Continuing Education Activity

Drug and alcohol use disorders in the workplace are common problems; high prevalence in healthcare settings has increased awareness of the issue. When these disorders occur in healthcare settings, the risk of career-ending consequences and the potential for unintended harm to patients make this an issue of high importance. Coworkers, as well as members of the interdisciplinary team, should be able to recognize signs and symptoms of substance use disorders so that impaired practitioners can receive assistance. Helping other healthcare team members will improve patient safety and lead to better retention of healthcare providers. 

This activity reviews the different facets of substance abuse disorders found in the workplace, the rules and regulations in Florida's Nurse Practice Act for nurses regarding the use of alcohol and drugs as the basis for disciplinary actions, and the proactive Intervention Project for Nurses strategy the state of Florida is utilizing to address this issue. The crucial role of the interprofessional team in recognizing and helping coworkers who have substance use disorders is highlighted in this activity.

Objectives:

• Determine the etiology of alcohol and drug-related impairment in the workplace.

• Evaluate the presentation of alcohol or drug intoxication in the workplace.

• Implement the management options available for alcohol and drug-related impairment in the workplace.

• Identify the importance of improving coordination amongst the interprofessional team members to help recognize and treat individuals affected by alcohol and drug-related impairment in the workplace.

Introduction

Alcohol use disorder and other substance use disorders represent a significant problem for healthcare professionals. Without identification and appropriate treatment, impairment usually progresses and compromises not only the workplace but, more importantly, threatens patient safety. The danger is significantly worse when the impaired health professional is responsible for treating critically ill patients in the intensive care unit, emergency department, or operating room. Medical professionals must recognize signs of this disorder in their peers for the sake of patients and those afflicted healthcare providers themselves.[1][2][3][4][3]

Health professional impairment is, unfortunately, much too frequently seen. Impairment results when a health professional, a physician, nurse, or allied health professional is unable to provide competent and safe patient care because of any substance use disorder. Any illicit substance, as well as prescription and non-prescription drugs, can impair the professional.  Impairment may also result from a psychological or physical condition that affects the health professional's judgment, such as overwhelming chronic pain. Any disorder, mental, physical, or substance-related, can cause the healthcare professional to lose focus and be unable to safely and effectively perform the duties required by their profession. Recognition of this inability to safely and effectively perform to the best of their ability is the determining factor in recognition of any performance-limiting impairment.[5]  

All health professionals must be aware of the safety issues that become apparent when a health professional is impaired. Ultimately, the signs and symptoms of impairment and the state and institution requirements for reporting individuals suspected of working while in an impaired state are critical to preventing injury to patients and loss of the professional expertise of afflicted colleagues.[6][7][8]

Impaired health professionals usually develop coping mechanisms that allow them to initially cover up their diminished capacity to provide safe patient care. Eventually, mistakes become more evident, medication errors are made more often, or procedural errors become more apparent. Initially, these violations may be subtle, and only an astute and observant fellow practitioner will notice a change in behavior or the signs and symptoms of impairment.[9] One common occurrence is the diversion by a health care professional of controlled substances such as opioids and benzodiazepines from a patient to themselves.[10]  The diversion can result in a patient being under-medicated or suffering unnecessarily due to a lack of appropriate medications.[10]

The misuse of substances over time also may result in the deterioration of the health professional's well-being. Use of stimulants, for example, may result in cardiovascular problems such as angina, hypertension, and myocardial infarction. Alcohol can lead to liver diseases such as cirrhosis. Patients suffer exposure to infectious diseases such as human immunodeficiency, hepatitis, and other blood-borne diseases. There are often coexisting mental disorders such as depression and anxiety; suicide can be an outcome for some. Impairment can lead to traumatic injuries such as falls, fractures, and head injuries.[11][12][13]

Florida State and Federal Rules and Regulations

Virtually all states include rules and regulations regarding the use of alcohol and drugs as the basis for disciplinary actions. Authorities deal with the diversion of drugs from patients very harshly. Almost all states also require reporting of health practitioners suspected of impairment. These rules and penalties vary from state to state.

The Florida Nurse Practice Act is an example of the typical state law regarding the use of controlled substances and the necessary reporting.[leg.state.fl.us, 2018] Each practitioner should consult the rules and regulations for their own profession.

464.018  Disciplinary Actions

(h)  Unprofessional conduct, which shall include, but not be limited to, any departure from or the failure to conform to the minimal standards of acceptable and prevailing nursing practice, in which case actual injury need not be established.[leg.state.fl.us, 2018]

Most states require reporting of unprofessional conduct, whether it be by a physician, nurse, or allied health professional. 

(i)  Engaging or attempting to engage in the possession, sale, or distribution of controlled substances as set forth in chapter 893 for any other than legitimate purposes authorized by this chapter.[leg.state.fl.us, 2018]

All states and the federal government take a dim view of healthcare practitioners who engage in the unlawful sale of prescription or nonprescription controlled substances. Penalties for violation can include fines and jail sentences.

(j)  Being unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, opioids, chemicals, or any other type of material or as a result of any mental or physical condition. In enforcing this paragraph, the department shall have, upon a finding of the secretary or the secretary's designee that probable cause exists to believe that the licensee is unable to practice nursing because of the reasons stated in this paragraph, the authority to issue an order to compel a licensee to submit to a mental or physical examination by physicians designated by the department. If the licensee refuses to comply with such an order, the department's order directing such examination may be enforced by filing a petition for enforcement in the circuit court where the licensee resides or does business. The licensee against whom the petition is filed shall not be named or identified by initials in any public court records or documents, and the proceedings shall be closed to the public. The department shall be entitled to the summary procedure provided in s. 51.011. A nurse affected by the provisions of this paragraph shall, at reasonable intervals, receive an opportunity to demonstrate that she or he can resume the competent practice of nursing with reasonable skill and safety to patients.[leg.state.fl.us, 2018]

All states have varying rules regarding the evaluation and prosecution of a healthcare practitioner who, due to mental illness or illicit use of controlled substances, places a patient's safety at risk. Health professionals have been prosecuted for felonies for harming patients due to unprofessional and dangerous conduct.

