Substance Use Disorders and Barriers to Treatment with Heidi McNeely, PhD, RN, PCNS-BC
Drug Diversion Prevention Officer Dr. Heidi McNeely shares an overview of the findings of her research on non-medical substance use and barriers to treatment. These include relinquishing control, our identity as healthcare professionals and shame.
Transcript:
Terri
Welcome back, everybody. My guest today is no stranger to the diversion mitigation community and is a returning guest. Dr. Heidi McNeely is the drug Diversion Prevention Officer at Children’s Hospital Colorado and PhD graduate of the University of Kansas. She is also a board member of IHFDA and a very active participant in the association. I asked Heidi on today so she could share the results of her dissertation with the listeners. Her focus was on non medical substance use and barriers to treatment. Heidi, before you share your findings and conclusions, welcome by the way. Thank you. Please tell us why you chose this topic. Was there a particular case or event that impacted you and drove you to this specific focus?
Heidi
Great. Thanks, Terry. So I think most of it why I chose this topic is specific to my role. I have been working in the diversion prevention field for the last about six years and so I definitely have a passion. I think over the last several years I’ve really been wanting to try to provide a more supportive program for nurses, physicians and other healthcare professionals when they are struggling with substance use. And I just am struggling. And I think a lot of people struggle across the country to have a program that can really support these employees, especially if there’s been diversion in the workplace. And how do they work with their organization to address any concerns around risk and those kinds of things, but then also have just kind of a welcome place and a soft place for these individuals to land after recovery. And so it’s not one specific case that stood out, but in general I was really wanting to understand more.
Heidi
The other part was I had heard from individuals who have had or been involved in diversion. I had heard from them that there was a lot of reluctance to seek treatment, a lot of fear and concerns when trying to go back to work or trying to find work after their treatment. And some of those things I was just really wanting to understand better, hoping that would inform not only myself, but others who are interested in this work as well.
Terri
Sure. All right, that sounds great. Yeah, there is a lot of work and I don’t know if it’s just because I’ve been more involved lately, but the tide definitely seems to be turning for the positive. More and more people are realizing that we need to not only monitor and catch, but then help and try to do something about it from that perspective. So I think that’s encouraging. And your research and your conclusions and the data that you put out there I’m sure is going to be something that will be used to help make that help that grow. Now they’re going to have some data to look at with that, so great. So talk us through what you looked at and your findings.
Heidi
Yeah, so just to clarify, I ended up focusing my research with treatment providers. So providers that give and provide services for nurses and physicians or other advanced practice providers with substance use disorder. And so I would have loved to have done it with healthcare professionals themselves who had been struggling with addiction and gone through treatment. But I had so many questions. I think this is a typical challenge of graduate students is that there’s so many things we want to know, but in a very condensed time frame, you really have to narrow that focus. And so the thought of being able to interview and meet with treatment providers I thought would help get some baseline information and really understand kind of larger picture. Especially because the treatment providers I was working with work with many nurses and physicians every year. This is like their primary clientele.
Heidi
And so I thought they could give a more holistic picture of what was going on. So that’s obviously one thing in me sharing some of these findings is that these would have to be validated with individuals who have gone through treatment themselves. But I do think these can be really helpful to then say what are the next steps? What additional information do we need to find out? So with that in mind, I interviewed treatment providers in the state of Colorado because that’s where I reside. And again, these are a variety of treatment providers, including inpatient facilities that they do services at, residential outpatient, different types of modalities, different training. For each of these treatment providers, there were some psychiatrists, some psychologists, some physicians, social workers, all kinds, licensed professional counselors, all kinds of people that I interviewed. So the nice thing is it was a good variety and then based on if they worked predominantly with nurses or physicians, most of them worked predominantly with physicians.
Heidi
However, a fair number of the treatment providers I interviewed, 16 treatment providers. Of those treatment providers, a fair number of them worked predominantly with nurses, about, I think, four of them. And then the rest of them worked with both nurses and or physicians. And that includes nurse practitioners and physician assistants and those kinds of advanced practice professional roles.
Terri
No pharmacists in the mix. No pharmacists?
