Substance Abuse and Nurses - the New Mexico Board of Nursing

Substance Abuse, Nurses and
the Diversion Program
Nancy Darbro, PhD, APRN, CNS
New Mexico
Diversion Program Coordinator

Introduction
• Theories of Addiction
• Disease concept
• Barriers to identification and intervention
• Impairment
• Prevalence
• Identification: signs and symptoms
• Risk factors
• DP monitoring, recovery and relapse

Theories of addictions (43 in 1980,
Letteri, Sayers & Parson, 1980)
• Psychoanalytic theory (inadequate,
dependent personality)
• Cognitive-behavioral theory (learned
behavior and conditioned responses)
• Interpersonal theory (social environment
of family and peer groups)
• Neurobiologic theory (brain biochemistry
leads to tolerance, craving =brain disease)

Multifactorial Model of Addiction
• Complexity of addiction supports a
multifactorial approach
• Inclusive vs. exclusive
• Research supports multiple causes
• Addiction is more than a personality
deficit, behavioral problem, genetic
disorder, family dysfunction or product of
culture. It is a combination of all of these.

Disease Concept of Addiction:
DSM IV Definition
• Abuse: any use of drugs that causes physical,
psychological, economic, legal or social harm to the
individual user or to others affected by the drug user’s
behavior.
• 1. recurrent substance use resulting in failure to fulfill
major role obligations at work, school or home
• 2. recurrent substance use in situations in which it is
physically hazardous, (driving, neglect of children,
providing care while impaired)
• 3. recurrent substance related legal problems ( arrests,
child support arrears)

Disease Concept of Addiction
• Substance Dependence: DSM IV
1. Tolerance
2. Withdrawal
3. Taken in larger amounts and over longer
period than intended
4. Persistent desire or unsuccessful efforts to cut
down or control use
5. Preoccupation in obtaining substance
6. Neglect of other activities
7. Continued use despite harmful consequences

Disease Concept of Addiction
1. Primary- genetic predisposition, brain
disease
2. Progressive- ongoing deterioration,
marked by early, middle and late stage
3. Chronic- relapsing medical condition
4. Fatal-accidental or medical complications

Primary
• Twin studies
• Family genetics
• Brain research-neurobiological changes
• Males of alcoholic fathers have
constitutional differences in effect of and
elimination of alcohol
• Genetic factors account for 40%-60% of
vulnerability to addiction (NIDA, 2007)

Progressive
• Review of Jellinik chart handout
• Applies to addictive process, not abuse
• Progressive deterioration
• Defense mechanisms are unconscious
• Lack of insight is perplexing to outsiders
• Physiological changes/brain changes due to
neurotransmitters and receptor sites
• Recovery is progressive too

Chronic
• Neurobiology of addiction
• Use for pleasurable effect (reward) or positive
reinforcement
• Continued seeking of pleasure/reward
• Sensitization or adaptation to reward (tolerance)
• Use to avoid adverse effects (withdrawal) or negative
reinforcement
• Rewarded behavior is reinforcing behavior (operant
conditioning)
• Changes in brain chemistry can be permanent
• Helps explain inability to reduce/control use and relapse
after abstinence (Koob & Le Moal, 2008)

Fatal
• History of physical/sexual abuse
• Increased morbidity-78% (Winick, 1992)
• Suicide attempts 4 times higher (Blume,
1998)
• Mortality rates 2-4 times higher (Lex,
1994)
• 4 out of 10 U.S. aids deaths are related to
drug abuse (NIDA,2007)

Barriers to Identification
• Stigma resulting from:
• 1. Moral model
• 2. “Addictive” personality model
• 3. “Us vs. them” model (family class,
socioeconomic, cultural)
• 4. Personality deficit model (narcissistic,
passive-dependent, impulsive, weak ego)

Stereotypes about addiction:
Alcoholics and addicts:
• Negative attitudes and behaviors lead to
resilience of the skid row stereotype
• Leads nurses to avoid detection at all
costs to avoid the stigma
• Leads nurses to avoid revealing their
recovery to avoid stigma as well
• (Chappel, 1992, Grover & Floyd, 1998).