(k)  Failing to report to the department any person who the licensee knows is in violation of this chapter or of the rules of the department or the board; however, if the licensee verifies that such person is actively participating in a board-approved program for the treatment of a physical or mental condition, the licensee is required to report such person only to an impaired professionals consultant.

Most states require health professionals who they believe are impaired to report to the appropriate authority. Failure to report may have negative consequences for the health practitioner who is aware of the impairment and fails to report to the proper authority.

(l)  Knowingly violating any provision of this chapter, a rule of the board or the department, or a lawful order of the board or department previously entered in a disciplinary proceeding or failing to comply with a lawfully issued subpoena of the department.

If the health professional knowingly violates the provisions, the consequence in most states is even more severe. All health professionals are obligated to be aware of the Practice Act rules and regulations in each state in which they hold a license.

(m)  Failing to report to the department any licensee under chapter 458 or under chapter 459 who the nurse knows has violated the grounds for disciplinary action set out in the law under which that person is licensed and who provides health care services in a facility licensed under chapter 395, or a health maintenance organization certificated under part I of chapter 641, in which the nurse also provides services.[leg.state.fl.us, 2018]

Most states have the right to specifically penalize a health professional who fails to report another health professional whom they know violates state laws. Besides the legal concerns, health professionals have an ethical and moral duty to patients to report a health professional with a diminished capacity to perform their duties.

(4)  The board shall not reinstate the license of a nurse who has been found guilty by the board on three separate occasions of violations of this chapter relating to the use of drugs or opioids, which offenses involved the diversion of drugs or opioids from patients to personal use or sale.[leg.state.fl.us, 2018]

In many states, the ongoing use of drugs or alcohol can result in the permanent loss of a medical license.

It is crucial that all health professionals review the Health Practice Act in each state where they hold a license and that they comply with the reporting requirements. If one is unsure of the requirements, most institutions will provide an attorney or other professional to understand the reporting process.[14][15]

Most states have statutes to help healthcare practitioners identify and treat impaired healthcare providers. Virtually all state medical boards require that a healthcare provider suffering from alcohol or drug substance use self-report, and individuals aware of the problem must report their peers. Due to the fear of reprisal, most states have a mechanism whereby a provider can confidentially report a peer directly to an agency that can investigate and deal with the problem. Providing there are no safety issues that directly affect a patient's care, the impaired practitioner can engage in treatment and rehabilitation and avoid board disciplinary action. [16][17][18]

If a health professional is already under discipline, has been terminated from rehabilitation, has sold drugs, or is at continuous risk to the public, the practitioner is less likely to receive the opportunity to seek private treatment without public consequences. However, if there is no danger to the patients, even The Joint Commission supports treatment rather than punishment.

To a certain extent, federal laws protect health professionals with substance use disorders. The Americans with Disabilities Act provides protection for healthcare providers in treatment and recovery programs for substance use disorders. It requires a "reasonable accommodation" for an individual who recognizes their alcohol or drug issues and participates in a rehabilitation program. Federal law does not consider a person to have a disability because they are using drugs. The Family Medical Leave Act requires employers to allow time off for qualified substance use disorder treatment.

Courts and statutes usually protect healthcare providers' and medical boards' efforts to address substance use disorder issues, particularly if practitioners have successfully completed treatment. However, if a practitioner harms a patient while under the influence of drugs or alcohol or an institution knowingly fails to protect a patient, the consequences can be severe. Examples include the following:

• A court granted immunity to the director of an impaired practitioner program, who suggested that healthcare professionals' privileges be suspended until they completed substance use disorder evaluation and treatment.

• During a medical malpractice case, a healthcare professional refused to turn over substance use disorder treatment records; the court ruled those records were privileged and confidential.

• A court dismissed a hospital from a malpractice suit that claimed negligent credentialing due to a health professional's prior alcohol and drug use. The court found the professional had completed successful treatment and had complied with a monitoring program for years, and the hospital acted reasonably in granting privileges.

• A  patient sued the hospital for improper credentialing because the health practitioner had committed malpractice in the past and was known by the hospital to be addicted to sedatives. The hospital was assessed punitive damages for negligent credentialing.

• A health professional admitted to being under the influence of an opiate during a surgical operation, and there was a large punitive verdict awarded.

Definitions

Addiction: A substantial loss of self-control indicated by compulsive alcohol or drug use despite the desire to stop. It may involve cycles of relapse and remission, and if untreated, may result in disability or premature death.

Drug diversion: The transfer of a controlled substance, such as a drug, from a lawful to an unlawful channel of distribution and use.

Substance use disorder: A disease of the brain characterized by the recurrent use of alcohol or drugs that result in functional impairment such as disability, health problems, and failure to meet responsibilities at home, work, or school.

Impairment: The inability or impending inability to provide safe, professional activities and duties due to a behavioral, mental, or physical disorder related to alcohol or drugs.

