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Alcohol and drug addiction: a sensitive issue for nursing.

The National Council on Alcoholism and Drug Dependence (NCADD) and the American Society of Addiction Medicine published their definition of alcoholism as "a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations ... It is characterized by continuous or periodic impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial" (JAMA, 1992). A substance abuse disorder is a legitimate disease like other common medical disorders such as Type II Diabetes, obesity, and many types of cardiovascular diseases and cancers. It has clear, definable symptoms. It can be diagnosed accurately and its progression can be predicted (Chemical Dependency Handbook for Nurse Managers, 2001).

Alcoholism: Some facts, consequences, and costs

* There are more deaths and disabilities each year in the U.S. from substance abuse than from any other cause.

* About 18 million Americans have alcohol problems.

* More than half of all adults have a family history of alcoholism or problem drinking.

* More than nine million children live with a parent dependent on alcohol and/or illicit drugs.

* One quarter of all emergency room admissions, one-third of all suicides and more than half of all homicides and incidents of domestic violence are alcohol-related.

* Heavy drinking contributes to illness in each of the top three causes of death; heart disease, cancer, and stroke.

* Almost half of all traffic fatalities are alcohol-related.

* Fetal alcohol syndrome is the leading known cause of mental retardation.

* Alcohol and drug abuse costs the American economy an estimated $276 billion per year in lost productivity, health care expenditures, crime, motor vehicle crashes and other conditions.

* Untreated addiction is more expensive than heart disease, diabetes and cancer combined.

* Every American adult pays nearly $1,000 per year for the damages of addiction.

(Nursing Knowledge International, 2006)

In general, it is estimated that 10% of the population has the disease of addiction. Nurses are equally susceptible to alcoholism, but are at a higher risk for drug addiction. Some studies have indicated that it may be 50% higher than the general population. So, in Nevada, we have approximately 30,000 licensed nurses--if we do the math, this statistic would indicate that we have about 3,000 licensed nurses who will meet diagnostic criteria for alcohol addiction at some time in their lives.

Cross addiction occurs when an addict realizes moods and feelings can be altered by mind altering chemicals. When one chemical becomes unavailable or problematic, the addict may become cross addicted to another chemical or behavior. Opioid addiction may progress to heroin addiction. Alcohol addiction may lead to benzodiazepine addiction. Rather than specify the type of chemical that one is addicted to, intervention and treatment must address the addictive behavior with a behavioral change.

When you think of a nurse addict, what do you imagine? Maybe you picture a lower functioning, incompetent individual who frequently calls out sick? You may think that you know about addiction and can detect an addict a mile away. You may say to yourself that you would never become addicted because you know better. You may be surprised to learn that the profile of an impaired nurse is contrary to what many believe. If you work with 10 nurses, without doubt one of those nurses is struggling with or is in recovery from the disease of addiction.

Addiction as a primary disease (not a symptom of another disease) is acute, chronic, progressive and predictable.

It is manifested in symptoms such as overdosing, acute withdrawal, or accidents needing emergency care. It is permanent as it requires changes in behavior at the onset of treatment and throughout the addict's life. It requires adherence to a daily regimen much like diabetes. Without treatment, the symptoms of the disease of addiction are exacerbated, affecting more and more systems with increasing severity. Sobriety may interrupt the symptoms, but the progression of the disease continues. Upon relapse, the severity of the symptoms picks up where it left off.

A colleague of mine once described addiction as a switch that gets flipped. An individual may go through life absent of addictive symptoms when a crisis flips the addiction switch. That crisis may be the loss of a loved one, a divorce, experiencing victimization in any form, even surgery or a motor vehicle accident. The switch turns on the disease of addiction and, from that time on, the individual must work daily to manage the symptoms of disease.

Addiction is incurable, irreversible, and ultimately fatal.

Today, there are no effective cures, only management of the symptoms to prevent an acute episode. Complete abstinence from mind altering chemicals, including alcohol, is necessary if the addict is to return to a "normal" life. Addiction is fatal; it actually wants to kill its host. It waits in the wings to consume the addict's life; give it the opportunity and death is eminent.

