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Recognizing Impairment in the Workplace

Contact Hours: 2

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Contact Hours: 2

This online independent study activity is credited for 2 contact hours at completion.

Course Purpose

To provide healthcare providers with an overview of alcohol and substance addiction, common state laws and regulations, recognizing impairment in the workplace, and resources to assist with evaluation and treatment.

Overview

Impairment in the workplace is a common problem in healthcare and it is estimated that 10% of healthcare providers will experience impairment during their career. However, only two out of three healthcare providers will be reported for impairment. This happens for several reasons and poses significant risks to the healthcare provider, patients that they care for, and the institution that they work for. To reduce the risks associated with alcohol and substance use, the healthcare provider must be able to identify it, recognize the symptoms, have knowledge of common laws, know how to report the impairment, and understand the various evaluations and treatments.

Objectives

  • Define alcohol and substance addiction
  • Describe behaviors and risk factors of impairment in the workplace
  • Analyze barriers to early identification of impaired healthcare providers
  • Understand regulatory mandates that govern discipline and treatment of impaired nurses in Florida
  • Summarize the essential steps to report or refer a nurse who may be impaired
  • Outline the treatments available to healthcare providers who are impaired in the workplace

Policy Statement 

This activity has been planned and implemented in accordance with the policies of FastCEForLess.com. If you want to review our policy, click here.

Disclosures

Fast CE For Less, Inc. and its authors have no disclosures. There is no commercial support.

Fast Facts: Recognizing Impairment in the Workplace

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Case Study

You are working during the night shift and overhear a conversation among your colleagues. They are discussing a concern for a peer who is suspected of substance use. “Have you seen Jane lately? She used to be so neat and clean but for the past several months she does not seem to care about her appearance. I worked with Jane this week and she seemed in a daze most of the shift. If I did not know better, I would think Jane was taking drugs or something,” said Jennifer, one of your colleagues. “Drugs! Not Jane, she would never take drugs. I have known Jane for four years. She’s an excellent nurse,” replied John. “Besides Jane certainly doesn’t look like a drug user. She is probably tired from working the night shift or maybe she is having some personal problems. We all deal with our problems differently,” said John.
Reflect on your healthcare career. Do you recognize having a similar conversation regarding one of your colleagues? It is estimated that 10-15% of healthcare providers will experience alcohol or substance use related impairment in the workplace. Healthcare providers always care for patients, but they do not always care for their coworkers or themselves. As a colleague, a healthcare provider must educate themselves on the signs, symptoms, behaviors, myths, and truths that represent substance abuse. While it may be very difficult to suspect a colleague of substance or alcohol use, and the fear of retaliation may keep some healthcare providers from action, it’s important to take the steps necessary to notify the appropriate persons and organizations of suspicions of alcohol and substance use. The healthcare provider must educate themself on the organization’s policy and procedures for employee substance use and employee assistance programs.

Definitions
Addiction A chronic, relapsing disorder characterized by compulsive drug seeking despite the desire to stop, continued use despite harmful consequences, and long-lasting changes in the brain. It is considered both a complex brain disorder and a mental illness and if left untreated, may result in disability or premature death.
Drug Diversion The transfer of a prescription medication, such as a narcotic, from a lawful to an illegal channel of distribution and use.
Substance Use Disorder A disease of the brain that occurs with the recurrent use of alcohol and/or drugs which causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home.
Impairment The inability to function normally to provide safe, professional activities and duties because of a behavioral, mental, or physical disorder that is a result of alcohol or drug use.  
Introduction

Impairment of the healthcare provider is a common problem in healthcare. It is estimated that approximately 10-15% of healthcare providers will experience some form of impairment while working. Impairment occurs when a healthcare provider is unable to provide competent and safe patient care because of the use of prescription or nonprescription drugs, alcohol, or mind-altering substances.  Impairment may also result from a psychological or neurologic condition that affects the healthcare provider’s judgment. As a result, the healthcare provider is unable to safely perform their duties in the manner that is essential to their profession. 

Alcohol and drug use disorder is a troubling and significant problem for healthcare providers. Without proper identification and treatment, it has the potential to compromise workplace and patient safety. The severity of danger to patient safety increases when the healthcare provider is responsible for treating and caring for critically ill patients. Because of the concerns for safety, a fellow healthcare provider must be able to identify signs of alcohol and drug abuse to protect the patients and themselves. Healthcare providers must understand the safety issues that occur when one is impaired.

Impaired healthcare providers will initially develop coping mechanisms that will allow them to cover up their diminished capability to provide safe patient care. Only an astute fellow healthcare provider will notice a change in behavior or signs of impairment. As the disorder progresses, the healthcare provider will make obvious mistakes, medication errors, or procedural errors.

To obtain mind-altering substances, in extreme cases impaired health providers will divert controlled substances, such as narcotic pain medications from a patient to themselves, which has the potential to result in patient suffering. Long-term use of mind-altering substances can also result in the deterioration of health in the healthcare provider. For instance, using stimulants chronically may cause cardiovascular problems such as hypertension, angina, and myocardial infarction. Long-term use of alcohol can cause cirrhosis of the liver. Also, patients may be exposed to infectious diseases such as human immunodeficiency virus (HIV), hepatitis, and other blood-borne diseases because of improper use of needles. Impairment can also lead to traumatic injuries such as falls, fractures, and head injuries.

