‘A Problem You’d Rather Not Address’

In this exclusive video interview, MedPage Today Editor-in-Chief Marty Makary, MD, MPH, of Johns Hopkins in Baltimore, discusses a MedPage Today investigation that found low enrollment among nursing rehabilitation programs with Marvin D. Seppala, MD, chief medical officer of the Hazelden Betty Ford Foundation, which operates recovery programs in several states, including some focused on nurses.

Following is a transcript of their remarks; note that errors are possible.

Makary: I’m Marty Makary with MedPage Today. It’s really an honor to be able to chat today with Dr. Marvin Seppala. He’s the CMO of the Hazelden Betty Ford Foundation, which really runs recovery programs in many states including some that focus on nurses, which is what we’ll discuss today. He’s a national expert in addiction medicine, a psychiatrist, an assistant professor at the Mayo Clinic and at the Betty Ford Graduate School for Addiction Studies. Dr. Seppala, Marv, great to see you, thanks for joining us.

Seppala: Thanks a lot, Marty. Glad to be here this morning.

Makary: So it’s really amazing to me as a surgeon that we see addiction in our specialties that have easy access to drugs, anesthesiology, surgery, and nursing — and nursing has been the highlight of a recent MedPage Today investigation led by Cheryl Clark that just came out. And it looks at these rehabilitation programs specific to nurses. Tell us a little bit about how common substance abuse disorder is in the medical field and among nurses.

Seppala: It’s been really difficult to get solid numbers in the medical field and among nurses. So the numbers that have been examined and survey researched — and a lot of people with this disorder won’t admit to it, which also adds to the problem — suggested it’s about the same as in the general population.

Makary: Is that about 1% to 3%?

Seppala: At any point in time, yeah. Yeah. And some deaths suggest even as high as 10% to 12% and there’s been increases during COVID that we’ve seen alcohol sales go through the roof, increased overdose deaths, that sort of thing. But in the healthcare setting there’s a couple of differences. People are less likely to smoke, less likely to use illicit substances, much more likely to use prescribed medications.

Makary: Tell us a little bit about the rehabilitation programs and the ones specific to nurses that you’ve been involved in.

Seppala: You know, alternative-to-discipline programs are now the norm, but they’re not standardized around the country. And what an alternative-to-discipline program is, is a response to difficulties that occurred historically when nurses especially were found to have a substance use disorder, they were either fired or lost their license. And the same thing was occurring at one point in time with physicians, but not to the same degree. Physicians had more leeway, more recognition that we’d like to keep them in the workplace. But nurses often were ending up in a legal situation — arrested or fired frequently. So there was a recognition of increased need to address this as illness, recognition of addiction as illness in the first place, and a need to do so with our peers in the healthcare setting. And with that, a change in how this is viewed and how it was treated.

And so these alternative-to-discipline programs would require treatment for the disease and ongoing monitoring. And those two things together have been shown to be extremely effective.

Makary: There are 4.2 million nurses practicing actively in the United States and using say, the low end of the estimate of substance abuse disorder that is 1% to 3%, that’s a lot of people who need these programs. Especially since you’ve shown how effective they can be. Yet Cheryl Clark and a MedPage Today investigative report found that they’re massively being under utilized. Let me give you some numbers here. In Ohio, there’s about a quarter million nurses, eight to 16 enrolled in these programs in the last year. Illinois, with 211,000 active nurses, 87 enrolled. California, about half a million nurses, between a hundred to 160 a year [enrolled]. Same is true for Texas, Virginia, Tennessee. On and on. Why such the massive underutilization of these alternative-to-discipline rehab programs that are effective. And instead, use of this old heavy-hand approach of simply firing people.

Seppala: Those numbers are just astounding to me that they’d be that low, even in states that claim to have programs, they’re that low. And I think there is this code of silence in medicine. No one wants to turn in anyone else. There’s a sense that addiction is a personal problem, not necessarily a disease. And so people don’t want to get involved. There’s fear of legal ramifications of what if I get sued for just mentioning my peer in the healthcare workplace. There’s a lack of training among all of us in healthcare. On average, physicians get 8 hours during medical training about addiction. Nurses get less. Even the mental health professionals, psychologists, and social workers get very little, most often elective courses on addiction.

And as a result, we have a healthcare system that doesn’t understand this disease, limiting confidence in addressing it, even identifying it among our peers. All those things add up. A lack of emphasis within the healthcare system also adds to that. And if there aren’t standard sort of means of addressing this illness, and every time it comes up, it’s novel. People don’t know what they’re doing, they make mistakes. And you hear about the problems, you don’t hear about the solutions.