Stereotypes about addiction:
Alcoholics and Addicts Are…….
1. Bums
2. Liars
3. Jerks
4. Lazy
5. Poor
6. Untrustworthy
7. Dirty
8. Selfish
9. Undependable

Stereotypes about health care
professional addicts and alcoholics..
1. Dangerous
2. Uncaring and careless
3. Unprofessional
4. Sloppy and unkempt
5. Unreliable
6. Poor practitioner
Stigma & Stereotypes = Denial & Resistance

Other Barriers to Recognition
• Conspiracy of silence, professional immunity
• Pharmacological optimism
• Caretaker mentality = “Malignant Denial”
• Self Diagnosis & Self Medication
• Identity shaped by career/licensure
• Lack of knowledge and education
• Underground culture of mistreatment

Problem of Addiction:
• Winick (1980) : Substance abuse will be high
in groups where there is…
1. Access to dependence producing substances
2. Freedom from negative proscriptions against
their use
3. Role strain or role deprivation
(Veterans, college students, musicians…..
physicians and nurses)

General risk factors
(SAMHSA, 1998)
• Family history of alcoholism
• Family history of criminality or antisocial
behavior
• Poor parental guidance or disicpline
• Parental use & positive attitudes towards
use
• Age of first use. Use before the age of 15
increases the likelihood of later addiction

Occupations with highest risk
for substance abuse share 8 work
related factors:
1. Availability of alcohol
2. Social pressure to drink
3. Working away from home
4. Freedom from supervision
5. Very low or high income
6. Collusion by colleagues to protect misuser
7. Occupational stress
8. Selection of predisposed people
(Simoneau & Bergeron, 2000).

Impairment
Inability to carry out professional duties and
responsibilities to acceptable standards
1. Impaired cognitive ability and memory
2. Altered motor skills
3. Difficulty making decisions
4. Diminished alertness
5. Poor judgment
6. Inability to cope with stressful events
7. Violations of NPA under unprofessional conduct
and incompetence

Impairment
• Nurses report that although they demonstrated
symptoms of impairment at work, these
symptoms were not addressed by colleagues
• Symptoms are often overlooked until they
become obvious
• Work is usually last place symptoms show up
• Most impaired nurses are not identified
• Most impaired nurses are not reported
(Frances & Miller, 1998).

Impairment and abuse are underreported
and overlooked
• The primary method for identifying impaired
nurses is coworkers
• 37% of nurses working with an impaired
colleague would not report them (Beckstead,
2002)
• Coworkers least likely to report impairment due
to alcohol (Beckstead, 2005)
• Most admissions into alternative programs come
via workplace complaints (NM DP annual report)

Impairment and abuse
• USA has a higher use of alcohol and drugs
than any other country (Winick, 1992)
• 15% of the world’s adults have serious
substance abuse problems (NIH, 1998)
• 2/3 of these adults abuse alcohol, 1/3
abuse other substances (NIH, 1998)
• 50% of automobile fatalities involve
alcohol impaired drivers (NIH, 1998)

Impairment and abuse
5 substances account for 96% of admissions
into treatment (SAMHSA, 2008)
1. 40% alcohol
2. 18% opiates, primarily heroin
3. 16% pot & hashish
4. 14% cocaine
5. 8% stimulates, primarily meth

Prevalence:
• Abuse and addiction difficult to distinguish
• Both can lead to impairment & are underreported,
under-researched & overlooked
• Alcohol use: 72%, disorders = 13.5%
• Drug use: 37%, disorders = 6.2%
(SAMHSA)
• Alcohol most commonly abused drug
• Marijuana second most commonly abused

Prevalence: Women (Blume, 1998,
Lex, 1994).
• Women drink and use drugs less than men
• Use prescription drugs more than men
• Have telescoping of symptoms: get sicker faster
with more virulent course of disease
• Start substance abuse later in life
• Abuse fewer substances, yet present with more
severe physical symptoms in treatment
• Seek help for physical complaints related to
abuse ie insomnia, nervousness, depression
• Often undetected by medical professionals

Prevalence : Women: cont.
• Triple Stigmatization (social stigma, moral
stigma, sexual stigma)
• Can date onset of abuse to a stressful life event
or loss
• Positive family history of addiction
• Early history of physical & sexual abuse
• Higher rates of co-morbid psychiatric dx, usually
depression and anxiety
• Higher rate of suicide attempts
• Higher rate of mortality

Prevalence: Nurses
• Previously thought to be higher in nurses
• Current research indicates similar to general
population: 8-20% (Storr, Trinkoff & Hughes,
2000).
• Nurses and doctors use prescription drugs and
alcohol at a higher rate
• Binge drinking elevated for psychiatric, critical
care and nurse administrators
• Highest in nurse anesthetists = 15%

Identification: signs &
symptoms cont.
• Missing drugs, interest in patients pain control,
and use of narcotics
• Frequent complaints of accidents & problems
• Slurred speech, shakiness, tremors
• Diaphoresis, runny nose
• Watery eyes, dilated/constricted pupils
• Carelessness about personal appearance
• Use of long sleeved clothing
• Appearance on unit on days off

Identification: signs &
symptoms
• Increasing isolation
• Frequent complaints of personal problems
• Mood swings, irritability, depression
• Frequent BR trips, unexplained absences
• Poor documentation, sloppy charting
• Episodes of poor judgment
• Elaborate excuses for being absent or tardy
• Frequent illnesses and changes to schedule

Risk Factors for Nurses
• Substance abuse is an “Occupational Hazard” for
nurses & doctors (Naegle, 1988).
• Professional reluctance to “see” abuse: direct
observations often ignored
• Avoidance of “addressing” abuse: transferred,
promoted, terminated
• Avoidance of “reporting” abuse: seen as work
performance issue, not unprofessional practice
• Resistance factors of professionals
• Malignant denial of professionals (Hankes &
Bissell, 1992).