Ultimately, it is important that all health providers are aware of the signs and symptoms of impairment and the state and institution requirements of reporting individuals suspected working while in an impaired state.

State and Federal Rules and Regulations

Virtually all states have rules and regulations regarding the use of drugs and alcohol as the basis for disciplinary actions, especially as it relates to diversion of drugs from patients. These states also require reporting of healthcare providers who are suspected of impairment; however, the rules and penalties vary from state to state.
The Florida Nurse Practice Act is an example of a typical state law regarding the use of controlled substances and the necessary reporting. Each healthcare provider should review the rules and regulations for their own profession in their state. An overview of the Florida Nurse Practice Act is as follows:

464.018 Disciplinary Actions

(h)  Unprofessional conduct, which shall include, but not be limited to, any departure from, or the failure to conform to, the minimal standards of acceptable and prevailing nursing practice, in which case actual injury need not be established.

Most states require the reporting of unprofessional conduct, whether it be by a nurse, physician, or allied health profession. 

Engaging or attempting to engage in the possession, sale, or distribution of controlled substances as set forth in chapter 893, for any other than legitimate purposes authorized by this chapter.

All states and the federal government oppose healthcare providers who engage in the unlawful sale of prescription or nonprescription controlled substances. Penalties for violation can include and jail sentences that vary by state.

(j)  Being unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, or chemicals or any other type of material or because of any mental or physical condition. In enforcing this paragraph, the department shall have, upon a finding of the secretary or the secretary’s designee finds that probable cause exists to believe that the licensee is unable to practice nursing because of the reasons stated in this paragraph, the authority to issue an order to compel a licensee to submit to a mental or physical examination by physicians designated by the department. If the licensee refuses to comply with such an order, the department’s order directing such examination may be enforced by filing a petition for enforcement in the circuit court where the licensee resides or does business. The licensee against whom the petition is filed shall not be named or identified by initials in any public court records or documents, and the proceedings shall be closed to the public. The department shall be entitled to the summary procedure provided in s. 51.011. A nurse affected by the provisions of this paragraph shall at reasonable intervals be afforded an opportunity to demonstrate that she or he can resume the competent practice of nursing with reasonable skill and safety to patients.

All states have varying rules regarding the prosecution of a healthcare provider that places a patient’s safety at risk. Healthcare providers have been prosecuted for felonies because of harming patients due to unprofessional and dangerous conduct such as illicit drug use.

(k)  Failing to report to the department any person who the licensee knows is in violation of this chapter or of the rules of the department or the board; however, if the licensee verifies that such person is actively participating in a board-approved program for the treatment of a physical or mental condition, the licensee is required to report such person only to an impaired professionals consultant.

Most states require healthcare providers to report to the appropriate authority a fellow healthcare provider who they believe is impaired. Failure to report the fellow healthcare provider may have negative consequences for the health practitioner that is aware of the impairment and fails to report to the appropriate authority.

(l)  Knowingly violating any provision of this chapter, a rule of the board or the department, or a lawful order of the board or department previously entered in a disciplinary proceeding or failing to comply with a lawfully issued subpoena of the department.

All healthcare providers must be aware of the nursing acts, rules, and regulations in each of the states they hold a license.

(m)  Failing to report to the department any licensee under chapter 458 or under chapter 459 who the nurse knows has violated the grounds for disciplinary action set out in the law under which that person is licensed and who provides health care services in a facility licensed under chapter 395, or a health maintenance organization certificated under part I of chapter 641, in which the nurse also provides services.

Healthcare providers have a moral and ethical duty to their patients to report another healthcare provider who exhibits a diminished capacity to perform their duties. Most states have laws that penalize a healthcare provider who fails to report another healthcare provider that is suspected of being under the influence of prescribed and non-prescribed drugs or alcohol.

(4)  The board shall not reinstate the license of a nurse who has been found guilty by the board on three separate occasions of violations of this chapter relating to the use of drugs or opioids, which offenses involved the diversion of drugs or opioids from patients to personal use or sale.

In many states, the ongoing use of drugs or alcohol can result in the permanent loss of a medical license. It is essential that healthcare providers review the health practice act in each state where they hold a license, and that they comply with the reporting requirements. If a healthcare provider is unsure of the requirements, most institutions will provide a professional to assist with understanding the reporting process.  

The American Nurses Association (ANA) has also released a Joint statement with the Emergency Nurses Association (ENA) and International Nurses Society on Addictions (IntNSA) which states:

  • Health care facilities must provide education to healthcare providers regarding alcohol and other drug use, and establish policies, procedures, and practices to promote safe, supportive, drug-free workplaces.
  • Health care facilities and schools of nursing must 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.
  • 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.
  • 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.

Most states have statutes that are designed to help healthcare providers identify and treat impaired health care providers. To prevent retaliation, most states have procedures in place for confidential reporting to an agency that can investigate the suspected substance and alcohol abuse. Almost all state boards require individuals who are aware of the substance or alcohol problem to report their fellow healthcare providers, and a healthcare provider who suffers from alcohol or drug use must self-report their addiction. Providing there has been no safety issues that directly affects patient care, the impaired healthcare provider can engage in treatment and rehabilitation and avoid board disciplinary action. However, if a healthcare provider is already under discipline, has been terminated from rehabilitation and treatment, has sold drugs or medications, or is at continuous risk to the public, the healthcare provider is less likely to be given the opportunity to seek treatment without public consequences .

