Covert Administration Research Articles

Covert medicine and deprivation of liberty

In this article, Richard Griffith considers the practice implications of a decision by the Court of Protection that highlights the need for a formal ‘best interests’ decision and continued independent monitoring through the deprivation of liberty safeguards concerning the covert administration of medicine to an incapable patient.

Covert administration of medicines: a contentious issue.

In its State of Care (2015) report the Care Quality Commission once again highlight unsafe management of medicines as a key concern in those care providers that require improvement. Underpinning the poor management of medicines is the unsafe and routine use of covert administration. In this article Richard Griffith looks at the legal and professional obligations for district nurses when they consider advising the use of covert medicines.

Covert administration of medicines in care homes

Covert administration of medicines in care homes

Covert administration in care homes flowchart

Covert administration in care homes flowchart

W5: Hair analysis in DFSA cases

Objectives Drug Facilitated Sexual Assault (DFSA) is defined by the covert administration of psychotropic substances to a victim in order to sexually abuse her or him. Most frequently used molecules are benzodiazepines, antihistamines, some neuroleptics and GHB. When delay between facts and sampling is too important for blood and urine analysis, hair can be an interesting alternative matrix to establish the involvement of drugs in the crime. However, the analysis and the interpretation may be tricky. The aim of this study is to present specific DFSA challenges through some case reports. Method In the pharmacology department of Garches Hospital, 3 locks of hair are used for a DFSA research. One strand is used to research 78 molecules in single LC-MS/MS technique (cocaine, amphetamines, designer drugs, opiates, benzodiazepines, some antihistamines and some neuroleptics). Another strand is used to search for cannabinoids by GC/MS. These two methods are fulfilled on 2 cm-length hair segments. The last strand is used to search for GHB by GC/MS on 5mm-length hair segments. Clinical case n° 1: A 15-year-old woman lodged a complaint against a friend of her and the boyfriend of the latter, for have been drugged and sexually abused 6 months before. 3 strands measuring approximately 32 cm each were collected from the victim. A significant increase of GHB was observed on three segments corresponding to the time of the facts. Clinical case n° 2 : A 10-year-old girl was admitted into intensive care unit for a moderate coma. The father admitted he drugged her daughter with GBL (GHB precursor). At her admission, GHB has been quantified in blood at 71 mg/L. The GBL bottle was also analyzed and was pure GBL. The father confessed that he tested the effects of the GBL to his wife a few days earlier. 4 weeks later, 4 strands were collected from the mother and her daughter. On the mother's hair, a significant increase of GHB was observed on the second segment, corresponding to the time of the facts. On the contrary, the undoubted take of GHB could not be highlighted in the daughter's hair. Clinical case n° 3: A 35-year-old woman who lived with a friend had a drink with him an evening. Afterward she felt dizzy, cold and lost consciousness. She lodged a complaint one month later. 4 strands of hair were collected. Several molecules were found on multiple segments of her hair : cocaine and metabolites, codeine, amphetamine, MDMA, MDA, pseudoephedrine, Hydroxyzine, cetirizine, doxylamine, diazepam, nordiazepam, temazepam, oxazepam, zolpidem, ketamine, cyamemazine, alimemazine, promethazine. Moreover, bromazepam was found only on the segment corresponding to the period of the facts at a concentration of 12 pg/mg, which could correspond to DFSA. But the question of the pharmacology effects of a single intake of benzodiazepine in a poly-addict person remains. Conclusion Hair is now an essential and unavoidable matrix in DFSA cases, but every analytical step can be delicate, especially the interpretation of findings. Though GHB research in hair has frequently been contested, these cases attest it can provide good results in such contexts. However, results may depend on the nature of the hair (hair color, age of the victim, texture,…) and negatives results must be interpreted very carefully, especially for children.

Public agencies in Serbia accidental error or bad intention

English term 'agency' has appeared in the Serbian legal system after the political changes in 2000. At first, the Law on Ministries in 2004 created bodies of state administration under the name of the agency and administrative organizations and in 2005 has been passed the Law on Public Agencies, which provides agencies as autonomous entities that are not directly part of the state administration. In addition, in the last ten years in Serbia was created a whole range of subjects of different legal status under the name of the agency. It should be borne in mind that the organization and structure of public administration in Serbia are mostly based on the Germanic tradition and that Serbia has long used the German term for persons performing administrative activities: 'Verwaltungsorgan'. Without any objective need, in addition to traditional forms of bodies performing administrative activities in Serbia has been created a new form called the agency. This has only brought the confusion into by then relatively harmonized system of governance structures, where the name of the former administration and some other subjects changed to agencies and some new, who previously did not exist, have been also created. This has led to the growth of covert administration. Agency name is not unknown in the world and in the US is used since the 18th century. However, instead of the name in English is translated into Serbian language in an adapted way, as it corresponds to the traditional Serbian terminology, this accidental error later turned into a bad intention of creating an ever-larger number of entities called agency.

