ALCOHOL AND DRUG

ABUSE AND ADDICTION

A HEALTH CARE PROFESSIONALS
RESOURCE GUIDE













Department of Health and Human Services
Division of Public Health - Licensure Unit
Nebraska State Office Building
301 Centennial Mall South Third Floor
P.O. Box 94986
Lincoln, NE 68509-4986 2011










TABLE OF CONTENTS

Introduction..1
Definitions....1
Understanding Addiction
Etiology..... . 2
Incidence...3
Physical & Behavioral Indicators of Alcohol or Drug Addiction.4-8
Reasons why Peers, Supervisors, Employers Dont Identify the Addicted Health
Care Professional......9

Intervention
Barriers to Intervention.10
Basic Principles to Intervention....10
NE Licensee Assistance Program.....11
Treatment/Educational Options........12

Return to Work
Guidelines..13
Sample Return to Work Agreement..... 14
NE Licensee Assistance Program Monitoring Agreement......15-16
Relapse Prevention Issues.17

Mandatory Reporting....18

Community Support Contacts and Additional Resources........19

References.....20



Department of Health and Human Services
Division of Public Health
Licensure Unit
PO Box 94986
Lincoln, NE 68509-4986
(402) 471-2115
http://dhhs.ne.gov/crl/chemguide.pdf
1
INTRODUCTION:

This resource guide was developed by the Nebraska Department of Health and Human Services,
Division of Public Health, Licensure Unit and the Nebraska Licensee Assistance Program (NE
LAP) for the purpose of providing information about alcohol and drug abuse and addiction
disorders and health care professionals. This guide provides information on how to recognize
the signs and symptoms of abuse or addiction, prevention intervention, treatment and return-to-
work considerations, recovery, and relapse.

The information presented in this guide is intended to be an educational tool and is not mandated
as regulation by the Department of Health and Human Services, Division of Public Health,
Licensure Unit.



DEFINITIONS:

Substance Use: A reasonable ingestion of alcohol or a mind-altering drug, for a clearly defined
beneficial purpose, that is regulated by that purpose

Substance Misuse: Inappropriate use of any substance, such as alcohol, a street drug or misuse
of a prescription or over the counter drug

Substance Abuse: Unreasonable ingestion of a mind-altering substance that causes harm or
injury to the health care professional

Addiction: A compulsive or chronic need for, or an active addiction to, alcohol or drugs

Enabling: The reactions or behaviors of family members, friends or co-workers that shield the
health care professional from the harmful consequences of their alcohol and/or drug use

Intervention: Helping a health care professional who is in denial as a result of his or her
addiction, recognize their need for help and treatment

Treatment: Education, counseling, structured programs and recovery groups designed to
overcome alcohol and drug abuse and arrest addiction

Recovery: A voluntarily maintained lifestyle characterized by sobriety, personal health, and
citizenship

Sobriety: Abstinence from alcohol and all other non-prescribed drugs

Relapse: A recurrence of the use of alcohol or drugs and the symptoms of addiction after a
period of sobriety
2
UNDERSTANDING ADDICTION:

Etiology

Research suggests that some of the population is genetically

predisposed to develop an alcohol or
drug addiction. Studies indicate that people identified as being addicted lack adequate production of
the brain chemicals dopamine and serotonin. When the person is introduced to alcohol/other drug
use, they report feeling normal for the first time. These outside stimulants take the place of brain
chemicals that might be depleted or lower than normal.
There are also several factors in the environment

, which contribute to a person developing alcohol or
drug addiction. Availability and accessibility of mind-altering drugs are two strong environmental
factors.
A psychological

factor focuses on a persons psychological needs. The person uses alcohol or drugs
to self-medicate emotional voids, such as sadness, loneliness and depression.
There is no reliable way to predict who will develop an alcohol or drug addiction. There is no
typical personality or set of physical attributes. There are also many health care professionals who
are susceptible to developing an addiction.

Individuals do not necessarily become addicted to a certain substance. However, they can become
addicted to the feeling it produces and will seek out the same or similar substance to get the same
feeling.

