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    Drug addiction among nurses: Confronting a quiet epidemic

    Many RNs fall prey to this hidden, potentially deadly disease.

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    YOUR COLLEAGUE on the night shift is a stellar nurse. Her background, experience, and demonstrated skills are top-notch. She is working extra shifts to help cover expenses while her husband is between jobs. While raising three young children, she also cares for her severely disabled father. You wonder how she does it all.

    This description fit Patricia Holloran, RN, whom friends and colleagues regarded as a "super nurse"—until hospital administration and the Connecticut Department of Health confronted her for drug diversion.

    Holloran was introduced to the nasal spray butorphanol (Stadol) when her doctor changed her migraine prescription. She often administered the injected form of this powerful narcotic to women in labor. When the women did not require a full dose, Holloran justified using the leftovers to help her sleep after a long night shift. It also helped her cope with the stress of taking on extra shifts, being the primary breadwinner, and caring for her three sons—along with her father, who suffered from rheumatoid arthritis. Months later, she was pocketing whole vials from the dispenser. "Stadol is not physically addictive," Holloran said. "I thought I could stop at any time. I was wrong."

    Holloran details her spiral into drug dependence and arduous path back to hospital nursing practice in her recent book, Impaired: A Nurse's Story of Addiction and Recovery (Kaplan Publishing, 2009). Her story shows that, with determination and support, nurses who suffer from addiction can recover and regain their practices.

    A nurse for more than 30 years, Holloran has returned to her favorite practice area, labor and delivery. She speaks to groups regularly about addiction, and oversees an anonymous recovery program called Nurses for Nurses. Two summers ago, Holloran stood with Connecticut Gov. M. Jodi Rell as the governor signed a bill creating the HAVEN assistance program for healthcare professionals in the state.

    STIGMATIZED DISEASE Holloran's openness about her addiction and recovery are in stark contrast to the silent, often punitive environment that surrounds the issue of nurses and drug addiction. (For the purposes of this article, the term "drug addiction" includes alcoholism.)

    Addicted individuals feel tremendous shame and guilt, and fear losing their reputations, jobs, family, and friends, said the experts interviewed for this article. Drug addiction is even more devastating for healthcare practitioners: It is a breach of professional ethics, places patients at risk, and can affect the reputations of the facilities where they work. Nurses can be particularly hard on themselves and colleagues who may be addicted.

    "The stigma that addiction is a moral failure or lack of willpower rather than a disease is embedded in U.S. society," said Jack Stem, CNA, one of two peer advisors on addiction for certified nurse anesthetists in Ohio, and founder of Peer Advocacy for Impaired Nurses LLC. This attitude, he maintains, prevents nurses from seeking help. It deters facilities from providing adequate support programs for addicted and recovering nurses, and ultimately puts patients at risk.

    "Our number-one goal is to protect patients. Our secondary goal should be helping our colleagues—as we would help any patient under our care," Stem said.

    INCIDENCE OF ADDICTION The National Institute on Drug Abuse estimates that 10% of U.S. adults abuse drugs during their lifetimes. Accurate statistics are difficult to obtain because drug abuse and addiction are often cloaked in silence.

    The American Nurses Association (ANA) says approximately 10% of nurses are dependent on drugs, making the incidence of drug abuse and addiction among nurses consistent with that of the U.S. population. With nearly 3 million RNs employed in the U.S., that means almost 300,000 RNs may be substance abusers; put another way, if you work with 10 nurses, one of them is likely to be struggling with addiction.

    Drug addiction is a major health risk among nurses and other healthcare professionals, said Stem. Of the hundreds of cases that come before the State of Ohio Board of Nursing each month, well over half of them deal with addiction, he said.

    Some nursing specialties, such as anesthesia, critical care, oncology, and psychiatry, are believed to have higher levels of substance abuse because of intense emotional and physical demands, and the availability of controlled substances in these areas, according to "Substance Use Among Nurses: Differences Between Specialties," a landmark study in the April 1998 American Journal of Public Health.

    ADDICTION TRIGGERS Most RNs, regardless of their practice areas, experience the stresses of long shifts, mandatory overtime, and shift rotation, which are physically taxing and tough on family life and friendships. Added to that are emotional demands. Nurses often need to internalize their feelings to stay in control and make split-second, life-and-death decisions. "Nurses go from one emotionally and physically demanding situation to another, with little time to decompress," Holloran said.

    As the backbone of the U.S. healthcare system, nurses are essential to the quality of care and well-being of patients. Nurses with untreated addiction can jeopardize patient safety because of impaired judgment, slower reaction time, diverting drugs from patients, neglecting patients, and making mistakes, wrote Debra Dunn, RN, in an often-cited study, "Substance abuse among nurses—Defining the issue," in the October 2005 edition of the AORN Journal, which serves the Association of periOperative Registered Nurses.

