Why Didnt I Know

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Why Didnt I Know?

• Jane Tallant, RN, MSN
• Director of Recovering Nurse Program and
  Compliance
• Mississippi Board of Nursing

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Addictive Illnesses

• What causes addiction?
• What symptoms are exhibited?
• How do I intervene?
• What should I do if I suspect a relapse?
• How do I work with a nurse who has an addictive
  illness?

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The Reality of Substance Abuse Disorders among
Nurses

• Prevalence of addiction
• 15-18 of general population
• Nurses are at least as susceptible as the general
  public
• Estimates for nurses range from 6 to 25
• Early identification and treatment is essential
  to protect the public and the profession and our
  colleagues at risk

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The Reality of Substance Abuse Disorders among
Nurses
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The moral dilemma
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What is addiction?

• A disease
• Anything that interferes with the ability to
  function normally
• Classified in DSM-IV-TR as a mental disorder
• Has ICD-9 Code
• Responds to treatment
• Genetic component
• Accounts for 40-60 of vulnerability to addiction

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Addiction

• Use of mood-altering substances
• Loss of control of use
• Craving/compulsion
• Need to use despite risk and consequences
• Gradual disintegration of value/belief system
• Denial is the hallmark
• Interference with functioning
• Individual
• Family
• Society
• Workplace is the LAST domain to be effected

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Brain Disease

• Initial voluntary behavior
• Develops over time
• Causes changes in structure and function
• Distortions of cognitive and emotional
  functioning
• Pleasure reward system is distorted

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Brain disease

• Lack of insight is perplexing to outsiders

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Dependence DSM-IV-TR

• Maladaptive pattern leading to significant
  impairment or distress as manifested by (3 or
  more)
• Tolerance
• Withdrawal
• Substance taken in larger amounts or over longer
  period than intended
• Desire or efforts to cut down
• Time spent in activities to obtain, use, recover
  from substance
• Important activities given up
• Use despite knowledge of problem

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Substance Dependence (ASAM Criteria)

• Control
• Compulsion
• Consequences
• Distortion in thinking, most notably denial

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Chronic Illnesses
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NIH/NIDA
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How do these diseases compare?
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Chronic Disease Management
chronic disease, active symptoms ebb (toward
remission) and flow (toward relapse) over
time. periods of symptom remission and symptom
relapse before achieving permanent
remission. many who never achieve full remission
achieve long periods of remission, can decrease
the duration and intensity of relapse individual
suffering from addictive disease will need to
sustain daily activities that promote remission.
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Scope of problem

• Diversion is a universal problem
• Unnecessary pain and suffering
• Civil liability/malpractice/negligence
• Damage to reputation of the facility
• Loss of nurses to the profession
• Destruction of perception of nurses as trusted
  professionals

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What does an impaired nurse look like?
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The drug-addicted nurse

• Best nurse on the unit
• Well liked and respected
• Highly skilled
• Works overtime
• Gives pain medication
• Wastes narcotics

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Background indicators

• Family history of substance abuse
• History of frequent job changes
• Prior medical history of pain medication use
• Prior reputation as an outstanding employee
• I would add chronic pain

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Signs and Symptoms

• personality change
• blackouts
• problems at work/school
• mood/attitude changes
• legal problems
• health problems
• avoiding friends/family
• constant obsession
• appetite/sleep changes

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Signs and Symptoms

• high tolerance
• lying/dishonesty
• strained relationships
• financial problems
• loss of interests
• accidents
• depression/suicide attempts
• risk-taking behaviors
• changes in appearance

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Behavioral signs

• Family problems
• Poor interpersonal relationships
• Socially isolated
• Change in grooming
• Forgetfulness
• Confusion
• Difficulty handling stress

• Mood swings/alterations
• Inappropriate laughter
• Hyperactivity
• Sedation
• Depression
• Accelerated speech

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Occupational indicators

• Has emotional and/or physical problems
• Requests to work in areas where narcotics are
  given frequently
• Sloppy narcotic documentation
• Likes to work evenings or nights
• Takes lots of bathroom breaks, often with purse
• May disappear from unit for unexplained periods
  of time

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Occupational indicators

• Visits unit on days off
• Volunteers to count narcotics
• Difficulty completing assignments in a timely
  manner
• Documentation errors
• Medication errors
• Mood changes after meal times
• Social avoidance of staff
• Falls asleep at work

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Indicators of diversion

• Large amounts of narcotic wastes by one person
• Many narcotic sign-outs by one person
• Discrepancies between narcotic record, MAR and
  nurses notes
• Frequent incorrect narcotics counts
• Using access code of another nurse
• Dropped vials
• Patient reports of no pain relief after
  medication has been administered
• Alterations of telephone/verbal orders for
  controlled substances

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Nurses Drugs of Choice

• Meperidine
• Hydrocodone
• Other opioids (oxycodone, propoxyphene)
• Benzodiazepines (Xanax, Ativan)

• Alcohol
• tramadol (Ultram)
• Butalbital (Fiorinal)
• Ambien

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Intervention

• Document behaviors
• Work attendance
• Performance
• Behavior changes
• Clinical judgment
• Signs of possible drug diversion

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Ineffective responses

• Failure to document
• Failure to report concerns
• Attempting to counsel individually
• Attempting to diagnose problem
• Lack of specific plan

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What to do

• Know signs and symptoms
• Document clearly with objective facts
• Do not gossip
• Ethical and legal duty to report
• You are protecting patients, not punishing the
  caregiver
• Offering help to an impaired colleague

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Intervention

• Do not meet with person of concern individually
• Have a specific plan
• Involve family, loved ones
• Do not give up!!

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Return to practice

• Do not be judgmental
• Step in and help
• Be honest when you are troubled by behavior
• Recognize issues of restricted license
• Open, honest communication

• Ask questions about addiction, recovery and
  relapse
• Know signs of relapse
• React promptly if relapse indicators are present
• Drug screen periodically

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Signs of Relapse

• Defensiveness
• Irritability
• Self-pity
• Blaming others
• Making excuses
• Irregular attendance at 12-Step meetings
• Thoughts of social drinking
• Isolation, withdrawal
• Unwillingness to share story with others
• Lack of accountability
• Lack of gratitude

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Communication

• Talk about any concerns
• Talk with counselors at board
• Read the literature
• Attend open meetings

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Nurses in recovery enhance our profession!
They are not bad nurses trying to be good, they
have an illness and they are trying to get well.