Special Feature
Detecting and Preventing Substance Abuse in Health Care Professionals
By Laura Palmer, RN, MNEd, CRNA, is Assistant Director of the Nurse Anesthesia Program, University of Pittsburgh School of Nursing.
By Leslie A. Hoffman, RN, PhD, is with the Department of Acute/Tertiary Care School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.
Laura Palmer and Leslie Hoffman report no financial relationship to this field of study.
Problems resulting from substance abuse can impact care provided in any health care setting, including the care of critically ill patients. Ideally, an impaired provider will be recognized early and assisted to accept treatment before patient care is compromised. Regardless of the circumstances, concerns about patient care must be the central focus of actions taken to remedy the problem. In addition, risks to the health care provider cannot be underestimated. When signs of impairment become more obvious, the problem is typically at an advanced stage. This essay will focus on recognition of substance abuse in health care professionals, intervention strategies, recovery and re-entry into practice. The focus will be on abuse of performance-altering chemicals, specifically controlled substances available in the workplace, street drugs, and alcohol.
Incidence
Chemical dependency is a leading occupational hazard for health care professionals.1 The actual number of impaired providers is difficult to estimate due to varying definitions of terms such as use, abuse, impairment, dependency, and addiction. Accurate estimates are further complicated by the probability that individuals using or abusing substances are unlikely to report this behavior. Therefore, the data reported likely under-represent the scope of the problem.
Chemical dependency in physicians is estimated to be similar to that of the general population (10-15%) with the predominant substance being alcohol.2 The specialties of anesthesia, psychiatry, and emergency medicine show the highest rates, with the lowest rates seen in obstetrics, pathology, pediatrics, and radiology.1 Anesthesiologists are over-represented in drug treatment programs and experience higher fatality rates, likely due to drugs typically abused, eg, parenteral opioids.3,4
The National Council of State Board of Nursing reports that 6-8% of nurses experience chemical dependency that affects job performance.5 Nurses with very easy access are the most likely to misuse prescription-type drugs.6 Thus, State Boards of Nursing report more disciplinary actions against nurse anesthetists. Critical care nurses have a higher incidence of prescription substance use.7 The hospital environment can be the first encounter, although use of recreational drugs prior to medical school is associated with continued use in the academic environment.8 Therefore, substance abuse education focused on prevention is advised for all clinicians.
Contributing Factors
Four theoretical models are commonly cited to explain addiction: Genetic/Biological, Disease, Psychological, and Familial.9 None of these models support the traditional assumption that a stressful work environment and easy access are the primary predispositions. The vast majority of physicians and nurses who work in stressful environments do not develop substance dependence and reaction to the environment is more important than stressful conditions.10 Factors that increase risk include long work hours, varying sleep patterns from shift work or call, critical decision-making, and demands from attempting to balance family and professional responsibilities. Risk is increased by a family history of substance use or mental illness. When linked with certain genetic predispositions, the risk of becoming addicted increases dramatically.11
Some suggest that critical care and emergency department nurses are more likely to have a "sensation-seeking" personality trait (impulsive gene).12 The work environment adds other factors that increase risk, including dealing with death, fast paced decision-making and easy access. There may be a propensity to "self diagnose" and "self treat" for pain, anxiety, and depression. This propensity is enhanced by considerable pharmacologic knowledge and commonplace administration of drugs to patients. Some theorize that constant exposure to the often pleasurable reaction of patients who receive opioids or sedatives causes practitioners to want to "see for themselves" the reactions patients experience.
Choice of drug is another factor. Addiction to fentanyl and sufentanil occurs significantly faster than to other narcotics or sedatives. Those who have abused these drugs report that the sensation achieved by the first injection cannot be obtained on subsequent attempts. The consequence is rapid tolerance and addiction that can lead to escalation in fentanyl dosage to 50-100 ml/day in a few months. Sufentanil addiction is markedly faster with addiction in a few weeks. Doses that would be fatal are tolerated by the addict and provide a feeling of "normal." Both drugs are commonly available in anesthesia and critical care, which correlates to the increased fatalities in these specialty groups.
Recognizing Substance Abuse in the Workplace
Warning signs have been recognized for years. Some examples of classic signs follow. It is important to recognize that although these behaviors should raise suspicion, they are not definitive. Despite the perceived ease of recognition, many signs are overlooked. Friends and fellow practitioners often enable impaired providers through denial because it is difficult to accept that a highly educated, highly skilled clinician could have a substance abuse problem. A chemically addicted colleague may perform adequately for quite some time. When more obvious signs of impairment appear, the problem is usually at an advanced stage and intervention must be swift. Death from substance abuse can have a profound effect on colleagues who feel responsible for not recognizing the problem or intervening earlier. In retrospect, evidence is usually present, but not linked to the problem. Usually it requires several individuals, each with a different observation, to make the diagnosis. Unfortunately, this realization may not be present until after a critical event.
