Our Guest: Laura Iosue, Iosue Law, LLC
Legal heavyweight Laura Iosue returns to dissect the world of Recovery Monitoring Agreements (RMAs). But when do these supposed safeguards become a detriment? We’ll unpack Laura’s insights on RMAs, exploring specific situations where she urges caution. Tune in for a critical look at these agreements and discover whether they can truly pave the path to a successful recovery.
Transcript:
Terri
All right, everybody, I told you there would be a part B with Laura Iosue, and here we are. So we’re going to continue this conversation. Laura is a litigator, been in practice for over 30 years. Go back. This will be actually my third interview with her. There’s just a lot to talk about, I think, especially for me, because it’s just, it’s a new area for me that I don’t have a lot of experience or knowledge in, and she has a wealth of information. So in this episode, we are going to talk about recovery monitoring agreements. Now, for the sake of myself and many of the listeners, let’s start with the basics so that we are all on the same page. Just define for us what a recovery monitoring agreement is, and let’s start there.
Laura
A recovery monitoring agreement is an agreement that a practitioner enters into with their recovery monitoring agency. And so whatever. So a recovery monitoring agency. In Indiana, it’s called ISNAP, which is the Indiana state nurses Assistance program. Here it is contracted. The organization that has the contract is IPRP, Indiana professionals recovery program. It’s my understanding that every state has them. In Kentucky, it’s called care with a k. You know, sometimes they’re given neat names like PRN program. Right. Physicians or pharmacists Recovery Network. Right. You know, professionals recovery Network. So. But those are the organizations that are tasked with monitoring the sobriety and recovery of impaired practitioners. And so they’re basically assistance programs.
Laura
And what happens is when a person can go to their recovery monitoring agency voluntarily or they can be ordered to go into the recovery monitoring program by the board or sometimes even by a criminal court. I’ve seen that, too. And so what happens when they go into these programs is they are evaluated for a substance use disorder, sometimes also for a different. Like a dual diagnosis. Yeah. Well, yeah, alcohol. But also, maybe they have bipolar. Maybe there’s severe depression or something. So they would be evaluated, and then if they meet the criteria for the monitoring agency, they would be placed into a recovery monitoring agreement that they would sign. And what that is they have to comply with the terms of that agreement for whatever length of time it is deemed necessary by the monitoring agency.
Laura
And so terms of the agreement are generally, of course, your usual things, right? Keep your address updated and all that stuff. But the ones that are important to diversion would be random drug screens, right. In Indiana, it’s very often, it is 16, usually 16 drug screens a year, unless they’re working as a nurse. When they return back to working as a nurse, then it generally goes up to 26 drug screens a year. It might be Aana, celebrate recovery, smart recovery, some kind of a group meeting, however many per week. It might also encompass individual counseling. Sometimes if the person is working, there can be a narcotics restriction where they don’t have access to narcotics.
Laura
Often there is a quarterly report from the employer, from a nursing employer who has to give kind of a progress report, an update about how the person is doing at work. If the person’s not working in the field, like, let’s say they’re working at Target, they may be required to still give those updates to the monitoring agency. The question could be, well, why would you be in a recovery monitoring agreement if you’re not even practicing? It might because the person might not really be safe to practice yet. It might also be that the person is suspended from the practice and they cannot petition to get their license reinstated until they have been in recovery for x period of time. So there’s that. I realize again, Terri, I’m kind of all over the place here.
Terri
You asked a couple of, I mean, I was thinking that, too. One of my questions was going to be, do you only do it when you’re trying to return to work?
Laura
Right. No. I mean, I’ve had nurses who haven’t worked in several years, but they stayed in the program. One for the accountability piece is that’s good for their recovery, but also because they can’t get back in until. Right. Or I had one nurse recently who was on the OIG exclusion list because of a felony conviction, but his license was only on probation, but he really couldn’t work anywhere anyway because it was, you know, where are you going to work that Medicaid or Medicare isn’t accepted. Right, right. So, but he, you know, they stayed in it for a while anyway, but I’ve had several nurses who have stayed in it just for the recovery, you know, to assist with their recovery. But so the random drug screens, that’s a critical piece that I think we need to talk about, and that is generally with.
Terri
Let me, let me ask you one question. So does the recovery monitoring agreements start after? Does it start like the day they get into the program, or is that more something down the line once they know. Okay. Starts right at the beginning. If you’re going to be in our program, this is what you do. And then once you’re like, if it’s an inpatient, but now you’re outpatient, now you have to keep doing these things and whatever, and then you’re still, because at some point you graduate from the program. Right. So then do the conditions.
