Abstract

Introduction

Definition and Prevalence

Ramifications for Practice

References

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Narcotic Use and Diversion in Nursing

Mandy L. Hrobak
University of North Carolina Charlotte


Abstract

Narcotic use and diversion in nursing is a growing problem that may be difficult to identify. Clinical indicators can help managers and staff become knowledgeable about signs and symptoms. Areas related to job performance, personality/mental status, and diversion are looked at as indicators. Workplace access and deviant work group norms can contribute to the picture. Certain methods of diversion may be hard to detect. Institutions need to be prepared to handle incidences of narcotic use and diversion before they occur. Policies can help provide for positive outcomes for the institution and the nurse, should she/he decide to receive treatment. Patient safety is of the utmost concern. A supportive environment is important for reentry of the rehabilitated nurse at work. Alcohol and drug dependency are covered under the American Disability Act of 1990. Assistance programs, education, and further research are needed in this area.


Introduction

Narcotic use and diversion among nurses is a growing problem. Substance abuse is the number one reason named by state boards of nursing for disciplinary action (Sullivan & Decker, 2001). For this reason, the subject warrants further investigation by nurses. This paper addresses the issues staff needs to be aware of regarding narcotic and diversion. It is not just a management issue. The literature offers a portrait of the possible abuser. These signs and symptoms can act as guidelines for reporting concerns. Policies and procedures need to be in place before an incident happens to ensure for appropriate handling of the situation. Disciplinary action can involve treatment programs, as well as legal action. Staff also needs to be aware of appropriate actions regarding reentry of the nurse substance abuser and diverter to work. Although patient safety is the main concern, the rehabilitation process for the nurse is an important aspect.  


Definition and Prevalence

In 1983, Tappen described diversion as coping mechanism. Engaging in enjoyable activities can temporarily distract attention from the problem, provide pleasure, and restore energy, sometimes freeing energy for more creative problem solving (Tappen, 1983, p. 37). There is no mention of narcotic use or diversion. It wasn’t until 1984 that the American Nurses Association (ANA) publicly recognized the problem in nursing (Dabney, 1995). Today it is different although there is not a lot of research available. The statistics vary but all show that substance abuse and narcotic diversion is a growing problem for the profession.

Chemical dependency in nursing is defined (Smith, Taylor, and Hughes, 1998, p. 105) as a state of psychological and or physical addiction to a chemical substance or substances. Use of the substances, whether legally or illegally obtained, leads to a professional’s inability to perform duties and responsibilities according to nursing standards.

Substance abuse among nurses can range from 2% to 18% (Sullivan & Decker, 2001). The rate for prescription type drug misuse is 6.9% (Trinkoff, Storr, & Wall, 1999). The prevalence of chemical dependency is 6% to 8% (130 to 170,000) according to the ANA estimates (Smith et al., 1998). According to Burke, director of the Cincinnati Police Pharmaceutical Division, his squad arrested one health care professional every six days. 70% were nurses. He stresses that not all are caught (1998). In the state of North Carolina, there are 108,462 licensed nurses. In 2000, there were 90 nurses with drug related violations. Sixty-two nurses were enrolled in alternative treatment programs (North Carolina State Board of Nursing, 2001). So the statistics show there are more nurses diverting and using than actually reported.

Denial is a key aspect by the nurse and fellow coworkers. The picture may be vague at first, but eventually the nurse’s behavior makes it clearer. Certain indicators may alert others to a problem that should be investigated. Smith et al offer indicators of chemical impairment in the areas of job performance, personality/mental status, and diversion. Usually, there is not just one indicator but several. In the workplace, the nurse may offer to work overtime. There may be an increase in absenteeism, tardiness, and use of sick time with vague excuses. The nurse may take long or frequent breaks. Job performance becomes inconsistent as function declines. Charting suffers with errors and omissions. Inadequate reporting and discrepancies with what is charted may be apparent. The nurse does just enough to get by with increased complaints from other nurses, doctors, or patients. When challenged, the nurse may offer implausible excuses for behavior or become defensive. Behavior changes may include mood fluctuation, sleeping on the job, or isolation. The nurse may have a chaotic home life or feel picked on at work. They may over react emotionally with snapping out or disproportionate crying.

