FL: Impairment in the WorkplacePage 4 of 11

2 Substance Use Disorder

The term substance use disorder (SUD) covers everything from abuse to dependency or addiction* to alcohol or drugs. Substance use disorder affects all economic classes, ages, ethnicities, genders, and any other labels. It is a progressive and chronic disease that can result in death if left untreated. However, while it cannot be cured, it can be effectively managed and treated (NCSBN, 2011; SAMHSA, 2017, 2015; Crowley et al., 2017).

*Compulsive use of chemicals, and inability to stop using them despite the myriad of negative consequences.

Substance use disorder has historically been seen as a problem stemming from the use/abuse of substances such as drugs or alcohol. Users were seen as lacking willpower or personal responsibility and their behavior as a “moral failing.” Medical research has advanced our knowledge of how alcohol and drugs affect the brain, temporarily and permanently, and addiction came to be understood as a “chronic, relapsing brain disease.” But that disease does not affect everyone in the same way and it operates in a complexity of factors, including behavioral and social, that need to be considered in both prevention and treatment (Crowley et al., 2017; Volkow et al., 2016; Strobbe & Crowley, 2017).

Although our understanding has changed, the older views and stigma often persist and still have the power to interfere with seeking help for drug use issues and dealing with responses from family, friends, colleagues, and society at large. Research has shown that policies and programs based on the older beliefs and attitudes are often ineffective, while newer programs that take into account the brain disease model and the web of factors have demonstrable success (Crowley et al., 2017; Strobbe & Crowley, 2017; NCSBN, 2011).

Abuse, Dependence and Addiction

The Center on Addiction (formerly the Center on Addiction and Substance Abuse [CASA] at Columbia University) defines the difference between alcohol or drug abuse and addiction as one of severity. Abuse is a mild substance problem with a person exhibiting 2 or 3 symptoms of addiction. Abusers may experience serious problems related to their substance abuse but are able to “stop using or change their pattern of use without progressing to addiction” (COA, 2018).

This follows the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) where the term substance use disorder (SUD) has replaced both substance abuse and substance dependence in the terminology and SUDs are defined as mild, moderate, or severe determined by the number of diagnostic criteria met by an individual (SAMHSA, 2015; Volkow et al., 2016).

Substance use disorders “occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school or home” (SAMHSA, 2015). Diagnosis will consider evidence of impaired control, social impairment, risky use, and pharmacological criteria (SAMHSA, 2015).

Risk and Protective Factors for SUDs

Risk factors are “characteristics at the biological, psychological, family, community, or cultural level that precede and are associated with a higher likelihood of negative outcomes.” Protective factors are those “associated with a lower likelihood of negative outcomes or that reduce a risk factor’s impact” (SAMHSA, 2015a).

Some factors remain fixed over time, while others may change. For example, genetic predispositions will not change, while factors such as income status, peer group, or employment status can vary over time. Neither risk nor protective factors exist in isolation; both operate within relationships, communities, and the larger society and can be affected by many things such as community resources, local norms and laws, and family violence or family support (SAMHSA, 2015a; HHS, 2016).

General risk factors, which tend to make any individual more susceptible to developing an SUD, include:


  • Depression
  • Anxiety
  • Low self-esteem
  • Low tolerance for stress
  • Other mental health disorders (such as learning disabilities)
  • Feelings of desperation
  • Loss of control over day-to-day circumstances
  • Feelings of resentment


  • Use of other substances
  • Aggressive behavior in childhood
  • Conduct disorder (social personality disorder, avoidance of responsibilities, impulsivity and risk-taking, alienation, and rebelliousness)
  • Reckless behavior
  • School-based academic or behavioral problems (ie, dropping out)
  • An involvement with the criminal justice system
  • Illegal behaviors
  • Poor interpersonal relationships


  • An early age of the first abuse
  • Alcohol and drug use by peers
  • Social or cultural norms condoning abuse
  • Faulty expectations about the positive effects of drugs and alcohol
  • An availability of drugs or alcohol


  • Male gender
  • Inner city or rural residence combined with a low socio-economic status
  • Lack of employment opportunities


  • Abuse of alcohol and drugs
  • A family dysfunction such as inconsistent discipline
  • A lack of positive family rituals and routines
  • Poor parenting skills
  • Family trauma (such as a death or divorce)


  • Inherited predisposition to alcohol or drug dependence
  • Deficits in natural neurotransmitters (such as serotonin)
  • An absence of aversive reactions such as flushing or palpitations (NCSBN, 2011; SAMHSA, 2015a; HHS, 2016; NCSBN, 2011).