Sumisión química en casos de presuntos delitos contra la libertad sexual analizados en el Instituto Nacional de Toxicología y Ciencias Forenses (Departamento de Madrid) durante los años 2010, 2011 y 2012

IntroductionDrug-facilitated sexual assault crimes can be applied in cases of covert administration of certain substances, as well as cases in which the victim voluntarily consumes these same substances. Materials and methodsThis study describes retrospectively cases of sexual assault related to the consumption of chemical substances. They were reported to the Madrid Department of the National Institute of Toxicology and Forensic Sciences during 2010, 2011 and 2012. We collected information related to the victim's profile, the type of biological samples given and the results of the toxicological analysis. ResultsOut of 306 cases of sexual assault or abuse referred, 107 have met the inclusion criteria. The victim's profile is of a young Spanish or Latin-American woman (mean age: 25.9 years) who admits to consuming alcohol prior to the episode and suffering from total or partial amnesia with regard to the facts. The given samples were blood (27.1%), urine (14%) or both (57%). Toxicological analysis was positive in 87.9% of cases and the substances identified were ethanol (61.7%), pharmaceuticals (40.2%, mainly benzodiazepines), and illicit drugs (27.1%, primarily cocaine) either alone or in combination. ConclusionsThis study reflects the requirement to work in prevention and training of potential victims and healthcare personnel, proves that an early and adequate collection of samples are key factors to confirm the diagnosis and identifies that detected licit or illicit substances belong to a frequent consumption pattern.

An audit on covert administration of medications to adults with learning disabilities

Objectives: Covert medication involves the administration of any pharmacological agent in a disguised form. Despite some evidence that the practice is common, there are no legal guidelines for its use in England and Wales. We attempted to ascertain our current practice against standards for best practice that was devised.Method: Questionnaires were sent to a sample of 62 carers of adults (aged 18 years or over) with learning disabilities (intellectual disabilities). The questionnaires were based on standards set after consultation with a variety of sources.Results: A 94% response rate was achieved from questionnaire returns (n = 58).16% (n = 9) stated they were administering medications covertly. Of these, 78% (n = 7) were not aware nor had a policy in place for this practice. Seventy-eight per cent (n = 7) had no written record of the patients’ mental capacity. For those practising covert administration, most of the managers, General Practitioners (GPs, also known as Family Doctors) and Family members were made aware, but there were poor awareness levels by the pharmacists and the consultant psychiatrist (responsible clinician). The documentation of capacity assessment was poor.Discussion: Various key members of the multidisciplinary team were not made aware of the practice of covert administration. This may imply a deficiency in knowledge base on what constitutes defensible practice and this highlighted education and training needs. Interventions included presentations in a variety of settings to highlight the practice and standards. There is a need for repeating the audit with larger numbers.

Covert Medication Administration: The Practice of Hiding Medications in Long-Term Care Settings

Covert medication administration is the purposeful hiding of medications from patients, and the topic receives little attention. Awareness and research regarding this practice is limited to a handful of studies outside of the United States. These studies suggest a larger prevalence than reported and identify significant ethical and legal implications for bedside nurses. A review of the literature, discussion of prevalence, contributing factors, and potential consequences of this practice build the foundation for practice recommendations and suggestions for future research. In addition to recommendations for nurses regarding covert medication administration, additional research and exploration of this issue in the United States are proposed.

Jam today: the law and ethics of covert medication

Covert administration of medication has always been controversial and has not always been specified in care plans, it should be limited to incapacitated patients where the treatment is necessary and in best interests, or else authorised by mental health legislation or an appropriate court declaration. A lot of nursing and HCA practice that involves putting medication in food or drink may not actually be disguising it from the patient at all. The NMC guidelines do not refer to the Mental Capacity Act and are due for review, meanwhile the Maudsley Prescribing Guidelines are recommended. It is vital that HCAs and APs who administer or assist with medication understand their legal and ethical authority for hiding it, and reviewing the reasons with the wider team.

Covert administration of medication to older adults: a review of the literature and published studies

The aim of the study was to review published studies of covert medicines administration in older people, as well as carrying out a broad review of the subject. A review of MEDLINE, EMBASE, PsycINFO, BNI and CINAHL was conducted in order to identify studies providing quantitative or qualitative data on covert administration in older adults. National guidance on covert medication and the ethics and legality of the practice were also reviewed. Data were extracted from eight studies and one inspection report. In addition, one qualitative study was identified. Nine studies included a questionnaire or interview with staff and only one involved non-professional carers. Seven studies were from the UK. Disguising medication in food or drink was reported in 43-71% of nursing homes. In total, 1.5-17% of institutional patients were receiving medication covertly. Despite legislation, incomplete documentation was common and nursing staff alone often made the decision to administer medication covertly. Covert administration appears to be common in older adults with dementia but despite legislation it often takes place without documentation and consultation of all relevant parties. Staff education and training and local audit are needed to improve standards and safeguard vulnerable patients in institutions.

