SUBSTANCE USE DISORDERS:
NEW GUIDELINES
NCSBN- INSTITUTE OF
REGULATORY EXCELLENCE
JANUARY 16, 2013

NCSBN COMMITTEE- 2008-2010
• REVIEW AND DEVELOP BEST PRACTICES
FOR ALTERNATIVE TO DISCIPLINE
PROGRAMS AND DISCIPLINE
MONITORING PROGRAMS

NEW GUIDELINES
Nancy Darbro, PhD, CNS, RN
New Mexico Board of Nursing
Executive Director

Why alternative and discipline monitoring programs?
• High percentage of state board discipline cases deal with substance use issues
(Smith & Hughes, 1996)
• Cost effective and rehabilitative option
• Provide intense scrutiny of compliance and public protection
• Alternative programs have been functioning for over 20 years

Why alternative and discipline monitoring programs?
• Most nurses with substance use disorders are not identified in the workplace
• Most nurses with substance use disorders are not reported to regulatory agencies
• Nurse who are reported often practice for long periods during investigation
• 10% nurses needing treatment won’t get it

Why alternative and discipline monitoring programs?
• 90% of nurses with substance use disorders remain unidentified, unreported, untreated and continue to practice (Gossop et al., 2001; Tighe &
Saxe, 2006; McCabe, Cranford, West,
2008)
• Most who enter treatment do so due to external pressure or coercion

3 General Types of programs
• Alternative to discipline with statutory authority under Bon (57%)
• Peer assistance programs under state nursing associations (39%)
• Discipline monitoring with consent order or voluntary surrender of license

Types of alternative programs
• 1. Model A. statutory authority under BON
Model B. statutory authority under BON contracted to an outside agency
Model C. Special committee of the BON
• 2. Model D. Peer assistance program of state nursing association in collaboration with BON

Types of alternative programs
• Model E. Peer assistance program of state nursing association with no collaboration with BON
• Model F. Employee assistance program with no collaboration with BON

Types of disciplinary models
• 3. Model E. Consent order for suspension, stayed suspension or probation
• Model F. Disciplinary provision for voluntary surrender of license to BON

What is evidence based?
• Integration of best research with clinical expertise and patient values
• Rigorous exploration where all research data is analyzed, synthesized and structured into an integrative review
• Patient values and the expertise of the clinician might overrule findings (Sackett, et al, 2000)

Assumptions of alternative programs
• Reporting and identification will increase if there is an alternative to discipline option
• Reduces time between receipt of compliant and intervention of nurse
• Nurses are provided opportunity for rehabilitation prior to discipline
• Public is protected via close scrutiny of compliance, monitoring and reporting

Components of alternative programs
Individualized contract agreements
Treatment and aftercare monitoring
Abstinence based, no use model
Regular, random, observed drug screens
Verified support group attendance
Regular reports from self, supervisor, therapist, prescriber

Components of alternative programs
• Frequent, individual assessments via phone or face to face evaluations
• Practice restrictions and stipulations
• Prescription medication monitoring
• Intense scrutiny of compliance
• Individualized case management & monitoring, reporting of non compliance

Responsibilities of Alternative
Programs
• To protect the public while monitoring the nurse to ensure safe practice
• To encourage early identification, entry into treatment, and monitoring by program
• To identify and report non compliance to
BON in timely manner

Responsibilities of Alternative
Programs
• To facilitate nurses to maintain ongoing recovery consistent with safe practice
• To educate the public and nursing professionals and organizations
• To ensure adequate program staffing to implement program policies and contracts with nurses.