Addiction is a primary disease

. It has specific symptoms and is not to be confused with stress, poor
relationships, or unmanageable work demands.
Addiction is progressive

. If left untreated, the symptoms of the disorder will worsen.
Addiction is a chronic

relapsing disorder and it cannot be cured. Like many other disorders, the
symptoms of addiction can be temporarily stopped, but without significant lifestyle changes and
continued recovery maintenance, the symptoms will reoccur.
Addiction can be fatal. Many alcohol or drug overdoses, deaths by accident, and suicides involve an
individual who has an addiction. Additionally, long-term use of alcohol or drugs can affect certain
body systems or organs and lead to illness and death.
3

Incidence

Addiction affects a significant number of health care professionals. Limited data is available on the
rates of incidence because abusing or addicted health care professionals rarely report abuse or
addiction accurately for fear of disciplinary action against their license to practice. It is also difficult
to gather accurate statistics because employers often fail to recognize the signs and symptoms of
these disorders. Available literature on the subject estimates that between 10% to 15% of health care
professionals are afflicted with alcohol or drug addiction.

Health care professionals are at particular risk for alcohol/drug abuse or addiction for many reasons.
Drugs are one of the primary tools used by health care professionals to treat and help their patients.
They prescribe, administer and dispense medications every day. Exposure and accessibility to mind-
altering medications, pharmacological knowledge of the drugs which fosters a false sense of control,
and a tendency to self-treat or self-medicate are a few contributing factors.

When health care professionals find themselves in need of relief from pain and emotional stress,
they may find themselves self-prescribing or diverting medications from patients or from drug
supplies. If health care professionals do not suffer any negative consequences while self-medicating,
they may start doing it on a regular basis. When self-medicating, the health care professional
convinces himself/herself, Its only going to happen once. Unfortunately, without treatment of the
underlying causes for the self-medication, the drug use continues and escalates.

Many health care professionals do not receive the appropriate intervention and treatment needed due
to the lack of proper identification of abuse or addiction. Data gathered from reporting state agency
disciplinary action reports show that a majority of health care professional license revocations are
related to alcohol or drug addictions.
4

Physical and Behavioral Indicators of Alcohol or Drug Addiction:

There is no single indicator for a diagnosis of alcohol or drug addiction. If an indicator is
present, then others are usually present also.



Personal
Deteriorating personal hygiene
Multiple physical complaints
Accidents
Personality and behavior changes
Many medication prescriptions for self and/or family members
Emotional or mental crises
Deceit, lying, or denial


Using behaviors excused by family and friends
Home and Family
Drinking or using activities are a priority
Emotional outbursts, arguments or violence
Hiding use of alcohol or drugs
Fragmentation of family and eventual withdrawal from family
Neglect or abuse of children
Abnormal, illegal, or anti-social actions of impacted children
Sexual problems or misbehavior
Unexplained absences from home
Extramarital affairs
Separation or divorce
5



Observable decline in physical or emotional health
Medical/Physical
Atypical weight changes
Pupils either dilated or constricted; face flushed or bloated
Drug seeking behaviors, such as seeking medical treatment for migraines, back or
other pains or illnesses.

Emergency-room treatments: overdose, cellulitis, gastrointestinal problems,
systematic infections, unexplained injuries and accidents.

Inability to mentally focus and keep track of a conversation
Shakiness, tremors of hands, agitation
Slurred speech
Unsteady gait, falls
Runny nose and constant sniffling
Nausea, vomiting, diarrhea












6


Isolation from normal social relationships
Friends and Community
Embarrassing social behavior
Driving while intoxicated or drug impaired
Alcohol/drug related legal problems
Neglect of social commitments
Unpredictable behavior, such as impulsive spending or missing dates with friends

Workaholic behavior
Office/Health Care Practice Setting
Disorganized schedule
Unreasonable workplace behavior
Inaccessibility to patients and staff
Frequent trips to the bathroom or other unexplained absences
Decreased workload or workload intolerance
Excessive drug prescriptions and supplies
Excessive ordering of drug supplies
Frequent complaints by patients or clients regarding the professionals behavior, such
as professional manners or treatment disputes

Prolonged breaks from work station or work setting
Frequent absences or illness
Sporadic punctuality