Administration of medicines in food and drink: a study of older inpatients with severe mental illness

Difficulties in administering medicines to older people are common, and medicines are sometimes mixed with food and drink to aid administration. Little is known about this practice or that of covert administration. This study aims to examine the nature, frequency, safety, reasons for and documentation of the administration of medicines in food and drink. A cross-sectional survey of mainly older adults, who were inpatients at a U.K. tertiary referral centre, was carried out, and nursing staff and consultant psychiatrists were interviewed. Of the 110 patients, 34 (30.9%) were receiving medication mixed with food or drink, although for only 52.9% was the procedure documented in the patient's care plan and for 64.7% was it documented on the medication chart. No associated safety issues were identified. The main reasons for this practice were swallowing difficulties (61.8%) and refusal to swallow tablets (47.1%). Thirteen out of 110 (11.8%) patients were receiving covert medication, most commonly antipsychotics and anxiolytics or hypnotics. All were detained and lacked capacity to consent. Most had dementia but a few had chronic schizophrenia. For only 46.2% was covert administration documented in the care plan and for 69.2% on the medication chart. Administration of medication in food or drink and covert medication were common in this group of hospitalized patients with severe mental illness. Before administering medication covertly it is important to discuss the matter with the multidisciplinary team and, where appropriate, with the patient's relatives. It is also important to ensure that supporting documentation has been completed in order to avoid medico-legal difficulties.

The noncompliant patient in psychiatry: the case for and against covert/surreptitious medication.

Nonadherence to treatment continues to be one of psychiatry’s greatest challenges. To improve adherence and thus improve the care of patients, clinicians and patients’ family members sometimes resort to hiding medication in food or drink, a practice referred to as covert/ surreptitious medication. The practice of covert drug administration in food and beverages is well known in the treatment of psychiatrically ill world-wide but no prevalence rates exist. Covert medication may seem like a minor matter, but it touches on legal and ethical issues of a patient’s competence, autonomy, and insight. Medicating patients without their knowledge is not justifiable solely as a shortcut for institutions or families wishing to calm a troublesome patient and thus alleviate some of the burdens of care giving. The paramount principle is ensuring the well-being of a patient who lacks the competence to give informed consent. Ethically, covert/surreptitious administration can be seen as a breach of trust by the doctor or by family members who administer the drugs. Covert medication contravenes contemporary ethical practice. Legally, treatment without consent is permissible only where common law or statute provides such authority. The practice of covert administration of medication is not specifically covered in the mental health legislation in developing countries. Many of the current dilemmas in this area have come to public attention because of two important developments in medical ethics and the law - the increasing importance accorded to respect for autonomy and loss of the parens patriae jurisdiction of the courts [parens patriae means ‘parent of the country’; it permitted a court to consent or refuse treatment on behalf of an ‘incapacity’, or alternatively to appoint a guardian with such powers].

Covert medication in older adults who lack decision-making capacity

Any mentally competent adult has the right to give or refuse consent to treatment or nursing intervention. The ethical principle underpinning this free choice is respect for autonomy, and the nurse's professional duty to respect the decision of the patient is enshrined within the NMC's Code of Conduct (NMC, 2008). Capacity is paramount to consent and problems arise in practice when the patient is deemed to lack capacity. In this instance, the provisions of the code of practice of the Mental Capacity Act apply (2005). The aim of this article is to present the issues that arise when patients lack decision-making capacity, especially in relation to older adults with dementia who lack the capacity to consent to medication, as well as the covert administration of medication. In relation to consent and covert administration, the nurse is required to balance respect for the patient's autonomy with their desire to act beneficently and in a non-maleficent manner and emphasis will be given to these underlying ethical principles throughout the article.

Covert administration of medicines to adults must be the last resort

The Mental Welfare Commission for Scotland recently reported that it found, during its inspections, that covert administration of medicines was routine practice. The commission has warned that the law demands that this type of administration is only to be used as a last resort. This article looks at the legal and professional obligations on the nurse prescriber when they consider the use of covert medicines.

Covert Administration of Psychotropic Medications in the Emergency Department: An Opposing View

We read with interest and concern the report by Lewin et al in the January 2006 issue of Annals of Emergency Medicine.1 They reported a case of covert psychotropic medications to subdue an agitated patient in the emergency department (ED). They argue that use of covert psychotropic medications might be an effective strategy to control a select group of extremely violent patients. We feel that the use of covert medications is unethical and inherently problematic.