Note: While sources essentially agree on the larger categories, they may provide variations on examples within each category.

Just as with risk factors, protective factors operate in various realms—personal, family, social, community—and in some cases will vary across a lifetime affected by gender, age, and ethnicity. Protective factors can include intelligence, easy temperament, and positive self-image; positive parenting and supportive early childhood experiences; cultural ties and participation; religious and spiritual connections; and good social relationships.

Protective factors (like risk factors) may cluster together and can lower the possibility of negative outcomes or reduce the negative impact of a risk factor, but neither protective nor risk factors are guarantees of outcome in and of themselves. Individuals, institutions, work groups, and communities can take steps to reduce risk factors and they can take steps to increase protective factors. Improving personal health and learning about risk factors, establishing organizational fairness and transparency while offering health promotion resources, team support for high standards, providing timely feedback, and colleague debriefings are among the many positive actions that can be taken (Smith, 2017; NIDA, 2016; SAMHSA, 2015a; Red Lake Chemical Health, 2013).

Risk and Protective Factors for Nurses

Nurses are, of course, subject to any of the risk and protective factors already discussed, but research shows that “risk factors unique to a nurse’s workplace can predispose them to developing a substance use disorder.” Some research even cites addiction and substance abuse as occupational hazards for healthcare professions. Certain nursing specialties, including emergency department, psychiatric, oncology, and anesthesia, have higher rates of certain types of substance use disorders, and because these higher rates are seen among physicians in those specialties as well, there may be common factors (NCSBN, 2011).

In a 2014 research project, 65% of respondents to the project survey believed that greater emphasis during nursing professional training on how to make early identification of risk factors was the most important strategy to help prevent substance abuse (Cares et al., 2014).

For nurses, risk factors include:

  • Role strain (burnout, work overload, inadequate support
  • Problems of daily living), loss of significant other, poor coping skills, insecurity, isolation
  • Enabling by peers and managers—symptoms overlooked
  • Attitudes towards drugs and drug use
  • Lack of education regarding a substance use disorder
  • Lack of controls
  • Physician prescribing practices (NCSBN, 2011)

Researchers have also identified five particular attitudes that can cause problems for nurses and increase the likelihood of developing a substance use disorder. These include:

  • Substance use is an okay way to cope with life’s problems and a means to enjoyment, comfort, and getting along
  • “Pharmacological optimism” that can come from training that emphasizes a faith in what drugs can do and seeing positive effects of them on patients
  • A sense of entitlement that one must work and substance use is an acceptable means to that end
  • Invulnerability that health care providers sometimes feel to the effects of illnesses their patients have or the inability to see themselves as the recipients of care
  • Using training to self-diagnose and self-medicate in order to keep working, with the stress and fatigue leading again to see the means justifying the end (NCSBN, 2011)

Curiously, there is often a real lack of education among nurses about how addiction works and how to recognize its signs. The occupational hazard of readily available drugs when combined with poor management (a failure to observe secure control and administration of controlled substances within a workplace) can add to the risks for nurses and other healthcare workers. Loose prescribing practices for narcotics can create an additional risk and may manifest itself as a nurse who self-diagnoses and then gets a physician friend to write a prescription.

In its comprehensive resource guide, Substance Use Disorder in Nursing, the National Council of State Boards of Nursing (NCSBN) identifies the top four risk factors for nurses in the workplace as “access, attitude, stress, and a lack of education” (NCSBN, 2011).

Protective factors for nurses have been much less well studied. Obviously, all the protective factors previously discussed can benefit nurses as well. Improving personal health and health knowledge are especially relevant, and the team and organizational protective factors are critical. Research has shown that, among nurses, beliefs in the values and norms of society, school and religious beliefs, and strong early attachment to a parent are all protective, as are work satisfaction, workplace social support, and workplace constraints regarding substance use. As will be discussed later, protective factors come into play in building an occupational environment that supports a strong recovery program for those working to overcome substance use disorder (NCSBN, 2011; Smith, 2017).

Back Next