Consequences of Healthcare Professional Impairment

Patients

• The decreased trust of health professionals
• Infection from contaminated needles
• Medical error victims
• Reaction to wrong drugs
• Undue pain

Peers

• Discipline from failure to report
• Legal liability from shared patients/shared patient care
• Stress from increased workload as a result of an impaired professional

Professionals

• Accidental injuries
• Billing and insurance fraud
• Communicable infections from the use of unsterile drugs and needles
• Felony prosecution
• Heart disease
• Liver disease
• Malpractice actions

Institutions

• Civil liability from failure to recognize an impairment
• Decreased institutional reputation
• Decreased revenue from diverted drugs
• Poor work quality
• Increased absenteeism
• The increased cost of Workers' Compensation

Etiology

The most common causes of workplace impairment are chemical and substance use, including the following: 

• Alcohol presenting as acute intoxication and chronic alcohol use
• Prescription drug use, commonly opiates and anxiolytics
• Nonprescription drug use, including a variety of opiates and other illicit drugs

Often, there are underlying stressors that contribute to the impairment of the individual in a healthcare setting. The following are common stressors:

Genetic

• Neurotransmitter deficits
• Family history of substance use disorder

Mental/Physical Fatigue

• Staff shortages may drive stimulant use.
• Stressful job responsibilities
• Environmental factors
• Excessive workload
• Pregnant
• Shift work
• Prolonged traveling
• Sleep deprivation
• Social activities

Injuries

• The use of opioid pain medications due to injuries leads to addiction and an inability to control consumption after the injury is resolved.
• Chronic pain syndromes may require long-term pain relief and include controlled substances.

Personal Stress

• Personal relationship issues
• Family or personal health issues
• Financial matters
• Addictions, such as gambling or sex 

Physical Illness

• Diabetes, epilepsy, arthritis, asthma, cancer, and other long-term illnesses that result in chronic pain
• Recurring medical conditions
• Acute or chronic pain

Psychological

Addictive personality

• Anxiety
• Feelings of resentment
• Depression
• Low self-esteem
• Unable to cope with stress

Questionable Competence

• Unfamiliarity with the work environment or work practices and procedures
• Poor training
• A gradual erosion of skills and lack of refresher training

Work-related stress

• Organization change
• Restructuring
• Long work hours
• Shift-work
• Changing responsibility
• Increasing responsibility

Epidemiology

Alcohol and drug use is a significant problem in the healthcare profession. As much as 15% of all health professionals are thought to be impaired or recovering from alcohol or drug use. Accurate statistics of the exact number of individuals afflicted are unknown but are believed to be similar to or exceed the rate of impairment in the general population.[19][20][21]

Alcohol and substance use disorders are a significant problem in health care. Diseases related to alcohol and drugs are one of the leading causes of preventable disability and death. While it is ubiquitous, it may be beyond the ability of the health professional to control. Genetic factors are thought to play a role in up to 50% of individuals with substance use disorder.[22][23][24]

• Alcohol and substance use contributes to injuries, missed work, decreased productivity, social harm, liability, and increased health costs. Because of the extensive risks to individuals and institutions, it is beneficial to assist employees in managing alcohol and substance use.

• Use and diversion of drugs are seen throughout the healthcare profession, but they are most prevalent in individuals who work in anesthesiology, emergency, intensive care, or pharmacy. Some health professionals may also engage in binge drinking, regular heavy drinking, and illicit drug use.

• When a health professional also develops a mental health issue such as depression, anxiety, schizophrenia, or severe personality disorder, the risk of impairment due to self-medication and treatment increases significantly.

• The rate of drug use by healthcare providers is thought to be as much as five times higher than the reference rate for nonmedical professionals. High stress specialties have the highest incidence of substance use problems. For example, emergency physicians experience substance use at a higher rate than most other physicians. 

Substance use among doctors, nurses, and allied health professionals is related to a variety of factors; for example, personality traits that lead individuals to select high-stress positions in medicine, such as high achievement, obsessiveness, and a high work ethic also may influence an individual to chose stimulants to maintain what they believe is a higher level of performance. Health professionals also have relatively direct access to prescription drugs, making it easier to obtain addicting medications. Health professionals tend to use benzodiazepines and opiates more than illicit street drugs, most likely due to the ease of access. Substance use in healthcare providers is expected to increase due to long hours, stress, and increasingly widespread workforce shortages in healthcare.[25][26]

Pathophysiology

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines a substance use disorder which is divided into mild, moderate, and severe. Substance use disorders occur when the recurrent use of alcohol and/or drugs causes significant impairment, including health problems, disability, and the inability to meet major responsibilities at home, work, or school. A substance use disorder diagnosis is based on evidence of social impairment, impaired control, risky use, and pharmacological criteria.[27]

Substance Use Disorder

As with most behavioral and psychiatric disorders, the interplay between genetic risk, temperamental traits, and the environment may predispose an individual to substances use. Once exposed to substances, brain reward systems reinforce substance use, resulting in repeated use and lower ability to control substance use. 

Alcohol Use Disorder

The pathophysiology of alcohol use disorder is unknown, but its development may result from a complex interplay of genetics, environmental factors, personality traits, and cognitive functioning.

Tobacco Use Disorder

There are almost half a million deaths each year in the United States secondary to cigarettes.

Stimulant Use Disorder

Cocaine, methamphetamine, and amphetamine are the most commonly used substances in this group.

Hallucinogen Use Disorder

LSD, ecstasy, and psilocybin are included in this group.

Opioid Use Disorder

In the United States in 2014, it was estimated that 1.9 million individuals were using prescription opioids, and 586,000 were using heroin.

