Amidst the pandemic's second wave in the fall of 2020, Tiffany Swedeen, RN, a nurse in recovery from substance use disorder, was struggling.
Working at an intensive care unit near Seattle for the better part of 16 years, she was used to caring for the sickest of the sick and feeling confident in her skills and abilities.
Suddenly though, "I didn't anymore," Swedeen said. Pandemic protocols changed frequently, and whether any of the COVID treatments helped or harmed was hard to tell at first. "I would have nightmares about the patients that I couldn't save, and it was most of the patients."
She had been sober for four and a half years and had built a platform to help other nurses navigate the recovery process. That made it all the more painful to feel her own resolve crumbling.
After failing to get support from her family over the holidays, Swedeen went to work on Jan. 3, 2021, feeling "alone" and "unworthy." She put two more patients on ventilators and left her shift at the hospital with several stolen syringes of high dose fentanyl. She used them at home and blacked out for most of the day.
Swedeen wasn't feeling suicidal "in any active sense." But, she said, "I felt impulsive and reckless and wanted to escape my feelings."
Within an hour of returning to the hospital for her shift on Wednesday, Jan. 6, 2021, her manager asked to meet with her. She looked Swedeen in the eyes and said she was sorry.
"I wanted to disappear," Swedeen said.
The Scale of the Problem
The pandemic's heightened stressors, longer hours, and short-staffing without any clear end in sight has led some experts to suggest that the battle with substances -- mainly alcohol and opioids, but also methamphetamine -- has intensified in the field.
Of the roughly 4.2 million nurses in the U.S., conservative estimates suggest that 1% to 3% may have a substance use disorder. Other experts interviewed by MedPage Today suggested an even higher proportion -- closer to one in 10 nurses.
During the pandemic, around one in five nurses said their alcohol consumption had increased, and 3% said they had increased their substance use, according to a survey published by the American Nurses Foundation in October. Among critical care or intensive care nurses, estimates of increased alcohol consumption jump to one in three.
There's currently no reliable data on the number of nurses whose substance use slid into the realm of a disorder or on how many with an addiction that had been under control relapsed during the pandemic.
Because of stigma around substance use and fear of losing their jobs or their licenses, most nurses with substance use problems do not seek out help voluntarily, said Deborah Koivula, RN, CARN, in her role as the Eastern Regional Coordinator for the Statewide Peer Assistance for Nurses (SPAN) education and advocacy program in New York. (See sidebar on how most nurses with substance use issues do not seek help voluntarily.)
In fact, nurses typically engage in treatment late in the process of their disease. Nine out of 10 of the nurses who connect with SPAN do so only after a legal or employment issue, such as being caught diverting narcotics or driving under the influence, prompts them to ask for help, she said.
And a recent MedPage Today investigation found enrollment in alternative-to-discipline programs -- the route widely considered nurses' best chance at recovery, without disciplinary action -- is "tragically small," according to one nursing expert.
Enrollment in such programs could be an indicator of trends, but programs contacted by MedPage Today reported widely varying experiences.
Rodrigo "Rigo" Garcia, MBA, MSN, APN, CRNA, of the Parkdale Center in Chesterton, Indiana, said he "absolutely, 100 percent yes" has been seeing more nurses relapse during the pandemic. When he spoke to MedPage Today in August, in an interview monitored by a media relations representative, he cited both increases in enrollment in treatment and in the alternative-to-discipline programs he oversees.
On the other hand, nursing boards and commissions in Oregon, Ohio, and Washington told MedPage Today that the number of nurses enrolling in their alternative-to-discipline programs had either remained consistent with pre-pandemic enrollment or actually declined.
Oregon's State Board of Nursing hasn't seen any changes in the number of nurses who entered either the alternative-to-discipline program or public probation in 2020 or 2021, said its communications manager, Barbara Holtry. However, she cautioned: "We have no way of knowing how many other nurses may be out there who have sought treatment" privately.
California saw a decline overall in the number of participants in its recovery programs for nurses and other healthcare professionals (including dentists, physicians, veterinarians, and other healthcare professionals) from July 1, 2020 to June 30, 2021, according to Vincent Miranda, an information officer specialist for the California Board of Registered Nursing. But it's unclear whether that lower enrollment should be attributed to the pandemic, he said, because enrollment has declined every year since 2010, with the exception of 2013.
Miranda attributes the decline to stigma and a "knowledge gap," citing a recent study in the Journal of Nursing Regulation that found nurses would benefit from better guidelines and education around substance use problems.
Problem Signs
However, there have been worrying signals that the problem is deeper than the story told just by enrollment numbers.
Despite "steady" enrollment in his state's alternative-to-discipline program for the last 5 years, Grant Hulteen, who oversees Washington Health Professional Services, said he's now seeing staffing issues at testing sites used by programs to track nurses' sobriety and keep them accountable.
Most alternative-to-discipline programs require nurses to submit to random urine analyses and other tests. But COVID-related staffing problems have shut down or limited some collection sites. Some sites no longer have the ability to conduct special tests, such as hair and blood tests, Hulteen said.
Because of increasing nursing shortages and the continuing uncertainty brought by new variants, it may be that the healthcare environment hasn't yet stabilized enough for some nurses to begin to seek help, said Koivula.
"That pending wave is still out there," she speculated.
"Just like going through any natural disaster," she said, "it's often after the fact that first responders are realizing the trauma that they've experienced."
Another sign that some substance use problems are still under the radar during the pandemic is the severity of those who do reach treatment.
The typical nurse-participant entering one of Garcia's addiction recovery programs 2 years ago was someone who had diverted drugs for 3 to 6 months and who was experiencing a moderate level of mental health issues, depression, or anxiety, he said.
