Annie was stuck on one thought: How could this happen – again?
A veteran critical care nurse in New Jersey, Annie started diverting Demerol and Dilaudid from the supply closet at her hospital after her grandmother died in 1989.
With computerized records in their infancy, Annie was able to sign for the drugs and inject herself intramuscularly. For a while, she got away with it.
When she was caught, she was actually relieved.
Annie went into inpatient rehab for 28 days. She was reported to the state licensing board and lost her RN license for 2 years.
But her employer stood by her. Once she completed the inpatient rehab program, she was able to continue working in the hospital, albeit in an educational role, where she wouldn’t have direct access to medications.
After 2 years, Annie regained her RN license. There was no long-term oversight from the state licensing board, no continuing counseling required.
She was clean for 16 years. Then her mother died. Annie was forced to sell her house and move in with her aging father to care for him. If that stress wasn’t enough, Annie chose this period to return to clinical practice ? this time in the ED.
When her father died, Annie couldn’t cope. She started diverting Percocet and was caught much quicker. She was reported to the state. She lost her job.
It was 2005. She was 47 years old. She was faced with a grim prospect: losing her license, her career and, if things continued to spiral downhill, her life. And all she kept asking herself was: How could this happen . again?
Cunning & Baffling
Annie is a real nurse. Her story is just one of hundreds of other RNs across the U.S. struggling with the often-misunderstood disease of addiction.
The prevalence of addiction among RNs has been disputed in studies during the past 2 decades. Some researchers say nurses are no more likely to face substance abuse disorders than the general population – less than 1 percent. But because of the long hours, constant stress and other pressures, as many as one in five RNs may face addiction issues during their careers, according to the American Nurses Association.
Drug and alcohol addiction can be devastating for any individual, their family and friends. For nurses with substance use disorders, the effects can reach further, potentially affecting the quality of care patients receive, and in some case, even costing patients’ their lives, said Joanne Cole, RN, director of the Recovery and Monitoring Program (RAMP), run by the Alternative to Discipline Committee of the New Jersey Board of Nursing.
“The 12-step programs call addiction cunning and baffling,” Cole said. “Many nurses who become addicted ? particularly to opioids ? believe the medication gives them more energy, makes them feel better and, in their heads, they are functioning at a higher level.”
Of course, the opposite is true.
Every year, hundreds of nurses in the U.S. have their licenses suspended or revoked because they harmed a patient, diverted or misappropriated drugs, and couldn’t safely practice because of their addiction.
Years ago, nurses caught with addiction problems were dismissed or charged. “As we began recognizing addiction as a disease, the focus changed from disciplining the nurse to helping them get better,” Cole said.
Today, more than 40 states have non-disciplinary programs in place to work with nurses and other healthcare professionals with substance use disorders.
Florida, North Carolina, Texas, Oklahoma and Tennessee had some of the earliest successful Alternatives to Discipline program models. When New Jersey created RAMP in 2003, they saw what worked in other states and adapted it for use locally, Cole said.
(For a list of State Resources for Nurses Battling Addiction, click here.)
“Alcohol and drug addiction is the No. 1 disease in the country,” Cole said. “It’s insidious because it creeps up on many people. They start taking meds for pain or to help them stay awake longer. Soon they’re taking more than they need. They’re diverting or forging scripts to get the meds.”
Denial is pervasive – not just among those with addiction issues – but also among their families, friends, coworkers and more.
Nurses are referred to RAMP by a variety of sources including employers and coworkers. RNs are evaluated and encouraged to participate in an inpatient treatment program for 30 days or more. Often, paying for treatment becomes an issue, so RAMP leaders work to educate nurses, their families and insurance companies about the nature of addiction.
“A 30-day inpatient program allows the nurse time to make the necessary internal change,” Cole said. “It gives them time to work on their own recovery instead of juggling their home life, work life and families.”
If a nurse can’t get into an inpatient treatment program, RAMP leaders work with the individual to get them long-term outpatient treatment.
Once enrolled in RAMP, nurses receive a letter from the state Board of Nursing. In cases where there is no harm or prescription fraud – about 99 percent of cases – the letter will remain confidential as long as the nurse does what RAMP requires.
RAMP participants must attend a treatment program, which includes:
• attending 12-step meetings (90 in 90 days, then a minimum of three per week) and weekly peer support groups;
• completing a monthly self-report and submit to random drug screenings.
Nurses also agree to have their employers and therapists regularly update RAMP on their progress.
“Our goal is by the end of the 5-year period, the nurse has a healthy plan for managing this disease that prevents relapse,” Cole said.
