Chemical Dependency Drug Diversion in Nursing Presented by
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 Dependency Definition: : 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. merriamwebster. com/dictionary/addiction
Drug Diversion Definition: “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 Rights High 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 Chemical Dependency Causes: Unmet needs Threats to personal/social identity Stress Burnout Socioeconomic factors Comorbid physical/mental problems Chronic 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. 0 b 013 e 3182872901 • 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 21 st Century. International Journal of Mental Health & Addiction, 7(4), 530 -540. doi: 10. 1007/s 11469 -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. 0 b 013 e 31826 ba 3 ca • Wright, E. L. , Mc. Guiness, T. , Moneyham, L. D. , Schumacher, J. E. , Zwerling, A. , & Stullenbarger, N. E. (2012). Opioid abuse among nurse anesthetists and
References (cont. ) • Alligood, M. R. , & Tomey, A. M. (2010). Nursing theorists and their work (7 th 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/0010/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 rolemodeling: 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/
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