Signs of diversion can be subtle. The nurse may volunteer to administer medications for others or hold the narcotics keys/count. Their patients receive more PRN pain medications but report non-effective pain relief. There may be frequent reports of lost or wasted medications. Medications should be checked for tampering such as torn packets, missing vial tops, puncture holes, and uneven fluid levels. This nurse may request to work in an area of high pain medication administration. If injecting at work, there may be blood spots on clothes.

Physical signs of use or withdrawal include hand tremors, headache, diaphoresis, abdominal/muscle cramps, diarrhea, nausea, irritability, or restlessness. These may disappear with use and are usually evident in the later stages of addiction. The problem with these indicators of addiction is that they can also be signs of psychological problems. Regardless, these behaviors impair clinical judgment and put patients at risk (Smith et al., 1998).

Workplace access should also be considered in the picture. Experience and knowledge may not be enough to protect healthcare workers. A study by Trinkoff et al. looked at the relationship between prescription type drug misuse and workplace access. They found that drug abuse rates of healthcare workers are comparable to the public, but prescription type misuse is higher. The 1994 study looked at three main points. They were perceived availability of a controlled substance, frequency of administration, and degree of control. The results showed that nurses, who used daily and had easier perceived access with poor control, had 2x greater odds of using. As the index for access rose, so did misuse (Trinkoff et al., 1999).

Drug addiction in nursing is based on a medical model. Dabney looked at the social science perspective and feels it is a blend of both. Peer influence with acceptance of lesser deviant behavior and exposure to that mentality influence outcomes. In his study, he found that group norms for stealing in the healthcare profession were pervasive. This included stealing of supplies, over the counter drugs, and nonnarcotic prescription drugs. These were witnessed even more frequently than self-reported. Most rationalized or condoned this behavior. They, however, looked down on narcotic diversion and use. He felt that work group norms are linked strongly to attitudes and that they influences the overall environment for more deviant behavior (Dabney, 1995).

Burke points out that most diverters are users, not sellers. But most use at work. The methods of substitution of the drug with another liquid or split shots are two methods where there is no waste discrepancy. This makes these methods hard to detect (Burke, 1999). Not all diverters are users. Tranbarger (1997) describes a nurse who would go to the pharmacy to restock the narcotics. On the way back to the unit, she would go to the restroom, pocket the meds, and discard the paperwork. She took the drugs home for her boyfriend to sell.


Ramifications for Practice

Unit staff needs to be educated about narcotic use and diversion in order to report to the nurse manager any appropriate concerns. If they are unaware as to what is going on, they may actually enable the abusing nurse with behaviors such as covering for them (Smith et al., 1998). Once concerns are brought to the nurse manager’s attention, she/he needs to make a plan of action. Data needs to be gathered. Meticulous notes as to specific incidences are imperative. The manager needs to be aware of the organizational policy, state laws, and requirements of the state board of nursing. Twenty-five state boards of nursing currently have confidential alternative treatment programs (Smith et al., 1998). The state of North Carolina has a comprehensive decision tree they follow as well as an alternative treatment program (North Carolina State Board of Nursing, 2001).

Intervention needs to be done quickly to provide for patient safety. Once prepared adequately, the nurse manager informs the nurse that she/he needs to be

evaluated after presenting the facts (Sullivan & Decker, 2001). It is important to have policies in place prior to having a problem. Everyone involved needs to be knowledgeable about them. Jackson (1997) describes the case of a nurse who was suspected of diverting. There was enough evidence to suspend the nurse pending a fair treatment hearing. Policy was not followed correctly by administration and the manager was forced to let the nurse return to work. Thompson, Handley, and Uhing-Nguyen describe the process of policy formation at their facility. They used a three pronged approach of identifying resources, establishing a committee, and educating the task for members. Other components included prevention/early intervention strategies, identification of impaired practice, treatment, and reentry into practice (Thompson et al., 1997).

