Substance Use Disorder & Addiction: When the Disease Impacts Our Own

Transcription

1 Substance Use Disorder & Addiction: When the Disease Impacts Our Own New England Polysomnographic Society Friday, September 8, 2017 Mashantucket, CT Adam C. Barrett, M.Ed., BSN, CARN

2 Program Goal To enhance the understanding of how Substance Use Disorders (SUD)/Addiction can impact the healthcare professional and how to best address and support a colleague with a substance use disorder

3 Objectives of this Program Define the terms: Substance Use Disorder (SUD)/addiction and impaired practice from a brain-based disease perspective Describe how being a healthcare provider with a SUD can potentially impede recovery when faced with stigma and lack of forgiveness by colleagues List the common signs and associated behaviors of healthcare provider with a SUD/addiction/addiction Discuss the challenges a healthcare provider with SUD/addiction faces when returning to practice

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5 Neurotransmitter Regulation in the Brain Amygdala Fear responses & emotions Prefrontal Cortex Executive functions Cingulate Gyrus Anxiety regulation & sociability Hippocampus Memory storage & retrieval Thalamus Sleep/arousal/message relay Hypothalamus Stress responses/temperature Nucleus Accumbens ( the pleasure center ) Motivation, pleasure, addiction

6 The Reward/Control Pathway Reward/Survival Circuit ( go switch): Nucleus accumbens Control Circuit ( Stop switch): prefrontal cortex The brain experiences a surge of satisfaction (dopamine) when a physical or emotional need is met or when pain is relieved; activate a survival message to do it again and again When drugs and addictive behaviors hijack the reward/control pathway, the stop switch becomes disabled while the go switch is flipped to the on position sending the message that what we are doing is necessary for survival These messages are so powerful they override common sense of the new brain and drown out the need to engage in most other activities The nucleus accumbens is the heart of the reward/control pathway

7 Drugs and the pleasure response in the brain: Dopamine: a neurotransmitter present in the regions of the brain that regulate movement, emotion, cognition, motivation and feelings of pleasure. Nearly all addictive drugs directly or indirectly target the brain s reward system by flooding the circuit with dopamine. The overstimulation of this system, which rewards our natural behaviors, produces the euphoric effects and teaches the individuals brain to repeat the behavior.

8 Dependence & Physical Dependence May occur with the regular (daily or almost daily) use of any substance, legal or illegal, even when taken as prescribed. Occurs because the body naturally adapts to regular exposure to a substance (e.g., caffeine or prescription drug). When the substance is taken away, symptoms can emerge while the body re-adjusts to the loss of the substance. Physical dependence can lead to craving the drug to relieve the withdrawal symptoms. Drug dependence/addiction refer to substance use disorders, which may include physical dependence but must also meet additional criteria.

9 American Society of Addiction Medicine (ASAM) Addiction is a primary, chronic disease of the brains reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to biological, psychological, social and spiritual manifestations. This is reflected in the individual pursuing reward and/or relief by substance use and other behaviors. The addiction is characterized by impairment in behavioral control, craving, inability to consistently abstain, and diminished recognition of significant problems with one s behaviors and interpersonal relationships. Like other chronic diseases, addiction can involve cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

10 Addiction Illogical, compulsive drug use! G. Douglas Talbott, M.D.

11 Key Terminology: Unfit for duty: An employee may be deemed unfit for duty if they are affected by a drug (prescribed, over the counter or illicit) or alcohol, or the combination, in any detectable manner wherein such use or influence may affect the safety of the employee, coworkers, patients, members of the public, the employee s job performance or the efficient operation of the hospital. Impaired Clinical Practice = Unfit for Duty

12 Key Terminology: Diversion of Controlled Substances: Intentionally and without proper authorization, using or taking possession of a prescription medication through the use of prescription, ordering, or dispensing systems. Examples include but are not limited to: medication theft using or taking possession of a medication without a valid order or prescription, forging or inappropriately modifying a prescription, or using or taking possession of a medication waste, e.g., left over medication.

13 Why is SUD and impaired practice so difficult to talk about/address? U.S. culture addiction in general Highly emotional topic Denial re: in health care professionals Fear of public perception If we acknowledge, we must act How does it make me feel? Old/Out dated attitudes/misconceptions Introspection is key!

