At about 9:30 a.m. on a warm mid-July morning in 2002, an occupied trailer home in Terrace was shrouded in silence—broken only by the whining of a dog inside when a healthcare worker knocked on the locked door. An unexplained absence from work, several unreturned phone messages, and now, this chilling quiet hinted that something was very wrong. The worker called the police.

Some time during the previous 24 hours, the 45-year-old woman inside had sought relief from the nightmarish onset of drug withdrawal, and perhaps from an inner turmoil that may have driven her to self-medicate in the first place. On her chest, she had placed five 100-microgram patches of Fentanyl—a synthetic opiate used to control intense pain.

The painkiller, which is about 100 times more potent than morphine, is usually delivered to patients via 20-, 50-, 75- and 100-mcg patches. Widely hailed as a less intrusive delivery method than intravenous injection, the patches are applied to patients’ skin and absorbed over a 72-hour period.

At first, the soothing, violet notes of Fentanyl mercifully lifted the woman above agitation, nausea, and the shakes. But over a period of hours, they swelled into an overpowering opiate wave which rushed her away forever.

By 10 a.m. the worker, acting on the advice of police, broke into the trailer. Within minutes, an ambulance crew determined that the woman had been dead for some time.

Details about the triumphs, talents, passions, and struggles of the woman—who had lived alone—or about the grieving sisters and parents she left behind, are of course nowhere to be found in the coroner’s report which became the clinical, final chapter of her life. But several disturbing facts are.

She had been a registered nurse at Mills Memorial Hospital in Terrace. Her demise ended a 23-year career in healthcare and a long battle with drug addiction. She had been removed twice from work due to drug abuse and misuse at work, and had almost completed a two-year probation program under supervision of her doctor, a requirement for returning to work at the hospital. Her access to drugs at Mills Memorial had been denied for more than a year, but was restored in February 2002.

Almost immediately after her death was discovered, questions swirled among the few hospital staff who learned its real cause: How had she obtained the drugs, which were not prescribed to her and had been partially used by patients at the hospital? How and why did she have unsupervised access to Fentanyl? Were patients at risk while she was on the job? Was this an accidental overdose, or a suicide?

According to one observer, the quest for answers was “contentious and ugly.”

At least some answers are found in a Northern Health Authority (NHA) audit. Narcotic control processes at Mills Memorial were found to be weak at times: for example, drugs left over from patient use had not been tracked, and drug accounting procedures, which usually involve co-signing by more than one staff member, were not always followed. Ledger sheets were not always completed, allowing some late entries to occur. Narcotic discrepancies weren’t followed up.

Although the audit concluded it was impossible to say whether the Fentanyl had been stolen, it made clear that opportunity existed for this to happen—and that the nurse had access to the drug. The Coroner’s report offers no conclusion on this point, but one internal NHA memo, issued in September 2004, suggested the patches used by the nurse had been removed from patients.1

Suicide was officially ruled out. Although the woman had previously been treated for depression and an anxiety disorder, and “was very knowledgeable about narcotic use and abuse,” the coroner noted that the woman may not have been aware of the amount of active narcotic left in used patches, which recent analyses show may contain up anywhere from 31 to 84 per cent of the original narcotic. The nurse’s use of five patches demonstrated “intent to ingest a significant amount of narcotic, but … not necessarily … to take her own life,” concluded the coroner.

Initial inquires by Northword about the nurse’s death, which has escaped public notice until now, elicited a range of reactions from Terrace hospital employees: from sincerely blank looks, to one angry admonishment to drop this “bad story … write about something positive,” to careful denials of any knowledge of these events.

But perhaps the silence, motivated as much by respect for a grieving family as by fear of blame and/or discipline for leaking information to media, obscures an opportunity to confront the most compelling issues around this tragic loss: pervasive prescription drug abuse, our stereotypes around it, and the peculiar quandary of health professionals struggling with addiction.

Between eight and 12 per cent of people suffer from substance abuse disorders, according to the U.S. National Institute on Drug Abuse, in a report titled Prescription Drugs: Abuse and Addiction, July, 2001.

Of these, abuse of prescription drugs is increasingly recognized as a serious concern. While recent data on its prevalence in Canada is scarce, U.S. research2 shows that new users of prescription drugs have increased dramatically: from 1990 to 1998, among people using pain relievers (181 per cent), tranquilizers (132 per cent), sedatives (90 per cent), and stimulants (165 per cent). In 1999, an estimated 4 million people—almost two percent of Americans aged 12 and older—engaged in recent, non-medical use of prescription drugs.

That drug addiction generally is beset by stereotypes is also clear.

“If you ask society what drug addiction looks like, they’ll say Skid Row, the Downtown East Side, people in lower socio-economic brackets at the margins,” says Paul Farnan, an addictions specialist who co-ordinates the Physicians’ Health Program of B.C. in Vancouver.3 “But it could be you, it could be me.”

