Drug Diversion in Nursing
Lindsey is a top performer on her Med Surg unit. Considered a clinical expert, she is bright and well-respected. Hardworking and helpful, she befriends everyone. Lindsey was recently voted Employee of the Month, and always receives glowing evaluations. She’s clearly in line for Charge Nurse.
Lindsey is also an addict and diverts drugs at every opportunity.
Most of us believe we would readily recognize an impaired colleague in our midst. Unfortunately, that is not true. This false belief means many of us are enablers to our substance abusing colleagues.
Profiling the Super Nurse
The Super Nurse is the most competent and least likely nurse to be suspected of having serious problems. She’s a high achiever with low self-esteem and poor coping skills. Her home life may be in chaos, but she hides behind a plastic, perfect facade of control.
The Super Nurse works extra shifts, and is willing to come in early or stay late. She volunteers to float, and to work weekends and holidays. Indicators of weak boundaries, these serve a secondary purpose of increased access to drugs as well as less supervision.
The Super Nurse manages two jobs. Her primary job is to divert drugs. Her secondary job is patient care. She is constantly preoccupied with obtaining and using drugs.
Lindsey keeps her eyes open for any fresh surgery admits, plotting how to gain access to them and their pain meds every two to four hours if they are not her own patients.
When discharging patients, Lindsey urges them to take pain meds “for the trip home” but instead gives them a look-alike, non-narcotic substitute and pockets the narcotic.
Volunteering to do admission interviews, Lindsey eagerly searches through bags of home meds, purses, and belongings, thrilled when she discovers a bottle half full of narcotics. She will find a way to keep her prize and not send the pills to Pharmacy.
Wasting a drug? Lindsey finds it extremely easy to divert the waste and still get a co-signature. Many busy nurses are fine with co-signing a narcotic waste they did not witness.
Lindsey regularly and thoughtfully encourages other nurses to take a break while she covers. She then uses that time and increased access to patients to offer prn pain meds, administering substitutes.
To Lindsey, patients are no longer people, but sources of drugs. Like all addicts, Lindsey lies, manipulates, and steals. Hence she has enormous denial, guilt and conflict. All of which spurs her drug use.
Later in her disease, Lindsey will begin to call off more and more frequently. When working, she will have “on the job absenteeism” in the form of long breaks and disappearances.
Addiction as a Disease
Are addicts weak and morally flawed? Or is addiction a medical condition for which there is treatment?
As nurses, our beliefs about addiction and addicts can interfere with the very spirit of nursing. Personal and emotional beliefs aside, we must educate ourselves. We can then conduct our practice as informed practitioners. Read Jake the Addict Patient
Drugs change the brain’s structure and how it functions.
“Drug addiction is a brain disease that can be treated.”
Nora D. Bolkow, M.D., Director, National Institute on Drug Abuse.
Addicts are not “bad” people who need judgement. They are sick people who need treatment.
The Diagnostic and Statistical Manual 5, (DSM-5), as well as the ICD-10 (International Classification of Disease, 10th Edition), lists substance abuse as a diagnosable, treatable and reimbursable condition.
The cardiac patient is not blamed for their illness, but the addict is frequently blamed and shamed.
Reward Pathways and Addiction
Mood altering drugs target the brain’s reward system by flooding the circuit with dopamine. The resulting euphoria teaches the abuser to repeat the behavior.
Mood altering drugs release 2-10 times the amount of dopamine than do natural rewards of food, water, and sex, and are addictive.
Addiction is a state in which the user engages in compulsive behavior, even when faced with negative consequences. Repeated attempts to quit are reliable indicators of addiction.
“It’s easy to stop smoking. I’ve done it a hundred times.”
Mark Twain 1835-1910
Over time, the drug abuser develops tolerance and no longer experiences pleasure. They then require larger amounts of drugs just to feel normal. It is no longer about feeling good, but about not feeling bad.
Reasons for Drug Diversion
Lindsey is addicted to drugs for several reasons. Normally socially uncomfortable, she loves the rush of feeling powerful, confident and assertive. At those times, she is overly social and engages in sporadic excessive talking.
