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

NCSBN COMMITTEE REVIEW AND DEVELOP BEST PRACTICES FOR ALTERNATIVE TO DISCIPLINE PROGRAMS AND DISCIPLINE MONITORING PROGRAMS REVIEW AND DEVELOP BEST PRACTICES FOR ALTERNATIVE TO DISCIPLINE PROGRAMS AND DISCIPLINE MONITORING PROGRAMS

NEW GUIDELINES Nancy Darbro, PhD, CNS, RN New Mexico Board of Nursing Executive Director

Why alternative and discipline monitoring programs? High percentage of state board discipline cases deal with substance use issues (Smith & Hughes, 1996) High percentage of state board discipline cases deal with substance use issues (Smith & Hughes, 1996) Cost effective and rehabilitative option Cost effective and rehabilitative option Provide intense scrutiny of compliance and public protection Provide intense scrutiny of compliance and public protection Alternative programs have been functioning for over 20 years Alternative programs have been functioning for over 20 years

Why alternative and discipline monitoring programs? Most nurses with substance use disorders are not identified in the workplace Most nurses with substance use disorders are not identified in the workplace Most nurses with substance use disorders are not reported to regulatory agencies Most nurses with substance use disorders are not reported to regulatory agencies Nurse who are reported often practice for long periods during investigation Nurse who are reported often practice for long periods during investigation 10% nurses needing treatment wont get it 10% nurses needing treatment wont get it

Why alternative and discipline monitoring programs? 90% of nurses with substance use disorders remain unidentified, unreported, untreated and continue to practice (Gossop et al., 2001; Tighe & Saxe, 2006; McCabe, Cranford, West, 2008) 90% of nurses with substance use disorders remain unidentified, unreported, untreated and continue to practice (Gossop et al., 2001; Tighe & Saxe, 2006; McCabe, Cranford, West, 2008) Most who enter treatment do so due to external pressure or coercion Most who enter treatment do so due to external pressure or coercion

3 General Types of programs Alternative to discipline with statutory authority under Bon (57%) Alternative to discipline with statutory authority under Bon (57%) Peer assistance programs under state nursing associations (39%) Peer assistance programs under state nursing associations (39%) Discipline monitoring with consent order or voluntary surrender of license Discipline monitoring with consent order or voluntary surrender of license

Types of alternative programs 1. Model A. statutory authority under BON 1. Model A. statutory authority under BON Model B. statutory authority under BON Model B. statutory authority under BON contracted to an outside agency contracted to an outside agency Model C. Special committee of the BON Model C. Special committee of the BON 2. Model D. Peer assistance program of 2. Model D. Peer assistance program of state nursing association in state nursing association in collaboration with BON collaboration with BON

Types of alternative programs Model E. Peer assistance program of state nursing association with no collaboration with BON Model E. Peer assistance program of state nursing association with no collaboration with BON Model F. Employee assistance program Model F. Employee assistance program with no collaboration with BON with no collaboration with BON

Types of disciplinary models 3. Model E. Consent order for suspension, 3. Model E. Consent order for suspension, stayed suspension or probation stayed suspension or probation Model F. Disciplinary provision for Model F. Disciplinary provision for voluntary surrender of license to BON voluntary surrender of license to BON

What is evidence based? Integration of best research with clinical expertise and patient values Integration of best research with clinical expertise and patient values Rigorous exploration where all research data is analyzed, synthesized and structured into an integrative review Rigorous exploration where all research data is analyzed, synthesized and structured into an integrative review Patient values and the expertise of the clinician might overrule findings (Sackett, et al, 2000) Patient values and the expertise of the clinician might overrule findings (Sackett, et al, 2000)

Assumptions of alternative programs Reporting and identification will increase if there is an alternative to discipline option Reporting and identification will increase if there is an alternative to discipline option Reduces time between receipt of compliant and intervention of nurse Reduces time between receipt of compliant and intervention of nurse Nurses are provided opportunity for rehabilitation prior to discipline Nurses are provided opportunity for rehabilitation prior to discipline Public is protected via close scrutiny of compliance, monitoring and reporting Public is protected via close scrutiny of compliance, monitoring and reporting

