Role of Occupational Health

Professionals in managing

substance use disorder among

health care workers.

Dr Lija Gireesh, DNP, APRN, FNP-BC, COHN-S

Lead Nurse Practitioner

Employee Health Services, Christiana Care Health Systems

AOHP 2019 National Conference

Learning Outcomes

1. List three common manifestations

observed in people with substance use

disorders.

2. Identify two resources for help for

workers with substance use disorders.

3. Describe at least two elements for a

successful workplace substance use

disorder prevention program

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Scenarios

Definition

Substance use disorders occurs when the

recurrent use of alcohol and/or drugs

causes clinically and functionally significant

impairment, such as health problems,

disability, and failure to meet major

responsibilities at work, school, or home

(SAMSHA).

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Significance

Leading cause of missed workdays over the past year

◦ Pain medication use (29 days)

◦ Illicit drug use (unspecified) (18 days)

◦ Marijuana use disorder (15 days)

◦ Alcohol use disorder (14 days)

Employer costs related to substance use disorders costs nearly $81billion.

Employees who abuse drugs are more than three and a half times as likely to have an accident on the job, and five times more likely to have an off-the-job accident that impacts workplace performance

Five times more likely to allege worker’s compensation

https://www.areadevelopment.com/workplace-trends/workforce-q4-2017/impact-of-substance-abuse-on-finding-a-quality-workforce.shtml

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Drug of abuse at workplace

Alcohol

Prescription stimulants

Illegal stimulants

Antidepressants

Prescription sedatives

Benzodiazepines

Herbal drugs

Opioids

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Physical signs of Substance Use

Disorder Changes in sleep patterns.

Changes in eating habits

Cold sweaty palms

Red, watery eyes, pupils larger or smaller than usual

Extreme hyperactivity, excessive talkativeness.

Slowed or staggering walk, poor physical coordination.

Tremors or shakes of hands, feet or head.

Irregular heartbeat.

Runny nose, hacking cough

Puffy face, blushing, or paleness

Deterioration of hygiene or physical health

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Behavioral signs of Substance Use

Disorder Unusual smells on breath, body or clothes.

Needle marks on lower arm, leg or bottom of feet.

Frequent rubbing of the nose

Frequent twisting of the jaw, back and forth

Changes in attitude and activities

Excessive need of privacy

Changes in social networks

Unexplained need of money

Anxiety

Depression

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Drug Diversionary Behaviors

Reports that drugs have been wasted or containers broken without witness

Administer prn medications at maximum dosages when other nurses don’t

Have patients report variance in pain relief in the absence of change in dosage or frequency

Frequently volunteers to get medications out of secured cabinets and administer them

Request transfers to night shift or to areas with minimal supervision

Seek assignments to areas where opioids are used extensively

Routinely administer controlled substances to confused patients

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Red Flags

Appearance changes

Loose fitting clothes with multiple pockets

Often cannot be located in his or her assigned area

Volunteers, frequently, to work overtime, extra days

Opioid shift count errors that arise repeatedly when the same nurse is on duty

Patients repeatedly fail to achieve the expected level of pain relief from their prescribed analgesics

DRAMA

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Signs and Symptoms of Substance

Use Disorders in Health Care

Workers

In 10% of cases presenting symptom is

death

Signs and symptoms too difficult to

appreciate until it is too severe to ignore.

Substance use disorder relapse rate is

high (30-60%)

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• Neurobiological factors: Alterations in neurotransmitters

of the reward system

• Genetic Predisposition: Accounts for 50% of alcohol

addiction

• Psychological factors: Comorbid psychiatric conditions

• Personality: Impulsivity and sensation seeking

• Occupational factors: Exposure and access to

substances of abuse

» Stressful nature of work

» Attitude/Personality

» Occupational exposure

Risk factors for Substance Use

Disorder

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Resources

SAMSHA: Substance Abuse and Mental

Health Services Administration

HHS: Department of Health and Human

services; Opioid initiative

White House Office of National Drug

Control Policy (ONDCP)

NIDA: National Institute on Drug Abuse

American Nurses Association: code of ethics

Workplace monitoring programs

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SAMSHA: Substance Abuse and

Mental Health Services

Administration

Behavioral Health is

essential to Health

Prevention works

Treatment is effective

People Recover

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Drug Free work place programs

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American Nurses Association

Code of ethics for nurses: “incompetent, unethical, illegal, or impaired practice”

A nurse who is aware of such a practice has an ethical

obligation to report

“Concerns should be expressed to the person carrying out the questionable practice” before reporting to a higher authority, such as a supervisor (ANA, 2001).

