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Substance Abuse is defined as "The use of illegal drugs or the use of prescription or over-the-counter drugs or alcohol for purposes other than those for which they are meant to be used, or in excessive amounts" (NCI Dictionary of Cancer terms, 2022). Substance abuse may lead to many physical, mental, emotional, and social issues as well as job-related problems. It can affect anyone in the country, but jobs with high stress, easy access to controlled substances, and variable work hours are at increased risk for substance abuse (Ivey, 2015). As this can affect the ability to make proper judgment calls, substance abuse among nurses can create patient safety issues among other safety issues.

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Statement of the Global Health issue (Tamara)

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Statement of the Global Health issue (Tamara)

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Globally, some 535 million people are estimated to suffer from drug use disorders and who require treatment services, according to the United Nations Office on Drugs and Crime (2019).

The United Nations office on Drugs and Crime (2019) reported that in 2017, an estimated 271 million people, or 5.5 percent of the global population aged 15-64, had used drugs in the previous year compared to 2016.

Nurses are on par with the rates of substance abuse in the general population (Foli et al., 2021).

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United Nations : Office on Drugs and Crime

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Vienna, 26 June 2019 - Improved research and more precise data have revealed that the adverse health consequences of drug use are more severe and widespread than previously thought. Globally, some 35 million people are estimated to suffer from drug use disorders and who require treatment services, according to the latest World Drug Report, released today by the United Nations Office on Drugs and Crime (UNODC).

The higher estimates for 2017 are the result of improved knowledge of the extent of drug use from new surveys conducted in India and Nigeria, both among the ten most populous countries in the world.

The Report also estimates the number of opioid users at 53 million, up 56 per cent from previous estimates , and that opioids are responsible for two thirds of the 585,000 people who died as a result of drug use in 2017. Globally, 11 million people injected drugs in 2017, of whom 1.4 million live with HIV and 5.6 million with hepatitis C.

"The findings of this year's World Drug Report fill in and further complicate the global picture of drug challenges, underscoring the need for broader international cooperation to advance balanced and integrated health and criminal justice responses to supply and demand," said Yury Fedotov, UNODC Executive Director.

Severity and complexity of World Drug Situation increasing

In 2017, an estimated 271 million people, or 5,5 per cent of the global population aged 15-64, had used drugs in the previous year. While this is similar to the 2016 estimate, a longer-term view reveals that the number of people who use drugs is now 30 per cent higher than it was in 2009. Although that increase was in part due to a 10 per cent growth in the global population aged 15-64, data now shows a higher prevalence of the use of opioids in Africa, Asia, Europe and North America and the use of cannabis in North America, South America and Asia compared with 2009.

Estimated global illicit manufacture of cocaine reached an all-time high of 1,976 tons in 2017, an increase of 25 per cent on the previous year. At the same time, the global quantity of cocaine seized in 2017 rose by 13 per cent to 1,275 tons, the largest quantity ever reported.

North America's synthetic opioid overdose crisis also reached new heights in 2017, with more than 47,000 opioid overdose deaths recorded in the United States, an increase of 13 per cent from the previous year, and 4,000 opioid-related deaths in Canada, a 33 per cent increase from 2016.

Fentanyl and its analogues remain the key problem of the synthetic opioid crisis in North America, but West and Central and North Africa are experiencing a crisis of another synthetic opioid, tramadol. Global seizures of tramadol jumped from less than 10 kilograms in 2010 to almost 9 tons in 2013 and reached a record high of 125 tons in 2017.

The most widely used drug globally continues to be cannabis, with an estimated 188 million people having used the drug in 2017.

The Report shows that an area where the international community has had a degree of success is in addressing new psychoactive substances (NPS), evidenced by a decline in the number of NPS identified and reported for the first time to UNODC. NPS have not been taken up in the market to the extent feared a few years ago, and the international community has reacted in a timely manner to assess the harms caused by NPS and to schedule those that warranted international control.

Prevention and treatment continue to fall short

Prevention and treatment continue to fall short in many parts of the world, with only one in seven people with drug use disorders receiving treatment each year.

This is particularly striking in prisons. This year's Report provides in-depth analysis of drug use and its adverse health consequences in prison settings, which suggests that the prevalence of infectious diseases such as HIV, hepatitis C and active tuberculosis, and related risks, are disproportionately higher among prison populations than among the general population, in particular among those who inject drugs in prison.

Fifty-six countries reported that they provided opioid substitution therapy in at least one prison in 2017, while 46 countries reported not having such a treatment option in prison settings. Needle-syringe programmes are far less available in prison: 11 countries reported their availability in at least one prison, but such programmes were confirmed as absent in 83 countries.

The Report shows that effective treatment interventions based on scientific evidence and in line with international human rights obligations are not as available or accessible as they need to be, and national governments and the international community need to step up interventions in order to address this gap.

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The World Drug Report and further content is available here: https://www.unodc.org/wdr2019/

The 2019 World Drug Report provides a global overview of the supply and demand of opiates, cocaine, cannabis, amphetamine-type stimulants and new psychoactive substances (NPS), as well as their impact on health. It highlights, through improved research and more precise data, that the adverse health consequences of drug use are more widespread than previously thought.

In 2017, around 53.4 million people worldwide had used opioids in the previous year, 56 per cent more than the estimate for 2016.

