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Recognizing Impairment in the Workplace

Disclosure Statement

            This nursing activity aims to outline the challenging yet crucial issue of identifying and responding to interactions with potentially impaired coworkers in the workplace. The evidence regarding indicators, diagnosis, reporting responsibilities, investigation, treatment, and return-to-work process for impaired health care workers is discussed to promote education and reduce the stigma associated with this critical issue.

After this activity, the nurse should be prepared to:

• recognize the statistics regarding substance use disorder (SUD) in the United States and among healthcare providers specifically
• discuss the identified risk factors and effective methods for preventing SUD
• highlight the indicators of SUD and drug diversion that a healthcare provider should be watchful for in the workplace
• clarify the professional, ethical, and personal responsibilities of a nurse with concerns regarding the potential impairment of a coworker
• briefly review the investigation and intervention steps that should occur when SUD is suspected in a healthcare provider
• describe the diagnostic criteria and the treatment options available to healthcare providers diagnosed with SUD, including alternative-to-discipline programs (ATDs or ADPs), residential programs, and outpatient programs
• discuss the return-to-work procedures for healthcare providers diagnosed with SUD

Tolerance to medication is defined as the gradual need for an increased dose of a particular substance over time to achieve a similar effect. The development of tolerance varies significantly by individual and medication, reflecting the brain’s ability to adapt physically to its environment. This phenomenon is not limited to pain medication or illicit drugs but also occurs with other substances and circumstances (Lynch, 2025; Volkow & Blanco, 2023). Physical dependence is the physiological adaptation to a substance that develops with consistent and regular use, contributing to SUD. The medication becomes necessary for normal homeostasis and functioning. Physical dependence correlates with opposing withdrawal symptoms if the medication is no longer used. Misuse of prescription drugs is ingesting or utilizing these medications in a manner, at a dose, or by an individual outside of the prescribed context. This includes taking another person’s medication or using pain medication to induce feelings of euphoria. The medical terms of substance abuse and substance dependence have been replaced in recent years by substance use disorder (SUD). This may refer to an individual addicted to nicotine, alcohol, prescription medications, or illicit drugs (Khan, 2026; Volkow & Blanco, 2023). Addiction involves a combination of physical dependence and compulsive drug-seeking behaviors despite significant negative repercussions (National Institute on Drug Abuse [NIDA], 2020b; Volkow & Blanco, 2023). The Emergency Nurses Association (ENA) and the International Nurses Society on Addictions (IntNSA) clarify that addiction is a primary, chronic disease affecting the reward, motivation, memory, and related brain circuitry that leads to characteristic biological, psychological, social, and spiritual manifestations (American Nurses Association [ANA], 2016; Khan, 2026; Strobbe & Crowley, 2017).

Substance Use Disorder in the United States

The physiologic changes that affect individuals who misuse substances vary but may include temporary increase in dopamine in the brain, increased workload on the heart, acute kidney injury that may progress to chronic kidney disease with prolonged use, a decrease in the liver’s blood supply related to scar tissue, and increased risks for integumentary complications such as rashes, sores, ulcers, extravasations, and infection (NIDA, 2020a; Volkow & Blanco, 2023).

It is estimated by the National Association of State Alcohol and Drug Agency Directors (NASADAD) that 59% (167.2 million) of the US population used alcohol, tobacco (including vaping), or an illicit drug in a 1-month time frame in 2023. Of this group, approximately 17% were characterized as having an SUD (Whitter & Silva, 2025). The Substance Abuse and Mental Health Services Administration (SAMHSA, 2025) conducts the National Survey on Drug Use and Health (NSDUH) regarding substance use in the United States, which was last performed in 2024. This survey collected self-reported data from 70,241 noninstitutionalized Americans aged 11 or older, covering all 50 states and the District of Columbia. It does not include data on residents of long-term care facilities, people who are incarcerated, or individuals experiencing unsheltered homelessness (SAMHSA, 2025). The 2024 SAMHSA (2025) report estimates 134.3 million Americans used alcohol in the last month, including over 5.1 million people under 21 years old. Of those Americans over age 12 who report alcohol use, 57.9 million report binge drinking, and over 14.5 million report heavy drinking. Prescription pain reliever misuse in the past year was reported by 2.8% of respondents over age 12, or nearly 8 million Americans; 70.1% of these users report abusing prescription pain medication to relieve pain. The estimated usage in the last month of cocaine, prescription sedatives, tranquilizers, or other CNS depressants, prescription stimulants, hallucinogens, methamphetamine (meth), and inhalants is provided in Table 1 (SAMHSA, 2025).

