"When I went to nursing school, I pulled all-nighters to study," Barbara says. "Speed is what got me through."

After getting her nursing license, Barbara found a hospital job. Seeking friendships, she drifted toward coworkers who hit the bars and used cocaine after their night shift. Though Barbara took pains to deny and hide her addiction, she ultimately failed. "You try hiding it with all sorts of stuff-garlic, mouthwash-and it just doesn't work. The alcohol comes pouring out of you."

Barbara moved from job to job, state to state. Each time, her drug use escalated. By the time she developed a crack habit she was unemployable. "I couldn't even hold down a waitress job," Barbara says.

Stress, drug access raise risk
There's no solid evidence that nurses abuse alcohol and other drugs at rates higher than the general population. Yet nurses-like physicians, pharmacists, and many other health care professionals-can obtain drugs by forging prescriptions or pilfering supplies at work. Easy access and high job stress creates a huge opening for abuse.

"The doctors write the orders and the nurses have the drugs right there in their hands, giving them to the patients," says Jim Lea, MD, coordinator of the Health Professionals Program at Hazelden Springbrook in Newberg, Ore. "The number one risk for nurses is working in a plastic surgery office or maxillofacial surgery office. Second is the high-stress nursing position-the emergency room, recovery room, or intensive care. In each case, there's lots of drug access and basically no accountability."

A nurse who becomes impaired by addiction poses a safety threat to patients and colleagues. Poor concentration, mood swings, mistakes in patient care-all are effects of drug abuse.

What's more, addicted nurses can quickly spark professional conflicts. Nurses are obligated by a Code of Medical Ethics to report an impaired colleague. But pointing the finger can lead to accusations of not being a team player, or of inviting the wrath of management. The dilemma creates pressure for nurses to enable a coworker's drug habit or simply deny it.

Besides, addiction can be a hard charge to prove. Isolated behaviors, such as sloppy charting or absenteeism, can be signs of depression or anxiety as well as addiction.

What gives many addicted nurses away are transparent attempts to divert drugs for personal use. According to Susanne J. Danis, RN, a nursing instructor at the University of Phoenix, such nurses may:

• Frequently volunteer to administer medications, especially stimulants and narcotics.
• Document that they've administered the maximum doses of drugs to patients when other nurses do not.
• Report that drug containers have been broken and supplies have been depleted.
• Seek transfers to work areas or shifts with minimal supervision.

Addiction threatens licensure
The traditional way to deal with an addicted nurse has been to punish them. Nurses with documented drug problems have lost their job and often their nursing license as well. Kathy, a recovering nurse, says that she resigned from her last nursing position rather than face punitive action due to her addiction. This was nearly 20 years ago, before any movement to intervene with impaired nurses and get them into treatment.

"There's still a lot of shame," says Kathy. "Nurses really hide their using, and it's very hard to get people to come forward. Once you've been disciplined, anyone who wants to hire you can check on your license on the Internet and find out that you've violated your professional ethics. So, it's really hard to get hired again."

Bob Larsen, MD, coordinator of Hazelden's Health Care Professional Program in Center City, notes that nurses share many of the same blocks to recovery experienced by health professionals in general. Examples include: difficulty accepting the role of a patient; difficulty asking for help; workaholism, or using work as an escape from facing one's issues; and poor self-care.

"Seeing themselves as 'different' is part of what got addicted health care professionals into trouble," says Larsen. "They have trouble transitioning from healer/caretaker to patient. They think 'I'm too smart for this.' But they find out intelligence doesn't protect them from this disease."

Impaired nurses trail other health care professionals when it comes to accessing confidential, non-disciplinary recovery resources. During the 1980s, the American Medical Association lobbied state legislatures to allow impaired physicians to keep a medical license in good standing-as long as they completed addiction treatment and agreed to let a state board monitor their recovery. By the early 1990s, all 50 states had such programs-options that offered confidential peer assistance for addicted docs and diversion from discipline if they followed the program.

Karla Bitz, RN, associate director for the North Dakota Board of Nursing, tracks diversion programs for nurses. In 2000, she reports, 40 boards of nursing across the country had non-disciplinary programs for addicted nurses. However, some states still offer no such option and some with diversion programs take a tougher approach, one that favors more discipline versus compassionate care.

"Addiction in nurses needs to be looked at as a disease," says Bitz. "Without an alternative, nurses will probably end up going through the disciplinary route. But our board feels strongly that these people-with the proper help-are excellent nurses."

