Jack Stem, CRNA, is a Peer Assistance Advisor for the Ohio State Association of Nurse Anesthetists and maintains an educational website for health care providers on the risk of addiction at www.jackstem.com/

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Questions

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Evelyn Corsini:

Tell us your story and why you started your website?

Jack Stem, CRNA: I have been an RN since 1978 and a CRNA since 1981. I have had chronic pain since the early 70's when I was diagnosed with spondylolisthesis. A few days rest and a prescription analgesic (a\oxycodone and acetaminophen) were sufficient to relieve the pain in the past. In the early part of 1990 that changed. My spondylolisthesis had advanced and the few days off and one prescription didn't relieve the pain. I was working 70+ hours per week at the time so I kept working despite the pain, taking my meds and muddling through. With the pain progressing and poor pain management, I began keeping the wastage of opioids at the end of the work day, using it intramuscularly at night in an attempt to get more sleep. It's clearly evident (in hindsight) that I was addicted to my meds.

Denial is so strong in the addict. It allows us to continue doing things we would never consider before addiction became a part of our life. It's hard to explain in this type of forum since time and space is limited. I can say this...before I became an addict, I hated working with "them". I wish I had a nickel for every time I said or thought, "If you loved your family you would stop doing this." Well, I discovered the hard way that you can love your family more than anything else in the world, but when the disease of addiction is active, you can't stop "doing this" (using). Brain chemistry and structure are significantly altered in such a way that the ability to choose to postpone pleasure until a later time is lost. "Natural" activities such as sex and achievement no longer provide satisfaction (the "high") intense enough to compete with the satisfaction the drug produces. Obtaining and using the drug becomes the only thing that matters.

Likewise, chronic, unrelieved pain causes significant alterations in brain and nerve paths as well as chemical changes that enhance and perpetuate pain. If the plan for managing pain is inadequate, obtaining and using pain medication becomes the only thing that matters. This is what health care professionals call "drug seeking behavior".

As you can see, the behavior is identical even though the "cause" is different. This leads to the misinterpretation of the behavior by the person in pain as the behavior of an addict. Now a huge cycle begins that many people cannot stop. Death, intentional (suicide) or unintentional (accidental overdose) eventually becomes the final outcome for far too many people who have chronic pain or addiction.

Bottom line? There is a large body of knowledge available about both of these diseases that isn't making it to the clinician or the public. That's the motivation for my web site.

EC: Do health care workers view addiction as a disease or a moral weakness? How does this effect their management of chronic pain?

JS: I can't speak for all health care workers, but I will say there are far too many who don't even have a basic understanding of the pathophysiology of pain or addiction. If you are a licensed health care professional, there is no excuse for not staying current with management strategies for pain or addiction. None.

If there is a lack of understanding of the pathophysiology of chronic pain, it's impossible to effectively evaluate, diagnose, plan treatment, and evaluate that plan in a scientific manner. Treatment will be based on myth, misbelief, and misunderstanding.

Think about it. If someone with diabetes received a dose of insulin which lowered their blood sugar from 300 to 250, the health care professional would not say to them, "Mr. Patient, I've given you as much insulin as I can. You will simply have to find another way to lower your blood sugar further. Besides, we wouldn't want you to become addicted to your insulin!" But that's what chronic pain patients hear everyday all over the world. We could also label the diabetic as "chemically dependent", since they need it to control their blood sugar levels.

Ridiculous you say!? Of course it is. But it's no more ridiculous than telling someone in pain receiving inadequate doses of pain medication to "find another way" to relieve their pain. Pain medicine must be individualized just as insulin must be individualized. This is where some of the difficulty arises when managing chronic pain. Laboratory tests can accurately tell us someone's blood sugar. Unfortunately, there is no lab test to tell us how much pain someone is having. We have to believe what they tell us. If the health care professional believes someone is "drug seeking" for pleasure and not pain relief, that person is most likely going to remain in pain.

Also, if the health care professional hasn't kept up with the research on addiction over the last few decades, it's very easy to get caught up in the "drug war" mentality. Yes, we do need to have a plan for interdiction of illegal drugs entering this country and being sold on the streets. But when that police mentality begins to interfere with the doctor/patient relationship and the treatment of chronic pain, it's time to take a long hard look at where police presence should end. There have been numerous physicians and other health care professionals in the news over the past decade, who have been investigated and prosecuted for treating chronic pain patients, despite following current, scientific protocols. When physicians see this, many stop treating chronic pain patients for fear of the same fate.

