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Chemical Dependency & Drug Diversion in Nursing

Presented by Nathan Buchinger, RN, CCRN

Objectives• To understand the prevalence of nurses who practice

while under the influence of drugs or alcohol• To understand the importance of reporting suspicious

behavior• To examine the efficacy of punitive and non-punitive

approaches to chemically dependency in health care• To examine theories and assumptions regarding nurses

and drug dependency• To understand what current evidence-based research

states about this issue

Chemical DependencyDefinition:

: A physical or psychological habituation to a mood- or mind-altering drug, such as alcohol or cocaine

*Chemical Dependency. (2007). The American Heritage Medical Dictionary. Retrieved from http://medical-dictionary.thefreedictionary.com/chemical+dependency

Addiction noun \ə-ˈdik-shən, a-\

: compulsive need for and use of a habit-forming substance (as heroin, nicotine, or alcohol) characterized by tolerance and by well-defined physiological symptoms upon withdrawal; broadly : persistent compulsive use of a substance known by the user to be harmful

*Addiction. (n.d.). Merriam-Webster’s online dictionary. Retrieved from http://www.merriam- webster.com/dictionary/addiction

Drug DiversionDefinition:

“The transfer of a prescription drug from a lawful to an unlawful channel of distribution or use” (Inciardi, Surratt, Lugo, & Cicero, 2007, p. 2).

“Theft, forgery, or alteration of prescriptions by health care workers” (Inciardi, Surratt, Lugo, & Cicero, 2007, p. 2).

Drug diversion is illegal!

Prevalence

Previous estimates: 1 in 5 nurses practice while impaired (Griffith, 1999)

Most current estimate: About 1 in 10 (Dunn, 2005)

Rate of drug addiction in the US: 1 in 10 (Dunn, 2005)

Relevance to Nursing

ANA Standards of Care

Standard 7: Ethics“Delivers care in a manner that preserves and protects healthcare consumer autonomy, dignity, rights, values and beliefs” (ANA, 2010, p. 47)

Standard 10: Quality of Practice“Demonstrates quality by documenting the application of the nursing process in a responsible, accountable, and ethical manner” (ANA, 2010, p. 52)

Standard 11: Communication“Conveys information to … others in communication formats that promote accuracy” (ANA, 2010, p. 54)

Standard 16: Environmental Health“Promotes a practice environment that reduces environmental health risks for workers and healthcare consumers” (ANA, 2010, p. 61)

Patient RightsHigh Quality Patient Care

“[Nurses] first priority is to provide you the care you need, when you need it, with skill, compassion, and respect” (AHA, 2003, p. 2)

A Clean and Safe Environment

“[Nurses] use special procedures to avoid mistakes in your care and keep you free from abuse and neglect” (AHA, 2003, p. 3)

Root Cause Analysis

Problem

Causes:

Chemical Dependency

Unmet needsThreats to personal/social identityStressBurnoutSocioeconomic factorsComorbid physical/mental problemsChronic Pain

Relevant Nursing Theories

• Erickson’s Modeling and Role Modeling Theory:• “All people want to be the best that they can possibly be;

unmet basic needs interfere with holistic growth whereas satisfied needs promote growth” (Erickson, Tomlin, & Swain, 2002, p. 56).

• “Object loss results in basic need deficits” (Erickson, Tomlin, & Swain, 2002, p. 88).

• Barker’s Tidal Model of Mental Health Recovery:• “People who experience any of the myriad threats to their

personal or social identities, commonly called mental illness or mental health problems, experience a human threat that renders them vulnerable” (Barker, 2003, p. 6-7).

Theories of Drug Use• Three Main Categories of Causation Theories:

• Biological: Innate physical mechanism• Genetic• Metabolic Imbalance

• Psychological: Compulsion & continued use• Positive/Negative Reinforcement• Pleasure seeking• Inadequate Personality Theory• Risk taking behaviorism

• Sociological: Individual within society

Commonly Abused Drugs

• Opioids• Vicodin• Percocet• Oxycontin• Morphine• Methadone• Fentanyl• Codeine• Dilaudid• Demerol

