It Is Time to Consider Alternatives to Discipline Programs

Substance use disorders (SUDs) among health care professionals (HCPs) can potentially destroy careers and lives, hurt employers’ financial bottom line and reputation, and jeopardize patient safety. Unfortunately, HCPs who have developed SUDs may work under the influence or divert medications from their places of employment. The hope is that they are discovered or self-refer for treatment before harming a patient or themselves. If the HCP is caught, along with embarrassment and shame comes the real possibility of losing both job and license to practice, as well as criminal prosecution.

But state licensing boards increasingly have used an alternative to discipline in some cases of drug diversion, understanding that the behavior often is a symptom of an underlying SUD. Professional assistance programs (PAPs) exist in almost all states and can provide a pathway for licensed HCPs who have diverted to return to practice during or after SUD treatment.^1,2 Furthermore, PAPs have shown success rates, measured by abstinence and retention to work through follow-up, varying from 60% to 90%.^3-5

Historically, HCPs discovered diverting would almost always have had their employment terminated. Some health care employers are planning or have instituted an alternative to discipline that would allow HCPs to maintain employment while receiving treatment for SUDs. Unfortunately, most employers have been slow to consider this approach. Opponents of this approach argue that keeping a known diverter on staff is unsafe and puts the employer and patients at risk, and that not having the strictest possible penalties may incite diversion. Proponents of the alternative- to-discipline approach, however, argue that data from state PAPs have shown that with the right elements, the option can prove highly successful and even improve patient safety.^3-5 An alternative-todiscipline approach may encourage HCPs living with SUDs to self-report, and coworkers may also feel more comfortable reporting concerns if they know that it would not necessarily result in the employee being fired. It could also be argued that by terminating employment, employers pass on the problem to another institution, putting more patients at risk. Following a diversion complaint, state disciplinary processes can take 6 to 18 months before an HCP is removed from practice.⁶ Employers may also not learn as much as they could about the diversion, because HCPs are no doubt incentivized not to be forthright during an investigation tion if they know that termination would be the likely result. Termination also means that the employer is not addressing individuals’ problems and is passing up an opportunity to play a part in their recovery. In 2020, of the estimated 41 million Americans over age 12 years who had a SUD, only approximately 7% received treatment.⁷

The thought of creating an alternative to discipline can be overwhelming to some employers; such a program can be costly and labor intensive. However, the resources required to create and maintain a program can be minimal, assuming the organization resides within a state that has a robust PAP. One strategy is to require that the employee apply for, be accepted into, and maintain compliance with a state’s PAP to retain employment. By using this approach, employers can take advantage of the structure and monitoring resources already in place. Every state’s PAP is different, depending on the profession and state, but they generally have comparable structures. Initially, PAPs require cessation of practice for a period while the HCP begins treatment for the SUD. Following approval from a treatment provider, the HCP eventually returns to practice with certain workplace restrictions and a monitoring plan. Restrictions typically include no handling of controlled substances and possibly reduced hours for a period. These restrictions are eased as the HCP successfully progresses through the PAP. Monitoring requirements include the HCP being required to continue SUD treatment and submit to frequent random drug screens to ensure that they abstain from unauthorized use of alcohol or drugs for the duration of their participation in the PAP. The HCP will also have an assigned workplace monitor, often a supervisor, who is responsible for routine progress reports to the administrators of the PAP. This communication must be 2-way, because it is critical that the employer know whether the HCP has been noncompliant with other aspects of the PAP. The time required to successfully be discharged from a PAP varies based on the individual’s progress. However, the minimum required time is generally at least 2 years.^1,2

Employers that institute an alternative-to-discipline approach must decide on eligibility criteria. Such an approach may not be deemed appropriate in all diversion cases. Instances in which HCP action caused or could have caused serious patient harm, such as drug substitution or tampering, may present such an egregious violation that an alternative-to-discipline approach may not be palatable. Diversion for trafficking purposes may be another reason not to use an alternative to discipline. Past job performance and the perceived level of cooperation with the diversion investigatory process may also be factors considered in deciding whether to offer a nonpunitive approach.

It is important to note that regardless of whether an employer uses an alternative-to-discipline approach, there remains an obligation to report controlled substances diversion to the US Drug Enforcement Administration and state regulatory agencies, including licensing boards.⁸ Regardless of the decision regarding continued employment, the employer also has a responsibility to provide information about SUD treatment to the employee.

SUDs continue to affect HCPs and their employers and patients. Effective alternative-to-discipline programs require long-term commitment by the employer and the HCP, but they can be successful in saving lives and livelihoods while having a positive impact on patient safety.

Stephen M. Webster, PharmD, MBA, is the associate director of pharmacy, drug diversion detection, and prevention at the University of Rochester Medical Center in New York.

REFERENCES

1. Alternative to discipline programs for substance use disorder. National Council of State Boards of Nursing. Accessed February 10, 2022. https://www.ncsbn.org/alternative-todiscipline.htm

2. State programs. Federation of State Physician Health Programs. Accessed February 10, 2022. https://www.fsphp.org/state-programs

3. Geuijen PM, van den Broek SJM, Dijkstra BAG, et al. Success rates of monitoring for healthcare professionals with a substance use disorder: a meta-analysis. J Clin Med. 2021;10(2):264. doi:10.3390/jcm10020264

4. Smiley R, Reneau K. Outcomes of substance use disorder monitoring programs for nurses. J Nurs Regul. 2020;11(2):28-35. doi:10.1016/S2155-8256(20)30107-1

5. Mumba MN, Baxley SM, Cipher DJ, Snow DE. Personal factors as correlates and predictors of relapse in nurses with impaired practice. J Addict Nurs. 2019;30(1):24-31. doi:10.1097/JAN.0000000000000262

6. Bettinardi-Angres K, Pickett J, Patrick D. Substance use disorders and accessing alternative-to-discipline programs. J Nurs Regul. 2012;3(2):16-23. doi:10.1016/S2155-8256(15)30214-3

7. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2020 National Survey on Drug Use and Health. October 2021. Accessed February 24, 2022. https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf

8. Other security controls for practitioners. 21 CFR 1301.76 (2022). Accessed February 11, 2022. https://www.ecfr.gov/current/title-21/chapter-II/part-1301/subject-group-ECFRa7ff8142033a7a2/section-1301.76