Like Lara, nurses are much more likely than the general public to have a family member who has struggled with alcoholism. People who have cared for an afflicted relative may be inspired to enter nursing because it is a helping profession. But this background may also be a factor in the odds of becoming addicted. If the disease runs in their family, they may be more susceptible. And if they think of themselves as someone who helps others, rather than someone who should ask for help, they might not recognize their own downward spirals in time. ER, OR, PACU, and ICU nurses, who might see unexpected deaths and tragedies more frequently, experience substance abuse in larger numbers than other nurses. As in Lara’s case, the drugs can both energize them and seemingly help them to cope with these traumas.
Certified registered nurse anesthetists (CRNAs) may be even more vulnerable than other nurses to chemical dependency. Experts estimate that the addiction rate among CRNAs and anesthesiologists “has reached staggering levels,” at more than 15 percent. Nurse anesthetists are at a higher risk for substance use disorders because “they’re playing with rocket fuel,” said CRNA Art Zwerling, an American Association of Nurse Anesthetists (AANA) peer assistance advisor. “The stakes go way up because folks are working with and diverting drugs that are much more powerful.” People can become hooked on fentanyl, which is eighty times more potent than morphine, from just one exposure. “It’s also that we work in isolation and the production pressure in anesthesia is horrendously escalated,” Zwerling said. “People have bad times on call, remember how comfortable their patient looked when they were given fentanyl, and see that as a potential stress reducer.”
Jan Stewart, a CRNA for twenty-eight years, was the president of AANA and a nationally recognized lecturer. The AANA called her “a dedicated professional whose expertise knew no bounds and who was committed to the mission of providing high-quality, compassionate care to all patients. She was acclaimed by many as a leader among leaders and a friend to all.” Following back pain so intense that she needed surgery, Stewart eventually became addicted to painkillers. She died at age 50 of an overdose of sufentanil, an opioid hundreds of times more powerful than morphine. That’s how many nurses, like anyone, become addicted: They have a legitimate prescription whose effects become irresistible.
Perhaps the most persuasive reason that CRNAs and critical care nurses are more prone to addiction is the same reason that nurses are more vulnerable than the public. They have easier access to the drugs. It seems intuitive but it’s worth mentioning: Studies show that nurses who have easier access to these substances abuse them more often. (Doctors’ substance abuse is also linked to their ease of access as well as the frequency with which they prescribe the drugs.) The effect of access is twofold. The drugs are simple to get, and the nurses’ familiarity with them instills a confidence and a “pharmacological optimism” that they can self-medicate without becoming addicted. They believe they are more invulnerable than the general population.
Actually, the opposite may be true. Medical professionals tend to get sicker than the average drug addict because the medications they have access to are more powerful and habit-forming than street drugs.
How are they able to steal from hospitals, nursing homes, hospice centers, and other workplaces? Lara’s initial strategy of taking only drugs that were to be wasted is an inconspicuous method. Other nurses take patients’ doses for themselves and chart that they gave it to the patients, or they document, for example, that they gave a patient two pills when they actually gave only one. They might sign out drugs for people who have already been transferred or discharged from the unit. They can steal prescription pads and forge prescriptions, take samples from supply closets, back-date medical records, write verbal orders that a doctor didn’t give, or take advantage when coworkers forget to log off drug-dispensing machines. Or they get creative. A nursing home RN in Florida ate the gel from two narcotic patches meant to relieve pain for a burn victim and a patient with muscular dystrophy. He gave the patients placebos.
When the addicts aren’t obvious, like Fatima sticking her hand into a sharps box, their behavior may go unnoticed for months to years. Because these are often highly skilled nurses, they are, for a time, able to work competently under the influence. “Often, it’s our best people,” Laurie Badzek, director of the ANA’s Center for Ethics and Human Rights, has said. “They have such good clinical skills that they can be impaired and still be functioning at a good level. But eventually, it catches up [with] them.”
Even when managers do suspect drug abuse, they don’t necessarily act immediately. Hospital administrators might wait because they want to catch the employee red-handed, assemble a file’s worth of evidence, or avoid reacting in a way that might draw public attention. Many employers don’t provide candid references for employees (even fired employees) because they are afraid of lawsuits or desperate to shoo them out of the workplace. Addicted nurses can then job-hop, expanding their access to the narcotics they crave.
Coworkers who observe suspicious behavior might not be certain what they saw, what it means, or what to do about it. As of 2013, nurse anesthesia programs are required to include chemical dependency content in their curricula. Other nursing schools “should incorporate prevention and education,” according to the American Association of Colleges of Nursing, but the AACN doesn’t monitor whether schools comply. Students become nurses who may not be adequately educated about the dangers and prevalence of chemical dependency, how to recognize when colleagues might be impaired, and how to help them. This lack of awareness “enables an abusing nurse to continue and prevents colleagues from documenting and reporting the suspicion,” nurse Debra Dunn wrote in an article for the Association of PeriOperative Registered Nurses. “This passive environment condones the code of silence. Embedded in nursing culture is the practice of covering up for a colleague with a perceived problem, which can actually exacerbate the original problem rather than help the individual concerned. . . . Usually, by the time a nurse is caught and confronted, most of the people in the unit knew there was a problem.”
Nurse addicts may hide their secret for as long as possible, because they don’t realize they can get help without losing their license or they keep believing they can quit without assistance. They often continue to steal medications until they get caught. When they are caught, the consequences can be steep: License suspension is the most common result, and civil and criminal penalties are possible. Prosecutors can demand that a nurse not only surrender her license, but also that she never again work in healthcare. If a nurse turns herself in, however, she has a chance to save her livelihood. Nursing boards are usually more interested in helping nurses to rehabilitate and return to the workplace than juries, who are more inclined to kick nurses out of the field.
Eventually, most nurse addicts will have two choices: get help or get caught. “The good news is if the nurse enters treatment, they’re covered by the American Disabilities Act, so that helps to protect their license,” said Al Rundio, president of the International Nurses Society on Addictions and a practicing nurse himself. “But if they get confronted by the DEA prior to getting in treatment, they’re not covered by ADA so their license is more at risk. The longer you let it go on, the bigger the problem becomes.”
Certainly the focus on reparative programs rather than punitive measures is not without controversy. A relapse could endanger an impaired nurse, her patients, and her workplace. And not every rehabilitative program succeeds. A Los Angeles Times and ProPublica investigation revealed that participants in a California nursing board program continued to work while impaired, including more than eighty nurses whom the board deemed “public safety threats.” Even when the board expelled nurses from the program, the reporters found, “The board takes a median 15 months to file a public accusation—the first warning to potential employers and patients of a nurse’s troubles. It takes 10 more months to impose discipline.” California eventually instituted stricter rules, and ended an anonymous rehabilitative program for doctors following complaints that doctors in treatment were bungling surgeries.