    The availability of medications at work and the acceptance that drugs have the power to help you feel and perform better increases healthcare professionals' risk of drug abuse. "Nurses have seen for themselves that medications can solve problems," said Holloran. Because of their access to and familiarity with drugs, nurses may feel comfortable using them on their own. "We have the erroneous belief that, because of our skills and knowledge, we can self-medicate without becoming addicted," Holloran added.

    DRUGS OF CHOICE While nurses' abuse of drugs and alcohol is roughly equivalent to the general population's, Dunn's study said, dependence on prescription-type medication use is higher for nurses, and addiction to street drugs, such as cocaine and marijuana, is much lower than the population. The most frequently abused substance is alcohol, followed by amphetamines, opiates (such as fentanyl), sedatives, tranquilizers, and inhalants, according to the ANA.

    A study on monitoring the diversion of controlled substances in the March 2007 Hospital Pharmacy details the typical ways that nurses obtain drugs in a healthcare setting. Nurses may ask doctors to write a prescription for them, or steal a script and forge prescriptions themselves, the study said. They also may divert drugs by administering a partial dose to a patient and saving the rest for themselves, or by asking a colleague to cosign a narcotics record saying a drug was wasted without witnessing the drug's disposal. Some nurses have signed out medications for patients who have been transferred to another unit or obtained as-needed medications for patients who have refused or not requested them.

    REPORTING AN IMPAIRED COLLEAGUE Substance abuse usually is noted first by fellow staff members. Some nurses may be reluctant to report a colleague. However, those who remain quiet about a colleague's drug abuse risk patient care and safety, the facility's reputation, and even their colleague's life.

    The New York State Nurses Association's model drug policy states: "Employers have an ethical obligation and most have a legal mandate to report an impaired nurse to the appropriate legal and regulatory authorities in order to safeguard consumers." The policy adds that nurses also "have an ethical obligation to address impairment of a colleague."

    While patient safety is the primary reason to report a nurse suspected of abusing drugs, a second reason is to help that nurse. Holloran said, "As bad as that day was when I was confronted for diverting drugs, it most likely saved my life."

    ADDICTION A TREATABLE DISEASE The ANA regards addiction as a "chronic, progressive, and treatable" disease. Addiction only gets worse if left untreated, and can be fatal due to overdoses, accidents, or the chronic effects of the disease over time.

    The ANA strongly advocates that medical facilities establish educational programs that teach nurses how to recognize colleagues who may be abusing drugs, and ensure that they know the facility and state board of nursing (BON) policies. Nursing staffs, the ANA said, also should know how to support colleagues who participate in rehabilitation programs. This provides recovering nurses with support and supervision while they regain full nursing practice.

    "Many nurses are not educated about how to recognize or intervene with a colleague who is abusing drugs or alcohol," Stem said. Too many healthcare facilities choose to fire employees with addiction problems rather than deal with the issue directly, leaving the addicted individual free to apply for employment elsewhere and put other patients at risk, he added.

    SELF-REPORTING RARE Holloran and Stem agree that addicts rarely self-report for fear of losing their jobs, licenses, and livelihoods. Another major factor, they said, is that addiction causes chemical and physical changes in the brain that lead many addicts to think they are in control—until they hit rock bottom or overdose and die.

    In most instances, intervention creates an "artificial rock bottom," when the nurse can be offered treatment and rehabilitation in lieu of discipline, such as losing their licenses. "Most nurses will agree to undergo treatment and monitoring—if only to save their licenses—until they get to the point where they want to stay clean and drug-free," Stem said.

    WHAT TO DO IF YOU SELF-REPORT OR ARE CONFRONTED Whether they self-report or are confronted, nurses should enter an intervention program in lieu of discipline, said Marilyn Clark Pellett, RN, an attorney who has represented nurses in disciplinary hearings before the Connecticut Board of Nursing for many years. All but a handful of states have them. Through an intervention program, nurses sign contracts that specify they will undergo rehabilitation, therapy, and frequent drug testing, and attend 12-step programs.

    If nurses have been involved in diverting drugs, Pellett said, their employers have an obligation to report this to drug control authorities and the state BON. Nurses should seriously consider legal representation if formal action is being brought against them, especially in cases of serious diversion or drug dilution.

    A nurse's license may be temporarily suspended until he or she demonstrates progress in recovery, Pellett said. A number of medical facilities have supervisory programs that allow recovering nurses to return to duty. Recovering nurses, however, will not have access to narcotics and must be constantly supervised by other nurses until their licenses are fully restored, which can take months or years depending on the nurse's situation and the state BON's procedures.