14 Disease vs. Moral Failure The stigma that addiction is a moral failure or lack of willpower rather than a disease is embedded in U.S. society. This attitude prevents (healthcare providers) nurses from seeking help. It deters facilities from providing adequate support programs for addicted and recovering nurses, and ultimately puts patients at risk. Our number-one goal is to protect patients. Our secondary goal should be helping our colleagues as we would help any patient under or care. Embracing the concept that addiction is a definable medical illness is imperative to help remove the stigma associated with substance abuse, making it easier for nurses to seek treatment. (Dunn, 2005)

15 Risk Factors in SUD Familial Runs in families Genetic Vulnerabilities for inherited subtypes (about 50% of substance abuse is genetic ) Peer Group Highly influential on development Self esteem issues & dynamics selfmedication: Particularly relevant in emotional dysregulation/moodiness and anxiety Access

16 Prevalence of Substance Use Disorder in Nursing It is estimated that approximately 10 % of the US population are effected by SUD/substance abuse. SAMHSA (2009) Is it higher for nurses/hc providers? Studies indicate 6-17% In 2008, the ANA estimated that 8% to 10% of nurses use alcohol or other drugs to the extent that they impair their professional performance. ANA (2008) The highest risk areas appear to be ER, Critical Care, and Nursing Homes

17 HC Providers: Who we are.. Caretakers from an early age Empathetic and caring personalities Socialized to be good High percentage from dysfunctional homes Up to 62% of nurses have reported having a family history of substance abuse High degree of substance use in our lives

18 A Profession at Risk for Substance Use Problems Why? Fast-paced, demanding schedules Compassion Fatigue Risk for physical injury An expectation of perfection in an imperfect setting Knowledge of pain and stress-relieving medications Access to medications High stress: physical, emotional, spiritual Unrealistic demands on our time Computer/technology is depersonalizing the caring process which is a dis-satisfier for many HC providers

19 Denial: a defense mechanism Some nurses may erroneously believe that they are immune to the negative consequences of drug use and that they have the ability to control their own medication use. (Dunn, 2005)

20 What do we use for soothing? Food Alcohol Opiates Prescription Drugs (Benzo s & others) Related behaviors: Shopping Gambling/Spending Sex Isolative behaviors (TV, computers, etc.)

21 Combine the Risk Factors, Access to Narcotic and any Pre-Disposition to Addiction = Set up for a Substance Use Disorder Experts have debated for years if substance use disorders are caused by genetic pre-disposition, a lack of healthy coping skills or environmental factors It is clear that there are multiple factors which place the nurse at risk and the issue of Substance Use is a significant concern for our profession.

22 Time for Self Reflection: Attitudes toward Substance Abusers For many HC providers, dealing with a colleague with a SUD can conjure up a host of negative feelings from our past experiences As HC providers, we work with substance abusing patients with drug seeking behaviors who can be manipulative and difficult for the staff to manage Demanding your time and attention from the patients who are really sick

23 Attitude toward HCP with SUD When a colleague develops impaired practice, there is often a dis-belief or denial of the situation. We often make excuses or cover for them in effort to provide support. He/she has been under a lot of stress lately. We can also be initially angry: How could she/he do that to his/her patients?... We trusted her/him. For some, seeing a colleague with impaired practice brings up the related emotions of a substance users in their family. They never stop using they just hurt everyone around them! They don t care about anyone but themselves!

24 So what do we do? Educate about risk factors, healthy coping strategies and resources available Encourage to self identify the risk factors of their profession and seek healthy coping strategies Recognize and support our colleagues with substance use disorders Identify the support services in your state/region and provide them to our nurse colleagues in need

25 Journal Entry Read journal entry of a nurse in need of treatment for SUD

26 What are the Occupational Signs of Substance Use Disorder/Impairment in Clinical Practice High absenteeism & tardiness, long breaks Vague or Dramatic illnesses & excuses Frequent trips to bathroom or off unit Unusually willing to float or stay late Readily volunteers to medicate other patients At work when not assigned/scheduled Poor job performance Illogical charting / Med Errors Frequent breakage and un-witnessed spills of medication Discrepancies between patient reports of pain relief and charted meds Consistently signing out the maximum amount of narcotics Excessive overtime It is important to note that the behaviors listed above, separately or in combination, are not reliable evidence by themselves of a substance use problem. No conclusion should be reached in this regard without additional reliable evidence of substance use.

