Last year, the health care world was rocked by the arrest of David Kwiatkowski, a Michigan native and itinerant cardiac technologist who traveled the country plying his trade. He was also a fentanyl addict. To feed his addiction, he stole IV drugs from operating rooms in 19 hospitals across the country, possibly infecting hundreds of patients with Hepatitis C. As experts rewrite the rules to try and prevent a repeat of this devastating outbreak, they may wind up turning for guidance to the demographic that arguably knows the topic best: recovering drug addicts.
Thirty-three years old, with close-cropped hair and a tidy goatee, Kwiatkowski pleaded not guilty last month in a federal indictment on seven counts of stealing drugs, and seven more of tampering with a consumer product—namely fentanyl. His case is complicated, crossing state lines, involving potentially hundreds of victims, witnesses and hospital administrators. From 2008 to 2012, Kwiatkowski worked for hospitals in seven states across the country (in Arizona he was reportedly discovered passed out in the men's room with a needle mark in his elbow and a fentanyl syringe in the toilet next to him).
Kwiatkowski was due to face trial next month, but a judge postponed it until October 2013 to give prosecutors time to comb through the wreckage. John P. Kacavas, U.S. Attorney for the New Hampshire district, has said Kwiatkowski is facing up to 98 years in prison and $3.5 million in fines. Kwiatkowski is suspected of infecting at least 32 patients with Hepatitis C at the Exeter, N.H. hospital where he worked from April 2011 to May 2012.
And that’s just the New Hampshire patients. Eighteen other hospitals have sent letters to thousands of patients advising them to get tested for Hepatitis C, a major risk in injection drug-use and an illness the Centers for Disease Control (CDC) says kills more Americans each year than HIV. Now the civil suits are starting to roll in against the hospitals and the staffing agency who hired Kwiatkowski to them, citing their failure to protect patients from Kwiatkowski’s addiction.
“He was observed at UPMC stealing drugs,” says Brendan Lupetin, a Pittsburgh attorney who filed the first class-action lawsuit against the University of Pittsburgh Medical Center and Kwiatkowski’s staffing agency. AS FAR BACK AS 2008, Kwiatkowski worked as a radiological technician at UPMC-Presbyterian, in the heart of the UPMC complex. The suit states that in May of that year another employee saw Kwiatkowski lift his shirt in an operating room and shove a syringe of fentanyl down his pants. Later it was found that Kwiatkowski had swapped out the fentanyl syringe for a syringe filled with saline—a syringe he’d previously used on himself. The suit says UPMC supervisors found three empty fentanyl syringes in his clothes and an empty morphine syringe in his locker.
UPMC fired Kwiatkowski, Lupetin said, but they didn’t file the required Form 106 to alert the DEA of Kwiatkowski’s conduct, which Lupetin says would have alerted drug enforcement officials of Kwiatkowski's conduct and possibly have prevented him from moving on to other jobs with such ease. UPMC has said they thought the staffing agency would file the form, since he was officially being paid by them. UPMC spokespeople did not respond to The Fix’s request for comment.
The Pittsburgh class-action suits seek damages for the more than 2,000 patients who have been advised to get Hep C testing, citing possible medical costs, lost work-time and pain and suffering. Lupetin says attorneys in the states where Kwiatkowski worked—after UPMC fired him, he got jobs at facilities including Baltimore Veterans Affairs Medical Center, Johns Hopkins Hospital, Maryland General Hospital, Arizona Heart Hospital in Phoenix, Temple University Hospital in Philadelphia, and Hays Medical Center in Hays, Kansas, where six patients have tested positive with his strain of hep C—will doubtless be filing similar suits.
The Kwiatkowski case is not just a case of one dope fiend’s egregious drug theft and the blind eye facilities and agency workers turned to it. It’s a stunning example of the unanticipated ways addiction can threaten public health, and healthcare facilities and policymakers need to begin thinking of new ways to protect society from the consequences of addiction.
“This case highlights how public-health agencies have to respond to the cracks in the system,” says David Smith, M.D., founder of the legendary Haight-Ashbury Free Clinic in San Francisco. Smith, a godfather of American addiction medicine, has been working for 50 years in an epicenter of injection-drug use and has spent a great deal of his career trying to protect people with addiction and the general public from infection resulting from IV drug use. Smith has seen a lot of hep C. Yes, 70 to 80 percent of cases can be curable, “but it’s not simple,” he says. “It’s not like having an infection in your throat, you give them pills and it goes away. These people are going to have problems for the rest of their lives.”
