1 SUBSTANCE USE DISORDER IN NURSING A Resource Manual and Guidelines for Alternative and Disciplinary Monitoring Programs
3 SUBSTANCE USE DISORDER INNURSING A Resource Manual and Guidelines for Alternative and Disciplinary Monitoring Programs
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5 CONTENTS Chapter 1 Introduction and Purpose 1 Purpose of the Manual Use of Terms Substance Use Disorder Committee Chapter 2 Substance Use, Abuse and Addiction 5 Etiology Neurobiology of Addiction Signs and Symptoms of Addiction in Nurses Stages of Addiction Role of Family and Support Systems Summary Chapter 3 Risks and Protective Factors for Nurses 13 Different Rates of Abuse between Specialties Gender and Substance Abuse Top Four Risk Factors Summary Chapter 4 Regulatory Management of Nurses with a Substance Use Disorder 25 State Nursing Practice Acts The Traditional Disciplinary Approach Challenges of the Disciplinary Approach Immediate Action The Non-Disciplinary Approach Contracts between the Board and Outside Monitoring Programs Qualifications for Contractors or Subcontractors Outreach and Education Shared Information, Communication and Data Reporting Audits and Evaluations Other Ways to Ensure Accountability
6 iv Board Assistance with Referrals to Alternative Programs and Community Resources Summary Chapter 5 Screening, Intervention and Referral to Treatment 41 Brief Interventions Summary Chapter 6 Substance Use Disorder in the Workplace 49 Developing a Culture of Transparency and Support Supportive Workplace Environment Lateral Violence and Stress Education in the Workplace Value of Proactive Policies and Procedures Prevention of Diversion Regular Monitoring as Prevention Internal Investigations Managing the Nurse with a Substance Use Disorder Identification of a Substance Use Disorder Identifying and Investigating Reports of Impaired Practice Documentation During a Workplace Intervention Action Plan Implementation Practical Tips Follow-Up Return to Practice Indicators of Relapse Reporting Nurses with a Substance Use Disorder Reporting Guidelines to Boards of Nursing Filing Complaints to the Board of Nursing Traditional Discipline and Alternative Programs Summary Chapter 7 Types of Programs 79 Models of Disciplinary Alternatives for Nurses with a Substance Use Disorder Alternative Program Models Disciplinary Models Policies and Procedures Information Available to the Board Advantages of the Alternative Program Controversies about Alternative Programs and Boards of Nursing Summary Chapter 8 Program Entry 93 Admission Criteria for Alternative Programs Screening and Assessment Guidelines Initial Intake Assessment Procedures for Admission into the Alternative Program
7 v Comprehensive Clinical Assessment Maintaining Current and Effective Treatment Referrals in the Community 99 Summary Chapter 9 Alternative to Discipline Program Participant Contracts 105 Initial Entry Requirements Mandatory Treatment and Recovery Monitoring Requirements Practice Requirements and Limitations Return to Work Program Notification Requirements Special Contracts and Provisions for Nurses Prescribed Potentially Addicting or Impairing Medications Special Contracts and Provisions for Psychiatric Monitoring Special Contracts and Provisions for Nurses with Chronic or Acute Pain Issues Completion of Alternative Program Criteria for Success for Nurse Participants Criteria for Success for Programs Criteria for Success for Employers Criteria for Success for the Public Chapter 10 Treatment and Continuing Care 117 Continuum-of-Care Model The Change Process and the Transtheoretical Model Elements and Stages Stages of Recovery Professional Support Groups Online Support Groups and Treatment Case Management Medication Management in the Treatment of a Substance Use Disorder Substance Use Disorder and Mental Health Disorders Recovery and Relapse Issues Summary Chapter 11 Return-to-Work Guidelines 133 Return-to-Work Contracts and Releases Qualifications for Supervisors and Work-Site Monitors Procedures for Receiving Updates from the Monitoring Program Return to School Rather than the Workplace Chapter 12 Monitoring and Compliance 139 Relapse and Program Noncompliance Drug and Alcohol Testing Drug Screening Compliance Issues and Recommendations Recommendations for Uniform and Standardized Review Submission of a Positive Drug Screen Failure to Submit a Drug Screen Refusal to Submit to Testing Submission of a Dilute Specimen
