Substance Use Disorders and Implications for Nursing

Course Content

Authors: Mallory Antico and Beth Hawkes

Contact hours: 3 hours.

Learning objective and out comes.

At the end of completing the course material the learner will be able to:

Understand the definition and diagnostic criteria of substance use disorders.
Understand the risk factors for SUD and the additional risk factors for nurses.
Understand the pathophysiology of SUD.
Identify signs and symptoms of impairment of a co-worker while on duty.
Identify commonly occurring behaviors and actions in nurses involved in diversion.
Describe the nurse’s role in reporting a suspected SUD.
Identify common barriers to reporting an impaired nurse and strategies that can be used to overcome them.
Identify ways bias and stigma can impact those with SUD.
Explain the treatment options for SUD.
Explain the difference between disciplinary action from the board of nursing and alternative-to-discipline programs.

Introduction

Substance use disorder (SUD) is a complex condition characterized by a cluster of cognitive, behavioral, and physiological symptoms indicating an uncontrolled use of a substance despite harmful consequences. Though significant impairments in daily functioning set in, people with SUD typically present with an intense focus on these substances. The diagnosis of SUDs can be applied to alcohol, tobacco, cannabis, hallucinogens, inhalants, opioids, sedatives, and stimulant use (APA, 2013). According to the Substance Abuse and Mental Health Services Administration (SAMHSA, 2022), millions of Americans ages 12 and up suffer from SUD. For nurses, the rate of SUDs closely mirrors that of the general population. Prescription medications, including opioids, are more frequently misused by nurses compared to the general population (Trinkoff et al., 2022).

There has been significant progress over time in the understanding of SUDs as an illness needing treatment rather than a moral failure requiring penalties. These changes are reflected in nursing through programs that promote the treatment of impaired nurses and re-entry into the workforce. Nurses play a critical role in creating awareness, correcting myths, and identifying, and reporting suspected SUD. With a good understanding of the presentation and treatment resources, nurses are better equipped to seek help for themselves and other nurses (NCSBN, 2014).

Historical Perspective of SUD and Shifting Trends

History of the Relationship Between People and Substances

The history of substance use is as long as human history itself. While it is not within the scope of this article to provide an in-depth look at the long and complex relationship people have with substances, some general historical context will be provided to frame the shift in approaches that shape today’s treatment of SUD. This relationship looks different across cultures depending on the substance type plus religious, geographical, sociopolitical, cultural, and industrial influences. In the United States, it wasn’t until the mid-1800s that substance use began to be looked upon as socially displeasing. In the early 20th century, some substances were criminalized (Robinson & Adinoff, 2016).

Early 20th-century treatment approaches were based on the assumption that substance misuse was a moral failing and that the condition fell outside the scope of medicine. Rather than a disease, addiction was seen as a behavior violating religious, moral, and legal codes. Abstinence and willpower were the cures for moral failings and behaviors. In the first edition of the Diagnostic and Statistical Manual (DSM) in the 1950s, substance use was mostly viewed as part of other psychological problems. Around the same time, the American Medical Association (AMA) followed the lead of the World Health Organization (WHO) by viewing alcoholism as a medical disorder. The third edition of the DSM was the first time that substance use was classified independently. The late 20th century brought many scientific advances in mental health and new information about the pathophysiology of substance use and addiction changed the way substance use was approached in medicine. Overall, there has been significant progress in the field of SUDs. An improved understanding of the disease of substance use has led to a push towards treatment and not punishment (Robinson & Adinoff, 2016).

Societal Viewpoint of Addiction Influences Nursing

Despite advances in the literature, there is still a pervasive stigma associated with SUDs. Critics of addiction as a disease contend that there are no addicts, only bad decision-makers (Henden et al., 2013). Likewise, nursing regulatory bodies historically framed addiction as autonomous, rational choices rather than compulsive behaviors that are a disease consequence. As a result, regulatory bodies would publicly report nurses and take punitive action (Dunn, 2005). In a 2019 cross-sectional study of boards of nursing discipline data, substance misuse was the most common reason for state boards of nursing to take disciplinary actions against a nurse (Zhong, Martin, & Alexander, 2022).

Fortunately, there is a shift towards treating nurses with SUD rather than punishing them. Leading nursing organizations now embrace the medical model over the moral model. The American Nurses Association (ANA) endorses the position of the Emergency Nurses Association and the International Nurses Society on Addictions in the organizations' joint statement: "Drug diversion, in the context of personal use, is viewed primarily as a symptom of a serious and treatable disease, and not exclusively as a crime" (ANA, 2016). Likewise, the National Council of State Boards of Nursing (NCSBN) views SUD as a chronic, primary, and progressive disease requiring treatment (NCSBN, 2014).

Overview of SUD

Pathology Pathways in SUD

The pathophysiology of SUD is incredibly complex. It involves many neurobiological mechanisms in various parts of the brain, genetics and epigenetic changes, and psychosocial aspects (Uhl, Koob, & Cable, 2019). It is outside of the scope of this article to comprehensively cover all of these topics, however, a general overview will be discussed to aid in understanding the clinical manifestations of the disease and targeted treatment.

Neurological Pathways in SUD (The Reward System)

Neuroscience has come a long way in identifying the areas of the brain involved in reward. The brain reward system is called the mesolimbic system, and it is composed of brain structures responsible for mediating the physiological and cognitive process of reward. Neurotransmitters, such as dopamine and beta-endorphins, facilitate communication to the reward center with dopamine playing the most critical role (Bettinardi-Angres & Angres, 2010; Lewis, Florio, Ponzo & Borrelli, 2021).

Ten separate classes of drugs have known effects on the brain reward system (see Table 1). These substances can directly activate the reward pathways and usually produce a more intense activation than normal adaptive behaviors. Besides caffeine, all these substances can cause a substance use disorder (APA, 2013).

Table 1. Classes of Substances that Have Known Effects on the Brain Reward System (APA, 2013).

Caffeine

Cannabis

Hallucinogens

Inhalants

Opioids

Sedatives

Hypnotics

Anxiolytics

Stimulants

Tobacco

Reward is the brain’s natural adaptive process of associating different stimuli (generated from activities or events such as eating, sleeping, sex, exercise, and social interactions) with a positive or desirable outcome. A memory of the desired outcome is created leading to an adjustment in the individual’s behavior to a search for a positive outcome (Lewis, Florio, Ponzo & Borrelli, 2021; Bettinardi-Angres & Angres, 2010). For an individual with SUD, the pathway involved in essential behaviors, such as eating, sleeping, and sex, is taken over by the substance of choice which then eventually depletes the reward system and fails to maintain a positive outcome. The individual’s initial motivation may have been to feel pleasure or relieve discomfort. Eventually, the reward pathway becomes less sensitive or insensitive to the natural stimuli and rather provides positive feedback when the substance is used. The individual’s brain then begins to rely on the substance to create a positive outcome (Bettinardi-Angres & Angres, 2010).