Many federal laws also protect healthcare providers with substance use disorder who are seeking treatment. For example, The Americans with Disabilities Act (ADA) provides protection for healthcare providers in treatment and recovery programs for substance use disorder. The ADA ensures that people with disabilities have the same rights and opportunities as everyone else. This includes people with addiction to alcohol and people in recovery from opioid and substance use disorders. The Americans with Disabilities Act (ADA) describes a person with a disability as:

  • One who has a physical or mental impairment such as mental health disorder, alcohol addiction, or diabetes that substantially limits one or more major life activities, a person with a history of an impairment, such as cancer or recovery from illegal drug use, that substantially limited one or more major life activities.
  • A person who has been regarded as having an impairment, such as someone who has a family member who is HIV positive and is presumed to be HIV positive as well, and face discrimination as a result.
  • Someone with a disability who is treated negatively on the assumption of the disability.

Federal law does not consider a person to be disabled simply because they are using drugs. In addition, the Family Medical Leave Act (FMLA) requires employers to allow unpaid, job-protected time off for qualified substance use disorder treatment with continuation of group health insurance coverage under the same terms and conditions as one had not taken leave.

Courts and statutes usually protect a healthcare provider’s efforts to address substance use disorder issues, particularly if a healthcare provider has successfully completed treatment. However, if a healthcare provider harms a patient while under the influence of drugs or alcohol or an institution knowingly fails to protect a patient from an impaired healthcare provider, the consequences can be severe. Examples include the following:

  • A court granted immunity to the director of an impaired program who suggested that a healthcare provider’s privileges be suspended until they completed substance use disorder evaluation and treatment.
  • During a medical malpractice case, a healthcare provider refused to turn over substance use disorder treatment records. The court agreed and ruled those records were privileged and confidential.
  • A court dismissed a hospital from a malpractice suit that claimed negligent credentialing due to a healthcare provider’s prior alcohol and drug use. The court found that the provider had completed successful treatment and had complied with a monitoring program for years, and the hospital acted reasonably in granting privileges.
  • A patient sued the hospital for improper credentialing because a healthcare provider had committed malpractice in the past and was known by the hospital to be addicted to medications. The hospital was charged punitive damages for negligent credentialing.
  • A healthcare provider admitted to being under the influence of an opiate during a surgical operation, and a large punitive verdict was awarded.
Genetic Factors

Alcohol and substance use are a significant problem in the healthcare profession. It is thought that as much as 15% of all healthcare providers are impaired or recovering from alcohol or drug use. Diseases related to alcohol and drugs are one of the leading causes of preventable disability and death. While it is ubiquitous, it may be beyond the ability of the healthcare provider’s control. Genetic factors are thought to play a role in up to 60% of individuals who are at risk for addiction. Genetic factors include a family history of substance use disorder and neurotransmitter deficits. Genetic factors are not exclusive to being hereditary but are inclusive of environmental factors as well. For instance, a child of an alcoholic is two to three times more likely to struggle with alcohol abuse later on in life. This predisposition is not caused by inheriting the genes for alcoholism, but rather a result of environmental exposure that led to a specific expression of those genes. Statistically, a family history of alcoholism is linked to an increased risk of genetic predisposition to alcoholism, depending on how close the relatives are to each other. A child who has one parent who struggles with alcohol use disorder has a three to four times increased risk of becoming an alcoholic themselves. Having extended relatives, such as aunts, uncles, grandparents, and other family members that struggle with alcohol use does not have the same strong association. While these relationships can influence whether one inherits genetic mutations that predispose them to alcohol use disorder, growing up in an environment influenced by addiction can also predispose a person to the condition. The environment affects how genes are expressed and learned behaviors can change how one perceives drugs or alcohol.

Neurotransmitter deficits result from excessive use of drugs and alcohol. Nerve cells are responsible for nearly all the observations, communications, and actions that occurs in the brain and central nervous system. This is especially true as it relates to the process of substance abuse and addiction. Nerve cells will initially receive a signal that occurs with the consumption of a drug and will respond by releasing a specific neurotransmitter. Nearly all drugs work by blocking, interfering, or enhancing the natural processes of neurotransmitters, which results in feelings of euphoria and other desirable effects of drug use. There are seven neurotransmitters that are most notable. They are listed below:

