The Nurse, The Addict

WHEN JOHN MARCUM (NOT HIS REAL NAME) REGAINED consciousness, his head ached from being slammed against the operating room floor. He could taste blood from nearly biting his tongue in half. The last thing the thirty-seven-year-old nurse could remember was anesthetizing a patient who required emergency surgery. The operation began just minutes after Marcum, thinking he was finished for the day, had mainlined 500 milligrams of Demerol into his right arm.

Three days later, Marcum woke up in intensive care. “1 was sure my career was as good as over,” he says. “But I really didn’t care about my career-or anything else-by then.”

As a nurse John Marcum knew that the drugs he injected, along with the 1,000 milligrams he had planned to use later that night, would have been fatal. The odds are he’s alive because he wasn’t alone when he sei2ured. Today Marcum is drug-free and working as a nurse. He credits his recovery to treatment he received in Fort Worth’s CareUnit Hospital-a psychiatric facility with a special program for the chemically dependent nurse.

According to Clair Jordan, executive director of the Texas Nurses Association, some 16,000 of the 200,000 Registered Nurses and Licensed Vocational Nurses in Texas are dependent on alcohol or addictive drugs. That’s two out of every twenty-five nurses-a staggering figure to anyone who’s ever been in a hospital. Yet even that startling statistic is considered conservative by some nursing professionals. Says Deanna Alexander, a recovering alcoholic and drug addict who is a national activist in the movement to help chemically dependent nurses. “The gross loss of health care providers every year is equal to the output of three medical schools and ten nursing schools.”

Marcum fell into the trap of addiction much the way other substance abusers do. He started drinking when he was eleven; then he moved to marijuana and cocaine. By his early twenties, Marcum was married with two children, a full-time job, and a heavy college load. Although he always dabbled in drugs, it wasn’t until his demanding schedule slacked off, giving him more free time, that he became a heavy user.

With his easy access to drugs, Marcum may have fallen harder than the addict on the street. Drugs are the tools of his trade, and he is well-versed in dosages and side effects. When he needed to relax, he took a vial of Demerol home. When that wasn’t possible, he issued half a dose to his patient and saved the rest for himself.

Nurses like Marcum, Alexander, and others hope to focus attention on a problem they see as reaching epidemic status. But hospital administrators downplay the scope of the problem.

“Between 10 and 16 percent might be true in national surveys, but that is not true at Presbyterian,” says Barbara Woodard, associate executive director and chief nursing officer at Presbyterian Hospital. Presbyterian doesn’t follow the pattern, she says, because of a monitoring system that reduces the opportunity to use drugs and a new state-administered peer assistance program that addresses the problem of substance abuse among all employees. ’”Our program is as much for the protection of the individual patient as it is for the nurse,” Woodard says. “It would be very difficult to get past our monitoring system.”

The chemically dependent nurse, say those who have studied the problem, often conforms to a pattern. Typically, he or she is the first to work and the last to leave, always seeking out private moments to secure drugs. Drops of blood, the result of injecting through clothing, might stain an otherwise spotless uniform. The nurse is often irritable, restless, and easily provoked. Emotional outbursts are not uncommon.

Betty Worsham discovered early in her career that Demerol helped her cope with the pressure of working double shifts at a local hospital. “At first.” she says, “I dabbled in drugs during college. Later, after I got out of school, I only snorted cocaine on the weekends.” Then she discovered her drug of choice-Demerol, a prescription narcotic.

At first, she imposed her own criteria for using drugs. “’I didn’t want to risk having a car accident, so 1 wouldn’t ever drive home high,” she says. “And I didn’t use just any drug like some people do; morphine gave me headaches and made my neck stiff.”

After a while, her self-imposed restrictions became less important. She was injecting Demerol four to five times during her shift, then coming home to snort cocaine. To pay for an increasingly expensive habit, she began dealing drugs. “I’d stay high until four a.m., then I’d have a really hard time getting to sleep,” Worsham says. “So I’d take enough Valium to bring me down before I went to work.”

