Prescription for Change
BCNU co-authored report calls for reforming how nurses with substance use disorders are treated
The news media has reported on several high-profile cases of BC nurses with substance use disorders (SUDs) sounding the alarm about their employer's one-size-fits-all treatment plans, including an over-reliance on 12-step programs and the need for total abstinence.
BCNU supports the rights of all nurses struggling with SUDs to participate in alternative, individualized treatment strategies. In fact, BCNU co-authored a 2019 report that calls for major changes to the way nurses with SUDs are treated. The report, Promoting Evidence-Based Treatment Approaches for Nurses with Substance Use Disorders: Report and Recommendations, was also authored by the BC Centre for Substance Use, Douglas College, University of Victoria and RainCity Housing.
The in-depth study describes the current regulatory approach, and delivers a series of recommendations aimed at improving the standards for addiction treatment in BC. Those long-awaited reforms include promoting evidence-based, patient-centered treatment approaches, reducing opportunities for harm and coercion and promoting individualized risk management.
Current Regulatory Approach
No community or profession is immune to SUDs. And nursing – with its high stress and burnout levels, heavy workloads, staff shortages and injuries – is certainly no exception.
The report reveals that BC nurses with SUDs are usually offered a cookie-cutter treatment approach, "regardless of the severity of the substance use disorder, job environment and work duties … leaving nurses with SUDs at high risk of relapse."
The BC College of Nurses & Midwives (BCCNM) gets involved after learning of a registrant's possible addiction. The report describes how those nurses are asked to undergo an independent medical exam (IME), "which is often carried out by one of a small number of physicians, many of whom have a financial interest in a monitoring company."
Nurses diagnosed with a SUD are then "offered a non-individualized return-to-work plan regardless of the type of SUD or severity."
Typical plans include inpatient residential treatment in a private facility, followed by mandatory attendance in a religious-based 12-step program, abstinence from drugs and alcohol (other than tobacco and caffeine) and ongoing testing to ensure compliance.
Nurses are given little or no choice when it comes to choosing their own path to recovery. Those who want to return to work must follow the addictions specialist's mandatory treatment plan, or lose their job and their licence to practise nursing.
The report states that "the overwhelming majority of BC nurses with opioid use disorders are currently offered primarily non-pharmacological and abstinence-based approaches, including referral to psychosocial treatment interventions which are not evidence based, and short detox periods which, for people who use opioids, increase the risk of relapse and fatal and non-fatal overdose."
There's growing recognition that the status quo is not fair for nurses or their patients.
"Data indicates that the current approach is extremely punitive and coercive," says BCNU professional practice and advocacy department coordinator Deborah Charrois. "Treatment and recovery approaches are often out-dated and can lead to a relapse. Meanwhile other evidence-based outpatient services and treatments are being withheld."
Charrois, one of the report's co-authors, says that under the current coercive system nurses can be forced into treatment plans with unsafe or ineffective modalities. They can also be barred from using the same individualized evidence-based and culturally safe care BC nurses routinely provide to patients with SUDs.
The report reveals how the current system focuses on an abstinence-only approach and punishes professionals who relapse, resulting in "negative professional, employment and reputational consequences."
For example, the report's authors exposed numerous inconsistencies between peer-reviewed scientific evidence and the existing practice of treating BC nurses with SUDs. Those inconsistencies include mandatory or coercive attendance at 12-step support group meetings.
Studies show those sessions may actually increase the risk of relapse. The report notes that more "high-quality research is needed in order to determine the efficacy and utility of this approach," and calls for ending mandatory attendance in support groups like Alcohol Anonymous (AA).
Supporters of abstinence-based treatment claim that AA – founded by two recovering alcoholics in 1935, and based on Christian beliefs, not scientific research – has saved the lives of millions of substance users around the world. They also state that many 12-step programs have been adapted for atheists and agnostics. But critics, including some nurses enrolled in AA and similar programs, say they find it extremely difficult to place their hopes for a new life on an unknown higher power.
Other studies included in the report prove that relapse after enrolling in a 12-step program isn't just a nursing problem. Relapse is rampant among the general public, with 91 to 94 percent of participants relapsing after withdrawal from opioids and 43 to 83 percent relapsing after treatment for alcohol use disorder.
