Chemical Dependency & Drug
Diversion in Nursing
Presented by Nathan Buchinger, RN, CCRN
• To understand the prevalence of nurses who practice while
under the influence of drugs or alcohol
• To understand the importance of reporting suspicious behavior
• To examine the efficacy of punitive and non-punitive
approaches to chemically dependency in health care
• To examine theories and assumptions regarding nurses and
drug dependency
• To understand what current evidence-based research states
about this issue
Chemical Dependency
: A physical or psychological habituation to a mood- or mind-altering drug,
such as alcohol or cocaine
*Chemical Dependency. (2007). The American Heritage Medical Dictionary. Retrieved from
Addiction noun \ə-ˈdik-shən, a-\
: compulsive need for and use of a habit-forming substance (as heroin,
nicotine, or alcohol) characterized by tolerance and by well-defined
physiological symptoms upon withdrawal; broadly : persistent compulsive
use of a substance known by the user to be harmful
*Addiction. (n.d.). Merriam-Webster’s online dictionary. Retrieved from
Drug Diversion
“The transfer of a prescription drug from a lawful to an unlawful
channel of distribution or use” (Inciardi, Surratt, Lugo, & Cicero,
2007, p. 2).
“Theft, forgery, or alteration of prescriptions by health care
workers” (Inciardi, Surratt, Lugo, & Cicero, 2007, p. 2).
Drug diversion is illegal!
Previous estimates: 1 in 5
nurses practice while impaired
(Griffith, 1999)
Most current estimate: About 1
in 10 (Dunn, 2005)
Rate of drug addiction in the
US: 1 in 10 (Dunn, 2005)
Relevance to Nursing
ANA Standards of Care
Standard 7: Ethics
“Delivers care in a manner that preserves and protects healthcare
consumer autonomy, dignity, rights, values and beliefs” (ANA, 2010, p.
Standard 10: Quality of Practice
“Demonstrates quality by documenting the application of the nursing
process in a responsible, accountable, and ethical manner” (ANA,
2010, p. 52)
Standard 11: Communication
“Conveys information to … others in communication formats that
promote accuracy” (ANA, 2010, p. 54)
Standard 16: Environmental Health
“Promotes a practice environment that reduces environmental health
risks for workers and healthcare consumers” (ANA, 2010, p. 61)
Patient Rights
High Quality Patient Care
“[Nurses] first priority is to provide you the
care you need, when you need it, with skill,
compassion, and respect” (AHA, 2003, p. 2)
A Clean and Safe Environment
“[Nurses] use special procedures to avoid
mistakes in your care and keep you free from
abuse and neglect” (AHA, 2003, p. 3)
Root Cause Analysis
Problem Chemical Dependency
Unmet needs
Threats to personal/social identity
Socioeconomic factors
Comorbid physical/mental problems
Chronic Pain
Relevant Nursing Theories
• Erickson’s Modeling and Role Modeling Theory:
• “All people want to be the best that they can possibly be; unmet basic
needs interfere with holistic growth whereas satisfied needs promote
growth” (Erickson, Tomlin, & Swain, 2002, p. 56).
• “Object loss results in basic need deficits” (Erickson, Tomlin, & Swain,
2002, p. 88).
• Barker’s Tidal Model of Mental Health Recovery:
• “People who experience any of the myriad threats to their personal or
social identities, commonly called mental illness or mental health
problems, experience a human threat that renders them vulnerable”
(Barker, 2003, p. 6-7).