Within a few months, Worsham was so strung out on Valium and Demerol that every day became a struggle. If Worsham’s peers suspected that she was using drugs, she says, they never confronted her. Nor did they mention her slurred speech and unsteady gait. Worsham got caught only after a patient complained of continued pain after Wor-sham supposedly had given her pain medication. A physician, himself a recovering addict, became suspicious and reported Worsham to her supervisor.

Although her supervisor never confronted Worsham until the physician raised the red flag, Worsham says she displayed most of the classic symptoms. She wore long sleeves to hide the needle marks, and her eyes were frequently dilated. She withdrew from social activities, kept sloppy records, and was always the first nurse to arrive for her shift and the last to leave. She also took frequent breaks, often racing to the restroom where, with one foot pressed against the door, she injected a patient’s medication into her hip. Her patients received injections of water.

Worsham also was an overachiever, a characteristic often associated with chemically dependent nurses. While being an overachiever hardly goes hand-in-hand with ’ substance addiction, Alexander says impaired nurses typically excel in school, work hard, and hold supervisory’ positions.



IN ANOTHER SETTING, the symptoms of drug addiction might have signaled a red alert to an employer. But in a profession where nurses are considered caretakers, says Alexander, they do a very poor job of taking care of themselves or their peers. “Instead, a nurse is protected, promoted, transferred, or ignored,” she says, “and nurses keep on protecting each other until the drug user or alcoholic is half dead. Then we become a lynch mob.”

Ironically, harsh measures designed to protect the public have often hindered the identification of chemically dependent nurses. Though staffers who foiled to report their peers for drug abuse stood in jeopardy of losing their own licenses, few did so. When a supervisor did discover a nurse using drugs on the job, Alexander says, the nurse was often fired on the spot, rather than reported to the state boards. With her license still intact, the nurse was able to go from one employer to the next, covering up any signs of chemical dependency. Acute nursing shortages, according to Alexander, encouraged subsequent employers to overlook a suspicious job history. But the law is changing. This year, the Texas Nurses Association lobbied for a Peer Assistance Bill that could alter the way chemically dependent professionals are treated. The bill, sponsored by Sen. Chet Brooks, Pasadena, and Rep. Frank Madia, San Antonio, went into effect i September. But there is still much work ahead as a newly formed committee prepares to design, fund, and implement a peer assis-tance program throughout the state.

The bill, which went through six drafts before it was accepted, still lags dramatically behind similar laws that have protected physicians for years. And although the Peer Assistance Act provides the means for identifying chemically dependent nurses, it is not a cure. Many hospital administrators refuse to recognize the disease. Others simply don’t have the means or desire to implement impaired nurse policies in their hospitals. The new law, however, requires the licensing board to give a nurse the opportunity to participate in an impaired nurse program.

Nurses like Betty Worsham, who have gone full circle from addiction to treatment and then back to work, are providing the models the state can look to for examples of how successful peer assistance programs can be. Worsham is luckier than some, perhaps, because she has been allowed to return to the profession in which she has invested most of her adult life. But Worsham has paid an expensive price for her rehabilitation. As part of her return-to-work contract, she is required to keep detailed records of her progress and meet regularly with her supervisor and a nurse advocate. She must also submit to random urine or blood samples in the presence of a qualified witness and attend Alcoholics Anonymous or Narcotics Anonymous meetings several times a week. Every week Worsham also attends the Impaired Nurses Support Group in an Arlington church, the first of its kind in Texas. Dean-na Alexander, who founded the group in 1983, leads the discussions.

The Impaired Nurses Support Group is loosely modeled after the support groups that physicians have attended for years. The non-denominational meetings begin and end with a prayer like Alcoholics Anonymous meetings, and participants frequently talk about a twelve-step approach to sobriety.

Alexander started the support group because she never felt comfortable discussing her drug problems at AA meetings. As a nurse she felt isolated from others whom she assumed took the attitude that she of all people should know better. But when she learned of other nurses in AA, she decided to form a peer support group, The first meeting attracted thirty-five nurses of all ages and backgrounds. Their only goal was to remain alcohol- and drug-free.

