Narcotic Use and Diversion in Nursing


    Interesting article; nearly every unit I've visited has a story about diversion.

    Narcotic Use and Diversion in Nursing
    Mandy L. Hrobak
    University of North Carolina Charlotte
    Narcotic use and diversion in nursing is a growing problem that may be difficult to identify. Clinical indicators can help managers and staff become knowledgeable about signs and symptoms. Areas related to job performance, personality/mental status, and diversion are looked at as indicators. Workplace access and deviant work group norms can contribute to the picture. Certain methods of diversion may be hard to detect. Institutions need to...

    Click link above for remainder of article.
    Last edit by sirI on Oct 26, '09 : Reason: edited for copyrights
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  3. by   sheilagh
    That was an excellent article,their is so much to explore on this topic. I am bringing copies to my nursing support group,thank you for posting it!
  4. by   jackstem
    A good overview of the "problem". I give a presentation on substance abuse and chemical dependence in the anesthesia professional every year to the anesthesia programs in Ohio. As a recovering "retired" CRNA, peer assistance advisor and chair of the practitioner wellness and peer assistance committee in Ohio, I am contacted by several nurse anesthetists or anesthesia departments each month.

    Substance abuse/chemical dependence is the number one health risk associated with the practice of anesthesia. Since accurate statistics are difficult to gather because of the stigma associated with this disease (if you are recovering and working, would you want anyone to know? Of course not! Our colleagues are less tolerant of addiction in nurses than they are in their "regular" patients!), there is no doubt the numbers quoted are well below the actual rate. The American Association of Nurse Anesthetists (AANA) is celebrating 26 years of peer assistance this year. Despite the active participation of many CRNAs, both recovering and non-recovering, the association didn't really "come out of the closet" about this deadly disease until a respected association president died of an accidental overdose of sufentanil . She was a dynamic leader and an excellent anesthetist, working on numerous committees and holding elected office in state and national organizations. Only a couple of months after leaving the office of AANA president (1999-2000), she was found dead in her home by her daughter. The association did what almost all organizations (an almost everyone else) does, they kept the reason for her death quiet. Fortunately her daughter didn't want her mother's death to be "for nothing". She spoke at our first annual Peer Advisors workshop in 2007. She said, "If my mother was vulnerable to this disease, then I have no doubt anyone can develop it." She requested that the AANA develop a program about this occupational hazard in order to educate the members in order to prevent or detect the early signs of chemical dependence in a colleague in order to get them into treatment as soon as possible. Today the Jan Stewart Memorial Lecture Series, started in 2004 at the annual meeting in Seattle, is presented every year, touching on healthy ways of dealing with the stresses associated with the profession.

    Chemical dependence isn't about willpower, lack of morals, or "poor educational" status. In fact, studies have shown the "average" anesthetist seeking treatment is a male, 35 years old with eight years of experience, and finished in the upper third of their graduating class. People seem to think the more you know about controlled substances, the less likely you are to become addicted. Does that mean the more you know about cancer (like an oncologist) the less likely you are to develop cancer? Of course not! But it DOES mean those who understand and can recognize the signs and symptoms of the disease (whether addiction, cancer, or any other chronic, progressive disease) will seek treatment sooner. We all know the sooner you treat a disease the better the chance of achieving and sustaining remission. My brother-in-law died from Rocky Mountain Spotted Fever at the age of 37! Why? Because he ignored the symptoms for too long before seeking treatment. He died of overwhelming sepsis despite vancomycin and every other antibiotic they used. His son developed signs about a week after his Dad died. He took tetracycline and has a family of his own today.

    If you look at the way we treat other chronic diseases (early recognition, evidence based treatment protocols, and long term follow up and continuing care) compared to the way we treat chemical dependence (myths and misunderstanding..."the addict has to hit bottom before treatment will work", or, "The addict has to want treatment or it won't work"), then it becomes glaringly clear why so many addicts relapse and/or die. We wait until their behavior becomes so abnormal we CAN'T ignore it anymore. We provide too little evidence based treatment for too little time (studies show a significant difference in sustained recovery when treatment lasts 90 days or more, yet most treatment lasts 28 days). There is little ongoing care and follow up (yet we all know that people with heart disease, diabetes, cancer and other chronic diseases do significantly better with aggressive treatment and long term follow up care). Until we treat chemical dependence as the chronic brain disease that it is (there are still those who argue addiction isn't a disease. Read the literature...and you won't be in that shrinking population), we will continue to see increasing numbers developing the disease and the same numbers relapsing. People rationalize the way addiction has historically been treated by saying the addict did it to themselves. Ummm, OK. Smokers develop lung cancer, oral cancer, COPD, heart disease, etc. because "they did it to themselves". We don't withhold treatment, limit treatment, or treat them like "low-lifes". People who sunbathe develop skin cancers, including melanoma. Didn't they "do it to themselves"? How about the person who develops Type II diabetes because they eat poorly and exercise too little?

