Nurses' substance use varies by specialty
Study results pave way for targeted education
Nurses who specialize in emergency care, critical care, oncology, and psychiatry are more likely to use substances such as marijuana, cocaine, or alcohol than nurses who work in occupational health, women's health, pediatrics, or general practice, suggesting that preventive initiatives can be targeted toward high-risk specialties.
Those results were reported in a recent study, which also noted that overall substance use is no greater among nurses than among the general population.1
The authors point out that substance use among nurses is a serious problem that threatens careers, as well as the quality of care delivered to patients. The American Nurses Association in Washington, DC, estimates that as many as 6% to 8% of nurses have a drug or alcohol addiction.2
However, the recent study measured substance use, not abuse, says lead author Alison M. Trinkoff, ScD, RN, an associate professor in the Department of Psychiatric, Community, and Adult Primary Care Nursing at the University of Maryland School of Nursing in Baltimore. It showed that 32% of 4,438 registered nurses who responded anonymously to an eight-page mailed survey had used marijuana, cocaine, or prescription-type drugs, or had engaged in binge drinking or smoking at least half a pack of cigarettes per day during the past year.
For study purposes, prescription-type drug use was defined as taking medication without a prescription or taking more than amounts prescribed. Binge drinking was defined as having five or more alcoholic drinks on one occasion.
Data lacking on predictors
"We have a fair amount of data in the literature on nurses who are in treatment [for addiction] and what those people look like, but we don't really have much on what we can notice early on in terms of predictors or factors we can associate with use that can ultimately become problem use," Trinkoff tells Hospital Employee Health.
The study does not indicate what portion of the 32% might have a substance abuse problem, but Trinkoff says she is examining those data from the survey for a subsequent report, and so far the numbers are "not excessive."
Predominant characteristics of survey respondents were: female, 96%; white, 94%; mean age, 44.3 years; married, 74%; never been married, 9%; bachelor's degree or higher, 47%; residing in rural area, 30%; employed, 89%.
The most common specialty was medical/ surgical (17%), followed by home/community/ public health (12%) and adult critical care (11%).
Oncology and critical care nurses were younger, with a mean age of 39 years, while those in gerontology, general practice/school/occupational, and administration were older, with a mean age of 50 years.
For purposes of comparison, a sub-group of 702 nurses was designated as a reference category. It was composed of specialties with the lowest substance use rates: women's health, general practice/school/occupational, and general pediatrics.
Of the 32% of nurses who reported substance use during the past year, 4% had used marijuana or cocaine and 7% had used prescription-type drugs (such as amphetamines, opiates, sedatives/hypnotics, or tranquilizers). Binge drinking was reported by 16% and cigarette smoking by 14%.
Rates varied greatly by specialty. For all substances combined, oncology nurses reported the highest past-year prevalence (42%), followed by psychiatry (40%) and emergency and adult critical care (both 38%).
For marijuana/cocaine use, emergency and pediatric critical care nurses had the highest rates (7%), followed by adult critical care nurses (6%). The reference group rate was 2%.
Prescription-type drug use was less varied across specialties, with oncology (9%), rehabilitation (9%), and psychiatry (8%) reporting the highest rates, compared with 5% in the reference category.
Binge drinking was highest among oncology (26%), emergency (25%), and adult critical care (22%) nurses. The reference group rate was 11%.
The highest rates of cigarette-smoking were reported in the specialties of psychiatry (23%), gerontology (18%), and emergency (18%). Lowest smoking rates were reported by pediatric critical care nurses (8%), an even lower rate than the reference group's 10%.
Trinkoff says the numbers probably are underreported due to the nature of the study.
"It's a touchy subject," she says. "We had anonymity, but it may not be enough to reassure everyone. In general, when you do these kinds of studies with a sensitive topic, you have to figure that you're getting an underreport."
Nevertheless, the data from this and an earlier study comparing nurses' substance use to that of the general population showed nurses' rates were no higher.3 The new study takes the rate analysis a step farther by comparing specialties. The researchers hypothesized that rates might differ because nurses' work varies across the specialties, and that occupational exposure to drugs varies, as well.
"It doesn't necessarily mean that people would be using drugs from the workplace, but it just might mean that if you're using a lot of drugs to help people, you might get a little bit of a comfort with it. You might be very familiar with different drugs and how they work, so maybe it would eliminate a barrier that some people in the general population would have when it comes to using these things on their own. Access is a definite risk factor," Trinkoff explains.