Abnormally High Response to Substances

Using Positron emission tomography (PET) scans and Magnetic resonance imaging (MRI), several studies have demonstrated a significant difference in the way the brain reward system reacts to substances in previous users or people with a family history of addiction versus control controls. They show that people with SUD experience the substance more intensely than the control subjects (Bettinardi-Angres & Angres, 2010).

Other studies show decreased responsiveness to regular stimuli and an exaggerated response to the substance of use. This increased response is often described as “the magical connection” as most substance users describe the experience as extremely powerful when they first use their substance of misuse. The magical connection sometimes is a paradoxical response such as an opiate producing stimulation and an increase in energy instead of sedation The positive response from the drug is stored in the memory and the user seeks to recreate the experience. Unfortunately, the drug fails to provide the same response creating a vicious cycle of increased use, tolerance, and withdrawal (Bettinardi-Angres & Angres, 2010).

Learning and Memory

Learning and memory are important components of SUDs with a biological component. In response to rewards that the brain attributes as necessary for survival, the brain creates neural mechanisms of learning and memory. In SUDs, these survival memories develop around the substance. The user then becomes devoted to obtaining and using the substance. Hence a user might have no considerations beyond the need to use once placed in an environment of past use. There is a diminished capacity to incorporate new learning strategies and shows decreased awareness of other reward systems or the need to invest energy in them. The user shows poor insight into their behaviors as their need is fueled by survival-related clues (Bettinardi-Angres & Angres, 2010; Uhl, Koob, & Cable, 2019).

Motivation

Motivation has also been shown to have a biological component. MRI studies have demonstrated that the prefrontal cortex, which is responsible for decision-making, gets activated with the amygdala (the fear-based part of the brain), creating a connection for craving. This activates a neurotransmitter called glutamate, which then creates an unpleasant feeling associated with craving that can cause the substance user to try to reduce this discomfort through substance use (Bettinardi-Angres & Angres, 2010; Uhl, Koob, & Cable, 2019).

Decision-Making

Neural mechanisms that enable people to reflect and choose wisely appear to be weakened in substance users. The substance user is likely to move from self-directed behavior to automatic sensory-driven behavior. Denial feeds off of the progressive deterioration of decision-making. Denial is then reinforced by the powerful reward of the addiction and the deficits in learning, motivation, memory, and decision-making (Bettinardi-Angres & Angres, 2010; Uhl, Koob, & Cable, 2019).

Risk Factors

SUDs are influenced by a combination of genetic, environmental, psychological, and social factors. These risk factors can increase the likelihood of an individual developing a SUD. It's important to note that having one or more risk factors doesn't guarantee that someone will develop a substance use disorder, and protective factors can mitigate these risks (Dugash, 2023).

Biological Factors

A family history of SUDs can increase an individual's risk due to potential genetic predisposition. Variations in brain structure and function, neurotransmitter imbalances, and other biological factors can contribute to SUD vulnerability (Dugash, 2023).

Psychosocial Factors

Co-occurring mental health conditions, such as depression, anxiety, or personality disorders, can increase the risk of SUD. A tendency to act impulsively without considering the consequences and a desire for novel and intense experiences can place one at risk for SUD. Individuals with low self-esteem and ineffective coping mechanisms may turn to substances as a way of self-medication (Dugash, 2023).

Associating with peers who use substances can influence an individual's substance use decisions. Having friends, family members, or romantic partners that use substances increases the risk (Buckstein, 2023). Easy access to substances, whether legal or illegal, increases the risk of use. Childhood abuse, neglect, or other traumatic experiences can contribute to SUD vulnerability. Family dysfunction, a lack of support, or inconsistent discipline can increase the risk (Dugash, 2023).

SDOH are conditions and factors in the social and physical environment that can influence an individual's overall health and well-being, including the likelihood of developing SUD and the outcomes for those who have SUD. These determinants play a significant role in shaping the risk of SUD and its impact on individuals and communities. SUD has been known to disproportionately impact the historically underrepresented, underserved, and disenfranchised groups based on gender identity, race, ethnicity, citizenship, sexuality, and economic status (Mulhern, 2022).

Access to basic needs has a significant impact on SUD risk. Poverty and economic instability can increase the risk of SUD due to stress, limited access to education, lack of resources for healthy coping strategies, and other factors. Unemployment or limited job opportunities can contribute to SUD, as individuals may turn to substances as a coping mechanism or due to social dislocation. Economic disparities can result in differential access to healthcare, treatment, and prevention programs (Mulhern, 2022).

Unstable or unsafe housing can contribute to the risk of SUD. Homelessness is strongly associated with substance use. Neighborhoods with high levels of crime and drug availability can influence substance use patterns. Food insecurity and poor nutrition can negatively affect overall health and increase susceptibility to SUD. Inadequate transportation can make accessing help for substance use impossible to obtain. Easy access to alcohol or illicit drugs in the community can facilitate substance use and addiction (Mulhern, 2022).

Limited access to healthcare services, including mental health and addiction treatment, can lead to undiagnosed or untreated mental health conditions, which can contribute to SUD. In the United States, Black and Hispanic patients receive less treatment than their white counterparts (Dynamed, 2022). High levels of trauma, such as physical or sexual abuse, can increase the risk of SUD as individuals may use substances to cope with their traumatic experiences. Trauma has a lasting impact on health, even if it occurred many years prior, and can be responsible for epigenetic changes (Mulhern, 2022).

Inadequate access to quality education and limited educational attainment can hinder individuals' understanding of the risks associated with substance use (Mulhern, 2022). Individuals who are unaware of the risks of substance use may be more at risk for experimentation and initiation (Dugash, 2023). Insufficient social support networks, including family and community support, can increase the risk of SUD. Strong support systems can serve as protective factors (Mulhern, 2022).

Discrimination and stigma can deter individuals from seeking help for their SUD due to fear of social consequences, thereby exacerbating the problem. Those who are impacted by systemic oppression experience increased stress. They may worry about their safety and how their lives are affected by policy which can contribute to substance use (Mulhern, 2022).