7


Unsatisfactory documentation performances
Office/Health Care Practice Setting (continued)
Withdrawal from professional committees or organizations
Defensive if questioned or confronted
Less creativity; coasting on reputation from previous work
Questionable practice judgment
Short absences from the work setting followed by inadequate or elaborate
explanations

Alcohol on breath with attempts to cover with mints or mouthwash
Observed occurrences of intoxication, drowsiness, or hypersensitivity during work
hours

Deadlines barely met or missed altogether
Illogical or sloppy documentation with regard to accountability of controlled
substances

Increased interest in patient pain control
Patient complaints of ineffective pain medications
Discrepancies in treatment orders, progress notes and medication records
Frequent incorrect medication or narcotics count
Appearing at the workplace on days off



8

Frequent job changes or relocations
Other Professional Problems
Impatience for state licensure by endorsement prior to verification of credentials
Unusual medical history
Vague letters of reference
Inappropriate or inadequate qualifications
Deterioration of professional reputation
Increasing malpractice claims
Licensure issues

The most critical component in identification of addiction is to identify the personal and practice
baseline from which a person has normally functioned. Negative behaviors and practice that clearly
move away from the individuals baselines are common indicators of addiction, especially if they appear
related to use of alcohol or drugs. Health care professionals will work to maintain their personal, family,
and professional standards, and may continue functioning successfully for a long time in spite of their
active addictions. Eventually, they will reach a point of personal or practice deterioration that is
impossible to ignore.
9


Reasons why Peers, Supervisors, or Employers Dont Identify Health Care
Professional Addiction

Uncertainty or disbelief about signs and symptoms
Reluctance or refusal to identify signs and symptoms
Hoping that things will get better
To avoid the licensure or legal sanctions for the professional that might occur
The risks of involvement with an addicted colleagues case
Enabling the addicted health care professionals behavior
a. Ignoring it
b. Covering up for it
c. Trying to protect him or her
d. Making excuses for him or her
e. Supporting the colleague by doing their work for them
10
INTERVENTION:

Barriers to Intervention
Many health care professionals do not understand their role in identifying the signs and
symptoms that indicate a co-worker or peer may have a problem related to alcohol or drug use.
Fear is the number one barrier for supervisors and colleagues. Thoughts of What if?, What if
Im wrong?, What if he/she denies it? and What will happen to them, or to me? are
common concerns when deciding whether or not to intervene. Supervisors and colleagues often
disregard the signs and symptoms due to a misconception that they must be able to prove alcohol
or drug abuse or addiction prior to an intervention. The goal of intervention is not to diagnose an
alcohol or drug problem, but to make sure a problem is recognized and dealt with for the well-
being of the professional and before a patient or client may be harmed.


Basic Principles of Intervention

Report unmistakable signs of abuse or addiction immediately to a supervisor, administrator, or to
Human Resources.

Document specific observations, including date, time, place, and practice or conduct
concerns

If appropriate, become familiar with the health care professionals practice baseline
Follow your workplace policy on reporting of practice or conduct concerns
Do not discuss suspicions with colleagues; follow workplace practices
11
Nebraska Licensee Assistance Program
If you are a health care professional with concerns about an alcohol or drug problem or concerns
about a colleague, contact the Nebraska Licensee Assistance (NE LAP), provided by the Best
Care Employee Assistance Program, for further guidance and assistance with your concerns.
The NE LAP will provide assistance in managing the situation and possibly conducting an
intervention. The NE LAP is an assessment, treatment referral, case management, monitoring,
and educational service designed to help licensees, certificate holders, and registrants of the State
of Nebraska work through alcohol or drug abuse or addiction problems.

The NE LAP offers health care professionals an opportunity to discuss alcohol or drug abuse
issues openly and confidentially with the professionally trained NE LAP Coordinator.

NE LAP office hours are Monday through Thursday, 8:00 a.m. to 8:00 p.m.; Friday 8:00 a.m. to
4:30 p.m.; and Saturday, 8:30 a.m. to 1:00 p.m. A 24-hour answering service is also available.
The NE LAP can be contacted by phone at (402) 354-8055 or (800) 851-2336 or visit the
website at www.lapne.org.
12
Treatment/Educational Options
Several levels of treatment and self-help recovery groups are available for someone who is alcohol
or drug dependent.

