Recognizing Alcohol and Drug Impairment in the Workplace in Florida

Etiology

The most common causes of workplace impairment are chemical and substance use, including the following: 

• Alcohol presenting as acute intoxication and chronic alcohol use
• Prescription drug use, commonly opiates and anxiolytics
• Nonprescription drug use, including a variety of opiates and other illicit drugs

Often, there are underlying stressors that contribute to the impairment of the individual in a healthcare setting. The following are common stressors:

Genetic

• Neurotransmitter deficits
• Family history of substance use disorder

Mental/Physical Fatigue

• Staff shortages may drive stimulant use.
• Stressful job responsibilities
• Environmental factors
• Excessive workload
• Pregnant
• Shift work
• Prolonged traveling
• Sleep deprivation
• Social activities

Injuries

• The use of opioid pain medications due to injuries leads to addiction and an inability to control consumption after the injury is resolved.
• Chronic pain syndromes may require long-term pain relief and include controlled substances.

Personal Stress

• Personal relationship issues
• Family or personal health issues
• Financial matters
• Addictions, such as gambling or sex 

Physical Illness

• Diabetes, epilepsy, arthritis, asthma, cancer, and other long-term illnesses that result in chronic pain
• Recurring medical conditions
• Acute or chronic pain

Psychological

Addictive personality

• Anxiety
• Feelings of resentment
• Depression
• Low self-esteem
• Unable to cope with stress

Questionable Competence

• Unfamiliarity with the work environment or work practices and procedures
• Poor training
• A gradual erosion of skills and lack of refresher training

Work-related stress

• Organization change
• Restructuring
• Long work hours
• Shift-work
• Changing responsibility
• Increasing responsibility

Epidemiology

Alcohol and drug use is a significant problem in the healthcare profession. As much as 15% of all health professionals are thought to be impaired or recovering from alcohol or drug use. Accurate statistics of the exact number of individuals afflicted are unknown but are believed to be similar to or exceed the rate of impairment in the general population.[19][20][21]

Alcohol and substance use disorders are a significant problem in health care. Diseases related to alcohol and drugs are one of the leading causes of preventable disability and death. While it is ubiquitous, it may be beyond the ability of the health professional to control. Genetic factors are thought to play a role in up to 50% of individuals with substance use disorder.[22][23][24]

• Alcohol and substance use contributes to injuries, missed work, decreased productivity, social harm, liability, and increased health costs. Because of the extensive risks to individuals and institutions, it is beneficial to assist employees in managing alcohol and substance use.

• Use and diversion of drugs are seen throughout the healthcare profession, but they are most prevalent in individuals who work in anesthesiology, emergency, intensive care, or pharmacy. Some health professionals may also engage in binge drinking, regular heavy drinking, and illicit drug use.

• When a health professional also develops a mental health issue such as depression, anxiety, schizophrenia, or severe personality disorder, the risk of impairment due to self-medication and treatment increases significantly.

• The rate of drug use by healthcare providers is thought to be as much as five times higher than the reference rate for nonmedical professionals. High stress specialties have the highest incidence of substance use problems. For example, emergency physicians experience substance use at a higher rate than most other physicians. 

Substance use among doctors, nurses, and allied health professionals is related to a variety of factors; for example, personality traits that lead individuals to select high-stress positions in medicine, such as high achievement, obsessiveness, and a high work ethic also may influence an individual to chose stimulants to maintain what they believe is a higher level of performance. Health professionals also have relatively direct access to prescription drugs, making it easier to obtain addicting medications. Health professionals tend to use benzodiazepines and opiates more than illicit street drugs, most likely due to the ease of access. Substance use in healthcare providers is expected to increase due to long hours, stress, and increasingly widespread workforce shortages in healthcare.[25][26]

Pathophysiology

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines a substance use disorder which is divided into mild, moderate, and severe. Substance use disorders occur when the recurrent use of alcohol and/or drugs causes significant impairment, including health problems, disability, and the inability to meet major responsibilities at home, work, or school. A substance use disorder diagnosis is based on evidence of social impairment, impaired control, risky use, and pharmacological criteria.[27]

Substance Use Disorder

As with most behavioral and psychiatric disorders, the interplay between genetic risk, temperamental traits, and the environment may predispose an individual to substances use. Once exposed to substances, brain reward systems reinforce substance use, resulting in repeated use and lower ability to control substance use. 