Purpose of Guidelines
• Practical, evidence based direction for:
• Evaluating
• Treating
• Monitoring
• Managing
• Reporting
• Educating

Eligibility Criteria: A nurse is ineligible if:
• Has diverted for purpose of selling or distributing to others, caused known harm or potential to cause harm
• Is not eligible for licensure in the state
• Has a history of disciplinary action not related to substance use

Eligibility Criteria: BON approval is needed prior to admission if:
• Has a felony conviction or pending criminal action
• Has caused patient harm, abuse or neglect

Eligibility Criteria: BON approval is needed prior to admission if:
• Has been unsuccessfully discharged or terminated from any alternative program for non compliance
• Is receiving medication assisted treatment
• Has been prescribed controlled substances for dual diagnosis or chronic pain

Screening and Assessment
• Initial screening to determine eligibility and motivation
• All pertinent information related to the case from employers, investigators, and complainant
• All demographic is included, employment, academic, health, psychiatric, SUD, family/social, legal, financial history

Contracts
• Written, full disclosure of requirements reviewed and voluntary signature
• Length of contract and dates signed
• Non-disciplinary nature unless violations occur
• Reporting requirements, self, employer, therapist, 12 step attendance and sponsor involvement

Contracts continued
• Frequency and time limits of random drug screens and reports
• Consequences of relapse and reporting of noncompliance
• Appropriate waivers and releases

Recovery Monitoring
Requirements
• Comprehensive requirements:
• Initial treatment
• Continuing care treatment
• Drug screens results, support group attendance, sponsor, supervisor, therapist, provider reports, & PMP monitoring
• Practice & work limitations

Recovery Monitoring
Requirements
• Close scrutiny of compliance with all requirements
• Face to face or phone evaluations at least quarterly
• Comparison of all reports for consistency, and accuracy of information, signatures, etc.

Special Considerations for Nurses
Prescribed Controlled Substances
• Dual diagnosis common and not disqualifying
• Medical and psychiatric assessment, treatment and follow up
• Neuropsychiatric, neuropsychological evaluation as needed
• One prescriber and one pharmacy

Return to Work Guidelines
• Best outcomes include back to work employment contract
• Supervisor/manager involvement and accurate reporting to program
• Authority to request for cause drug screen
• Educated and informed supervisors, managers, co-workers

Return to Work Guidelines
• Close contact, communication, engagement with alternative program staff
• Work restrictions on adverse work conditions
• No nights, overtime, agency, home health, or shift work

Program Completion
• Must meet minimum expectations of good compliance with all requirements
• Includes recent relapse prevention plan
• Submit request for discharge with supporting documentation
• Most programs 3-5 years

Policies and Procedures
• Internal policies and procedures provide standards for implementation
• Administrative and statutory authority
• Intake and admission criteria
• Case management criteria for compliance
• Identification and reporting of non compliance

Program Education and
Outreach
• Extremely important, yet undervalued
• Lack of education about substance use disorders is major risk factor
• Education efforts should be maximized
• Education should target all stakeholders
• Via seminars, presentations, workshops, newsletter columns, FAQs, one to one

Program Evaluation
• Annual evaluation recommended
• Include statistics about referrals, admissions, relapse and non compliance, successful discharges, recidivism rates
• Case loads of case managers
• Educational presentations and plans
• Number of participants

Conclusions: What we have
• Evidence based recommendations for:
• Eligibility criteria
• Screening and assessment
• Treatment and continuing care
• Contract requirements & components
• Recovery monitoring requirements
• Practice stipulations and limitations

Conclusions: What we have
• Special population contracts
• Standards for treatment programs
• Support group requirements
• Drug and alcohol testing
• Return to work guidelines
• Monitoring and reporting non compliance

Conclusions: What we have
• Program completion requirements
• Policies and procedures
• Program education and outreach
• Program evaluation criteria

What we know
• Treatment for substance use disorders works
• Health care professionals have a higher rate of recovery than lay public
• Monitoring of practice and recovery is effective and protects the public

What we know
• Addiction is the single most disabling condition for health care professionals (Talbott & Wright,
1987, Coombs, 1997)
• Treatment and monitoring works (Ganley,et al,
2005; Graham & Schultz, 1998, NIDA, 1999)
• 80-90% of nurses are successful in recovery
(Hughes, T.L., Smith, L. & Howard, J.J., 200;
Shaw, et al. 2004).

Available for download: ncsbn.org
Substance Use Disorder in
Nursing: A Resource Manual and
Guidelines for Alternative and
Disciplinary Monitoring Programs