Heidi
No. Again, I had to narrow it down to try to just make sure that I had enough time to get everything done. I would have loved to do all healthcare professionals, but in our state there’s peer assistance programs specifically for nursing professionals and physicians. A lot of the other healthcare disciplines fall within one of those programs, but the numbers that they see is far fewer than what they see for physicians and nurses. And so it provided a bigger kind of audience of people that this was relevant to. And so that’s why I kind of narrowed to those groups, but would love to see the work expanded to encompass other disciplines as well. I have lots of different themes that kind of came through in the research. The first part I really focused on as you mentioned was the barriers and facilitators. So what helps nurses and physicians to seek treatment, to be successful in their treatment and going back to work, or what gets in the way of that.
Heidi
And after doing the work and I’m a nurse by background, been a nurse for 22 years, so I’m not throwing us under the bus, hopefully here, but sometimes we are not great patients. I’m sure it’s not the first time you’ve heard that. But I think based on some of themes really an overarching takeaway is that often health professionals get in their own way. And some of themes that I think are related to that are this sense of control and as healthcare professionals, especially having the knowledge that we do not wanting to relinquish that control and say okay, someone else is going to dictate how this looks for me or is going to tell me what I need to do. But not just that. There’s a lot tied to our identity as healthcare professionals. So as a nurse or as a physician, they latch onto that so often that the fear of getting into treatment and potentially not being able to go back to work gets in the way of them ever really being willing to get started or to recognize that their substance use is getting in the way of them doing their job.
Heidi
So I do think that identity can actually facilitate once they are in treatment because a lot of times that’s a motivator for them to get back to work. At least this is what treatment providers were saying. But in the beginning it is very much a barrier because they’re so fearful or concerned about losing that identity or not living up to the expectations of that identity that they’ll delay getting into treatment or they’ll kind of fight against that for a while until they really.
Terri
At first, I was thinking when you were talking about that, it’s like, well, I wonder if it’s healthcare professionals or if it’s level of education. Would you see the same thing with a lawyer, an engineer? I mean it’s the level of education. We think we know better, we want control, we hold on to things. But then when you said it impacts them getting back to work, that is where it becomes different, right? Because we handle controlled substances and so that is part of the identity. If I can’t handle this, then I can’t go back to work. Like what do I do? And that is really all tied. Whereas for an educated lawyer, well, they’re not exposed to it all the time, right? So they could go back to work and not have to disclose and nobody would necessarily ever know.
Heidi
Yeah, especially when diversion has been part of it. Right. It’s one thing I think it may be. And again, this wasn’t specific to findings. But you have to question is it different if somebody self reports because they’re using at home or outside of work and they don’t feel that it’s necessarily impacting their work? But when it crosses that boundary and they’re going to work impaired or they’re taking the medications that they’re using from work, then I think there’s a lot of that fear and concern, which is totally valid, that this could impact their license or their ability to get a job. But I agree with you. I’m sure the identity of your role is there for, like you said, lawyers or pilots probably would be another common group. Right. But I also think that we have this kind of higher expectation and unrealistic views of some professionals in our society, and that definitely came out loud and clear through the research.
Heidi
So a lot of themes around higher expectations, one that they set for themselves, but also that others had for them. So it could be their peers, it could be their family members. There was a lot of sharing around stressors from family members saying, like, hey, I married a doctor, like, not an addict. What’s happening? Why can’t you rise above this? And it was almost like whether it was self talk or others saying it to him, there was this expectation that if you’re a nurse or a physician, this should never happen to you. You’re better than this. You have the abilities, the skills, the knowledge, all of that, to kind of rise above and to not be struggling with this. And I think that’s just not fair. It’s not fair, but I think it’s a reality we have to deal with.
Terri
Will you expect them to have the pharmacological knowledge that didn’t you notice that you were having issues? You should have stopped it at the very beginning. It’s like, okay, if you couldn’t control the addiction, but you should have realized the moment it happened right. And gone a different direction. Yeah. No, I hear what you’re saying.
