Opioid Tampering By Health Care Providers Can Lead To Hepatitis C Transmission

MedicalResearch.com Interview with:
ChongGee Teo, MD, PhD
Chief, Laboratory Branch
Division of Viral Hepatitis

Medical Research: What is the background for this study?

Dr. Teo: Hepatitis C outbreaks in the course of providing healthcare continue to occur. Some happen when hepatitis C virus (HCV) is transmitted to patients following breakdowns in safe injection and infection control practices, and mishaps during surgery. Another route of provider – to patient HCV transmission is diversion, self-injection and substitution of opioids intended for anesthetic use (collectively referred to as “tampering”). A patient acquires infection when an HCV-infected provider, who is an injecting drug user, self-injects from a syringe prefilled with opioid anesthetic, fills the syringe with a volume substitute (e.g., saline or water), and then administers the adulterated preparation to the patient.

The study consisted of two parts:
1) to quantify the extent that anesthetic opioid tampering contributes to hepatitis C outbreaks by analyzing healthcare-associated outbreaks occurring between 1990 and 2012 in developed countries.

2) to estimate the probabilities of provider-to-patient transmission reflecting the “real-world” setting in which a patient presents for health care, unaware of risks posed by procedures conducted by a provider who may or may not be an injecting drug user or HCV infected.

Medical Research: What are the main findings?

Dr. Teo: Disproportionately many cases of HCV infection from healthcare-associated hepatitis C outbreaks were attributable to provider tampering of anesthetic opioids. Thus, tampering was associated with 17% (8/46) of these outbreaks, but 53% (438/833) of cases.

Of the eight tampering outbreaks studied, four (50%) were transmitted by anesthesiologists or nurse anesthetists, and the other four by allied health professionals. Six of the outbreaks (75%) involved fentanyl tampering. Spain hosted the largest outbreak (between 1988 and1997), involving 275 cases, and Australia the next largest (between 2006 and 2009), with 49 cases. Five outbreaks were reported from the United States, which generated 81 infected patients; the largest outbreak occurred in New Hampshire (between 2010 and 2012), involving 32 cases.

Modeling studies showed that the likelihood of HCV transmission to a patient from exposure to an opioid preparation tampered by a provider unknown to be an injecting drug user or HCV infected (0·004%) is about >100 higher than from exposure to surgery conducted by a surgeon unknown to be HCV-infected (0·0004%). This risk escalates >15,000 times when exposure is to an opioid preparation tampered by a provider who is an injector. To pose a 50% risk of transmission, a surgeon, even when HCV-infected, can take as long 30 years, but a provider who is an injector takes only weeks or months, depending on how successful the provider is with opioid tampering at the workplace.

Medical Research: What should clinicians and patients take away from your report?

Dr. Teo: Testing for and treatment of HCV infection in providers, regardless of whether or not they are injectors, have access to controlled substances, or conduct exposure prone procedures, are beneficial and can extend from care and management recommendations and guidelines already developed for providers infected by blood-borne viruses. In the era of highly efficacious anti-HCV therapy, providers should feel less helpless after being found HCV infected and be more willing to avail themselves to testing and curative treatment.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Teo: To reduce the risk of harm to patients from providers who tamper with anesthetic opioids, the following measures are suggested:

  • periodic opioid screening of providers
  • raising greater awareness among healthcare staff about provider substance abuse and provider diversion of controlled drugs
  • educating healthcare staff on how colleagues abusing narcotics might be identified
  • adopting computerized dispensing and charting systems to monitor controlled drug access
  • and enabling staff recruitment agencies and bodies that credential and license healthcare professionals to verify past criminal history and reports of adverse actions taken by regulatory authorities and employers.


Nosocomial hepatitis C virus transmission from tampering with injectable anesthetic opioids.

Hepatology. 2015 Mar 22. doi: 10.1002/hep.27800. [Epub ahead of print]

Hatia RI1, Dimitrova Z, Skums P, Teo EY, Teo CG.

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MedicalResearch.com Interview with: Chong-Gee Teo, MD, PhD (2015). Opioid Tampering By Health Care Providers Can Lead To Hepatitis C Transmission 

Last Updated on April 22, 2015 by Marie Benz MD FAAD