Laura
Yeah, I mean, it’s a little, you know, you gret. Okay. So I guess the best way to do it, say it, is this. In Indiana, the program director, I really like her a lot. She’s great. But I want to sit down with her and find out exactly what their criteria is. So. But if, you know, if someone has diverting from work, legal trouble. Right. You know, very often we’re seeing a five year recovery monitoring agreement. It’s my understanding that the research shows that it’s the five year mark that is better for success. That’s my understanding. Again, I’m not a therapist or anything, you know, but. And I did not sleep at a Holiday Inn express last night. I’m just saying. But the young kids don’t get that joke. You don’t even get that joke.
Terri
No, I don’t get that joke.
Laura
Where the person would say, oh, I’m not a doctor, but I slept at a Holiday Inn Express last night.
Terri
All right, I think I’ve said this.
Laura
To you before, Terri. Google it. So that’s a five year recovery monitoring agreement for someone with severe substance use disorder. Right. But then if it’s, you know, there are various levels. It might be a three year recovery monitoring agreement if it’s, you know, substance abuse, but not, you know, a use disorder. Right. Or I recently had someone who was put in a recovery monitoring agreement for a year because they believed that person was at risk for developing substance use disorder. Right. And so. So it was just for a year. So as far as graduating from the program. Yeah, you graduate it when you complete it. Now, there are times is the person. Is the practitioner who’s in the agreement, are they gonna slip up? Sometimes that can happen in various forms.
Laura
So in talking about random drug screens, what’s involved is it’s my understanding that there’s an app on the phone, and every day you check in on the app to see if you have to screen that day. And then you have to go. If today’s your day. Yep, you gotta go. You gotta screen. And. And then they’re, of course, checking for dilutes. They’re checking to be sure it’s actual urine, you know, or any positives. Right. Or negative for something that it ought to be positive for. That’s critical too. Right, right. So that is the cumbersome. I think that’s the cumbersome piece for a lot of people.
Terri
And potentially expensive, I would imagine.
Laura
And sometimes it’s a real barrier. People are like, you know what? I would rather give up my license because I can’t afford this. I’ve seen that time and again. It’s sad, particularly for an LPN, right, who’s not making as much. You know, that’s, it’s, it’s a real problem. So. But then there’s also people. They might miss a check in. They slept. They slept through it. You know, they’re working nights, whatever. They missed the check in or they didn’t show up for a test because. For a screen like their kid was sick or, you know, something like that. Or a transportation barrier.
Terri
Yeah.
Laura
You know, so those are really hard things, I think, when, I think the availability of AA meetings and NA meetings virtually, you know, in most places. And I shouldn’t say that, I mean, I’m sure there are rural areas, even here indiana, that they don’t really have good Internet access. But you know, if you have access to the Internet, that really should not be a problem at this point. Right. I mean, three AAna meetings a week and you can attend them remotely. That really shouldn’t be a problem. Even therapy is done remotely a lot of the times now. Right? So a lot of those things, those barriers have been removed. But a urine screen, you can’t phone that one in. And it is costly. And then, you know, I had a kid last week.
Laura
It wasn’t, it was a kid who’s on criminal probation, not a practitioner at all. But he got called in to screen that day. Well, it was Friday before Christmas. Never occurred to him that the testing facility closed early. So he was going to get in trouble for a miss screen. And he was like, I went there. I had no idea that they were. It never occurred to him, you know, those things are problems or people that have alternative work schedules. Those things are, you know, it’s hard. It’s really hard.
Laura
There are times that you can get. I don’t know what you call it. I just was looking at it yesterday. It’s like a break. Like you can get a recession if you’re going to be out of the country or something.
Laura
Right, right. And then they might want you to come back and take a peth test to be sure you weren’t using. Right, right.
Terri
Yeah. That was an excuse for something.
Laura
Correct.
Terri
Is there, is there ever a time that you would recommend not signing an RMA? When would that be?
Laura
You know, in my previous life at the AG’s office, I always thought, absolutely. Go get signed up right away. In cases where it’s not clear cut that the person has a substance use disorder. Like, it’s a. It’s a one off, you know, a DUI. They were out with girlfriends, and they had one too many mimosas at breakfast. Okay. And they’re right on the line, and there’s been no issue. What I’ve been doing is I have that person. Sometimes I do this.
Laura
Not always, but I think it’s a good idea to get an evaluation elsewhere first, and then you know what you’re dealing with, because if the person has a criminal charge, in my experience, if a person has a criminal charge and or a licensing charge with any kind of illegal situation that has something to do with alcohol or other substances, they’re gonna put them in an RMA. And sometimes people are like, I don’t have a substance use disorder. I had a bad night. You know, my boyfriend and I, we had a huge fight, or my dad died, or you know. Know.