Sergeant Burke reinforces the need for institutions to be proactive, especially with regards to diversion. He suggests a controlled substance committee that meets at least monthly, with members from all disciplines. He also suggests procedures for reporting, tracking, and investigation of discrepancies (Burke, 1999). Managers need to look at their narcotic control system in general. Tranbarger (1997) states that no system is perfect and periodic monitoring of narcotic administration by unit, by shift, and by person. This will help identify suspicious patterns.

If the nurse decides to participate in an alternative program, it may be on a continuum of care. This means that initially there will be inpatient detoxification followed by varying levels of outpatient treatment. If they return to work, based on recommendations of that treatment, there are decisions that need to be made regarding practice. They can be assigned to a unit where few mood altering drugs are given or they can return to their unit with restrictions on their ability to administer narcotics (Sullivan, 2001). All practice by the nurse should be closely monitored but an environment of support is needed. The possibility of relapse is there and patient safety is a concern. Transburger (1997) states that there is more success with recovery when it is tied to a person’s employment and license. Support groups need to be available. Random testing helps with abstinence.

Employers must be aware of the Americans with Disabilities Act of 1990 (ADA). It prohibits discrimination in personnel policies if the person has a qualifying disability (Sullivan, 2001, pg. 345). Drug and alcohol dependency is included as a qualifying disability for nurses. This is only true if it is self-reported or diagnosed. Nurses are not protected, however, if they are using drugs or under the influence at work which subsequently endangers the lives of patients. Under this act, employers much keep the employees records confidential in a separate locked file cabinet with limited access. Other provisions include sick leave, treatment opportunities, and providing for reasonable job accommodations as with any other disabilities. Legal issues regarding relapse are vague. The manager needs to consult human resources if this occurs (Sullivan & Decker, 2001).

Nursing must be proactive in its response to narcotic use and diversion amongst its own. It is the responsibility of all involved to know the portrait of a nurse drug abuser or diverter. Insidious at first, the picture becomes clearer as the nurse enters into an addictive cycle. Policies for action need to be in place prior to incidents to allow for the best possible outcomes for our patients and the nurse. Prevention and monitoring strategies are important. Education is key in recognizing the problem and helping the recovering nurse with reentry into the workplace. The ANA and the National Council for State Boards of Nursing recognize the need for assistance programs, education, and research (Smith et al., 1998).


References

Burke, J. (1999). Facing up to drug diversion. American Journal of Health System  Pharmacy, 56 (18), 1823-27.

Dabney, D. (1995). Workplace deviance among nurses. Journal of Nursing  Administration, 25(3), 48-55.

Jackson, B. (1997). An administrative blunder, a nurse accused of mishandling controlled substances continues to practice. Journal of Nursing Administration, 27 (12), 8-12.

North Carolina Board of Nursing, (2001). Discipline department. Retrieved January 21, 2002 from http://www.ncbon.org/.

Smith, L., Taylor, B., & Hughes, T. (1998). Effective peer responses to impaired
Nursing practice. Nursing Clinics of North America, 33(1), 105-18.

Sullivan, E. & Decker, P. (2001). Effective leadership and management in nursing.
Upper Saddle River, NJ: Prentice Hall.

Tappen, R. (1983). Nursing leadership: concepts and practice. Philadelphia, PA:
F.A. Davis Company.

Thompson, N., Handley, S., & Uhing-Nguyen, S. (1997). Substance abuse in nursing,
forming policies. Nursing Management, 28(2), 38-43.

Tranbarger, R. (1997). A nurse executive’s nightmare, the rogue nurse. Nursing Management, 28(2), 33-6., R.,

Trinkoff Storr, S., & Wall, M. (1999). Prescription-type drug misuse and workplace Access among nurses. Journal of Addictive Diseases, 18(1), 9-17.

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