Implicit bias refers to attitudes or stereotypes that subconsciously affect an individual’s understanding, actions, and decisions. These biases can impact various aspects of healthcare, including the assessment, diagnosis, and treatment of SUD. Providers may be more likely to overlook or underdiagnose SUD in certain patients based on characteristics like race, gender, or socioeconomic status. In addition to those characteristics, it is very common for people to have a substance use implicit bias (Ashford, Brown, & Curtis, 2018)

Implicit bias can contribute to stigmatization and discrimination against individuals with SUD. This can lead to negative stereotypes, blame, and a lack of empathy or support from healthcare providers. Patients who are perceived as more "trustworthy" or "compliant" may receive better communication and engagement from providers, while others may experience dismissive or punitive attitudes. Patients who sense bias in their interactions with healthcare providers may be less likely to engage in treatment and follow medical advice, leading to poorer outcomes (Ashford, Brown, & Curtis, 2018)

Implicit bias can play a role in the criminalization of substance use, leading to more punitive legal consequences for certain groups. For example, individuals from minority communities may face harsher penalties for drug-related offenses (Ashford, Brown, & Curtis, 2018). In the case of nurses with SUD, implicit bias can impact whether or not coworkers report nurses who are impaired or diverting medications. Bias can impact the consequences nurses with SUD face in their careers. (Gabele, Keels, & Blake, 2023).

Addressing the social determinants of health is a critical aspect of preventing and treating SUDs in individuals and communities. Interventions that aim to improve socioeconomic conditions, increase access to healthcare and mental health services, reduce stigma, and provide educational opportunities can reduce the risk of SUD and enhance outcomes for those with SUD. Comprehensive strategies that take into account these social factors are more likely to be effective in reducing the burden of SUDs (Mulhern, 2022).

Early Substance Use

Early initiation of substance use, particularly during adolescence, can increase the likelihood of developing a SUD (Dugash, 2023; Buckstein, 2023). The United States has a high rate of youth who have tried illicit drugs. Exposure to substances in utero can also increase a person’s risk for SUD (Buckstein, 2023).

Societal attitudes and norms regarding substance use can influence an individual's perception and behaviors regarding substances. Some cultural groups may be less likely to seek treatment. Others may hide their substance use. In some cultures that normalize the use of certain substances, individuals may be at greater risk of SUD (Dugash, 2023).

Stress and Life Events

High levels of stress, major life changes, or significant life events, such as divorce or loss of a loved one, can contribute to substance use. The relationship between stress and substance use is complex and bidirectional, with stress contributing to substance use, and substance use exacerbating stress. Many individuals turn to substances as a coping mechanism to alleviate stress. When people experience stress, they may use substances to numb emotional pain or to temporarily escape from their problems (Dugash, 2023).

Stress can be a precipitating factor that leads individuals to initiate substance use. They may begin using substances to fit in with peer groups, deal with stressors, or seek a sense of relief. In those who are already substance users, stress can trigger cravings, which can be powerful and lead to relapse for those in recovery. It can also lead to an increase in substance use, as individuals may use larger amounts or use more frequently when they are stressed (Dugash, 2023).

Chronic stress can lead to changes in the brain's reward and stress systems, making individuals more susceptible to substance use and addiction. Stress can alter the functioning of neurotransmitters like dopamine, which play a role in the reward and pleasure associated with substance use (Uhl, Koob, & Cable, 2019) Understanding the link between stress and substance use is essential for the prevention and treatment of SUDs (Dugash, 2023).

Gender (Assigned at Birth) and Age

Gender differences exist, with some substances being more commonly used by one gender than the other. SUD is generally more prevalent in men. Men are more likely to use alcohol and illicit drugs while women are more likely to use prescription drugs. Age can also affect vulnerability, as adolescence and young adulthood are critical periods for the development of SUDs (Dugash, 2023).

Co-occurring Medical Conditions

Certain medical conditions may lead individuals to misuse prescription medications, potentially leading to a SUD. This includes mental health disorders such as depression anxiety, and personality disorders, as well as chronic pain and sleep disorders (Dugash, 2023).

Risk Factors for Nurses

In addition to the risk factors in the general population, nurses have additional and unique risks related to the workplace (Toney-Butler & Siela, 2022; Darbro & Malliarakis, 2012). Nursing is a very stressful occupation; nurses need to frequently engage in shift work, long work hours (12-hour shifts), extra shifts due to frequently recurring staffing shortages, shift rotations, and mandatory overtime in some settings. These stressful work hours could contribute to developing SUDs. Trinkoff and Storr (1998), examined the relationship between work schedule characteristics and substance use and found that, in general, the more adverse the schedule characteristics, the greater the likelihood of substance abuse.

Nurses are likely to witness trauma, violence, and multiple deaths throughout their career; caring for patients with very high acuity; potential for transmission of infectious agents; and insufficient staffing might result in heavy workloads all occur frequently in nursing and increase the risk for substance misuse. Nurses’ ability to self-medicate and good knowledge of the therapeutic benefits of medications can make them more likely to use substances (Trinkoff et al., 2022).

Ease of access is one of the most remarkable risk factors of SUD in nursing and is an occupational hazard. In a recent survey by Trinkoff et al, (2022), nurses in nursing homes and assisted living; home health/hospice, and government/community/military settings reported the highest prescription-type misuse. For a similar randomized population analysis completed 25 years ago, hospital nurses had the highest prescription misuse. Most hospitals have adopted better systems of handling these drugs with automated dispensing systems, which limit and control access, suggesting that workplace exposures could impact these differences (Trinkoff et al, 2022).

Clinical Presentation of SUDs

SUD is characterized by a wide range of clinical manifestations that result from repeated and harmful use of different substances. These manifestations can vary depending on the substance, the severity of the disorder, and individual factors. The Diagnostic and Statistical Manual of Mental Disorders (DSM) outlines specific criteria for diagnosing SUD, which include a pattern of behaviors and symptoms. People with SUD may experience cravings, which are intense desires or urges to use the substance, which may be difficult to control. They may not be able to limit or control substance use, often resulting in using larger amounts or for longer periods than intended (Dugash, 2023). Tolerance is when a marked increase in dose is needed to achieve the desired effect or when there is a markedly reduced effect from taking the usual dose (APA, 2013).

Withdrawal, another possible manifestation of SUD, refers to a group of unpleasant and potentially life-threatening physical symptoms the individual experiences when blood and tissue concentration of the substance decline in someone who has maintained prolonged use. Withdrawals vary greatly among the different substances of misuse. Alcohol use withdrawal must include two of the following symptoms: diaphoresis; nausea; vomiting; tremors; insomnia; agitation; anxiety; seizures; or transient visual, tactile, or auditory hallucinations. Opioid use withdrawal is often described as producing flu-like symptoms and includes three of the following: emotional distress, nausea, vomiting, diarrhea, muscle aches, lacrimation, rhinorrhea, yawning, diaphoresis, elevated temperature, and insomnia (APA, 2013).

