SUBSTANCE USE DISORDERS: NEW GUIDELINES NCSBN- INSTITUTE OF REGULATORY EXCELLENCE JANUARY 16, 2013.

SUBSTANCE USE SUBSTANCE USE DISORDERS:DISORDERS:

NEW GUIDELINESNEW GUIDELINES

NCSBN- INSTITUTE OF NCSBN- INSTITUTE OF REGULATORY EXCELLENCEREGULATORY EXCELLENCE

JANUARY 16, 2013JANUARY 16, 2013

NCSBN COMMITTEE- 2008-NCSBN COMMITTEE- 2008-20102010

• REVIEW AND DEVELOP BEST REVIEW AND DEVELOP BEST PRACTICES FOR ALTERNATIVE TO PRACTICES FOR ALTERNATIVE TO

DISCIPLINE PROGRAMS AND DISCIPLINE PROGRAMS AND DISCIPLINE MONITORING PROGRAMSDISCIPLINE MONITORING PROGRAMS

NEW GUIDELINES NEW GUIDELINES

Nancy Darbro, PhD, CNS, RNNancy Darbro, PhD, CNS, RN

New Mexico Board of NursingNew Mexico Board of Nursing

Executive DirectorExecutive Director

Why alternative and Why alternative and discipline monitoring discipline monitoring

programs?programs?• High percentage of state board High percentage of state board

discipline cases deal with substance discipline cases deal with substance use issues (Smith & Hughes, 1996)use issues (Smith & Hughes, 1996)

• Cost effective and rehabilitative optionCost effective and rehabilitative option

• Provide intense scrutiny of compliance Provide intense scrutiny of compliance and public protectionand public protection

• Alternative programs have been Alternative programs have been functioning for over 20 yearsfunctioning for over 20 years

Why alternative and Why alternative and discipline monitoring discipline monitoring

programs?programs?• Most nurses with substance use disorders Most nurses with substance use disorders

are not identified in the workplaceare not identified in the workplace

• Most nurses with substance use disorders Most nurses with substance use disorders are not reported to regulatory agenciesare not reported to regulatory agencies

• Nurse who are reported often practice for Nurse who are reported often practice for long periods during investigationlong periods during investigation

• 10% nurses needing treatment won’t get it10% nurses needing treatment won’t get it

Why alternative and Why alternative and discipline monitoring discipline monitoring

programs?programs?• 90% of nurses with substance use 90% of nurses with substance use

disorders remain unidentified, disorders remain unidentified, unreported, untreated and continue unreported, untreated and continue to practice (Gossop et al., 2001; to practice (Gossop et al., 2001; Tighe & Saxe, 2006; McCabe, Tighe & Saxe, 2006; McCabe, Cranford, West, 2008) Cranford, West, 2008)

• Most who enter treatment do so due Most who enter treatment do so due to external pressure or coercionto external pressure or coercion

3 General Types of 3 General Types of programsprograms

• Alternative to discipline with Alternative to discipline with statutory authority under Bon (57%)statutory authority under Bon (57%)

• Peer assistance programs under Peer assistance programs under state nursing associations (39%)state nursing associations (39%)

• Discipline monitoring with consent Discipline monitoring with consent order or voluntary surrender of order or voluntary surrender of licenselicense

Types of alternative Types of alternative programsprograms

• 1. Model A. statutory authority under 1. Model A. statutory authority under BONBON

Model B. statutory authority under BON Model B. statutory authority under BON

contracted to an outside agencycontracted to an outside agency

Model C. Special committee of the BONModel C. Special committee of the BON

• 2. Model D. Peer assistance program of 2. Model D. Peer assistance program of

state nursing association instate nursing association in

collaboration with BON collaboration with BON

Types of alternative Types of alternative programsprograms

• Model E. Peer assistance program of Model E. Peer assistance program of state nursing association with no state nursing association with no collaboration with BONcollaboration with BON

• Model F. Employee assistance Model F. Employee assistance program program

with no collaboration with BONwith no collaboration with BON

Types of disciplinary modelsTypes of disciplinary models

• 3. Model E. Consent order for 3. Model E. Consent order for suspension, suspension,

stayed suspension or probationstayed suspension or probation

• Model F. Disciplinary provision for Model F. Disciplinary provision for

voluntary surrender of license to voluntary surrender of license to BONBON

What is evidence based?What is evidence based?

• Integration of best research with Integration of best research with clinical expertise and patient valuesclinical expertise and patient values

• Rigorous exploration where all research Rigorous exploration where all research data is analyzed, synthesized and data is analyzed, synthesized and structured into an integrative reviewstructured into an integrative review

• Patient values and the expertise of the Patient values and the expertise of the clinician might overrule findings clinician might overrule findings (Sackett, et al, 2000)(Sackett, et al, 2000)

Assumptions of alternative Assumptions of alternative programsprograms

• Reporting and identification will increase if Reporting and identification will increase if there is an alternative to discipline optionthere is an alternative to discipline option

• Reduces time between receipt of Reduces time between receipt of compliant and intervention of nursecompliant and intervention of nurse