AnandamideA neurotransmitter exclusively associated with use of marijuana and hashish. This neurotransmitter more specifically affects memory, helping to explain memory loss or impairment associated with chronic marijuana use.
DopaminePlays a role in substance abuse of nearly all types, but most notably cocaine, methamphetamines, and opiates. Dopamine is responsible for the “reward” feeling in the brain, and when stimulated consistently can lead to powerful drug addictions.
EndorphinsAct specifically as neurotransmitters for opiate-based drugs like heroin, morphine, Oxycontin, Fentanyl and many other prescription pain medications. Some consider opiates to be the most powerful type of drug addiction known.
Gamma-Aminobutyric Acid (GABA)Drugs like sedatives and tranquilizers stimulate and interfere with processes related to GABA function. This neurotransmitter can have dangerous effects due to its sedative action and central nervous system depressant behavior.
GlutamateA powerful and potentially dangerous neurotransmitter when released in large amounts and is triggered using potent substances like ketamine, angel dust, and alcohol. Glutamate influences the brain and central nervous system in fine and gross motor skills and learning functions.
NorepinephrineThis neurotransmitter is associated with the use of stimulants such as cocaine and methamphetamine. Cocaine also interferes with the normal functioning of norepinephrine, which affects sensory processing and can cause anxiety, among other effects.
SerotoninA neurotransmitter primarily associated with hallucinogenic drugs like ecstasy or LSD. Serotonin influences sexual desires and sleep during active drug use, but upon cessation can cause significant disruptions in the normal healthy functioning of both.

Alcohol and substance use of the healthcare provider contributes to accidental injuries while being impaired, missed work, decreased productivity while at work, medication errors, drug diversion, billing and insurance fraud, increased risk for communicable infections from contaminated drugs and needles, social harm, legal liability, undue patient pain, and increased health costs. Because of the extensive risks to patients and institutions, it is beneficial to assist healthcare providers in managing alcohol and substance use.

Excessive use of alcohol and diversion of drugs are seen throughout the healthcare profession, but they are most prevalent in healthcare providers who work in anesthesiology, emergency, intensive care, and pharmacy. The higher rate of drug use by these healthcare providers is thought to be as much as five times higher than the rate for nonmedical professionals. It is proposed that this is due to the high levels of stress that is associated with the fields of healthcare. It is also proposed that healthcare providers in these select fields of work have certain personality traits, such as high achievement, obsessiveness, and a high work ethic. Healthcare providers with these personality traits are at risk for using stimulants to maintain what they believe is a higher level of performance. Some healthcare providers may also engage in binge drinking, regular heavy drinking, and use of illicit drugs. Likewise, when a health professional develops a mental health issue such as depression, anxiety, schizophrenia, or severe personality disorder, the risk of impairment due to self-medication and treatment increase significantly. Health professionals have relatively direct access to prescription drugs, making it easier to obtain addicting medications. The impaired healthcare provider tends to use benzodiazepines and opiates more than illicit street drugs. This is most likely due to the ease of access to prescription drugs. Due to long hours, stress, and increasingly widespread workforce shortages in health care, substance use in healthcare providers is expected to increase.

Signs and Symptoms of Impairment

Dire consequences are associated with healthcare provider impairment. Often the impairment goes unreported or untreated because alcohol and substance users often do not admit they have a problem, and when they do, they will often self-diagnose and self-treat without seeking help from qualified professionals. Colleagues may also contribute to the lack of reporting out of fear of retaliation. Patients are also often uncomfortable reporting an impaired health provider, especially when the provider is responsible for their care. Impaired healthcare providers as well as their colleagues and patients are unlikely to act until an alcohol or drug problem reaches a critical level and results in a significant healthcare problem or legal involvement. For this reason, healthcare providers must recognize a clear ethical, moral, and legal duty to identify and report a colleague who is impaired. Unfortunately, while alcohol and drug use are considered by most to be a disease, healthcare providers are often reluctant to report their concerns. It is difficult for a colleague to confront a potentially impaired healthcare provider for fear of damaging their reputation, especially if the suspicion is proved to be wrong. Only two out of three healthcare providers with direct, personal knowledge of a colleague’s impairment will report a peer to the proper professionals, despite the legal risks for not reporting. In many cases, however, reporting may be the only approach that encourages the impaired healthcare provider to seek evaluation and treatment.

Impaired healthcare providers are often difficult to identify because they are often bright, well-trained, careful, and make a strong effort to avoid being caught. When the signs or symptoms of alcohol or drug use finally are noticed, the problem typically has been going on for a long time.

The following table of signs and symptoms of alcohol and substance use can help a healthcare provider identify a potential impaired colleague and diversion behaviors:

Abnormal wasted opioidsAltered ordersAnger management issuesArriving to work lateBloodshot eyes
Constricted pupilsDefensivenessDenialDiaphoresisDifficulty meeting deadlines
Dilated pupilsDiminished alertnessDiscrepancy in controlled substance recordsDisheveled appearanceDishonesty
DistractedDocumentation errorsExcessive sick timeFatigueFrequent accidents
Frequent mistakesFrequent pain complaintsFrequent report of patients not receiving pain reliefFrequent unexplained absencesFrequent use of gum or mints
HyperactivityHypoactivityImpossible reasons for behaviorIncreased opioids sign-outsInsomnia
Intoxication at social functionsIsolationLeaving work earlyLyingMaximum use of pain medications
Mood changesMood changesNot performing narcotic countsObsession with opioidsOffering to medicate patients
ParanoidPerforation of the nasal septumPoor chartingPoor concentrationPoor judgment
Poor quality workRounding at odd hoursRunny noseSedatedSleepiness
Slurred speechSuicidal thoughtsTrack marksTremorsUnexplained nausea, vomiting, or diarrhea
Unsteady gaitWatery eyesWearing long-sleeves at inappropriate times (hiding track marks)Weight gainWeight loss 

All healthcare providers should receive education regarding alcohol and substance use disorders. Employers should assist in improving healthcare provider knowledge about the signs and symptoms of alcohol and substance use disorder, offer guidelines that promote safe practices and a defined reporting mechanism for concerning situations, and offer assistance to healthcare providers who suffer from alcohol and substance use.