"When it comes to assistance for addiction, I just don't see the clarity around nurses that I do for physicians," says Chris Lind, RN, national health services director for Hazelden and supervisor of the Health Care Professionals Program. "But it's improving with the public consciousness that addiction is a treatable disease. We have an extreme shortage of health care workers, especially nurses, and we need to help these folks access treatment in order to save their careers and save their lives."

Diversion programs are key
Nurses have lagged behind most other health professions in terms of gaining compassionate, confidential resources of help, largely because they lack financial resources and political clout, says Marvin Seppala, MD, corporate medical director for Hazelden. He says Minnesota and Michigan are model states in terms of developing diversion programs that offer continuity and fairness for the range of licensed health professionals in their states.

In Minnesota, for example, the Health Professionals Services Program (HPSP) was created in 1994 under Minnesota Statute 214.29 "to enhance public protection and provide confidential support for regulated health care professionals whose ability to practice with reasonable skills and safety may be impaired due to illness." HPSP's main goal is to provide early intervention before patient safety is compromised, according to Monica Feider, program manager. HPSP covers a range of licensed health care professionals such as nurses, physicians, dentists, pharmacists, psychologists, and chiropractors.

Currently, 174 nurses (out of 87,000 in the state) are part of the program, with 63 percent either self-referred or referred by a third party; the rest were referred by the Board of Nursing. Each participant agrees to an individualized monitoring program that includes addiction treatment, continuing care, and practice issues. Monitoring usually involves regular reports from the person's therapist and work supervisor, participation in support groups, and random drug screens. The average length of monitoring is 36 months. If the participant stays sober and complies with the terms of monitoring, the case is closed and remains confidential (ie, it doesn't go to the Board of Nursing).

This kind of rigorous follow-up is what helped Barbara return to a career in nursing. For five years, she received monitoring. "I was getting counseling three times a week and urine checks three times a week. I was going to Twelve Step meetings every day, and I had a wonderful sponsor."

Today she works as an independent contractor with a nursing agency. She has seven-and-a-half years of sobriety. "You've got to chase your sobriety like you chased your drugs and your alcohol," Barbara says.

Nurses find special recovery track at Hazelden
Hazelden offers a special treatment track for addicted health care professionals at both its Springbrook and Center City campuses. Both sites welcome nurses.

Nurses enter treatment in a variety of ways. Some are required to get help as a condition for keeping their license. Others seek treatment independently of any diversion or peer-assistance program.

"Even when nurses come here for treatment on their own, we will recommend that they self-report to the Health Professionals Services Program [Minnesota's diversion program] or the equivalent program in their state," says Chris Lind, RN, supervisor of the Health Care Professionals Program in Center City. "Most folks do that, and we think it's really to their benefit. Then they'll have someone to help oversee their ongoing care."

According to Jim Lea, MD, coordinator of the Health Professionals Program at Hazelden Springbrook, the policy at Springbrook is the same: "We promote all nurses to enlist in a monitoring program for the advocacy they get and the safety that it provides them."

In addition to assessment services, residential care, renewal programs, and family education offered to all Hazelden primary care patients, nurses receive:

• Mentoring from a recovering health care professional.
• Individual counseling and group therapy that focus on returning to professional practice.
• A personal plan for continuing care, with follow-up contacts throughout the first year after treatment and referrals to support groups for recovering nurses.

Hazelden also works closely with diversion programs, offering progress reports, periodic drug screenings, and related documentation that nursing boards require.

Aftercare is a crucial component to recovery, says Marvin D. Seppala, MD, who oversees Hazelden's health professionals programs. "When nurses comply with the terms of their monitoring and aftercare program, it's a win-win for everyone. The health, dignity and career of the nurse is restored and public safety is protected."

For more on the Center City program, call (800) 257-7810; for information on the Springbrook program, call (800) 333-3712.

Addicted nurses can seek help from a range of sources, including treatment centers, state diversion groups, peer-assistance groups, employee assistance programs, and mutual-help groups such as Alcoholics Anonymous and International Nurses Anonymous (INA). INA offers support and networking for newly recovering nurses; for more information go to http://members.aol.com/IntNursesAnon or contact Kathy Kavanaugh at (704) 992-0678 or wkavanaugh@aol.com.

--by Doug Toft

Published in The Voice, Summer 2003