Research on addiction has also shown that the recovery rate for addiction/alcoholism (the same thing) is similar to successful management of other chronic diseases.

EC: Are there specific professions or groups of health care workers who are at higher risk of addiction?

JS: Yes. Critical care, emergency room, OR, and anesthesia professionals have a somewhat higher risk of becoming chemically dependent or addicted. High risk patients and procedures, long hours, poor sleep patterns, and poor coping strategies all increase the risk of chemical abuse in these specialties.

Since anonymous reporting of these problems isn't reliable, it's difficult to put an exact percentage on those who become addicted. The number usually quoted when it comes to anesthesia providers is in the range of 10 - 20% in a 30 - 35 year career. There are many leaders in anesthesia, both MD and CRNA, who would rather not discuss this topic. There will be many who respond to this interview with comments that will range from "There is a problem but it's not that bad”, to “This guy is an addict! How can you believe what he's telling you?" This refusal to accept what current research reveals is the major obstacle to preventing addiction or diagnosing it early when treatment could possibly be more successful.

Since you contacted me about doing this interview I know of 2 nurse anesthetists who have died as a result of their addictive disease. This is a tragedy that need not happen as often as it does. Until the medical community accepts this as a disease, we will continue to lose some of the best and brightest clinicians available.

EC: What are some signs of a drug impaired co-worker and what should I do if I have concerns about someone?

JS: Some of the most common signs of impairment include mood swings, poor record keeping, unexplained absences, frequent trips to the restroom, wearing long sleeves even when it's warm, slurred speech, nodding off, showing up at the hospital at odd times or on a day off, willingness to give coffee breaks, insisting on being the one to administer pain medication, and a history of caring for patients having more pain than the anesthesia record would indicate they might have.

Concerns for a colleague should be discussed with their supervisor. Having a one-on-one confrontation with an addict will not be successful and may even increase the risk of suicide. This is why an organization or facility must have a policy and procedure to follow when this occurs. Information is gathered, including a review of all records the individual has had reason to chart on as well as pharmacy records.

Intervention, if necessary, should be done with an interventionist when possible, or under the direction of one. Admission to a facility familiar with addicted health professionals should be pre-arranged. Family, friends, and colleagues comprise the intervention team. Individuals who are not supportive of the individual should not be part of this team. The intervention is to show the person the reasons diversion is suspected, that treatment is available, they must enter now, and then wait for their response. If they refuse treatment, the consequences are listed, including arrest and prosecution. Since many states have an alternative program which allows a professional to receive treatment anonymously and to protect their license, this should be explained to them. Most will accept treatment. If they do, they are taken to the treating facility directly from the intervention. Under no circumstances should they be left alone since this is the most likely time for suicide. Everything necessary for admission is already completed including the personal items they will need while in treatment.

EC: Can a health care worker in recovery continue in clinical practice?

JS: In many instances the answer is yes. I have many colleagues who have returned to practice and have had long, successful, clean and sober careers and lives. The professional who is considering returning to practice must sign a contract with their licensing board. This contract includes:

• How many hours they may work (generally no call time is allowed for a specific amount of time)
• How many 12 Step meetings they must attend in a week
• Attendance at a "professional" support group comprised of other recovering health care professionals
• How and when they must give urine or blood samples for drug screen
• If they must take medication (naltrexone, antabuse, etc.)
• Ongoing counseling

EC: Do health care professional organizations, on a local or national level, provide peer assistance hot lines or other resources for their members who are concerned about their own impairment?

JS: Yes, many do. The American Association of Nurse Anesthetists (AANA) has a 24 hour hotline listed on their web site. We also have State Peer Assistance Advisors (SPA) who man this hotline. I am a SPA in Ohio along with another colleague. While all 50 state medical boards have an alternative program available to their members, not all Boards of Nursing are as supportive of their colleagues. This is something the American Nurses Association, the AANA, and other specialty organizations are trying to change. The road to accomplishing this is anything but smooth and requires education of all health care professionals in order to accomplish this goal.

As a state peer assistance advisor, we not only take hotline phone calls, we also give lectures at meetings for a variety of professional organizations. It's only through education that we will begin to treat both chronic pain and addiction successfully. Both of these diseases are treatable.