Author: Theresa D. Roberts, MHS, RT(R)(MR)

Objectives: Upon the completion of this CME article, the reader will be able to:

1. Discuss the impact that alcohol and drug abuse by a healthcare worker has on the medical profession and the potential legal implications that are involved.
2. Recognize the physical, behavioral, and job performance traits commonly seen with substance abuse.
3. Describe the complications related to the major categories of commonly abused drugs and be able to recognize their common street names.
4. Explain the steps that should be taken when dealing with a healthcare coworker who is demonstrating signs of alcohol and or substance abuse.

Most people in the general population are unaware of how widespread drug addition has become. Even fewer are aware of the number of healthcare professionals that are addicts. Substance abuse affects people in all socioeconomic groups and geographic areas. This article is intended to convey: useful information in identifying the types of substances that are abused and the behaviors that are suggestive of an impaired coworker; an understanding of the professional responsibility to report impaired coworkers; and an understanding of the legal, ethical, and safety implications of substance abuse.

According to the most recent government estimates, patterns of substance abuse vary by employment status. A greater percentage of unemployed individuals when compared to employed people report a higher use of cigarettes (50.1%), illicit drugs (18.2%), and heavy alcohol (10.6%). However, there are many more people who are employed than unemployed, so in terms of actual users, the number of employed people who report drug and heavy alcohol use far outnumber unemployed people who do so. In an article published by the American Journal of Nursing (AJN), 1 in 7 nurses will experience a problem with drugs and or alcohol over the course of his or her career. There is also documented evidence that offspring of alcoholic parents are more likely to grow up and become alcoholics themselves. The combination of genetics, the individual’s environment, and psychological factors plays an important role in the disease process of drug addition.

Alcohol and drug abuse by an employee can create a variety of problems for the employer, coworkers, and clients. The American Nurses Association (ANA) estimates that 6% to 8% of nurses use alcohol and or drugs to an extent that is sufficient enough to impair professional performance. The financial loss to companies in the United States due to substance abuse totals $100 billion a year according to The National Clearinghouse for Alcohol and Drug Information. This cost can be measured in the expense of absenteeism, injuries, health insurance claims, loss of productivity, employee morale, theft, and fatalities. The Occupational Safety and Health Administration (OSHA) estimates that 65% of all work related accidents can be traced to substance abuse.

In 1983, Florida was the first state to enact a "diversion law", which channels a substance abuser out of the traditional legal disciplinary process and into a lengthy course of treatment. By 1992, 12 other states had enacted similar legislation and 18 states had bills on this topic that were pending.

Once reported, the healthcare worker who hasn’t come to terms with his or her problem may express anger and feelings of betrayal. The impaired worker may render an entire department dysfunctional. This can occur prior to and after the discovery of substance abuse. The disclosure of a substance abuse problem within a coworker may often lead to feelings of paranoia or "finger pointing" at others. There is often a heightened awareness of the problem in the department. Many members of the healthcare team worry about being labeled as a "whistle blower" or "not a team player". Personal reluctance to report an impaired coworker may compound the problem for the impaired healthcare worker and the department, as well as endanger patient safety. An addicted healthcare worker is often regarded as a "professional embarrassment". Often when addiction is suspected, the employee may resign or be dismissed from their position. When this occurs, the problem of substance abuse is not adequately addressed, thereby transporting the individual’s addictive behavior to their next job.

Legal Issues:

Most states have mandatory laws that require healthcare professionals to report addicted and or impaired coworkers. Most healthcare professionals are either licensed or certified by national organizations, which govern the specific profession and require similar reporting, as do the state agencies. For example, in the State of Florida, the Board of Nursing can sanction nurses who fail to report any person known to be in violation of the Florida Nurse Practice Act. A person reporting a suspected coworker (without malice) cannot be sued for defamation of character. The Federal Rehabilitation Act of 1973 and The Americans With Disabilities Act of 1990 regard recovering alcoholics and drug addicts as handicapped individuals who cannot be denied employment provided the addiction is under control. The Drug Free Workplace Act of 1988 requires employers to:

1. Maintain an environment that is drug and alcohol free
2. Have a formal policy
3. Conduct an employee awareness program.

The act also permits the employer to require drug testing if the job is drug related and there is a business necessity for doing so. Employer imposed drug testing in the absence of a written policy may constitute a 4^th amendment rights violation that protects against unreasonable search and seizure.

