, yes, diversion. We substantiated that diversion had occurred. So it’s very much, I would always use the analogy of like if, you know, if you lift up a rock and shine a light underneath, you’ll be surprised at what you find underneath it. And I think if, you know, if there’s a health system that’s not actively looking and doing that detection work, they’re always surprised then when they start what they do find that, yes, diversion, very much you think of maybe diversion is happening somewhere else or it’s a problem in general, but not for us in particular. Drug diversion is happening in all of our hospitals and health systems. And it does need that conscious and active monitoring to detect, to detect it.
Neil Braun
It’s not going to be something that just you identify always by happenstance.
Terri
Definitely. And if someplace doesn’t have any kind of process to look for it, people know that. The people that have that, the substance use disorder, they know that and so nobody’s looking and they take advantage of that wherever they can. So you’re right. So those are some pretty interesting numbers that you find. And that is a lesson for everybody that’s not looking at all or doing anything to mitigate. Those are probably the kind of numbers that you’re going to find, depending on how big you’re. Your facility is and your health system is. What does a formal investigation look like or what did it look like when you were with the program?
Neil Braun
So one of the processes that we put in place was that again, because this needed to be multisectoral, needed to be collaborative, we needed to have buy in from the teams that were directly impacted as a result of observing or identifying signs of drug diversion. So essentially, there would be most cases, a conversation I’d be having with the manager of the patient care area or the unit where the signs of diversion were emerging from, to say, well, based on this, what do we think is. Do we think that drug diversion is a possibility? Not to say it’s confirmed because you do an investigation to investigate, to make a conclusion, but just to say, is it a possibility based on the evidence we have in front of us already?
Neil Braun
If they say yes, I would say again, using our policy and our protocol documents that were created to say, great, we have a process for investigating and actually looking into making determinations as to what happens. So with the support of the unit manager, I would then communicate out to the senior leaders of the unit that was involved to pharmacy, to professional practice. In most cases, investigations involve nursing. So it’d be to nursing professional practice, to hr, to risk and to security. And then there would be reps from all six of those teams that would then come together as part of an investigation team that I would share. And with those folks together, we would start to essentially make decisions about, well, what are the steps we need to take now based on the.
Neil Braun
What are the actions or steps we need to take now based on the evidence that we have and then what additional investigating or digging to get more information, what steps would we have to take? And in most cases, you know, the folks that are in this group, they’re sort of responsible for their own areas. So it’s. I mean, it’s not that we necessarily collectively be saying, yes, this is the steps we need to take. Although there would be that guidance, it would essentially be, say, HR would be like, well, if you’re telling me that somebody is taking out a whole bunch of control of a particular controlled substance and there’s no documentation to support them doing that’s, you know, sign that we could have a risk to the organization and to the patients that we serve.
Neil Braun
So per the collective agreement, that means I have grounds to remove this particular staff member from service pending an investigation. So they would take the lead in terms of doing those actions from an HR perspective that they would need to do if we did have, say again, unaccounted for controlled substance, that we’re not sure what had happened to it. Similar to the U.S. Canada has legislation to say if you have losses of controlled substance, you need to report it to the federal government. So pharmacy typically would take the lead in terms of making those reports. So it’d be that kind of. And there’d be other examples of other steps that we take in the immediate term. But then we’d also then decide, well, what additional evidence do we need to do?
Neil Braun
We need to collect to get some sense about whether we can substantiate if drug diversion occurred. In a lot of cases, this would be supporting doing an interview with the staff that we’d associated with the signs of diversion. So that may mean doing additional chart reviews, additional audits of transactions on automated dispensing cabinets. But a lot then would that evidence would then set up for the manager of the unit and a representative from the HR team to do an interview with the staff. And typically through that process we would get some sense, in many cases we would get some sense about, say the person may admit to diversion and say they had a substance use issue, which would then lead them towards a treatment pathway.
