A GUIDE FOR ASSISTING COLLEAGUES WITH SUBSTANCE
Washington HealthProfessional ServicesA GUIDE FORASSISTINGCOLLEAGUESWITH SUBSTANCEUSE DISORDERFebruary 2019
A Guide for Assisting Colleagues with Substance Use gton Health Professional Services Program3Physician, Pharmacist and Other Professional Programs4Recognizing a Problem5Signs and Symptoms6Ethical Considerations7Barriers to Action8What You Can Do9Employer Intervention10Referral for Treatment11Return to Practice12Regulatory Requirements13Contact Washington Health Professional Services14Additional Resources14Websites15Voluntary Substance Abuse Programs, RCW 18.130.17516Request for Speaking EngagementWashington Health Professional ServicesPO Box 47864Olympia, WA 98504-7864360-236-2880whps@doh.wa.govwsna.org
A Guide for Assisting Colleagues with Substance Use Disorder1IntroductionLimited data exists on the number of health professionals who misuse alcohol andother drugs. It is widely believed that health professionals misuse alcohol and otherdrugs at about the same rate as the general population (10-15%). The American NursesAssociation estimates that 6-8% of nurses use alcohol or drugs to an extent that issufficient to impair practice. Healthcare professionals are highly trained, self-motivatedand are often expected to assume leadership roles, therefore may have great difficultyin acknowledging personal needs and are fearful of losing their careers; it is commonto hear, “I could not reach out for help.”Substance misuse can result in negative consequences for health professionalsincluding loss of family, license, or even life. Substance misuse also jeopardizes thepublic which depends on them for care. The associated cost is significant and affectsemployers, co-workers, clients, family and the community at large. Absenteeism, accidents, injuries, stress-related illnesses and violence are only some consequences thatcan result if the disease is left untreated.Unfortunately early recognition leading to intervention and treatment is oftendelayed. The problem is denied, rationalized or minimized. Co-workers, colleaguesand supervisors may protect, blame, promote, transfer, or even ignore the affectedprofessional. It is difficult to take proactive action for many reasons, yet it is a responsibility to assist colleagues who may be suffering from substance use disorder.This handbook will assist in helping health professionals whose practice may beimpaired due to substance misuse. The focus is on what you can do to identify concerning behaviors and take effective action. It is our hope that this handbook will giveclear-cut steps for action, rather than enable a problem to continue to an inevitableconclusion.“Health Professionals have a right and an obligation to ask for help when theyare struggling with impairment. When they request assistance, they deservethe same care and respect that they give their own patients and clients everyday.”— P. Bradley Hall, MDWest Virginia Medical Professionals Programwsna.org
2A Guide for Assisting Colleagues with Substance Use DisorderBackgroundEach year healthcare professionals with substance use disorders go undetected anduntreated. In 1986, in response to the nursing community’s request for a just cultureapproach to substance use disorder, the Washington State Nurses Association andthe Board of Nursing (now the Nursing Care Quality Assurance Commission) workedto establish an alternative to traditional discipline, supporting nurses to maintaintheir license and safely return to practice. This is accomplished through referral fortreatment, defined regulatory monitoring, and practice oversight by an approvedsubstance use monitoring program.Revised Code of Washington 18.130.175, Voluntary Substance Abuse MonitoringPrograms, was adopted in 1988 and has become a nation-wide model for Alternative toDiscipline monitoring programs. In addition to recognizing substance use disorder asa treatable disease, the legislature sought to overcome stigma allowing professionalsto report and obtain medical care without fear of discipline.In establishing the use of voluntary substance use monitoring programs the legislature made its intentions clear:It is the intent of the legislature that the disciplining authorities seek ways toidentify and support the rehabilitation of health professionals whose practiceor competency may be impaired due to the abuse of drugs or alcohol. TheLegislature intends that such health professionals be treated so that they canreturn to or continue to practice their profession in a way which safeguardsthe public. The Legislature specifically intends that the disciplining authoritiesestablish an alternative program to the traditional administrative proceedingsagainst such health professionals.The Substance Abuse Monitoring Program (SAMP) began as part of the Boardof Nursing and wrote its first return to practice agreement in November 1988. Nowknown as Washington Health Professional Services (WHPS), the program providesmonitoring and advocacy services to nurses with Substance Use Disorder, allowingnurses to continue providing valuable services to the citizens of Washington State.wsna.org