Risk Factors: The Big 4
Attitude
• Substance use seen as acceptable means of
coping with life problems
• Developing faith in drugs to promote physiologic
& psychological healing (pharmacological
optimism)
• Sense of entitlement and rationalization
• Status of health care professionals as being
invulnerable to illnesses
• Permissive attitude toward self-diagnosing and
self prescribing
• Lack of education about addiction

Risk Factors: The Big 4
Attitude continued ….
• Familiarity and training in administration of
drugs leads to increased risk
• Rationales for self-medication: Fatigue, physical
ailments, loss of family relationships, quarrels,
insomnia, ambivalence
• Social norms favorably influence diversion
• Negative attitude & behavior toward substance
abusers leads to resilience of stigma &
avoidance of identification

Risk Factors: The Big 4
Access
• Lack of institutional controls in storing and
distributing narcotics
• Physician prescribing practices, easily obtained
hallway & other prescriptions
• Access and familiarity with drugs increases risk
• Administering drugs to others increases
willingness to self medicate
• Drugs are the “panacea” for ailments

Risk Factors: The big 4
Access continued ….
• Critical care areas with easy access have
increased risk, CCU, ICU, Oncology, ER
• Perceived availability, frequency of
administration & degree of control over
drugs equal increased risk
• Social drinking is sanctioned as a stress
reliever

Risk Factors: The Big 4
Stress
• Caring for need of the ill
• Frequent emergencies
• Responsibility for life and death situations
• Irregular and extended hours
• Frequent shift changes
• Staffing difficulties
• Work overload
• Nurses report greater on job stress than
physicians and pharmacists

Risk Factors: The big 4
Lack of Education
• Schools of nursing lack education on
addiction
• Employers do not support proactive
policies for addressing symptoms
• Employers do not implement identification
and intervention training for staff
• Stigma & Denial still stronger than
education and information

Summary of Risk Factors:
• Substance abuse is an “Occupational Hazard” for nurses
& doctors (Naegle, 1988).
• Professional reluctance to “see” abuse: direct
observations often ignored
• Avoidance of “addressing” abuse: nurses are transferred,
promoted, terminated
• Avoidance of “reporting” abuse: seen as work
performance issue, not unprofessional practice
• Nurses receive hasher sanctions (Shaw, et al,2004)
• “Malignant denial” of professionals (Hankes & Bissell,
1992).

Intervention: Worst thing is to
do nothing!
• Anyone can express a statement of concern
• Observation
• Documentation
• Use factual and objective data(date, time
incident)
• Report to supervisor/charge nurse & follow up
• Review and know your P & P
• With any violation of NPA, file a complaint

Intervention: What do I do
• Don’t ignore
• Don’t overlook
• Don’t excuse
• Do pay attention
• Do document
• Do report

Why alternative to discipline
programs
• 67-70% of disciplinary action for Boards of
Nursing are related to alcohol or substance
abuse (Smith & Hughes, 1996)
• 56% of complaints received New Mexico in 2007
• NCSBN and ANA both called for discipline
alternatives for nurses in the 1980’s
• Alternative programs were developed to offer
rehabilitation prior to discipline.
• Alternative programs bypass high costs of
investigation and disciplinary hearings

Assumptions of programs
• Reporting and identification of nurses with impaired
practice will increase if there is an alternative to
discipline option (Hood & Duphorne,1995)
• Eliminates loophole of impaired practice from complaint
until investigation and hearing
• Nurses are provided an opportunity for rehabilitation
prior to discipline.
• The public is protected via close supervision and
monitoring of practice
• Nurses who are non compliant will be identified,
reported and removed from practice quickly

3 general types of programs
#1: Alternative to discipline with statutory
authority under BON
#2: Peer assistance programs under state
nursing associations
#3: Discipline with consent order or
voluntary surrender of license

Need for regulation
• Health care is the largest industry
• Nurses are the largest group of health
care professionals
• Substance abuse is the #1 health care
problem across the population
• Substance dependency is the #1
preventable health problem

Purpose of Regulation
• Protection of the public
• Responsibility to monitor the profession
• Accountability for safe practices
• Development of best practices
• Responsibility for quality assurance of
education/practice

NM BON complaint process
• Nurses who have a complaint alleging use
and/or abuse of drugs/alcohol shall be
given an opportunity to be admitted to the
DP
• Nurses must submit written request for
admission into DP
• Nurses must admit to an addiction or
problem with substance abuse.