Table 1

 Substance Users in 2024 Over Age 11, per the NSDUH

(SAMHSA, 2025)

Of the 8 million Americans who reported prescription pain reliever misuse in the 2024 NSDUH (SAMHSA, 2025), 42.3% obtained the pain reliever they misused from a family member or friend. Over 43% of people who misused prescription pain relievers were either prescribed the medication or stole it from the provider. Nearly 7% of people bought pain relievers from someone selling them (SAMHSA, 2025). The rate of opioid use disorder decreased from 3.0% in 2021 to 2.6% in 2024 (SAMHSA, 2025). Despite the reduction in the prevalence of opioid use disorder (OUD), the morbidity and mortality related to opioid misuse remain high. Roughly 2,500 to over 4,000 US residents died monthly during 2024 from opioid overdoses. According to the Centers for Disease Control and Prevention (CDC, 2026), almost 160,000 Americans died due to opioid overdose from 2020 to 2024.

The opioid epidemic began in the 1990s. Between 1999 and 2023, it is estimated that over 800,000 US deaths occurred due to opioid overdose. These deaths have come in three distinct waves in that period. The first wave of overdose deaths occurred in the 1990s and was due to an increase in the prescribing of opioids within the medical community (CDC, 2025). This timing correlates with a national initiative to better identify and manage pain. An article by Dr. Mitchell Max was published in 1990 in the Annals of Internal Medicine, followed by an initiative by the American Pain Society to assess and consider pain more seriously in patients, naming it the “5th vital sign.” This prompted the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) to publish new standards in 2000 to improve pain management for patients. Additionally, a new prescription opioid, oxycodone hydrochloride extended release (OxyContin), was aggressively marketed by pharmaceutical companies starting in 1996. This first increase in deaths due to OUD is now considered an adverse effect of the increased focus, new standards, and aggressive marketing of the new opioid (Alpert et al., 2022; American Academy of Emergency Medicine, n.d.; Duff et al., 2022; Joint Commission, 2025). The second wave began in 2010, largely due to increased heroin use, an illicit opioid synthesized from morphine. The third and final wave started just 3 years later, in 2013, and was comprised primarily of deaths related to synthetic opioids such as fentanyl. In 2023, opioid-related deaths fell significantly for the first time since 1999 (CDC, 2025).

SUD in Healthcare Workers

The ANA (2025b) includes language on impaired practice in its Code of Ethics, section 3.5. The prevalence rate of SUD among healthcare workers (HCWs mirrors that of the general population, which is roughly 8% to 13% (Merlo, 2025b). However, HCWs have an increased risk of OUD due to frequent access to these medications at work (Saver, 2023; Trinkoff et al., 2022). The ENA and IntNSA (Strobbe & Crowley, 2017) define impaired practice as a decreased level of competence evidenced by changes in work habits, job performance, appearance, or other erratic or concerning behaviors. The National Council of State Boards of Nursing (NCSBN, n.d.-b) estimates that roughly 7% to 11% of the nursing workforce is either using substances or has an SUD (Trinkoff et al., 2022). This is so important within the medical (and nursing) communities that SAMHSA (2026) has developed nationwide training for HCWs. Federal mandates have also been put in place for SUD and OUD training for all practitioners holding a U.S. Drug Enforcement Administration (DEA, n.d.) prescribing license (American Academy of Physician Associates, 2023).

The American Addiction Centers (AAC, 2024) has found that HCWs are 10% to 15% more likely to develop an SUD than the general public. Their findings indicate that up to 10% of nurses will misuse substances during their lifetime, and as many as 100,000 HCWs will have an SUD in any given year. As much as 4.4% of HCWs report heavy alcohol consumption, and 5.5% struggle with illicit drug use (AAC, 2024). Historical estimates of the prevalence of SUD in nurses extend as high as 18% to 20%. Recent studies show that 32% of nurses experienced increased substance use during the COVID-19 pandemic (Arble, 2023).