The study suggests that substance use is not randomly distributed across nursing. Factors such as stress, working conditions, and access to drugs might create a higher likelihood of use among health professionals in certain specialties. Other predisposing factors might relate to personality traits of people who enter certain specialties. For example, studies have shown that emergency or critical care personnel are more likely to be "sensation-seekers" who crave crisis exposures.4,5
Physician data show connection
The model for the hypothetical connection between specialty and substance use comes from data regarding physicians, Trinkoff notes. Recreational marijuana use has been linked to sensation-seeking among physicians.6 Several studies demonstrate a high rate of substance use among emergency physicians7 and psychiatrists.6-9 Low rates have been shown for pediatrics7 and community medicine.8
Also from a psychological perspective, those who enter a helping profession might do so because of certain "unmet needs," she suggests, which could lead to substance use, as well.
"There's so much agreement from the physicians to the nurses that it suggests these are health profession issues - issues for people working in health care - and not a unique nurse phenomenon," she says.
Noting that the lower drug-use specialties were school and occupational health, women's health, and general pediatrics, she says those specialties may not be lower stress, but might involve needs that are less critical, and might require the use of less drugs in practice.
While specialty-related stress could be a factor, "I don't know if any one specialty gets the prize when it comes to stress other than to say that to some extent, it depends on the fit of the person with what's expected of them," says Trinkoff. "In some specialties there is a lot of death and dying, and some people are comfortable with helping people in those circumstances. If not, they're probably going to have a problem if they work in that specialty. From an occupational health perspective, it has to do with the fit of the person to the [work] environment."
An advantage of identifying at-risk specialties is creating the opportunity to focus interventions, "assuming that most [health care institutions] don't have unlimited budgets and resources," she says. "From an epidemiologic perspective, you look for the groups that may have some risk instead of just targeting everybody."
Nursing is a difficult job, she points out, and it's not getting any easier under a spreading managed care system. (See related story, below right.) In many states, nurses who turn to substance use often are not treated as well as physicians, who generally have better peer-referral networks for treatment and re-entry into the profession.
"Nurses in some states are actually treated punitively, even sent to jail," she says. "I'd like to see the rehabilitative public health disease model used as opposed to the slapping-the-handcuffs-on-her type of thing."
By finding the areas where problems might be concentrated, occupational health practitioners, employee assistance counselors, and others can be "clued in," she adds, and possibly made more aware of how to intervene and use peer-assistance models in nursing.
"That's probably the way to go," Trinkoff states. "If someone is sent to jail, they lose their career, their [health insurance] coverage so they can't be treated, and there are even stories about nurses who have become homeless and gone on welfare after they've been detected."
Every hospital should have employee assistance program policies that go into effect when a nurse is detected with a drug or alcohol problem, she advises. Treatment works well in the nursing population because nurses are highly motivated to retain their licenses and professional credentials.
Early detection is important, "before it gets to the point where somebody passes out on the floor with a needle in her arm," she says. When nurses know something constructive will be done for colleagues suspected of substance abuse, they will be more likely to report it.
"Nobody wants to think they will be responsible for getting someone fired. When constructive policies are in place, it's best for everyone," Trinkoff states. "The earlier this is dealt with in a person's life, the better the outcome."
References
1. Trinkoff AM, Storr CL. Substance use among nurses: Differences between specialties. Am J Public Health 1998; 88:581-585.
2. American Nurses Association. Addictions and Psychological Dysfunctions in Nursing. Kansas City, MO: ANA; 1984.
3. Trinkoff AM, Eaton WW, Anthony JC. The prevalence of substance abuse among registered nurses. Nurs Res 1991; 40:172-175.
4. Zuckerman M. Sensation Seeking: Beyond the Optimal Level of Arousal. Hillsdale, NJ: Lawrence Erlbaum; 1979.
5. Hafner RJ, Proctor N. Student nurses' specialty choice: The influence of personality and education. Contemp Nurse 1993; 2:38-43.
6. McAuliffe WE, Rohman M, Santangelo S, et al. Psychoactive drug use among practicing physicians and medical students. N Engl J Med 1986; 315:805-810.
7. Hughes PH, Baldwin DC, Sheehan D, et al. Resident physician substance use by specialty. Am J Psychiatry 1992; 149:1,348-1,354.
8. Myers T, Weiss E. Substance use by interns and residents: An analysis by personal, social, and professional differences. Br J Addict 1987; 82:1,091-1,099.
9. Domenighetti G, Tomamichel M, Gutzwiller F, et al. Psychoactive drug use among medical doctors is higher than in the general population. Soc Sci Med 1991; 33:269-274.
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