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(Editor’s note: In this first part of a two-part series on addictions among health care professionals, we explore why same-day surgery professionals are particularly at risk and give you three suggestions for addressing the issue. We provide a warning list of signs of addiction and give you a list of additional resources. We also share one nurse’s nightmare when she had one incident of misusing a drug. In next month’s issue, we’ll examine why anesthetists are more at risk, tell you signs that an anesthetist is addicted, and discuss return-to-work issues.)
Susan graduated in the top third of her class at nursing school. She was committed to her career in outpatient surgery and loved being a nurse. Along the way, she sacrificed her own personal health by working long hours, taking extra shifts without a break, and rarely asking for a day off. As the number of surgery cases increased, she tried to maintain perfectionism. She began using drugs to keep her going until the end of the day. As she became addicted, her life began to spiral downward. She never meant for her situation to get this bad, but she had been caught stealing drugs from her employer. She couldn’t face anyone, not even members of a recovery group.
Reluctantly, she joined a group of five other health care professionals who had gone through similar experiences. She learned that her addiction was a disease and that she needed to get well. Susan completed her recovery and successfully returned to work.
The average person doesn’t hear about the success stories such as this one, says Nancy Kehiayan, RN, MS, CS, director of the Colorado Nurse Health Program in Lakewood. "The only people we hear about are people like Robert W. Downey Jr., who’s famous," says Kehiayan, referring to the actor who, after a series of drug troubles and criminal run-ins, recently was sentenced to spend a year in a live-in drug rehabilitation program.
Kehiayan’s program was developed by the state board of nursing as an alternative to the board’s disciplinary process. It provides nurses with opportunities and support for recovery and treatment. The program has graduated 73 nurses. A large percentage of them are still practicing "and taking care of hundreds and hundreds of patients," Kehiayan says.
In general, about 85% of health care professionals avoid relapses after receiving treatment, says Eric B. Hedberg, MD, associate medical director of the Talbott Recovery Campus in Atlanta, which specializes in chemical dependency treatment of medical professionals. "The 15% that do relapse generally have other psychiatric diagnoses or other circumstances that play into the relapse," Hedberg says.
People who work in outpatient surgery particularly are at risk for addictions, says Diana Quinlan, CRNA, MA, chairwoman of the Peer Assistance Advisors Committee at the American Association of Nurse Anesthetists in Park Ridge, IL. (See "What are the warning signs of chemical dependency?" in this issue.) One reason is the high volume of cases, Quinlan says. "Every time you set up drugs for another case, you increase risk," she says. "When you’re doing 10 cases a day and have rapid turnover, things can get a little slipshod as far as narcotic accountability."
In fact, surgery centers have gained a reputation as sorely lacking in accountability for unused narcotics, Quinlan says. "Sometimes I hear the story that no one counts [unused] drugs for weeks at a time," she says.
The lack of accountability puts every professional in the facility at risk because anyone can appear to be the offender when drugs are misused, Quinlan says. "It can be my word against someone else’s word," she says. "I want something more concrete than that to protect me as a provider." Also, surgery centers often don’t have resources for "fancy" systems for narcotic accountability, Quinlan says. "That’s makes them vulnerable," she says.
The stress of being pushed to handle a large volume of cases, coupled with rapid turnover, can create an environment that makes it easier for professionals to start using narcotics, Quinlan says. "Life is stressful, you get pushed to the limit, and you never know what you’ll do," she says. (See "Misuse of drugs: One nurse’s nightmare," in this issue.)
Anesthetists, in particular, are overrepresented among health care professionals with addictions, according to Quinlan and others. In fact, "The greatest occupational hazard facing the CRNA [certified registered nursing anesthetist] is not hepatitis B, nor HIV, but rather substance abuse," Quinlan maintains.1
Hedberg agrees that anesthetists are most at risk. "For ORs and surgicenters, the population that’s going to have the largest incidence of substance abuse is anesthesia," he says.
According to the Epidemiologic Catchment Area program of the Bethesda, MD-based National Institute of Mental Health, the lifetime prevalence of substance-use disorders among adults in the United States is 16.4%, Hedberg says. "So you have to assume that at least as many health care professionals will have substance-abuse problems, and it may be higher among health care professionals due to availability," he says.
Consider the following suggestions for addressing drug and alcohol addiction in your program:
• Be familiar with legal issues. Know your state’s requirements regarding chemical dependence among health care professionals, advises the Park Ridge, IL-based American Society of Anesthesiologists (ASA) in a brochure titled Chemical Dependence in Anesthesiologists: What You Need to Know When You Need to Know It. (For information on how to access the brochure, see "Resources," at end of article.) "Hospitals, medical staffs, and individual physicians have occasionally been found negligent for failure to monitor or restrict the privileges of an impaired physician," the association warns. "Therefore, to be aware of and yet to ignore chemical dependence may result in legal liability."
Most states provide immunity to members of a professional society or medical staff committee whose purpose is to review the quality of medical services, the ASA says. "Persons who give information to such committees are also usually granted immunity, providing they believe the information is true; they are not reporting it with malice; and they discuss it only with the committee," the association says.