Nurses Helping Nurses
In New York, the Professional Assistance Program (PAP) is the official alternative-to-discipline program for nurses and other healthcare workers with addiction problems. What makes the Empire State unique is the depth of its Statewide Peer Assistance for Nurses (SPAN) program.
SPAN is a separate and distinct organization from PAP – though the groups’ missions run parallel, said Barbara Waite, NPP, APRN-BC, Eastern New York regional coordinator for SPAN.
Created in 1995, SPAN offers peer assistance for nurses with substance use issues; while PAP provides monitoring to ensure nurses are practicing safely and not endangering the public.
“Participation in SPAN is not mandated by PAP, but it is strongly encouraged and supported,” Waite said.
Nurses with substance use issues are referred to PAP or SPAN from a multitude of sources including employers, colleagues and self-referral. As a support program, SPAN is open to all nurses with addiction issues.
The all-nurse group, lead by nurse facilitators, helps one another come to grips with their addiction, to recognize their own personal triggers to substance abuse, and to discover new ways to deal with stress and live their lives more fully.
“We ask people to make a commitment to us and we make a commitment to them,” Waite said. “For example, if they have licensing issues, we accompany them to meetings with PAP and act as their advocates.
Though SPAN is based in Albany, there are six regional coordinators throughout the state and a multitude of meeting locations. SPAN participants meet regularly in small groups.
“At SPAN, we hope to get nurses at the beginning of this process,” Waite said. “When a nurse is caught diverting drugs, working under the influence, or a colleague confronts them, they are really in shock. They don’t know how they got to that point and they don’t know what to do next.
“We can walk them through the process, discuss their options, educate them about this disease and act as their advocates,” she added. “But we can’t do any of that if they don’t come to us and ask for help.
“SPAN is nurses helping nurses.”
Coming on Board
Pennsylvania is one of the most recent states to join the alternative-to-discipline movement.
In spring 2009, the Pennsylvania Nurse Peer Assistance Program (PNAP) was created to help nurses with drug and alcohol addiction.
PNAP includes referrals to treatment programs and counselors, monitors nurses’ progress, and acts as both support and advocate for nurses, according to Kathie Simpson, RN, executive director of operations of PNAP.
“Alcohol or drug addicted nurses were once considered by many to be pariahs, banished from the profession, receiving little help and less sympathy,” Simpson wrote. “Slowly over the past 25 years, attitudes have changed and the focus is now on treatment and rehabilitation.”
Before PNAP was created, nurses with addiction issues were directed to the state’s Professional Health Monitoring Programs, which was seen by many to be punitive-based. The Disciplinary Monitoring Unit – which can suspend or revoke an RN’s license – continues to be directly involved if the addicted nurse injured a patient or committed fraud.
PNAP was created with a dual purpose: to help the nurse individually, and ensure licensed nurses are practicing safely.
When a nurse contacts PNAP, they work with trained peer counselors to create a plan for recovery. The plan can include inpatient treatment, outpatient treatment, 12-step programs, peer counseling, random drug tests and more.
PNAP has been operating for less than 18 months and more than 1,000 nurses have been referred to the program – less than 1 percent of the state’s nursing workforce. But nursing leaders fear other nurses with addiction issues may exist.
“We really want to get the word out now about PNAP,” Simpson said. “We want nurses with substance abuse issues to get help now. We want them well and back to work caring for patients in Pennsylvania.”
Alternative-to-discipline programs are not foolproof. In New Jersey, for example, a few of the 1,000-plus participants have relapsed during the 5-year monitoring period. When that happens, the 5-year time clock simply starts again, Cole said.
There are many success stories of nurses “graduating” out of monitoring programs and regaining control of their lives.
Annie is one of them.
“I went into recovery with my heart and soul,” she said. “I really wanted to learn why this happened twice and what I could do to make sure it didn’t happen again.”
During her 5-year monitoring period, Annie learned how to treat addiction as a disease. She accepted she was an addict and that she needed to be constantly vigilant. But this time, she wasn’t alone.
“RAMP helped me not to be ashamed of my disease and to own it,” Annie said. “My addiction is part of me, but it doesn’t define me.”
She’s used her time in recovery well: earning a master’s degree and finding a new position in nursing continuing education at a community college. Although it is not mandatory, Annie still goes to therapy and 12-step meetings.
Her next project – with the blessing of Cole – is to start a support group for RAMP graduates.
“This is just one more way to help me continue my recovery in a positive light,” Annie said. “Hopefully others will feel the same way.”
Lyn A.E. McCafferty is a contributor to ADVANCE.