Heidi
Yeah. A lot of the treatment providers I talked to, some of their clients didn’t use opioids or other drugs, but used alcohol. That’s probably one of the most common substances that’s used, and especially around alcohol, but I think it may bleed over into the other substances as well. But there was almost like a rationalization of use. There’s no way I can get through my crazy schedule, whether it was in school or whether it was professionally and what their shifts were, or just how stressful it was taking care of really sick patients or in the environment they worked in. There almost seems like the professionals are able to rationalize why they have to use and that it’s really a means to destress, calm down after a difficult shift, things like that.
Terri
Almost a better professional makes them a better professional because they can keep going.
Heidi
Yeah. At least in their mind, they were able to rationalize it because they felt better after they used whatever it was, the substance. But I also think definitely some of the treatment providers called this out. That’s just kind of the culture of these roles. Having been a nurse for 22 years, also that really resonated with me. It was very common to say, even after a night shift at seven in the morning, let’s go out for a drink, let’s go tonight I’m going to go home and have some wine because man, today was a rough day. So I do think that whether it’s talked about a lot in the workplace or it’s expected when people socialize outside of work, at work related parties, those kinds of things, at least for alcohol, I think it’s very normalized and it becomes something that’s kind of an expectation. This is just a common way to destress, this is a common way that we socialize, all of that.
Heidi
And I don’t think that’s unique just to this scenario. But it does make it a lot harder when someone is struggling with substance use or excessive use, that these kinds of social situations or social expectations can be a challenge and really kind of bump up against their willingness to go into treatment. Because again, it comes back to the rationalization. If everybody else is doing it, why is mine any different or any worse than anybody else’s? One thing that I found that I thought was really surprising was a lot of the treatment providers said their clients didn’t know that treatment specifically for healthcare professionals was available and they weren’t aware, like, how do I report? How do I get into treatment? Where do I find programs? And so I found that was surprising, but also kind of frustrating because I think we could do a better job and I think we could make that known more, for sure.
Heidi
One of the other things that came to a facilitator for keeping them in treatment and going back to work was the long term monitoring. That tends to happen with professionals, but not with everybody. So the two to five years of urine drug tests or breathalyzer test and intensive check ins and accountability, a lot of the treatment providers said that this was a huge barrier for their clients early on and something that they just didn’t appreciate. But after really getting into treatment and buying into their recovery and dedicating their willingness and time to that, they said that’s really one of the saving graces for them, that the long term monitoring, the accountability, they really felt like was the right thing and was really good for them in their recovery. So I think that’s good to hear. But what we don’t know is how long does that need to continue to help really increase the success of professionals when they’re in treatment, right?
Terri
Yeah. Do they ever feel like they’re in the clear? I’ve talked to people that recovery 20 years later, the meetings and everything else is still just part of their life. But yeah, we’re not quite sure how tempting what their thoughts are in their mind 20 years later. Is it just that they keep up with all those things because they want to stay active or really, are they still struggling with those thoughts? That’s kind of interesting. Yeah, and I think the two to five years would be daunting at the very beginning. And like you say, it’s good to hear that they were grateful for it and it’s the right thing. So it’s not necessarily that things need to change on that front, but we need to somehow get them to understand that they will be grateful for it, that it is worth it two to five years out of your life is worth it to get on the other side of that.
Heidi
Well, and the interesting thing when you say that, another theme that came out was this kind of pressure to maintain a lifestyle. So not just to maintain their professional identity, but to maintain the level of pay, the benefits that come along with, especially for physicians, right, of being a physician, being invited to benefits, having social parties, having the income to be able to pay for things out of pocket that a lot of other individuals don’t have the luxury of. And so there was a lot around that, like, I have to be able to keep receiving a paycheck to keep this lifestyle up, to make our house payments, to do whatever. But I also think there was some interesting findings around the differences between nurses and physicians and that a lot of times physicians can pay for the treatment they need and the intensiveness or the length of the treatment they need if their insurance doesn’t cover it, where nurses often can’t pay.
Heidi
So they tend to not necessarily be able to get as long a treatment as comprehensive or that becomes a barrier to them even going to treatment at all.
Terri
Interesting. Okay.