Inpatient/Residential Treatment: Inpatient treatment usually consists of a minimum inpatient stay
of at least 28 days and medical management of detoxification. Residential treatment provides
medical supervision of detoxification. The professional receiving inpatient or residential treatment
is removed from the availability of alcohol or drugs and daily outside distractions. This setting gives
the individual the time needed to focus on the task of understanding and accepting the addiction and
working on sobriety and recovery.

Extended Treatment: This type of treatment usually is recommended at the conclusion of a 28-day
inpatient or residential treatment program. This treatment option is very structured and can range in
length anywhere from two months to two years. During the period of extended treatment and
recovery, the individual moves into a halfway or three quarter way house and obtains employment
prior to completion of the program.

Outpatient Treatment: This type of treatment offers more flexibility and provides less disruption to
the individuals everyday life than residential or inpatient treatment. Those receiving treatment are
able to remain living in their home environment and may also be allowed to continue to work. The
individual receives treatment on a two to three hour, three to four days or evenings, basis at the
treatment providers facility.

Continuing Care/Aftercare: This type of treatment is a vital extension of the primary treatment
program and ranges from six months to one year in length. Continuing care usually involves one
weekly aftercare group meeting and may also include individual counseling sessions with an
alcohol/drug counselor.

Twelve-Step Meetings: Alcoholics Anonymous (A.A.) and Narcotics Anonymous (N.A.) are self-
help recovery groups and are an integral part of maintaining sobriety and a healthy recovery from
addiction. Generally, a minimum of at least two meetings per week are required throughout
treatment and continuing care programs.
13

RETURN TO WORK:

Guidelines

A health care professional who has received treatment or is in a structured treatment program for
alcohol or drug addiction should be returned to work under a monitoring plan that includes an
agreement on their treatment, recovery and work activities. The NE LAP can assist in setting up
a work site monitoring plan and coordinate the monitoring of the professionals compliance with
their treatment plan and progress. Monitoring improves the prognosis of recovery and rebuilds
trust in the professionals work capabilities.


A NE LAP monitoring plan generally addresses the following

:
1. Remaining treatment requirements
2. A recovery plan, including requirements for continuing care/aftercare and
documented attendance at Twelve-Step meetings and utilization of a sponsor

3. Utilization of a peer assistance program such as a Licensee Support Group, where
available

4. Regular phone or written progress reports to the NE LAP

5. Regular conferences between the workplace and NE LAP monitoring
coordinators

6. Random body fluid screens, with specifications on who is responsible for the cost
of screenings

7. Provision for re-evaluation and revisions of the plan.
The monitoring plan is customized according to the health care professionals field of practice,
work setting and personal and family factors.

14
SAMPLE RETURN TO WORK AGREEMENT



This agreement is to clarify expectations regarding the return to work of

_____________________________ at ________________________________.
(health care professional) (employer)

This agreement shall be in effect from ___________________, 20___, to ________________, 20___.

The contents of this agreement are mutually agreed upon and may be modified as agreed upon by both
parties.

I agree to the following:

1. Abstain from the use of all alcohol/other drugs and mind-altering substances. In the event that
medications may be needed as a part of my health care, I agree to notify my employer and provide
evidence of a prescription from a licensed medical practitioner. Over-the-counter drug use must also
be reported.

2. Abide by the monitoring agreement as set forth by the Nebraska Licensee Assistance Program (NE
LAP).

3. Random body fluid screening at the discretion of my employer or the NE LAP. Body fluid screens
will be paid for by______________________________ (employee/employer).

4. Work a schedule set by employer, ________days/hours as agreed to by both parties.

5. Not administer or have access to any controlled substances (or access to controlled substances only
under direct supervision of ___________________________.

I have read and understand the above agreement. I agree to abide by the terms listed. I understand that if
I fail to conduct myself according to this agreement, I will be subject to disciplinary action, up to and
including employment termination, and a report would be made to the Division of Public Health,
Investigations Unit.


_____________________________________ _____________________________
(Signature: Employee) (Date)

_____________________________________ _____________________________
(Signature: Employer) (Date)


(It may be necessary to modify this agreement to fit the individuals health care professional practice
and worksite requirements.)