Cannabis +Use Disorder

Despite the acceptance of this substance, Federal law still prohibits use.[28][29]

Toxicokinetics

Substance use disorders correlate with several negative consequences for healthcare providers, including the following toxic effects:  

Toxic Effects of Drug Use

• Opioids: respiratory and CNS depression
• Barbiturates: respiratory depression
• Benzodiazepines: respiratory depression
• Amphetamines: euphoria, grandiosity, pupillary dilation, prolonged wakefulness, hypertension, tachycardia, anorexia, fever, paranoia, cardiac arrest, and seizures
• Cocaine: impaired judgment, pupillary dilation, hallucinations, paranoid ideation, angina, and sudden cardiac death
• Phencyclidine: violence, impulsivity, psychomotor agitation, nystagmus, tachycardia, hypertension, analgesia, psychosis, delirium, and seizures
• LSD: visual and auditory hallucinations, depersonalization, anxiety, paranoia, psychosis, and flashbacks
• Marijuana: euphoria, anxiety, paranoid delusions, the perception of slowed time, impaired judgment, amotivational syndrome, dry mouth, increased appetite, conjunctival injection, and hallucinations
• MDMA: euphoria, disinhibition, hyperactivity, life-threatening hypertension, tachycardia, hyperthermia, hypernatremia, and serotonin syndrome

Toxic Effects of Alcohol Use

• Excessive alcohol consumption commonly causes preventable death.
• More than 85,000 deaths a year are directly attributed to alcohol use.
• Toxic effects include emotional lability, slurred speech, ataxia, blackouts, coma, and death.

History and Physical

Dire consequences are associated with healthcare provider impairment. Often, the impairment goes unreported or untreated because of the following:

• Alcohol and substance users often do not admit they have a problem.
• Alcohol and substance-using health professionals tend to self-diagnose and self-treat and do not seek help from other professionals.
• Colleagues may be fearful of reporting due to the potential for reprisal.
• Patients are often uncomfortable taking action against health professionals responsible for their care.
• Lapses in clinical judgment and performance are usually late signs of impairment, making diagnosis difficult unless the practitioner admits they have a problem.

Impaired practitioners, as well as their colleagues and patients, are unlikely to take action until an alcohol or drug problem has reached a critical level and resulted in a significant healthcare disaster or a legal entanglement.

For this reason, healthcare workers must recognize a clear ethical, moral, and legal duty to identify and report an impaired colleague. Unfortunately, while most health professionals consider alcohol and drug use to be a disease, health professionals are often reluctant to report their concerns. It is difficult for a colleague to confront a potentially impaired healthcare provider for fear of damaging the professional's reputation, especially if the suspicion is proven wrong.

Regrettably, only an average of 2 out of 3 healthcare practitioners with direct, personal knowledge of a colleague's impairment will report a peer to the proper authority professionals despite the legal risk for not reporting. However, in many cases, reporting may be the only approach encouraging the impaired doctor, nurse, or allied health professional to seek evaluation and treatment.

Impairment may be due to alcohol, street drugs, or taking prescription drugs from a patient, friend, or family member. Health professionals may take injectable medications from a patient or dilute the drug with saline. 

The following are the most commonly used medications: 

• Benzodiazepines
• Cocaine
• Ecstasy
• Heroin
• Ketamine
• Marijuana
• Methamphetamines
• Opioids
• Sleeping pills
• Stimulants

Impaired health professionals are often difficult to identify because they are often bright, well-trained, careful, and make a strong effort to avoid being caught. When the signs or symptoms of alcohol or drug use finally get noticed, the problem has typically been ongoing for a long time.

The following signs and symptoms of alcohol and drug use can help a health practitioner identify a potential problem:

Symptoms of Alcohol and Drug Use Disorder

• Abnormal wasted opioids
• Altered orders
• Arriving to work late
• Difficulty meeting deadlines
• A discrepancy in controlled substance records
• Dishonesty
• Documentation errors
• Excessive sick time
• Frequent mistakes
• Frequent reports of patients not receiving pain relief
• Frequent unexplained absences
• Increased opioids sign-outs
• Leaving work early
• Maximum use of pain medications
• Mood changes
• Not performing narcotic counts
• Obsession with opioids
• Offering to medicate patients
• Paranoid
• Poor charting
• Poor quality work
• Rounding at odd hours

Signs of Alcohol and Drug Use

• Anger management issues
• Bloodshot eyes
• Constricted pupils
• Defensiveness
• Denial
• Dilated pupils
• Diminished alertness
• Diaphoresis
• Disheveled appearance
• Distracted
• Fatigue
• Frequent accidents
• Frequent pain complaints
• Frequent use of gum or mints
• Hyperactivity
• Hypoactivity
• Insomnia
• Intoxication at social functions
• Isolation
• Lying
• Mood changes
• Impossible reasons for behavior
• Perforation of the nasal septum
• Poor concentration
• Poor judgment
• Runny nose
• Sedated
• Sleepiness
• Slurred speech
• Suicidal thoughts
• Track marks
• Tremors
• Unexplained nausea, vomiting, or diarrhea
• Unsteady gait
• Watery eyes
• Wearing long sleeves at inappropriate times (hiding track marks)
• Weight gain
• Weight loss 

Behaviors Associated With Drug Diversion

• Altered orders for drugs
• Controlled substance discrepancies
• Frequent trips to the bathroom
• Frequent medical loss
• Frequent corrections on medication records
• Higher-than-average opioid administration
• Higher-than-average opioid wastage
• Incorrect counts (particularly opioids)
• Patients complaining of poor pain relief
• Tampering with capsules or vials
• Unexplained disappearance

Many health professionals may turn to alcohol and drugs when going through a stressful time in their lives. They may use illicit substances to help them cope with problems such as family issues, malpractice cases, work stress, or financial pressures.