All healthcare facilities should be alcohol and drug-free environments. The risk of employing an impaired healthcare provider is reduced through pre-employment drug testing, cause testing when impairment is suspected, random testing, and regular practice evaluations, although each of these is controversial. While most institutions support pre-employment testing and cause testing for suspected impairment, less support for random testing of healthcare providers exists. Further, not all healthcare providers working in a hospital setting are employees of the institution, such as with contract and registry workers. Having healthcare professionals who are contract or registry workers make it difficult for an institution to mandate drug screening.

Steps to Reporting Impaired Peers
  1. Evaluate the signs and symptoms expected and compare them against the overt findings of the peer. Ask honest questions. Compare the signs and symptoms associated with impairment against those of the colleague. If there is a strong suspicion, it is better to err on the side of patient safety and report.
  2. Concerned about reporting? Review personal ethics, morals, and the principles under which you became a health professional. A fellow professional should not be allowed to use substances and place a patient’s safety at risk. Would anyone want them caring for his or her own family member in their present state? Allowing another professional to continue to use alcohol or drugs and place patient lives at risk is not appropriate. No matter what the consequences to the individual, reporting is the proper course of action. Enabling another health professional to cover up their alcohol or drug use is not appropriate, and it is dangerous. Do not make excuses or cover up for an impaired healthcare provider. The potential is not only the individual will be harmed but also their patients. The healthcare provider has, unfortunately, put themselves in the situation and must accept the consequences.
  3. Consider and review hospital and state reporting requirements. Become educated about the rules and regulations. Most states and institutions will protect a reporting healthcare provider against the retaliation of a colleague. Review the organization’s policies and procedures regarding alcohol and substance use and the assistance the institution offers. If unsure, consider contacting the risk management nurse or lawyer of your institution. Usually, either one can assist in following the appropriate steps. If these resources are unavailable, consider discussing the situation with the department manager.
  4. Once a fellow healthcare provider is identified as potentially having an alcohol or drug use disorder, report it immediately to avoid any negative consequences for the individual reporting, the patients, or the individual with the disorder. While it may initially seem like a negative, reporting a peer is a positive that protects patients and gets your colleague into a treatment program before they cause a severe or even fatal medical error. Once criminal behavior or patient safety is abrogated, the consequences are severe. The sooner an individual is investigated, the less likely they are to do real harm.

Unfortunately, sometimes it may be easier to pass the problem on to someone else. It is crucial not to ignore signs or symptoms of impairment. It is inappropriate to transfer an impaired healthcare worker or threaten termination. Passing the problem on to another department or institution is not an ethical or moral solution.

Diagnosis of Alcohol and Substance Abuse Disorder

Substance use disorder is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which is the standard classification of mental disorders used by mental health professionals in the United States. The criteria for substance use disorder is divided into three categories: mild, moderate, and severe. Substance use disorder occurs when the recurrent use of alcohol and/or drugs causes significant impairment including health problems, disability, and the inability to meet major responsibilities at home, work, or school. A diagnosis of substance use disorder is based on evidence of social impairment, impaired control, risky use, and pharmacological criteria. The evaluation of a healthcare provider with a substance use or potential substance use disorder is a challenge. Healthcare providers may make efforts to hide or cover up their use of alcohol or drugs. Evaluation and diagnosis for impairment of the healthcare provider should be conducted by a clinician experienced in dealing with substance use disorder.

Substance use disorder is described as a problematic pattern of use leading to clinically significant impairment or distress that is manifested by two or more of the following experiences within a 12-month period:

  • Often take larger amounts or for a longer period than was intended.
  • Persistent desire or unsuccessful efforts to cut down or control use.
  • A great deal of time spent in activities necessary to obtain, use, or recover from the substance’s effects.
  • Crave or have a strong desire or urge to use the substance.
  • Recurrent use causing failure to fulfill primary role obligations at work, school, or home
  • Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by its effects.  
  • Important social, occupational, or recreational activities are given up or reduced because of use.
  • Recurrent use in situations in which it is physically hazardous.
  • Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that was likely caused or exacerbated by the substance.
  • Tolerance
  • Withdrawal

DSM-5 specifies mild, moderate, and severe based on the number of diagnostic criteria met by the healthcare provider at the time of diagnosis:

  • Mild: 2 to 3 criteria 
  • Moderate: 4 to 5 criteria       
  • Severe: 6 or more criteria

