Pharmacy Purchasing & Products: What is the risk of addiction in health care professionals compared with the general public?

Rodrigo Garcia, MSN, CRNA, MBA: The addiction risk among health care professionals (HCPs) is higher than in the general public. Approximately 10% of US adults will struggle with a drug or alcohol use disorder at some point in their lives, while a conservative estimate of 15% of HCPs currently meet or will meet the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for diagnosis of substance use disorder during their careers.1,2

Several issues drive the incidence of addiction in HCPs. First, due to the nature of their employment, HCPs have unique access to potentially addictive medications, unlike most members of the general population. Oftentimes the HCP is tasked with ordering, tracking, stocking, or administering these medications. This close access is the most significant risk factor for addiction. Moreover, HCPs also have expert knowledge in how to use these drugs; they understand weight-based calculations, drug-drug interactions, drug half-lives, and potency. For these reasons, the addiction may progress undetected for a significant length of time. Finally, HCPs often experience occupational hazards that can precipitate addiction, including long work hours, prolonged states of high stress and anxiety, and a lack of self-care. These factors can give rise to mental health issues that may be relieved with substances of abuse.

PP&P: What is pharmacy’s role in drug abuse prevention and education?

Garcia: The role of pharmacy is unique in the health care environment, as pharmacists and pharmacy technicians are involved in almost every step of the medication-use process and can yield significant influence in drug abuse prevention efforts. In addition, because the DEA typically holds pharmacy responsible for managing controlled substances throughout the facility and for reporting diversion or any misappropriation of controlled substances, it is imperative that pharmacists remain vigilant and actively monitor for and investigate possible diversion.

Pharmacy should be highly involved in educating hospital staff and administration regarding the risk to the organization when HCPs divert drugs and/or practice in an impaired state. Utilizing proactive diversion identification techniques, such as education and awareness campaigns, creation of a culture of self-reporting, automated dispensing machine analytics, controlled substance waste analysis, and random drug screenings, will increase the likelihood of uncovering addiction in the early stages, thereby potentially averting a sentinel event. Pharmacists must remain current with new diversion identification techniques in order to keep pace with potential diverters, or ideally, one step ahead.

Although diversion will never be completely eliminated in any institution, implementing a comprehensive diversion prevention program, typically led by pharmacy, will improve opportunities for self-reporting by the impaired provider, increase early identification of potential diversion, and reduce the overall potential for diversion.

PP&P: What risk factors and behaviors are associated with addiction in HCPs?

Garcia: HCPs are tasked with responsibilities that require a high level of training, concentration, improvisation, and responsiveness. Substance use that inhibits the HCP’s faculties puts patients at risk of harm; for example, they may experience suboptimal care, accidental injury, or unnecessary pain.

HCP impairment takes many forms, and it is essential to address and manage all possibilities appropriately. For example, consider that substance abuse occurring outside of work hours also can impact patient care. A provider who arrives for their shift still recovering from the previous night’s alcohol or drug consumption cannot work effectively. Moreover, an HCP who is attempting to quit drinking or taking drugs may experience debilitating withdrawal symptoms that could impact the quality of their work. An HCP who is preoccupied with how and when they will secure the next dose to stave off withdrawal symptoms cannot provide proper patient care.

The pharmacist’s role in remaining vigilant to these circumstances is based on perceived and actual provider changes in behavior and habits. By trending and monitoring metrics such as medication usage, automated dispensing cabinet access times, controlled substance waste compliance, and general physical and emotional disposition, pharmacy personnel will be in the best position to identify impairment in the earliest stages.

PP&P: How can a coworker best help a staff member they suspect of having a substance abuse disorder?

Garcia: Attempting to help a coworker is one of the most difficult, anxiety-producing events one can experience. The employee may fear that their suspicions are incorrect, and they might worry that speaking up will ruin the suspected diverter’s career. Their impulse might be to confront the suspected impaired provider directly and ask for an explanation. However, initiating this type of conversation often causes the impaired HCP to try harder to hide their diversion. In an attempt to help, codependency may surface, and the coworker might tip off the HCP that they are suspected of practicing while impaired.