Heidi
So that’s kind of high level overview of some of the barriers and facilitators. Obviously there’s a lot more there. And as you mentioned at the beginning, I’m working on publications that are under review right now, so hopefully the full findings will come out and be available. But the next major focus outside of facilitators and barriers was all around stigma. And how does stigma impact their ability to get through treatment, to get into treatment and then to come out on the other side and go back to work. And really the biggest theme that I found here was the stigma was majority of the stigma that treatment providers talked about for individuals came from the individuals themselves. So it was individualized stigma or self stigma. Those are kind of the terms that we use. Rarely did they think or recall instances when the nurses and physicians they worked with said, I’m feeling stigmatized by somebody else.
Heidi
Somebody said something to me somebody looked at me a certain way, I was denied a job, those kinds of things. That was really the only example. We call it enacted stigma. That’s the kind of term assigned to it. But that stigma that you experience from others is enacted stigma. And the only example that came out in this study was not getting a job offer after they revealed that they had been through recovery. But all the other stigmas came from either people they were close to, mostly family, rarely did it come from their managers or their peers. They said they were very typically supportive. But most of what I heard in the interviews was the individual nurses and physicians that these treatment writers worked with, the stigma they struggled with almost all what they manifested in their mind and what they had against themselves and their addiction or their substance use not external to that.
Heidi
Which doesn’t mean the external is not informing their feelings. But I think, like I said, sometimes we get in our own way. So that definitely came through, I think.
Terri
With anything that we’re struggling with, whether, I don’t know, let’s say public speaking and we think people are judging us, but they’re not. It’s us, right. So I think that is a very common we’re just hard on ourselves where the eyeballs looking in. It’s like, really? You’re not the focus here. Get over it. Right. But we do that to ourselves with everything, I think, all of the issues that we have. So I guess this is really no different. We’re just hard on ourselves. And I can see why they are hard on themselves for this in particular. Just like I’m hard on myself if I don’t organize something well. And it’s like talk on it. I should have known, I should have done better on that. Whatever piece of it’s like, it’s okay once in a while. So I can see why they are. But it’s really the same way.
Terri
We’re hard on ourselves for all kinds of things. We’re our worst enemy, really.
Heidi
Yeah, well, that right. That ruminating one feeling really bad about yourself or your actions, but also being so focused and worried about what others are going to think or what others will say or all of that. And that’s what we call anticipated stigma or perceived stigma. How will others perceive me? Or the anticipation of if I go back to work, like, everyone’s going to ask questions or no one’s going to think I’m going to be a good nurse or a good doctor. They’re going to think, I can’t do this, when really most of their colleagues when they went back, were super supportive. I’m here if you need anything, like, how are you doing? Didn’t question their ability to be a nurse or a doctor and were really there to support them. But so much of that makes treatment at least initiating it, I think, a barrier or those initial several months of treatment.
Heidi
A lot of the treatment providers said it was very prevalent. And of course, like you said, it seems like a no brainer. Of course that’s going to be. But for me, I really went into the research anticipating that they were going to have received stigma all around in various ways. And again, not having talked to nurses and physicians themselves, maybe they actually do have examples of those, but that’s not what came out in their treatment. That’s not what they talked about to their providers. They talked about the fear of somebody saying something, so what do If this person comes back? So a lot of providers said that they spend lots of months talking to their clients about, okay, how do you have these conversations if they come up? But then when their clients go back to work, they said rarely do these ever even happen.
Heidi
So we spend so much time dealing with those fears, concerns, that self stigma that it ends up once we can work through that, with the individual usually not being experienced in a way that.
Terri
They anticipated it being, yeah, that totally makes sense. And it’s like an example I gave of speaking like, well, just avoid it. You don’t have to. You don’t spend all your time thinking about what’s going to happen when I have to speak. But these people are living with this all the time, whether it’s how to hide it from people, how to deal with it, how to keep going. Maybe some are thinking they need help. Some are at the point where I can’t do this anymore. I’m ready to give up. It is all consuming. And so it’s kind of almost a 24/7 thing for them in their mind, beating themselves up already, right. They’ve done the damage over and over again. So why wouldn’t somebody else agree with them?
Heidi
Yeah, you’re horrible.