Individuals with SUD may find themselves spending a significant amount of time obtaining, using, or recovering from the effects of the substance. They may begin to neglect their responsibilities, such as failing to meet work, school, or home obligations. Substance use can lead to social and interpersonal problems such as conflicts in relationships, social withdrawal, and challenges with family and friends. They may experience a loss of interest in previously enjoyed activities, even ones that are unrelated to the substance use itself. Engaging in risky activities while under the influence, such as driving under the influence or unprotected sex, is another manifestation of SUD. Hiding or being secretive about substance use from others may occur. Individuals may experience legal issues related to substance use, such as arrests for drug-related offenses or driving impaired. Attempts to quit are often unsuccessful. Despite its harmful manifestations, individuals continue using the substance even though they are aware of its negative physical, psychological, or social consequences (Dugash, 2023).

Assessment of SUDs

Clinicians assess SUD through a comprehensive evaluation process that includes both clinical interviews and standardized assessment tools. The assessment is crucial for determining the severity of the disorder, developing an appropriate treatment plan, and monitoring progress over time. The initial assessment often starts with a face-to-face interview with the individual. The clinician will ask a series of questions to gather information about the person's substance use history, current and past use patterns, and any associated problems. This interview may cover areas such as the type, frequency, and quantity of substance use, withdrawal symptoms, cravings, and consequences of use (Dugash, 2023).

Words affect how we see ourselves and one another. Labeling words creates stigma, stereotyping, and discrimination. Individuals who are labeled are devalued. Bias and stigma can be addressed by choosing a positive language. It is important for the nurse to use sensitive language in the interview that decreases the stigma around SUD (see Table 2) (Ashford, Brown, & Curtis, 2018).

Table 2. Terms that perpetuate stigma and what to use instead (Ashford, Brown, & Curtis, 2018)

Negative Terms	Positive Terms
Addiction	Treatable health disorder
Severe substance use disorder	Substance Use Disorder
Substance abuse disorder	Substance Use Disorder
Substance use disorder	Substance Use Disorder
Substance dependence disorder	Substance Use Disorder
Substance abuser, addict, alcoholic, or opioid addict	A person with SUD or patient
Abuse	Misuse
Relapse	Recurrence of use or return to substance use
Recovering addict	Person in long-term recovery
Abuse and dependence	Substance Use Disorders

Quantification of substance use is important to keep the assessment as objective as possible. This is easier for some substances than others. Alcohol use uses the number of standard-size drinks. In the United States, the standard drink is defined by the National Institute on Alcohol Abuse and Alcoholism. A standard-size drink equals 12 fluid ounces of regular beer, 8-10 fluid ounces of malt liquor or malt beverages, 5 fluid ounces of wine, 2-3 fluid ounces of liqueur, or 1.5 fluid ounces of distilled spirits such as rum or vodka (See image 1). (National Institute on Alcohol Abuse and Alcoholism, 2023).

Image 1. What is a standard drink? (National Institute on Alcohol Abuse and Alcoholism, 2023).

Risk thresholds for alcohol in the United States as defined by the National Institute on Alcohol Abuse and Alcoholism are:

For males (assigned at birth), five or more standard drinks in a day or more than 15 drinks per week on average
For females (assigned at birth), four or more standard drinks in a day or more than eight drinks per week on average (National Institute on Alcohol Abuse and Alcoholism, 2023).
Similar definitions for heavy drinking for gender minority populations have not been established (Dugash, 2023).

Tobacco is easily quantifiable. It should be established whether the patient is a daily or occasional user and how many cigarettes or portions of a package of smokeless tobacco are used daily. When assessing long-term smoking history to identify possible health consequences, pack years are used. To determine pack years, take the number of packs per day and multiply it by the number of years the person has been smoking cigarettes. Prescription drug misuse can be quantified by the dose and the frequency per day on average. There are no agreed-upon definitions for unhealthy use of other substances. For some substances, any use is considered unhealthy. Illicit drugs are much more difficult to quantify because the amount of drug compared to additives can vary widely (Dugash, 2023).

The provider must also identify the route of substance administration. Substances can be consumed orally, smoked, inhaled nasally, or injected into the subcutaneous tissue, muscle, or veins. Patient education will be tailored depending on the route of administration, for example, if a person is injecting a substance it would be important to discuss the risk of needle sharing (Dugash, 2023).

Another important assessment, especially in those who use synthetic opioids, is an overdose history. A history of an overdose indicates a very high risk of another overdose in the next year. Those who are at risk for overdose can be taught how to mitigate their risk of death from an overdose (Dugash, 2023).

Clinicians often use standardized screening tools or questionnaires to assess substance use. Some common screening tools include the CAGE (Cutting Down, Annoyance by Criticism, Guilty Feeling, and Eye-openers) Questionnaire, AUDIT (Alcohol Use Disorders Identification Test), and DAST-10 (Drug Abuse Screening Test). Depending on the substance and circumstances, structured assessments like the Addiction Severity Index (ASI) may be used to gather in-depth information on various life domains affected by SUD (Dugash, 2023). The American Academy of Pediatrics recommends the CRAFFT screening to identify problematic substance use in the adolescent primary care setting. CRAFFT stands for:

C — Have you ever ridden in a Car driven by someone who was impaired by a substance?
R — Have you ever used a substance to Relax?
A — Do you ever use Alone?
F — Do you ever Forget things that you did while using?
F — Do Family or Friends tell you to cut down?
T — Have you ever gotten into Trouble when using?

Identifying substance use early can help decrease substance use in adulthood and mitigate some of the negative effects (Buckstein, 2023).

A physical examination may be conducted to assess the individual's overall health and screen for any medical complications related to substance use. This is especially important for substances like alcohol or opioids, which can have several physical health impacts. In some cases, urine or blood tests may be used to detect the presence of substances in the individual's system. This can confirm recent substance use or help identify substances of abuse (Dugash, 2023; Buckstein, 2023).

Providers may use psychological assessments to evaluate the individual's mental health and identify any co-occurring disorders, such as depression, anxiety, or trauma-related disorders, which often co-occur with SUD. The risk of SUD is higher in those with personality disorders, especially borderline personality disorder. Addressing comorbid mental health disorders is crucial to treating SUD (Dugash, 2023).

It's important to assess the individual's social and environmental context, including family dynamics, support systems, housing, employment, and legal issues. These factors can influence the course of SUD and treatment planning. Information from family members, friends, or other sources can provide valuable insights into the individual's substance use and its impact on their life. The affected individual’s motivation and readiness to change their substance use behavior must also be assessed to help determine the most appropriate treatment approach, such as motivational interviewing techniques (Dugash, 2023; Buckstein, 2023).

