Drug Diversion
Drug diversion continues to be a growing problem within the profession of nursing. “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” (National Council of State Boards of Nursing, p. iv, as stated in Houston, 2010). Nursing managers must be cognizant of this problem. All nurses, within the various settings of nursing, should learn the signs and symptoms of possible drug diversion and act as advocates on behalf of their fellow nurses and especially the safety of all patients.
Prevalence
Detection of diversion is commonly under noticed as denial is prevalent and self-disclosure is nominal within this sensitive subject matter (Saver, as stated in Huston, 2010). There is a lack of recent, solid research about the impaired nursing practice. To encourage more research, prevalence should not be the main concern of researchers. A more important aspect is studying the nature of substance abuse problems and expanding the possibilities on recovery (Huston, 2010). Another avenue of research could focus on the nurses that do not have drug abuse problems and the variety of healthy coping mechanisms that these nurses utilize (Huston).
According the National Association of Drug Diversion Investigators (NADDI), drug diversion involves any criminal act involving a prescription drug. NADDI was established in 1989. The organization facilitates communications between law enforcement agencies, state regulatory agencies, pharmaceutical manufactures and healthcare professionals as a central ground to aid in the prevention of drug diversion. The three main functions of NADDI are: 1) Cooperative education and training in the specifics of pharmaceutical drug diversion, investigation, prosecution and prevention 2) Sharing investigative information and communicating with a wide variety of interested parties with regard to the nature, scope and impact of pharmaceutical drug diversion. 3) Developing more effective measures to combat the problem (NADDI, 2011).
It is unclear on the actual number of nurses that have substance abuse problems as more hospitals do not do random drug testing unless a problem is actually witnessed (LaFerney, 2010). Possibly 20-25 percent of nurses have substance abuse issues, although not necessarily while working. Rates of nurses abusing drugs are lower than the general public (LaFerney, 2010). With regard to drug abuse in general, pharmaceutical drug abuse has grown significantly in recent years. As of 2006, almost 7 million Americans were abusing prescription drugs. This is more than those abusing all other street drugs combined; cocaine, heroin, hallucinogens, Ecstasy and inhalants (NADDI, 2011).
Risk Factors
Disciplinary action by the State Boards of Nursing is most frequently due to diversion of drugs. The most common medications that nurses are diverting and abusing are narcotics and benzodiazepines (LaFerney, 2010). Patients that have entrusted their lives to the care of nurses that are abusing medications can have the most ill-fated consequences. Neglect, impaired care and even death are imminent outcomes. There are also risks involving loss of license, criminal charges, and the misrepresented costs to the healthcare system (LaFerney, 2010).
A study done by West, as cited in Huston, 2010, substantiated three early risk factors for substance abuse among nurses. A family history, risks of alcohol abuse and individuals that seek excessive sensations were found to be predictive. Another study done by Kenna and Lewis, as cited in Huston, 2010, concludes that younger nurses are at higher risk for substance abuse. This holds true for substance abuse among the general population. Abuse of alcohol also increases overall risk of drug use, although a direct correlation to drug diversion is not implied.
There are multiple signs that are frequently seen in an impaired nurse. These include but are not limited to: spending excessive time in the medication room, frequent reports of spilling or dropped medications, excessive wasting of medications, recurrent over-time use, numerous sick days and/or tardiness and an overall poor job performance. Physical symptoms of a possible drug diversion and impaired nurse can include: fatigue, poor hygiene, confusion, mood changes such as energy bursts and irritability and indifference (LaFerney, 2010).
Treatment and Rehabilitation
The American Nurses Association (ANA) supports treatment for nurses that have addiction problems. The majority of states offer non-disciplinary programs for rehabilitation. Some programs are voluntary, although many programs are coercive and meticulous (Huston, 2010). The American Medical Association (AMA) supports the examination and treatment of addiction as a chronic medical disorder. This position is encouraging as it may persuade more RN’s to seek treatment, just as one would with a medical disorder such as hypertension (Huston, 2010). The California Board of Registered Nursing (CA BRN, 2012) has a diversion program for licensed nurses with California residency. The program was devised for rehabilitation, protecting the privacy of the RN and helping ensure a safe return to the practice of nursing. The program is completely voluntary and is completed in approximately 4 to 5 years. Upon entering the program, the RN may not work until the diversion evaluation committee formally decides that the RN is compliant with therapy, drug testing and concurrently not working as an RN. This is detailed in a signed contract between the BRN and the nurse. The nurse must be deemed safe to return to the practice of nursing (CA BRN, 2012). The CA BRN also offers information on support groups throughout the state. Participants in the program have protected confidentiality as mandated by California law. Chemical impairment records are destroyed for those nurses that complete the program successfully (Huston, 2010). Support and treatment can also be found through private facilities which are provided on the CA BRN website.
Re-entry into Practice
ProPublica is an independent, non-profit news organization based out of New York. ProPublica has twice won a Pulitzer for reporting in 2010 and 2011. ProPublica, along with the Los Angeles Times, has investigated the CA BRN drug diversion program. The investigation found numerous issues concerning public safety. The investigative article claims that California is the least timely with regard to the discipline of its registered nurses than any other state (Weber, & Ornstein, 2009). The diversion program within California, created in 1985, has a success rate for recovered nurses at only 50 % (Weber & Ornstein). There are nurses that have been expelled from the diversion program due to non-compliance. These nurses are then labeled by the state as a public risk. These are nurses who, during the program, failed drug testing, continued to practice nursing and/or were convicted of selling drugs. These nurses are still able to gain employment as registered nurses due to the delay of authoritative action taken by the CA BRN. The article states that there is not a reliable, timely method for public disclosure. On average, it can take up to three years for some nurses to be fully investigated and disciplined (Weber & Ornstein). The CA BRN diversion program is completely confidential so there is not a fail-safe way to know who has quit the program or which nurses are experiencing a relapse. Some of these nurses are then continuing to work and possibly harming patients. The CA BRN does not confiscate licenses; participants sign a contract that they will not work until clean, “a risky honor system”, this can enable the RN to continuing working impaired (Weber & Ornstein).
There appear to be more questions left unanswered than those that are clear when it comes to drug diversion and the Registered Nurse. The stigma tied to drug abuse has extremely negative connotations. The issue creates a lack of trust within the profession on numerous levels. There are issues with not divulging information about diversion for fear of being labeled as a whistle-blower. On the other end of the spectrum, there is the trepidation of working with a rehabilitated RN. “We are a profession known for its caring nature toward others, yet often we fail to care for ourselves” (Huston, 2010, p. 283.).
More information on the CA BRN diversion program can be found at http://www.rn.ca.gov/diversion/index.shtml.