In reply

In reply

The epidemiology of drug facilitated sexual assault

The files of the Victorian Institute of Forensic Medicine were reviewed for all cases of alleged drug facilitated sexual assault for the 12 month period concluding in April 2003. Seventy-six cases were identified from a total of 434 (17.5%) cases of adult sexual assault. The median delay from alleged incident to time of examination was 20 h. Alcohol consumption in the hours prior to the assault was reported by 77%. Alcohol was still present in 37% when subsequently examined, with an average blood alcohol concentration of 0.11% at the time of examination. Forty-nine percent reported using prescription medications and 26% reported the use of recreational drugs. Drugs not reportedly consumed by the subject were detected in 15 cases (20%) of the study group or 3% of all adult sexual assault cases. The drugs detected included cannabis (four cases), antidepressants (4), amphetamines (3), benzodiazepines (4) and opiates (3). The study indicates that covert administration of drugs in the setting of adult sexual assault appears uncommon. The true incidence however may be higher (due to non or delayed reporting) or lower (due to inaccurate self reporting of drug consumption) however the frequent findings of high concentrations of alcohol has implications for the health and safety of these individuals.

An Unusual Case of Subterfuge in the Emergency Department: Covert Administration of Antipsychotic and Anxiolytic Medications to Control an Agitated Patient

Pediatric, nursing home, and institutionalized psychiatric patients frequently receive medications covertly or against their will. Surreptitious medicating of emergency department (ED) psychiatric patients may occur but has not been reported. We discuss competing ethical, therapeutic, and legal issues in potential conflict during the treatment of an acutely psychotic patient who had homicidal and suicidal ideation and presented to a busy, urban ED. The practice of covertly medicating may not be uncommon in EDs, but fear of professional censure probably inhibits open discussion and documentation of such events. No specific statutory, ethical, or case law in the United States seems to control this type of situation.

Ethical Issues in Surreptitious Prescribing

Back to table of contents Previous article Next article LettersFull AccessEthical Issues in Surreptitious PrescribingPaul Noroian, M.D.Paul NoroianSearch for more papers by this author, M.D.Published Online:1 Aug 2005https://doi.org/10.1176/appi.ps.56.8.1023AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: I was pleased to see the topic of surreptitious prescribing addressed in the April issue of Psychiatric Services (1). In the course of my work in state hospitals in Massachusetts, I have had to make decisions about whether to prescribe medications concealed in food or fluids. In most of these cases, guardians and other nonclinicians were the main advocates of this type of prescribing. I agree with the authors that there may be a role for this type of prescribing in work with patients with dementia and severe retardation, when the patient is not aware of the medications prescribed and a guardian has given consent for them. However, it is less clear whether any role exists for this type of prescribing for patients with psychotic illness, who are aware of the medications that they take.One ethical issue in this population is whether an adult with the capacity to understand the implications of having a medication prescribed has the right to know what is being given. The finding of incompetence does not preclude an individual's having the capacity to recognize that he or she is being given a medication that has the potential to cause adverse effects—which creates a dilemma if the patient develops side effects. Does the patient have a right to know about these side effects and the fact that they are caused by a medication? A physician has an ethical obligation to explain side effects to patients, even to patients deemed incompetent. A patient's discovery of the fact that medication is being given surreptitiously could have devastating effects on the treatment relationship and the patient's ability to trust the psychiatrist and the treatment team, an issue raised by Ahern and Van Tosh in their Taking Issue commentary in the April issue (2). I would also be concerned that a psychotic patient who learns accidentally that he or she is being medicated surreptitiously might stop accepting all treatments and potentially all food and nourishment. For inpatients deemed incompetent who have a high level of awareness, it could be quite difficult to shield this information, given the number of staff on different shifts who might accidentally disclose information about the concealed medication. For these reasons, the practicality of this practice is far from certain. Further reports on the application of this practice would be welcome.Dr. Noroian is assistant professor of psychiatry at the University of Massachusetts Medical School and director of psychiatry at Worcester State Hospital in Worcester, Massachusetts.Reference1. Whitty P, Devitt P: Surreptitious prescribing in psychiatric practice. Psychiatric Services 56:481–483,2005Link, Google Scholar2. Ahern L, Van Tosh L: The irreversible damage caused by surreptitious prescribing. Psychiatric Services 56:383,2005Link, Google Scholar FiguresReferencesCited byDetailsCited ByProof in the Pudding: The Value of a Rights Based Approach to Understanding the Covert Administration of Psychotropic Medication to Adult Inpatients Determined to Be Decisionally-Incapable in Ontario's Psychiatric Settings1 January 2021 | Journal of Law, Medicine & Ethics, Vol. 45, No. 2 Volume 56Issue 8 August 2005Pages 1023-1023 Metrics History Published online 1 August 2005 Published in print 1 August 2005