Makary: Has there been opposition to these programs or mischaracterization of these programs?

Seppala: There certainly has been both among the people that are involved in them. The nurses that may be placed in such a program could be resistant partially because of the very nature of addiction. Addiction re-prioritizes drive states in such a way that continued use becomes even more important than life itself. Survival is no longer the priority of the reward system of our brain. And as a result if someone threatens that, we’re going to get angry about it or resistant to it, and may not want to involve oneself in such a program and speak poorly of them. There’s also states that have seen difficulties over time and factions within those states — California, for example — that have tried to end these programs because they just don’t want any risk. They think in the healthcare workplace they want to fire everybody that may have a substance use disorder, which is a false premise. You know, you can’t fire everybody. You can’t even identify it. And if you use that sort of a punitive approach, no one’s coming forward and you miss the bulk of the problem.

Makary: Are some programs too harsh?

Seppala: Yeah. Some programs are too harsh about this issue because it’s real easy to see it as a problem that you’d rather not address. You know, you’d just rather it go away, go work somewhere else, than have to deal with it in our system. And as a result, because of the stigma about this illness, the misunderstanding about this illness, people can be very harsh about it.

Let’s say that part of your return to work agreement and contract includes that you’ll be monitored in the healthcare workplace. And your monitor is a supervisor who really has poor understanding of this and has a marked bias about this disease. They may be very harsh about how you’re treated, and put in a situation where you can’t find shifts you can work because for some period of time you can’t provide medications to patients on a hospital unit. And so that supervisor says, well, since you can’t do that and you don’t get to work here, then we’re not going to really work very hard at finding you another position right now. So yes, it can get very harsh. Or the expectations could be extreme. You’ve got to go to a meeting every day and psychotherapy twice a week and do all these other things effectively leaving you with no free time, no downtime outside of the workplace. And the requirements of the program, which could appear harsh as well.

Makary: Sounds like it can cross over from being therapeutic and helpful to a penalty, in other words, vindictive.

Yeah it sure can, easily. And partially because of these biases about whether it’s an illness or not, people just see it as a character flaw. They aren’t going to see you as capable of rehabilitation. They aren’t going to see you as capable in the healthcare workplace and they just assumed you were gone. So there’s a good chance they may treat you very harshly.

Makary: It’s interesting, the parallels to patient safety, where we’ve seen the same sort of approach of simply firing somebody who makes a mistake for being human basically, and not addressing the problem. Now, the MedPage investigation also found significant variation in the quality of these programs by state variation in their outcomes and the recovery rates, and then their complication rates. You’ve thought a lot about this problem. How do we get at better standardization?

Seppala: I think we need a federal approach because currently it’s state-by-state. So we have basically over 50 different ways of going about this. And as a result of both that issue, with a lack of standardization and the lack of numbers, the lack of metrics to use to look at outcomes, we’re left without the ability to really improve the system. You would think that with all these different states doing different things, you would have that opportunity to use those metrics. But unfortunately we don’t have a lot of research in this area. So we need that. We need the standard approach, we need metrics, we need the ability to really examine what we’re doing. Like any other illness, examine the treatment, examine the outcomes, and make changes based on the results.

Makary: It’s pretty clear to me that on a policy level, our sort of federalist system where licensed actions are done at individual states, and then would have an action and jump to another state, that’s a clear policy failure. But a lot of people listening are working at a hospital or in a clinic. And this problem may be very close to them or it may be about to emerge in some situation. When people want to do something about this issue on a local level at their hospital, what can you tell them right now about these alternative-to-discipline rehab programs?

Seppala: In a hospital setting it’s necessary to inform all of your employees about such systems so that they understand that this is an attempt on the part of the system to provide both safety for the patient and care for the employee. And I think of both of those things as absolutely necessary in such a system because these alternative systems allow for both and provide both. And if you inform the whole workplace, all your nurses, all your providers know, that that’s the case. That we’re going to do both, that we see this as a disease that we’re going to do everything we can to get you back into the healthcare system working ultimately. Then it opens opportunity because then the people that do not have a substance use disorder that start to recognize problems might actually report those problems more frequently than they otherwise would because they know that both will occur.

Makary: Dr. Seppala, thank you so much for your work as CMO of the Betty Ford Foundation. Thanks for your leadership with these alternative-to-discipline rehab programs, you’ve been a real pioneer in this space. Folks can learn more about it in the recent MedPage Today investigation by Cheryl Clark. Pretty remarkable at the state level, how they’re being massively underutilized. Thanks for joining us today, Marv.

Seppala: Thanks a lot, Marty.