Focused on their high calling to protect patients from cross-transmission and full-blown outbreaks, infection preventionists may find it difficult to muster compassion for those who willfully endanger their frail charges by stealing the very medicine needed to comfort them.
Healthcare workers who divert drugs are understandably reviled for potentially harming patients by depriving them of pain relief and putting them at risk of infections from tampered medications. A seemingly endless series of outbreaks of bloodborne infections bear start witness to this all too common trend in healthcare. But somewhere beneath the distortions of addiction and denial, shame and stigma, is a person who once sought to care for others.
People like John Furman, PhD, MSN, CIC, COHN-S, director of Washington Health Professional Services (WHPS) in Olympia, are now trying to care for them, and if possible, restore them as healthcare workers empowered again to help others.
“I don’t want to make a direct analogy, but it can be said that to some degree that Washington state looks at substance abuse disorder as chronic relapsing disorder much the same as asthma and diabetes,” Furman says. “Now it’s not exactly the same -- I’m not trying to pull the wool over anybody’s eyes -- but the point is that all healthcare professionals should have the right to have their legitimate medical condition [treated]. And if it can be managed successfully they should have the right to reenter the workforce and continue their profession just as anyone else would.”
That said, there are public safety issues to be strongly considered, and if a nurse referred to the WHPS cannot make the necessary changes or further acts to endanger patients the state nursing commission may revoke their license.
“In many cases they can return to practice, that can be accomplished, but in some cases it can’t and they do end up losing their license,” Furman says.
WHPS is the state alternative to a discipline substance abuse monitoring program for nurses with substance use disorders, again seen as medical conditions driven by biological traits that can change over time. Though opioids may certainly be the drug abused, the situation with nurses is not simply an extension of the national opioid epidemic that has become a public health crisis. Despite the recent focus on the opioid epidemic, the number of substance abusing health care workers remains in the same general range as it has for years.
“I don’t see a big difference with regard to the numbers and rates of HCWs with substance use disorders or the circumstances surrounding their initiation and continued use all the way up to diversion,’ says Furman, a 35-year veteran in the field. “I think the numbers and research has stayed fairly steady over the years. Depending on the research you look at about 10% to 15% of the general population with some level of substance abuse disorder and that’s mirrored in the healthcare professional profession -- with healthcare workers having a higher rate of prescription drug abuse than the general population. With the opioid epidemic that gap may be narrowing a little bit.”
As infection preventionists are well aware, nurses can suffer injuries moving patients and endure chronic pain thereafter.
“We have many nurses in our program -- and it is my experience with other states’ programs that are fairly similar --with chronic pain issues that have a great deal to do with their substance use disorders,” he says. “[These include] nurses who have hurt themselves on the job and have been mismanaged by their healthcare provider with regard to their pain issues or possibly by their employer with regard to bringing them back on duty prematurely and not providing appropriate oversight and support. That really contributes to their [drug] behavior if a nurse who doesn’t have sufficient leave time because of that comes back prematurely from an injury.
The Malleable Brain
Thus, the occupational hazards of healthcare work can lead to substance use for pain, which may cross over into abuse if addiction sets in through a process called neuroplasticity.
“The brain is malleable and changes in response to different stimuli whether they are internal or external,” he says. “It is also important to realize that at one point medical science thought our brain was set in concrete by late adolescence or early adulthood. Now we know that our brain changes all the time throughout our lifespan. When an individual is exposed to something – drugs, alcohol, opioids, – the brain changes in response to that exposure and becomes an addicted or chemically dependent brain. By removing that exposure and also having psychotherapy as part of treatment then the brain is able to change and reset back to its original state.”
Common drugs used or diverted by healthcare workers include hydrocodone, morphine, oxycodone, fentanyl, Ambien, Xanax, valium and Ritalin, Furman says. Common diversion methods include medication substitution, removal of medication without orders, frequent medication overrides, giving less than high-end ordered and diverting the waste, signature/order falsification and savaging from waste, he notes.
“In Washington state right now the average age of nurse is about 48 years,” he says. “So they are getting older and they are more prone to musculoskeletal injuries and other injuries that may result in chronic pain issues. It is a significant issue.”
The majority of nurses come into the WHPS program after a complaint has been filed against their license for substance misuse. It may be personal misuse or it may involve drug diversion at their workplace, but the vast majority are referred by the state nurse commission, he says.
“However, we do have an alternative discipline tract that most nurses take to enroll in the program,” Furman says. “So even though a complaint’s been filed – and the rule of thumb is that no patient harm has occurred as a result of the behavior – they are allowed the option to come into the program in lieu of discipline. That means there is no formal action taken against their license and the fact that they are in the program is non-public in nature. This is never reflected as part of a public document.”
In Washington and many other states, you can look up a nurse’s name and see if they have had any discipline taken against their license. If so, it will be noted in the public record and include some details of the incident. The alternative track at WHPS can spare a nurse this public disclosure and the attendant stigma.
“Our mandate from the legislature is two-fold,” he says. “One is they have directed the state Department of Health, which licenses healthcare providers, to provide an alternative to the traditional disciplinary process for health professionals with substance abuse disorders. The second part of that mandate is that we are to make every effort to safely allow nurses to continue or return to practice. The legislature looks at health care workers in total as a state resource. If there is something that can be done to retain that resource – something that can be reasonably and safely done – they want that to be explored.”
Conditions vary from state to state, and in some cases relapse means automatic license revocation. In the WHPS program, nurses that do overcome their addiction and return to the workforce are subject to random drug tests, ordered to attend counseling or a support group, and have a series of work conditions that can include:
- Worksite restrictions, e.g., no home health work.
- Will not have multiple employers
- Limits on overtime and shift rotation.
- Will not float from unit to unit.
- No access to controlled substances for at least 12 months
Returning to Work
“In Washington, our graduation rate – the number of nurses who graduate from our program – is about 65% to 70%,” he says. “We feel pretty good about that and also the nurses are in the program for a minimum of five years. The standard throughout the nation is at least three to five years.” Nurses in the program must call in or check in via a computer every work day.
“If they are selected to take a drug test that day they must submit a sample that calendar day,” Furman says. “Test results may result in sanctions on their license.”
Though admitting it sounds counterintuitive given medicine is their profession, Furman says the lack of education about drugs and addiction is still a major contributor to the problem.
“There is very little direct education in nursing schools with regard to substance abuse, especially addressing the risk to health professionals,” he says. “Some states have enacted legislation that requires a certain number of hours or at least to some degree [education] as part of the nursing curriculum. But that is in very few states and it needs to be much broader. Then in the healthcare facility itself they should have clear policies and procedures on substance abuse. Those should not sit on a shelf. They need to be part of new orientation and revisited as part of mandatory ongoing training on a routine scheduled basis.”