    While nurses can retain or recover their licenses, Pellett observed that most nurses underestimate the amount of time that the rehabilitation and supervision process requires.

    Pellett and others in the drug addiction field view substance abuse as an occupational hazard for licensed healthcare workers. The general population doesn't have constant access to drugs as nurses, doctors, pharmacists, and others do.

    "When healthcare professionals deal with other hazardous substances, such as biohazards, radioactive materials, or toxic waste, we find ways to protect these people," Pellett said. "We should view drugs in the same way."








    HOW TO RECOGNIZE AN IMPAIRED COLLEAGUE

    SITUATION ONE: You dread going to work because the nurse on the previous shift often leaves you with incomplete charts and patients complaining about pain. No wonder he's worked at three different hospitals in five years.

    SITUATION TWO: A nurse on your shift has become moody, takes frequent bathroom breaks, and no longer wants to socialize with colleagues. She's often late for work, and her once-neat handwriting has become sloppy.

    SITUATION THREE: She's the best nurse on the floor. Patients, hospital administration, and physicians love her. She often volunteers to work extra shifts and prefers acute-care units where drugs are frequently administered.

    You have just noted behaviors of colleagues whose nursing practice could be impaired by drugs or alcohol.

    Following are some signs indicating that a colleague may be impaired, according to Linda Barile, BSN, MN, PhD, a program director of HAVEN, a confidential program for licensed healthcare professionals with drug addiction and mental health problems in Connecticut:

    » Changes jobs frequently

    » Prefers night or off-shifts where there is less supervision and more access to medication

    » Pinpoint pupils or glassy-eyed

    » Smells of alcohol or makes excessive use of breath mints and mouthwash

    » Falls asleep during meetings or has trouble focusing on work

    » History of chronic pain from an injury or recently had surgery

    » Good relationships with doctors who may prescribe medication for them

    » Significant family problems

    » Often volunteers to administer narcotics to patients

    » Patients may complain of inadequate pain relief

    » Incomplete charting and practice errors

    » Anxious to work overtime or extra shifts

    » Can be moody or isolated, lethargic or high-strung

    Barile estimates that 90% of the nurses she sees in her work at HAVEN come into the program with chronic pain. All too often, she said, addiction is a risk for nurses who take medication in the longer term so they can deal with chronic pain, or they may have other comorbidities, such as mental illness.

    Anyone is at risk of addiction, no matter whether he or she is young or older, an LPN or RN, or has a master's degree or PhD, Barile said. "First the person takes the drug, and then the drug takes the person."








    What are nurses' attitudes about addiction in their ranks?

    Ultimatenurse.com, an information and discussion forum for nurses, invited RN to conduct an online survey of its registered members to find out. The 10-question survey, posted Feb. 18-20, 2009, netted 313 responses. Here are the questions and a summary of answers:

    1) HAVE YOU EVER WORKED WITH NURSES YOU FELT WERE ADDICTED TO DRUGS?

    Fifty-nine respondents said they had worked or are working with nurses impaired by drug addiction. Several nurses said they had supervised other nurses who had returned to work following treatment for addiction. Eighty-eight said they were certain they never worked with drug or alcohol-addicted nurses. Others were not certain, given the strict privacy policies at their facilities. Some commented that keeping addiction problems private was challenging when nurses would return from a leave of absence, were supervised by others, and no longer had access to narcotics. "Once that happened, entire shifts would know," one respondent said.

    2) HAS PATIENT CARE BEEN AFFECTED BY NURSES WITH DRUG-ADDICTION PROBLEMS AT YOUR FACILITY?

    A total of 76 said drug-addicted nurses had hurt patient care at their facilities by diverting pain medications, failing to recognize changes in patient assessments, and making medication errors.

    3) HOW GOOD ARE EMPLOYEE-ASSISTANCE PROGRAMS (EAPS), PEER-SUPPORT, AND REHABILITATION SYSTEMS AT YOUR FACILITY TO HELP DRUG-ADDICTED NURSES RECOVER?

    Most said they had no personal knowledge of these support systems. However, 39 reported good-to-excellent EAPs, peer-counseling, and rehabilitation resources. One remarked, "If the nurse realizes there is a problem and goes to the nursing supervisor, there is a lot of support." A total of 56 rated their programs and support of drug-addicted nurses as fair, poor, or nonexistent. "I had to look for help and support outside the facility," said one respondent. Nurses in such facilities tended to report that nurses with addiction problems were fired. One commented, "My employer at the time of my active addiction chose to fire me, thus saying it was no longer their problem." Some said that because of the stigma of drug abuse and fear of losing their licenses, they left their jobs before employers found out about their addiction. One noted, "I quit before I found out about the EAP and peer-support program. I was so scared. I went into rehabilitation on my own."