8 vi Submission of a Substituted or Adulterated Specimen Noncompliance with Employment Limitations or Restrictions Noncompliance with Treatment Requirements Criteria for Referral to the Board Termination Criteria Board Responsibilities Completion of Alternative Program Criteria for Success with Nurse Participants Summary Chapter 13 Drug Testing 149 Guiding Principles Terminology Key Parameters in Urine Drug Screening What Drugs Must Be Screened Drug Testing Thresholds (Cutoffs) The Challenge of Alcohol (Ethanol) Testing Ethyl Glucuronide (EtG) and Ethyl Sulfate (EtS) Comparison of Detection Times for Ethyl Glucuronide (EtG), Ethyl Sulfate (EtS) and Ethanol Evaluation of Alcohol Ingestion Hair Testing Description of Services for Drug Testing Service Providers DTSP Laboratory Results Summary Chapter 14 The Importance of Outreach and Education for Alternative Programs 163 Education and the Workplace Culture Transtheoretical Model CAGE Model Modes of Outreach Online Programs Special Educational Strategies Target Audiences Continuing Education Topics Online Educational Resources Strategic Planning for Outreach and Education Evaluation Summary Chapter 15 Special Population Guidelines 173 Chronic Pain Medication-Assisted Treatment Contract Guidelines for Chronic Pain and Other Mind-Altering Chemicals Older Populations Student Nurses Anesthesia Professionals Summary
9 vii Chapter 16 Alternative Program Evaluation 183 Evaluation Components Performance Measurement or Assessment Process or Implementation Evaluation Outcome or Impact Evaluation Cost-Effectiveness and Cost-Benefit Assessment Types of Evaluation Teams Checklist of Resources for an Appropriate Team Selection Internal Evaluations Finding and Hiring an Outside Evaluator Managing an Evaluation Headed by an Outside Evaluator Creating a Contract Expectations about Contacts between the Evaluator and Alternative Program Participant and Employer Evaluations Legislative Sunset Review Process Evaluation Constraints Reporting and Using Evaluation Results Writing a Final Report Evaluation Concerns Measuring Success Summary Chapter 17 Summary 197 Screening and Assessment Contracts Treatment Continuing Care Drug Screening Return to Work Outreach and Education Program Evaluation Accountability Conclusion Appendix A: Guidelines for Alternative Programs and Discipline Monitoring Programs Appendix B: Texas Board of Nursing Disciplinary Matrix Appendix C: Texas Board of Nursing Disciplinary Matrix Chart Appendix D: Pre-Workshop Assessment Appendix E: Alternative Program Continuing Education Overview Appendix F: Alternative Program and Host Facility Agreement to Provide Continuing Education Appendix G: Education Activity Summary Evaluation Appendix H: Definitions
10 viii Appendix I: Administrative Law Appendix J: Frequently Asked Questions Appendix K: Commonly Abused Drugs Appendix L: Prescription Drug Abuse Chart Appendix M: Facts about Prescription Drug Abuse
11 LIST OF TABLES Table 1: Models of Alternative Programs for Nurses with a Substance Use Disorder Table 2: Recommended Minimum Basic Panel (Urine)
13 LIST OF FIGURES Figure 1: Risk Factors for a Substance Use Disorder in Nursing
15 CHAPTER ONE INTRODUCTION AND PURPOSE The term, substance use disorder refers to the full range of complaints from abuse to a dependency or addiction to alcohol or drugs. The term addiction refers to the compulsive use of chemicals (drugs or alcohol) and the inability to stop using them despite all the problems caused by their use. A person with an addiction is unable to stop drinking or taking drugs despite serious health, economic, vocational, legal, spiritual and social consequences. A substance use disorder does not discriminate according to economic class, age, ethnic background, gender or any other labels. A substance use disorder is a progressive and chronic disease and if left untreated can be fatal. It is estimated that more than 22 million people in the U.S. abuse drugs or alcohol. Three million are classified with a dependence or abuse of both alcohol and illicit drugs while 4 million are dependent on or abuse illicit drugs but not alcohol and 15 million are dependent on or abuse alcohol but not illicit drugs (SAMHSA, 2008). Several million more adults engage in a form of risky drinking that could lead to alcohol problems. These patterns include both binge drinking and heavy drinking on a regular basis. In addition, 53 percent of men and women in the U.S. report that they believe one or more of their close relatives have a drinking problem (SAMHSA, 2008). The negative consequences of drug abuse and alcoholism affect not only individuals who abuse drugs but also their families and friends and various businesses and government resources. Although many of these effects cannot be quantified, the economic cost of drug abuse to taxpayers is a drain of nearly $534 billion each year from increased health care, lost productivity, premature deaths, crime and auto accidents related to alcohol and drug abuse (NIDA, 2007). More deaths, illnesses and disabilities result from substance abuse than any other preventable health condition (NIDA, 2007). The Office of Drug Control Policy (2004) estimated that in 2002 illegal drug use cost America close to $181 billion: $129 billion in lost productivity $16 billion in increased health care costs $36 billion in other costs such as efforts to stem the flow of drugs The American Nurses Association (ANA) estimates that six to eight percent of nurses use alcohol or drugs to an extent that is sufficient to impair professional performance.