• Nurses are provided opportunity for Nurses are provided opportunity for rehabilitation prior to disciplinerehabilitation prior to discipline

• Public is protected via close scrutiny of Public is protected via close scrutiny of compliance, monitoring and reporting compliance, monitoring and reporting

Components of alternative Components of alternative programsprograms

Individualized contract agreementsIndividualized contract agreements

Treatment and aftercare monitoringTreatment and aftercare monitoring

Abstinence based, no use modelAbstinence based, no use model

Regular, random, observed drug screensRegular, random, observed drug screens

Verified support group attendanceVerified support group attendance

Regular reports from self, supervisor, Regular reports from self, supervisor, therapist, prescribertherapist, prescriber

Components of alternative Components of alternative programsprograms

• Frequent, individual assessments via Frequent, individual assessments via phone or face to face evaluationsphone or face to face evaluations

• Practice restrictions and stipulationsPractice restrictions and stipulations

• Prescription medication monitoringPrescription medication monitoring

• Intense scrutiny of compliance Intense scrutiny of compliance

• Individualized case management & Individualized case management & monitoring, reporting of non monitoring, reporting of non compliancecompliance

Responsibilities of Alternative Responsibilities of Alternative ProgramsPrograms

• To protect the public while monitoring To protect the public while monitoring the nurse to ensure safe practice the nurse to ensure safe practice

• To encourage early identification, entry To encourage early identification, entry into treatment, and monitoring by into treatment, and monitoring by programprogram

• To identify and report non compliance To identify and report non compliance to BON in timely mannerto BON in timely manner

Responsibilities of Alternative Responsibilities of Alternative ProgramsPrograms

• To facilitate nurses to maintain To facilitate nurses to maintain ongoing recovery consistent with ongoing recovery consistent with safe practicesafe practice

• To educate the public and nursing To educate the public and nursing professionals and organizationsprofessionals and organizations

• To ensure adequate program staffing To ensure adequate program staffing to implement program policies and to implement program policies and contracts with nurses. contracts with nurses.

Purpose of Guidelines Purpose of Guidelines

• Practical, evidence based direction for:Practical, evidence based direction for:

• EvaluatingEvaluating

• TreatingTreating

• MonitoringMonitoring

• ManagingManaging

• ReportingReporting

• EducatingEducating

Eligibility Criteria: A nurse is Eligibility Criteria: A nurse is ineligible if:ineligible if:

• Has diverted for purpose of selling or Has diverted for purpose of selling or distributing to others, caused known distributing to others, caused known harm or potential to cause harmharm or potential to cause harm

• Is not eligible for licensure in the Is not eligible for licensure in the state state

• Has a history of disciplinary action Has a history of disciplinary action not related to substance usenot related to substance use

Eligibility Criteria: BON Eligibility Criteria: BON approval is needed prior to approval is needed prior to

admission if:admission if:

• Has a felony conviction or pending Has a felony conviction or pending criminal actioncriminal action

• Has caused patient harm, abuse or Has caused patient harm, abuse or neglectneglect

Eligibility Criteria: BON Eligibility Criteria: BON approval is needed prior to approval is needed prior to

admission if:admission if:

• Has been unsuccessfully discharged Has been unsuccessfully discharged or terminated from any alternative or terminated from any alternative program for non complianceprogram for non compliance

• Is receiving medication assisted Is receiving medication assisted treatmenttreatment

• Has been prescribed controlled Has been prescribed controlled substances for dual diagnosis or substances for dual diagnosis or chronic painchronic pain

Screening and AssessmentScreening and Assessment

• Initial screening to determine eligibility Initial screening to determine eligibility and motivationand motivation

• All pertinent information related to the All pertinent information related to the case from employers, investigators, and case from employers, investigators, and complainantcomplainant

• All demographic is included, All demographic is included, employment, academic, health, employment, academic, health, psychiatric, SUD, family/social, legal, psychiatric, SUD, family/social, legal, financial historyfinancial history

ContractsContracts

• Written, full disclosure of requirements Written, full disclosure of requirements reviewed and voluntary signaturereviewed and voluntary signature

• Length of contract and dates signedLength of contract and dates signed

• Non-disciplinary nature unless Non-disciplinary nature unless violations occur violations occur

• Reporting requirements, self, Reporting requirements, self, employer, therapist, 12 step employer, therapist, 12 step attendance and sponsor involvementattendance and sponsor involvement

Contracts continued Contracts continued

• Frequency and time limits of random Frequency and time limits of random drug screens and reportsdrug screens and reports

• Consequences of relapse and Consequences of relapse and reporting of noncompliancereporting of noncompliance

• Appropriate waivers and releasesAppropriate waivers and releases

Recovery Monitoring Recovery Monitoring RequirementsRequirements

• Comprehensive requirements:Comprehensive requirements:

• Initial treatmentInitial treatment

• Continuing care treatmentContinuing care treatment

• Drug screens results, support group Drug screens results, support group attendance, sponsor, supervisor, therapist, attendance, sponsor, supervisor, therapist, provider reports, & PMP monitoringprovider reports, & PMP monitoring

• Practice & work limitationsPractice & work limitations

Recovery Monitoring Recovery Monitoring RequirementsRequirements

• Close scrutiny of compliance with all Close scrutiny of compliance with all requirementsrequirements

• Face to face or phone evaluations at Face to face or phone evaluations at least quarterlyleast quarterly

• Comparison of all reports for Comparison of all reports for consistency, and accuracy of consistency, and accuracy of information, signatures, etc. information, signatures, etc.

