The Silent Epidemic Infiltrating Nursing: Drug Diversion

You've heard me talk about the power of vulnerability. I've shared quotes and videos from Brene' Brown but I am completely blown away by the story I am about to share with you. The story of Claudia and Rodrigo, Nursing professionals willing to share their story of addiction, codependency and the silent epidemic infiltrating our profession.

Claudia

Claudia

Claudia, how long have you been a Nurse and what areas of Nursing have you worked in?  I graduated from Indiana University in May of 2004 and became a registered nurse in the same year. I was given a unique opportunity to work in surgery during my junior year in college. I absolutely enjoyed all aspects of nursing specifically the specialized care in surgery. Shortly after graduation, I began working full-time in surgery as a circulating nurse.  After a few years, I took interest in management and became one of the Charge nurses of the department as well as team leader for several specialties.

You had the unique position of working with your husband at a time when his opioid dependency likely affected his job performance. You recognized changes in his behaviors and sought out help from colleagues but it seemed nobody had the courage to address the problem. Why do you think that is?  I believe no one had the courage to speak up because they were intimated by Rodrigo’s position and reputation. He held a strong position as the chief nurse anesthetist and clinical coordinator for the school of Anesthesia. In addition, he was well respected and very much liked by his peers, patients, and students. He was everyone’s “go to” person.  If someone had a difficult induction or case, everyone knew to contact Rodrigo. Anesthesia came very natural to him.  He was always the nurse anesthetist who could pop in a central line, epidural, arterial line, or IV lines on his first try. Often times, he was tasked with providing anesthesia care to some of our most difficult surgical cases.  While I was working with him, he was the ONLY anesthesia provider to receive so many accolades and awards for his excellent care. It was very difficult to be certain of what was actually going on.  Most coworkers knew something wasn’t “right” but to jump to the conclusion that one of the best providers in the hospital was struggling with dependency almost seemed absurd. Can you see why reporting him would be difficult? 

Prescriptive opioid use is on the rise in the country and health care providers are working in high stress environments with easy access to benzodiazepines and narcotics. What factors influence a Nurse to turn to narcotic use or drug diversion?  Substance use disorder can present for many reasons. 1. The nurse or healthcare worker has increased access to these medications along with expert knowledge of how the medications work. 2. Increased stress, long hours, difficult case loads, lack of resources, and mounting pressure to perform often puts the provider in the precarious position to do “whatever it takes” to meet the goals.  Unfortunately, a pill or drink can be the easiest way to do it.  3. The healthcare provider is often struggling from other underlying issues such as depression, anxiety, or PTSD, they self- medicate to “escape” or relieve their symptoms.  It is becoming very evident that the occupational hazards of being a nurse correlates directly with increased addictions.  Caregivers are expected to be comforting, nonjudgmental, patient, and caring.  However, a nurse that admits to a problem and asks for help is more times than not shamed into silence and labeled as a “failure”.  I have worked with hundred of addicted nurses in recovery and they all say the same two things.  First, they ALL knew they were in trouble and needed help.  Second, they all felt that as nurses, they were expected to be selfless caregivers and were not empowered to safely ask for help for themselves.  As a nurse myself, I would have to agree.

I helped a family member through an alcohol addiction and found it to be one of my most stressful experiences of my life. Your situation seemed even more challenging since you worked at the same hospital. You had your reputations and children to manage. How did you get yourself through this experience?  If I said it was easy, I would be lying. Rodrigo’s addiction went on for months. At first, I thought I could confront him and he would submit and go to treatment. I clearly remember the FIRST time I confronted him with my suspicions. He quickly denied and accused me of being “paranoid” and not understanding of his high demanding position as a father and anesthesia provider. Since he worked on average 50-60 hours a week and was very successful, I thought my suspicions could be wrong so I pulled back. For a few weeks, I closely monitored his production at work, his communication with our family, and his demeanor.  I quickly started to notice many changes. He was isolating, moody, over working, and often times hard to locate.  At this time, I knew he was in trouble. I felt helpless, depressed and anxious. Since I didn’t know what my role was supposed to be during his addiction, I became very co-dependent and enabled his behavior. I made sure he was up every morning and arrived to work on time, did rounds on his patients at work, cared for the kids, and took on the household duties.  Rodrigo’s addiction consumed my life, every second and minute of my day.  How did I get through this? I believe it was by the grace of God, my higher power.

What advice would you give to a Nurse who suspects a coworker of drug diversion or addiction?  If you suspect a co-worker is struggling from substance use disorder, please report them to management.  Every facility should have a policy in place to deal with this exact situation.  Often times, the potential legal consequences or dismissal of their position can be a strong motivator for treatment. Less than 5% of addicts will voluntarily seek treatment.  Most feel they can stop on their own or that they will be lambasted if they admit their disease.  In my experience, most providers are given a second chance if they surrender to treatment and follow the complete recommendations of the clinical treatment team.   I would also advise them to never confront the suspected addict.  That will make the situation much more difficult to handle and scare the provider further down the rabbit hole. 

I imagine most people exposed to drug diversion would want to crawl under a rock and forget about their experience. You and Rodrigo have chosen to embrace your experience and share with other healthcare providers. That takes a tremendous amount of courage and willingness to be vulnerable. Why have you chosen this path?  As silly as it may sound, I think this path chose us. It hasn’t been easy, we have lost friends, family, employment opportunities, and respect of many people we once called friends.  Fortunately, we have very tough skin and are rarely influenced by the judgment of others.  We were absolutely shocked to see how few resources and information is available to professionals that require assistance.  We were even more surprised to see how many professionals actually need help.  We were fortunate to find our way back to health, employment, and stability.  If it were not for the selfless acts of a few that helped us along the way, it would have undoubtedly turned out much differently for us.  We feel we are obligated to help those that are now or will be in the position that we once were in.  When someone holds your hand for the first time, with tears of gratitude in their eyes, and thanks you for saving their life or their family because your story or actions helped them, then you know you are in the right place in life.  We often say that the nursing and the anesthesia was what we needed to go through to experience the addiction.  Only then would we have the experience, insight, and gratitude in our hearts for our true life calling of treating the addicted professional and their families.  We believe this is what we were put on earth to do.  