Today more than one hundred nurses, from eighteen to sixty-seven years old, belong to the Arlington support group, and new branches have opened recently in North Dallas and Richardson. Although males make up only 3 percent of the nursing population. 25 percent of the support group members are men. Alexander has not been able to pinpoint a reason for the higher number of male nurses in the group.



DURING A TYPICAL meeting, members discuss topics such as return-to-work problems, legal aid, and stress. They are supportive of each other, yet blunt when they believe a member is hiding his or her feelings. When someone is on the verge of relapse, members are quick to intervene. Hardly meeting goes by without tears, smiles, and words of encouragement. The anguish is shared by all when a member, distraught over a family crisis, tells why, after being drug-free for months, she reached for a syringe. When a young woman relates her disappointment over losing a custody battle, others respond sympathetically.

But the support group is but one stretch of the road back to normalcy. Detoxification- the withdrawal from alcohol or drugs-can trigger seizures and hallucinations, the shakes, abdominal cramping. And even after a nurse gets through detox, psychological pain remains. According to Alexander, 2 percent to 3 percent of nurses in recovery have an underlying psychological disorder (hat requires ongoing treatment; the others must learn to restructure their lives through total abstinence, education, and group support.

Inevitably, the nurses deal with feelings of rejection and guilt. While most insist they never endangered their patients’ lives, they’re less sure of the quality of their job performance. Certainly a narcotic slows a person’s reaction time, admits Marcum. But. he adds, once heavily addicted, a nurse may perform better when using a drug than when going through withdrawal.

Curiously, considering the magnitude of the problem as defined by the nursing groups involved, there have been few patient complaints relating to drug-dependent nurses. One reason may be a general ignorance of the problem. Though doctors and administrators say an occasional patient may complain of recurring pain after heavy doses of painkillers, few lay blame with the nurse.

Lobbyist Wayne Ewen says he knows of only one malpractice suit related to drug use, and that involved a doctor. But in a lawsuit-happy society, he adds, an immunity provision in the bill that protects any individual who reports a suspected nurse was important. “Without an immunity provision, people are afraid to get involved,” Ewen says.

Recovering nurses may find themselves caught in legal tangles with their employers over the issue of stolen or diverted drugs. And all nurses who complete treatment must go before the nursing board in Austin, where they face the possibility of probation or revocation of their license for varying periods of time. Those who return to their old jobs do so by virtue of a return-to-work contract.

In July of 1984, Parkland Memorial Hospital set an example for the entire health care community by implementing the first formal impaired nurse program in the area. Anita Daniel. R.N., director of nurse recruitment and retention at Parkland, began her Impaired Nurses Program with thirteen nurses and a commitment to the belief that no nurse should lose a job because of chemical dependency. Today, all but three continue to work at Parkland; only one was terminated. The return-to-work contract at Parkland requires nurses to submit to random toxicology screens every week, attend AA and Impaired Nurses meetings, and abstain from mood-altering drugs unless prescribed by their physician. Daniel also limits the amount of overtime a nurse works.

Although being among the first to establish a formal program to allow chemically dependent nurses to return to work is a bold move for Parkland, the number of nurses in the program hardly reflects the scope of the problem, Daniel feels. With more than 900 nurses at Parkland, thirteen participants represent only a scratch on the surface of the substance abuse problem. Nor are great numbers of nurses being reported to the RN or LVN Board of Nurse Examiners. During the past five years the number of cases involving substance abuse has increased by a hundred per year, according to Jordan, but it still reflects a general reluctance among nurses to report their peers.

The future, some nurses believe, looks brighter. Since Parkland started its program, thirty-five other health care institutions have followed. In addition, a Dallas nurse established Anesthetists in Recovery (AIR), a national support group with its headquarters in Dallas. Although anesthetists represent only a fraction of the nursing population, the percentage of anesthetists who use drugs is much higher. Statistics issued by AIR indicate that of the 23,000 anesthetists nationwide, one in seven uses drugs,

Despite great strides in the treatment ofchemical dependency, the day when allnurses can seek help without fear is still along way off. Devising a system for monitoring nurses will require a trial-and-errorprocess that the Peer Assistance Committeewill have to endure.