• Designate an individual to deal with addiction concerns. Have a designated person in your program that an individual can go to and expect care and concern, not punitive action, urges William P. Arnold III, MD, associate professor of anesthesiology at the University of Virginia Health System in Charlottesville and former chair of the ASA’s Task Force on Chemical Dependence. What’s the proper response? Show "tough love," Arnold says, "which might imply saying, You’re not going to be working for a while, and we’ll refer you for evaluation and treatment if indicated.’"
Initially, professionals typically are worried about the impact on their careers, Arnold says. "I have a couple of responses," he says. "One is that, Your career is already in jeopardy.’ The second is that, trying to predict the future is not the right thing to do at the time. Initially, it’s one day at a time.’"
Human resource staff and employee assistance program staff can be helpful, Kehiayan suggests. "It’s very hard for managers to get involved in psychiatric and chemical dependency," she says. The important step is to make a referral and ensure the professional gets treatment, Kehiayan says.
• Have a better accounting system for wasted drugs. The standard practice in health care facilities is for the wasting of drugs to be observed by another person, Kehiayan says. However, "nurses are very busy and trust each other," she says. "They think, OK. I’ll sign for that,’ but they don’t always observe." If you’re not accounting for every drug, you’re not doing your best for your patients or employees, Quinlan maintains. She contends that no drug should be "wasted."
"If it’s not all administered, it should be returned to a responsible individual to dispose of it properly," she advises. "Having a nurse watch you as you dump a clear liquid substance in a trash can, and you say it’s fentanyl, and the nurse signs off, is ridiculous. We don’t know it’s fentanyl."
Misco in Cleveland offers hand-held products that perform quick chemical analysis on site. (For contact information, see "Sources," at end of this article.) These devices, which cost approximately $300, perform quick chemical analyses. You can perform random tests as part of your quality assurance process, Quinlan suggests. Your staff may see this as another layer of "red tape" that slows down their day and makes it more difficult, she warns. "But another level of accountability is another level of protection," Quinlan advises.
1. Quinlan D. Peer assistance: A historical perspective. AANA NewsBulletin 1996; 50:14-15.
For more information on impaired health care professionals, contact:
• William P. Arnold III, MD, Associate Professor of Anesthesiology, University of Virginia Health System, P.O. Box 800710, Charlottesville, VA 22908-0710. Telephone: (434) 924-2283. E-mail: firstname.lastname@example.org.
• Nancy Kehiayan, RN, MS, CS, Director, Colorado Nurse Health Program, 44 Union Blvd., Suite 630, Lakewood, CO 80228. Telephone: (303) 716-0212, ext. 103. Fax: (303) 716-0789. E-mail: email@example.com.
For more information on hand-held devices that perform chemical analyses, contact:
Every state medical society has a program for the identification and management of chemically dependent physicians. Most of these will provide assistance with confidential investigation, intervention, treatment referral, and aftercare monitoring, and will advocate for the recovering physician with the state board of medicine.
The telephone number for the American Society of Anesthesiologists’ (ASA) Hotline on Chemical Dependence is (847) 825-5586. With strict confidentiality, personnel will provide callers with the appropriate telephone numbers for their locality and, if possible, will offer the name of a confidential consultant who can provide additional information and resources.
A brochure titled Chemical Dependence in Anesthesiologists: What You Need to Know When You Need to Know It is available on the web: www.ASAhq.org/ProfInfo/chemical.html. The brochure is also available in printed form for $2 per copy. Also, providers can contact the ASA to be provided with appropriate treatment telephone numbers for their locality and, if possible, the name of a confidential consultant who can provide additional information and resources. Contact:
• American Society of Anesthesiologists, 520 N. Northwest Highway, Park Ridge, IL 60068. Telephone: (847) 825-5586.
For help addressing addiction among health care professionals, contact:
• Pat Green, Secretary/Treasurer, International Nurses Anonymous (INA), 1020 Sunset Drive, Lawrence, KS 66044. Telephone: (785) 842-3893. E-mail: Patlgreen@aol.com. INA is a network of nurses in recovery. Membership is open to any nurses (student or former nurses included) who consider themselves members of a 12-step group. It offers a geographic listing of nurses who have given permission for their names to be distributed to other recovering nurses. Confidentiality is assured.
• Rusty Ratliff, Anesthetists in Recovery (AIR), 2205 22nd Ave. S., Minneapolis, MN 55404. Telephone: (612) 724-8238. E-mail: firstname.lastname@example.org. AIR is a national support organization of certified registered nursing anesthetists recovering from chemical dependency and offers education and peer assistance.
• American Association of Nurse Anesthetists (AANA), 222 S. Prospect Ave., Park Ridge, IL 60068-4001. Peer Assistance Hotline: (800) 654-5167. Web: www.aana.com/peer. The AANA’s Peer Assistance Advisors Committee assists individuals and organizations in formulating guidelines for intervention, treatment, aftercare, and re-entry into the workplace. For a free informational packet (item 1052) on peer assistance, e-mail: email@example.com or call (847) 692-7050, ext. 3009. The web site (www.aana.com/peer/directory.asp) has a peer resource directory by state. A free copy can be obtained by contacting Susan Burger by mail at the address above, by e-mail at firstname.lastname@example.org, or by fax at (847) 692-6968.