• Barbiturates• Amytal• Phenobarbital• Seconal

• Benzodiazepines• Ativan• Xanax• Librium• Valium• Halcion• Restoril

• Sleep Meds• Ambien• Sonata• Lunesta

• Amphetamines• Adderall• Dexedrine• Biphetamine

• Propofol

Signs of Impairment• Attendance

• Excessive call-ins & tardies

• Frequent trips to the restroom

• Long or frequent breaks• Early arrival or late

departure• Performance

• Assignments require more effort/time

• Absentmindedness• Carelessness• Complaints regarding

poor care• Behavior

• Poor hygiene• Mood swings/irritability• Poor recall

• Handling of Controlled Substances• Frequent med errors• Unwitnessed/Excessive

wastes• Frequents spills/drops• Patient complaints of not

receiving documented meds• Use of infrequent drugs

• Physical signs• Tremors• Nervousness• Alcohol odor• Slurred speech• Unsteady gait• Excessive use of breath

mints• Unusual fatigue• Blackouts

Roles in Reporting• Floor Nurses

• Know the signs• Ethical duty to report• Confront when patients are

at risk• Go to manager right away

• Charge Nurses• Same as floor nurses• Do not ignore• Do not lighten the

assignment• Do not accept excuses

• Nurse Managers• Same as above• Explain to nurse

observations made• Listen to their side in

private• Report to next in chain of

command• Document everything in

writing

• Administrators• Follow hospital protocol• Perform investigation• Gather all relevant data• Meet with the impaired

nurse, Human Resources, and nurse manager

• Apply corrective action• Report to State Board of

Nursing • Follow-up

Alternative-to-Discipline Programs

• Four Tenets of ATD Programs• Assistance is better than discipline• Self-regulation• Swift removal of impaired nurses

from work place• Workplace safety promotion

Reinstatement

Safety Recommendations

• Know the signs of impairment

• Know who to report to & what to report

• Truly witness wastes• Know your role• Only reinstate

compliant, rehabilitated nurses

• Random drug testing?

• QSEN Competencies• Patient-centered

care• Teamwork and

collaboration• Safety• Quality• Evidence-based

practice

For Further Study

“Good Medicine, Bad Behavior: Drug Diversion in America”

http://www.goodmedicinebadbehavior.org/explore/pain_management.html

References• Earley, P. H., & Finver, T. (2013). Addiction to propofol: A study of 22

treatment cases. Journal of Addiction Medicine, 7(3), 169-176. doi:10.1097/ADM.0b013e3182872901

• Inciardi, J. A., Surratt, H. L., Lugo, Y., & Cicero, T. J. (2007). The diversion of prescription opioid analgesics. Law Enforcement Executive Forum, 7(7), 1–14.

• Monroe, T., Pearson, F., & Kenaga, H. (2008). Procedures for handling cases of substance abuse among nurses: A comparison of disciplinary and alternative programs. Journal of Addictions Nursing, 19(3), 156-161. doi: 10.1080/10884600802306024

• Monroe, T., & Pearson, F. (2009). Treating nurses and student nurses with chemical dependency: Revising policy in the United States for the 21st Century. International Journal of Mental Health & Addiction, 7(4), 530-540. doi:10.1007/s11469-009-9208-2

• Monroe, T., & Kenaga, H. (2011). Don’t ask don’t tell: Substance abuse and addiction among nurses. Journal of Clinical Nursing, 20(3-4), 504-509. doi: 10.1111/j.1365-2702.2010.03518.x

• Monroe, T. B., Kenaga, H., Dietrich, M. S., Carter, M. A., & Cowan, R. L. (2013). The prevalence of employed nurses identified or enrolled in substance use monitoring programs. Nursing Research, 62(1), 10-15. doi: 10.1097/NNR.0b013e31826ba3ca

• Wright, E. L., McGuiness, T., Moneyham, L. D., Schumacher, J. E., Zwerling, A., & Stullenbarger, N. E. (2012). Opioid abuse among nurse anesthetists and anesthesiologists. AANA Journal, 80(2), 120-128.

References (cont.)• Alligood, M. R., & Tomey, A. M. (2010). Nursing theorists and

their work (7th ed.). Maryland Heights, MO: Mosby Elsevier.• American Hospital Association. (2003). The patient care

partnership: Understanding expectations, rights and responsibilities [PDF document]. Retrieved from http://www.aha.org/content/00-10/pcp_english_030730.pdf

• Barker, P. J. (2003). Psychiatric and mental health nursing: The craft of caring. London: Arnold.

• Erickson, H. C., Tomlin, E. M., & Swain, M. A. (2002). Modeling and role-modeling: A theory and paradigm for nursing. Cedar Park, TX: Est. Co.

• Manchikanti, L., Fellows, B., Ailinani, H., & Pampati, V. (2010). Therapeutic use, abuse, and nonmedical use of opioids: A ten-year perspective. Pain Physician, 13(5), 401-435.

• Manchikanti, L., Helm, S., Fellows, B., Janata, J. W., Pampati, V., Grider, J. S., & Boswell, M. V. (2012). Opioid epidemic in the United States. Pain Physician, 15(3), ES 9-38.

• Quality and Safety Education for Nurses Institute. (n.d.). Competencies. Retrieved from http://qsen.org/competencies/