27 Signs and Symptoms of Substance Use Poor Concentration and/or Judgment Memory loss for events or conversation Frequent accidents Sloppy appearance Wearing long sleeves Hand tremors Uses breath purifiers Calling colleagues at odd hours Mood swings Argumentative Becomes defensive easily Diaphoretic Jittery-jumpy-nervous Flushed appearance Bloated appearance Alcohol on breath Drowsiness on duty Frequent bruises/burns Ocular changes: pin point or dilated pupils, glossy eyes It is important to note that the behaviors listed above, separately or in combination, are not reliable evidence by themselves of a substance use problem. No conclusion should be reached in this regard without additional reliable evidence of substance use.

28 Signs of Diversion with Automated Medication Administration Systems: Over-riding medication profiles Removing the maximum dose (when range is provided Not returning or wasting properly Medicating patients that are not assigned to them Discontinuing Narcotic drips for other patients Volunteering to remove medications for other nurses Multiple null-transaction entries (browsing patient profiles) Consistently identified as the highest user on a unit

29 What to do when diversion is suspected with Automated Medication Administration Systems The Manager or Pharmacy Department can generate various reports: Usage Report (poor indicator by itself, must correlate with other data) Waste reporting Over-ride reports Discrepancy reports Drawer open times (newer feature, may not be available on all models) Narcotic withdrawals per 24 hour.

30 When diversion is suspected with Automated Medication Administration Systems (continued) Tedious, but useful, is the comparison of automated medication entries with the patient s Medication Administration Record (MAR) If multiple nurses are identified, it is important to compare the data with the nurses work schedule to ensure that passwords have not been compromised by the nurse with a substance use disorder

31 Caution for False Detection: Dispensing data should be reviewed monthly for trends. Nurses working significant overtime or 12 hour shifts can falsely elevate the narcotic pulls per 24 hour data Certain nurses who are more in-tune with pain management may end up as the highest user Nurses who take more acutely ill patients often end up as the highest users.

32 Best Practice Standards for Controlled Substance Handling: Scheduled, mandatory password changes (minimally q 3-6 months) Caution employees regarding password viewing when witnessing medication wasting (Adopt ATM rules of 3 feet distance and look away) Utilize ID badge, finger-print or eye scan technology if available Institute a return dose system for all narcotic infusions with random audits of the returns

33 Best Practice Standards for Controlled Substance Handling: Reduce over-rides Reduce the practice of nurses removing medications for each other. (The person removing the medication should be the nurse documenting the medication) Return to best practices regarding Narcotic Count: 2 RN s, on-coming shift views the integrity of the medications More frequent scheduling of narcotic count

34 Best Practice Standards for Controlled Substance Handling: Return to best practice regarding wasting: Must be actually witnessed Dispose in a non- retrievable waste site Utilize commercially prepared IV Narcotic infusions Institute a chain of custody policy for all narcotic infusions mixed by the facility: Identify by code number the infusion bag and document who prepared the infusion Utilize a secure tamper-proof device for the injection port Document a chain of custody for transportation of the medication to the unit. Institute a policy to document the medication by bag ID number.

35 Problem is Identified, Now what do I do about it? This greatly depends on several factors: -Your role at the facility -Your relationship to the nurse identified -Mandatory reporting laws in your state -Facility Policies and Procedures related to substance use on the job -Union Contract

36 How do you address a Substance Use Problem when the HCP is currently under the influence of substances? The priority is to remove them from patient care Secure a private setting and allow for a support person for the employee (either union representative or nurse colleague) Address the observed behaviors from the concern for him/her point of view Keep conversation brief Have the employee properly evaluated by a licensed independent practitioner for safety risk/ stability Schedule a follow-up meeting to address the specifics of the situation Drug testing if specified in policy Provide safe transport to a safe location

37 Important Considerations Before Addressing a HCP with a Substance Use Problem There is often a high degree of emotions associated with the situation When substance use gets to the level of effecting the HCP work situation, the disease of addition has negatively impacted all other components of that individuals life Family, friends, social connections and finances are generally all strained Extreme sense of guilt and shame The colleague is at risk for self harm Thus, it is imperative that the facility have plan for that employee to be properly evaluated by a licensed independent practitioner for safety risk/stability and provide safe transport home.