Risk Factors for SUD

The risk factors for SUD in HCWs can be categorized as general or group-specific. The general risk factors for SUD apply universally. They include a genetic or molecular predisposition, a family history of SUD, a personal history of substance use, a comorbid psychiatric condition such as depression or anxiety, and the early first use of tobacco or alcohol (Merlo, 2025b; Mosel, 2024; Strobbe & Crowley, 2017). The SAMHSA (2025) also found an increased risk for SUD among individuals with a history of stress early in life due to poverty, child abuse, or neglect. In adolescents and young adults, peer-group pressure is a well-documented risk factor for substance use (Mosel, 2024). Group-specific risk factors apply only to HCWs and include:

• increased access to narcotics, sedatives, and other commonly misused substances
• increased work-related stress and multiple responsibilities
• increased exposure to illness, death, and trauma
• sleep deprivation due to shift work
• personality traits common to HCWs, such as independence, resiliency, self-reliance, and perseverance
• knowledge of pharmacology and pharmacokinetics
• a sense of perceived invulnerability (Cousin et al., 2022; Henson, 2024; Merlo, 2025b; Strobbe & Crowley, 2017)

According to Bryant and colleagues (2023), specific risk factors for SUD in nurses include a belief that substance use aids with coping, anxiety, and interpersonal disengagement. HCWs who use substances often report doing so to relieve stress, treat pain or depression, or increase their work performance (DEA, n.d.; Henson, 2024). It should be noted that the significant increases in substance use during the COVID-19 pandemic include unique mediators such as anxiety and secondary trauma (Arble, 2023; Bryant et al., 2023).

Prevention of SUD

      The CDC (Dowell et al., 2022) has published guidelines for the safe and responsible prescription and administration of controlled substances for HCWs. The CDC’s Guidelines for Prescribing Opioids for Chronic Pain identify strategies that limit the risk of opioid misuse. These guidelines aim to educate prescribers and other HCWs on strategies to reduce the risk of SUD among their patients or their patients’ friends and family. Many of these elements can be self-applied to prevent SUD in HCWs. The guidelines review various types of nonpharmacological pain management strategies, including physical (e.g., physical therapy and mobilization), direct (e.g., acupuncture and transcutaneous nerve stimulation), and indirect (e.g., music therapy and aromatherapy) methods. Before prescribing or administering a controlled substance, patients must be educated regarding the risks of dependence and SUD. If the patient agrees to proceed with treatment despite these risks, they should be educated regarding the safe storage (i.e., locked medication cabinet) and disposal (e.g., local and national drug take-back programs) of controlled substances. They should be counseled on the potential risks of sharing medications with family and friends, such as causing physical dependence, overdose, and medication withdrawal symptoms, as well as the risk of progression to illicit drugs such as heroin use (Dowell et al., 2022; NIDA, 2020a, 2020b).

The SAMHSA (2016) identifies three general categories of evidence-based prevention strategies for SUD. For the general public, universal prevention strategies can strengthen protective factors and reduce risk factors for SUD among participants. These programs tend to have the greatest impact because of the large number of targeted individuals. Examples of universal prevention programs or policies include raising the minimum legal drinking age and implementing national school-based programs. Selective prevention strategies target a subgroup of individuals at increased risk of developing SUD; this allows programs to focus their efforts and resources on a smaller group, but it also reduces their reach. Finally, indicated prevention programs target individuals already using potentially addictive substances but have not yet developed an SUD. Team Awareness and Team Resilience are examples of prevention programs for adults that have been successful for workplace or clinic-based SUD prevention efforts and could be implemented or piloted by health care organizations (SAMHSA, 2016).

While the CDC (Dowell et al., 2022) supports extensive patient education before prescribing controlled substances to prevent misuse, many experts also advocate for increased education for HCWs. They point toward the potential efficacy of improved curriculum at the student level, as well as extensive education for new employees during orientation programs regarding the risk factors, indications, and possible complications of SUD (Griffith et al., 2021). Health care organizations should establish employee assistance programs as an anonymous and low- or no-cost early intervention option for at-risk employees struggling with mental health or substance use. At an individual level, nurses should be aware of self-care strategies to prevent SUD, including maintaining healthy coping skills, engaging in regular exercise, pursuing enjoyable hobbies, and maintaining strong relationships with friends and family outside the workplace (Cousin et al., 2022; Merlo, 2025a).