Alcohol and drug addiction is compulsive behavior. It may develop from an unhappy life, poor life choices, a family history of addiction, boredom, denial, or thrill-seeking. 

Institutional Considerations

Most health professionals lack training and education regarding the signs and symptoms of addiction, identifying those addicted, and the correct manner to engage in the intervention. 

All health professionals should receive education regarding alcohol and substance use disorders. Employers need to assist in improving physician, nurse, and allied health professionals' knowledge about the signs and symptoms, how to report them, and available treatment options.

• Employers can and should provide workers with strategies that promote patient safety and provide assistance in reporting concerning health professionals.

• Employers should offer guidelines that promote safe practices and a defined reporting mechanism for concerning situations.

• Employers should offer assistance to health professionals who suffer from alcohol and substance use.

The policy at any healthcare facility should be an alcohol and drug-free environment. The following mechanisms can decrease worksite impairment:

• Pre-employment drug testing
• Cause testing (if suspicion exists)
• Random testing
• Regular practice evaluations

Each of these is controversial. While most institutions support pre-employment and cause testing, less support exists for random testing of healthcare professionals. Further, not all professionals working in a hospital setting are necessarily employees of the institution. This fact may make it difficult for an institution to mandate screening.

Institutions should promote a culture that delineates the expectations of employees and consequences. A policy that supports providing help with alcohol and drug use disorders should also be in place.

Institutions have an opportunity to help identify employees and practitioners with alcohol and drug impairment. In particular, supervisors should be trained in the signs and symptoms of alcohol and drug use disorder. They should be familiar with the institution's policies and procedures for getting the individual the help they need.

Evaluation

The evaluation of a health professional with substance use or potential substance use disorder is a challenge. Health professionals may make efforts to hide or cover up their use and use of alcohol or drugs. Evaluation and diagnosis will be conducted by a clinician experienced in dealing with potentially challenging patients.[30][31]

DSM-5 Diagnostic Criteria for Evaluating and Diagnosing a Substance Use Disorder

A problematic pattern of use leading to clinically significant impairment or distress is manifested by two or more of the following within a 12-month period:

1. Often use larger amounts or for a longer period than was intended
2. Persistent desire or unsuccessful efforts to cut down or control use
3. A great deal of time spent in activities necessary to obtain, use, or recover from the substance’s effects
4. Crave or have a strong desire or urge to use the substance
5. Recurrent use causing failure to fulfill primary role obligations at work, school, or home
6. Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by its effects  
7. Important social, occupational, or recreational activities given up or reduced because of use
8. Recurrent use in situations in which it is physically hazardous
9. Continued use despite knowledge of having a persistent or recurrent physical or psychological problem was likely caused or exacerbated by the substance
10. Tolerance
11. Withdrawal

Severity

DSM-5 specifies mild, moderate, and severe based on the number of diagnostic criteria met by the patient at the time of diagnosis:

• Mild: 2 to 3 criteria 
• Moderate: 4 to 5 criteria       
• Severe: 6 or more criteria

DSM-5 Diagnostic Criteria for Evaluating and Diagnosing an Alcohol Use Disorder

1. Recurrent drinking, resulting in failure to fulfill role obligations
2. Recurrent drinking in hazardous situations 
3. Continued drinking despite alcohol-related social or interpersonal problems
4. Evidence of tolerance
5. Evidence of alcohol withdrawal or use of alcohol for relief or avoidance of withdrawal
6. Drinking in larger amounts or over longer periods than intended
7. Persistent desire or unsuccessful attempts to stop or reduce drinking
8. A great deal of time spent obtaining, using, or recovering from alcohol
9. Important activities are given up or reduced because of drinking
10. Continued drinking despite knowledge of physical or psychological problems caused by alcohol
11. Alcohol craving

Severity: The severity of alcohol use disorder at the time of diagnosis can be specified as a subtype based on the number of symptoms present: 

• Mild: Two to three symptoms    
• Moderate: Four to five symptoms
• Severe: Six or more symptoms

Laboratory Testing

Alcohol

Diagnosis of an alcohol problem can be made in the outpatient department by using the CAGE questionnaire, which includes the following: (need to) cut down, annoyance (on drinking), guilt (about drinking), and an eye-opener.

Screening tools like the ten-question Alcohol Use Disorder Identification Test (AUDIT) and the abbreviated 3-question Audit-consumption (Audit-C) are recommended for screening.

Laboratory tests to confirm the diagnosis include:

• Serum alcohol concentration
• Direct alcohol biomarkers: ethyl glucuronide
• Liver enzymes: aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin, and albumin to test for liver damage. An AST: ALT ratio of 2 to 1 is indicative of alcohol-induced liver disease.
• Hemoglobin and complete blood count to determine the presence and severity of anemia, pancytopenia, and macrocytosis. A mean corpuscular volume greater than 100 fL constitutes macrocytosis. Pancytopenia and macrocytosis usually require very heavy, prolonged use and often liver disease.
• Gamma-glutamyltransferase (GGT) –  an indicator of excessive alcohol use when elevated. The reference range is 8 to 40 IU/L (females) and 9 to 50 IU/L (males).
• The patient's social network, especially family, should be involved in treatment to the extent possible (and agreed to by the patient, if a legally competent adult), provide additional history and therapeutic support, and help monitor the patient's progress and adherence to treatment.