    Substance use disorders are associated with several negative consequences for healthcare providers, including the following toxic effects:  
AmphetaminesEuphoria, grandiosity, pupillary dilation, prolonged wakefulness, hypertension, tachycardia, anorexia, fever, paranoia, cardiac arrest, and seizures
Barbiturates Respiratory depression
Benzodiazepines Respiratory depression
CocaineImpaired judgment, pupillary dilation, hallucinations, paranoid ideation, angina, and sudden cardiac death
LSD Visual and auditory hallucinations, depersonalization, anxiety, paranoia, psychosis, and flashbacks
Marijuana Euphoria, anxiety, paranoid delusions, the perception of slowed time, impaired judgment, amotivational syndrome, dry mouth, increased appetite, conjunctival injection, and hallucinations
MDMAEuphoria, disinhibition, hyperactivity, life-threatening hypertension, tachycardia, hyperthermia, hypernatremia, and serotonin syndrome
Opioids Respiratory and CNS depression
PhencyclidineViolence, impulsivity, psychomotor agitation, nystagmus, tachycardia, hypertension, analgesia, psychosis, delirium, and seizures

Alcohol use disorder is the medical term for alcoholism and alcohol abuse. The DSM-5 has specific diagnostic criteria for evaluating and diagnosing alcohol use disorder which include the following:

• A great deal of time spent obtaining, using, or recovering from alcohol
• Alcohol craving
• Continued drinking despite alcohol-related social or interpersonal problems
• Continued drinking despite knowledge of physical or psychological problems caused by alcohol
• Drinking in larger amounts or over longer periods than intended
• Evidence of alcohol withdrawal or use of alcohol for relief or avoidance of withdrawal
• Evidence of tolerance
• Important activities are given up or reduced because of drinking
• Persistent desire or unsuccessful attempts to stop or reduce drinking
• Recurrent drinking in hazardous situations
• Recurrent drinking, resulting in failure to fulfill role obligations

The severity of alcohol use disorder at the time of diagnosis can be specified based on the number of symptoms present:
• Mild: Two to three symptoms
• Moderate: Four to five symptoms
• Severe: Six or more symptoms

Toxic effects include emotional lability, slurred speech, ataxia, blackouts, coma, and death. More than 85,000 deaths a year are directly attributed to alcohol use.

There are also multiple behaviors associated with drug diversion. The following is a short list of frequent behaviors of the impaired healthcare provider:

• Altered orders for drugs
• Controlled substance discrepancies
• Frequent trips to the bathroom
• Frequent medical loss
• Frequent corrections on medication records
• Higher-than-average opioid administration
• Higher-than-average opioid wastage
• Incorrect counts (particularly opioids)
• Patients complaining of poor pain relief
• Tampering with capsules or vials
• Unexplained disappearance

In some instances, alcohol and drug use have an underlying organic or inorganic cause. One must consider the possibility that the impaired healthcare provider is using alcohol or illicit drugs to cover up psychosis, schizophrenia, mania, bipolar disorder, organic brain disorder, or personality disorders.

Laboratory Testing to Confirm the Diagnosis

Diagnosis of an alcohol problem can be made in the outpatient department by using Cut down, Annoyed, Guilty, and Eye-opener (CAGE) questionnaire which includes the following:

  • Have you ever felt you needed to Cut down on your drinking?
  • Have people Annoyed you by criticizing your drinking?
  • Have you ever felt Guilty about drinking?
  • Have you ever felt you needed a drink first thing in the morning
    (Eye-opener) to steady your nerves or to get rid of a hangover?

Each response to the four CAGE questions is scored with points; either 0 points for “no” or 1 point for “yes.” The higher the score, the greater the indication that the patient might have problems controlling alcohol consumption or an AUD. A total score of 2 is clinically significant and that the patient should be subject to further review for alcoholism.

Screening tools like The Ten question Alcohol Use Disorder Identification Test (AUDIT); a 10-item screening tool developed by the World Health Organization (WHO) to assess alcohol consumption, drinking behaviors, and alcohol-related problems, and The abbreviated 3-question Audit-consumption (Audit-C) are also recommended for screening. Likewise, the following laboratory tests are also recommended in determining alcohol and substance use:

  • Serum alcohol concentration
  • Direct alcohol biomarkers: Ethyl glucuronide
  • Liver enzymes – aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin, and albumin to test for liver damage. An AST: ALT ratio of 2:1 is indicative of alcohol-induced liver disease.
  • Hemoglobin, complete blood count – to determine the presence and severity of anemia, pancytopenia, and macrocytosis. A mean corpuscular volume greater than 100 fL constitutes macrocytosis. Pancytopenia and macrocytosis usually require very heavy prolonged use and often liver disease.
  • Gamma-glutamyl transferase (GGT) – an indicator of excessive alcohol use when elevated. The reference range is 8 to 40 units/L (females) and 9 to 50 units/L (males).
  • Drug of abuse screen
  • Urine drug levels
  • Blood drug levels
  • Hair drug levels
  • Saliva drug levels
  • Breath drug levels
Evaluation and Treatment

Often, the evaluation and treatment of a healthcare provider with alcohol or substance addiction is challenging. Typical treatment occurs over months to years and includes follow-up care and monitoring, sometimes by legal entities. The most important predictor of successful treatment is when a healthcare provider admits the addiction and is willing to accept and follow the prescribed treatment. In many cases, treatment is forced upon a healthcare provider by a court or medical board, or it occurs because of peers, family, and friends intervening and encouraging therapy. Those who are self-motivated and have insight into their disease are much more likely to have a successful treatment outcome.