Laura
You know, I know that theory is that if someone gets picked up for DUI, they have probably driven drunk before. I get that. I don’t know that statistic. I don’t know where that study came from. I don’t know anything about that. But I do know that sometimes people just have a really bad night.
Laura
You know, and so when I’m not sure if the person has that obvious that they need some kind of monitoring, I don’t have them do it right away. I absolutely do not. I think that. Go ahead.
Terri
I was just going to say, I would guess that the monitoring agreement is often attached to the ability to work. So if they refuse to do it, does that?
Laura
If you’re at that point.
Terri
Okay.
Laura
Oftentimes people call me before they’re there yet. Right. If somebody calls me because they’re a nurse or because they got a DUI and they happen to be a nurse and doesn’t even know about it. Right, right. And it was a one off, you know, DUI. Now, the other question is, do I have to tell work that I got a DUI? Right. That comes up all the time. And what I say is, you got to look at your employee handbook. Most employee handbooks, I’m finding, are available online. The practitioner might have access to it, whereas somebody else wouldn’t. Right. You log in, you look it up, but look at that and see, do I have to report this to my employer, because sometimes you don’t. Again, it’s only convictions.
Terri
Well, and I mean, I think a lot of policies say you have to report if you’re on any medication that could be impairing. Yeah, but they’re not reporting that either.
Laura
Right.
Terri
You know, I’m on a, you know, benzodiazepine for sleep. I’m not going to tell my employer that. So they’re not adhering to those policies either, probably for the most part.
Laura
Right?
Terri
Yeah.
Laura
Right. So, you know, so those are the instances, you know, where I would tell somebody, don’t do it until you have to. And the reason is, because it is hard. They get stuck in. Look, I’m an advocate of a recovery monitoring agreement for people with a severe substance use disorder. I think they need it. It holds them accountable. It keeps everybody safe. Right. I mean, I think that the goal of this entire process, the licensing process, is to protect the public from an unsafe practitioner, but it’s also to protect a practitioner from an unfounded grievance. Right. Okay. So I am a huge proponent of recovery monitoring agreement. When it’s necessary.
Laura
If we’re not sure that it’s necessary, and there’s never been any indication that it’s affected work or that the person, their judgment is not impaired, it becomes very cumbersome, in my experience, for a client to do those check ins, to take off time of work and go pee in a cup, particularly if they’re young and they have little kids. Right. And so they’re navigating, you know, taking time off of work, but then going and picking up the kids from daycare. And, I mean, it’s. It’s very hard.
Terri
If they say no to a monitoring agreement, does that often then end up kicking them out of the program, the recovery program? Or are they. Do they understand these nuances which agree to the recovery.
Laura
I think we’re talking about two different things. So indiana, you are only in the Indiana state nurses assistance program. You’re only in it if you are in a. If you signed a recovery monitoring agreement.
Terri
Oh, okay. Okay. So they’re not even in it. If they say, okay, it’s one. It’s all together. So now, all right, so the person who won’t sign one cannot be part of the program, and they’re completely on their own for, if they need help, where they’re gonna get it. So your thought is get another assessment to see if you even need it. Or let’s talk about. Yeah. How you landed, where you land them. Okay.
Laura
Right. And indiana, if someone fails to comply with a recovery monitoring agreement, they, if they’re dropped from it. Right. The. For repeated failures, ISnaP is mandated to report that to the board.
Laura
So, you know, if you’re in a recovery monitoring agreement and maybe you and I don’t want to say you shouldn’t have been. Right. I don’t want to say that because I have great respect for our recovery monitoring program. I really do. And I collaborate with them with questions and that kind of thing. So I have great respect for them. And they’re the trained professionals. I shouldn’t be in the business as a lawyer trying to negotiate a shorter length of an. I have seen other lawyers do it, and when I was at the attorney general’s office, it made me insane because I thought, you stay in your lane and they’ll stay in their lane. Okay. And so, when. When I. And that’s why on the front end, I’m saying, let’s get a different evaluation. Sometimes I say that, sometimes I don’t.
Laura
But, you know, if the person has another evaluation, then I can use that later to say to some other arbiter, a tribunal, whether it’s the board or something else, to say whether or not this length of the RMA or these conditions are appropriate. I don’t think that I should be negotiating with the recovery mile agreement what the terms are or the length.
Laura
Because they’re the professionals. I have respect for them.
Terri
Yeah. And they probably do assessments that just because they’re a healthcare professional, they probably like. No, you don’t have, you know, you got yourself into a bit of legal trouble here, but we don’t think you have a substance use disorder. I would think they would probably say that at times.
Laura
I mean, I would hope. I don’t. I don’t know exactly what their criteria are. Yeah, I don’t know. So. Yeah, but, yeah, but given the idea of if you are in an RMA because, you know, because that’s what you need to do, but then, you know, you’re having trouble complying.