16 2 Chapter One Others estimate that nurses generally misuse drugs and alcohol at nearly the same rate (10 to 15 percent) as the rest of the population. That means that if you work with 10 nurses, one of them is likely to be struggling with a substance use disorder. Although the rates of substance abuse and dependence are similar to those of the general population, and only a very small percentage is ever disciplined, the amount is still disturbing because nurses are the medical caregivers who are most often responsible for the health and well-being of the general population (Trinkoff & Storr, 1998). Only about one-third of one percent of all actively licensed nurses are sanctioned each year for their conduct (Kenward, 2008). However, the same system made it difficult for nurses to obtain treatment. The Substance Abuse and Mental Health Services Administration (SAMHSA) reported that only 14 percent of Americans addicted to alcohol and drugs actually seek treatment for their addictions (SAMHSA, 2008). But it was not until the 1970s and 1980s that addicted nurses were even offered treatment prior to disciplinary action (Torkelson, Anderson, & McDaniel, 1996). Although the condition, substance use disorder, was already considered a treatable disease by the American health care system, the disease concept was not widely extended to the addicted health care provider. Nurses and doctors were denied the same nonpunitive approach being offered to the patients they served. Many of these providers did not receive treatment until after they had been criminally charged. This mindset began to change when boards of nursing petitioned state legislatures to approve diversion legislation. The new legislation made it possible to offer treatment to addicted nurses without having a negative impact on their licenses as long as they continued to meet certain requirements. Forty-one states, the District of Columbia, and the Virgin Islands have since developed programs to channel nurses with a substance use disorder into treatment and recovery programs, monitor their return to work and prevent their licenses from being revoked or suspended. Purpose of the Manual The purpose of the Substance Use Disorder in Nursing manual is to provide practical and evidence-based guidelines (Appendix A) for evaluating, treating and managing nurses with a substance use disorder. The authors developed the guidelines by conducting an exhaustive review of the research literature on alcohol and drug abuse and surveying alternative to discipline programs to assess their current practices. The result is a comprehensive resource of the most current research and knowledge synthesized from both the literature and the field. While the manual was developed for alternative to discipline programs and boards of nursing in an effort to enhance program content and its delivery, it also provides essential theoretical and practical guidelines for clinicians, educators, policymakers and public health professionals. Information on prevention, detection and intervention of substance use disorder cases is presented. The manual also contains key research findings, guidelines and program recommendations and provides examples of model contracts, forms and reports. An extensive body of scientific evidence shows that approaching addictions as a treatable illness is extremely effective financially and across the broader societal impacts. When treatments for nurses are individually tailored to meet their needs and an appropriate supportive monitoring system is in place, then recovering nurses are not impaired and can practice safely. It is the hope of the National Council of State Boards of Nursing that this manual will be a helpful tool that can be used to implement better practices in helping the healers to heal themselves and at the same time helping to protect the public.
