Nurses fighting an opioid crisis from within

While nurses join other healthcare providers in battling the opioid epidemic on the front lines by caring for patients with overdoses or chronic substance use, they also are fighting a more private struggle.

With easy access to potent drugs and the autonomy to practice with minimal supervision, coupled with the realities of a highly demanding and stressful job, nurses might be tempted to abuse or divert the medications they steward for their patients. What’s worse is that with so much to lose, nurses might not get help until the problem hurts their patients or themselves.

In these cases, state boards of nursing are tasked with regulating licenses and addressing problems such as substance use when they occur. Nursing boards typically take a non-punitive stance in cases of problematic substance use, offering nurses an opportunity to get treatment for their disorder and retain their license. However, criminal charges can be filed by hospitals, employers or patients for neglect, theft or other issues associated with substance use or diversion among nurses.

Extent of problem

The American Nurses Association estimates that as many as 15% of registered nurses may be fighting a substance use problem or are in recovery. While substance use problems aren't necessarily more prevalent among nurses than in the general population, the issue takes on a different form among nurses because of how accessible controlled substances are to the profession.

A 2015 report published in Substance Abuse revealed that out of 300 nurses participating in a health assistance program, almost half admitted in an anonymous poll to drug or alcohol use at work, with 40% acknowledging that the use affected their professional competency.

In addition, about 60% of respondents said their problem could have been detected earlier, and that they didn’t seek help out of embarrassment and fear over losing their nursing license.

Finding ways to improve early detection and intervention is the goal of the Missouri State Board of Nursing. Mariea Snell, assistant professor and faculty coordinator of nursing at Maryville University and vice president of the state nursing board, is working to move beyond the traditionally reactive way of handling substance use problems among nurses.

Missouri has been collecting data on how and when substance use-related infractions among nurses occur, Snell says, and is working to provide analysis that will help identify trends and potential prevention and treatment interventions.

“There’s the thought that we’re seeing this more only because we’re able to detect it more,” says Snell. “This kind of problem is a combination of things. We have more opioids on the market and more access to it. And we have the technology now that detects it more frequently. I don’t believe necessarily that this is a new phenomenon. It’s just sort of a perfect storm of access and ability to detect.”

A nurse's problems with substance use or diversion are already in full swing by the time they reach the attention of the state board, Snell says. While states have been collecting data on numerical trends, little has been done on what factors might contribute to substance abuse and diversion among nurses, and what preventive measures might be taken. Snell hopes that as Missouri’s data analysis progresses, the state board will be able to identify risk factors, as well as what steps the state could take in cases of problematic use or diversion.

“We’re beginning to see those trends,” Snell says. “We see trends in settings where there’s less overall supervision but increased access.” For example, home healthcare has comparatively high rates of substance use and diversion for these reasons. “It seems to be a little too tempting for people who might have had some tendencies to begin with,” Snell says.

Trends by shift and unit

Electronic medical records and automated dispensing systems were supposed to help prevent abuse and diversion, but opportunities still exist. Snell says Missouri's board is looking into what types of units and which shifts might be most conducive to problems, and the initial results are surprising.

“Looking at shift work, we were surprised to see no significant difference between day and night shifts,” Snell says. “We see more errors in medication administration at night, but it’s not diversion-related.”

As for what types of nursing units are most prone to problems, Snell says the trend seems to point to the more acute units. Operating room nurses and certified registered nurse anesthetists have high rates of problematic use and diversion, and Snell says “it all comes down to access.”

Although the final analysis has not been completed, Snell shared initial data revealing that just over one-third of drug abuse issues among registered nurses occur in the hospital setting. Among hospital units, it appears that emergency departments, operating rooms, intensive care units and psychiatric units are fairly even on prevalence, she says. Problems appear most prevalent during 12-hour day shifts, she adds.

Travel nursing also poses concerns. “They’re very difficult to monitor,” Snell says of these professionals. “It’s hard because by the time [facilities] have noticed there’s a problem, they’ve already moved on to a new assignment.”

Seeking to protect patients

Snell hopes the investigative work being done in Missouri will benefit patients. She recalls a case in which a nurse injected a dying patient with a mixture of water and mouthwash after diverting the patient’s pain medication, and the patient died in agony. Stories such as this motivate Snell to find ways to help both nurses and patients.

“From the state board perspective, we don’t want to go around revoking licenses, but we’re there to protect the public,” she says. “We definitely feel it’s of high importance to figure out where these problem areas are.”

Snell says she is working to identify prevalence of abuse among nurses who had a prior history of drug problems, but the data aren't available yet. In many cases, nurses with recent or significant substance use histories work under restricted licenses, but the state might have to offer more.

Missouri is now offering a self-reporting program that will allow nurses to report and address a problem in order to get help without losing their license, Snell says. “I see it as the best next step to combat this from a professional standpoint,” she says.

Rachael Zimlich, RN, is a freelance writer based in Ohio.