Indications of SUD

Compared to the general population, SUD in HCWs is underevaluated, underdiagnosed, and undertreated. This likely results from several factors, especially a lack of peer and self-reporting due to the fear of legal, professional, social, and financial consequences of SUD diagnosis (Stone et al., 2021). Although nurses in the United States are required to identify and report indications of SUD among coworkers, many do not because of fear of retribution, punishment, or professional damage to their colleagues. Further, many nurses choose not to self-report due to fear of termination (DEA, n.d.; Stone et al., 2021). HCWs also note that guilt, shame, and fear of tarnishing their professional reputation contribute to their decision not to self-report (Cousin et al., 2022; Merlo, 2025a, 2025b). Practicing under the influence of substances increases the risk of medical and documentation errors and decreases productivity, appearance, and general health (Merlo, 2025b). Education on SUD for HCWs should clearly outline the advantages of reporting concerns, as well as the potential consequences. Ultimately, impairment in HCWs places patients at risk of harm. There is also a risk of damage to the reputation of the HCW, the health care organization, the nursing profession, and the medical field (DEA, n.d.; Strobbe & Crowley, 2017). Enhanced participation in scholarly forums on SUD by all HCWs will improve the collective understanding of SUD as a treatable disease, not a moral failing or personal weakness (Strobbe & Crowley, 2017). Increasing awareness of the signs and symptoms of impairment, SUD, and drug diversion will help HCWs identify coworkers who may be struggling with these issues (Table 2).

Table 2

Signs of Impairment, SUD, and Drug Diversion

The ANA (2025a) Code of Ethics specifies within Provision 3.5 that a nurse “establishes a trusting relationship and advocates for the rights, health, and safety of recipient(s) of nursing care, protection of patient health and safety by acting on impaired practice.” Well-intentioned HCWs often are unsure how to handle a situation where a colleague may be impaired or diverting controlled substances. Concerned nurses should keep detailed records of behaviors or events that indicate a potential issue, including the time and date, exactly what occurred, and any bystanders who could serve as potential witnesses. Many states allow anonymous reporting to the state ATD program (or ADP; Griffith et al., 2021; Merlo, 2025a). If possible, the concerned colleague should approach their impaired coworker directly and encourage them to seek help and treatment for their condition (ANA, 2025a; DEA, n.d.; Griffith et al., 2021; Merlo, 2025a, 2025b). If the subject is unwilling to admit that they have a problem and seek treatment, and suspicions have been confirmed to a satisfactory degree, the colleague should discuss their concerns with the impaired coworker’s manager or supervisor (ANA, 2025a; DEA, n.d.; Griffith et al., 2021; Merlo, 2025a). Alternatively, concerned individuals can contact local police, organizational security, or the DEA if there is suspicion of diverted or stolen controlled substances (DEA, n.d.). Many health care organizations have established clear policies and procedures for reporting and investigating these concerns. A detailed record of recent events will promote the smooth functioning of this system. In addition to establishing who should report concerns regarding substance use and to whom, institutional policies should specify when and how preemployment and probable-cause toxicology screens (drug testing) should occur (Geuijen et al., 2021; Griffith et al., 2021). It bears mentioning that inadequate staffing levels, increased patient loads, and long shifts may cause behavioral symptoms that mimic indicators of SUD, and these potential explanations should be considered and ruled out during the investigation (Trinkoff et al., 2022; Yoon et al., 2025).

If an intervention occurs, concerns should be communicated to the subject in an objective, detailed, empathetic, and respectful manner, while avoiding blame, accusations, or arguments. Interventions should be led by a professional who is familiar with the subject’s role but is not a friend, employer, or close colleague, if possible. The intervention should include an immediate action plan with consequences clearly outlined if the plan is deviated from or declined. The subject may react to the intervention with anger, threats of legal action, resistance, or aggression. Interventions should be confidential and typically include the subject’s peers, staff, and family members. Only those who support the intervention and agree with the plan should participate (Merlo, 2025a).

