Did I do the right thing?

Keys (and friends! Welcome all!),

First, knowing the questions came from more than one person sheds a little more light on the variety of questions.

Second, degrees mean very little when it comes to this disease (and many others). When I was in treatment, the best counselor there was an older black man with a certificate in chemical dependency counseling (back in the day as they say). He was a recovering heroin/cocaine "street" addict (His description, not mine). The reason I push attending the open meetings of AA, NA, and Al Anon is to get you out of the textbooks (typically written by academicians, not those who have lived it) and in with those who have experienced this disease, both as the addict and as the person(s) who live or work with the addict. Believe me when I say there is much more going on (for everyone) than "simple" guilt. Guilt is a complex emotion that is rarely based on one incident or issue.

Guilt and shame are 2 separate emotions. A quick look at the difference between the 2 helps us see which we are feeling.

Guilt is a healthy emotion that let's us know when we have done something "wrong", prompting us to seek forgiveness and to repair the relationship through discussion and clarification. This leads to stronger relationships with those we care about.

Here's an important point that may help decrease the amount of guilt all of you are experiencing. If you lack the knowledge that would have helped you (and your colleagues) to recognize the signs of the disease in another health care provider (such as frequent bathroom breaks, or volunteering for increasing amounts of overtime, offering to provide frequent breaks, offering to pass meds, declining handwriting and poor charting, see a more complete list here), then guilt isn't necessary (but it's a natural response). Being guilty about something you don't know is part of shame (which I'll discuss in a moment).

Now, if you want relieve the guilt in a healthy fashion...learn as much as you possibly can about this disease and it's increasing prevalence in the profession. Not just from books, but from actually talking to recovering addicts and their families. Learn how to advocate for change in the profession so we recognize it sooner, intervene early and effectively, and change treatment to evidence based protocols. There is no better way to say "I'm sorry" to your friend than to be prepared to prevent it from happening again in him, yourself, or other nurses. Just as we can't prevent type II diabetes in everyone, we can't prevent addiction in everyone either. But that doesn't mean we don't keep trying, we don't keep searching for a better understanding of the disease and find better protocols (based on science, not beliefs and myths) to prevent and treat the disease when it does happen.

Shame, on the other hand, is an unhealthy emotion in which we believe WE are the problem. we screwed up because we are defective and don't deserve forgiveness. WE should have known better (How?), we should have recognized it sooner (How?). We should have done something? (What?) Without specific knowledge and training, how would any of those things happen? But shame will drive that guilt...no matter how many degrees we possess...if we BELIEVE we are somehow defective. Nurses are excellent at being guilty (I know, I was in the profession a long time...started in ER and ended in anesthesia). In fact, it's been said more than once, "Nurses are professional codependents." Again, you can't say that about everyone. But you posted the word "GUILT" 4 times in this post alone. Codependents are extremely good at feeling guilty for all sorts of things they couldn't have known or did or didn't do. The only folks I know with an equally overdeveloped sense of guilt are Catholics (and I'm a "recovering Catholic" myself! LOL! That's not a "dis" on Catholics...so please don't take it that way, or I'll have to kick some butt. Political correctness was INVENTED by codependents! Like addicts, codependents have an overly sensitive emotional system when it comes to the addict). You have nothing to feel guilty about regarding your friend and colleague. But from here on out, if you do nothing to change this lack of knowledge in yourself and your "dysfunctional" family at work, then you have plenty to feel guilty about.

As I said, it's extremely difficult to recognize signs and symptoms of a disease that you receive little (if any) training about. The persistent myths (by health care providers and the general public) regarding this disease are proof of the lack of education. Stigma results from the lack of education regarding this disease (and many others). Addiction is one of those diseases where not being a person with the disease makes empathy extremely difficult. While I can successfully treat someone with heart disease, cancer, or diabetes without having suffered with the disease (i.e., as a purely scientific geek), it's very, very difficult to pick up on the nuances of thoughts and behaviors resulting from addictive disease if you haven't experienced it first hand. Combine lack of education about the actual disease of addiction (as opposed to the many consequences of the disease like cirrhosis, esophageal varices, domestic and other violence, trauma, etc.) with lack of experience, and it's no wonder there are all sorts of misconceptions. The problems is, these misconceptions cost people their lives.

