DESCRIPTION

For nearly two decades, problematic substance use has been described as "the nation's number one health problem," contributing to "the death and ill health of millions of Americans every year and to the high cost of health care"(Hogan et al., 2001). More recently, nonmedical use of prescription medications has become "the nation's fastest-growing drug problem" (Office of National Drug Control Policy (ONDCP), US. Executive Office of the President of the United States 2011). Current conditions have culminated in a national "opioid epidemic," with increased rates of drug overdoses and deaths (Manchikanti et al., 2012).

Evidence suggests that the prevalence of substance use disorders among nurses is similar to that of the general population (Kunyk, 2015). Related factors include family history, job-related stress, depression, knowledge of medications (Dunn, 2005), access to medications (Maher-Brisen, 2007), and perceived invulnerability. Impaired practice is defined as "diminished competence, as evident in changes in work habits, job performance, appearance, or other behaviors" (ANA, 2015). Alcohol and other substance use by nurses potentially places patients, the public, and nurses themselves at risk for serious injury or death.

Nursing students are also at risk for problems related to substance use (ANA, 2015). A lack of education, inconsistent policies and procedures (McCulloh Nair, Nemeth, Sommers, & Newman, 2015), and insufficient supervision or intervention (Nair, Nemeth, Williams, Newman, & Sommers, 2015) may contribute to unsafe patient care by nursing students who are using substances. Students whose substance use is discovered may be expelled without receiving appropriate treatment or follow-up, denying them a path to recovery, and eventual safe entry into the profession.

Standards for nursing education include "care of self in order to care for others" (American Association of Colleges of Nursing, 2013). It is the responsibility of nurses and nursing students to be aware and to take appropriate actions when "unethical, illegal or impaired practice or actions that place the rights or best interests of the patient in jeopardy" (ANA, 2015). Focusing on the patient's best interests and the integrity of the practice of nursing should guide the concerns expressed to the appropriate authority (ANA, 2015).

Different conceptual models have been applied to the phenomenon of substance use disorders (Strobbe, 2015). The American Society of Addiction Medicine has defined addiction as "a primary, chronic disease of brain reward, motivation, memory, and related circuitry[horizontal ellipsis][that] leads to characteristic biological psychological, social, and spiritual manifestations" (American Society of Addiction Medicine, 2011). When viewed and treated as a chronic medical illness, treatment outcomes for substance use disorders are comparable to those of other diseases-such as asthma, diabetes, and hypertension-and can result in lasting benefits (McLellan, Lewis, O'Brien, & Kleber, 2000).

In contrast to this bio-psycho-social-spiritual model, a common and contrasting view of nurses and other health care providers with substance use disorders is reflected by the "moral or criminal model," in which addiction is depicted as personal weakness, a lack of character or willpower, and disregard for social norms. According to this model, the use of substances is considered volitional, i.e., a matter of personal choice, and within voluntary control of the person using. In response, social scorn, isolation, and punishment may be harshly imposed (Strobbe, 2015). This may be especially true when drug diversion-the illegal distribution or use of prescription drugs for unintended purposes (Centers for Medicare and Medicaid Services, Department of Health and Human Services, 2014)-is involved.

ENA/INTNSA POSITION.05.*

It is the position of the Emergency Nurses Association and the International Nurses Society on Addictions that:

1. Health care facilities provide education to nurses and other employees regarding alcohol and other drug use, and establish policies, procedures, and practices to promote safe, supportive, drug-free workplaces.

2. Health care facilities and schools of nursing adopt alternative-to-discipline (ATD) approaches to treating nurses and nursing students with substance use disorders, with stated goals of retention, rehabilitation, and re-entry into safe, professional practice.

3. Drug diversion, in the context of personal use, is viewed primarily as a symptom of a serious and treatable disease, and not exclusively as a crime.

4. Nurses and nursing students are aware of the risks associated with substance use, impaired practice, and drug diversion, and have the responsibility and means to report suspected or actual concerns.

BACKGROUND

Two primary approaches have been used when addressing nurses with impaired practice or drug diversion. Discipline usually entails due process, involving a state board of nursing. If the nurse is found guilty, the license is suspended or revoked, and no state board recovery program is offered (Crowley & Morgan, 2014; National Council of State Boards of Nursing [NCSBN], 2011). If employment is terminated, then the nurse may no longer have health insurance or access to treatment. In cases of diversion, legal charges may be filed, with loss of license and livelihood, and the nurse may be prosecuted, and incarcerated, resulting in a criminal record that may forever prohibit future employment as a nurse.

In alternative-to-discipline (ATD) programs-which are generally administered by a third party through contractual agreements with a state board of nursing-the nurse refrains from practice for a designated time while undergoing treatment, establishing sobriety and a program of recovery. Assessment may include a psychiatric evaluation. Specialized treatment often involves individual and group therapy, frequent random urine drug screens, and mutual support group attendance, such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Caduceus meetings for health professionals in recovery. An initial return-to-work agreement may involve reduced hours, limited shifts, and restrictions in assignments (e.g., no access to narcotics), with continued treatment and monitoring for periods of up to 3 to 5 years, and a gradual lifting of restrictions with demonstrated progress (Crowley & Morgan, 2014; NCSBN, 2011). Many, but not all, state boards of nursing offer ATD programs for nurses with substance use or mental health disorders. Considerable variability exists from state-to-state, and individual employers may or may not subscribe to these principles and practices. In addition, sanctions against nurses may be more severe than those received by other health care professionals.

Supported by the groundwork of the American Nurses Association (ANA, 2015; Murphy-Parker, 2013). ATD programs for licensed nursing professionals are also noted to be of value to the nursing student (Monroe, 2009; Murphy-Parker, 2013). The National Council of State Boards of Nursing advocates for schools of nursing to adopt such programs, and to apply them to student nurses (NCSBN, 2011).

Professional monitoring programs that employ an ATD approach have been shown to be effective in the treatment of health professionals with substance use disorders, and are considered a standard for recovery, with high rates of completion, and return to practice (DuPont, McLellan, White, Merlo, & Gold, 2009; McLellan, Skipper, Campbell, & DuPont, 2008). In addition, ATD programs have been shown to identify and enroll more nurses with substance use disorders, with potentially greater impact on protecting the public than disciplinary programs (Monroe, Kenaga, Dietrich, Carter, & Cowan, 2013).

RESOURCES

American Nurses Association (ANA). (2015). Code of ethics for nurses with interpretive statements. Silver Springs, MD: Author.

American Nurses Association (ANA), & International Nurses Society on Addictions (IntNSA) (2013). Addictions nursing: scope and standards of practice. Silver Spring, MD: http://Nursesbooks.org.

Crowley, K., & Morgan, C. (2014). Re/entry: A guide for nurses dealing with substance use disorder. Indianapolis, IN: Sigma Theta Tau International.

International Nurses Society on Addictions (IntNSA). (2015). Core curriculum of addictions nursing (3rd edition). Philadelphia, PA: Wolters Kluwer.

Michigan Media. (2015). Drug Diversion.https://vimeo.com/135620252

National Council of State Boards of Nursing (NCSBN) (2011). Substance use disorder in nursing: A resource manual and guidelines for alternative and disciplinary monitoring programs. Chicago, IL: Author. Retrieved from http://www.ncsbn.org/SUDN_11.pdf

Substance Abuse and Mental Health Services Administration (SAMHSA). (n.d.). Drug-free workplace programs. Retrieved from http://www.samhsa.gov/workplace

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