One in ten doctors and nurses abuse drugs or alcohol. Is this surprising to you? It was to me when I first read it.

Although this number (10-15%) is equivalent to abuse rates in the general public, those of us in healthcare have a special responsibility to be able to think and act clearly as we are responsible for providing safe patient care. Drug use is particularly concerning in healthcare as there is increased access to addicting substances. This can be especially true in correctional healthcare, a low tech setting with fewer barriers to access. For example, very few correctional systems have electronic lockout systems such as pyxis.

Some impaired healthcare professionals gravitate to a correctional setting with the perception that the system has fewer safeguards than a traditional setting; so drug diversion is less likely to be detected. Unfortunately, this may be an accurate appraisal, especially in smaller or disorganized settings where strong narcotics security is not in place. Even well-managed settings can become lax about shift narcotics counts or double-lock systems. Here are a few diversion methods that I have become aware of in my practice. Could any of these happen in your setting?

• The foil backing of a bubble pack of oxycontin was slit. Pills were replaced with a similar looking over-the-counter medication and taped back in place. Bubble packs of the same medication were banded together and the tampered pack was placed in the middle. The diversion was not noticed because nurses were only counting the number of packs each shift, rather than looking at the actual blister packs.
• An entire page of a narcotics ‘red book’ was sliced from the book along with the full pack of medication. Nurses were counting based on what was in the drawer rather than what was in the book index so it was unclear when the theft took place.
• A hospice patient was on liquid morphine at fairly high doses. A sealed box of multiple bottles was double locked in the long-term inventory. When active stock was depleted, the sealed box was opened to find that it no longer contained all the original bottles. The count had been done for some time by just looking to see that the box was still in long-term inventory so it was unclear when it had been tampered with.

According to the National Council of State Boards of Nursing, there are four risk factors for narcotic diversion. How does your setting line up with these risks:

• Access:  Relatively easy access to narcotics in the clinical area
• Attitude: A relaxed attitude toward narcotics security in the setting
• Stress: A high stress work environment including shift rotation and frequent short staffing
• Lack of Education: Staff members are not regularly educated or warned of narcotic diversion concerns

One of the greatest ethical challenges you may face as a nurse is confronting a colleague who appears to be abusing substances. An atmosphere of suspicion and feelings of betrayal can negatively impact work relationships. Many nurses would rather look the other way than deal with the after math of talking to a colleague or reporting suspicious behavior. An article from American Nurse Today has some helpful information on signs and symptoms of a substance abusing nurse:

Physical Signs

• Tremors
• Slurred speech
• Watery eyes
• Sweating
• Unsteady gait
• Runny nose
• Change in grooming

Behavioral Changes

• Frequent mood changes
• Angry outbursts
• Defensiveness
• Lack of concentration
• Blackout periods
• Frequent lying
• Poor judgment

Actions

• Wearing long sleeves even when it is hot
• Unexplained absences from the nursing unit
• Medication errors
• Reports of lack of pain relief from assigned patients
• Offering to medicate co-worker patients
• Increased narcotic sign-outs

Being aware of drug diversion and staff members working impaired is both an ethical and legal concern. We have a responsibility to our patients and other team members to address concerns about a colleague’s substance use behaviors. In fact, we have a responsibility to our impaired colleague to initiate action so they get the help they need to overcome their addition.

Have you witnessed drug diversion or impaired nurse behavior in your setting? Share your insights in the comments section of this post.