Your description of the unit as a dysfunctional family is right on. And as a result of varying degrees of dysfunction, different people will react differently. You stated, "he lied to us". Yes, he did. It's part of the disease. But because you haven't learned about the disease process, including the areas of the brain affected, you're going to continue have a hard time "wrapping your head around all of this." Areas of the brain include memory, learning, motivation, and the areas associated with impulse control. This means they don't learn from their negative consequences (they CAN'T learn during active disease), they don't remember incidents and conversations when under the influence, they don't want to do the things they used to enjoy, and they can't control obsessive thoughts about their drug(s), or stop the complsive use of the drug once they get going.

You said you let him down because you didn't recognize the signs and symptoms. Go to the list of signs at this link and see how many you don't know. How can you diagnose appendicitis if you don't know the signs and symptoms? As ER nurses, we have (I had) the responsibility of understanding and recognizing those diseases and disorders I am going to see in those entering my department. Some stats on alcohol and ER admissions:

• Every day, over 20,000 people enter emergency departments in the United States for alcohol related injuries and illness - an estimated 7.6 million annually.
• 7% of injured adult patients are intoxicated when they present to the emergency department, another 20% will screen positive for alcohol use or abuse. These individuals represent the 18 million adults each year who have alcohol disorders. (Source: Emergency Nurses Association. Emergency Nurses Position Statement (2004). Approved by the ENA Board of Directors July 2004. Statistical citations available at: www.ena.org/about/position/AlcoholScreening.asp. Retrieved 1/10/2005).
• ER patients with unmet treatment needs (alcohol or other drugs) are 81% more likely to be admitted during their emergency visit, and 46% more likely to have reported making at least one emergency department visit in the previous 12 months.
• Tennessee patients with unmet treatment needs who received emergency medical services accounted for $777.2 million in extra hospital charges for the state in 2000, which translates to an additional $1,568 for each emergency patient with an addiction problem that wasn’t addressed. (Extrapolate those numbers to todays costs for ALL ER's in the country!).

Nurses are in great company. Primary care physicians miss or misdiagnose alcohol-abusing patients by these amazing numbers:

• 94% of primary care physicians fail to diagnose substance abuse when presented with early symptoms of alcohol abuse in an adult patient.
• 41% of pediatricians fail to diagnose illegal drug abuse when presented with a classic description of a drug-abusing teenage patient.
• Only a small percentage of physicians consider themselves “very prepared” to diagnose alcoholism (19.9%), illegal drug use (16.9%), and prescription drug abuse (30.2%). In sharp contrast, 82.8% feel “very prepared” to identify hypertension; 82.3%, diabetes; 44.1%, depression.
• Most patients (53.7%) say their primary care physician did nothing about their addiction: 43% say the physician never diagnosed it, and 10.7% say the physician knew about it, but did nothing about it. Less than a third of primary care physicians (32.1%) carefully screen for substance abuse.
• Nearly 75% of patients say their primary care physician was not involved in their decision to seek treatment.
• 29.5% of patients said their physicians knew about their addiction and prescribed psychoactive drugs such as sedatives or Valium, which could cause additional problems.
• 54.8% of patients feel physicians do not know how to detect addictions.
• 35.3% of patients thought their physician was too busy to detect their addiction.
• The typical patient had a substance abuse problem for 10 years before receiving treatment.
• 57.7% of physicians say they don't discuss substance abuse with their patients because they believe their patients lie about it, and nearly 85% of patients agree. (lying is part of the disease!!! Do they not discuss other potentially fatal diseases with patients for the same reason?)
• 35.1% of physicians cite time constraints, and 10.6% are concerned they won’t be reimbursed for the time necessary to screen and treat a substance-abusing patient.

Are alcohol and drug screening, brief interventions, and treatment referrals for patients performed in your ER? If not, why not. (That's not an accusatory tone or meant to be threatening in any way. It's a legitimate and appropriate question). A major reason may be (depending on state insurance laws where you are) a clause in insurance laws that state if any treatment is provided to someone whose reason for being admitted is due to alcohol or drugs, the insurance provider may deny payment. So, if I'm a doc in the ER, or a hospital administrator, and I know if I document anywhere in the chart this patient may be here as a result of substance abuse the bills won't get paid, why in the world would I chart something that tells the insurance provider?!? So, the bills get covered, and then the patient is discharged with a chronic, progressive, potentially fatal (for them and those around them) disease. Is that ethical? No! Is it professional? No! Does it happen? EVERYDAY! If this was an accepted disease, this wouldn't happen. "But they did this to themselves!" Yeah, so do lung cancer patients who smoke. So do adult onset diabetics who overeat, don't exercise, etc. We don't withhold payment when their disease needs treatment.