Assessments are not limited to the initial evaluation. Ongoing assessments and monitoring are crucial to track progress and adjust treatment plans as needed. Clinicians work closely with individuals to develop a plan that may include counseling, therapy, medication-assisted treatment, support groups, and other resources aimed at helping them achieve and maintain recovery (Dugash, 2023).

Diagnosis

Pathological patterns of behaviors related to the use of these substances form the basis for the diagnosis of SUDs. These patterns are present over a 12-month period. The four main criteria are impaired control, social impairments, risky use, and pharmacological criteria. These groupings are broken down into eleven criteria (see Table 3) (APA, 2013).

SUD is classified by severity based on the number of criteria present. Severity is described as mild, moderate, or severe. Mild SUDs are estimated by the presence of two to three symptom criteria, with moderate by four to five criteria, and six or more criteria in severe SUDs. It is important to note that SUD exists on a non-linear continuum or cycle. Some individuals never progress to severe SUD and changing severity over time is reflected in the increase or decrease in use/criteria met. A complete report from the individual, a report from knowledgeable others, a clinician’s observations, and biological testing are required routinely to determine severity at different time intervals and establish the appropriate level of care (SAMHSA, 2019; APA, 2013). Substance abuse is addressed broadly in this discussion, in practice an individual’s assessment should address the specific substance of misuse, such as alcohol use disorders or opioid use disorders (APA, 2013).

Treatment

SUDs are treated through a variety of approaches, which can be tailored to an individual's specific needs and the severity of their disorder. Treatment for SUDs typically involves a combination of medical, behavioral, and psychosocial interventions (Dynamed, 2022; McKay, 2023).

Medical Treatment

Certain medications can be used to assist in the treatment of SUDs. These medications can help reduce cravings and withdrawal symptoms. For example, methadone, buprenorphine, and naltrexone are used in the treatment of opioid use disorder. Other medications are also used for alcohol use disorder and tobacco use disorder (Dynamed, 2022).

Sometimes emergency treatment for SUDs is needed, such as in the event of an overdose. The specific treatment for an overdose can vary depending on the substance involved, its quantity, and the individual's condition. Patients with SUD and their loved ones should be instructed on what to do if they suspect an overdose has occurred. If a substance overdose is suspected, they should immediately call 911 for professional medical assistance. As much information as possible should be provided, including the type of substance, quantity, and any observable symptoms. Instructions from the 911 operator should be followed (Stolbach & Hoffman, 2023).

While waiting for emergency medical services, they should be taught to ensure the safety of the individual and those around them. Remove any immediate dangers, such as sharp objects or hazardous materials, and keep the person lying down if possible. If the overdose involves opioids, and there is access to naloxone (Narcan), it should be administered according to the instructions provided with the medication to temporarily reverse the effects of opioid overdose and is available in some areas without a prescription (Stolbach & Hoffman, 2023).

In the emergency department setting, clinicians assess, stabilize, and provide appropriate care to individuals who have used substances in dangerous amounts. Assessment findings can include a decreased level of consciousness, constricted pupils (opioids), and decreased respiratory rate and volume. If the person is in respiratory distress, has a weak pulse, or is unconscious, immediate life-saving interventions, such as airway management, oxygen administration, and intravenous access, are initiated. The specific substance involved must be identified to provide appropriate treatment (Stolbach & Hoffman, 2023).

Individuals who have attempted suicide through overdose should receive a psychiatric evaluation to assess their mental health and potential risk of self-harm. Appropriate interventions, including crisis counseling and hospitalization, may be recommended (Stolbach & Hoffman, 2023).

For most patients who arrive at the emergency department with excessive substance use, supportive care is the hallmark of treatment. Intravenous fluids may be administered to maintain hydration and electrolyte imbalances may be corrected. Glucose should be checked and hypoglycemia should be corrected if present. Medications to control symptoms or complications, such as antiemetics for nausea and vomiting, may be given. Those who have ingested substances with delayed or long-lasting effects may be admitted to the hospital for observation and further treatment (Stolbach & Hoffman, 2023).

In cases of opioid overdoses, naloxone (Narcan), an opioid antagonist, may be administered to reverse the effects of opioids and improve respiratory function. Naloxone is effective for opioid overdoses and can be administered intravenously or intranasally (Stolbach & Hoffman, 2023). Side effects of naloxone may be mild such as nausea and vomiting or severe such as hypertension, hypotension, ventricular fibrillation, or ventricular tachycardia. The patient’s respiratory status and level of consciousness should be closely monitored (Vallerand, Sanoski, & Quiring, 2019).

Emergency department staff often play a role in connecting individuals with SUDs to appropriate treatment and support services. This may include referrals to addiction treatment programs or counseling services. Individuals who survive overdoses should be connected with SUD treatment and support services to reduce the risk of future overdoses. If possible, same-day and next-day appointments should be made. Some emergency departments will initiate medications for opioid use disorder, such as buprenorphine, although barriers exist to implementing these programs. To mitigate the effects of possible future overdoses, intranasal naloxone can be sent home with the patient for bystanders to use to resuscitate patients after an overdose (Stolbach & Hoffman, 2023).

Psychosocial Treatment

Various forms of counseling and therapy are crucial components of SUD treatment. These may include cognitive-behavioral therapy (CBT), motivational interviewing, contingency management, and family therapy. Therapy helps individuals understand and change their behaviors related to substance use. For individuals with co-occurring mental health disorders, integrated treatment addressing both the SUD and mental health condition is important. Learning skills and strategies to prevent relapse is a key aspect of SUD treatment (McKay, 2023).

CBT teaches patients how to identify thoughts that lead to precipitating substance use and alter those attributions to help guide a change in behavior. Education is a key component of CBT. Patients learn about the cycle of substance use and addiction and identify the situations, emotions, and thought patterns that trigger substance use. Through a process called cognitive restructuring, individuals work with a therapist to challenge and reframe maladaptive beliefs and thought patterns related to substance use and replace them with healthier thought patterns to drive a behavior change (McKay, 2023).

CBT helps those with SUD learn new and more effective coping strategies. These may include relaxation techniques, problem-solving skills, assertiveness training, and emotion regulation strategies. CBT for SUD teaches assertive communication, how to accept and respond to criticisms, how to decline a substance when offered, and stress management. If there is a relapse, the therapist and individual analyze the situation to determine what led to the event and how to avoid another in the future (McKay, 2023).

CBT can be used in conjunction with other therapies to treat SUD. For example, the community reinforcement approach (CRA) and combined behavioral intervention (CBI) use CBT principles while incorporating other strategies to address a wider variety of issues that patients experience during recovery. For example, CRA includes couples therapy for those with partners, employment assistance, and social activities. CBI uses CBT approaches along with motivational interviewing and twelve-step programs (McKay, 2023).

