How long did it take you to get caught?

jackstem · Jul 31, 2010

Guys,
I am not a nurse in recovery and I have not ever had any substance abuse/addiction problems. I've experienced the loss of several coworkers over the years to substance abuse (four that were fired, one of those four has subsequently ODed and died) and I guess if any of you would like to respond, I could use a little perspective on the course of events that led you to get where you are.

I'm sorry for the loss of your friends and colleagues.

Here is one area where I am really befuddled. One of the most expert, kind, proficient nurses I knew got caught diverting and was fired.

Chemical Dependence (also known as Addiction, Substance Abuse Disorder, Substance Misuse Disorder) is a genetically based, environmentally induced disease affecting the areas of the brain involved in pleasure, motivation, memory, decision making, and impulse control. Intelligence, education, being a "good" (or religious) person have nothing to do with addiction. We would never say to an oncologist, "With all of your training, skill, and knowledge, how could you let yourself develop cancer?" The same goes for cardiologists who have heart attacks, dentists who have cavities, and pulmonologists with asthma. That's because all of those diseases or conditions are accepted as "legitimate", while addiction is seen as a like of morals and/or willpower.

The internal component for developing addiction is the presence of the gene(s) rendering the person vulnerable to development of the disease. The environmental triggers include exposure to several classes of mood altering chemicals in the right amount, for the right amount of time, under the right conditions. It's estimated that 12 - 20% of the population carry the gene. This is one of the reasons people find it hard to accept addiction as a disease. Why? Because 80 - 88% of the population can use drugs and alcohol without becoming addicted, so people assume the only reason a person keeps using is because they want to. Sure, almost all addicts chose to start using mood altering substances. Some are exposed as a result of conditions requiring the use of these substances, such as anesthesia, treating severe pain, or psychiatric conditions. No one ever expects to become addicted. It's always the "other guy" (the one with no willpower or lacking a solid moral base). Many diseases are like this; cancer, Type II diabetes, coronary artery disease, and malignant melanoma. Not all smokers develop lung cancer. Not all sedentary, obese individuals develop diabetes. Not all couch potatoes with diets high in saturated fats will develop heart disease.

I honestly don't think she was ever impaired at work -- at least, she didn't act like she was.

Early signs can be subtle and missed if you're not looking for them. As the disease progresses symptoms become more pronounced until it's impossible to hide it any longer.

She did work a lot of OT which is apparently one of the hallmarks of diversion.

This is to stay close to their source of drugs.

One of my other coworkers saw her at home after she had been fired, and apparently she had been diverting for 2+ years before she got caught. What I want to know -- is that common, for people to go for months and even years without getting caught diverting?

It depends on the drugs used. The more potent the drug, the faster the onset and progression. Alcohol can take years before the person begins to show serious signs. Fentanyl, sufentanil, crystal methamphetamine and "crack" cocaine have a more rapid onset and a much shorter progression of the disease, achieving the same level of impairment as alcohol (years) in a matter of months!

Also, was she using at work? Does everybody take their stuff home and use there, or do you use on the job, or does it depend on who you are?

Again, it depends on several factors, including, but not limited to the drugs used, genetic makeup, access, and environmental variables (high stress jobs, school, family conditions, and poor life skills).

If you want to understand the pathophysiology of this disease better, check out the DVD, "Pleasure Unwoven" by Dr. Kevin McCauley, a recovering physician. He states:

"Addiction begins as a disorder of genes and pleasure and ends as a disorder of choice." - Kevin McCauley

Feel free to PM me anytime.

Jack

TXRN2 · Jul 31, 2010

as usual, jack, you are a wealth of information & wisdom!! very well put!

jackstem · Aug 1, 2010

as usual, jack, you are a wealth of information & wisdom!! very well put!

thanks! very few training programs at any level provide more than a cursory discussion of the pathophysiology of this disease or the risks involved in our profession. it's difficult to effectively deal with any disease if we don't understand it. despite the enormous amount of information gathered over the past 25 years regarding this disease, it's not being disseminated to the front line providers. there also exists a large number of nursing professionals who don't see the need to change the curriculum or make mandatory ceus for license renewal. the stigma related to this disease is due the lack of education and understanding of the disease process. many diseases have had stigma associated with them until the underlying pathology was discovered. epilepsy, leprosy, and hiv/aids are examples.