All healthcare providers need to be familiar with the reporting requirements of peers with alcohol or drug addiction within their institution and in their specific state. If a healthcare provider suspects a colleague has an alcohol or substance use problem, they should refer the impaired healthcare provider to the proper authority in their institution or state. In several states, reporting is required by law. In states where it is required, immunity is usually granted if reporting is not done with malicious intent.

There are two types of programs that assist an impaired healthcare provider; programs that are operated by state licensing boards to deal with an impairment that has resulted in harm to patients, and health programs managed by societies, which seek to help healthcare providers with substance use issues before they harm patients or commit crimes.

The following are some of the treatment options available to help alcohol and drug-impaired healthcare providers:

  • Professional associations offer peer assistance programs to assist impaired healthcare providers
  • State boards offer peer assistance programs and support for healthcare providers that voluntarily or through mandate seek counseling and treatment
  • Professional schools provide programs for their students
  • In Florida, Rule 64B31-10.001 pairs an impaired healthcare provider with a program or consultant to provide intervention, evaluation, and referral. The program monitors the impaired healthcare provider and no medical services are provided.

Treatment and evaluation programs are state licensed and accredited. Programs usually have a multidisciplinary team to manage the healthcare provider. Depending on the degree of addiction, services may be in either an outpatient or inpatient setting and can be modified depending on the impairment affecting the healthcare provider.

Treatment Techniques of Alcohol and Substance Abuse

It is challenging to treat any healthcare provider for alcohol or substance use disorder, and it is more challenging if the treatment is under duress. Treatment usually involves the following steps:

  • Intervention that is voluntary, in an institution, or mandated by a licensing board
  • Evaluation of the healthcare provider to determine the degree of impairment
  • Settings that consist of inpatient or outpatient treatment and depends on the healthcare provider’s degree of addiction and their risk for withdrawal
  • Treatment occurs through counseling, group therapy, or residential inpatient treatment program

Healthcare providers have a high success rate when they accept their disease and are willing to undergo treatment. Most health professionals who undergo intervention and treatment early and have not harmed a patient or committed a crime, can retain their licenses, and eventually return to clinical practice.

Florida Mandated Impaired Practitioner Treatment

Under Chapter 456, there are designated treatment program requirements for impaired healthcare providers.

In Florida, a healthcare provider can avoid disciplinary action if they admit the impairment, voluntarily enroll in a treatment program, withdraw or limit practice as prescribed by the impairment consultant managing the case, and release all medical records to the consultant managing the case.

Florida Intervention Project for Nurses

In Florida, nurses have the option of the Intervention Project for Nurses. This is a statutorily approved evaluation and treatment program approved for impaired nurses. Intervention Project for Nurses consultants are designated via contract to initiate interventions, recommend evaluations, and refer those deemed impaired to appropriate treatment programs. The Intervention Project for Nurses also monitors the long-term care of the nurses in the program.

  • All treatment programs in Florida must gain approval by the Intervention Project for Nurses.
  • The Intervention Project for Nurses does not provide treatment; it only providers referral and monitoring.
  • Programs include state-licensed psychiatrists, counselors, and addiction specialists that specifically treat healthcare professionals.
  • Intervention Project for Nurses facilities hold a multi-disciplinary, state-licensed, and they may include outpatient, residential, partial, or complete hospitalization.
  • Treatment programs accredited through the CARF International or the Joint Commission.
  • Treatment programs and providers must apply and gain approval by the Intervention Project for Nurses.
  • The Intervention Project for Nurses provides a list of available programs and providers.
  • Additional information found on the state board website.
Intensive Outpatient Programs

These programs provide regular, intense treatment but limit disruption to family, school, or work schedules. The healthcare provider stops practice until successful treatment is completed and they have reached the stage of monitoring where they can return to patient care. Outpatient licensed counselors usually meet with the healthcare provider for several hours, multiple times each week.

Residential Programs

Typically, these programs are located within a hospital or a specialized facility where healthcare providers live in a highly structured environment for 30 to 90 days. In the early phase, the healthcare provider may undergo medical withdrawal and detoxification. Eventually, these they will transition to outpatient programs.

Partial Hospitalization Programs

Includes regular intensive daily sessions, usually five days per week, but the patient does not stay overnight.

Institutional Programs 

An employer may mandate a healthcare provider to obtain treatment for impairment or face reporting and termination. Some employers offer addiction assistance programs to help with alcohol or drug problems. Programs often include health promotion, education, referral to treatment centers, treatment, and are often employer paid.

It is expensive for an employer to hire and train a healthcare provider. Employers often are willing to assist a healthcare provider with the help they need to maintain their job and career. By providing treatment to a healthcare provider, the employer will save the cost of job replacement, avoid accidents that  can cause harm to a patient, and reduce the risk of liability issues for the institution, decrease absenteeism, and avoid workers compensation claims.

Prognosis

The prognosis of alcohol and substance abuse depends on early versus late diagnosis, motivation of the healthcare provider with the identified impairment, follow-up treatments, and the success of cognitive behavior therapy. Healthcare providers who are motivated to maintain their career and healthcare licenses often are more often successful in their treatment and go on to lead productive careers.

Acute and long-term treatment and monitoring are necessary to care for patients with alcohol and substance use disorders.

