RN Rehab

**The second of two parts on Texas nurses battling substance abuse problems. (Part one is here.)

For years, Leanne Malone balanced drug addiction and nursing, caring for her Port Arthur patients while on methamphetamines. When she was arrested, she thought her career might be over.

But Texas gives some nurses with substance abuse problems second chances, and Malone was one of them. The Texas Board of Nursing enrolled her in the Texas Peer Assistance Program for Nurses, a state-run rehab program for nurses with chemical dependency or mental illness. After completing a several month long outpatient treatment plan, she was back at work, minus the addiction.

The thought of receiving care from a drug-addicted caregiver — even a recently rehabilitated one — makes many patients shudder. But addiction among nurses is not rare. A Texas Tribune review of the 383 disciplinary actions taken by the nursing board between June and September of 2009 found about a third of the cases involved substance abuse.

Mike Van Doren, the nurse rehabilitation program director, said most nurses who are reported to the nursing board for substance abuse problems lose their licenses. Patient safety is the first priority, he said, and flagrant offenses are not tolerated. “The major intervention is 'You’re fired',” he said.

But the state believes many nurses have a viable chance of overcoming their addictions. And firing every nurse with an addiction or a lapse in judgment would only exacerbate the nursing shortage facing Texas and the rest of the country. At any given time, between 600 and 700 nurses are enrolled in the rehab program; more than half of them will graduate and return to their nursing jobs. “We want to help nurses who have a legitimate need,” Van Doren said.

Substance abuse violations among Texas nurses run the gamut. In some cases reviewed by The Tribune, nurses tested positive for street drugs like marijuana or cocaine when they submitted to random drug screenings on the job. In others, they failed to acknowledge off-duty drunken driving arrests on their license renewal applications. Nurses were frequently reported to the board for stealing pain medication from hospital dispensing systems or taking unused doses that were reserved for but not given to patients. Others were reprimanded for filling fraudulent prescriptions for painkillers or anti-anxiety medications. Still others reported for work under the influence, making mistakes or falling asleep on the job.

Alex Winslow, the executive director of the consumer advocacy group Texas Watch, said if Texas nurses “violate the public trust,” they need to be held accountable. “But [nurses] should be allowed to go through rehab so long as there is a stiff and stringent program,” he added.

About 90 percent of nurses in the state’s rehabilitation program struggle with chemical dependency. The others receive care for mental illness. More than a quarter of participants have dual diagnoses. 

The Peer Assistance Program caters a treatment plan to the specific needs of each nurse. In some cases, a nurse will simply need a drug and alcohol education course. Another might require a long-term treatment program that can last several months. For the majority of patients, treatment falls somewhere in the middle. “Most nurses are going for a 4-to-6-week intensive outpatient program,” Van Doren said. “We don’t allow them to go back to work until they’ve completed treatment.”

The vast majority of nurses are reported to the board by their peers, and don’t come forward themselves. For many, including Malone, acknowledging addiction is one of the most difficult parts of recovery. “I thought I had done a good job of compartmentalizing my addictions and separating it from my family life and work,” she said. “But addiction is a sneaky thing.”

After her arrest in the late 1980’s, Malone lived in a halfway house, hoping that the nursing board would allow her to practice again if she maintained her sobriety there. It wasn’t until she heard about and contacted the Peer Assistance Program and quickly heard back from an advocate there that she got her full reality check. “I really believe that advocate saved my life,” she said.

According to the program’s participant handbook, a nurse must remain in the rehabilitation program for a minimum of two years, and demonstrate safe-nursing practices for 12 months before successfully completing it.

Like many patients, Malone underwent treatment on an outpatient basis. After progressing through the rehab process and remaining clean, she was allowed to practice nursing again — so long as her drug screenings continued to show up negative. Since Malone’s treatment, she has been a passionate advocate for the program, and now works as its clinical supervisor. She has maintained her sobriety for more than 20 years.

Malone acknowledges that the long-term recovery outlook for anyone who struggles with substance abuse is glum: Only about 10 percent will succeed in recovery. “Those are horrible statistics but that’s the truth,” she said.

About 95 percent of the nurses who are investigated for some form of misconduct are reported by their co-workers or employers, and there are limits on who can participate in the rehabilitation program. Nurses who have had disciplinary actions taken against them in the past five years, have already participated in the rehab program, or have legal actions or pending criminal charges against them cannot enroll.

The cost of the treatment program, which a nurse must typically pay out of pocket, doesn’t make enrolling any easier. Van Doren said the initial assessment can run between $100 and $300. Full treatment plans can cost up to $6,000. Drug tests, which occur one to three times a month on average for a nurse in the program, can cost more than $50 a piece. The state requires those who complete the program to be monitored for the next two to three years.

The Peer Assistance Program has a small endowment fund to help nurses who need a financial boost, but the stalled economy hasn’t helped. Some drop out of the program because they can’t afford it. In those instances, their cases are closed and returned to the nursing board. The price of recovery is something that the state needs to fix, said Winslow, the consumer advocate. “We absolutely need to address the cost issue,” he said.

Experts say rehab programs aren’t just critical for the nurses; they’re critical for the health care industry. Across the country, hospitals and doctors struggle to find enough nurses to care for their patients — a problem that’s swelling as baby boomers age. 

Said Malone: “We are doing a very good job of education and responding appropriately to that.”