Many signs of SUD are non-specific and may be observed among members of any group of those afflicted by SUD. What will be observed among individuals in a personal situation may also be observed in their employment environment. Some signs are especially relevant in the workplace because they indicate an impaired ability to accomplish work tasks safely, efficiently, and correctly. Some workplace signs are especially noticeable or dangerous in the nursing field.

Complicating the issue is that signs of SUD can be conflated with those from stress (Alunni-Kinkle, 2015), or may indicate a different problem, and they vary to some extent depending on the person’s drug of choice (eg, alcohol vs. opioid). In addition, some signs will be specific to certain nursing specialties.

When considering all the various charts and checklists, it can seem as if almost anything can be a warning sign of substance use disorder. In the end it may help to look at the big picture: what is the sum of the various signs and how do they compare to the nurse’s baseline behavior? We need to observe carefully and document objectively.

As one nurse-writer observed, nurses tend to take extra care to avoid detection, and so may not manifest drug use in the same way as the disheveled street-corner addict (Paton, 2017).

Behaviors

• Severe mood swings, personality changes, panic attacks, defensiveness, anger outbursts
• Frequent or unexplained tardiness, work absences, illness or physical complaints
• Elaborate excuses
• Underperformance
• Difficulty with authority
• Poorly explained errors, accidents or injuries
• Wearing long sleeves when inappropriate
• Confusion, memory loss, and difficulty concentrating or recalling details and instructions
• Visibly intoxicated – slurred speech, lack of coordination/moving unsteadily, smell of alcohol on breath; excessive use of mints, gum, mouthwash, or hand sanitizer
• Refuses drug testing
• Ordinary tasks require greater effort and consume more time
• Unreliability in keeping appointments and meeting deadlines
• Relationship discord or isolation (eg, professional, familial, marital, platonic)

Signs

• Physical indications (eg, track marks, bloodshot eyes)
  • Shakiness and tremors
  • Dilated or constricted pupils (opioids constrict)
  • Watery eyes and nose
  • Fatigue, falling asleep, or even blackouts
  • Frequent episodes of nausea, vomiting and/or diarrhea
  • Significant weight loss or gain
• Deterioration in personal appearance – but employed addicts may take special pains with appearance
• Found comatose or dead

Workplace specific signs and behaviors

• Lack of concentration, forgetfulness, and frequent errors
• Underperformance—not carrying a full load of work
• Frequently late, calls in sick, or leaves early
• Always on the job, work late, extra shifts (for drug access)
• Decreased quality of care and documentation
• Frequent absences from the unit (eg, excessive bathroom trips)
• Isolation from colleagues
• Signs indicating drug diversion (see next section) (Paton, 2017; AANA, 2016; WA DoH, 2016; Stone et al., 2016; Cares et al., 2014; Alunni-Kinkle, 2015; NCSBN, 2014, 2011; Monroe & Kenaga, 2010).

Note: While sources generally agree on the larger categories, they may provide many variations on examples within each category. There is a great deal of overlap in general behavior and signs with those that are workplace critical.

Indications of Drug Diversion

Behaviors

• Consistently uses more drugs for cases than colleagues
• Frequent volunteering to count narcotics, administer narcotics, relieve colleagues of casework, especially on cases where opioids are administered
• Consistently arrives early, stay late, or frequently volunteers for overtime
• Frequent breaks or trips to bathroom
• Heavy wastage of drugs
• Drugs and syringes in pockets

Signs

• Patient complaints of ineffective pain relief or patient has unusually significant or uncontrolled pain after anesthesia
• Anesthesia record does not reconcile with drug dispensed and administered to patient
• Times of cases do not correlate when provider dispenses drug from automated dispenser
• Inappropriate drug choices and doses for patients
• Missing medications or prescription pads
• Drugs, syringes, needles improperly stored
• Signs of medication tampering, including broken vials returned to pharmacy
• Inaccuracies in controlled substances noted when a particular nurse works
• Signatures and initials appear forged
• Controlled substances signed out for patients with no orders
• Excuses about shared access codes or forgetting to get witness signatures (AANA, 2016; Stone et al., 2016; Cares et al., 2014; NCSBN, 2011).

Note: As with other lists, sources display a great deal of overlap but vary in their examples. In some cases, this is due to special issues in certain practice areas such as anesthesia.

Consequences in the Workplace

“Diversion” means the transfer of a controlled substance from a lawful to an unlawful channel of distribution or use.

Uniform Controlled Substances Act (1994)

“Diversion” means “any criminal act involving a prescription drug.”

National Association of Drug
Diversion Investigators

In 2016 the American Association of Nurse Anesthetists (AANA) released a comprehensive position statement on SUD for anesthesia professionals. It includes an important discussion of the many consequences of drug diversion (drug theft) and SUD in the workplace.

Because nurses have a duty to protect their patients’ safety and work unimpaired, a failure to do so can have far reaching consequences for patients, the nurse, other colleagues, families and friends, the facility, and even the wider community. Impaired practice can poison a work environment with mistrust that potentially affects patient care on a larger scale.

The AANA identified the following categories of consequences:

Patient

• Undue pain, anxiety, side effects from improper dosing
• Allergic reactions to substituted drugs
• Infections from contaminated needles or drugs
• Victim of medical errors (eg, medication, procedural)
• Loss of trust in the healthcare system

Impaired professional

• Adverse health effects (respiratory depression, organ failure, death)
• Chronic health effects (liver impairment, heart disease
• Infections from unsterile drugs, needles, injection techniques
• Accidents resulting in physical harm
• Familial and financial problems
• Loss of social statues
• Decline in work performance and professional instability
• Felony prosecution, prison, civil malpractice
• Actions against license
• Billing or insurance fraud

Colleagues

• Injury or infection from improperly stored equipment (needlesticks)
• At risk for medical/legal secondary liability
• Stress from increased workload
• Disciplinary action for failure to report or false witness

Facility

• Costly investigations
• Loss of revenue from diverted drugs or reimbursement for adverse events
• Poor quality work and need to compensate for other employees
• Civil liability re: drug diversion
• Civil liability for patient harm
• Damaged reputation
• Increased worker’s compensation cost costs (AANA, 2016)

Similar concerns and risks have been raised on the Centers for Disease Control and Prevention (CDC) Safe Healthcare Blog (CDC, 2014, 2014a) and found in ongoing research at the Mayo Clinic (Berge et al., 2012). While some may think that drug diversion is a victimless crime, it is in reality a multi-victim crime. It can harm diverters themselves but also their patients and co-workers and can affect the reputation of their employer (Berge et al., 2012).

The CDC identifies several types of patient harm that can result from drug diversion including:

• Substandard care delivered by an impaired healthcare provider,
• Denial of essential pain medication or therapy, or
• Risks of infection (eg, with hepatitis C virus or bacterial pathogens) if a provider tampers with injectable drugs.

The CDC is especially concerned with the possibilities of disease outbreak due to drug diversion activities. Between 1983 and 2013 it identified 9 outbreaks—4 bacterial and 5 of Hepatitis C virus—directly tied to drug diversion activities of healthcare professionals, 3 of them nurses. These incidents each demonstrated gaps in prevention, detection, or response to drug diversion at the relevant facilities and indicate the need for stronger controls and prevention measures (CDC, 2017).