    There is no doubt a genetic link to the development of the disease of addiction. What does that mean? It means the person who "experiments" with mood altering substances is at risk to develop the disease. But let's face it, drinking alcohol is ingrained in our culture and many others. We celebrate births, new jobs, promotions, the new house, graduation, etc. with alcohol. We sell alcohol at sporting events, restaurants, comedy clubs, grocery stores, etc. Many religions use alcohol in the form of wine during their religious ceremonies. Native American tribes use peyote and other mood altering substances during many of their rituals, as do other cultures and religions. For 80 - 85% of the population, mood altering substances won't become a problem. That means they "know when to say when" and are capable of "drinking responsibly". But 15 - 20% WILL have a problem. My goodness! If there was a substance or substances that caused breast cancer (or prostate cancer) in 15 - 20% of those exposed to it there would be marches on Washington, we'd have all sorts of telethons and other fund raising activities to find a cure, and those companies that produced the substance would hounded and sued until they disappeared. The only reason the tobacco companies aren't gone is politics. While smokers are "frowned upon", there are specific areas designed at workplaces and throughout our cities to accommodate smokers. I've often thought about walking into the smoking area with a tourniquet and syringe of saline just to see the reaction. I mean come on! If they can have their nicotine break, why can't I have my fentanyl break? It's OK to sell nicotine gum as replacement therapy for smokers, but not OK to have methadone clinics available for the heroin/opioid dependent person trying to stop mainlining their drug? When you start looking at chemical dependence as a chronic, progressive, fatal (if untreated) disease...treatment makes sense, and long term recovery is possible when evidence based treatments and long term follow up care is utilized as it is for diabetes, htn, and other "acceptable" diseases.

    The bottom line is this, we are ALWAYS going to have mood altering substances legally available (there is discussion of mood altering substance use in literature from ancient China and Egypt), whether it's alcohol, opioids or other substances to control pain, treat insomnia, and a variety of other conditions. I'm not advocating a new prohibition.. What I am advocating is treating substance misuse (much less negative than the term substance abuse) and chemical dependence as the "conditions", syndromes, or diseases that they are.

    Intelligence has nothing to do with this disease. Neither does "moral fiber" or character. If a person has the genetic possibility of developing chemical dependence and is exposed to the right substance, in the right amount, under the right conditions, dependence will develop. The problem we have with this disease is the target organ is the brain, and the effects are seen in the most primitive areas of our brain. This area is involved in most of our instincts are found (like finding food, water, and activities that keep the species, caring for offspring, etc.), as well as learning and motivation. As the disease progresses the person is motivated to obtain and compulsively use the drug, and becomes less capable of learning from the negative consequences of their actions while under the influence of their drug of "choice" (ironic that the inability to choose to stop using a substance is known as the drug of choice). Likewise, as the brain is altered more and more by the increasing amounts of the substance they are misusing, it begins to "see" the drug as important for survival, more important than food, water, or sex! One of the lectures at our national meeting in San Diego was by a Steven D. LaRowe, Ph.D., Center for Drug and Alcohol Program, Medical University of South Carolina, and the Substance Abuse Treatment Center
    Ralph H. Johnson VA Medical Center. He explained how the brain can control your actions when survival is at stake. He posed the question, "If you had lost your job, home, and all your earthly possessions, and you and your children were starving, would you resort to illegal activities to save your life and the life of your children?" Well, DUH! Of course you would! Well, because drugs that can trigger addiction alter the chemistry in the very areas of the brain necessary for that survival instinct, and actually cause the release of dopamine and other "pleasure" substances in amounts 100 to 1,000 times more than natural stimulators (like sex, food, and doing a great job or caring for our kids), the "addict" will participate in illegal activities in order to obtain their drug of "no choice". That's why a rat which has become addicted to a substance will push the lever for the substance rather than push a lever that dispenses food or water. They will continue to push the lever for the substance until they are dead despite the fact that they can have as much food and water as they want. It doesn't matter how intelligent the rat is. And I think most people agree that rats don't have a conscience or a moral code (I understand they are conducting a study right now using attorneys instead of rats......JOKING, JOKING!).

