Substance Abuse in Nursing: What Are the Signs and What To Do About It?

If you suspect a coworker is impaired by drugs or alcohol at work, you have an ethical duty to act, to your patients, your profession, and your employer. Here is how to recognize the signs and what to do next.

The American Nurses Association estimates that up to 10% of nurses have a substance abuse problem, and some studies put it as high as 1 in 5. Many are addicted to prescription drugs and caught in the opioid epidemic the CDC has tracked for years. Plenty of these nurses were never long-term users. They fell into tolerance and dependence after a legitimate prescription or after self-medicating through emotional trauma.

An impaired nurse usually believes she is fine. She is not. She cannot care for patients safely, and her behavior can put their lives at risk.

The Signs of Substance Abuse

Addiction builds gradually. It starts with misuse, moves to tolerance as the body needs higher doses for the same effect, and ends in addiction, where the craving becomes a brain disorder driving compulsive use the person can no longer control.

Addicted nurses are hard to spot. The textbook picture of the down-and-out street addict rarely matches the employed nurse, who takes extra care to avoid detection. Free access to drugs, clean needles, and syringes also removes the financial strain that exposes other addicts.

Physical signs

Nurses show the same physiological effects as any other user:

• Shakiness and tremors
• Dilated or constricted pupils (opiates cause constriction)
• Watery eyes and nose
• Fatigue, slowed breathing, nodding off, or blackouts
• Slurred speech
• Unsteady movement
• Frequent nausea, vomiting, or diarrhea
• Unusual weight loss or gain

Poor grooming is a classic sign, but an employed addict often grooms carefully to keep up appearances.

Changes in behavior

When the problem is recent, a shift in behavior is often the first thing coworkers notice. When it has built over time, it may only become clear in hindsight. Watch for:

• Poor concentration, forgetfulness, and frequent errors
• Hyperactivity and euphoria, joking and laughing, seemingly untouched by job stress
• Underperformance and not carrying a full workload
• Declining quality of care and documentation
• Isolation from coworkers and strained relationships
• Frequent anger and defensiveness
• Arriving late, leaving early, and calling in sick often
• Always volunteering for late or extra shifts (because that is where the drugs are)
• Lying, often to the point of getting caught
• Brief, unexplained absences from the unit or frequent bathroom trips
• Wearing warm clothing in hot weather to hide needle marks

Signs of drug diversion on the unit

Addicted nurses find clever ways to feed a growing craving that overrides patient care and their own judgment. Any of these, especially when repeated, is a red flag:

• Narcotic signouts spike when a specific nurse is on duty
• Frequent errors in narcotic counts, narcotic records, or patient medication records
• Unusual numbers of wasted-narcotic signouts (and how often does a trusting cosigner actually watch the drug get disposed of?)
• One nurse's patients regularly reporting poor pain relief after receiving their pain meds
• A nurse who repeatedly offers to give other nurses' patients their medication
• Changes made to verbal or telephone orders for narcotics

What to Do If You Suspect a Coworker

Do not enable. Nurses slide into this easily because they are carers and protectors. Enabling means covering up poor performance and errors, reducing the nurse's workload, accepting excuses, and giving in to manipulation. Whether you want to stay out of it, avoid a confrontation, or protect a colleague, do not look the other way. An impaired nurse is a real threat to patients.

Start by sharpening your own knowledge of the signs, symptoms, and behaviors. Pull your workplace policy on employee substance abuse and find out what help exists, onsite or through your local nursing association. Check what your Board of Nursing does with impaired nurses. The trend now favors rehabilitation and a return to work after treatment over harsh discipline.

Next, document the facts that support your concern. Take that information to a nursing services manager. If you are close to the nurse, especially if they have confided in you, encourage them to get help before they are caught, and support them through it.

Acting is hard, but the duty to protect patients comes first. Show the same care and compassion for a struggling coworker that you would for a patient. Few addicts seek treatment on their own. Most only do so once confronted or once their job is on the line. Those who enter a structured treatment program have a strong chance of recovery and of returning to the profession.