Nurses should be aware of the institutional policies and procedures for reporting concerns about SUD among colleagues, as well as any related statutes in their state. For example, nurses in Florida (2026b) can be denied a professional license and subject to disciplinary action for the following:

464.018(j) “Being unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, or chemicals or any other type of material or as a result of any mental or physical condition. In enforcing this paragraph, the department shall have, upon a finding of the State Surgeon General or the State Surgeon General’s designee that probable cause exists to believe that the nurse is unable to practice nursing because of the reasons stated in this paragraph, the authority to issue an order to compel a nurse to submit to a mental or physical examination by healthcare providers designated by the department. If the nurse refuses to comply with such order, the department’s order directing such examination may be enforced by filing a petition for enforcement in the circuit court where the nurse resides or does business. The nurse against whom the petition is filed shall not be named or identified by initials in any public court records or documents, and the proceedings shall be closed to the public. The department shall be entitled to the summary procedure provided in s. 51.011. A nurse affected by this paragraph shall at reasonable intervals be afforded an opportunity to demonstrate that she or he can resume the competent practice of nursing with reasonable skill and safety to patients.”

464.018(k) “Failing to report to the department any person who the nurse knows is in violation of this part or of the rules of the department or the board. However, a person who the licensee knows is unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, chemicals, or any other type of material, or as a result of a mental or physical condition, may be reported to a consultant operating an impaired practitioner program as described in s. 456.076 rather than to the department (Florida Legislature, 2026b, para. 11 and 12).”

Diagnosis of SUD

According to the American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual of Mental Disorders (DSM-5 TR; APA, 2022), SUDs are defined as a configuration of symptoms resulting from the use of a specific substance, ranging in severity, which results in a variety of physical, social, financial, and psychological consequences. The diagnosis of SUD is clinically based on a thorough patient history. The DSM-5 TR lists eleven different diagnostic criteria covering four broad categories: lack of self-control (1 to 4), social impairment (5 to 7), personal risk (8 and 9), and pharmacological criteria (10 and 11). The diagnosis of SUD is considered when a patient meets at least two of the requirements from any category. Mild SUD is diagnosed when a patient meets two or three criteria, moderate SUD is diagnosed when the patient meets four or five criteria, and severe SUD is diagnosed when six or more criteria are met (APA, 2022).

SUD is defined by the APA (2022) as a destructive repetition or habit of ingesting/administering an intoxicating substance that causes substantial anguish or drastically affects the patient’s ability to function professionally, socially, or otherwise. These effects are evidenced by two or more of the conditions listed here within 1 year:

ineffective attempts to reduce the use of the substance or a wish to do so

an intense need or impulse to use the substance

a persistent ingestion/administration of the substance even though they have experienced repeated relational challenges (i.e., with surrounding friends and family members) related to its use

a persistent ingestion/administration of the substance in environments where it is unsafe

the development of tolerance, which is a gradual reduction in the physical impact/effect of a given substance when administered at a consistent dose or amount, requiring an increase in dose or amount to achieve the prior effect

a persistent ingestion/administration of the substance for a longer time and at a higher dose or amount than planned

a considerable investment of time related to the substance, procuring it, ingesting/administering it, or recuperating from the consequences of its use

a persistent ingestion/administration of the substance, interfering with significant responsibilities and commitments (i.e., academic, professional, or familial)

a decrease in attendance or participation in significant events at work, at home, or with friends/family due to the use of the substance

a persistent ingestion/administration of the substance even though they are aware of a significant challenge directly related to the substance use

the development of withdrawal as evidenced by the signs and symptoms of withdrawal syndrome for that particular substance or the use of the substance to prevent these symptoms

(APA, 2022, pp. 652-653)