Motivational interviewing is a client-centered, collaborative, and goal-oriented approach to counseling and psychotherapy. It is designed to help individuals explore and resolve ambivalence about change, particularly in the context of behaviors that are harmful or counterproductive including substance use. First, a patient’s willingness to change is assessed. Then strategies such as using empathy, reflective listening, and open-ended questions are used (McKay, 2023).

Case management can assist with access to housing, employment, and other social services that can support an individual's recovery and stability. Involving family members in the treatment process can be beneficial, as it can improve family dynamics and provide a support system for the individual in recovery. Support groups like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) can provide a sense of community and a structured support system for individuals in recovery. Some individuals benefit from complementary and holistic approaches such as mindfulness, yoga, exercise, and nutrition as part of their treatment plan (McKay, 2023).

Care Settings

The choice of treatment setting for SUD should be based on a comprehensive assessment of the individual's needs, the severity of the SUD, the presence of co-occurring mental health issues, and the availability of support and resources. Treatment settings can vary in terms of intensity, duration, and the level of care provided. The individual's need for a structured and supervised environment is considered. If there is a risk of severe withdrawal symptoms, the individual may require medical detox in an inpatient or residential setting. The individual's motivation and readiness for change should also be considered. Motivated individuals may benefit from outpatient settings, while those with lower motivation might require more structure and supervision. Individuals with a history of relapse may require a more intensive treatment setting to address underlying issues that contribute to relapse (McKay, 2023).

Inpatient/Residential treatment is a highly structured, 24-hour care environment that is best suited for severe cases or those requiring detoxification. Partial hospitalization or day programs provide intensive treatment during the day while allowing individuals to return home at night. Intensive outpatient programs offer more flexible hours and intensity compared to inpatient programs but still provide comprehensive treatment. The least intensive option is outpatient treatment, which typically offers individual and group counseling on an outpatient basis (McKay, 2023).

The choice of setting should be made in partnership with the provider and the patient, taking into account the specific needs and circumstances of the individual with SUD. Developing a long-term recovery plan, which may include ongoing therapy, regular check-ins, and a support network, helps individuals maintain their sobriety. The duration of treatment varies depending on the person's needs and can range from a few weeks to several months or even years. Ongoing support and aftercare are essential for maintaining long-term recovery. Success in SUD treatment often depends on the person's motivation and commitment to change, as well as the support system in place (McKay, 2023).

SUD in Nursing

Case Study

Linda is a new graduate on the oncology unit of a teaching hospital and today is one of the most challenging days at work. Her co-worker Meredith was walked off the unit by the unit manager and two security officers. Two hours later an emergency in-service for substance abuse was convened for the weekend. Linda suspects that Meredith was taken off work for substance-related issues.

Prevalence

In the United States, nursing represents the largest sector of the healthcare workforce (Smiley et al., 2021). Research studying the prevalence of SUDs among nurses is lacking, despite the unique risk factors and potentially disastrous consequences of nurse SUD on patient care delivery. In the existing literature, substance use among nurses is affected by different variables, such as practice setting, stress levels, and the type of substance being used. For example, nurses in positions with higher stress levels were more likely to have an SUD. SUD of prescription drugs was reported highest amongst nurses working in long-term care and home health. Those two settings also have the highest rates of alcohol misuse. Compared to the general population, nurses use illicit substances less (Tinkoff et al, 2022).

Diversion in the Workplace

Diversion occurs when medication is redirected from its intended destination for personal use, sale, or distribution to others (NCSBN, 2014). It includes drug theft, use, and tampering (adulteration or substitution). Every organization that dispenses controlled substances has the potential for diversion. Nurses with substance use frequently depend on diversion at work to maintain their use (Toney-Butler & Siela, 2022). Drugs are diverted in organizations at many points. It is not easy to detect drug diversion. According to the NCSBN (2014), "Drug diversion among healthcare workers is substantially underestimated, undetected, and underreported.” It is therefore imperative for nurses to understand diversion, be conscious of the possibility of diversion, and report any suspicion to their leadership.

There are several signs of potential diversion in the workplace that nurses should be familiar with. Evidence that controlled substances have been removed without a provider’s order or for discharged or transferred patients could be a diversion. If controlled substance containers appear to be tampered with the substances may have been removed and replaced with saline. If a nurse pulls higher amounts of controlled medications than the other staff, has high numbers of overrides and discrepancies, or has a higher amount of wastage, it may be a warning sign of diversion. Sometimes nurses who are diverting offer to administer pain medications to other patients. Incomplete or late documentation, patient complaints of unrelieved pain, and patient pain levels that are consistently higher for one staff member can also indicate diversion is occurring Nurses can also observe for unexplained disappearances of staff or frequent bathroom trips (Toney-Butler & Siela, 2022; NCSBN, 2014).

Case Study Continued

Linda sits back and reflects at her time on the unit and her interactions with Meredith. On her first day of work, she remembers feeling slightly nervous and lacking confidence. Meredith has suspected her struggle, reassured her and offered to assist her with three patient medication administration. That became a norm for her and Meredith.

Consequences

In addition to posing a threat to patients and other healthcare workers, diversion poses significant legal and financial risks. Workers’ compensation, missed work, and decreased productivity are all costly consequences for organizations. It also poses a significant risk to patient safety because patients may receive substandard care from an impaired healthcare worker. Patients whose medications have been diverted may experience insufficient analgesia or anesthesia. There is significant liability, fines, and sanctions, and the unwanted notoriety and loss of reputation (Toney-Butler & Siela, 2022).

Prevention

At the organizational level, establishing a just culture where staff is encouraged to “if you see something, say something” should be implemented. Staff should be trained to recognize and report signs of drug use, especially environmental services staff. Sharps containers should not be overfilled and should have small openings so that items cannot be removed. Organizations should identify core competencies related to identifying SUD and diversion and educate all new employees during orientation. Policies that address diversion, govern the safe disposal of controlled substances, and outline reporting processes should be developed and implemented (Toney-Butler & Siela, 2022).

The most common way drug diversion occurs is during wasting. It is possible to prevent such diversion by reducing the need to waste controlled substances and managing waste disposal appropriately. Automatic dispensing container overrides should be minimized. Organizations can reduce waste events by buying unit doses and single-dose vials when possible. Staff should be held accountable for waste according to policy, including using designated waste containers instead of sinks. Staff should be knowledgeable about which medications are most commonly diverted (see Table 4.) (Nyhus, 2021).

Table 4. Commonly Diverted Drugs (The Joint Commission, 2019).