Special Considerations for Special Considerations for Nurses Prescribed Controlled Nurses Prescribed Controlled

SubstancesSubstances• Dual diagnosis common and not Dual diagnosis common and not

disqualifyingdisqualifying

• Medical and psychiatric assessment, Medical and psychiatric assessment, treatment and follow uptreatment and follow up

• Neuropsychiatric, neuropsychological Neuropsychiatric, neuropsychological evaluation as neededevaluation as needed

• One prescriber and one pharmacy One prescriber and one pharmacy

Return to Work GuidelinesReturn to Work Guidelines

• Best outcomes include back to work Best outcomes include back to work employment contractemployment contract

• Supervisor/manager involvement and Supervisor/manager involvement and accurate reporting to programaccurate reporting to program

• Authority to request for cause drug Authority to request for cause drug screenscreen

• Educated and informed supervisors, Educated and informed supervisors, managers, co-workersmanagers, co-workers

Return to Work GuidelinesReturn to Work Guidelines

• Close contact, communication, Close contact, communication, engagement with alternative engagement with alternative program staffprogram staff

• Work restrictions on adverse work Work restrictions on adverse work conditionsconditions

• No nights, overtime, agency, home No nights, overtime, agency, home health, or shift workhealth, or shift work

Program CompletionProgram Completion

• Must meet minimum expectations of Must meet minimum expectations of good compliance with all good compliance with all requirementsrequirements

• Includes recent relapse prevention Includes recent relapse prevention planplan

• Submit request for discharge with Submit request for discharge with supporting documentationsupporting documentation

• Most programs 3-5 yearsMost programs 3-5 years

Policies and Procedures Policies and Procedures

• Internal policies and procedures Internal policies and procedures provide standards for implementationprovide standards for implementation

• Administrative and statutory authorityAdministrative and statutory authority

• Intake and admission criteriaIntake and admission criteria

• Case management criteria for Case management criteria for compliancecompliance

• Identification and reporting of non Identification and reporting of non compliancecompliance

Program Education and Program Education and Outreach Outreach

• Extremely important, yet undervaluedExtremely important, yet undervalued

• Lack of education about substance use Lack of education about substance use disorders is major risk factordisorders is major risk factor

• Education efforts should be maximizedEducation efforts should be maximized

• Education should target all stakeholdersEducation should target all stakeholders

• Via seminars, presentations, workshops, Via seminars, presentations, workshops, newsletter columns, FAQs, one to onenewsletter columns, FAQs, one to one

Program EvaluationProgram Evaluation

• Annual evaluation recommendedAnnual evaluation recommended

• Include statistics about referrals, Include statistics about referrals, admissions, relapse and non admissions, relapse and non compliance, successful discharges, compliance, successful discharges, recidivism ratesrecidivism rates

• Case loads of case managersCase loads of case managers

• Educational presentations and plansEducational presentations and plans

• Number of participantsNumber of participants

Conclusions: What we haveConclusions: What we have

• Evidence based recommendations for:Evidence based recommendations for:

• Eligibility criteriaEligibility criteria

• Screening and assessmentScreening and assessment

• Treatment and continuing careTreatment and continuing care

• Contract requirements & componentsContract requirements & components

• Recovery monitoring requirementsRecovery monitoring requirements

• Practice stipulations and limitationsPractice stipulations and limitations

Conclusions: What we haveConclusions: What we have

• Special population contractsSpecial population contracts

• Standards for treatment programsStandards for treatment programs

• Support group requirementsSupport group requirements

• Drug and alcohol testingDrug and alcohol testing

• Return to work guidelinesReturn to work guidelines

• Monitoring and reporting non Monitoring and reporting non compliancecompliance

Conclusions: What we haveConclusions: What we have

• Program completion requirementsProgram completion requirements

• Policies and proceduresPolicies and procedures

• Program education and outreachProgram education and outreach

• Program evaluation criteriaProgram evaluation criteria

What we know

•Treatment for substance use disorders works

•Health care professionals have a higher rate of recovery than lay public

•Monitoring of practice and recovery is effective and protects the public

What we know

• Addiction is the single most disabling condition for health care professionals (Talbott & Wright, 1987, Coombs, 1997)

• Treatment and monitoring works (Ganley,et al, 2005; Graham & Schultz, 1998, NIDA, 1999)

• 80-90% of nurses are successful in recovery (Hughes, T.L., Smith, L. & Howard, J.J., 200; Shaw, et al. 2004).

Thank youThank you

Available for download: ncsbn.orgAvailable for download: ncsbn.org

Substance Use Disorder in Substance Use Disorder in Nursing: A Resource Manual and Nursing: A Resource Manual and

Guidelines for Alternative and Guidelines for Alternative and Disciplinary Monitoring ProgramsDisciplinary Monitoring Programs