Treatment of SUD in HCWs

            Historically, nurses and other HCWs with SUD experienced the same disciplinary mechanisms used for other practice infractions, administered by the Board of Nursing (BON) and corresponding state medical and allied health boards. These punitive policies were generally ineffective, endangering public safety by discouraging impaired HCWs from seeking help. Professional discipline typically results in a report to the Office of the Inspector General, which can complicate or preclude the HCW’s ability to obtain future liability or health insurance coverage. In the early 1980s, the ANA recommended that state BONs develop nonpunitive, early intervention programs to advocate for the rehabilitation of HCWs. These ATDs (or ADPs) offer assistance instead of judgment (American Society of Addiction Medicine [ASAM], 2024; Griffith et al., 2021; Stone et al., 2021). They advocate protecting public safety by addressing substandard practices, not by eliminating well-trained HCWs with a treatable illness. The ANA further stresses the importance of supporting or instituting policies and actions that promote patient safety and HCW well-being via collective bargaining. ATD programs should remain confidential and anonymous—except in instances of gross professional misconduct—to encourage willing participation by those struggling with SUD (Griffith et al., 2021; Merlo, 2025a; Strobbe & Crowley, 2017).

Most states now offer ATD programs for impaired HCWs, but it is unclear whether an anonymous ATD program is currently available in Alaska, Georgia, Hawaii, Nebraska, or Wyoming (NCSBN, n.d.-a). The National Organization of Alternative Programs (NOAP, n.d.) was founded in 1999 to facilitate the multidisciplinary promotion of public safety by rehabilitating, monitoring, researching, educating, and standardizing ATD programs. This group emphasizes fitness to practice and the retention of trained and successfully treated HCWs in active recovery. Their primary values consist of public safety, HCW retention, education, equality, and cooperation with regulatory and professional organizations (NOAP, n.d.). In most states, the HCW must take a temporary leave of absence from medical practice while undergoing initial treatment, usually by temporarily or conditionally suspending their license to practice in that state (ASAM, 2024). Some states allow the nurse to continue working while in treatment. When referred to an ATD program by their employer or another party, the nurse in question should accept the BON’s settlement to enter the ATD program without requesting a formal hearing, as this usually ensures anonymous entry. Most BON hearings are recorded publicly, breaching anonymity, and may become adversarial and expensive. This acceptance can avoid disciplinary action, which could carry legal ramifications. It typically involves signing a contract that outlines the treatment plan, the terms and conditions of a conditional license, and any consequences for breach of contract or premature abandonment of treatment. Eligibility for ATD programs varies by state, and some disqualify nurses who have caused patient harm or diverted controlled substances for sale to others (ASAM, 2024; Griffith et al., 2021; NCSBN, n.d.-a, n.d.-b). Experts stress that open and forthright communication with the state BON and legal staff throughout the process is crucial (ASAM, 2024; Griffith et al., 2021; NCSN, n.d.-b). A high rate of nurses with SUDs choose to participate in ATDs (approximately 80%). Most nurses who declined the program had previously participated unsuccessfully (Naiser et al., 2025). If a nurse or other HCW has an SUD and declines to participate in the ATD rehabilitation program recommended by the state BON, then the traditional discipline process should occur with removal from practice if negligence can be proven (NCSBN, n.d.-a, n.d.-b).

The Joint Position Statement on Substance Abuse Among Nurses and Nursing Students (Strobbe & Crowley, 2017) outlines the following four points:

• Health care facilities [should] provide education to nurses and other employees regarding alcohol and other drug use and establish policies, procedures, and practices to promote safe, supportive, drug-free workplaces.
• Health care facilities and schools of nursing should adopt ATD approaches to treating nurses and nursing students with SUDs, with stated goals of retention, rehabilitation, and reentry into safe, professional practice.
• In the context of personal use, drug diversion is viewed primarily as a symptom of a serious and treatable disease and not exclusively as a crime.
• Nurses and nursing students are aware of the risks associated with substance use, impaired practice, and drug diversion, and have the responsibility and means to report suspected or actual concerns (p. 105).