Ethical Issues:

Consumers of the healthcare industry (patients, doctors, employees and the public) depend on trained, responsible, reliable, trustworthy, knowledgeable professionals to render them medical care. All members of the healthcare team must come together to maintain the safety and security of all patients.

Professional healthcare workers take an oath to act in safeguarding patients and the public when health care is adversely affected by incompetent or illegal practices. No rationale exists for breaching this trust. The Management of medical facilities has a responsibility to develop policies and procedures to ensure a safe environment. More specifically, policies and procedures should be developed that address the handling of narcotics and any non-compliance with the following of such procedures. Patient safety and the promotion of health are necessary aspects for supplying competent health care. When the issue of substance abuse in the workplace is addressed, it is a "win-win" situation. Being a "friend" and not reporting a coworker who is impaired may result in the person becoming totally incapacitated or deceased. When a healthcare provider does not report a suspected impaired coworker, they are enabling him or her to continue their addictive behavior. Substance abuse is a disease. With counseling and close monitoring, most professional healthcare workers are permitted to return to a functional care giving role in their specific healthcare field and maintain their value as an individual member of society.

Drug abuse is not a single, immediate event, but rather a gradual process. The road to addiction is not clearly marked. The addict does not know when he or she is moving from one stage into the next, because there is no clear discernible line of separation. For each person the process will differ, depending on the choice of substance, the potency of the drug, how the drug is administered, and the frequency of use. The following lists serve as examples of the various signs and symptoms commonly associated with substance abuse.

• Deteriorating appearance
• Slurred speech
• Tremors
• Lethargy
• Alcohol on the breath
• Weight loss
• Coughing
• Unexplained bruises

 Behavior

• Mood swings
• Lying
• Isolates self from coworkers
• Inappropriate behavior to a situation
• Forgetfulness
• Poor concentration
• Uncharacteristically quiet
• Excessively talkative

• High rate of absenteeism for implausible reasons
• Noncompliance with accepted policies and procedures
• Deteriorating job performance
• Inability to meet deadlines
• Sloppy/illegible/erroneous or absent charting
• Transfers to an after hours shift or area where he or she is isolated

Excluding cigarettes, alcohol, and tetrahydrocannabinol (marijuana), the substances most often abused can be organized into four major categories, which are the sedatives, analgesics/opiates, stimulants, and hallucinogens. Sedatives are used for their "calming effect". They are commonly abused because they "relieve the stress" of every day life or are used to help promote sleep at night for individuals who suffer from insomnia. Numerous sedatives exist with the most common categories being the barbiturates, the benzodiazepines, methaqualone, meprobamate, and glutethimide. Sedatives are addicting and with excess usage, they can lead to respiratory depression, aspiration, and death. The list below contains some of the more common drugs in this category along with some of the common street names.

• secobarbital – seconal (reds) / pentobarbital – nembutal (yellow jackets) / amobarbital – tuinal (blues)
• diazepam – valium / chlordiazepoxide – librium / lorazepam – ativan / oxazepam – serax / alprazolam – xanax / flurazepam / dalmane
• methaqualone – quaaludes
• meprobamate – miltown or equanil
• glutethimide – doriden

Medically, the analgesic/opiates are used for controlling pain. Like the sedatives, they are addicting and as a category are commonly abused. With hardcore users, this drug category can produce a cycle of obtaining a "fix" followed by a "rush" that leads to a "high", then a return to normal, which then promotes a "craving" for more. This is the pattern commonly seen in people who abuse heroin. It is important to understand, however, that most abusers of analgesics/opiates do not "fit in" to this hardcore picture. This is because many of the drugs in this category are obtained by prescription. Many individuals, especially healthcare workers, will have contact with numerous physicians that might prescribe "mild-to-moderate" painkillers for various ailments. Unfortunately, in today’s health care system, these physicians are not aware that the individual is also receiving the same prescription from other doctors. Numerous drugs exist in this category, but some of the more common ones include heroin, morphine, codeine, propoxyphene (Darvon), oxycodone (Percodan), hydrocodone (Vicodin), hydromorphone (Dilaudid), and levorphanol (Levo-Dromoran).