A Guide for Assisting Colleagues with Substance Use Disorder3Washington Health ProfessionalServices ProgramThe Washington State Department of Health, in conjunction with various professionalhealth boards and committees, developed and implemented the Washington HealthProfessional Services (WHPS) program on August 1, 1991. Currently WHPS serves as theapproved voluntary substance use monitoring program for the Nursing Care QualityAssurance Commission (NCQAC).Purpose: Protect the public while monitoring the nurse to ensure safe practice Encourage early identification, entry into treatment and entry into a contractualagreement for monitoring Identify, respond to and report noncompliance to the NCQAC in a timely manner Facilitate entry and maintenance of ongoing recovery consistent with patient safety Be transparent and accountable by providing information to the publicPhysician, pharmacist andother professional programsThere are separate substance use monitoringprograms for physicians, pharmacists and otherallied health professionals:Washington Physician HealthProgram (WPHP)Providing substance use and behavioral healthservices to physicians, physician assistants,podiatrists, dentists and veterinarians.„ 206-583-0127 or wphp.orgWashington Recovery AssistanceProgram for Pharmacy (WRAPP)Services include:Providing substance use and behavioralhealth services to pharmacists and pharmacytechnicians. Confidential consultation with nurses, colleagues, employers or otherconcerned individuals„ 1-800-446-7220 or www.wsparx.org/WRAPP Comprehensive intake services Referrals for evaluation and treatmentWashington Recovery andMonitoring Program (WRAMP) Monitoring of program compliance and safety to practice Education and outreachThe best way for nurses to seek assistance from WHPS is to contactthe program directly at 360-236-2880. This is the shortest road torecovery and provides for the greatest degree of confidentiality.Referrals are also commonly made by professional associations, colleagues, employers,and treatment providers.Providing substance use monitoring services toall other allied health professions.„ 360-236-2880, option 2While situated differently (e.g., the WRAPPprogram is part of the Washington state pharmacyAssociation) these programs are all authorizedunder 18.130.175 RCW and operate similarly.R E SO U RC E SFederation of Physician Health Programs„ www.fsphp.orgNational Organization ofAlternative Programs„ alternativeprograms.orgNational Council of State Boards of Nursing„ www.ncsbn.org/substance-use-in-nursing.htmAmerican Association of Nurse Anesthetists„ istanceAmerican Society of Hospital Pharmacists„ inician-Well-Being-and-Resiliencewsna.org
4A Guide for Assisting Colleagues with Substance Use DisorderRecognizing a ProblemThe first step in assisting a health professional with substance use disorder is recognition. Illness should not be presumed by a single sign or symptom, but rather bychanges in behavior and job performance over time. Because health professionalsdefine themselves by their profession, evidence of the disease on the job often indicates late stage illness. Workplace problems are a last step in a downward spiral andoften coworkers are shocked when the illness is uncovered.This guide is not intended to diagnose a problem, but rather to assist in identifyingsigns and symptoms of a problem, documenting concerns and communicating themeffectively. Co-workers often feel uncomfortable when confronted with a substanceuse problem in a professional. Some of the barriers which may prevent one fromtaking action include fear, lack of knowledge and negative attitudes regarding drugand alcohol use.Co-workers, colleagues, and supervisors may attempt to rescue or cover up forthe professional out of sympathy or fear. This only enables and hastens the addictionprocess.It is important that all health professionals are educated and aware of the signsand symptoms of substance use disorder. Some may overlap with psychiatric conditions, however in either case the situation must be addressed in a timely manner andin accordance with workplace policies and procedures.The workplace is typically thelast place substance use disordermanifests itself.Disruptions in family, personal health andsocial life can all occur while the workplaceremains unaffected.Even small intrusions into the workplaceshould be taken very seriously.wsna.org