As with any other chronic disease, anyone can develop the disease of addiction. The signs and symptoms are not readily apparent in the early stages. There is a genetic element that predisposes an individual to this disease, but this genetic loading does not guarantee the development of addiction. Anyone who is exposed to mind altering substances is at risk for this disease.

The Impaired Nurse

Nurses have a higher predisposition for chemical addiction than the general population. As nurses, we believe that drugs really do work, so why not for us? We self diagnose and self medicate and believe that a pill or an injection will readily relieve pain and suffering because we see that it does every day. Erroneously, we believe that because we are educated about medications we are not as susceptible to abusing them. We have ready access to narcotics, and, as the Board's attorney puts it, we have the keys to the candy store.

Nursing is an extremely stressful role. Working a variety of shifts can lead to disrupted sleep patterns and deprivation. Although we work in an environment of literal life and death circumstances, we are expected to control our emotions--often a difficult, if not impossible, task. Patients are sicker than ever and resources have dwindled. Crises are commonplace in healthcare settings and nurses are expected to cope and "fix it."

Employers can enable a nurse to stay steeped in her addiction through a lack of knowledge about the disease of addiction, especially in how to confront suspicious behavior. Denial is strong in the addict and in colleagues and employers who may fear litigation based on an accusation of impairment. Rationalization of a nurse's behavior and excusing sloppy performance is sometimes easier than confronting what appear to be addictive symptoms. In the absence of a "dirty" drug screen, the employer may doubt having legal grounds for termination and reporting to the Board of Nursing.

This enabling behavior is dangerous. Patients are put in jeopardy as the nurse becomes increasingly ill. The employer does a disservice to the nurse when intervention could be life-saving by recommending treatment and recovery for this deadly disease. We have heard from those nurses who are successful in keeping their disease in remission that they are thankful that their employer and colleagues cared enough to intervene.

At the Board, we have fielded telephone calls from employers and colleagues about how to identify nurses who may be diverting medications, impaired, or have the disease of addiction. The attached table is a helpful tool in identifying when a nurse is in need of intervention.

When does a nurse's drug use become a problem? When it affects another person, whether it is exposing other nurses to working with someone who is either impaired or diverting drugs, exposing patients to potential harm by the impaired nurse or by depriving them of the pain medication that is being diverted by the nurse, or by defrauding patients of financial resources because the drugs that the nurse has diverted are being billed to the patients. Managers and colleagues have a fundamental role in early recognition and intervention in the face of a nurse's addiction. Being knowledgeable about the disease of addiction and its warning signs will prepare us to intervene before harm comes to patients and to those who need our support, the nurses with this chronic, progressive, and often fatal disease.

"Helping the impaired nurse is difficult, but not impossible. The choices for action are varied. The only choice that is clearly wrong is to do nothing." NCSBN, 2001

By Debra Scott, MSN, RN, FRE

Executive Director, Nevada State Board of Nursing

Shakiness Mood alterations/swings Diligent/extra shifts

Tremors Inappropriate laughter Frequent requests for
 work schedule/
 assignment alterations
 to get drug access

Slurred speech Hyperactivity/sedation Difficulty completing
 assignments in a
 timely manner

Watery eyes Depression Sloppy documentation

Constricted or Impaired concentration Unacceptable behavior
dilated pupils

Diaphoresis Blackouts Appearance on unit on
 days off

Unsteady gait Hiding track marks with Frequent trips to
 long sleeves bathroom

Runny nose Accidents/emergencies Brief unexplained
 absences from unit

Nausea, vomiting, Relationship problems Medication errors

Wt loss/gain C/o physical pain Isolation from

 Insomnia Mood changes after

 Frequent reports of
 poor pain relief by

 Obsession with
 narcotic cabinet
 or Pyxis

 Volunteering to
 medicate co-workers'


Large amounts of wasted narcotics attributed to one specific nurse

Many narcotic sign-outs by a particular nurse

Significant increases in stock replacements

Discrepancies between narcotic record and patient record

Discrepancies between patient reported pain relief and patient record

Alterations of verbal or telephone orders for controlled substances

Frequent incorrect narcotic counts

Evidence of vial tampering

Using Pyxis code of another nurse
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Author:Scott, Debra
Publication:Nevada RNformation
Date:Aug 1, 2010
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