the thing i find baffling is the overwhelming resistance to educating students and colleagues about the risk of developing this disease, prevention strategies, and recognizing the early signs in order to intervene before the disease progresses to the late stages making treatment more difficult and long term recovery possible. (how's that for a run-on sentence?)

it's clear the strategies used to deal with this disease aren't working (and haven't for the 4 decades since i graduated high school!). yet we continue to do the same things over and over and over. statistics from a study by substance abuse an [color=#009600]d mental health services administration (samhsa) reveal a dramatic rise of 400 percent in the non-medical misuse of prescription pain medications from 1998 to 2008. the age when a child first uses mood altering chemicals is 12 years old overall, and even younger when you like at specific areas (in se kentucky it's 11 y/o). where do they get the medication? from the family medicine cabinet. we need to begin educating nurses, in school and in practice, if we hope to reverse this trend. nurses are the logical group to target for education since we are the largest front line providers in the country.

for an excellent presentation on the disease of addiction, check out the dvd "pleasure unwoven". there are some clips on youtube.

jack

michigooseBSN · Aug 2, 2010

I think that there is often another factor at work. Many diverting nurses are, at least at first, very hard working compassionate nurses and their co-workers are either reluctant to believe the worst (that they are in fact diverting drugs) and/or they don't want to get them in trouble.

This is in fact enabling behavior whether conscious or unconscious. I feel sure this must have been the case for me. It must have been if not obvious, as least suspicious, that I was diverting but it was years before I had the intervention that saved my life. What do you think, Jack?

jackstem · Aug 2, 2010

I think that there is often another factor at work. Many diverting nurses are, at least at first, very hard working compassionate nurses and their co-workers are either reluctant to believe the worst (that they are in fact diverting drugs) and/or they don't want to get them in trouble.
This is in fact enabling behavior whether conscious or unconscious. I feel sure this must have been the case for me. It must have been if not obvious, as least suspicious, that I was diverting but it was years before I had the intervention that saved my life. What do you think, Jack?

ABSOLUTELY!!! The more potent the drug, the faster the decline. If you inject the drug IV, the faster the decline. If you inject a potent drug IV, the decline proceeds at Warp Factor 9+!

As I said in a previous post, I went from first IM injection to almost dead in about 5 months. I lost lots of weight in that time because I was either puking or not eating (or both). When I finally accidentally OD'd and came close to dying, I finally told my best friend I was addicted to fentanyl. His response, "Thank goodness. We thought you had cancer or AIDS!"

Not the response I expected. I had quite a resentment for several years because no one intervened even though they knew something was wrong and that I was most likely dying. Denial, fear they might be wrong or they might be right about me being an addict (there's no way Jack would be addicted...he's too smart! Cancer doesn't care how smart we are and neither does addiction!), fear "they" might cause the loss of my license, career, marriage, etc. All of these things keep colleagues, friends and family from intervening. his is one of the reasons the disease is difficult to treat and long term recovery isn't likely after the first time through treatment. By waiting for more proof, someone else to intervene, or for the addict to "hit bottom", 3 things happen. First, a chronic, progressive, potentially fatal disease is allowed to progress to late stage disease. Second, the risk of dying from an OD or an accident (falls, drowning, etc.), harming a patient, or harming someone else (DUI, etc.) is significantly increased. Third, it's almost guaranteed that the impaired nurse will get caught and face criminal charges as well as license suspension or revocation.

We do no favors by waiting to intervene. Early recognition of signs and symptoms, intervening when sufficient "evidence" is gathered, and intensive treatment (preferably inpatient for as long as possible) with intensive, long term aftercare and monitoring, and sufficient time away from work to allow the brain to recuperate and to develop the needed tools to deal with the stress of returning if appropriate (determined by treatment team). The longer the monitoring program the more likely a successful return to practice.

We have got to begin to change the paradigm our profession has about this disease and those who have it. If we don't the rate will continue to rise and we will continue to lose some of the best clinicians available. We will also continue to bury our colleagues long before their time.

Jack

Michaelxy · Aug 5, 2010

Chemical Dependence (also known as Addiction, Substance Abuse Disorder, Substance Misuse Disorder) is a genetically based

I am sorry to muddy the waters and detract from your otherwise good post, but this has yet to be proven. If it had then an addict would not be viewed as they are currently viewed. ie. "I just been diagnosed with cancer" "OMG, I am so sorry" v.s. "I am an addict" " Well get your act in order loser"

I am of the belief that addiction is not yet considered a disease by many, and as such a stigma still clings. I have yet to see definitive proof that it is. For me as a former multi addict, I think I was just being plain selfish and desired self gratification. Not so sure I can blame my DNA on this one.