Alcohol Use Disorder

The pathophysiology of alcohol use disorder is unknown, but its development may result from a complex interplay of genetics, environmental factors, personality traits, and cognitive functioning.

Tobacco Use Disorder

There are almost half a million deaths each year in the United States secondary to cigarettes.

Stimulant Use Disorder

Cocaine, methamphetamine, and amphetamine are the most commonly used substances in this group.

Hallucinogen Use Disorder

LSD, ecstasy, and psilocybin are included in this group.

Opioid Use Disorder

In the United States in 2014, it was estimated that 1.9 million individuals were using prescription opioids, and 586,000 were using heroin.

Cannabis +Use Disorder

Despite the acceptance of this substance, Federal law still prohibits use.[28][29]

Toxicokinetics

Substance use disorders correlate with several negative consequences for healthcare providers, including the following toxic effects:  

Toxic Effects of Drug Use

• Opioids: respiratory and CNS depression
• Barbiturates: respiratory depression
• Benzodiazepines: respiratory depression
• Amphetamines: euphoria, grandiosity, pupillary dilation, prolonged wakefulness, hypertension, tachycardia, anorexia, fever, paranoia, cardiac arrest, and seizures
• Cocaine: impaired judgment, pupillary dilation, hallucinations, paranoid ideation, angina, and sudden cardiac death
• Phencyclidine: violence, impulsivity, psychomotor agitation, nystagmus, tachycardia, hypertension, analgesia, psychosis, delirium, and seizures
• LSD: visual and auditory hallucinations, depersonalization, anxiety, paranoia, psychosis, and flashbacks
• Marijuana: euphoria, anxiety, paranoid delusions, the perception of slowed time, impaired judgment, amotivational syndrome, dry mouth, increased appetite, conjunctival injection, and hallucinations
• MDMA: euphoria, disinhibition, hyperactivity, life-threatening hypertension, tachycardia, hyperthermia, hypernatremia, and serotonin syndrome

Toxic Effects of Alcohol Use

• Excessive alcohol consumption commonly causes preventable death.
• More than 85,000 deaths a year are directly attributed to alcohol use.
• Toxic effects include emotional lability, slurred speech, ataxia, blackouts, coma, and death.

History and Physical

Dire consequences are associated with healthcare provider impairment. Often, the impairment goes unreported or untreated because of the following:

• Alcohol and substance users often do not admit they have a problem.
• Alcohol and substance-using health professionals tend to self-diagnose and self-treat and do not seek help from other professionals.
• Colleagues may be fearful of reporting due to the potential for reprisal.
• Patients are often uncomfortable taking action against health professionals responsible for their care.
• Lapses in clinical judgment and performance are usually late signs of impairment, making diagnosis difficult unless the practitioner admits they have a problem.

Impaired practitioners, as well as their colleagues and patients, are unlikely to take action until an alcohol or drug problem has reached a critical level and resulted in a significant healthcare disaster or a legal entanglement.

For this reason, healthcare workers must recognize a clear ethical, moral, and legal duty to identify and report an impaired colleague. Unfortunately, while most health professionals consider alcohol and drug use to be a disease, health professionals are often reluctant to report their concerns. It is difficult for a colleague to confront a potentially impaired healthcare provider for fear of damaging the professional's reputation, especially if the suspicion is proven wrong.

Regrettably, only an average of 2 out of 3 healthcare practitioners with direct, personal knowledge of a colleague's impairment will report a peer to the proper authority professionals despite the legal risk for not reporting. However, in many cases, reporting may be the only approach encouraging the impaired doctor, nurse, or allied health professional to seek evaluation and treatment.

Impairment may be due to alcohol, street drugs, or taking prescription drugs from a patient, friend, or family member. Health professionals may take injectable medications from a patient or dilute the drug with saline. 