Treatment for SUD among HCWs or laypersons should be individualized, comprehensive, and biobehavioral. Inpatient or residential programs typically facilitate detoxification in a safe environment and offer around-the-clock support, but this option naturally involves significant expense. Medications for acute withdrawal during detoxification may be utilized, especially for patients with alcohol or benzodiazepine withdrawal, such as diazepam (Valium), chlordiazepoxide (Librium), and medication for opioid use disorder (MOUD), such as methadone (Dolophine), which may be used for weaning patients off narcotics. Intensive outpatient or day programs are typically less costly. Either option should consist of extensive patient education (even for HCWs); ongoing individual, group, and possible family therapy; and strategies for relapse prevention. Individual psychotherapy is usually based on cognitive behavioral therapy (CBT). In a group setting, community reinforcement groups like Alcoholics Anonymous (AA) and similar 12-step programs may assist throughout recovery and prevent relapse over time. Research also supports the effectiveness of contingency management or motivational incentives, which reward participants tangibly for maintaining sobriety and abstinence. Participants in ATD program studies have cited the importance of participating in a support group with nurses or other HCWs struggling with SUD. They also indicate that initially, random drug screening and a highly structured program are extremely helpful (ASAM, 2024; Naiser et al., 2025). Quantitative studies demonstrate that random drug screening is over 95% effective at assisting participants with maintaining sobriety. Treatment programs for HCWs should be more intensive and consist of a longer monitoring portion than standard SUD treatment programs (Smiley, 2021).

Barriers to recovery and sobriety maintenance include family history, use of strong opioids, concurrent psychiatric Issues, and use of more than one drug (Merlo, 2025a). To alleviate some of the burden, the Family and Medical Leave Act (FMLA) guarantees a period of unpaid leave for those in treatment for SUD, temporarily securing their job placement. The Mental Health Parity and Addiction Equity Act ensures that most insurance plans provide equivalent coverage for outpatient, inpatient, and emergency care related to SUD (U.S. Department of Health and Human Services, 2021). Finally, some professional liability products have begun covering the expense of disciplinary hearings in recent years (O’Neill, 2021). Many states offer legal reprieve through first-offender programs (FODPs), which may facilitate treatment and probation to avoid a criminal conviction. If a criminal conviction is in place, this may preclude the HCW from obtaining a nursing or other state license, depending on the regulations in their state (Griffith et al., 2021). State legislatures establish the guidelines by which nurses and other HCWs can obtain SUD treatment. For example, the Florida regulation referenced above, section 456.076, establishes the Florida Impaired Practitioner Program; details are available on the Florida Legislature’s website (Florida Legislature, 2026a). A small section of this legislation is highlighted below, indicating eligibility for the program, some of the confidentiality terms, and conditions of legal immunity and liability:

(9)(a) Except as provided in paragraph (b), when the department receives a legally sufficient complaint alleging that a practitioner has an impairment and no complaint exists against the practitioner other than impairment, the department shall refer the practitioner to the consultant, along with all information in the department’s possession relating to the impairment. The impairment does not constitute grounds for discipline pursuant to s. 456.072 or the applicable practice act if:

1. The practitioner has acknowledged the impairment;

2. The practitioner becomes a participant in an impaired practitioner program and successfully completes a participant contract under terms established by the consultant;

3. The practitioner has voluntarily withdrawn from practice or has limited the scope of his or her practice if required by the consultant;

4. The practitioner has provided to the consultant, or has authorized the consultant to obtain, all records and information relating to the impairment from any source and all other medical records of the practitioner requested by the consultant; and

5. The practitioner has authorized the consultant, in the event of the practitioner’s termination from the impaired practitioner program, to report the termination to the department and provide the department with copies of all information in the consultant’s possession relating to the practitioner.

(b) For a practitioner employed by a governmental entity who is also certified by the department pursuant to part III of chapter 401, the department may not refer the practitioner to the consultant, as described in paragraph (a), when the practitioner has already been referred by his or her employer to an employee assistance program used by the governmental entity. If the practitioner fails to satisfactorily complete the employee assistance program or his or her employment is terminated, the employer shall immediately notify the department, which shall then refer the practitioner to the consultant as provided in paragraph (a).

(10) To encourage practitioners who are or may be impaired to voluntarily self-refer to a consultant, the consultant may not provide information to the department relating to a self-referring participant if the consultant has no knowledge of a pending department investigation, complaint, or disciplinary action against the participant and if the participant is in compliance and making progress with the terms of the impaired practitioner program and contract, unless authorized by the participant.

(11) In any disciplinary action for a violation other than impairment in which a practitioner establishes the violation for which the practitioner is being prosecuted was due to or connected with impairment and further establishes the practitioner is satisfactorily progressing through or has successfully completed an impaired practitioner program pursuant to this section, such information may be considered by the board, or the department when there is no board, as a mitigating factor in determining the appropriate penalty. This subsection does not limit mitigating factors the board may consider (Florida Legislature, 2026a, para. 28–31).