Substance Use Disorder

• Drug of abuse screen
• Urine drug levels
• Blood drug levels
• Hair drug levels
• Saliva drug levels
• Breath drug levels

Treatment / Management

Often, the evaluation and treatment of a health professional with alcohol or drug addiction are challenging. Typical treatment occurs over months to years and includes follow-up and monitoring, sometimes by legal entities. The most important predictor of successful treatment is when a healthcare professional admits the addiction and is willing to accept and stick with the prescribed treatment. In many cases, treatment is forced upon a health practitioner by a court or medical board or occurs due to peers, family, and friends encouraging therapy. Those who are self-motivated and have insight into their disease are much more likely to have a successful treatment outcome.[32][33][34]

All healthcare providers need to be familiar with peer reporting requirements for alcohol or drug addiction within their institution and in their specific state. If someone suspects a colleague has an alcohol or substance use problem, they should refer the impaired health practitioner to the proper authority in your institution or state. In several states, reporting is required by law. In states where it is required, as long as reporting that is deemed false is not done with malicious intent, immunity is usually granted. Besides the state and institutional requirements, all health professionals have a duty to "first do no harm" and protect patients from the harm that might come from an impaired professional.

Do not wait until impairment affects performance; all health professionals must report at the first sign of impairment. This report should be considered an act of kindness as the short and long-term consequences are grave for health; an impaired health professional can harm a patient.[35]

Evaluation and Treatment Referral Programs

The following are some of the treatment options available to help alcohol and drug-impaired health professionals:

• Professional associations offer peer assistance programs to assist impaired professionals.
• State boards offer peer assistance programs and support for health professionals who voluntarily or through mandate seek counseling and treatment.
• Professional schools provide programs for their students.
• In Florida, Rule 64B31-10.001 pairs an impaired practitioner with a program or consultant to provide intervention, evaluation, and referral of impaired health professionals. The program monitors the impaired practitioner. No medical services are provided.[flrules.org, 2015]

The following are two types of programs:

1. State licensing boards operate practitioner programs for impaired health professionals with an impairment resulting in harm to patients.
2. Practitioner health programs are managed by societies, which seek to help health professionals with substance use issues before they harm patients or commit crimes.

Evaluation and treatment programs are state-licensed and accredited. Programs usually have a multidisciplinary team to manage the health professional. Services, depending on the degree of addiction, might be in either an outpatient or inpatient setting and are modified depending on the impairment affecting the health professional.

Treatment Techniques

Treating any patient for alcohol or drug use disorder is challenging, and it is more challenging if the treatment is under duress. Treatment usually involves the following steps:

1. Intervention: voluntarily, institution, or mandated by a licensing board
2. Evaluation: the health professional is evaluated to determine the degree of their impairment.
3. Setting: depending on their degree of addiction and whether they may or may not suffer withdrawal, the practitioner will be considered for inpatient or outpatient treatment.
4. Treatment: counseling, group therapy, or residential inpatient treatment program. In some cases, the health professional is hospitalized for a few days until withdrawal symptoms resolve.

Health professionals who accept their disease and are willing to undergo treatment generally have a high success rate. They are usually bright, have a history of high achievement, and have a will to succeed, which is typically a good sign for treatment success. The recovery rates for health practitioners are generally higher than the general population. Most health professionals who undergo intervention and treatment early and have not harmed a patient or committed a crime can retain their licenses and eventually return to clinical practice.

Florida Mandated Impaired Practitioner Treatment

Under Chapter 456, there are designated treatment program requirements for impaired practitioners.

In Florida, a health professional can avoid disciplinary action if they complete the following:

1. Admit the impairment
2. Voluntarily enroll in a treatment program
3. Withdraw or limit practice as prescribed by the impairment consultant managing the case
4. Release all medical records to the consultant managing the case

Florida Intervention Project for Nurses

In Florida, nurses can choose the Intervention Project for Nurses.[S. 456.076] This is a statutorily approved evaluation and treatment program approved for impaired nurses.[leg.state.fl.us, 2001] Intervention Project for Nurses consultants are designated via contract to initiate interventions, recommend evaluations, and refer those deemed impaired to appropriate treatment programs. The Intervention Project for Nurses also monitors the long-term care of the nurses in the program.

• All treatment programs in Florida must gain approval from the Intervention Project for Nurses.
• The Intervention Project for Nurses does not provide treatment; it only provides referral and monitoring.
• Programs include state-licensed psychiatrists, counselors, and addiction specialists who specifically treat healthcare professionals.
• Intervention Project for Nurses facilities hold a multidisciplinary state-license, and they may include outpatient, residential, partial, or complete hospitalization.
• Treatment programs are accredited through the CARF International or the Joint Commission.
• Treatment programs and providers must apply for and gain approval from the Intervention Project for Nurses.
• The Intervention Project for Nurses provides a list of available programs and providers.
• Additional information can be found on the state board website: floridasnursing.gov, 2018.

Types of Treatment Programs

Intensive Outpatient Programs

These programs provide regular, intense treatment but limit the disruption to family, school, or work schedules. The practitioner typically stops practice until successful treatment is completed and they have reached the stage of monitoring where they are allowed to return to patient care. Outpatient licensed counselors usually meet with the practitioner for several hours multiple times each week.

Residential Programs

These programs are typically located within a hospital or a specialized facility. Patients live in a highly structured environment. Typically, patients live in the facility for 30 to 90 days. In the early phase, they may undergo medical withdrawal and detoxification. Eventually, these patients transition to outpatient programs.

Partial Hospitalization Programs

Includes regular intensive daily sessions, usually five days per week, but the patient does not stay overnight.

Institutional Programs 

An employer may mandate an employee to obtain treatment for impairment or face reporting and termination. Some employers offer addiction assistance programs to help with alcohol or drug problems. Programs often include:

• Health promotion
• Education
• Referral to treatment centers
• Treatment
• Often employer paid

It is expensive for an employer to hire and train a health professional. Employers are often willing to assist employees with the help they need to maintain their jobs and careers. By treating an employee, the employer will save the cost of replacing the employee, avoid accidents that harm patient safety and cause liability issues for the institution, decrease absenteeism, and avoid worker compensation claims.