The following are the most commonly used medications: 

• Benzodiazepines
• Cocaine
• Ecstasy
• Heroin
• Ketamine
• Marijuana
• Methamphetamines
• Opioids
• Sleeping pills
• Stimulants

Impaired health professionals are often difficult to identify because they are often bright, well-trained, careful, and make a strong effort to avoid being caught. When the signs or symptoms of alcohol or drug use finally get noticed, the problem has typically been ongoing for a long time.

The following signs and symptoms of alcohol and drug use can help a health practitioner identify a potential problem:

Symptoms of Alcohol and Drug Use Disorder

• Abnormal wasted opioids
• Altered orders
• Arriving to work late
• Difficulty meeting deadlines
• A discrepancy in controlled substance records
• Dishonesty
• Documentation errors
• Excessive sick time
• Frequent mistakes
• Frequent reports of patients not receiving pain relief
• Frequent unexplained absences
• Increased opioids sign-outs
• Leaving work early
• Maximum use of pain medications
• Mood changes
• Not performing narcotic counts
• Obsession with opioids
• Offering to medicate patients
• Paranoid
• Poor charting
• Poor quality work
• Rounding at odd hours

Signs of Alcohol and Drug Use

• Anger management issues
• Bloodshot eyes
• Constricted pupils
• Defensiveness
• Denial
• Dilated pupils
• Diminished alertness
• Diaphoresis
• Disheveled appearance
• Distracted
• Fatigue
• Frequent accidents
• Frequent pain complaints
• Frequent use of gum or mints
• Hyperactivity
• Hypoactivity
• Insomnia
• Intoxication at social functions
• Isolation
• Lying
• Mood changes
• Impossible reasons for behavior
• Perforation of the nasal septum
• Poor concentration
• Poor judgment
• Runny nose
• Sedated
• Sleepiness
• Slurred speech
• Suicidal thoughts
• Track marks
• Tremors
• Unexplained nausea, vomiting, or diarrhea
• Unsteady gait
• Watery eyes
• Wearing long sleeves at inappropriate times (hiding track marks)
• Weight gain
• Weight loss 

Behaviors Associated With Drug Diversion

• Altered orders for drugs
• Controlled substance discrepancies
• Frequent trips to the bathroom
• Frequent medical loss
• Frequent corrections on medication records
• Higher-than-average opioid administration
• Higher-than-average opioid wastage
• Incorrect counts (particularly opioids)
• Patients complaining of poor pain relief
• Tampering with capsules or vials
• Unexplained disappearance

Many health professionals may turn to alcohol and drugs when going through a stressful time in their lives. They may use illicit substances to help them cope with problems such as family issues, malpractice cases, work stress, or financial pressures.

Alcohol and drug addiction is compulsive behavior. It may develop from an unhappy life, poor life choices, a family history of addiction, boredom, denial, or thrill-seeking. 

Institutional Considerations

Most health professionals lack training and education regarding the signs and symptoms of addiction, identifying those addicted, and the correct manner to engage in the intervention. 

All health professionals should receive education regarding alcohol and substance use disorders. Employers need to assist in improving physician, nurse, and allied health professionals' knowledge about the signs and symptoms, how to report them, and available treatment options.

• Employers can and should provide workers with strategies that promote patient safety and provide assistance in reporting concerning health professionals.

• Employers should offer guidelines that promote safe practices and a defined reporting mechanism for concerning situations.

• Employers should offer assistance to health professionals who suffer from alcohol and substance use.

The policy at any healthcare facility should be an alcohol and drug-free environment. The following mechanisms can decrease worksite impairment:

• Pre-employment drug testing
• Cause testing (if suspicion exists)
• Random testing
• Regular practice evaluations

Each of these is controversial. While most institutions support pre-employment and cause testing, less support exists for random testing of healthcare professionals. Further, not all professionals working in a hospital setting are necessarily employees of the institution. This fact may make it difficult for an institution to mandate screening.

Institutions should promote a culture that delineates the expectations of employees and consequences. A policy that supports providing help with alcohol and drug use disorders should also be in place.