"Now, we're seeing drug abuse for a year and a half. We're seeing advanced stages of mental health, depression, and anxiety. We're seeing helplessness and hopelessness. We're seeing suicide ideations increase," said Garcia, a volunteer member of the American Association of Nurse Anesthesiology's Peer Assistance Advisors Committee and paid speaker for Alkermes, the maker of extended-release naltrexone (Vivitrol) for substance use disorder treatment.
Intake numbers might not have changed due to the high demand for nurses in the workforce right now, suggested Tracy Traut, director of the Indiana Professionals Recovery Programs. But the nurses who have walked in her door since the pandemic started are much farther along in their addiction.
"[T]heir pathology and the number of things that they're dealing with in terms of mental health and bad, maladaptive coping mechanisms has tripled," Traut explained. "We have people who are in their 40s that are all of a sudden popping up and using drugs at work because they're trying to cope with all the stress in the middle of COVID."
Another significant trend she's seen as the pandemic unfolded is the rise in amphetamine abuse among nurses struggling with addiction. Before November 2021, the top drugs of choice for those in the program were opiates followed by alcohol, Traut told MedPage Today.
"Amphetamines are running neck and neck now with opiates," she said. "It's not just Adderall or cocaine -- it is meth. They are smoking meth."
Kelli Jacobsen, MSW, LCSW, started working with nurses at the Utah Professionals Health Program, an alternative-to-discipline program based in Salt Lake City, a little over a year ago when the pandemic was already in motion.
Throughout her career, she said, it's been pretty typical to see a person with a history of substance use that can be traced back years, perhaps starting with marijuana or alcohol in high school that then took years to progress. Now that profile has abruptly shifted.
"What I've noticed through this pandemic is this rapid development of severe use over such a short period of time," Jacobsen said. At one point a couple of months ago, she recalled, the program had a batch of nurses that self-reported their substance use.
All but two of them "really didn't have much of a substance use history until the pandemic -- maybe 6 months to a year before the pandemic they started, and then it really rapidly progressed during the pandemic."
Vanishing Support for Those in Recovery
Garcia, who is in recovery himself, blames the pandemic: Because everyone on the front lines was so focused on responding to outbreaks, staff did not notice reports of complaints and overlooked clear warning signs -- attributing changes in personality and behavior to pandemic-induced stress.
That was the case for Leah Alanis, RN, a nurse in New Hampshire who has an addiction to alcohol.
She mirrored Swedeen and other nurses MedPage Today spoke with in pointing to the one-two punch of the pandemic and holiday-related isolation in pulling the support system out from under her.
She had been going to Alcoholics Anonymous meetings at least four times a week. But when the pandemic hit, those in-person meetings transitioned to Zoom, which wasn't the same for her. Weekly dinners with her sober girlfriends stopped, and other friends began pulling out of her life, afraid that her healthcare exposure might give them the virus, Alanis explained.
While her work in an outpatient urology practice was stressful -- she was calling patients having to tell them their surgeries would be canceled or postponed due to the pandemic -- the real problem for her was that loss of support.
After what began as "one of those, like, 10-day around-the-clock drinking benders -- missing work, missing life" in March 2020, Alanis did not find her way to sobriety until nearly the end of that year.
On three separate occasions, in March, in May, and in July through the early wave of the pandemic, Alanis went through withdrawal and wound up at a local hospital. She begged hospital staff to help get her into an inpatient treatment program, but there were no beds.
Alanis made it to work most of the time, albeit a bit disheveled. When co-workers asked if she was okay, she'd just lie.
The holidays have always been a difficult time, Alanis said. She felt isolated from her family living far away in Texas. The cold, dark New England winters didn't help.
Alanis said she started to drink again after work on Dec. 22, 2020, "and I didn't stop until the 29th, when I physically could not put the bottle to my face anymore."
That day, Alanis texted her boss: "It's either I go to treatment or I'm going to die."
Her boss texted back that she'd been waiting for Alanis to admit she had a problem.
"She said, 'Please, please go get the help you need and come back to us strong,'" Alanis said.
"That text saved my life," she said.
One Day at a Time
Alanis got into "rehab" and has mapped out a route to recovery. She connected with other recovery programs outside of Alcoholics Anonymous, joined an exercise accountability program, and has immersed herself fully in "holistic healing." She also has been working with counselors to understand what drove her to drink so much in the first place.
She was able to renew her license without stipulations after an investigation by the nursing board but has been placed on an "absence monitoring" program at work under which she can be penalized if not compliant.
Alanis, who had reached nearly 1 year of sobriety when she spoke to MedPage Today, said she felt guilty not helping her colleagues on the front lines of the pandemic. She just began training to work as a "runner" at a local hospital on weekends and is learning to trust herself. She knows the environment could test her resilience, but said she's prepared to stop if she finds she isn't doing well and believes "that I'll be able to say ... 'I thought I could do this for you guys, but I can't.'"
For Swedeen, life changed after being confronted by her manager, but she still said she's relieved to have been caught.
"If I would have stayed in that department, under that amount of stress with ... just such easy access to narcotics. I think the outcome would have been probably tragic," she said.
Swedeen reached out to her case manager at the alternative-to-discipline program she's enrolled in, who decided to extend her contract for an additional 14 months. And she resigned from her position at the hospital, in lieu of termination. The nursing commission did not end up revoking her license but did leave a charge of "unprofessional conduct" visible to anyone who searches her name in the National Practitioner Data Bank. She is pursuing her masters' degree in nursing education and hopes in the future to consult on creating curricula for nursing schools and improve substance use prevention and treatment programs for nurses like her.
In the time she has left in the alternative-to-discipline program, Swedeen said, "I will fight tooth and nail to not relapse again."
Last Updated December 30, 2021
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'Pending Wave' of Nurse Substance Use Problems? - MedPage Today
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