15


NEBRASKA LICENSEE ASSISTANCE PROGRAM
Monitoring Agreement

I understand participation in the Nebraska Licensee Assistance Program (NE LAP) is voluntary and
during my participation I agree to take personal responsibility for adherence to and completion of the
following mutually agreed upon terms and conditions:

I, Name, agree to participate in the Nebraska Licensee Assistance Program (NE LAP) monitoring
program and to adhere to the rules and regulations set forth in this agreement. I understand that certain
criteria must be met in order to successfully complete the NE LAP monitoring program and I agree to
complete the following:
1. Abstain from all personal use or possession of any controlled substances and other prescription
drugs, or mind-altering substances unless prescribed or administered to me by a licensed
practitioner for a diagnosed medical condition. Advise all treating physicians, dentists, and other
licensed treating practitioners of my history of substance abuse/dependency, and of all substances I
am taking at the time of treatment.

Request that the licensed practitioner send the NE LAP a letter reporting the medical reason for the
use of any controlled substance and/or prescription drugs included in my treatment.

Report on a monthly basis to the NE LAP any controlled substance and other prescription drugs, or
mind-altering substances used by or administered to me. This monthly report does not need to be
submitted if I have not used a controlled substance or other prescription drugs. Failure to submit a
monthly report indicates that I have not taken any controlled substance or prescription drugs during
that month.

2. Abstain from the consumption of alcohol.

3. Notify the NE LAP Coordinator if I am hospitalized or must undergo any surgical procedures.

4. Report any changes of employment to the NE LAP Coordinator.

5. Complete continuing care/aftercare with Treatment Facility in City, Nebraska (six months
minimum if you completed intensive outpatient treatment and one year if you completed
residential treatment), including any additional treatment recommendations made by my provider
or the NE LAP.

6. Attend a minimum of two 12-Step meetings each week and maintain a meeting attendance
verification record. Submit the meeting verification record on a monthly basis to the NE LAP
Coordinator.

7. Obtain a Twelve-Step program sponsor and utilize my sponsor at least weekly for assistance with
working my recovery program.

8. Contact the NE LAP Coordinator by telephone at least one time a month, or more if requested, to
provide progress updates.

16
9. Submit a written quarterly report to the NE LAP Coordinator outlining my recovery activities and
progress.

10. Cease the practice of my profession upon relapse and notify the NE LAP Coordinator immediately.

11. Arrange a timely return for a reassessment with the NE LAP Coordinator, or affiliate provider
designated by the NE LAP, if there are relapse or non-compliance issues.

12. Meet all the requirements of my NE LAP monitoring program until I am discharged by the NE
LAP, generally at least one year, unless extended involvement is recommended by your provider or
the NE LAP.

13. Complete necessary authorizations to exchange information between NE LAP and my employer,
treatment providers, and others as requested.

14. Comply with my treatment providers, employers, or NE LAPs body fluid screen program.

15. Pay for the expenses incurred outside of NE LAP services which are my responsibility.


I have read, understand, and agree to the above terms of the NE LAP Monitoring Agreement.




______________________________________ _____________________
Licensee/Registrant/Credential Holder Date




_____________________________________ _______________________
NE LAP Coordinator/Witness Date
17
Relapse Prevention Issues


The health care professional returning to work after addiction treatment will face many transition
back to work stressors that may include:

Practice or licensure restrictions
Fear of criticism or avoidance by colleagues
Suspicions and mistrust of colleagues
Self-imposed stress, such as over-working or trying to make up for past mistakes
Personal stress from trying to meet work obligations and family responsibilities and
treatment and/or recovery commitments

The health care professional should return to a work schedule that is as accommodating for treatment
and recovery activities as possible. The treatment providers recommendations for work schedule
should be incorporated into the monitoring plan. Considering the additional demands of treatment
and recovery activities on the health care professionals time, work schedules (when at all possible)
should be restricted to a reasonable work week, generally no more than 40 hours. An overload of
personal and professional stress after the completion of treatment, a crucial time in the recovery from
addiction, can lead to a relapse.
18

MANDATORY REPORTING:

Mandatory reporting requirements were incorporated into the Uniform Credentialing Act (UCA)
December 1, 2008. The law applies to all professionals that were regulated by the former Bureau of
Examining Boards of the Nebraska Department of Health at the time the legislation was passed. The
regulations, 172 NAC 5 Regulations Governing Mandatory Reporting by Health Care Professionals,
Facilities, Peer and Professional Organizations, and Insurers, became effective May 8, 1995.