Magsulfate, BSN, RN · Aug 5, 2010

Yeah, what jack said.

catmom1, BSN, RN · Aug 5, 2010

I am sorry to muddy the waters and detract from your otherwise good post, but this has yet to be proven. If it had then an addict would not be viewed as they are currently viewed. ie. "I just been diagnosed with cancer" "OMG, I am so sorry" v.s. "I am an addict" " Well get your act in order loser"
I am of the belief that addiction is not yet considered a disease by many, and as such a stigma still clings. I have yet to see definitive proof that it is. For me as a former multi addict, I think I was just being plain selfish and desired self gratification. Not so sure I can blame my DNA on this one.

Michael, even if addiction were proven to be genetically based, many in the nursing profession (and in society at large) would look down on the "loser addicts" anyway. Many nurses never let a few facts get in the way of their prejudice against nurses with addiction.

:mad:

However, just because addiction is genetically based, as I believe it is, addicts still have accountability and responsibility for making moral choices and getting help for the disorder before it destroys their lives and the lives of many around them.

Catmom :paw:

jackstem · Aug 5, 2010

i am sorry to muddy the waters and detract from your otherwise good post, but this has yet to be proven. if it had then an addict would not be viewed as they are currently viewed. ie. "i just been diagnosed with cancer" "omg, i am so sorry" v.s. "i am an addict" " well get your act in order loser"
i am of the belief that addiction is not yet considered a disease by many, and as such a stigma still clings. i have yet to see definitive proof that it is. for me as a former multi addict, i think i was just being plain selfish and desired self gratification. not so sure i can blame my dna on this one.

you're correct that addiction is not yet considered a disease by many, which feeds the stigma associated with addiction. but stigma is based on lack of knowledge or inaccurate knowledge regarding the stigmatized person or thing. false "beliefs" will drive inappropriate actions and behaviors toward the stigmatized person or thing, in this case, the addict and the disease of addiction. holding the belief that addiction isn't a disease or genetically based doesn't mean the belief is accurate or "true". many didn't believe epilepsy was a disease. they believed it was demon possession. as medical science advanced, that belief was eliminated. same thing with leprosy. people believed it was a result of sin or the sins of the person's parents. now we know it's an infection and can be treated with antibiotics.

"belief" - noun

1. something believed; an opinion or conviction: a belief that the earth is flat.

2. confidence in the truth or existence of something not immediately susceptible to rigorous proof:

as health care professionals we must base our services on the current, best scientific evidence currently available. it's not "ok" to base our professional decisions and actions on "beliefs". a great example of the difference between a belief and a fact is given in #1 in the definition above. for a long time people believed the earth was flat and the sun moved around the earth. now we know the earth is a sphere orbiting a star. very few people believe the earth is flat in the present time. if someone did believe the earth was flat, despite the scientific evidence that it is round, we'd wonder what in the world is wrong with them. there is growing scientific evidence that genes play a vital part in susceptibility to addiction. continuing to "believe" it's a moral weakness or lack of willpower might be "ok" for the non-health care professional. we don't have that luxury.

below are several sources of information regarding the current science regarding the genetic components of addiction. it's fascinating reading and is providing us increased understanding in the causes of addiction and improved treatment protocols as well as other areas of science involving the brain, including other psychiatric illnesses and non-health care related issues such as learning, memory, etc. enjoy!

jack

the genetics of addiction, a clip from the acclaimed dvd "pleasure unwoven"

the role of genetics in addiction (from the university of pennsylvania health system web site)
100 million people in the u.s. have at least 1 alcoholic drink daily.
14 - 20 million are alcoholics.
that means approximately 4 out of 5 people who have at least 1 drink per day are not alcoholics.
why is that?
is it because those 14 to 20 million people who are alcoholics have no will power...or they're just morally inept...or they lack scruples...or they didn't toilet train properly? of course not!
it doesn't make sense. what does make sense is the role of genetics...
initial theories of a single "alcoholic gene" have essentially been disproven by research. we believe that multiple genes play a role in the transmission of addiction from one generation to another. it is called polygenic inheritance

what we learn from the research?
alcoholism can skip generations. if parents are not alcoholics, that does not mean that a child cannot be an alcoholic.
if you have an alcoholic parent, that doesn't mean you will be an alcoholic.
while studies show a significant increase in the incidence of alcoholism in the children of alcoholics, the father to son transmission is particularly strong.
in type 2 alcoholism, which is relegated to men, the son of an alcoholic father is 9 times at greater risk of being an alcoholic compared to the general population.
recent studies suggest that heroin addiction is even more mediated by genes than alcoholism.
if one researches families in which there's an addicted person, one will invariably find another addicted person in the family-an aunt, uncle, grandfather-sometimes with a different form of addiction-but it's genetics, not willpower, scruples or toilet training, that plays a vital role in determining whether one will have the disease of addiction.