Relapse 

                  Relapse is the resumption of drug use after remission (i.e., cessation of use). In a retrospective study of over 7,737 nurses participating in an SUD treatment program, it was found that relapse was an indicator for noncompletion of the program. The 64.7% of nurses who did not have a relapse completed the treatment program, while the 35.4% who had a relapse did not complete the treatment program (Smiley & Reneau, 2020). Factors that influence the risk of relapse include stigma surrounding SUDs, lack of belief in treatment effectiveness, and the assumption that treatment “ends” when the initial therapy is completed. Challenges that surround treatment for relapse include rigid timelines, denial by insurance, and care that is not individualized. Studies have shown that HCWs with OUD are at increased risk of relapse if they have a family history of SUDs, comorbid psychiatric issues, or severe OUD. Initial research indicates that drug monitoring during treatment can improve abstinence 1.5 times more than without, reducing relapses (Amirouche et al., 2023; Geuijen et al., 2021). Relapse creates opportunity for more frequent assessment, reassessment of motivation, involvement of primary care, and appropriate referrals (e.g., return to outpatient treatment, inpatient treatment, MOUD; Plante et al., 2025).

Return to Work

There is no nationwide standardized SUD program or return-to-work guideline for nurses, unlike physician programs, which are standardized and associated with each state’s medical licensing board (Smiley & Reneau, 2020). The ANA (2025b) advocates a pathway for nurses and other HCWs to return to work upon successfully completing their treatment program, as outlined in the current Code of Ethics. Most ATD programs have established standards that must be met before an HCW can return to practice, as shown in Table 3.

Table 3

Standards for Reentry into Practice

(Russell, 2020; Smiley, 2021)

Some states require a formal evaluation by an SUD specialist to release an HCW before they return to work or periodically for follow-up (NCSBN, n.d.-a). In most states, the HCW can return to work on an initially limited, conditional, or contingent basis. This period may include limitations on hours or patient load, restrictions on the administration or prescription of controlled substances, random toxicology screenings, and mandatory ongoing treatment in the form of support groups, group therapy, or individual outpatient treatment. Research suggests colleagues welcome the HCW back without judgment or a need to regain trust. Knowing their peers and coworkers are truly glad to have them back on the team facilitates the HCW’s self-acceptance and helps them overcome feelings of guilt and shame (Griffith et al., 2021; Merlo, 2025a). Many HCWs cite significant difficulty with stigma upon returning to work following treatment for SUD (Naiser et al., 2025). The three stages of recovery from SUD are often referred to as early sobriety (the first year), sustained recovery (1 to 5 years), and stable recovery (after 5 years). Maintaining a personal and social support system helps ensure an effective long-term recovery (Russell, 2020; Smiley, 2021). The unique circumstances surrounding the COVID-19 pandemic created opportunities for virtual treatment. In a quasi-experimental cohort study by Llavayol and colleagues (2026), satisfaction rates were very similar in both the in-person and virtual groups. The return-to-work status at 12 months was lower in the virtual group; however, this may have been due to the benefit of work cessation during the initial intervention (Llavayol et al., 2026). Beliefs and behaviors connected with elevated recovery rates of HCWs going through SUD treatment include:

• involvement or affiliation with AA
• personal acceptance that SUD is a disease process
• ongoing honesty
• an acceptance of principles which are spiritual (Merlo, 2025a)

            The unit nurse manager will closely supervise a nurse in recovery during active monitoring. The supervising nurse manager will have an ongoing opportunity to provide feedback to the BON or ATD facilitators regarding the nurse’s conduct (Merlo, 2025a; Russell, 2020). Table 4 lists components of recovery-friendly work environments to help with successful reentry to work during or after SUD treatment (Taylor & Petrillo, 2023).

Table 4

Components of a Successful Reentry and a Recovery-Friendly Work Environment

(Taylor & Petrillo, 2023)

For additional information on the pathophysiology, diagnosis, and treatment of SUD, please see the NursingCE continuing education activity entitled Substance Use Disorders.

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