Intervention Strategies
When there are suspicions of substance abuse, ethical obligations to protect patients and assist the provider should prevail. It is critical that every institution have an Impaired Provider Policy that clearly delineates steps to be followed. The suspected individual should not be confronted without the support of a team comprised of individuals who can offer support and treatment options. Most institutions employ staff specifically trained in these activities. Most professional associations have peer assistance hotlines that can also be invaluable resources.
Because the individual has gone to great lengths to conceal dependency, exposure may invoke denial, aggression, withdrawal, and suicidal thoughts. The focus should be on removing the worker from direct patient care and getting them into a treatment facility immediately. Forced resignation is not the answer as it allows the individual to seek employment at another facility, continue their substance abuse, or terminate their life.
Many states have regulations regarding mandatory reporting to licensure boards but this varies by state and profession. Diversion of controlled substances may require reporting to federal regulatory agencies. It is critical that all be aware of the laws of the state in which they practice. Most states provide immunity from civil suit for the reporter, especially if there is a mandatory requirement to report suspicious activity.
Effect on Licensure and Livelihood
There is no national standard for the management of substance abuse; consequently each state differs in licensure sanctions, treatment options, and re-entry provisions. The possibility of false accusation must be balanced by the risk that delay may result in overdose and death of the provider, or patient harm. The American Medical Association has classified addiction as a disease and there are programs in every state that operate within the parameters of state regulation and provide service to impaired physicians. State Boards of Nursing have established programs in 33 states, with some in development. Many focus on a disciplinary approach. Alternative approaches require the impaired provider to enter treatment and surrender their license during the rehabilitation program. In some states, re-entry into practice is dictated by contracts that specify responsibilities of the participant for a set period of time, commonly 3 years or more. Compliance results in the potential to return to work and clear one's license. Failure to comply involves disciplinary measures and can result in suspension or revocation of one's professional license. An employer is not required to provide re-entry and it may not be possible to acquire malpractice insurance.
Relapse
The treatment program should incorporate strategies of abstinence, recognition of "triggers," strengthening coping mechanisms, and acceptance of the disease. An estimated 70% of physicians return to medical practice following initial treatment. Data on relapse is unclear due to multiple factors.3 In a recent study of relapse of impaired physicians, 25% had one relapse and 58% of relapses occurred in the first 2 years of treatment, most while in a workplace monitoring program. The drug of relapse was the initial drug of choice in 85% of cases.3 The likelihood of relapse increases with each relapse. Risk of relapse is also increased in those who used a major opioid and had a coexisting psychiatric illness or family history of substance abuse. There are conflicting opinions regarding the wisdom of allowing a recovering substance abuser to practice in a setting with easy access to the drug of choice.
Conclusion
Substance abuse in health care professionals can have devastating personal and professional consequences, both to the individual and patients for whom they care. It is the ethical and legal responsibility of every health care provider to be aware of the signs of this disease and understand the need to assist these individuals to obtain treatment. As with most diseases, prevention is preferable to treatment. Ongoing educational programs should be in place to increase awareness of initiating factors, practice implications, and treatment modalities. When possible, the family should be involved since they can monitor and intervene at the earliest signs. Although impaired professionals may initially be defensive and resistant to discovery and treatment, they usually emerge from recovery grateful and may become the best resource and advocate for prevention in the workplace.
References
- Talbott GD, et al. The Medical Association of Georgia's Impaired Physicians Program. Review of the first 1000 physicians: analysis of specialty. JAMA. 1987; 257(21):2927-2930.
- Hughes PH, et al. Prevalence of substance use among US physicians. JAMA. 1992;267(17):2333-2339. Erratum in: JAMA 1992 Nov 11; 268(18):2518.
- Domino KB, et al. JAMA. 2005;293(12):1453-1460.
- Menk EJ et al. JAMA. 1990;263(22):3060-3062.
- https://www.ncsbn.org/chem_dep_handbook_ch4.pdf. Accessed January 24, 2007.
- Trinkoff AM, et al. Prescription-type drug misuse and workplace access among nurses. J Addict Dis. 1999;18(1):9-17.
- Trinkoff AM, et al. Relationship of specialty and access to substance use among registered nurses: an exploratory analysis. Drug Alcohol Depend. 1994; 36(3):215-219.
- Baldwin DC, et al. Substance use among senior medical students. A survey of 23 medical schools. JAMA. 1991; 265(16):2074-2078.
- Glantz M, et al. Vulnerability to Drug Abuse. Amer Psychological Assn. 1992.
- Jex SM, et al. Relations among stressors, strains, and substance use among resident physicians. International Journal of the Addictions. 1992; 27(8):979-994
- Foster S, et al. Professional Study and Resource Guide for the CRNA. Illinois: AANA Publishing, Inc. 2001.
- Benjamin J, et al. Population and familial association between the D4 dopamine receptor gene and measures of Novelty Seeking. Nature Genetics. 1996;12(1):81-84.
- Hughes TL, Smith LL. Is your colleague chemically dependent? American Journal of Nursing. 1994; 94(9):30-35.
- http://www.medbd.ca.gov/Pubs_Diversion.pdf Accessed January 24, 2007.
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