38 Initial Intervention Meeting (continued) Ensure Human Resources is present at the meeting After initial information/observations are provided by management, it is in the best interest of the nurse to terminate the meeting and request a minimum of hours before responding Since there are serious potential licensure and criminal considerations the empoyee should consider seeking legal counsel prior to responding.

39 Mandatory Reporting Laws Duty to Report laws vary state to state. Important to check your individual state board of nursing regulations related to mandatory reporting at the National Council of State Boards of Nursing Mandatory Reporting Law in Massachusetts: (The following information is referenced from the Massachusetts Board of Registration in Nursing at CMR 9.03(26) Duty to Report to the Board: A nurse who holds a valid license and who directly observes another nurse engaged in any of the following shall report that nurse to the Board in accordance with Board guidelines: a) abuse of a patient; b) practice of nursing while impaired by substance abuse c) diversion of controlled substances

40 BORN Complaints and Alternative to Discipline Programs The availability of Alternative to Discipline Programs vary state to state Check at In Massachusetts, if a complaint is filed with the BORN and is related to impaired practice/diversion, the nurse is offered Substance Abuse Rehabilitative Program (SARP) as an alternative to discipline SARP is a comprehensive 5 year license- leverage program

41 Mandatory Pharmacy Reporting Laws Related to Missing Narcotics When narcotic diversion is involved, the Pharmacist has a duty to report the loss narcotics to the Drug Enforcement Agency (DEA) Depending upon the amount of loss the DEA can notify the local police to arrest the nurse for narcotic diversion In most states they also must file a lost narcotic report to the Department of Public Health (DPH)

42 Final Termination Meeting If impaired practice is confirmed the following issues should be addressed by management /HR: Alternate worksite employment within the agency Leave of absence options Access to benefit time and wages Health insurance while the nurse seeks recovery care FMLA options Disability Insurance Options Unemployment eligibility Re-hire/seniority options Retirement/pension options

43 Self Reporting to BORN: Self reporting will often speed up the entry process by 3-6 months. Facilitates the recovery process sooner It is important for the nurse to evaluate thoroughly and possibly seek legal guidance Self reporting can also prohibit the nurse from utilizing their own personal liability insurance

44 BORN - Alternative to Discipline Programs for Substance Use Issues Most states have some form of an alternative to discipline program for nurses with licensure complaints related to substance use issues Typically the nurse agrees to enter an extensive license- leveraged program while seeking recovery. The SARP s primary mission is public safety Practice restrictions are common. Most programs require the nurse to stop working as an RN for 1-2 years. Upon return to work as a nurse, there are often practice restrictions related to administration of narcotics and/or overtime and off shift work

45 BORN - Alternative to Discipline Programs for Substance Use Issues (continued) Most programs are 5 years in length, however some states have programs with a 3 year requirement Upon return to work, most programs require supervision and submission of quarterly status updates from supervisors All programs require daily call in for randomized drug testing, and at least weekly support group involvement Most programs have travel restrictions while in the program

46 Benefits of an Alternative to Discipline Program In most states it halts the discipline process and if the nurse successfully completes the program, their license is un-blemished The nurse has a disciplined road map toward recovery License leverage programs often strongly encourage the nurse to take care of themselves and focus seriously on their recovery

47 Challenges of an Alternative to Discipline Program In most programs the nurse must sign a contingent surrender agreement which means if the nurse fails to meet the requirements of the program or relapses and fails the requirements, they surrender their license Nurses cannot work as a nurse for a duration specified in the contract (generally 1-2 years), which can pose a financial challenge

48 MNA Peer Assistance Program or via the MNA web site at The program is free, confidential and not tied to the licensure board Program provides peer support from volunteer nurses who either work in the field of Addictions or are in recovery. Many are SARP graduates. Weekly Nursing Support groups are located throughout the state Promotion materials are available, free of charge, upon request

49 Duty to Report Remaining silent may result in charges against the nurse who knew something but did nothing because this nurse supported an environment that permitted a colleague s negligence or malpractice. (Dunn, 2005)

50 Nursing: A Profession at Risk for Substance Use Problems Prevention Strategies: Learn healthy coping skills for the stress of direct care nursing. Prioritize things you enjoy Get enough sleep and exercise Laugh, have fun with friends Be sure to put your own mask on first!!!

51 Other Resources:

52 Thank you for your time, I welcome your Questions?