Terri
Yeah. Right.
Laura
And part of the trouble complying is because you have a bunch of kids and, you know, or whatever, then. Then you’re going to get booted from the program, which means then it’s going to go to the board. Right now. That isn’t to say that you get one dilute or one missed screen or that you’re automatically booted. Of course not. You’re going to staff it and they’re going to say, all right, well, let’s try this. Let’s try soberlink, or let’s try increasing your drug screens, or, you know, let’s extend your recovery monitoring agreement for three months, whatever. You know, that’s. But there comes a point after repeated failures that they’re going to staff it and say, this is not sustainable, you’re out.
Terri
Right? Yeah. Okay. That makes sense. Okay. All right. Do you have any experience with the American Disabilities act and how any of this might play into. My understanding is a substance use disorder is covered under that. But you have to be in recovery or getting some help. But it’s a very complicated.
Laura
It’s very complicated, and I don’t know a lot about that. I’m not going to. I’m going to be honest with you. I don’t know a lot about that. However, I will tell you that when I was at the attorney general’s office, we would oftentimes have the Indiana State nurse assistance program that says abstinence based. It says that in our statute, abstinence based. Okay, well, it was interpreted as strict abstinence from any substances. Okay, well, then what happens when you get a nurse who has add and that nurse needs to take Adderall to function better as a nurse? Right. Or she has severe neuropathy and gabapentin helps her? Right. Fibromyalgia, something like that. Right. Indiana’s board had taken abstinence based to mean. I think I just said that. Absolute strict abstinence. Well, when I was at the AG’s office, I was like, this is.
Laura
This is a lawsuit waiting to happen because of exactly what you said. Right. Add is a medical condition, and we know that Adderall or concert or, you know, ritalin, methylfinity, it helps. It’s controlled. Okay. All right. Well, ultimately, it is my understanding, and I haven’t looked at the case in a while.
Terri
You were right.
Laura
It was a lawsuit because the Indiana state. Indiana nursing board did get sued, and now they. There were nurses who quit nursing because they weren’t allowed to take their adderall, and they quit nursing, and you know now. Because they were in a recovery monitoring agreement and took their adderall. Right. Okay. And I’ve had a couple of those nurses call me and say, you know, they destroyed my life. Now, why were they in a recovery monitoring agreement? Okay.
Terri
They had a substance use disorder.
Laura
Fine. Okay. But they would have functioned better and their recovery would have been easier and stronger if they had been allowed to take their prescribed medication. So the. As I said, it’s funny I’m talking about add, and here I am talking like this, but whatever.
Terri
Have you taken your dose today? Have you taken your dose today?
Laura
Maybe that’s something I’ve considered, but, hey, I came this far without it, but, you know, so, anyways, but so they did end up getting sued, and now, yes, they have to be able to take their adderall. So it’s a balance. And I think, again, it comes back to protecting the public from an unsafe practitioner and protecting a practitioner from an unfounded grievance or if you want to extrapolate that to unnecessary conditions on their license.
Terri
Yeah, yeah. I’ve got somebody that I’m going to be doing an interview with on the fitness for duty and how it’s very detailed and it looks for the. I mean, there are people that are trained to do these assessments, and that’s what we need is a thorough assessment, because, as you said, it depends on the situation and the person and what’s going on and to kind of lay these things out. And so I think that’s a piece that is maybe missing. With some programs, we have to kind of complete the circle. Right.
Laura
And sometimes the programs are looking at it one way, but the board is looking at it another way. So, you know, I don’t want to put anything on, particularly our assistance, our nurses assistance program, because, like I said, I have great respect for them. And, you know, but sometimes the board, there is a disconnect sometimes.
Terri
Yeah. Again, we’re not all on the same page. It’s either due to ignorance that, you know, we just don’t understand it.
Laura
And I think people get stuck in their silos. They absolutely get stuck in their silos. And, you know, that’s why, Terri, you know, this podcast is phenomenal. Right. Because I think it helps bring those silos together.
Terri
Yeah. So we can start to kind of see a different way of looking at things. I know I’ve learned a lot just talking to different people, or you think you. You think you know what you’re. You know, and then you’re like, oh, okay, think about that, because we don’t all have the same area of expertise. So you’re right. Gotta break down those silos.
Laura
Yeah.
Terri
Yeah. Okay. Well, I want to thank you again for all the time that you have spent with me. This has been very interesting, and I thank you for sharing.
Laura
I thank you for having me. I love doing this. I love chatting with you. So if I lived in Cheyenne, we would probably be having coffee together every morning.
Terri
There you go. I would love that. All right. Thank you very much, Laura. I hope you have a great rest of your day.
Laura
You too. Thanks, Terri.