Neil Braun
They may offer an alternate explanation which we may deem as credible based on the evidence that they provide or the explanation they provide, or we may deem as not credible. And, and that would then necessitate some other actions as well. But we typically make a point of having a clinical person in that interview space so that they could then hear what the person is, what the person we identify with the signs of diversion is saying and assess whether what they’re saying is actually credible from a clinical, from an operations perspective.
Neil Braun
And then through all those processes at the end, once we identify, once we either substantiated or not substantiated diversions has occurred, the team would come back together, run through its findings and create recommendations around how could we potentially mitigate what we’ve seen happen here from happening at this, in this particular unit, in this particular site, potentially even across the health system.
Terri
Okay. Is a drug screen usually part of the investigation?
Neil Braun
No. And I think that has to do with legislation and collective agreements in Canada. So it’s, I know that this is something that’s used in some jurisdictions in the US but it’s not something we ever used in this Country.
Terri
Okay. And is it the HR representative that typically leads the interview portion of it?
Neil Braun
They do. They. And again, that’s also looking both from an. From a. An investigation perspective in terms of. In terms of doing an interview with the person, but also knowing too what the collective agreements, what the processes that are stipulated there. So they’ll be kind of the experts in that, and we’ll also be the experts through, in terms of process for conducting an interview. But they’re doing this in collaboration, again, with the unit manager, to make sure that unit manager can provide the context in terms of how practice operates on that particular unit, what other staff maybe doing as. As common practice on that unit. So it’s very much a collaboration between those. Those two folks as being kind of the experts and closest to. To the unit and to the practice?
Terri
Sure, yeah. When a union or collective agreement. Is that what you call it? Collective agreement is involved? It gets. There’s a lot more rules.
Neil Braun
There is. And there’s also, if there’s a medical issue that’s. That’s leading to the behavior that’s being observed. So in that, some cases, how investigations would end is that the staff would essentially say they’re not fit to attend an interview because of a medical issue, and then as medical information is submitted through the following processes to establish that, yes, this person has a medical issue. If there’s what’s called a medical nexus, if there’s a medical nexus from explaining behaviors that are conducted in the workplace, that is, a person is experiencing substance use disorder, which is leading them to divert controlled substances, we would take that also as evidence to say that diversion has occurred.
Neil Braun
And so that way we’re trying to provide every opportunity to get a staff’s perspective in terms of what we’re seeing in our side of the table, in terms of evidence. So that can come in an interview, but it can also come through this. This sort of secondary medical information that can support us to make a conclusion about whether diversion occurred or not.
Terri
Okay. And then is it typical whether they said, I have an underlying medical condition that ends up being substance use disorder, or they just admit. Yes. Is it the goal then to get them into some sort of a recovery program?
Neil Braun
And that’s very much it. And that’s where it starts to transition a little bit from decision making with the actual staff to HR and to disability management, and they then again would apply the collective agreement with the union in terms of how they can or can’t proceed. But we typically say, as a matter of course, is that we make the organization would make every effort where possible to support treatment and recovery for individuals identified as having substance use disorder. Certainly there’ll be other factors too. Every case is, every case is individual and unique. So certainly there’s going to be decisions made in a case by case basis as to whether treatment and recovery is the appropriate course for that employee.
Neil Braun
But as a general principle that’s, I mean, I think that’s the outcome that we’d all like to see is that people are, people that are struggling with a medical issue are given the opportunity to get well.
Terri
Okay. And is there any government stance on reentry back into work or is that facility dependent? Is it allowed? Never allowed.
Neil Braun
So, and that’s part of where the professional practice role in these investigations comes in is that if you say it is a nurse who’s diverted is experiencing substance use disorder, regardless of the reasons for the diversion, if there’s signs of diversion that are observed, that needs to be reported to the regulatory body. So say in the US you call them say the nursing board or pharmacy board in this country, regulatory college is more the common term. But typically we would, you know, once we have evidence to suggest that it’s like this person has withdrawn controlled substances without proper documentation order, or an order or something of that nature, it would get reported to say if it’s a nurse to the nursing college here, they would then have it within their purview to say this person can’t work.