Components of alternative programs Individualized contract agreements Treatment and aftercare monitoring Abstinence based, no use model Regular, random, observed drug screens Verified support group attendance Regular reports from self, supervisor, therapist, prescriber

Components of alternative programs Frequent, individual assessments via phone or face to face evaluations Frequent, individual assessments via phone or face to face evaluations Practice restrictions and stipulations Practice restrictions and stipulations Prescription medication monitoring Prescription medication monitoring Intense scrutiny of compliance Intense scrutiny of compliance Individualized case management & monitoring, reporting of non compliance Individualized case management & monitoring, reporting of non compliance

Responsibilities of Alternative Programs To protect the public while monitoring the nurse to ensure safe practice To protect the public while monitoring the nurse to ensure safe practice To encourage early identification, entry into treatment, and monitoring by program To encourage early identification, entry into treatment, and monitoring by program To identify and report non compliance to BON in timely manner To identify and report non compliance to BON in timely manner

Responsibilities of Alternative Programs To facilitate nurses to maintain ongoing recovery consistent with safe practice To facilitate nurses to maintain ongoing recovery consistent with safe practice To educate the public and nursing professionals and organizations To educate the public and nursing professionals and organizations To ensure adequate program staffing to implement program policies and contracts with nurses. To ensure adequate program staffing to implement program policies and contracts with nurses.

Purpose of Guidelines Practical, evidence based direction for: Practical, evidence based direction for: Evaluating Evaluating Treating Treating Monitoring Monitoring Managing Managing Reporting Reporting Educating Educating

Eligibility Criteria: A nurse is ineligible if: Has diverted for purpose of selling or distributing to others, caused known harm or potential to cause harm Has diverted for purpose of selling or distributing to others, caused known harm or potential to cause harm Is not eligible for licensure in the state Is not eligible for licensure in the state Has a history of disciplinary action not related to substance use Has a history of disciplinary action not related to substance use

Eligibility Criteria: BON approval is needed prior to admission if: Has a felony conviction or pending criminal action Has a felony conviction or pending criminal action Has caused patient harm, abuse or neglect Has caused patient harm, abuse or neglect

Eligibility Criteria: BON approval is needed prior to admission if: Has been unsuccessfully discharged or terminated from any alternative program for non compliance Has been unsuccessfully discharged or terminated from any alternative program for non compliance Is receiving medication assisted treatment Is receiving medication assisted treatment Has been prescribed controlled substances for dual diagnosis or chronic pain Has been prescribed controlled substances for dual diagnosis or chronic pain

Screening and Assessment Initial screening to determine eligibility and motivation Initial screening to determine eligibility and motivation All pertinent information related to the case from employers, investigators, and complainant All pertinent information related to the case from employers, investigators, and complainant All demographic is included, employment, academic, health, psychiatric, SUD, family/social, legal, financial history All demographic is included, employment, academic, health, psychiatric, SUD, family/social, legal, financial history

Contracts Written, full disclosure of requirements reviewed and voluntary signature Written, full disclosure of requirements reviewed and voluntary signature Length of contract and dates signed Length of contract and dates signed Non-disciplinary nature unless violations occur Non-disciplinary nature unless violations occur Reporting requirements, self, employer, therapist, 12 step attendance and sponsor involvement Reporting requirements, self, employer, therapist, 12 step attendance and sponsor involvement

Contracts continued Contracts continued Frequency and time limits of random drug screens and reports Frequency and time limits of random drug screens and reports Consequences of relapse and reporting of noncompliance Consequences of relapse and reporting of noncompliance Appropriate waivers and releases Appropriate waivers and releases

Recovery Monitoring Requirements Comprehensive requirements: Comprehensive requirements: Initial treatment Initial treatment Continuing care treatment Continuing care treatment Drug screens results, support group attendance, sponsor, supervisor, therapist, provider reports, & PMP monitoring Drug screens results, support group attendance, sponsor, supervisor, therapist, provider reports, & PMP monitoring Practice & work limitations Practice & work limitations

Recovery Monitoring Requirements Close scrutiny of compliance with all requirements Close scrutiny of compliance with all requirements Face to face or phone evaluations at least quarterly Face to face or phone evaluations at least quarterly Comparison of all reports for consistency, and accuracy of information, signatures, etc. Comparison of all reports for consistency, and accuracy of information, signatures, etc.