A Guide for Assisting Colleagues with Substance Use Disorder5Signs and SymptomsMany signs and symptoms of substance use disorder are non-specific, but when an individual’s behavior is observed and documented over time,the concern becomes clear and it is time to act. It is very important that health professionals receive education on substance use disorder andare familiar with workplace policies and procedures.Common Signs and Symptoms of Workplace ImpairmentDunn, D. (2005) Substance abuse among nurses-defining the issue. AORN Journal, (82)4.Fearful, anxious, panic attacksFeelings of impending doomPsychosocialParanoid ideationShameful, guilty, lonely, or sadDefensive (e.g. denial, rationalization)Runny nose, watery eyesDilated or constricted pupilsPhysicalSleeping on the jobBloodshot or glassy eyesUnsteady, stiff, or listing gaitTremors, restlessnessImpaired cognitionIncreasing forgetfulnessBehavioralIsolation or withdrawalMood swings (e.g. erratic outbursts, emotionally labile)Frequent complaints of vague illness or injuryRequests jobs in less supervised settingsSeems like a workaholic (e.g. frequently works overtime, arrives early and stays late)Volunteers to count narcoticsEvidence of tampering with vials or capsulesMakes frequent medication errorsFrequent medication loss, spills, or wastingOvermedicates compared to other staffJob PerformancePatients complain of ineffective pain reliefFrequent tardinessFrequent unexplained disappearances from the unitDisorganized illogical chartingElaborate, implausible excuses for behaviorCasually asks physicians for prescriptionsNot adhering to safety policiesDecreased job performancewsna.org
6A Guide for Assisting Colleagues with Substance Use DisorderEthical ConsiderationsMisuse of prescribed medications, non-prescription drugs, and alcohol is a violationof the Washington State Nurse Practice Act and the American Nurses Association(ANA) Code of Ethics for Nurses. (See regulatory reporting requirements page 12.)Health professionals impaired by alcohol or other drugs pose a serious risk ofharm to patients, organizations and themselves. Organizations have a duty to protectthe patient as well as an ethical obligation to assist their employees. The followingguidelines and/or ethical issues should be considered: Each employer should have a policies which include: 1) for causedrug testing, 2) identification of the persons who will interact with theemployee concerning their practice concerns, 3) a referral process forevaluation and treatment, 4) clear consequences associated with refusingtreatment and 5) confidentiality as defined by state and federal law. It is the responsibility of a colleague or co-worker to document and reporta potentially impaired health professional’s behavior to the employer ordesignated supervisor. The health professional should not be allowed toprovide patient care until he/she has been evaluated and received treatment. In most cases the professional may be offered treatment in lieu of termination.It is more cost effective to help the professional get treatment and return him/her to the workplace than to replace them. Valuable expertise and servicehistory will be lost if the professional’s employment is preemptively terminated. The health professional has the right to refuse treatment. Although theymay put themselves in jeopardy if they do, it is each person’s right to makethat decision. The employer needs to make it clear that if evaluation andtreatment are rejected, the professional’s employment may be terminated. It is important to note that suicide risk is increased after anintervention. It is necessary to assure the health professional isnot left alone after an intervention until a plan is in place.ResourceThe American Society of AddictionMedicine website is a good resource fordiscussion on ethical and proceduralconsiderations.„ www.asam.orgwsna.org
A Guide for Assisting Colleagues with Substance Use Disorder7Barriers to ActionMajor factors determining whether a health professional is confronted and offered help are the knowledge, courage and attitudes of thosearound. In order to be of assistance to someone who may have a problem, it is essential to be informed and knowledgeable. Knowing the signsand symptoms of substance use disorder and the resources available are critical to successful intervention.There are many barriers which block taking action in the face of concerns. The three most common barriers are:Lack of knowledge Of substance use disorder as a primary disease with signs and symptomsand a specific course that can be identified, documented and treated.That substance use disorder does exist in healthcare professions.Of the signs and symptoms of a problem in the workplace.On how to take action in the workplace and what resources are available.Fear Of what may happen to the person if you intervene.Of the reaction of the person towards you.That somehow you may be sued for speaking up.That you may be the one to cause a professional tolose a job or place their license in jeopardy.Attitudes and beliefs that Chemically dependent people are morally bankrupt. Most are highlyfunctioning, working people. Substance use disorder is an equal opportunitydisease that can affect all people, of all ages, in all professions.You can independently help a colleague who may have a problem.There is no need to refer or to contact other sources of help.These attitudes, fears and lack of knowledge are barriers to effectively helping a colleague. We can break through these barriers by acknowledgingthem, being educated about substance use disorder, signs and symptoms, workplace policies and available resources to help us take responsibleaction.wsna.org
