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The sneaky prevalence of substance abuse in nursing

Starr, Kristopher T. JD, MSN, RN, FNP-C, CEN, CPEN

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doi: 10.1097/01.NURSE.0000460727.34118.6a
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IN ONE OF MY DEBUT pieces for this journal, I wrote about the 24/7 RN and the nature of nursing licensure—the fact that while you may leave work, your license doesn't have an on/off switch. You're responsible for behaving professionally and meeting your state board of nursing continuing-education requirements on your own time throughout your career.

If one takes a stroll through the continuing-education requirements for professional nurses state by state, you find some interesting mandatory education requirements. For instance, Kentucky requires education on pediatric abusive head trauma, while Texas mandates tick-borne illness education. The most fascinating for me was Nevada's requirement for 4 hours of bioterrorism education.

So, why the litany of education issues? Well, I found it revealing what Delaware and West Virginia have come to recently require of their RNs (and I do so enjoy singling out my home state). The focus of these two jurisdictions' continuing-education goals is “substance abuse.”

Now, for two states to address mandatory education on substance abuse, one might conclude some emerging drug or alcohol problem among RNs in these two states or, worse yet, nationally. So let's have a look at the evidence.

Using 2009 captured data, Monroe et al. suggested that less than 1% of employed RNs were working with a known substance abuse problem and that less than 1% of RNs were in active substance abuse treatment programs or alternative to discipline (ATD) diversionary programs.1

Less than 1% nationally doesn't immediately strike one as a burgeoning problem, does it? But recall that the data presented are based on reported cases. What's the evidence for unreported or suspected cases?

The American Nurses Association suggests that up to 10% of the RN work force may be dependent on drugs or alcohol.2 So these figures are a little more concerning.

The most disturbing statistical “potential” comes from Monroe and Kenaga, who suggest that between 14% and 20% of all RNs in the United States may have a problem with dependence or abuse of drugs and/or alcohol, which likely addresses the suspected prevalence of unreported substance dependence cases.3 One out of every 5 to 7 RNs is affected by substance abuse—now that grabs your attention.

Interested in what's happening here in my home state (remember, one of two that mandate substance abuse continuing education for RNs), I spoke to the executive director of the Delaware State Board of Nursing about substance abuse. She suggested that up to 35% of all new complaints to the Board for discipline center on substance use, dependence, or abuse issues.4 Thirty-five percent!

What does the addicted or diverting RN look like? Are there certain tell-tale signs that say “ah-ha, that RN has a substance dependence issue”? Here are some common concerns that should raise the red flag:

  • a staff member who looks disheveled or doesn't seem to care about his or her appearance, or who's “late, lazy, not timely, in a daze”5
  • opioid shift count errors that arise repeatedly when the same RN is on duty
  • an RN who often can't be located in his or her assigned area
  • an RN whose patients are scheduled for pain medication but fail to get them despite their being signed out of stock. Also consider the possibility of drug diversion if an RN's patients repeatedly fail to achieve the expected level of pain relief from their prescribed analgesics.5

So, why the doom and gloom about substance abuse? The reason is simple. Given the statistics presented, from 1 in 10 to 1 in 5 RNs may suffer from substance dependence or abuse issues.

Have you observed behaviors that concern you about one of your colleagues? And what about yourself—Do you need that drink or medication to get through to the next day, shift, moment? If you know any RNs who you suspect may have a problem, lead them to help if you can, or offer support and give guidance. Make sure you understand the mandatory reporting laws in your jurisdiction—you may be required to report any licensed healthcare professional you suspect is impaired from substance use.

If you recognize yourself in this article or someone has brought a concern about you to your attention, here's your chance to take hold of a situation that only promises to destroy the career that you've worked very hard to achieve and maintain.

Many state Boards of Nursing have ATD programs if the RN self-reports a substance dependence or abuse issue before a formal disciplinary complaint is filed. Urge those you're concerned about to take control of the situation before the issue winds up controlling them. Consider reporting yourself if the many pressures of life have steered you to an unhealthy, substance driven outlet. The power to change your life for the better, or for one of your colleagues, is all yours.


1. Monroe TB, Kenaga H, Dietrich MS, Carter MA, Cowan RL. The prevalence of employed nurses identified or enrolled in substance use monitoring programs. Nurs Res. 2013;62(1):10–15.
2. American Nurses Association. Position statements on abuse of prescription drugs and random health care worker drug testing.
3. Monroe T, Kenaga H. Don't ask don't tell: substance abuse and addiction among nurses. 2010;20(3–4):504–509.
4. Zickafoose P. Personal communication. December 3, 2014.
5. Thomas CM, Siela D. The impaired nurse: would you know what to do if you suspected substance abuse? 2011;6(8):e1.
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