Institutions have an opportunity to help identify employees and practitioners with alcohol and drug impairment. In particular, supervisors should be trained in the signs and symptoms of alcohol and drug use disorder. They should be familiar with the institution's policies and procedures for getting the individual the help they need.

Evaluation

The evaluation of a health professional with substance use or potential substance use disorder is a challenge. Health professionals may make efforts to hide or cover up their use and use of alcohol or drugs. Evaluation and diagnosis will be conducted by a clinician experienced in dealing with potentially challenging patients.[30][31]

DSM-5 Diagnostic Criteria for Evaluating and Diagnosing a Substance Use Disorder

A problematic pattern of use leading to clinically significant impairment or distress is manifested by two or more of the following within a 12-month period:

1. Often use larger amounts or for a longer period than was intended
2. Persistent desire or unsuccessful efforts to cut down or control use
3. A great deal of time spent in activities necessary to obtain, use, or recover from the substance’s effects
4. Crave or have a strong desire or urge to use the substance
5. Recurrent use causing failure to fulfill primary role obligations at work, school, or home
6. Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by its effects  
7. Important social, occupational, or recreational activities given up or reduced because of use
8. Recurrent use in situations in which it is physically hazardous
9. Continued use despite knowledge of having a persistent or recurrent physical or psychological problem was likely caused or exacerbated by the substance
10. Tolerance
11. Withdrawal

Severity

DSM-5 specifies mild, moderate, and severe based on the number of diagnostic criteria met by the patient at the time of diagnosis:

• Mild: 2 to 3 criteria 
• Moderate: 4 to 5 criteria       
• Severe: 6 or more criteria

DSM-5 Diagnostic Criteria for Evaluating and Diagnosing an Alcohol Use Disorder

1. Recurrent drinking, resulting in failure to fulfill role obligations
2. Recurrent drinking in hazardous situations 
3. Continued drinking despite alcohol-related social or interpersonal problems
4. Evidence of tolerance
5. Evidence of alcohol withdrawal or use of alcohol for relief or avoidance of withdrawal
6. Drinking in larger amounts or over longer periods than intended
7. Persistent desire or unsuccessful attempts to stop or reduce drinking
8. A great deal of time spent obtaining, using, or recovering from alcohol
9. Important activities are given up or reduced because of drinking
10. Continued drinking despite knowledge of physical or psychological problems caused by alcohol
11. Alcohol craving

Severity: The severity of alcohol use disorder at the time of diagnosis can be specified as a subtype based on the number of symptoms present: 

• Mild: Two to three symptoms    
• Moderate: Four to five symptoms
• Severe: Six or more symptoms

Laboratory Testing

Alcohol

Diagnosis of an alcohol problem can be made in the outpatient department by using the CAGE questionnaire, which includes the following: (need to) cut down, annoyance (on drinking), guilt (about drinking), and an eye-opener.

Screening tools like the ten-question Alcohol Use Disorder Identification Test (AUDIT) and the abbreviated 3-question Audit-consumption (Audit-C) are recommended for screening.

Laboratory tests to confirm the diagnosis include:

• Serum alcohol concentration
• Direct alcohol biomarkers: ethyl glucuronide
• Liver enzymes: aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin, and albumin to test for liver damage. An AST: ALT ratio of 2 to 1 is indicative of alcohol-induced liver disease.
• Hemoglobin and complete blood count to determine the presence and severity of anemia, pancytopenia, and macrocytosis. A mean corpuscular volume greater than 100 fL constitutes macrocytosis. Pancytopenia and macrocytosis usually require very heavy, prolonged use and often liver disease.
• Gamma-glutamyltransferase (GGT) –  an indicator of excessive alcohol use when elevated. The reference range is 8 to 40 IU/L (females) and 9 to 50 IU/L (males).
• The patient's social network, especially family, should be involved in treatment to the extent possible (and agreed to by the patient, if a legally competent adult), provide additional history and therapeutic support, and help monitor the patient's progress and adherence to treatment.