8A Guide for Assisting Colleagues with Substance Use DisorderWhat You Can DoObservation and Data CollectionThe suspicion that a professional is misusing alcohol or drugs, or may have someother type of psychiatric condition affecting practice, generally arises from a seriesof observations rather than from an isolated instance. When this occurs:Don’t panic, but do act. Overreacting maycreate additional problems but patientsmust be protected and legal rights assured.The only thing you can do wrong is to donothing.Document carefully. All reports and directobservations of questionable behaviorshould be recorded with dates, timesand names of observers, reporters, andthe professional in question, descriptionof circumstances, action taken, and theprofessional’s response. Notes should befactual and data should be objective.Discuss your concerns with a supervisor orother senior colleague. Specific concernsrelated to impaired practice should bedocumented and then shared confidentiallyper policy. An immediate concern regardingpatient safety should be shared with thesupervisor in charge at the time. This willenable the supervisor to evaluate thesituation and determine an appropriatecourse of action.Continue to observe, document and shareyour observations.Following-up with your supervisor is vital.If the situation warrants immediate actionand you are concerned about patient/clientsafety, you may need to contact other keyadministrators.If there is an Employee AssistanceProgram available in your workplace,it may be helpful to contact them forguidance. Providing a brochure informingthe professional that the EAP programis available and encouraging them toseek assistance may be appropriate. It isimportant that you do not take over anactive role with the professional but ratheroffer support and refer to the appropriateresource for assistance.Washington Health Professional Servicesor one of the other approved monitoringprograms are also resources to healthprofessionals and employers.Washington Health Professional Services360-236-2880whps@doh.wa.govwsna.org
A Guide for Assisting Colleagues with Substance Use Disorder9Employer InterventionDo Don’t Prepare a planJust reactReview documentationIntervene aloneRequest help from othersTry to diagnose the problemEnsure security is readily availableExpect an admission of a problemDecide who will present what informationGive upAsk the health professional to listen toeveryone before responding to intervenersUse labelsExpect denialLeave the individual with a sense ofhope knowing that they are a goodhuman being deserving of helpStick to the job performanceHave professional resources availableConduct a for-cause drug testProvide for safe transportDebrief with intervenersReport as necessary to thestate alternative program and/or licensing authorityIf the health professional appears to be under the influence in the work setting, the issue must be addressed immediately. Remove the professionalfrom the unit/department, get a drug screen, and evaluate the need for emergency treatment (either medical and/or psychiatric). If immediatemedical intervention is needed, transport the individual to the emergency room. Once the immediate emergency is stabilized, then develop aplan of action to address the problem.Source: Ohio Nurses Foundation (2008). Guidelines for managers of impaired nurses: Nurse’s with chemical dependency and/or psychiatric issues.wsna.org
10A Guide for Assisting Colleagues with Substance Use DisorderReferral for TreatmentThe purpose of treatment is the safe withdrawal from alcohol or other drugs, to helpthe professional honestly face the addiction and to develop new attitudes that willhelp them embrace a drug and alcohol-free lifestyle. Treatment is just the first steptowards recovery.For the health professional seeking help for substance use disorder, the most likelysource will be a multi-disciplinary treatment program that is recovery oriented, hasabstinence as a goal and supports an ongoing recovery approach, e.g., participationin a 12-step (AA, NA) or other type (SMART Recovery, Refuge Recovery) support group.The treatment program must have a broad rehabilitation component which supportsrestoration of function and ongoing sobriety.Treatment may be provided in either an outpatient or inpatient setting. Treatmentvaries in length depending on the problems identified and what is determined asappropriate. Day treatment may also be an option.There are health professional specific substance use disorder treatment programs.These programs provide specialized treatment geared to t
Revised Code of Washington 18.130.175, Voluntary Substance Abuse Monitoring Programs, was adopted in 1988 and has become a nation-wide model for Alternative to Discipline monitoring programs. In addition to recognizing substance use disorder as a treatable disease, the legislature sought
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