Nurse Manager Considerations

To mitigate risk through the encouragement of reporting, nurse managers must play an active role in helping their staff understand SUD and the need to promptly report any suspicion. Building on scientific evidence that shows that SUD is a chronic illness needing treatment, the nurse manager should encourage a culture of observing and reporting clues for the benefit of the suffering nurse as well as the patients who entrust their care to the nurses (NCSBN, 2014). Managers must be adequately informed on their facility’s policies and procedures as well as their state’s nurse practice act and regulations regarding substance use disorder. Individual states dictate the requirements for reporting to the board of nursing based on public hazards. Nursing boards in many states have mandatory reporting requirements, which require nurses to file reports about unsafe practices or misconduct by other nurses. In general, nurses are required to report to another nurse who engages in the practice of nursing while impaired by substance misuse or diversion of controlled substances (NCSBN, 2014). Nurse managers play an important role in monitoring for diversion among staff. They must proactively observe for signs of diversion in their units. Signs of diversion should trigger further investigation. Nurse managers must know the organization's policies and promote a safety culture. Reports from automatic dispensing machines should be checked regularly for discrepancies by day of the week or time of day, overuse of overrides, and delays between pulling and administering or administering and wasting. The nurse manager needs to inform their staff that the reports are monitored and hold staff accountable for wasting according to policy (NCSBN, 2014).

Characteristics Encountered in Nurses with Diversion

Most substances diverted by healthcare workers are for personal use. A nurse engaging in diversion might be at the earlier stages of substance use and might not present with any signs of impairment. Noticeable signs of SUD for nurses often suggest that the nurse has been ill for a long time (Toney-Butler & Siela, 2022). A nurse therefore should be prompt in reporting suspected diversion irrespective of the suspected peer’s presentation. The nurse must also be aware of certain characteristics that at face value appear as strength but denote a potential for diversion. There are several typical presentations of a nurse who has SUD.

Super Nurse

A nurse with substance use may transfer from hospital to hospital, work as a travel nurse, or work in multiple facilities to avoid scrutiny. She may have resigned or been terminated within the last year. Nurses with substance use look for settings and positions with insufficient oversight and easy access. Examples are a night house supervisor in a small hospital or a staff RN in a procedural area. Nurses with a high level of achievement, an obsessive nature, or a strong work ethic might use drugs to help them perform better. It is not unusual for the nurse with substance use to be viewed as the most competent, well-liked, and respected nurse on the floor (Toney-Butler & Siela, 2022).

Helpful Nurse

The nurse with substance use might be very helpful with an ulterior motive. They might volunteer to cover breaks and administer pain medication. They are adept at identifying opportunities to procure drugs (Toney-Butler & Siela, 2022). An example is the charge nurse who gets to work early and immediately targets post-op patients likely to have narcotics ordered. She can then proactively offer patients pain medication.

High-Performer/Workaholic

Nurses with SUD often work overtime. They may come in early, or work late, allowing them access during shift reports. Overwork can signal weak boundaries (Toney-Butler & Siela, 2022).

Case Study Continued

Linda had great admiration for Meredith, she was loved by everyone, she moved so fast and always had great energy. Besides helping her with patient’s medications faithfully every single shift they worked together, Meredith began asking her frequently to witness wasting. Now looking back, she remembers that during wasting, Meredith would be in such a hurry that it didn’t allow Linda enough time to ensure rightful waste procedure are completed.

Presentations of an Impaired Nurse

Impairment is the inability or impending inability to provide safe, professional activities and to perform duties due to a behavioral, mental, or physical disorder related to alcohol or drugs (Toney-Butler & Siela, 2022). Nurses with SUD work while under the influence of drugs or other substances. Although some manage to work and function marginally, eventually, they cannot perform their jobs safely. They try to cover up their diminishing ability to provide safe patient care, but their performance deteriorates, and their risk-taking increases (Toney-Butler & Siela, 2022). More detailed characteristics of nurses with SUD who are impaired are described in Table 5.

Patient care becomes a means to an end. The nurse's primary job is procuring the substance. Most of the nurse’s energy goes into obtaining the substance and covering their tracks. Eventually, the impaired nurse loses self-control (a sign of addiction). As time passes, they become careless and reckless. In general, clinical judgment and performance problems are late indicators of impairment (Toney-Butler & Siela, 2022).

Table 5. Changes in an impaired nurse (Dynamed, 2021; Toney-Butler & Siela, 2022)

Case Study Continued

During report that morning, a colleague shared with Linda that Meredith must’ve had a rough night. She was very irritable, restless, and she couldn’t remember what surgery her patient

The Effects of COVID-19 Pandemic

In the United States, there was a marked increase in substance use and drug overdoses after March 2020 when COVID-19 was declared a national emergency (National Institute on Drug Abuse, 2022). The pandemic created many uncertainties for people worldwide. There were significant economic changes, worsening isolation, and less access to care. Nurses have been at the frontline of the pandemic since its onset and have been dealing with additional worker-related stress from the effects of the prolonged response to COVID-19. It is expected that a shortage of workers, long working hours, and stress will increase substance misuse among healthcare workers (Toney-Butler & Siela, 2022).

Reporting and Barriers to Reporting

Impaired nurses are very unlikely to report themselves as a major challenge with addiction is denial. There is a lot at stake for nurses with SUD: their career, livelihood, reputation, and social standing are all at risk. Despite the risks, nurses often self-diagnose, self-treat, and do not seek assistance from other professionals (Toney-Butler & Siela, 2022). When they do seek help, it's usually after experiencing a climactic event, such as an adverse event being reported to their employer or state board of nursing (Kunyk et al., 2016a).

Reporting impaired colleagues is essential for patient safety and the integrity of the healthcare system, but there are several barriers that can discourage or hinder the reporting process. Colleagues may fear retaliation from the impaired colleague or their superiors for reporting. They worry about potential negative consequences for their own careers or working conditions. Some healthcare workers may not be well-informed about the signs of impairment or the importance of reporting. Lack of education and awareness can be a significant barrier (NCSBN, 2014).

Sometimes, colleagues may have suspicions about a coworker's impairment but lack concrete evidence. They may be uncertain about whether their concerns are valid. According to NSCBN (2014), nurse managers and colleagues infrequently identify substance abuse. They easily provide other justifications for clues, leaving most nurses with SUD unidentified and untreated as they continue to practice placing themselves and their patients at risk.

There is often a stigma associated with substance use and mental health issues, which can deter individuals from reporting colleagues who are impaired. The fear of stigmatizing the affected worker can be a barrier to reporting. Healthcare professionals often have strong bonds with their colleagues, and they may hesitate to report someone they consider a friend. Loyalty and a sense of camaraderie can make reporting difficult (NCSBN, 2014).