Special Considerations for Nurses Prescribed Controlled Substances Dual diagnosis common and not disqualifying Dual diagnosis common and not disqualifying Medical and psychiatric assessment, treatment and follow up Medical and psychiatric assessment, treatment and follow up Neuropsychiatric, neuropsychological evaluation as needed Neuropsychiatric, neuropsychological evaluation as needed One prescriber and one pharmacy One prescriber and one pharmacy

Return to Work Guidelines Best outcomes include back to work employment contract Best outcomes include back to work employment contract Supervisor/manager involvement and accurate reporting to program Supervisor/manager involvement and accurate reporting to program Authority to request for cause drug screen Authority to request for cause drug screen Educated and informed supervisors, managers, co-workers Educated and informed supervisors, managers, co-workers

Return to Work Guidelines Close contact, communication, engagement with alternative program staff Close contact, communication, engagement with alternative program staff Work restrictions on adverse work conditions Work restrictions on adverse work conditions No nights, overtime, agency, home health, or shift work No nights, overtime, agency, home health, or shift work

Program Completion Must meet minimum expectations of good compliance with all requirements Must meet minimum expectations of good compliance with all requirements Includes recent relapse prevention plan Includes recent relapse prevention plan Submit request for discharge with supporting documentation Submit request for discharge with supporting documentation Most programs 3-5 years Most programs 3-5 years

Policies and Procedures Internal policies and procedures provide standards for implementation Internal policies and procedures provide standards for implementation Administrative and statutory authority Administrative and statutory authority Intake and admission criteria Intake and admission criteria Case management criteria for compliance Case management criteria for compliance Identification and reporting of non compliance Identification and reporting of non compliance

Program Education and Outreach Extremely important, yet undervalued Extremely important, yet undervalued Lack of education about substance use disorders is major risk factor Lack of education about substance use disorders is major risk factor Education efforts should be maximized Education efforts should be maximized Education should target all stakeholders Education should target all stakeholders Via seminars, presentations, workshops, newsletter columns, FAQs, one to one Via seminars, presentations, workshops, newsletter columns, FAQs, one to one

Program Evaluation Annual evaluation recommended Annual evaluation recommended Include statistics about referrals, admissions, relapse and non compliance, successful discharges, recidivism rates Include statistics about referrals, admissions, relapse and non compliance, successful discharges, recidivism rates Case loads of case managers Case loads of case managers Educational presentations and plans Educational presentations and plans Number of participants Number of participants

Conclusions: What we have Evidence based recommendations for: Evidence based recommendations for: Eligibility criteria Eligibility criteria Screening and assessment Screening and assessment Treatment and continuing care Treatment and continuing care Contract requirements & components Contract requirements & components Recovery monitoring requirements Recovery monitoring requirements Practice stipulations and limitations Practice stipulations and limitations

Conclusions: What we have Special population contracts Special population contracts Standards for treatment programs Standards for treatment programs Support group requirements Support group requirements Drug and alcohol testing Drug and alcohol testing Return to work guidelines Return to work guidelines Monitoring and reporting non compliance Monitoring and reporting non compliance

Conclusions: What we have Program completion requirements Program completion requirements Policies and procedures Policies and procedures Program education and outreach Program education and outreach Program evaluation criteria Program 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 you Available for download: ncsbn.org Substance Use Disorder in Nursing: A Resource Manual and Guidelines for Alternative and Disciplinary Monitoring Programs Substance Use Disorder in Nursing: A Resource Manual and Guidelines for Alternative and Disciplinary Monitoring Programs