I saw this, and had to post it. To those who participated in the poll, thank you! Drug addiction among nurses: Confronting a quiet epidemic - Many RNs fall prey to this hidden, potentially deadly disease. - RNweb


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'smodel 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."