Some users take drugs to enhance athletic or cognitive performance. Lindsey’s energy level and mood fluctuate throughout the day but when flagging, they can both be buoyed by drug use. She also enjoys the thrill of not getting caught and the associated risky behaviors.
Some nurses never use drugs themselves, but divert drugs to supply a demanding, addicted boyfriend, who may also be a drug dealer.
According to the American Nurses Association (ANA), nurses are uniquely at risk for many reasons:
- Access and exposure to mood altering drugs
- Tendency to self treat and self medicate both physical and emotional pain
- Belief in efficacy of pharmaceuticals in general
- Poor accountability in the work environment (policies/practices)
- Chemical dependency not addressed in school curriculum
Nurses as Enablers
Enabling is common among nurses, and enablers are required in order for the nurse addict to keep using.
Nurses are nice and loath to disrupt someone’s professional standing. The unspoken code of silence is strong. The bedside nurse believes that if something is really wrong, someone else will deal with it. Denial and avoidance are primary behaviors in enablers.
Caregivers to the core, coworkers protect and make excuses for the impaired nurse. “But she’s such a good nurse” or “She has back problems”. A nurse routinely nods off every time she sits down at the nurses station, and no one remarks on it. There must be some other explanation for her dilated pupils, or for her unusually high number of Omnicell overrides and wastes.
Another nurse disappears frequently, always needing to “get something out of my car”, or is frequently observed ducking in and out of the bathroom, rotating bathrooms to avoid notice. Coworkers pitch in and do the job for her.
Patients of the nurse addict report non-effective pain relief, but the following shift rationalizes that the patients are drug-seeking and to blame.
Even when suspicious, supervisors and coworkers believe that they must be able to prove drug use beyond a doubt before they say anything. This is not so. Concern means there is probable cause.
A recovering physician cautioned, “By the time you have suspicions, the disease is far advanced. A doctor will initially not “use” when on duty or on call, reserving drug use for recreation. If you see a doctor at work who is impaired, they have been using for a while”.
Likewise, by the time coworkers identify problems, the nurse addict is generally very ill. The goal of intervention is to make sure a problem is recognized before anyone is harmed.
Risk of Exposure
Risk of exposure ensures the drug user will not seek help. Nurse addicts live in fear and shame every waking minute. They are afraid of being exposed while convinced they are too clever to be caught.
They are terrified of:
- Bringing shame to their families. Often highly accomplished individuals within their families, they fear the inevitable humiliation exposure would bring
- Loss of licensure and gainful employment
- Loss of stature, respect and reputation
- Living without their drugs. Any threat of loss or separation from their substance of choice arouses anxiety
Impaired judgment caused from the disease itself prevents the impaired nurse from seeking help
Reporting as an Ethical Mandate
As nurses, our first and foremost responsibility is to our patients. Failure to report violates an ethical imperative, and jeopardizes public safety. Someone will get hurt. Meaningfully helping a drug-diverting nurse, thus preventing patient harm, means reporting to your employer.
Do not attempt to confront an abuser yourself. Document specific observations, including date, time and place. Notify your manager.
Knowing a co-worker is stealing drugs obligates the knower to report
Principles of Intervention
The foundation of substance intervention must be concern. When an individual is confronted with concern and compassion, it is generally accepted. Interventions must be well planned and conducted by nursing leadership according to hospital policy and in conjunction with Human Resources.
The new philosophy accorded the nurse addict and adopted by most Boards across the nation encourages intervention, advocacy, retention and re-entry into the workplace.
BON approved Drug Diversion Programs are an effective alternative to disciplinary action which would otherwise be taken against the nurse’s license. Participation is confidential and voluntary.
In other words, the record of the nurse who self reports and successfully participates in diversion programs will not be a matter of public record. The nurse has the ability to work the program and eventually return to work.
Lindsey ‘s best hope is that her addiction comes to light and she receives treatment. Left alone in her illness, she will make mistakes at work and eventually her patients will suffer.
Reporting enables the nurse addict to get help and return to safe practice. Be that concerned helper.
Until next time friend,