Terri
How could you do that? It just makes perfect sense that the people outside would do it too.
Heidi
The other interesting thing was kind of a language or terminology issue. And when I asked about stigma and provided a definition of what I meant by stigma, treatment providers said, well, funny, we don’t really use the term stigma, nor do many of our clients use that term, but that’s what I think. It’s very common to talk about stigma and how we see it, how we experience it, how we know it exists even structurally around mental illness and or substance use, various things. But they said that’s not really how they approach it. That usually how it’s presented is shame. And shame, though, when you look at the definitions of self stigma, that really is that stigma that you have for yourself, but it manifests in shame. And so they talked a lot about those themes around shame and whatnot. So just to clarify, because if anybody reads publications from this study, once they’re out or looks at other studies, you may see those themes or that terminology coming out instead.
Terri
Right, yeah, no, that makes sense when you say it. That is kind of I’m sure what it’s mostly about is just that shame that they have for what they have done and how they’ve let people down in their minds.
Heidi
Right, okay, yeah, there’s other themes that come through, but those I think are kind of the key things. But I could talk, I’ve done presentations that go on for multiple hours on the research and again would love if and when it’s available for people to read and to engage. I think some of the next steps, I think there’s still a lot of opportunity to really understand their experiences, to try to break down some of those structural barriers that get in the way of nurses and physicians and other healthcare professionals seeking treatment. So I think definitely doing more research with individuals. There is some great research out there and some of that has been done, but a lot of it doesn’t address all of these themes that I called out or the stigma piece. And I often think about HIV AIDS and some of the other things, even mental illness.
Heidi
Right. We’ve seen huge progress over the last few decades of how the public views, how individuals are treated, who have certain conditions, all of that, and definitely have seen decreasing stigma around a lot of these things that used to be very stigmatized. And so my hope is that as we continue to put emphasis and support individuals, that we’ll see that some of those stigma is decreasing as well. Because I do think the more that we can address that and really provide facts and clear presentation of what it’s like to go into treatment, what it’s like to be in recovery, and really like true and compelling stories, of individuals who’ve been successful when they have gone through treatment and recovery, I think will continue to help break down some of those barriers. So I would love to see more research in the area and then expanding that to really understand how are even the policies that are in place impacting treatment provision.
Heidi
So there was really three parts of my research. I talked a little bit about the facilitators barriers, the second on stigma, and the third was all around policies that are in place in stigmatizing language we see within policies that impact that. And I didn’t even go into that. But it is really interesting to see some of those trends kind of over decades of time. I think we’re doing a lot, we’ve made a lot of progress in the last probably since early 2000 with our policies and with funding and with other things to try to break down some of those barriers. But I just don’t think it’s operationalized the way that it’s intended it was intended to, and I think it has a long ways to go. So one of the treatment providers I talked to said there’s all this talk about parity about health and mental health being similar in the services that you provide and all of that.
Heidi
And they said it’s just lip service, it’s not happening. And so I think being able to really understand that more would be helpful as well.
Terri
Yeah. Did you have you made any changes in the way you approach things with your current position as Drug Diversion Prevention Officer? You can’t do it alone. Obviously you need the support of the facility and the leadership there. But have you identified things that you would like to see changed or were able to change or how you approach a case when you have one after your research?
Heidi
Yeah, I think anecdotally I can’t say for sure that I’ve done X, Y and Z and it’s different. But I think having the information that I have, I definitely think it has informed the way that I respond to questions or to situations or even in my response to individuals who might be going through something like this. So I definitely think it has informed that. I think there’s I mentioned there’s a lot of structural barriers and structural stigma there too that didn’t necessarily come out in this research, but that will continue to be an uphill battle for a while. So we are actively having conversations about how do we provide a more supportive kind of work environment. I think the biggest thing for me has been the awareness around how we normalize substance use in our professional lives, but not just that even in our personal lives.