Nurses may be concerned about legal consequences, such as being called as a witness or being drawn into a legal dispute, which can deter reporting. A workplace culture that does not prioritize patient safety and encourages silence about impaired colleagues can deter reporting. A culture that does not promote open communication and accountability can be problematic. Nurses may feel that they lack support from their organization, including access to Employee Assistance Programs or resources for managing impairment issues. Nurses at some organizations may believe that reporting impaired colleagues won't result in any meaningful change, and the colleague will continue practicing without intervention. In other settings, there may be a lack of clear and confidential reporting mechanisms. Employees may be uncertain about how to report concerns and whether their reports will remain confidential (NCSBN, 2014).

To address these barriers and encourage reporting of impaired nurses, it's essential for healthcare organizations to establish clear and confidential reporting mechanisms, prioritize a culture of safety and accountability, educate their staff about the importance of reporting, and provide support to those who come forward with concerns. The protection of whistleblowers and the creation a non-punitive environment for reporting can also help overcome some of these barriers (NCSBN, 2014). The primary goal should always be the safety and well-being of patients. In 2001, the American Nurses Association (ANA, 2016) Code of Ethics for Nurses was revised to address impaired practice specifically: "Nurses must be vigilant to protect the patient, the public, and the profession from potential harm when a colleague's practice, in any setting, appears to be impaired.”

Case Study Continued

The colleague who got report from Meredith shared with Linda that she would’ve never suspected Meredith would be using substances. She felt shocked when she later found out she was reported. Linda, too, was surprised and upon further reflection, she realized that her biases about Meredith may have contributed to her missing the warning signs.

Boards of Nursing

The Board of Nursing’s first responsibility is to protect the public from harm. Once a complaint is made, the Board of Nursing investigates and decides on an appropriate action for unsafe practice. They can mandate that a nurse be removed from practice, seek treatment, abstain from use, and be monitored (Mozingo, 2021).

There are two different regulatory options available to Boards of Nursing: Disciplinary action or alternative-to-discipline programs (ADPs). Disciplinary actions are reported to databases, such as the Nursys® data bank of the NCSBN. Each state has variations in disciplinary policy related to SUD, but punishment does not help nurses with SUD overcome their disease. More congruent with recognizing SUD as a disease, ADPs were created. ADPs are voluntary, non-public, and non-disciplinary monitoring programs (Mozingo, 2021).

Nursing outcomes in ADP programs are better than those in traditional disciplinary programs, although further research is needed to compare the outcomes of one ADP to others. Rather than experiencing a lengthy investigation from the Board of Nursing, nurses with SUD are removed from the workplace and provided with treatment. The goal is for the nurse to avoid disciplinary action, work through the program, and eventually return to practice without restrictions (Mozingo, 2021).

ADPs are not all uniform and they can lack consistency, but there are some common themes across programs. Most programs require abstinence from the substance. Some require participation in group meetings, for example, a 12-step program like Alcoholics Anonymous or Narcotics Anonymous. Through the program, there may be restrictions on the number of hours and shifts worked (Mozingo, 2021).

Nurses can self-refer or be referred by an employer, another party, or the BON/BRN. However, a referral does not guarantee eligibility. There are specific criteria for eligibility. Typical admission criteria to an ADP include holding a valid nursing license, acknowledging there is a problem, agreeing to take a break from practice until the program approves, and allowing for evaluation. Reasons for being denied entry into a program can include past disciplinary action, criminal action, or selling controlled substances. If the nurse is not eligible for the ADP, they are subject to disciplinary action by the Board of Nursing (Bettinardi-Angres, Pickett, & Patrick, 2012).

Enrollment in ADPs is low. Nurses must quit working while in treatment, and many cannot afford to do so. In addition to losing a paycheck, they may lose their healthcare benefits. Nurses may be hesitant about the requirements and restrictions as well as the length of the program. A concern is that nurses can potentially be in a program without their Board of Nursing’s knowledge. That means an impaired nurse can avoid the Board of Nursing entirely and move to multiple jurisdictions to practice. It can be challenging to find a balance between protecting the nurse’s confidentiality and public safety (Bettinardi-Angres, Pickett, & Patrick, 2012).

Case Study Continued

A year later, Linda saw Meredith at the grocery store. Meredith shared that she is enrolled in an ADP and is currently working on a limited basis based on the program’s requirements. She hopes to be reintegrated into nursing practice soon. She has been free from substance use for over six months.

Recovery

Recovery is defined as the act of regaining control of one's life or returning to a state of health. Recovery involves abstaining from all unauthorized, non-prescribed substances. Incremental stages of progress measure recovery. There is a positive association between bimonthly drug tests, daily check-ins, and staying in a program for at least three years with successful program completion. Many nurses recover successfully (Trinkoff et al., 2022). Often nurses with SUD are bright and high achievers with a will to succeed. The strongest predictors of success are a willingness to stick with a program, admitting that there is a problem, and re-entry to work (Toney-Butler & Siela, 2022):

Employment is a key functional index in addiction treatment. Returning to work is a top priority for nurses with substance abuse disorders. Nurses usually sign a contract to reenter the workplace. Contract lengths vary anywhere from six months to five years or on a case-by-case basis (Russell, 2020). Nurses are subject to specific work requirements which may include more stringent monitoring of performance at work, maintaining sobriety, meeting regularly for check-ins, having a workplace monitor, and submitting to toxicology tests. Those who violate their contracts can be terminated (Russell, 2020).

Every state program is different, but when returning to work, practice restrictions typically may include working only during the day and only on their assigned unit, a limit on overtime, no on-call shifts or temporary assignments, restricted access to controlled substances, and no working in a home or community setting. Some ADP programs restrict travel nursing, working in hospice, working for multiple employers, and working in ED, ICU, OR, PACU, or delivery rooms. Practice restrictions are typically in effect for one year after completing a program or on a case-by-case basis (Russell, 2020).

Recurrence is an instance of substance use that occurs after abstinence. Recurrence is always a possibility due to irreversible changes in the brain. The highest recurrence rate occurs in the first year, with the highest rate being for alcohol use. A recurrence can occur once or be a cycle of sobriety and recurrence (Russell, 2020).

Table 6. SUD Resources

The role of nurses as both caregivers and vulnerable individuals underlines the urgent need for comprehensive support systems, education, and destigmatization efforts within the healthcare community. In the face of the ongoing substance use crisis, recognizing the essential role nurses play and providing them with the resources and understanding they need to confront this challenge head-on is not just a matter of professional responsibility but a crucial step toward ensuring the health and well-being of both patients and those who care for them. Healthcare must work toward a future where nurses are empowered to seek help, where stigma is replaced by empathy, and where patient safety is always the top priority.