17 Introduction and Purpose 3 Use of Terms Throughout this manual the term substance use disorder is used more often instead of terms such as chemical dependency or addiction. The labels given to people with alcohol and drug problems can contribute to the stigmatization, de-medicalization and criminalization of those problems (White, 2007). For example, recent research found that when an individual was referred to as a substance abuser versus having a substance use disorder they were more likely to be thought of as personally culpable and therefore punitive rather than therapeutic measures could be taken (Kelly, Dow, & Westerhoff, 2009). In addition, substance use disorder represents the most current and accepted terminology used by experts in the field and the American Psychiatric Association s Diagnostic and Statistical Manual of Mental Disorders (2000). The term impaired is specifically not used because a person with a substance use disorder is not necessarily impaired; that is, always functioning poorly or incompetently. On the contrary, a nurse with a substance use disorder can be high-functioning and high-achieving. It s a myth that all alcoholics are skid row drunks and that all those with a substance use disorder are necessarily impaired. The last terms that need to be clarified are confidentiality and non-public. A confidential program means that all records regarding an individual participating in the alternative program are not shared with the board of nursing, employers, treatment providers, boards of nursing in other states or the public unless agreed to by the participant through the contract or signed consent to release information. Non-public is used in this manual to mean that all information including but not limited to reports, memoranda, statements, interviews or other documents either received or generated by the program shall remain privileged and confidential and participation in the alternative program is not disclosed to the public but is known by the board of nursing and can be required to be shared with employers, treatment providers and other state boards of nursing. Substance Use Disorder Committee Nancy Darbro, PhD, RN, CNS, LPCC, LADAC Joan K. Bainer, MN, RN, NE, BC Thomas A. Dilling, JD Karl A. Hoehn, JD Anjeanette Lindle, JD Kate Driscoll Malliarakis, MSM, RN, CNP, MAC Valerie Smith, MS, RN, FRE Carol Stanford Michael Van Doren, MSN, RN, CARN Kathy Thomas, MN, RN Kevin Kenward, PhD, MA
18 4 Chapter One References American Nurses Association (ANA). (1984). Addictions and psychological dysfunctions in nursing: The profession s response to the problem. Kansas City, MO: ANA. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Publishing, Inc. Kelly, J. F., Dow, S., & Westerhoff, C. (2009). Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. International Journal of Drug Policy, 21(3), National Institute on Drug Abuse (NIDA). (2007). Drug abuse prevention. A research update from the National Institute on Drug Abuse. Retrieved from prevention.html Office of National Drug Control Policy. (2004). The economic costs of drug abuse in the United States, (Publication No ). Washington, DC: Executive Office of the President. Substance Abuse and Mental Health Services Administration (SAMHSA). (2008). National household survey on drug abuse: Detailed tables. Rockville, MD: Office of Applied Statistics. Trinkoff, A. M., & Storr, C. L. (1998). Substance use among nurses: Differences between specialties. Journal of Addictions Nursing, 10(2), Torkelson, D. J., Anderson, R. A., & McDaniel, R. R. (1996). Interventions in response to chemically dependent nurses: Effect of context and interpretation. Research in Nursing and Health, 19(2), White, W. (2007). Language and recovery advocacy: Why we worry about the words. Recovery Rising: Quarterly Journal of the Faces and Voices of Recovery, 1, 3.
19 CHAPTER TWO SUBSTANCE USE, ABUSE AND ADDICTION In order to effectively deal with the abuse of substances among health care professionals it is first necessary to understand the components of addiction. The word addiction is often used as an umbrella term to describe a group of problems that can be broken out into drug addiction, alcoholism, substance use disorder and chemical dependence. All of these terms describe an addiction to brain-rewarding chemicals. Increasingly, addiction is also used to describe many pleasure-producing and compulsive behaviors. Members of Alcoholics Anonymous (AA), which is an international mutual-aid movement whose primary purpose is to stay sober and help other alcoholics achieve sobriety, call addiction a cunning, baffling and powerful disease. Etiology Drugs that are often abused are generally classified into different categories including: narcotics: opiates such as fentynal, hydromorphone, hydrocodone, oxycodone cannabinoids: marijuana depressants: ethanol, barbiturates, benzodiazipines stimulants: nicotine, amphetamines and cocaine hallucinogens: lysergic acid diethylamide or LSD and ecstasy inhalants: toluene and nitrous oxide hypnotic anesthetics: propofol or Diprivan These substances, along with alcohol, can produce a feeling of pleasure, relaxation or relieve negative feelings (Feltenstein & See, 2008). As the dependence or addiction progresses the benefits of using substances diminish and more drugs or alcohol are needed to feel the same level of pleasure. Vulnerability to drug addiction and alcoholism depends on the individual. Both are believed to have a genetic component that is influenced by environmental and social factors. The more risk factors a person has, the greater the chance that the use of alcohol and drugs will result in addiction. The National Institute of Drug Abuse estimates that genetic factors account for 40 to 60 percent of a person s vulnerability to addiction. The estimate includes the projected effects of environment on gene expression and function (NIDA, 2008).