    This is why time is so important in achieving recovery (or remission). Time is important for allowing the brain to recuperate (although it never recovers to the pre-addiction state) while providing time to learn new ways of dealing with cues that can lead to relapse. It takes time and repetition to develop and reinforce new synaptic pathways that are more active than the pathways that developed during addiction. This is where continued attendance at support groups, talking about cues, and remaining abstinent from all mood altering substances is so important to maintaining recovery. It's like working out to achieve physical fitness. Once you achieve the desired level of fitness, you don't stop working out. Maintaining fitness doesn't take as much effort as achieving fitness, but doing nothing guarantees you will very quickly end up out of shape again, usually worse than before since we usually increase caloric intake to feed the newly developed muscle tissue. When we stop working out, we rarely decrease our caloric intake meaning we regain all we lost and then some.

    Unfortunately, this forum doesn't allow the in-depth discussion necessary to obtain the amount of knowledge necessary to fully grasp all that is known about the disease. But there are educational opportunities available, which very few nurses (or MDs and other health care providers) take advantage of in their personal practice.


    Because no one believes it will happen to them. And, it's not really a disease, right?

  5. by   MizChelleRN
    Great article....but I really wanted to say ((((HI JACK))))) I thought maybe you'd left us. Happy to see you still checking on us. And I didn't realize you're from Ohio (me too)...
  6. by   jackstem
    Quote from MizChelleRN
    Great article....but I really wanted to say ((((HI JACK))))) I thought maybe you'd left us. Happy to see you still checking on us. And I didn't realize you're from Ohio (me too)...
    Awww shucks MizChelle, thanks! Nah...I've been crazy busy and was pretty sick this past week. Had a touch of P-New-Monia. Today was the first time I've felt like posting anything, anywhere. Shoot, I didn't check my email for 5 days and I had over 300 email (most were either telling you where you can get oxycodone without a prescription or some little blue pill...?). Not having health insurance really puts a kink in things. Fortunately sample packs of antibiotics aren't a problem with the powers that be.

    I'm celebrating the Cincinnati Bearcats 8-0 season and their number 5 (or 8) place in the national rankings depending on which poll you check. Shoot, they're ranked ahead of Ohio State for the first time that I can remember (which ticks off my ex-wife!).

    Life is good!

  7. by   jennanurse15
    Great post to read from Jack, thanks. I am from MN and being investigated for diversion, due to holes in my MARs. I am so afraid of this suspicion, because I am not using any thing at all! I just had very busy shifts and did not chart a few of my meds! do you have any advice for some one like me that has to defend herself against bosses saying that I am diverting!!?? Uggh help
  8. by   jackstem
    great post to read from jack, thanks. i am from mn and being investigated for diversion, due to holes in my mars. i am so afraid of this suspicion, because i am not using any thing at all! i just had very busy shifts and did not chart a few of my meds! do you have any advice for some one like me that has to defend herself against bosses saying that i am diverting!!?? uggh help
    hi jenn,

    advice? hmmmmmm...that can be a dangerous thing for a man to do!

    having said that, here goes.

    first, retain a license defense attorney. if you can't find a nurse-attorney, find an administrative lawyer (through the bar association in your city, county, or state) with experience facing the board of nursing. criminal defense attorneys, family attorneys, divorce attorneys are not the folks you want dealing with a licensure case (unless they have experience in doing so). i'm amazed at the number of nurses who don't retain an attorney when their license is at risk. if you represent yourself and make a mistake you could end up with a restricted license, suspension, monitoring, even revocation. the nurse practice act determines your scope of practice. if you don't know the act backward and forward, how in the world can you defend yourself effectively?it's difficult to remain objective when it's your license and possibly your livelihood at stake. i consult with a nurse attorney on cases involving substance misuse, chemical dependence, and possible diversion. it's amazing the number of nurses we see who didn't know they could have an attorney represent them. it's also amazing the number of nurses who say they really don't have the money to hire an attorney (even if it means a mistake based on ignorance of the laws could lead to sanctions and practice restrictions, even the loss of their license?. there are times in our lives where we have to do whatever it takes to raise the money needed to hire a specialist, such as life threatening medical problems, a serious law suit, and the possible loss of professional licensure and the inability to practice the very profession we love and worked hard to enter. (every nurse should have their own professional liability insurance with a license defense clause! that way you will have attorney representation covered, or at least a substantial portion of it. this type of insurance is very affordable and may even be tax deductible as a business expense...check with your tax professional).