Unfortunately, Smith noted, “usually what it takes to change the system is a crisis.”The Kwiatkowski case is not the first crisis of its kind, though his may prove to have perhaps the broadest geographical reach. In September a 49-year-old Jacksonville, Fla. radiology technician got 30 years in prison for stealing drugs and infecting two patients with hep C; one died. In 2010 Kristen Parker, a 27-year-old hospital technician and heroin addict also got 30 years for stealing IV drugs, infecting at least 18 patients at a Denver hospital with hep C. “I put getting my next fix above my career, my family, taking care of my son and the safety and well-being of my patients,” Parker said at her sentencing hearing.
In May 2012, the CDC reported that more than 4% of healthcare workers admit illicit drug use—and that's just the ones who admit it. So What can hospitals and other facilities do to protect their patients from the denial and cunning of workers with addiction?
A simple solution is to get recovering addicts to advise hospital administrators and state and federal public health officials on the best ways to prevent addicted healthcare workers from stealing drugs.
Ask Richard Garfein, PhD, MPH, professor in the Division of Global public Health at the University of California-San Diego’s department of medicine. Garfein is a former CDC epidemic intelligence service officer who used to investigate how patients contracted Hep C. He identified systemic risk factors and advised facilities how to develop policy to prevent infection. (He now studies the spread of infections, including Hep C, among untreated addicts on the US-Mexico border.)
Here is how officials think Kwiatkowski stole his drugs: He went into operating rooms where a nurse or doctor with access to locked drug-carts had prepared for procedures by laying out supplies on the carts; then he stole drugs from the top of the carts when others’ backs were turned. Cunning.
If that’s the case, Garfein said, “he must have been using the needle on himself and giving it back to the patient.” Another case Garfein had studied involved an anesthesiologist suspected of injecting a patient with painkillers from a large multi-dose vial, then using part of the rest on himself before using it on one other patient. What's stunning about Kwiatkowski is that he went nationwide, infecting at least 30 patients across the country.
“That's frightening,” Garfein says. “And it’s pretty cavalier—it’s pretty reckless. He must have a serious addiction.”
Garfein and Smith proposed a fairly predictable list of proposed preventative measures:
Drug screening. Both Garfein and Smith suggested mandatory drug-screening for any employee in proximity to addictive medications. Smith noted that it’s important to test for what’s available: the ordinary five-panel urine screen—which tests for cannabis, cocaine, methamphetamine, PCP and natural opiates—will not catch synthetic painkillers such as fentanyl. If Kwiatkowski had been doing cocaine, Smith notes, he would have been caught. “Obviously,” Garfein emphasizes, “you have to test for what you’re looking for.”
Inventory control. Many hospitals track inventory closely, Garfein says, through their billing departments. Should drug-carts be restricted even further? What about the nurses who turned their backs?—You can’t put locks and super-restrictive oversight on everything in a hospital environment, Garfein says. “It would be really hard, and I tell you this from experience working for a health agency—if you’re too restrictive, people can’t get their jobs done.”
Employee-assistance programs. Most employers, including hospitals, have EAPs that serve to educate employees about the risks of substance abuse. “Nobody wants to become an addict,” Garfein says, and EAPs send the message that “we want to make the barriers to get you help as low as possible.” Smith says the trend among hospitals today is toward hospital wellbeing or wellness committees that help to prevent and refer to treatment cases of addiction and other behavioral health problems. But these committees are largely focused on physicians, allowing contract employees such as Kwiatkowski to fall through the cracks.
Staff training. One way to catch cases of drug-theft among contract workers is to educate managers about the ways drugs can be stolen and the ways addicted employees may behave. Healthcare managers, like the general public, operate under stereotypes that need to be debunked. “They think the person that’s going to steal the drug is a street person walking in,” Smith says.
But let’s think outside the box. What better way to debunk stereotypes than to involve recovering addicts in the policymaking?
“You want to stop hackers, you hire a hacker,” Garfein muses. “I think that’s a really excellent recommendation.” He notes that if researchers are studying drug-abuse among prison inmates, they are required to have an inmate on their committee. Inviting recovering addicts to participate in policy-making would give much-needed insight into the thinking processes of people with addiction, as well as a healthy dose of compassion, Garfein says: “There’s a lot to be gained by talking with people who have been on the other side.”