Substance Use Disorder

• Drug of abuse screen
• Urine drug levels
• Blood drug levels
• Hair drug levels
• Saliva drug levels
• Breath drug levels

Treatment / Management

Often, the evaluation and treatment of a health professional with alcohol or drug addiction are challenging. Typical treatment occurs over months to years and includes follow-up and monitoring, sometimes by legal entities. The most important predictor of successful treatment is when a healthcare professional admits the addiction and is willing to accept and stick with the prescribed treatment. In many cases, treatment is forced upon a health practitioner by a court or medical board or occurs due to peers, family, and friends encouraging therapy. Those who are self-motivated and have insight into their disease are much more likely to have a successful treatment outcome.[32][33][34](A1)

All healthcare providers need to be familiar with peer reporting requirements for alcohol or drug addiction within their institution and in their specific state. If someone suspects a colleague has an alcohol or substance use problem, they should refer the impaired health practitioner to the proper authority in your institution or state. In several states, reporting is required by law. In states where it is required, as long as reporting that is deemed false is not done with malicious intent, immunity is usually granted. Besides the state and institutional requirements, all health professionals have a duty to "first do no harm" and protect patients from the harm that might come from an impaired professional.

Do not wait until impairment affects performance; all health professionals must report at the first sign of impairment. This report should be considered an act of kindness as the short and long-term consequences are grave for health; an impaired health professional can harm a patient.[35]

Evaluation and Treatment Referral Programs

The following are some of the treatment options available to help alcohol and drug-impaired health professionals:

• Professional associations offer peer assistance programs to assist impaired professionals.
• State boards offer peer assistance programs and support for health professionals who voluntarily or through mandate seek counseling and treatment.
• Professional schools provide programs for their students.
• In Florida, Rule 64B31-10.001 pairs an impaired practitioner with a program or consultant to provide intervention, evaluation, and referral of impaired health professionals. The program monitors the impaired practitioner. No medical services are provided.[flrules.org, 2015]

The following are two types of programs:

1. State licensing boards operate practitioner programs for impaired health professionals with an impairment resulting in harm to patients.
2. Practitioner health programs are managed by societies, which seek to help health professionals with substance use issues before they harm patients or commit crimes.

Evaluation and treatment programs are state-licensed and accredited. Programs usually have a multidisciplinary team to manage the health professional. Services, depending on the degree of addiction, might be in either an outpatient or inpatient setting and are modified depending on the impairment affecting the health professional.

Treatment Techniques

Treating any patient for alcohol or drug use disorder is challenging, and it is more challenging if the treatment is under duress. Treatment usually involves the following steps:

1. Intervention: voluntarily, institution, or mandated by a licensing board
2. Evaluation: the health professional is evaluated to determine the degree of their impairment.
3. Setting: depending on their degree of addiction and whether they may or may not suffer withdrawal, the practitioner will be considered for inpatient or outpatient treatment.
4. Treatment: counseling, group therapy, or residential inpatient treatment program. In some cases, the health professional is hospitalized for a few days until withdrawal symptoms resolve.

Health professionals who accept their disease and are willing to undergo treatment generally have a high success rate. They are usually bright, have a history of high achievement, and have a will to succeed, which is typically a good sign for treatment success. The recovery rates for health practitioners are generally higher than the general population. Most health professionals who undergo intervention and treatment early and have not harmed a patient or committed a crime can retain their licenses and eventually return to clinical practice.

Florida Mandated Impaired Practitioner Treatment

Under Chapter 456, there are designated treatment program requirements for impaired practitioners.

In Florida, a health professional can avoid disciplinary action if they complete the following:

1. Admit the impairment
2. Voluntarily enroll in a treatment program
3. Withdraw or limit practice as prescribed by the impairment consultant managing the case
4. Release all medical records to the consultant managing the case

Florida Intervention Project for Nurses

In Florida, nurses can choose the Intervention Project for Nurses.[S. 456.076] This is a statutorily approved evaluation and treatment program approved for impaired nurses.[leg.state.fl.us, 2001] Intervention Project for Nurses consultants are designated via contract to initiate interventions, recommend evaluations, and refer those deemed impaired to appropriate treatment programs. The Intervention Project for Nurses also monitors the long-term care of the nurses in the program.