    second, when it comes to making charting errors for meds, you'd be better off missing the antibiotic documentation than a controlled substance. yes, we get busy as all get out, especially with a nursing shortage. read the blog article by a nurse attorney entitled, "illegal processing of drugs documents is a felony and (fill in your state here) nurses are being charged!" the opening sentence states:

    regardless of how busy you are, how short staffed you are, or how high the patient acuity is on a particular unit, you have a professional and legal obligation to accurately document your administration, handling, and waste of a controlled substance.
    she goes on to say:

    if you need help with a chemical dependency or addiction, get help asap.

    if your issue is not dependency and just sloppy nursing practice, get out the mop and broom and clean up your nursing practice because you can be charged and convicted of illegal processing of drug documents for not documenting the administration and waste of a "dangerous drug" in accordance with the (state) law, facility policy, and professional practice standards.
    i repeat...if you don't have an attorney, get one. the single biggest mistake nurses make when facing any investigation by the board of nursing is representing themselves. when a nurse is being investigated by a licensing board, it is an adversarial situation. the board is not your friend and will not advocate for you. their job is to protect the public from unsafe nurses (whether it's from chemical dependence, mental health issues, lack of training, knowledge or skills). it doesn't matter that you haven't diverted medications. the very act of not documenting the administration of a controlled substance is a serious crime. in many states it is a felony. and if they have a strong suspicion that a nurse may be diverting due to chemical dependence but lack sufficient evidence to pursue that suspicion, they can, and will use illegal processing of drug documents to "protect" the public.

    with all of the fallout from the california investigation of the lack of accountability and general mess up with the alternative to discipline program, more and more states are "cracking down" on any nurse suspected of diversion or impairment. we don't have the luxury of prosecutors not prosecuting these cases. we also can't hope our employers won't report these types of cases to the board, the police, or both.

    if you have more specific questions pm me and we can discuss things privately.

    good luck and keep us posted!

    You can offer a hair sample for drug testing if they ask. Offer it at your expense. Makes a good defense if they claim you were eating them. I know one nurse barred from giving meds then canned in the past but no licensing issues.

    I never mess with narc documentation. That's the kiss of death; just suspicion could get odd write ups in order to get you removed if you accumulate enough and they can't pin anything else on you.

    I'd go with voluntary hair sample and give that to the DEA when they come.
  10. by   jennanurse15
    I did have negative results on the 2 samples I cooperatively gave. i am retaining an attorney, so I will not speak to this any longer. i will hope for the best, learn from this and i will keep you posted. PS I also had a violatiion of civil rights that started this whole thing. Wish me luck!
  11. by   jennanurse15
    I am not being investigated by BON, just hospital with no result yet in their findings. Do I really need to be concerned about the DEA. SOunds severe?
  12. by   jackstem
    Quote from jennanurse15
    i am not being investigated by bon, just hospital with no result yet in their findings. do i really need to be concerned about the dea. sounds severe?
    i say you should never say never. you're more likely to have to deal with the local police or sheriff if law enforcement gets involved.

    i did have negative results on the 2 samples i cooperatively gave. i am retaining an attorney, so i will not speak to this any longer. i will hope for the best, learn from this and i will keep you posted. ps i also had a violatiion of civil rights that started this whole thing. wish me luck!
    very, very smart! good luck and let us know what happens. if you have a criminal defense attorney for any criminal proceedings, be sure you have an administrative law attorney for any license activities. if you can find an attorney who does both, great! there aren't many that do both. the law is like need a specialist for special facing a licensing board.

    good luck!!!

  13. by   LStanfield
    JACK!!! You are EXACTLY the person I've been looking for! :bowingpur I have a few questions for you but for some reason I can't PM??? Please contact me however you can ASAP. I've taken some bad advice (nothing to do with diverting drugs) and I need to know what my options are and if I have a chance of staying out of a peer program... Please Jack, this is a "Nursing Licensure Emergency"!!!
  14. by   debnky
    Jack your articles are so informative and insightful. You are able to present the facts with a great twist of humor. I just wanted to say thanks, hope you continue to feel better.