knowledge-base for addiction related genes
on the basis of manually integrating 2343 items of cross-platform data linking genes and chromosome regions to addiction from peer-reviewed publications between 1976 and 2006, a list of 1500 addiction-related human genes were identified in our study. among them 396 genes were supported by two or more items of evidence. to cite this work, please refer to: li cy, mao x, wei l (2008) genes and (common) pathways underlying drug addiction. plos comput biol 4(1): e2. doi:10.1371/journal.pcbi.0040002

follow this link to see the gene "map" - cbi-knowledgebase for addiction related genes

neuromolecular med. 2004;5(1):85-108.

genes associated with addiction: alcoholism, opiate, and cocaine addiction.

kreek mj

,

nielsen da

,

laforge ks

.

laboratory of the biology of addictive diseases, the rockefeller university, 1230 york avenue, new york, ny 10021, usa.

[email protected]

abstract

drug addiction is a complex disorder that has a large spectrum of causes.

vulnerability to addiction has been shown in twin studies to have a robust genetic component.

this genetic basis for addiction has general and specific components for each drug abused. although many genes have been implicated in drug addiction, only a handful have either been replicated to have an association or to have an identified functional mechanism related to specific effects of abused drugs. a few selected genetic variants that currently look promising for the study of alcohol, opiate, and cocaine addiction are discussed in this article.

pmid: 15001815 [pubmed - indexed for medline]

the journal of neurotherapeutics volume 3, issue 3, pages 295-301 (july 2006)

molecular genetics of addiction vulnerability

george r. uhl

summary

classical genetic studies document strong complex genetic contributions to abuse of multiple addictive substances, to mnemonic processes that are likely to include those involved in substance dependence, and to the volumes of brain gray matter in regions that are likely to contribute to mnemonic/cognitive and to addictive processes. the working idea that these three heritable phenotypes are likely to share some of the same complex genetic underpinnings is presented. this review contains association-based molecular genetic studies of addiction that largely derive from my laboratory and their fit with linkage data from other laboratories.

these combined results now identify many of the loci and genes that contain allelic variants that are likely to provide the heritable components of human addiction vulnerability.

these data are also likely to have broad implications for neurotherapeutics. drugs with potential abuse liabilities are widely used for indications that include pain, anxiety, sleep, seizure, and attentional disorders. there is increasing nonmedical use of these prescribed substances.

increasing information about addiction vulnerability gene variants should help to improve management of risks of dependence in individuals who receive such therapeutics.

in addition, since mnemonic components that correlate well with individual differences in brain regional volumes are likely to play major roles in addiction processes, many addiction vulnerability genes are also good candidates to contribute to individual differences in mnemonic processes. recently elucidation of addiction-associated haplotypes for the "cell adhesion" nrcam gene illustrate several of these points.

the contribution of genetics to addiction therapy approaches

howard j. edenberg and henry r. kranzler

aindiana university school of medicine, 635 barnhill drive, ms4063, indianapolis, in 46202-5122, usa

buniversity of connecticut, school of medicine, 263 farmington avenue, farmington, ct 06030-2103, usa

abstract

addictions, including alcohol dependence, which is the focus of this article, are complex genetic diseases.

recently, several individual genes that contribute to the risk for alcohol dependence have been identified, and more are expected to be in the near future. among these are genes encoding alcohol and aldehyde dehydrogenases and gabaa receptor subunits. these reveal pathways of vulnerability and provide targets for rational drug design. it is likely that response to particular therapies is also a complex trait influenced by genetics, but studies to explore this are just beginning. we discuss some studies on bromocriptine, naltrexone, and serotonergic agents. adding a genetic component to treatment trials could greatly help to understand the biological basis of variations in the efficacy of therapies and, in the future, could lead to individualized choices of therapy.