There are three specific requirements for reporting:

1. Reports must be made within 30 days of the occurrence/action
2. Reports must be made when a person has first-hand knowledge of an occurrence

3. Reports are confidential and persons making the reports are immune from criminal or
civil liability, except for those who self-report

All professionals must report persons who are practicing without a license. All professionals
must report professionals of the same profession for:

1. Gross incompetence or gross negligence
2. Patterns of incompetent or negligent conduct
3. Unprofessional conduct
4. Practicing while impaired by alcohol, controlled substances, mind-altering substances
or physical, mental, or emotional disability

5. Violations of other regulatory provisions of the profession
All professions are to report professionals of a different profession for:
1. Gross incompetence or gross negligence
2. Practicing while impaired by alcohol, controlled substances, mind-altering substances
or physical, mental, or emotional disability

There are also requirements for self-reporting, for reporting by health facilities, peer review
organizations, professional associations, insurers and courts.

All mandatory reports filed are reviewed to determine if an investigation will be conducted. All
investigation reports are taken to the appropriate board for review and decision regarding
disciplinary/non-disciplinary action.
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COMMUNITY SUPPORT CONTACTS:


Nebraska Licensee Assistance Program ....800-851-2336
Center Pointe Professional Plaza 402-354-8055
9239 West Center Road
Omaha, NE 68124-1977
www.lapne.org

Alcoholics Anonymous (AA) ....888-226-3632
www.AA.org (National)
www.Area41.org (Nebraska)



A1-Anon ...888-553-5033
www.Al-Anon.Alateen.org

Narcotics Anonymous (NA) Nebraska
www.na.org McCook..308-345-5839
www.nebraskana.org Scottsbluff..308-632-7603
Lincoln...402-474-0405
Omaha402-978-3105

Licensee Support Group Meetings (LSG)
Health care professional support group meetings are available in Lincoln and Omaha. The meetings
are confidential in nature and are based on the Twelve Steps. For more information regarding
meeting locations and times, contact J udi Leibrock, NE LAP Coordinator, by phone at 1-800-851-
2336 or 402-354-8055.


ADDITIONAL RESOURCES

Angres, Daniel Bettinardi-Angres, Kathy and Talbott, Douglas, G. (1998). Healing the Healer, The
Addicted Physician.

Psychological Press: Madison, Connecticut.
Corley, Deborah M., Schneider, J ennifer P., and Richard Irons (2003). Embracing Recovery from
Chemical Dependency: A Personal Recovery Plan.

Gentle Path Press: Scottsdale, Arizona.
Coombs, Robert Holman (1997). Drug Impaired Professionals.

Harvard University Press:
Cambridge, Massachusetts and London, England.
Scimeca, Paula Davies, RN, MS (2008). Unbecoming A Nurse

. Sea Meca, Inc., Staten Island, New
York.
Scimeca, Paula Davies, RN, MS (2010). From Unbecoming a Nurse to Overcoming Addiction.
Sea Meca, Inc., Staten Island, New York.
20


REFERENCES:

Crosby, Linda, and Le Clair Bissell (1989). To Care Enough: Intervention with Chemically
Dependent Colleagues

. J ohnson Institutes: Minneapolis, Minnesota.
J ohnson, V.E. (1973). Ill Quit Tomorrow

. Harper & Row: New York.
McAuliffe, Robert M., and Mary Boesen McAuliffe (1975). The Essentials of Chemical
Dependency: Alcoholism and Other Drug Dependencies

. The American Chemical Dependency
Society: Minneapolis, Minnesota.
Sullivan, Eleanor, Bissell, L., and E. Addison-Wesley Williams (1988). Chemical Dependency in
Nursing: The Deadly Diversion

. Menlo Park, California.