Example of Reporting Requirements in Florida

Each state has different requirements for reporting of an impaired peer. If a healthcare provider believes a peer has an alcohol or drug problem, it is essential that they report it to their supervisor and the appropriate state-mandated authorities.

For example, in the State of Florida, the nurses have developed an effective reporting and treatment system. Nurses report to the Florida Department of Health or Intervention Project for Nurses. The call to the Intervention Project for Nurses is confidential. The Intervention Project for Nurses can be reached at 800.840.2720. The Intervention Project for Nurses in Florida provides an opportunity for intervention and monitoring of nurses that use alcohol or drugs. Many states have similar reporting mechanisms for healthcare providers.

In Florida, the Intervention Project for Nurses provides:

  • Rehabilitation in a confidential, non-punitive manner
  • The goal is to treat the health professional instead of the more punitive sanction of permanently losing their license
  • The Intervention Project for Nurses helps get the nurses into recovery and treatment program
  • The nurse does not return to practice until the Intervention Project reports they are safe to return to clinical duties

In Florida, any practitioner who believes a nurse is unsafe because of alcohol or drugs should make a report to either the Intervention Project for Nurses or the Department of Health. The Nurse Practice Act of the Nurse Practice Act states “Failing to report to the department any person who the licensee knows is in violation of this part of the rules of the department or the Board; however, if the licensee verifies that such person is actively participating in a board-approved program for the treatment of a physical or mental condition, the licensee is required to report such person only to an impaired professionals consultant.”

In Florida, the Intervention Project for Nurses provides an acceptable alternative to a legal remedy with discipline. Benefits of the Intervention Project for Nurses include:

  • Early recognition of impairment
  • Rapid intervention
  • Stops nurse’s practice for days rather than the Department of Health process which may take 1 to 2 years
  • Standardized evaluation process
  • Standardized treatment process
  • Standardized monitoring process that may involve the employer
  • Identifies potential relapses quickly
  • Avoids negative consequences, essentially getting evaluation and treatment before serious safety and criminal violations become apparent or are reported
The Florida Intervention Project Process
  • Self, peer, or employer referral
  • Intake evaluation
  • Intervention options offered
  • Professional selects intervention
  • If they do not agree on an intervention or fail to comply, they are reported to the Florida Department of Health
  • Continued monitoring by Intervention Project for 2 to 5 years
Benefits of the Florida Intervention Project for Nurses
  • Evaluates and quickly determines fitness to practice
  • Long-term monitoring
  • Long-term recovery support
  • Support and relapse prevention groups available
  • The nurse signs a contract
  • The nurse evaluated on progress
  • The nurse gets random blood or urine drug screens
  • Qualified practitioner treatment pre-screened
Fitness to Practice

The Intervention Project will evaluate and access a nurse’s ability to safely practice including stability, recovery, support systems, and specific job skills including problem-solving, judgment, cognitive function, and coping skills. The Intervention Project makes several requirements of the nurse and determines when they can return to work. Requirements and determinations include the following:

  • Agree to practice restrictions including no overtime and settings with less controlled narcotic access
  • Agree to random drug screens
  • Continued and ongoing treatment
  • Treatment required and completed to safely practice
  • Signed advocacy contract
  • Relapse prevention workbook
  • When the nurse can return to practice
  • Workplace monitoring and reporting

If a nurse consistently meets the fitness to practice guidelines set in place with positive work and monitoring reports, negative drug screens, regular attends support group meeting, meets their contract agreement they are quickly reintroduced into the workforce. After the Intervention Project program is successfully completed, fitness to practice is established, and long-term monitoring is completed, the nurse’s record is sealed. However, if the nurse fails the process, they will be reported to the Department of Health for disciplinary proceedings.

The Intervention Project process does not hire the individuals that provide evaluation or treatment, but it does offer appropriate referrals to health professionals skilled in the assessment and treatment of individuals with alcohol or drug addiction. Referrals made to local addiction specialists that work within the community.

Perhaps one downfall of the Intervention Project is that while the nurse does not have to pay for a referral to the Intervention Project for Nurses, they are personally responsible for paying for evaluation, treatment, and random alcohol and drug testing. This cost can be particularly onerous, considering the nurse is usually unable to work during the initial phases of evaluation and treatment. Fortunately, in many cases, employers and insurance policies pay for these services.

Conclusion

Healthcare providers must be able to recognize the signs and symptoms of impairment. They should also be able to evaluate their colleague’s job performance and consider the possibility of substance or alcohol use when consistent deficient performance is observed. They also must be able to identify the patterns of alcohol and substance use and know how to appropriately intervene by contacting a supervisor, institutional administration, or governmental agencies. Virtually all healthcare providers will encounter one or more impaired colleagues during their career. Without a solid knowledge of how to deal with the situation and institute a plan of action, significant and dangerous impairment problems may get buried and ignored. This burial has the potential to place the individual, peer, and the institution at risk. The key is to recognize a colleague that is impaired and needs help, documenting all findings in a clear and concise manner, reporting to the appropriate manager or state authority, and then making sure the colleague gets the help they need. The laws and statutes for reporting alcohol and substance use in a healthcare provider varies by states and it is the responsibility of the healthcare provider to be aware of the laws and statutes in the states where they hold licensure.

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