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World Drug Report 2019: 35 million people worldwide suffer from drug use disorders while only 1 in 7 people receive treatment

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Vienna, 26 June 2019 - Improved research and more precise data have revealed that the adverse health consequences of drug use are more severe and widespread than previously thought. Globally, some 35 million people are estimated to suffer from drug use disorders and who require treatment services, according to the latest World Drug Report, released today by the United Nations Office on Drugs and Crime (UNODC).

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3.1 million nurses in the U.S.  (U.S. Bureau of Labor Statistics, 2021)

Approximately 10% of nurses have substance abuse  (Strobbe & Crowley, 2017)

High heritability: 40-60%  (Yu & McClellan, 2016)

Risk factors for Nurses: Family history, Stress (Patients death, shortage), experiencing past emotional or physical trauma  (Epstein et al., 2010)

The annual cost of substance abuse: $510.8 billion in 1999 (Scholze et al., 2017)

Alcohol abuse cost: $191.6 billion

Tobacco use cost: $167.8 billion

Drug abuse cost: $151.4 billion

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Per Ivey (2015), it was estimated that 20% of nurses [had] a substance misuse, abuse, and or addiction problem in 2015. This issue has been recognized as a prevalent problem since 1980, so much so that a task force called the Peer Assistance Program was created to help combat the substance abuse problem among nurses.

In a recent study by Trinkoff et. al. (2022), it is found that in the past year nurses working in nursing homes, home health care, and home hospice have the highest rates of substance abuse with illicit drug use at 5.7% and prescription drug abuse at 9.9%.

Not only does substance abuse make nurses susceptible to physical, emotional, and social issues, but it also makes them susceptible to indirect risks such as car accidents and violence. Psychoactive substance abuse also interferes with working ability due to the reduction in brain activity leading to slow response and lack of reasoning. This can lead to work related accidents, safety issues, and adverse events (Rolim Scholze, 2017).

Nurses who have substance abuse problems prior to becoming nurses struggle to maintain sobriety due to easy access to substances at work. "Interestingly, six out of the ten participants in the study indicated that they had problems with substance abuse prior to becoming nurses. However, they relapsed after entering the nursing profession" (Mumba, 2018).

Mumba et. al. (2019), discusses that "the focus for the future should be on improving outcomes of peer assistance programs (PAPs), educating the nursing community on recognition of SUDs, supporting nurses with impaired practice in recovery, and reducing the impact on patient safety".

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Current health delivery model in use (Tamara)

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Current health delivery model in use (Tamara)

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According to the National Library of Medicine (NIL) (2021) the healthcare system has newly integrated roles to deliver diverse care to patients that have substance abuse issues including:

Screening for substance misuse and substance use disorders

Primary Care

Clinics

Delivering prevention interventions to prevent substance misuse and related health consequences

Early intervention to prevent escalation of misuse to a substance use disorder

Engaging patients with substance use disorders into treatment

Counseling

Programs

Facilities

Treating substance use disorders of all levels of severity

In patient

Out patient

Private vs. Public Facilities

Coordinating care across both health care systems and social services systems

Criminal justice

Housing

Employment support

Child welfare

Linking patients to Recovery Support Services

Peer Support Specialists

Long-term monitoring and follow-up

Case Workers

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Advanced Practice QI intervention (Kristy)

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Advanced Practice QI intervention (Kristy)

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An alternative to discipline (ATD) program would be recommended where a CASAC (credentialed alcoholism and substance abuse counselor) trained provider who would report directly to board of nursing (BON) to make recommendations and oversee the treatment of a nurse with substance abuse disorder.  The nurse will not be identified to the BON unless the treatment plan is not followed.  Treatment could be counseling, drug treatment program, random drug screening and work restrictions (Worley, 2019).  In addition to the ATD, nursing education will provide education to nursing staff regarding signs and symptoms of  substance use disorder and what impaired nursing practice may look like.  In addition to this, nursing education will provide education on what to do if a nurse is suspected of SUD.  Studies show that the longer it takes to get treatment the higher the chance of relapse so this treatment program should be in effect immediately (Mumba & Kraemer, 2019).

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Practicality of QI Intervention (Kristy)

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Practicality of QI Intervention (Kristy)

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Utilizing an alternate to discipline (ATD) approach more nurses with substance use disorder will be more likely to self report and supports a Just Culture. A mental health professional who is CASAC (Credentialed Alcoholism and Substance Abuse Counselor) will reduce costs when compared to someone that is doctorate prepared. The American Nurses Association supports ATD programs for nurses and nursing students (Worley, 2019).

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Substance abuse is a problem world wide. It is documented that nurses are on par with the rest of the population as far as numbers per capita of substance abuse, but nurses are at a higher risk simply due circumstance and proximity too high stress situations, access to controlled substances, and variable work hours (Foli et al., 2021).

We found that heredity, mental illness, stress, and trauma all play a role in risk factors for substance abuse. Nurses are exposed to a multitude of variables that increase their risk. The cost of substance abuse is on the rise, and these numbers only reflect the people that admit to having a substance abuse issue.

The QI intervention that we found to be most effective is the alternative to discipline program. ATD programs are self reported and sustain a supportive culture where there is no punitive damage to one's career for seeking help. This program also provides education for coworkers to help identify issues earlier in hopes of helping individuals with SUD sooner. We also found this model to be more sustainable by the hospitals because you can reduce costs by employing a counselor rather than a physician or doctorate prepared psychologist to help nurses with this disease.