Heidi
And so I know that’s something that has impacted me probably the most to feel like how often have I contributed to normalizing this, that it’s just okay and it’s really the only way to deal with stress, so let’s just do this. And I think that’s something that I’ve tried to be really sensitive to and how I talk about it, how I’m receptive to maybe how others are receiving that. But also I’ve been exploring some opportunities to do some work around resiliency for our healthcare professionals just because it was always an issue before, but ever since the pandemic too, it’s become just such a massive concern. And as we’ve seen people leave the profession, I think it’s something to focus on. But I do think resiliency is something far more than just the ability to bounce back. But all of these impacts, the high expectations we have for ourselves, the normalization of substance use or other unhealthy ways to cope with stressors in the job I think are things that we really need to strike, we need to tackle them as a profession.
Heidi
I think there’s definitely opportunities too to do this, start doing some more of this in training and education programs too. How do we programs to support people and to set them up for success.
Terri
Even more so, right? Yeah. You said something at the last conference. Here we are talking about diversion and substance use disorder and then, okay, I’ll see you down at the bar. It’s like, okay, that’s weird. In terms of the policies, are there any kind of bulleted points that you would like to throw out there that you would encourage people to cover in their policies when it comes to this whole topic?
Heidi
Yeah, the policies I looked at were national and state level policies more than organizational or institutional policies. So looking at what’s been enacted from the government more than the organization, I do still think that the power of language is something that needs to just be understood and we still tend to use terms that can be very stigmatizing. Not using people first language, it’s very difficult. I know that I am not perfect in how I use terms and those kinds of things as well, but definitely terminology that’s used can definitely impact whether people willing to vote for something or people are willing to write something in a policy or people feel comfortable with implementing that. So terminology is a huge theme and that came out and I think that is relevant across organizational policies or national or state level health policies or whatever public policy that’s out there.
Heidi
I’m just looking at my notes really quick. I do think there’s still a lot of punitive policies and definitely that are still existing from back in the kind of war on drugs theme where a lot of substance use and drug use was criminalized. And so I still think that there’s a tendency towards that even in healthcare organizations, that the tendency is somebody did something that was wrong and they need to deal with the punishment of that and then it becomes a punitive thing. Instead of the disease kind of focused mindset of this is a chronic relapsing brain disease, we need to address it as such, we need to provide support and medications when indicated and those kinds of things. So all of those things come out in the policies. There have been a couple of really good studies around how to decrease stigma and how that can help individuals feel comfortable with supporting or voting for a policy.
Heidi
And again, a lot of that has to do with language or really transparent stories. So when more people who have struggled with substance use are out there sharing their stories and putting a face to addiction and really making this real, but also talking about it appropriately, that this isn’t a moral failing, this is a disease, and this is something that we need to address, and it’s have a holistic approach to it that they tended to see. People were more inclined just based on language or based on sharing stories to support policies that would provide housing or job assistance or funding for treatment and those kinds of things.
Terri
Yeah, 100%. I’m always thrilled when I have somebody on the podcast that has gone through this recovery because that’s it I want to humanize it and get it out there because I know that I didn’t have a good grasp of this. And I’ve said before, when I originally started doing this work, it was all about the hunt and finding them, and that’s the last I thought of it. But there’s so much more that we need to be doing. And every time we can humanize that and give people a glimpse into it, I think it goes a long way to kind of changing them just bit by bit, and next thing you know, we’ve got people that are looking toward, let’s get them in recovery, let’s help them. This is also about the healthcare professional, not just the patient or the facility and getting them that help.
Terri
So all of that is great. Well, I’m looking forward to reading the full thing when it comes out. And what we’ll do is we’ll put a link to that too, as well, so people can get to that. But I want to thank you very much, Heidi, for the research that you have done and for sharing it with us. It’s needed in this space, and especially if it can bring a few more people over to the side of either willing to get help or to realizing that they kind of need to approach this when they’re in that. Interview interrogation phase to maybe give them some other talking points and ways to view it that might just make all the difference in the world to that person that is struggling and struggling to admit that they’re struggling. Right. Because we’ve got to hopefully we can I imagine it’s in their own time, but there’s some that we can do to influence it by the words that we use and the approach that we take.
Terri
And so hopefully we can start to have a more positive impact on that beginning of that willingness to get some help. That’s what we should all be going for. Yeah. All right. Thank you so much. Thank you, Heidi.