Neil Braun
Their nursing license is suspended until we can do an investigation. So certainly depending on the gravity of the evidence they’ve been, that’s been shared with them, that’s, you know, they’ll make their decision according to that evidence to say whether this person can work, whether their license is suspended, what have you. But as then they do their investigation and certainly they’ll ask us this to share what information we’re finding out. They’ll then make their decisions in terms of like when this, when and how this person can come back to practice. So typically if this is something someone who has diverted because they’re experiencing substance use disorder, they’ll typically say this person can’t work as a nurse for X period of time. And then when they do come back, there’ll be certain limits and conditions placed on their registration status.
Neil Braun
So say either they either can’t be working alone in an environment where they have access to controlled substances or any of their transactions regarding controlled substances will need to be, will need a co signature from another registrant things of those nature. And again there’ll be a period of time again case dependent as to when those conditions will be in place. So it’s again, it’s trying to kind of bring a person back into doing their work, but also making sure that the public is protected from any risks that may be present.
Terri
Yeah, absolutely. So a lot of what we’ve talked about sounds very similar in the US and Canada. Not a whole lot of differences. Is there something that you would say you have noticed is a difference between the way Canada handles something versus the U.S. When it comes to a drug diversion program?
Neil Braun
Yeah, there’s two things that I think that are maybe, I mean maybe I’ll give an example of one that I could see is maybe is a pro and one is a con. Although again depending on your perspective, it’s whether you call them pros or cons. But one difference is sitting in this country I’ll often see headlines coming from the US of the DEA levies a multimillion dollar fine against this health system. Or maybe in exceptional cases that somebody is in a leadership position, potentially has even been jailed in some cases. In my time doing the drug diversion lead role in the Fraser Health Authority, I never once saw the equivalent body in Canada would be Health Canada. They would be the one, the federal body that would be responsible for enforcing legislation around controlled substances.
Neil Braun
I never once heard a report of Health Canada levying a multimillion dollar fine against the hospital. I never heard about other consequences or anything else of that nature levied by Health Canada. And certainly I had pretty limited communication with them in the role that I had. They certainly the most they would have is they would ask for clarification in terms of loss reports that I would submit to them. So whereas I see in the US that certainly one of the motivating factors for health systems in terms of leaning into the drug diversion work is compliance with federal enforcement. That’s less so of an issue in this country. So that potentially creates some challenges in terms of getting more investment in terms of more capacity or resources.
Neil Braun
Where there may be a bit of an advantage in the Canadian health system is that with each province essentially funding its own health system for its entire province and having some degree of oversight or direction setting is that when there are instances of drug diversion that get some attention from policymakers or the public, there is an opportunity for provincial governments to lean in and say to their health systems, you need to be doing more around this. Or this is what in particular we want you to be doing around this. And so again, that’s how in my province, that’s how these drug diversion leads rules were set up as a result of provincial direction that hit the entire province’s health system all at once.
Neil Braun
So it’s not a case of different health systems having to have their own experience with drug diversion and deciding to lean into it and getting kind of a patchwork say, across the country or even within states in terms of who’s doing how much with regard to drug diversion.
Terri
Okay, yeah, that makes sense. Here we have ashp, which you’ve probably, I’m guessing, had looked at those guidelines. Do you have something comparable in Canada that also gives you guidelines as to what to do with a program?
Neil Braun
We do. And that’s another point of actually divergence between the two countries that I’ve seen is that with the ASHP guidelines around controlled substances management and drug diversion prevention, that I believe was released at the end of 2022, it really does. You know, you kind of see in terms of reading the article through, is that the focus at the start of the article or near the start is around detection and investigations, Sort of this thought that drug diversion, because it’s driven by substance use disorder, this is something that is going to just happen as a consequence of health systems having controlled substances? Yes, there is. Certainly it has its focus in the ASHP guidelines around control processes that might lead to be more difficult to divert, or it might standing out a little bit more. But really putting that focus around detection and investigation.