Alternatives to the Abstinence-Only Approach
Critics of abstinence-only treatment plans want the BCCNM to explore other options. The college had until very recently refused to allow people to return to practice while on suboxone. And there are concerns the college may refuse to provide nurses with extended-release naltrexone. (XR-NTX blocks the mind-altering effects of opiates and alcohol, and decreases the desire to take those substances.)
Although US studies of XR-NTX show promise in treating nurses with drug and alcohol problems, it is only offered in Canada for clinical and research purposes. The report recommends making XR-NTX available to BC nurses and their care providers, if they decide it is the best approach for them.
"Nurses deserve the same compassionate, high-quality health-care treatment options that are available to the public," says BCNU President Christine Sorensen. "The recommendations included in this report will help us achieve that goal.
"Today, in the middle of a global nursing shortage, made worse by the pandemic, it's critical to provide nurses with evidence-based treatments. We need nurses returning to work healthy."
Reducing Opportunities for Harm and Coercion
The report also emphasises the need to explore "conflicts of interest that exist, between physicians who conduct IMEs and the medical monitoring companies that are often a central component of the resulting treatment plan." Those IMEs are "often carried out by one of a small number of physicians, many of whom have a financial interest in a monitoring company."
The report recommends that any health-care provider who conducts IMEs not have a relationship with the monitoring company.
"Conflicts of interest in the health-care system are always a concern," notes Sorensen. "BCNU supports full transparency from all parties who play a role in advancing the health and well-being of our members and of all British Columbians."
Leap Supports Indvidualized Treatment Plans
BCNU's Licensing, Education and Advocacy Program (LEAP), helps members struggling with substance and mental health disorders, regulatory complaints and other professional issues. At least one percent of BCNU members utilize LEAP services annually, with about 15 percent of those seeking help with substance use. (To learn more about LEAP, see sidebar on page 50.)
"LEAP fully supports individualized treatment plans for nurses with SUDs," says Charrois. "The LEAP program doesn't unilaterally assign participants to a specific health-care provider. Instead, they're given a list of providers to choose from. We encourage doctors to base their recommendations for treatment on an individual's needs, not on a cookie-cutter approach."
Charrois points out that BCNU's LEAP staff currently ensure that nurses can choose their monitoring company and that monitors give nurses 24 hours to submit to random urine drug screens. Staff have also made sure that nurses in monitoring programs can arrange their own meetings and calls with monitors at a time that suits their schedules, and that support group attendance is not mandatory.
"Our union is totally committed to supporting nurses," says Sorensen. "All LPNs, RNs and RPNs who are BCNU members are eligible to apply for assistance through our LEAP program if they are concerned about their fitness to practice."
Charrois says BCNU, and the other organizations that released the report, hope to work with politicians, employers and the BCCNM to educate them on best practices for treating nurses with SUDs.
"We must encourage acceptance of individualized medical recommendations from a variety of professionals," says Charrois. "It's time to move past the current cookie-cutter approach and give nurses with SUDs a choice in their own treatment plan."
"We are facing a nursing shortage in BC and across the globe," adds Sorensen. "That's why it's so critical to provide nurses with evidence-based treatments.
"Imagine if – instead of stigmatizing these nurses – we partnered with BCCNM to develop individualized treatment plans that help members find a non-punitive pathway to deal with their health issues. Nurses need to have a voice in their treatment plan if there's to be any hope of recovery." •
UPDATE (Spring 2021)
THE AUTHORS OF PROMOTING EVIDENCE-BASED Treatment Approaches for Nurses with Substance Use Disorders, make several recommendations for the BC College of Nurses and Midwives. These include:
- Calling for the promotion of evidence-based, patient-centered treatment approaches, including pharmacotherapies shown to significantly improve outcomes of substance use disorders, and the rejection of modalities that have either proved unsafe or ineffective, such as coercive 12-step-based approaches.
- Reducing opportunities for harm and coercion, including addressing conflicts of interest that may exist between physicians who conduct independent medical examinations and the medical monitoring companies that are often a central component of treatment plans.
- Promoting individualized risk management when treating substance use disorders, and moving away from the “one-size-fits-all” approach to risk management that is often applied, regardless of severity of substance use disorder, job environment and work duties.