It is important to understand that trying to scare a coworker into sobriety is ineffective. The most effective way to address a situation in which a colleague is suspected of diverting is to elevate those concerns to a supervisor, who will follow the hospital’s policies and procedures and intervene as appropriate.

PP&P: What technology and automation can be used to help identify possible drug diversion?

Garcia: When attempting to identify diversion, conducting early, regularly scheduled audits of automated dispensing cabinet reports, and actively evaluating provider behaviors, are critical. Utilizing software that is designed to detect trends, changes in usage patterns, medication wasting practices, and patient procedures/diagnoses is useful to identify diversion in the early stages. Comparing the historical behavior of an individual provider, in addition to comparing one provider’s behavior to that of a coworker to elucidate patterns, will also help pinpoint diversion in the early stages. Finally, implementing a systematic method to confirm and reconcile waste medication hospital-wide is a key step.

Utilization of a quantitative refractometer can assist in the verification of returned controlled substance medication. Such a device enables the pharmacy to account for diluted samples, unexpected additives, and provider-reconstituted medications (eg, IV drip solutions). Consistent medication waste reconciliation processes can dramatically increase the likelihood of identifying diversion and/or an impaired provider in the earliest possible stages of diversion.

PP&P: What are the rights and responsibilities of an addicted HCP who seeks treatment?

Garcia: First and foremost, HCPs have a responsibility to the patients they serve to do no harm. If an HCP seeks help, it is most certainly available. Almost every state has an Alternative-to-Discipline (ATD) program for HCPs struggling with addiction (more information is available at: www.ncsbn.org/alternative-to-discipline and the Pharmacist Recovery Network website at: www.usaprn.org. The goal of ATD programs is to encourage HCPs to enter the program before they are caught diverting or practicing while impaired. However, many HCPs are unaware that such an option exists. Therefore, hospital-wide education would be instrumental to assisting these practitioners.

If a staff member is struggling with addiction, they should immediately contact their state’s ATD program for help. These programs work in conjunction with professional licensing boards to provide treatment resources, monitoring and accountability, as well as assistance in re-entering the field safely and effectively after recovery. Typically, when assistance is requested proactively before the HCP is caught diverting or practicing while impaired, they are assured not only confidentiality but also continued employment within the organization (see the TABLE for factors that determine continued employment). In addition, if they voluntarily enter the program and remain compliant with its terms, there will likely not be a sanction on their license. Legal matters are addressed on an individual basis and depend on the specifics of the indiscretions, as well as the hospital’s policies on reporting diversion. Every organization should be familiar with the federal requirements regarding diversion of controlled substances.

 

In addition to ATD programs, there are treatment centers across the country that specialize in treating addicted HCPs. Support groups for HCPs, education, training, and additional resources are abundant and readily available online.

HCPs who are struggling with addiction can and do recover every day. Seeking help is the first step to overcoming addiction.

References

1. National Institutes of Health. New Releases. 10 Percent of US Adults Have Drug Use Disorder at Some Point in Their Lives. November 18, 2015. www.nih.gov/news-events/news-releases/10-percent-us-adults-have-drug-use-disorder-some-point-their-lives. Accessed July 5, 2019.
2. Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 2013; Washington DC: American Psychiatric Association.

Rodrigo Garcia, MSN, APN-BC, CRNA, MBA, is the chief executive officer at the Parkdale Center, an addiction treatment center for professionals in Chesterton, Indiana. He holds a Baccalaureate degree in nursing from Valparaiso University in Indiana, an MS in nursing from DePaul University in Chicago, and he completed his anesthesia residency training and board certification at the Evanston Northwestern School of Anesthesia in Illinois. In addition, Rodrigo received an MBA with a focus in health care management from Indiana Wesleyan University in Marion, Indiana.