Neil Braun
The Canadian Society of Hospital Pharmacists, our ASHP equivalent, they last published their guidelines around drug diversion and controlled substances management in 2019. So about five years ago now, it’s almost flipped. It’s very much focused on the control. On the control processes. So basically every step of the way, from ordering a controlled substance to it being administered or wasted, how is that being accounted for? And how is the controlled substance being secured along all parts of the journey? Certainly it’s. That’s very important. Like, that’s one side of the coin. But the focus in those guidelines on the detection and investigation pieces, I think it’s limited to like one or two pages near the end of the. Of the guidelines.
Neil Braun
So it kind of suggests that I think there’s an opportunity for, in this country, at least for us to be focusing on both sides of the coin, and that certainly we paid attention to one side of it and certainly with other literature that’s been published around drug diversion in Canada, again, focus on control processes. But I think there’s an opportunity for us to be doing more in this country around the detection and investigation pieces.
Terri
Sure, yeah. Because you can do everything you know, you can to try to prevent it, to mitigate it, but people will continue to find ways around it because it’s a disease that, you know, desperation. Right. They’re going to whatever they can try to do.
Neil Braun
Yeah, 100%.
Terri
Yeah, yeah. Okay. And, you know, oftentimes we find definitions mean something different to different people and certainly maybe in different countries. When you talk about diversion in Canada, is it exactly what we talked about today, or does it have another meaning as well? If you mention that to healthcare professionals.
Neil Braun
Or the general population, it’s very interesting because up until, I’d say, about a year ago, if you were to use the term drug diversion in a clinical environment or maybe even in the general public, I think a lot of people would be thinking around what we’re talking about here, where you’re talking about nurses, doctors, pharmacists, healthcare workers taking controlled substances when they don’t have authorization to do so, and in a lot of cases, taking it for their own personal use. In this country, the term drug diversion, especially in the public perception of it, has changed that as there’s been an expansion of what’s sometimes in this country called safe supply or safer supply. So essentially this is using other opioids, most commonly hydromorphone, as a medication, as opioid agonist treatment.
Neil Braun
So in addition to, say, methadone and Suboxone, is using opioids that we typically would prescribe for pain, using that to. To manage substance use disorder. That’s attracted. It’s attracted controversy in this country in that there’s concern that some of what’s being prescribed, again, to mitigate a person’s substance use disorder is then patients that are receiving that are then turning around and then either selling or supplying it to other people who don’t have authorization to take it. So in that, in this case, we’re talking about clients essentially receiving opioids and then diverting it to somebody else. So that has. So in public discourse in this country that has gotten a lot of attention is using drug diversion to describe that scenario rather than talking about what’s actually happening within. Within the health care system. So in my article, I tried to.
Neil Braun
It was pointed out sort of in the review process that we needed to specify very clearly we’re talking about drug diversion within a Canadian healthcare system and not. And not outside of it.
Terri
Right, right. Did you say that hydromorphone is used in treatment for substance use disorder.
Neil Braun
That’s one of the medications that’s being used specifically for that. And that’s probably the most common one that’s used in these new safe or safer supply programs that have been established.
Terri
Okay. All right. Interesting. All right. Well, this is great. And it’s, I think it’s pretty cool that you were involved in. I mean, this is a big change of making something more formal with a diversion program. And I think that’s, I mean, of course this is where my passion is. So I think it’s really cool that you got to be involved in something like that and starting that with the grassroots in the beginning. Thank you for sharing that with us and what your kind of journey was like in your article.
Neil Braun
It, it’s something I started the role and I think mid-2017 and left by 2023, at the end of 2023, so around six or so years in the role. And so it’s again, my, my words of wisdom to folks that are maybe stepping into this journey or embarking on it is that it is a. And it does take time to establish the buy in and the awareness. And it doesn’t come overnight, but it can happen and it is important work to be doing. So for folks that are new into the role, stick with it is the advice that I give.
Terri
Yeah, great advice. Makes a difference. It’s an important program. Yeah. Well, thank you very much, Neil, for taking the time and sharing with us what you’ve done and what you’ve learned along the way.
Neil Braun
Thanks so much, Terry. Glad to share it with you.
Terri
Thank you.