Mandatory compliance with DP
• DP nurses are monitored by written
records and face to face evaluations
• Violations of the DP contract are reported
to the Board of Nursing
• DP nurses break their own anonymity
when they violate conditions of contract
• Any disciplinary action resulting from
formal hearings is public

Monitoring: DP Requirements
• Five year contract
• Treatment for addiction
• Abstinence
• Admission of chemical dependency
• Regular, random drug screens
• Attend and verify support group meetings
• Regular, written self report
• Supervisor & Counselor reports
• Face to face evaluations quarterly
• Practice stipulations

Benefits of DP
• Opportunity for recovery in lieu of discipline
• Structure for recovery
• Support of peers
• Paper trail
• Maintenance of license and work
• Protection of public
• Non-public until violations reported to BON
• Education and awareness of IP
• Earlier ID, intervention, referral and reentry

Are alternative programs
successful
• Public protection from impaired practice
• Early identification/intervention/treatment
• Quick entry into recovery monitoring
• Cost savings of monitoring vs. discipline
• Intense scrutiny of compliance
• Early detection of relapse/noncompliance
• Ongoing monitoring through discipline/
or removal from practice
• Nurses report they are better nurses after treatment and
recovery (Darbro, 2005)

Why do individuals relapse
• Withdrawal/negative affect stage leads to:
• Chronic irritability
• Emotional pain
• Fatigue
• Depression/Mood swings
• Loss of motivation for natural rewards
• All contribute to craving and relapse

Relapse rates of chronic illnesses
(McLellan et al, 2000)
• Drug addiction: 40%-60%
• Type 1 diabetes: 30%-50%
• Hypertension 50%-70%
• Asthma 50%-70%
• Relapse is part of any chronic disease, but
most stigmatized in addictive disease

Relapse: Depends as much on
environment as anything
(Vaillant, 1998).
• Highest risk in the first two years
• Highest rate in first year
• 75% in general population
• 45% in health care professionals

Relapse: Slip vs Relapse
• Slip not seen as a treatment failure
• Brief time of use
• Immediate confession
• Discussion in group meetings
• Speaking to sponsor
• Reporting to caseworker
• Acceptance of consequences
• Can result in stronger recovery

Relapse: Slip vs Relapse
• Relapse is also not a treatment failure and
only seen as one in addiction recovery
• Consistent and continued use
• Refusal to admit symptoms and impact
• Disruption in personal and family support
• Refusal to join and use self help groups
• Negative impact on private, professional,
social and legal aspects of life

Risk factors for relapse in health
care professionals
• Use of major opioid
• Dual diagnosis
• Positive family history of substance abuse
(Domino, et al, 2005)
• Delay in entering alternative program
• Termination from job
• Lack of support (Tipton, 2005)

Recovery: A difficult, full time
job
• Is a process, not an event
• Like addiction, marked by stages of early, middle
and late
• Tasks of recovery
• 1. Recognition of addiction as life-threatening
disease
• 2. Ability to maintain abstinence
• 3. Develop a structure to provide social and
practical support to stay sober

Recovery: 6 markers (Valliant,
1998)
• 1. Occurs over the long term, years not months
• 2. Occurs in a community structure
• 3. Supported by compulsory supervision &
application of negative consequences related to
substance use
• 4. Supported by a substitute, positive
dependency to compete with use
• 5. Results from a guilt free and drug free social
network
• 6. Involves membership in an inspirational selfhelp
group

Recovery
• 85-90% of health care professionals who
get treatment have successful recovery
• Fewer than 10% of people and health
care professionals who need treatment for
substance abuse get it

Who is the impaired nurse
(Bissell & Jones, 1981).
• Graduated in top 1/3 of class
• Holds advanced degrees
• Has responsible, demanding position
• Greatly respected by peers and bosses
• High pressure & stressful jobs
• Often promoted
• Ambitious and achievement oriented
• One or both parents abused substances

Conclusions
• Drug addiction is a treatable brain disease
• Addiction is a developmental disease
• All drugs of abuse hijack the brain’s
reward system & change neurobiology
• Drugs are more addictive than natural
rewards
• Drug use is an epidemic
• Addiction need not be a life sentence

Conclusions
• Addiction is the single most disabling
condition for health care professionals
(Coombs, 1997;Talbott & Wright, 1987)
• Treatment and monitoring works (Ganley,
et al, 2005;NIDA, 1999)
• 80-90% of nurses are successful in
recovery (Graham & Schultz, 1998; Shaw,
et al, 2004)

QUESTIONS OR COMMENTS

CONTACT:
• www.bon.state.nm.us
• All forms can be downloaded from website
• nancy.darbro@state.nm.us
• DP direct line: 505-841-8345