• Many institutions will provide general education to employees regarding the use of alcohol or drugs. For example, they may educate employees on avoiding binge drinking as it results in hangovers, which impair performance and cognitive function. Much like pilots who do not drink 12 hours before a flight, it is similarly vital for a medical professional to avoid alcohol or drug consumption at least 12 hours before a shift.

• Other education programs may encourage employees to recognize the early warning signs and symptoms of alcohol and drug addiction and help early interdiction before developing serious complications.

• Employees are often instructed on how to identify impaired peers. Individuals who work with an alcohol or drug-impaired individual are more likely to discover and report if they are trained in the signs and symptoms to suspect.

Drug and alcohol use are common problems for health professionals, particularly nurses and doctors. With the prevalence being high among health practitioners and the risk of consequences rising to career-ending, there is an increasing awareness of the issues. Further, the implications for patients may be life-threatening.

Fortunately, there is an increasing trend to recognize that individuals with alcohol and drug issues need evaluation and treatment instead of punitive sanctions.

All health providers need to recognize the signs and symptoms of substance use. There are appropriate tools to assist peers who need help. Together, healthcare providers can work toward improving patient safety and avoiding the permanent loss of a practitioner who has devoted years to their training.

Differential Diagnosis

In some instances, alcohol and drug use have an underlying organic or inorganic cause. Always consider the possibility that the impaired individual is using alcohol or illicit drugs to cover up one of the following:

• Psychosis
• Schizophrenia
• Mania
• Bipolar disorder
• Organic brain disorder
• Personality disorders

Prognosis

The prognosis depends upon whether the diagnosis was made early or late, the follow-up, the motivation of the healthcare professional with the identified impairment, and the success of cognitive behavior therapy. Individuals motivated to maintain their career and healthcare licenses are frequently more successful in their treatment and go on to lead productive careers.

Complications

Substance use leads to a number of problems, including accidents, death, health effects, crime, lower achievement, and safety risks for patients. Governmental and hospital staff should take steps to assist health professionals who admit to substance use.

Postoperative and Rehabilitation Care

Acute and long-term treatment and monitoring are necessary to care for patients with alcohol and substance use disorders.

Consultations

• Psychiatry, preferably an addiction specialist
• For health professionals, state medical boards and hospital staff bylaws may require specific consultations and referrals.
• Probable institution and state-mandated reporting

Deterrence and Patient Education

Cognitive-behavioral therapy, motivational therapy, and psychotherapy are necessary for treatment and to avoid remission. Unfortunately, barriers often prevent or deter health professionals from getting the help they need.

Barriers to Deterrence, Identification, and Treatment for Individuals

Barriers can make it challenging for health professionals to seek help for alcohol and drug addiction. These include:

• The belief that they can stop substance use on their own
• Concern over being labeled with a substance use disorder
• Concern over loss of confidentiality
• Concern over loss of license
• Denial of substance use
• Embarrassment
• Fear of criminal prosecution
• Fear of social stigma
• Lack of understanding of the disease
• Lack of knowledge of the treatment available
• Lack of knowledge of how to obtain assistance
• Reduced employment opportunities once diagnosed and public.
• Scared to expose themselves
• Unaware of alternative treatment programs that avoid public discipline
• Unwillingness to seek help

Barriers to Deterrence and Identification by Peers

• The belief that addiction is not a disease
• Danger and concern over retaliation
• Denial
• Easy to explain behavior as an error and not attribute it to impairment
• Embarrassment if wrong
• A false belief that the appearance of a person who uses substances is always disheveled
• Fear of social stigma of reporting a peer
• Not aware of the risk factors
• Poor attitudes about the success of treatment programs
• Reluctant to report if not 100% sure
• Unsure if it is stress or impairment
• Unsure of consequences to a peer, such as loss of license and job
• Unsure of reporting requirements

Pearls and Other Issues

Steps to Reporting Impaired Peers

Step 1

Compare the signs and symptoms associated with impairment against those of the colleague. Ask honest questions. If there is a strong suspicion, it is better to err on the side of patient safety and report.

Step 2

Are you concerned about reporting? Review personal ethics, morals, and the principles under which you became a health professional. A fellow professional should not be allowed to use substances and place a patient's safety at risk. Allowing another professional to continue to use alcohol or drugs and place patients' lives at risk is not appropriate. No matter what the consequences to the individual, reporting is the proper course of action. Enabling another health professional to cover up their alcohol or drug use is not appropriate, and it is dangerous.

Do not make excuses or cover up for an impaired professional. The potential is that the individual and their patients will be harmed. Unfortunately, the professional has put themselves in the situation and must accept the consequences.

Step 3

Consider and review hospital and state reporting requirements. Become educated about the rules and regulations. Most states and institutions will protect a reporting healthcare professional against the retaliation of a colleague. Review the organization's policies and procedures regarding alcohol and substance use and the assistance the institution offers. If unsure, consider contacting the risk management nurse or lawyer of your institution. Usually, either one can assist in following the appropriate steps. If these resources are unavailable, consider discussing the situation with the department manager.

Step 4

Once a fellow professional is identified as potentially having an alcohol or drug use disorder, report it immediately to avoid any negative consequences for the individual reporting, the patients, or the individual with the disorder. While it may initially seem negative, reporting a peer is a positive act that protects patients and gets the colleague into a treatment program before they cause a severe or even fatal medical error. The consequences are severe once criminal behavior occurs or patient safety is at risk.  The sooner an individual is investigated, the less likely they are to do actual harm.

