Spotting (and Helping) a Drug-Using Employee

One day, you notice it: A good employee has stopped being good. Her work, once so exemplary, has steadily deteriorated, although she’s weirdly possessive about it. What’s amiss? A derailed love life and no one to go home to? Financial troubles, enough to make her embezzle? Perhaps. Then, the tip-off: No one is bigger buddies with all the drug reps than she, and, most tellingly, she eagerly volunteers for snoozefest tasks like drug audits.

All signs point to a drug-using employee. What now?

Unfortunately, there’s no easy answer to this question. Rose Samaniego, practice coordinator with Oncology Consultants in Houston, knows this all too well after having found herself facing the above scenario a few years ago while at a previous practice. The employee - an experienced RN - had become addicted to her husband’s back pain pills, which she’d been pilfering to cope with life stressors. One day, while on a rare day off due to some unavoidable minor surgery, a fake prescription arrived at the practice for the employee. Busted.

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Certainly, such felonious behavior is legitimate grounds for dismissal, but taking that immediate, drastic step did not feel right to Samaniego or the practice’s physician. “We were a family; it wasn’t just an employee,” she says.

They opted to try to help the employee instead of dismissing her. Samaniego offered the embarrassed staffer counseling and assistance with finding drug rehab services. She accepted the help at first, but then resisted, saying she could solve it on her own. But she couldn’t. In the end, she lost both her job and her marriage.

Anytime you lose an employee for this reason, it’s a tragedy, but not just for that person. “If you have an abuser, it’s like an iceberg,” says 30-year veteran practice administrator Chris Kelleher of Columbia-based South Carolina OB/GYN Associates. “You’re only going to see the tip of the problem. … Ninety percent of the stuff is under the water. It’s what you don’t see that’s really scary.”

So true. With substance abusers you have a serious clinical liability issue on your hands, possibly unbeknownst to you for months. Critical bits and pieces might get left out of patients’ charts or follow-up duties such as calling patients regarding test results might not get done. This undermines the care that you’re giving - perhaps with dire consequences.

Confidence within your practice can suffer lethal blows in terms of working relationships, too. “There’s such a trust between the physician and the nurse. The physician looks at the nurse as a physician extender - lots of autonomy,” says Kelleher. “You get an impaired employee, and that creates a huge chasm between trust and liability.”

Discovering you’ve got a doped-up employee immediately presents you with some quandaries. “Because we are healthcare providers,” says Kelleher, “we have a dual sword: We care [about the drug-using employee] because as healthcare providers, that’s what we do. But we also have a responsibility to the patients to do no harm.”

You also have a responsibility to yourself. Prescriptions written in your name can jeopardize your license. If you do nothing, you may be sending a “watch my practice” red flag to the authorities.

Finally, what about the rest of your hard-working, drug-free staff? “It does impact the other members, who have to double-check the other employee,” says Kelleher. That fosters resentment. After all, what’s their reward for picking up the slack? More work.

So again: What to do?

If you’ve actually got a drug user:

• Intervene immediately. Yes, such confrontation is beyond hard. Kelleher points out that “personnel management is the hardest money you’ll ever earn.” But it’s essential you push through and do what needs to be done.

• Report the incident. You want to protect your own license to practice, so inform the DEA. This is the law. Here’s the scary part: You don’t really know the scope of the problem, says Helenemarie Blake, a medical attorney with Fowler, White, Burnett in Miami. Your drug-using staffer is already an established liar. Is her claim that she’s doing it for her own personal needs really true? Or is she in fact involved with distribution? That’s an exponentially bigger issue. “If [a faked prescription] hurts somebody or kills somebody and the physician didn’t do anything about it, the physician can be held liable,” warns Blake. Aiding and abetting are not recommended ancillary services that will build your practice.

As for pressing charges with the police, do you have to? Yes and no. There’s nothing on the books saying you must. However, “on the DEA report, there’s a question that says, ‘What law enforcement agency did you report to?’” says healthcare attorney Lourdes Martinez, a partner with the New York City-based Garfunkel, Wild, & Travis law firm. If you leave that blank, you could be leaving yourself open to a legal stinkeye. Report the incident as a theft, she says.

• Offer concrete help. Reporting the incident does not preclude you from helping your employee. Get that individual to see a qualified therapist “and have that physician certify [the employee] is being treated,” says Martin Kalish, a trained rheumatologist who is now a partner with the law firm of Arnstein & Lehr in Miami. This can help your employee if the DEA does pursue charges.

• Set limits. Make it clear to your at-risk employee that you care and you want to help, but due to her actions, she is officially “on notice.” Keep a careful, written record of how the whole affair plays out - for everyone’s protection.

The best way, though, is a pre-emptive strike at the problem:

• Guard your prescription pad. Always keep your pad (which should be the serialized kind) with you when you’re seeing patients. Do not leave one in each exam room for convenience’s sake. When you go out to lunch, lock it up every single time. If you think no one would ever swipe your pad out of your lab coat while you snarf a burrito in the next room, you’re wrong. And for heaven’s sake, never pre-sign some of the pages. Any gained efficiency is outweighed by the risk. Finally, consider using pads with carbon copies so you have proof that you - and only you - wrote a prescription.

• Use e-prescribing. The expediency of e-prescribing is indisputable, and the added layer of security is even better. Of course, you don’t want to broadcast your access info.

• Establish prescription call-in protocols. Take time to approve call-ins, and ideally, have just one person authorized to do this task. Perform regular oversight.

• Define substance abuse policies. Decide what these are. Write them down. Post them in obvious places. Make your practice’s expectations clear - repeatedly. “It has to be an issue that you don’t just put in an employee handbook and forget about,” says Kelleher.

Broach this subject during interviews. That way, the employee - if you hire him - can never claim he “didn’t know.”

• Know your employees. “Be more attentive to the individuals and employees,” advises Samaniego. “Be there for them. Not only on a professional level but a personal level. Get to know them.” Socialize with your staff, enough to know what’s normal and what’s not in anyone’s behavior. Is Miranda in the back office just a chronic kvetcher about money because she’s addicted to buying shoes, or something more nefarious?

• Encourage tattling by your staff. Not about silly, interpersonal junk they should’ve outgrown in grade school. But if one of their own is in trouble with drugs or alcohol, then snitching becomes the right thing to do; make that clear to your staff. Chances are, they’ll know about a problem long before you pick up on it. Confrontation can be a stopping point for many, so maintain an open-door policy and an anonymous “comments” box.

People caught in addiction are by definition bad at self-advocacy. If you can smooth a path to redemption for your employee, then do so. But do it wisely; don’t sacrifice yourself, says Blake. “The bottom line is you need to protect your livelihood and your practice if you have any hope of being strong for your family and for helping this employee.”

Shirley Grace is a former associate editor with Physicians Practice. She can be reached via physicianspractice@cmpmedica.com.

This article originally appeared in the April 2009 issue of Physicians Practice.