    4) HAVE YOU EVER BEEN ADDICTED TO DRUGS?

    Twenty survey participants reported problems with addiction. Most of these said they have been in recovery for years and successfully returned to full practice. One chose to practice nursing in areas where narcotics are not administered. Another works in a drug-rehabilitation facility. However, one respondent gave up nursing for fear of relapse.

    5) DO YOU HAVE RECOVERED NURSES AT YOUR FACILITY?

    Most respondents said they didn't know of any. Others have worked with several nurses who were supervised during their recovery and are now "doing fine." A few reported that they worked with nurses in recovery who relapsed and ultimately lost their licenses. One nurse said she worked with a colleague almost a decade ago who was heavily supervised and restricted from dispensing narcotics: "Some nurses were supportive, but others were rude and agitated at the prospect of having to pass controlled substances for that nurse. The verbalization was 'She shouldn't be here if she can't do her full job.'"

    6) WHAT CAUSES NURSES TO BECOME ADDICTED TO DRUGS, IN YOUR VIEW?

    The overwhelming response was "stress"—from work and family responsibilities, coupled with a predisposition toward addiction and availability of drugs at work. One nurse commented that many nurses are the "big breadwinners, adding stress to an already stressful career." Another said some nurses have come back to work following injury or surgery, still in pain and on medication. That plus working in a high-stress environment with the controlled substances available "sets nurses up for addiction." A third felt that every profession, not just nursing, comes with its own set of stressors: "Drug use provides an 'escape' from reality," and is easier than doing the "difficult internal work of developing safer and more appropriate coping skills."

    7) DO YOU FEEL THAT OTHER STAFF MEMBERS—SUCH AS PHYSICIANS, FOR INSTANCE—WHO ARE ADDICTED TO DRUGS GET TREATED DIFFERENTLY FROM NURSES?

    This question got a spirited response, with many nurses reflecting a comment from one participant who said, "Doctors generate a lot of money for hospitals. Indeed, they are treated differently." Some nurses felt that doctors tended to cover for one another and have the financial resources to obtain better treatment for addiction. Other nurses said they did not know or felt that treatment was fairly equal among all hospital staff.

    8) WHAT KEEPS NURSES FROM SELF-REPORTING IF THEY ARE ADDICTED TO DRUGS?

    The overwhelming response was "fear": of job loss, losing one's license and livelihood, losing respect of peers, family, and friends, and lifelong stigma. A few others cited "denial." They said the addiction process prevents nurses from knowing they have a problem. One commented, "Nurses are human. Most individuals don't self-report drug addiction until they reach rock bottom or are caught."

    9) DO YOU BELIEVE THE INCIDENCE OF DRUG ADDICTION AMONG NURSES IS GROWING?

    Responses were mixed. One participant who has been a nurse since the 1960s said, "I work with the same percentage of addicted nurses now that I have always worked with." Another nurse felt that addiction problems will continue to grow: "There is a reason there is a nursing shortage. It's a very, very difficult and taxing job. You need a lot of personal resources and support to do it well and to remain whole." A few nurses said the advent of automated medication and supply-management systems has helped to reduce the incidence of drug addiction.

    10) DO YOU BELIEVE THAT YOUR FACILITY IS TOO SOFT OR TOO HARD ON NURSES WITH DRUG PROBLEMS?

    One nurse responded that facilities in general are too soft. "I believe that healthcare professionals are in a unique and privileged position to have access to narcotics. We should be fiercely protecting patients from healthcare professionals who are high on drugs, as they are impaired and cannot provide a high level of care." Others felt that state boards of nursing have become too punitive, without a balance of consequences and support. "I would make professional nurse support groups more easily accessible and mandatory for the duration of the consent agreement. I would mandate 12-step recovery meetings during and after mandated treatment. There would be a committee within the board to do case management on nurses needing supervision. The contract I signed ... included all this and more, and kept me compliant until I wanted to be, until I got past the shame and fear." Several felt that facilities were tough on those who were caught but often take too long to investigate nurses who are suspected of substance abuse. Some nurses were frustrated when reporting suspected drug-abuse problems. One was made to feel like a "troublemaker." Another was told, "We're working on it. We need more proof." Three respondents recommended random drug screens for all nurses to detect problems at an earlier stage, rather than singling out a certain nurse who is suspected of drug abuse, or waiting until patient care is compromised. One commented that nurses with drug-abuse problems should be treated "like human beings with an illness rather than as criminals. A little compassion, my friends. ... We have all stumbled and fallen short."








    MARY ANN B. COPP is a freelance writer based in Ridgewood, NJ.

    STAFF EDITOR: STEVE MULLETT