Unfortunately, sometimes, it may be easier to pass the problem on to someone else, but it is crucial not to ignore signs or symptoms of impairment. Transferring an impaired healthcare worker or threatening termination is inappropriate. Passing the problem on to another department or institution is not an ethical or moral solution.

Example Reporting Requirements [Florida]

Each state has different requirements for reporting an impaired peer. If a health professional believes a peer has an alcohol or drug problem, they must report it to their supervisor and the appropriate state-mandated authorities.[leg.state.fl.us, 2018]

For example, the nurses have developed an effective reporting and treatment system in Florida. Nurses report to the Florida Department of Health or Intervention Project for Nurses. The call to the Intervention Project for Nurses is confidential. The Intervention Project for Nurses can be reached at 800.840.2720. The Intervention Project for Nurses in Florida provides an opportunity for intervention and monitoring of nurses who use alcohol or drugs. Many states have similar reporting mechanisms for health professionals, including physicians, nurses, and allied health professionals.[See Florida Nurse Practice Act S. 455.261]

In Florida, the Intervention Project for Nurses provides:

• Rehabilitation in a confidential, non-punitive manner
• The goal is to treat the health professional instead of the more punitive sanction of permanently losing their license.
• The Intervention Project for Nurses helps get the nurses into recovery and treatment programs.
• The nurse does not return to practice until the Intervention Project reports they are safe to return to clinical duties.

In Florida, any practitioner who believes a nurse is unsafe due to using alcohol or drugs should make a report to either the Intervention Project for Nurses or the Department of Health. The Nurse Practice Act [Florida Statute 464.018 1(k)] states, "Failing to report to the department any person who the licensee knows violates this part of the rules of the department or the Board; however, if the licensee verifies that such person is actively participating in a board-approved program for the treatment of a physical or mental condition, the licensee is required to report such person only to an impaired professionals consultant".[leg.state.fl.us, 2018]

In Florida, the Intervention Project for Nurses provides an acceptable alternative to a legal remedy with discipline. Benefits of the Intervention Project for Nurses include:

1. Early recognition of impairment
2. Rapid intervention
3. Stops nurses practice for days rather than the Department of Health process, which may take 1 to 2 years.
4. Standardized evaluation process
5. Standardized treatment process
6. Standardized monitoring process that may involve the employer
7. Identifies potential relapses quickly
8. Avoids negative consequences, essentially getting evaluation and treatment before serious safety and criminal violations become apparent or are reported

The Florida Intervention Project Process

1. Self, peer, or employer referral
2. Intake evaluation
3. Intervention options offered
4. Professional selects intervention
5. If they do not agree on an intervention or fail to comply, they are reported to the Florida Department of Health.
6. Continued monitoring by Intervention Project for 2 to 5 years

Benefits of the Florida Intervention Project for Nurses

• Evaluates and quickly determines fitness to practice
• Long-term monitoring
• Long-term recovery support
• Support and relapse prevention groups available
• The nurse signs a contract
• The nurse is evaluated on progress
• The nurse gets random blood or urine drug screens
• Qualified practitioner treatment pre-screened

Fitness to Practice

The Intervention Project will evaluate and assess a nurse's ability to safely practice, including stability, recovery, support systems, and specific job skills, including problem-solving, judgment, cognitive function, and coping skills. The Intervention Project enforces several nurse requirements and determines when they can return to work. Requirements and determinations include the following:

1. Agree to practice restrictions, including no overtime and settings with less controlled narcotic access
2. Agree to random drug screens
3. Continued and ongoing treatment
4. Treatment required and completed to practice safely
5. Signed advocacy contract
6. Relapse prevention workbook
7. When the nurse can return to practice
8. Workplace monitoring and reporting

If a nurse consistently meets the fitness to practice guidelines set in place with positive work and monitoring reports, has negative drug screens, regularly attends support group meetings, and meets their contract agreement, they are quickly reintroduced into the workforce. After the Intervention Project program is successfully completed, fitness to practice is established, and long-term monitoring is completed, the nurse's record is sealed. However, if the nurse fails the process, they will be reported to the Department of Health for disciplinary proceedings.

The Intervention Project process does not hire the individuals who provide evaluation or treatment, but it does offer appropriate referrals to health professionals skilled in the assessment and treatment of individuals with alcohol or drug addiction. Referrals are made to local addiction specialists who work within the community.

One downfall of the Intervention Project is that while nurses do not have to pay for a referral to the Intervention Project for Nurses, they are personally responsible for paying for the evaluation, treatment, and random alcohol and drug testing. This cost can be particularly onerous, considering the nurse is usually unable to work during the initial phases of evaluation and treatment. Fortunately, in many cases, employers and insurance policies pay for these services.

Enhancing Healthcare Team Outcomes

Professional Responsibilities

Nursing and other health professionals in Florida should know the reporting steps and the option to report to either the Intervention Project for Nursing or the Department of Health. All health professionals should know how to do the following:

• Evaluate peer job performance and consider the possibility of a drug or alcohol problem resulting in deficient performance
• Appropriately intervene
• Identify the patterns of alcohol or drug dependence
• Know when to contact a supervisor, institutional administration, or government agencies
• Recognize the signs and symptoms of impairment

Virtually all health professionals will encounter one or more impaired peers during their careers. Without a solid knowledge of how to deal with the situation and a plan of action, significant and dangerous impairment problems may get buried and ignored. This can potentially place the individual, peer, and institution at risk.

The key is to recognize an impaired peer who needs help, document all findings clearly and concisely, report it to the appropriate manager or state authority, and then ensure the individual gets the help they need.