Theories of Drug Use
• Three Main Categories of Causation Theories:
• Biological: Innate physical mechanism
• Genetic
• Metabolic Imbalance
• Psychological: Compulsion & continued use
• Positive/Negative Reinforcement
• Pleasure seeking
• Inadequate Personality Theory
• Risk taking behaviorism
• Sociological: Individual within society
Commonly Abused Drugs
• Opioids
• Vicodin
• Percocet
• Oxycontin
• Morphine
• Methadone
• Fentanyl
• Codeine
• Dilaudid
• Demerol
• Barbiturates
• Amytal
• Phenobarbital
• Seconal
• Benzodiazepines
• Ativan
• Xanax
• Librium
• Valium
• Halcion
• Restoril
• Sleep Meds
• Ambien
• Sonata
• Lunesta
• Amphetamines
• Adderall
• Dexedrine
• Biphetamine
• Propofol
Signs of Impairment
• Attendance
• Excessive call-ins & tardies
• Frequent trips to the restroom
• Long or frequent breaks
• Early arrival or late departure
• Performance
• Assignments require more
• Absentmindedness
• Carelessness
• Complaints regarding poor
• Behavior
• Poor hygiene
• Mood swings/irritability
• Poor recall
• Handling of Controlled Substances
• Frequent med errors
• Unwitnessed/Excessive wastes
• Frequents spills/drops
• Patient complaints of not
receiving documented meds
• Use of infrequent drugs
• Physical signs
• Tremors
• Nervousness
• Alcohol odor
• Slurred speech
• Unsteady gait
• Excessive use of breath mints
• Unusual fatigue
• Blackouts
Roles in Reporting
• Floor Nurses
• Know the signs
• Ethical duty to report
• Confront when patients are at
• Go to manager right away
• Charge Nurses
• Same as floor nurses
• Do not ignore
• Do not lighten the assignment
• Do not accept excuses
• Nurse Managers
• Same as above
• Explain to nurse observations
• Listen to their side in private
• Report to next in chain of
• Document everything in writing
• Administrators
• Follow hospital protocol
• Perform investigation
• Gather all relevant data
• Meet with the impaired
nurse, Human Resources,
and nurse manager
• Apply corrective action
• Report to State Board of
• Follow-up
Alternative-to-Discipline Programs
• Four Tenets of ATD Programs
• Assistance is better than discipline
• Self-regulation
• Swift removal of impaired nurses from
work place
• Workplace safety promotion
Safety Recommendations
• Know the signs of
• Know who to report to &
what to report
• Truly witness wastes
• Know your role
• Only reinstate compliant,
rehabilitated nurses
• Random drug testing?
• QSEN Competencies
• Patient-centered care
• Teamwork and
• Safety
• Quality
• Evidence-based
For Further Study
“Good Medicine, Bad Behavior: Drug
Diversion in America”
• Earley, P. H., & Finver, T. (2013). Addiction to propofol: A study of 22 treatment
cases. Journal of Addiction Medicine, 7(3), 169-176.
• Inciardi, J. A., Surratt, H. L., Lugo, Y., & Cicero, T. J. (2007). The diversion of
prescription opioid analgesics. Law Enforcement Executive Forum, 7(7), 1–14.
• Monroe, T., Pearson, F., & Kenaga, H. (2008). Procedures for handling cases of
substance abuse among nurses: A comparison of disciplinary and alternative
programs. Journal of Addictions Nursing, 19(3), 156-161. doi:
• Monroe, T., & Pearson, F. (2009). Treating nurses and student nurses with chemical
dependency: Revising policy in the United States for the 21st Century. International
Journal of Mental Health & Addiction, 7(4), 530-540. doi:10.1007/s11469-009-9208-2
• Monroe, T., & Kenaga, H. (2011). Don’t ask don’t tell: Substance abuse and
addiction among nurses. Journal of Clinical Nursing, 20(3-4), 504-509. doi:
• Monroe, T. B., Kenaga, H., Dietrich, M. S., Carter, M. A., & Cowan, R. L. (2013).
The prevalence of employed nurses identified or enrolled in substance use
monitoring programs. Nursing Research, 62(1), 10-15. doi:
• Wright, E. L., McGuiness, T., Moneyham, L. D., Schumacher, J. E., Zwerling, A., &
Stullenbarger, N. E. (2012). Opioid abuse among nurse anesthetists and
References (cont.)
• Alligood, M. R., & Tomey, A. M. (2010). Nursing theorists and their work
(7th ed.). Maryland Heights, MO: Mosby Elsevier.
• American Hospital Association. (2003). The patient care partnership:
Understanding expectations, rights and responsibilities [PDF
document]. Retrieved from
• Barker, P. J. (2003). Psychiatric and mental health nursing: The craft of caring.
London: Arnold.
• Erickson, H. C., Tomlin, E. M., & Swain, M. A. (2002). Modeling and rolemodeling: A theory and paradigm for nursing. Cedar Park, TX: Est. Co.
• Manchikanti, L., Fellows, B., Ailinani, H., & Pampati, V. (2010).
Therapeutic use, abuse, and nonmedical use of opioids: A ten-year
perspective. Pain Physician, 13(5), 401-435.
• Manchikanti, L., Helm, S., Fellows, B., Janata, J. W., Pampati, V., Grider, J.
S., & Boswell, M. V. (2012). Opioid epidemic in the United States. Pain
Physician, 15(3), ES 9-38.
• Quality and Safety Education for Nurses Institute. (n.d.). Competencies.
Retrieved from