Rodrigo, how long have you been a Nurse and what was your path to become a CRNA?  I have been a nurse since 1996.  I graduated with my BSN when I was 19 and felt like nursing was the perfect job for me.  I worked first in a level one inner city trauma center and then the ICU.  In between I did a rotation with the flight team and taught nursing classes at two colleges. In my mid-twenties I felt it was time for a change and enrolled in nurse anesthesia school.  I loved everything about it from the didactic challenges to the hands on skills and procedures I was being taught. 

Can you share the circumstances of the first time you diverted drugs from work?  It is important to understand that by the time diversion occurs it is merely a means to an end.  It is usually indicative of a very progressed state of the disease and reflects multiple missed opportunities by all involved to prevent this from happening.  However, it is the focal point because it can be directly seen and measured (the social component).  What cannot be seen are the biological and psychological aspects of the disease.  As in most cases, diversion occurred as a direct result of being physically and psychologically dependent on the medication.  A major misnomer is that ingestion of these substances is enjoyable.  The reality is that ingestion is needed to merely be able to function.  I had my first opiate medication when I was 28 years old following a surgery for a traumatic sports injury.  I was prescribed medication for surgery, post-op, and physical rehab for around 4 months.  Needless to say I was physically dependent when my prescription ran out.  The immediate withdrawal symptoms brought me to my knees and had me questioning my sanity.  Almost instantly, normalcy (not euphoria) was returned with one pill.  Very quickly, that one pill turned to 4, and then 8, and then I could never take enough just to be able to get out of bed.  As a nurse, I often disposed of medication that was above the ordered dosage.  Diversion seemed to make more sense because it could “help” me much better than the purpose it would serve down the drain.  That’s how it started; medication that would normally be disposed helped me to function and feel “normal”.  Again, this is the typical story.  It happens so regularly that they have been coined the “accidental addict”.  These addictions are not the result of social deviance but rather have a benign and situational onset.    However, in the eyes of the public, judgment is swift and decisive. 

Working in the operating room provided easy access to narcotics. It’s pretty easy to switch out a syringe and replace it with saline. Since you founded the Parkdale Center, you have heard stories from other healthcare addicts. These addicts are smart, know the hospital system, are often respected, competent team members and seem to be experts at not getting caught. They figure out how to pass the drug screening tests and often quit without any consequences. Hospital administrations don’t want the negative publicity and colleagues don’t want to be the whistleblowers. What is to be gained if a Nurse reports a colleague, especially if the colleague is a friend?  You are correct, the system is not such that reporting a colleague is conducive or beneficial to anyone involved.  It is much easier to turn a blind eye and pass the buck to the next unsuspecting hospital or facility.  However, as nurses we are required by our Nurse Practice Act to not turn a blind eye.  It is our obligation to be advocates for patients and their wellbeing.  If we suspect a coworker is a potential risk to harm a patient, it is our moral, ethical, and nursing obligation to report the event.  If the allegations are unfounded, nothing will come of the proactive report.  However, if indeed there was cause for concern, it is certain that a sentinel event was avoided and maybe even a life saved.  Moving forward, the only way to ensure these situations improve is to improve the policy and procedure for such circumstances.   There is a VERY effective way to protect the public, the institution, while helping the provider.  It is long overdue and only requires the powers that be to care enough to ask the question “How do we do it?”  Until then, the trajectory of addicted providers will unfortunately continue in the dangerous direction it has for the last 30 years.

It seems physicians have more support to return to the profession; whereas Nurses are met with much greater challenges. Can you describe the differences?  There are two major differences when comparing physicians and nurses.  First, physicians are well aware of the resources and support available to them if they require assistance.  In fact, physicians are presented with the notion that addiction will surface in their career, either with a colleague or with themselves.  They understand who to call and what to do if they need help.  They will receive confidential counsel with consideration also given to maintaining the integrity of their occupation.  Second, treatment is a mandatory component of all physicians with substance use disorder.  It is not an option.  Treatment is specific to their high-risk profession and will focus on developing strategies for long-term sobriety.  In other words, physicians are enabled and encouraged to ask for help if they need it without the stigma associated with drug addiction and they are then given the quality treatment specific to treat a highly accountable professional.  The combinations of these two factors allow reentry into medicine much easier than reentry into nursing. 

What advice would you have for a Nurse who is diverting drugs?  How different is the path for people who surrender and seek help verses those that continue to use until they get caught (if they get caught)?  The Parkdale Center is 100% confidential and helps providers stay in the health care profession.  My advice to a nurse who is diverting or addicted to medications is to listen to me when I tell you “You are not alone.  There are people that have done exactly what you are doing and they can help you get your life back on track.  Talk to them today”. I feel it is so important for the addicted provider to know that they are not alone.  Addiction is a shame based isolating disease that destroys self worth. There is a way back. People can save their careers.  There is hope. There is no doubt that asking for help before you are required to get it, bodes well for everyone.  The board of nursing, employer, local law enforcement, attorney general, and family can all relate and empathize with someone asking for help.  There may still be an element of consequences, in fact there should be, but proactively asking for help makes a world of difference when reentry into the profession is the objective. 

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