As an advocate for impaired nurses, part of what I do when a client hires me is provide educational programs for the unit where they work(ed). I provide sessions so colleagues can vent safely and learn about the disease and how they have been affected by the whole situation. The folks who say they haven't been affected are either in denial or lying. Anyone who works with or has a relationship with an active addict are affected, it a matter of degree. I've had to participate in and lead one intervention on 5 colleagues in the past 19 years. Believe me, I was affected! I was angry and hurt, just like you guys. But I had places to go and vent and deal with the emotions.

You all have been presented with an awesome opportunity to change the way things get done in your unit, your institution, and in your own practice. If you don't get everything out of this that you can, THEN you can feel guilty!!!!

Actively recovering addicts have a highly developed 6th sense when it comes to others in recovery. They are capable of seeing through the fog of confusion associated with the disease as well as the smoke screen produced by the active addict. It's not to say they never get fooled, but it is definitely more difficult. They also
bring a significantly higher level of empathy to the mix since they've been there.

I think a major reason is addiction isn't accepted as a legitimate disease is the lack of knowledge about the disease by health care professionals. Until that changes, our current paradigm regarding addiction will continue to be fed by myth, misbelief, and misinformation. Our professional and cultural paradigm won't change and valuable friends, family members, and colleagues will continue to die needlessly.

I continue to look at the history of HIV/AIDS as a method for affecting change in a culture's paradigm of stigma associated with an illness. Originally, it was considered a "Haitian" disease, quickly becoming a "gay disease". Until Ryan White and other non-gay, "asexual" individuals, who were not addicts (meaning children and other people who were extremely unlikely to have been infected by their own activities) became infected, it was easy to
ignore those who contracted the disease, which were mostly gay men, prostitutes, and IV drug addicts (the 21st century's version of "Lions and Tigers and Bears...OH MY!). All of these folks were considered immoral and therefore OK to scorn and ignore. But once the "innocents" began to develop the disease (after being infected by some immoral beast such as a philandering or drug addicted spouse, or the evil and infected health care provider), our society has a moral imperative to "save the innocents"!

If there is some way to engender that same sense of "save the innocents" for this disease, I have no doubt there will be a significant paradigm shift in the medical community and society.

Jack

Keys - Hey!! Just wanted to check on you and see how you were doing. Just please take care of yourself during this difficult time. We are here for you.

Anne, RNC

Jack - As an addict with, thank you God, 10 years clean as of August 16th, and my dh who is also an RN celebrates his 10th sobriety bday on July 16th, THANK you so very much for all the wisdom you give us every day. I appreciate it when I log on and get to absorb some of your kindness. You are such a blessing to all of us addict and I just wanted to say thank you!!!!!

Anne, RNC

Thank you Anne...that means a great deal to me. I really felt lost when I started my journey of recovery. I lost my marriage, most of my posessions, the career that I loved (where else can you get paid to wear pajamas and pass gas?), and almost my life (twice). When I finally "got it", I made a promise that if I ever had the chance to be there for another addict...I would be. Here it is 19 years later and the attitudes and stigma that still exists among our own colleagues hasn't changed much at all. It's time to change that! I thank God He's given me the opportunity to do that.

Just paying things forward. Hey, if you haven't already done so, read the thread about marijuana. Definitely worth the time.

HUGS!!!!!!!!!!!!!!!

Jack

Jack - I did read it, and it was well worth the time. I was one of those "problem" addicts, as I was called a few times early in rehab. I also look back at the times before I got help and the STUPID things I did to get a fix. I had already lost one nsg job (not the one that turned me in, it was another bridge I burned!) and took a job at McDonalds doing PR and some commercials, that kind of thing. I organized field trips for grade school kids to see the "Mickie D world". I was helping hang a banner from the roof of one of the stores, attaching it to the yellow letters in the front. I think it was about 16 or 18 ft.

Anyway, me and my sick little mind started thinking, "Man, I bet I could score some heavy pain meds if I "fell" off the roof. Crazy, huh?! So, of course, I "fell" off the roof and landed in the flower beds right in front of the store. Thankfully, it had rained earlier in the morning, so the ground was damp and softer. Of course, quite a crowd gathered, and the ambulance rig packaged me up and took me to the ER. Little did I know, all I would get was a shot of Toradol IM and crutches and a sling. Talk about disgusted!

It took me quite a while for me to actually think, "Man, am I glad I didn't end up a quad or para or something. Where was my head? At the bottom of an ampule of Demerol or whatever I thought I would be offered. I finally admitted what I had done. I still see him at times, he and my dh are good friends, and he said he is proud that I got clean and stepped up. I told him bluntly that if I hadn't gotten clean and into treatment, I would be dead. No question about it.

Thanks Jack! Anne, RNC