It is important to also discuss Dextromethorphan, which is non-prescription. This drug is found in over-the-counter cold remedies and is used as a cough suppressant. One of the side benefits that was found with the analgesic/opiate drug category is that besides their ability to decrease the sensation of pain, they were also good at decreasing the cough reflex. However, because they are addicting, these analgesic/opiate cough suppressants still require a prescription. Dextromethorphan is the exception. It is the mirror image of levorphanol, which is a strong painkiller. To explain mirror image drugs, when you stand in front of a mirror, the image that is seen is your exact opposite. When you raise your left hand the image in the mirror is raising its right hand. In our three-dimensional world, chemicals or drugs have mirror images and these mirror image drugs may be stronger, equal to, or weaker than their counterparts. Dextromethorphan fits this category because it has minimal to no affect in reducing pain but still has cough suppressant activity and was not found to be addicting like the other drugs in this category. Therefore, it is available over-the-counter. Unfortunately, in the past few years, this drug has also become one that is abused. It appears that when it is used in large amounts it produces an effect (similar to the hallucinogens) that users call "dexing" or "robotripping". As expected when any drug is abused, several deaths have been reported. The drug is often identified in over-the-counter cold remedies with the initials "DM". In the abuse setting, many individuals purchase Coricidin calling them "red devils", "triple-C’s", or "skittles".

The stimulants are the third category and these drugs have also received an enormous amount of notoriety. Physically, they are not as addicting as the analgesics/opiates; however, they produce a tremendous emotional dependence along with a drug tolerance. This drug tolerance leads to the use of larger and larger doses to obtain the same level of "feeling". As the dose increases, the complications are magnified. Overall, there are two main categories in this group (cocaine and amphetamine) but each of these has numerous members. Cocaine (snow, coke, rock, crack, etc.) can be snorted, inhaled, smoked, or injected intravenously. The common amphetamines include benzedrine (bene’s or whites), dextroamphetamine (dexedrine), crystal methamphetamine (Crystal Meth), and methylenedioxymethamphetamine (MDMA or Ecstasy).

The stimulant drug category is used for cerebral stimulation and can increase alertness and motor activity and can also decrease appetite. However, these drugs can lead to nervousness, anxiety, insomnia, paranoia, and rage. Thus, they are often combined with sedatives. The stimulants are used during the day to "make it through work" and at night the sedatives are used to minimize the stimulant-induced insomnia. Physically, these drugs can lead to hypertension, tachycardia, cardiac arrhythmias, hyperthermia (increased body temperature), seizures, stroke, and death.

The hallucinogens are used to produce distortion in time, visual hallucinations, and paradoxical feelings (feeling happy and sad at the same time). The drug that usually comes to mind when this category is discussed is LSD or lysergic acid diethylamide. However, this category also contains phencyclidine (PCP), ketamine (commonly called Special K), mescaline, and peyote. It should also be noted that the abuse of dextromethorphan (discussed above) is primarily to gain the affect that is seen with hallucinogens. Psychologically and physically these drugs can produce psychosis, panic reactions, depression, flushing, diaphoresis (profuse sweating), hypersalivation (excess saliva), seizures, muscular rigidity, coma, and death.

The inhalants are not considered as one of the main categories abused by healthcare workers who suffer from drug abuse. However, in the context of this article, this category should be briefly discussed. Inhalants include such substances as solvents, glues, adhesives, paints, varnishes, paint removers, aerosol propellants, and typewriter correction fluids. One of these agents that has become very popular in the past few years is called "poppers", which are volatile nitrites. These substances are used to gain a state of euphoria and excitation. However, as with all substances or drugs that are abused, serious central nervous system and cardiovascular complications can occur.

The healthcare worker should immediately intervene as needed to protect the safety of any patient in danger of physical or emotional harm of an impaired coworker. Offer to care for the patient(s) while he or she goes on a little break. Do not permit a visibly impaired coworker to care for patients. Immediately report observations of unsafe practices or impaired behavior to the appropriate supervisor. Accurately and completely document any suspicious behaviors or incidents prior to confrontation of a coworker. Ideally, the suspected employee’s supervisor (in the presence of a third person) should be the individual who confronts the employee suspected of substance abuse. Respect the healthcare workers’ right to confidentiality during the investigation process. Inappropriate disclosure of information or suspicions could be grounds for litigation, should the reputation of the healthcare professional be tarnished. Healthcare professionals should be supportive, not judgmental. Recognize that substance abuse and alcoholism are illnesses, for which we, the healthcare providers, took an oath to treat with professionalism and dignity.