• All treatment programs in Florida must gain approval from the Intervention Project for Nurses.
• The Intervention Project for Nurses does not provide treatment; it only provides referral and monitoring.
• Programs include state-licensed psychiatrists, counselors, and addiction specialists who specifically treat healthcare professionals.
• Intervention Project for Nurses facilities hold a multidisciplinary state-license, and they may include outpatient, residential, partial, or complete hospitalization.
• Treatment programs are accredited through the CARF International or the Joint Commission.
• Treatment programs and providers must apply for and gain approval from the Intervention Project for Nurses.
• The Intervention Project for Nurses provides a list of available programs and providers.
• Additional information can be found on the state board website: floridasnursing.gov, 2018.

Types of Treatment Programs

Intensive Outpatient Programs

These programs provide regular, intense treatment but limit the disruption to family, school, or work schedules. The practitioner typically stops practice until successful treatment is completed and they have reached the stage of monitoring where they are allowed to return to patient care. Outpatient licensed counselors usually meet with the practitioner for several hours multiple times each week.

Residential Programs

These programs are typically located within a hospital or a specialized facility. Patients live in a highly structured environment. Typically, patients live in the facility for 30 to 90 days. In the early phase, they may undergo medical withdrawal and detoxification. Eventually, these patients transition to outpatient programs.

Partial Hospitalization Programs

Includes regular intensive daily sessions, usually five days per week, but the patient does not stay overnight.

Institutional Programs 

An employer may mandate an employee to obtain treatment for impairment or face reporting and termination. Some employers offer addiction assistance programs to help with alcohol or drug problems. Programs often include:

• Health promotion
• Education
• Referral to treatment centers
• Treatment
• Often employer paid

It is expensive for an employer to hire and train a health professional. Employers are often willing to assist employees with the help they need to maintain their jobs and careers. By treating an employee, the employer will save the cost of replacing the employee, avoid accidents that harm patient safety and cause liability issues for the institution, decrease absenteeism, and avoid worker compensation claims.

• Many institutions will provide general education to employees regarding the use of alcohol or drugs. For example, they may educate employees on avoiding binge drinking as it results in hangovers, which impair performance and cognitive function. Much like pilots who do not drink 12 hours before a flight, it is similarly vital for a medical professional to avoid alcohol or drug consumption at least 12 hours before a shift.

• Other education programs may encourage employees to recognize the early warning signs and symptoms of alcohol and drug addiction and help early interdiction before developing serious complications.

• Employees are often instructed on how to identify impaired peers. Individuals who work with an alcohol or drug-impaired individual are more likely to discover and report if they are trained in the signs and symptoms to suspect.

Drug and alcohol use are common problems for health professionals, particularly nurses and doctors. With the prevalence being high among health practitioners and the risk of consequences rising to career-ending, there is an increasing awareness of the issues. Further, the implications for patients may be life-threatening.

Fortunately, there is an increasing trend to recognize that individuals with alcohol and drug issues need evaluation and treatment instead of punitive sanctions.

All health providers need to recognize the signs and symptoms of substance use. There are appropriate tools to assist peers who need help. Together, healthcare providers can work toward improving patient safety and avoiding the permanent loss of a practitioner who has devoted years to their training.

Differential Diagnosis

In some instances, alcohol and drug use have an underlying organic or inorganic cause. Always consider the possibility that the impaired individual is using alcohol or illicit drugs to cover up one of the following:

• Psychosis
• Schizophrenia
• Mania
• Bipolar disorder
• Organic brain disorder
• Personality disorders

Prognosis

The prognosis depends upon whether the diagnosis was made early or late, the follow-up, the motivation of the healthcare professional with the identified impairment, and the success of cognitive behavior therapy. Individuals motivated to maintain their career and healthcare licenses are frequently more successful in their treatment and go on to lead productive careers.

Complications

Substance use leads to a number of problems, including accidents, death, health effects, crime, lower achievement, and safety risks for patients. Governmental and hospital staff should take steps to assist health professionals who admit to substance use.