20 6 Chapter Two Other factors that can lead to addiction include the age when drug or alcohol use begins and the route of administration. A human brain is more vulnerable during the developmental stages, which continues into adulthood. Therefore, using mind-altering substances in childhood or adolescence interferes with the normal development of brain function as well as other delicate systems. Using mind-altering substances through injection or inhalation has an even stronger and more immediate effect. The brain receives a significant and often deadly jolt of stimulation which alters the brain neurochemistry. However, ingestion will at least give the body time to metabolize the substance and lead to a somewhat mitigated influence on the central nervous system. For nurses, the long hours, extra shifts, staffing shortages and shift rotations pose a unique challenge. The ready availability of medications and issues with the administration of narcotics can be liabilities for some nurses as well. Overall risk factors, especially those that tend to make all individuals more susceptible to developing a substance use disorder have been divided into general categories. These include: Psychological factors: depression anxiety low self-esteem low tolerance for stress other mental health disorders (such as learning disabilities) feelings of desperation loss of control over circumstances in one s life feelings of resentment Behavioral factors: use of other substances aggressive behavior in childhood conduct disorder (such as anti-social personality disorder) avoidance of responsibilities impulsivity and risk-taking behavior alienation and rebelliousness (such as reckless behavior) school-based academic or behavioral problems (including dropping out, involvement with the criminal justice system or the first illegal use at an early age) peers using alcohol and drugs social or cultural norms acceptance of alcohol and drug use poor interpersonal relationships Social factors: condoning the use of drugs and alcohol expectations about the positive effects of the drugs and alcohol access to or an availability of drugs Demographic factors: male gender inner city or rural residence combined with a low socio-economic status lack of employment opportunities
21 Substance Use, Abuse and Addiction 7 Family factors: use of alcohol and drugs by parents, siblings or spouse a family dysfunction such as inconsistent discipline a lack of positive family rituals and routines poor parenting skills family trauma (such as a death or divorce) Genetic factors: inherited genetic predisposition to alcohol or drug dependence deficits in natural neurotransmitters such as serotonin an absence of aversive reactions such as flushing or palpitations (Sullivan & Fleming, 2008) Neurobiology of Addiction Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use despite harmful consequences (NIDA, 2008). People may use mind-altering substances initially because they feel good. Later, as the disease of addiction progresses they may use these substances again to feel normal or to attenuate negative symptoms of withdrawal and cravings. However, the desire to recreate the positive feelings is the primary factor behind drug dependence even though research has demonstrated that tolerance to a particular substance can develop, which requires a higher dose to achieve the same desired effect. Drug addiction is a brain disease that can be treated. Nora D. Volkow, M.D., Director, National Institute on Drug Abuse Mind-altering substances affect the limbic system, which is a primitive system related to arousal that is located deep within the brain and is often called the pleasure center. Impulses move from the middle of the brain (limbic system) to the forebrain (the thinking center of the brain) and back again, releasing neurochemicals that influence and modulate brain activity. Dopamine is a naturally occurring, mind-altering substance and one of the essential neurotransmitters in the brain whose higher levels produce the feeling of euphoria associated with other imbibed mind-altering substances. Addiction to mood-altering substances is thought to occur as a result of decreased GABA brain function (Volkow & Fowler, 2000). GABA (gamma-aminobutyric acid) is a natural calming agent and insufficient levels of GABA can cause symptoms of anxiety, insomnia, epilepsy and other brain disorders. The short term use of mind-altering chemicals can cause temporary deregulation of the neurotransmitters in the brain and are expressed by some unique and usually temporary behaviors. Long term use can often cause permanent changes in the neuroregulatory system in the brain with resultant negative behaviors. The neuroregulatory changes that occur in drug addicts and alcoholics serve to reset their brain reward systems outside of normal societal limits. This leads to a loss of control over the use of mind-altering substances and the development of the compulsive use of such substances despite negative consequences (Koob & LeMoal, 2008). The changes in the brain from drug addiction erodes a person s self-control and ability to make sound decisions while sending intense impulses to use more drugs or alcohol (NIDA, 2008).