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Essential Elements

Build a team

Assess your workplace

Develop a policy

Plan and implement program

Evaluate program

Provide support

https://www.samhsa.gov/workplace

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When impairment is suspected

• No action

– Denial

– Fear of litigation and lack of established policies

– Change jobs when they perceive that their behavior is

scrutinized

• Enabling

– Covering up/ making excuses for impaired coworker to

protect their job

• Reporting

– Factual reporting to chain of command

– Confidential reporting

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Occupational Health Professionals

role in developing a program

Developing a Culture of Transparency and Support

Minimizing horizontal violence and stress at workplace

Supportive work place environment

Education in the workplace about the issue

Prevention actions for diversion

Proactive policies and procedures

Regular monitoring as prevention

Internal investigations

Identifying worker with substance use disorder

Managing worker with substance use disorder

Action plan

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SBIRT

• Screening

➢ Health care professional including EHS clinician

➢ Supervisor

➢ Self-administered questionnaires

• Brief Intervention

➢ Motivational interviewing

➢ Asking, assessing, advising and monitoring

• Referral to Treatment

Multiple tools are available online

➢ Use your EAP resources

➢ Follow-up and maintain support upon reentry to workforce.

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References American Nurses Association: Substance Use Disorders and the American Nurses Association Code of Ethics for Nurses.

https://connect.springerpub.com/content/sgrcn/24/3/163.full.pdf

Carter, T., McMullan, S. P. & Patrician, P. A (2019) Barriers to Reentry Into Nurse Anesthesia Practice Following Substance Use Disorder Treatment: A Concept Analysis. Workplace Health and safety, Apr;67(4):189-199. doi: 10.1177/2165079918813378.

Lambrechts, M. C., Ketterer, F., Symons, L., Mairiaux, P…et al (2015). The Approach Taken to Substance Abuse by Occupational Physicians: A Qualitative Study on Influencing Factors. The Journal of Occupational and Environmental Medicine, Nov;57(11):1228-35. doi: 10.1097/JOM.0000000000000549.

Monroe, T., Vandoren, M., Smith, L., Cole, J. & Kenaya, H. (2011) Nurses recovering from substance use disorders: a review of policies and position statements. The Journal Of Nursing administration, Oct;41(10):415-21. doi: 10.1097/NNA.0b013e31822edd5f

Mumba, M. N. (2018). Employment implications of nurses going through peer assistance programs for substance use disorders. Archives of Psychiatric Nursing, 32(4):561-567. doi: 10.1016/j.apnu.2018.03.001

Mumba, M. W., Baxley, S. M, Snow, D. E. & Cipher, D. J. (2019). A Retrospective Descriptive Study of Nurses With Substance Use Disorders in Texas. The journal of addictions Nursing, Apr/Jun;30(2):78-86. doi: 10.1097/JAN.0000000000000273.

NCSBN: A nurse mangers guide to substance use disorder in nursing https://www.ncsbn.org/Mgr_SUDiN_Brochure_2014.pdf

Phillips, J. A., Holland, M. G., Baldwin, D. D….et al (2015) Marijuana in the workplace: guidance for occupational health professiona ls and employers: Joint Guidance Statement of the American Association of Occupational Health Nurses and the American College of Occupational and Environmental Medicine. The Journal of Occupational and environmental Medicine, Apr;57(4):459-75. doi: 10.1097/JOM.0000000000000441

Riboldi, L., Bordini, L. & Ferrario, M. M. (2012). Fitness for work in health care workers: state of the art and possible operational recommendations for its formulation and management in relationship to alcohol and drug addiction. May-Jun;103(3):203-11

Substance Abuse and Mental Health services administration: https://www.samhsa.gov/ebp-resource-center

Warsley, M., Satterfield, J. M., Curtis, A., Lundgren, L. & Stare, D. D. (2018) Alcohol and Drug Screening, Brief Intervention, and Referral to Treatment (SBIRT) Training and Implementation: Perspectives from 4 Health Professions. Journal of Addictions Medicine, Jul/Aug;12(4):262-272. doi: 10.1097/ADM.0000000000000410

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