Farnan should know. In Prince George, where Farnan practised for 15 years, his addiction-afflicted patients included many of the white-collar variety, including nurses, doctors and lawyers.

People with advanced addictions aren’t easily recognized, notes Farnan, because they’re no longer doing drugs simply to numb physical pain or get high. They’re using to get “normal,” and to avert withdrawal symptoms which range from deeply uncomfortable to terrifying.

Research shows addictions are strongly correlated with a family history of dysfunction or abuse, genetic predispositions, poor social skills, early age of drug use, and environments where drug-using behaviour is approved. Compounded by working conditions commonly found in healthcare—frequently stressful environments, long and irregular hours imposed by shift work, and easy access to powerful drugs, these factors are even more potent.

“If you’ve already been dealt a hand like this, and you’re dabbling in prescription drugs to cope at work,” says Farnan, “you’re in danger of switching something on that you won’t be able to switch off easily.”

That switch, he explained, essentially rewires the brain so that particular stimuli—which can just as easily be cigarettes, heroin, gambling, sex, or compulsive eating as drugs—become inextricably linked with the production of dopamine, a neurotransmitter chemical that creates a feeling of well-being. That’s where dependency begins, and the resulting brain changes are measurable and long-term.

According to Farnan, health professionals develop chemical dependencies at rates more or less mirroring the general population. But health professionals who activate that switch face unique challenges in dealing with it—which include, but also go beyond, shameful stereotypes about users.

“Concern about confidentiality is one of the biggest obstacles,” says Farnan. Accessing help locally, particularly in a small town, could mean taking a seat in a waiting room where your colleagues can see you.

Also, continues Farnan, health professionals frequently rely on themselves for diagnoses, and sport a public image of professionalism, health-promoting behaviour, and immunity to illness and addiction. These things make it more difficult to face a spiralling drug habit.

As dependencies deepen, sufferers will do things they ordinarily wouldn’t. In a healthcare setting, this can mean stealing from the medication cupboard, saving drugs left over from patient use and even replacing patients’ prescriptions.

Of course, impairment on the job may spark complaints from patients or colleagues. For B.C. nurses, these trigger a review process involving the Registered Nursing Association of B.C. (RNABC). Nurses may be suspended and compelled to undergo treatment before returning to work. Up to five years of monitoring, including random urine testing, may follow.

Heather MacKay, director of regulatory services at the RNABC, says the association gets involved in about 30 reviews annually of nurses with substance abuse problems. Less than 10 per cent of these are self-disclosed problems; most are triggered by complaints.

According to MacKay, the number of substance abuse complaints has climbed steadily over the past five years. She says this could be related to rising stress on the job: as less seriously ill patients are increasingly treated as outpatients, hospital staff find themselves dealing with a higher proportion of inpatients with pressing needs.

But more complaints don’t necessarily mean more nurses are struggling with addictions than before.

“People may be seeing the RNABC involvement as supportive, rather than punitive,” she explains. Public safety vis-a-vis the nursing profession remains the RNABC’s top priority, but its relatively new consensual complaint resolution process, which resolves most cases, emphasizes a compassionate, unrushed approach to recovery.

Both Farnan and MacKay agree that recovery rates are high among health professionals—much higher than average, in fact. Treatment programs designed especially for them, having to account to many supportive people, and powerful incentives to return to work are highly effective.

Farnan believes certain insights are key to recovery: “Addiction is not a character flaw. It’s a disease which spares no one… And while it is not curable, it is treatable.”

He firmly believes our healthcare system shouldn’t be waiting until addictions progress to “rock bottom,” manifesting as the end product which informs addiction stereotypes. Earlier intervention and more preventative education is needed. But Farnan also observes that addiction is not a “cool subject” to government, and remains underfunded.

Could this be linked to stereotypes about who addicts are, and misperceptions of addiction as a character flaw rather than a disease? “Absolutely,” says Farnan.

Closer to home, the loss of a veteran Terrace nurse has provoked some organizational introspection.

The Northern Health Authority, citing B.C. privacy laws, refuses comment on why this particular nurse was allowed unsupervised access to Fentanyl. But it has scrutinized, and claims to have addressed, problems with narcotics handling practices.4 And the Terrace nurse’s death, and the resulting coroner’s report which was widely circulated among B.C.’s medical professional organizations, has resulted in widespread reconsideration of how Fentanyl in particular is handled.

The NHA’s vice-president of medicine, David Butcher, says he is not aware of any other cases of fatal overdoses, or revocations of licenses to practise due to impairment on the job, among healthcare professionals in Northern Health. If the NHA had such data, it wouldn’t necessarily be disclosed. “If we were commenting at all, it would be to our board,” explains Butcher.

But concern at the NHA for employee health remains paramount, says Butcher, particularly if it impairs the ability to care for patients. “As an employer … we have to make sure that our staff have access to treatment options and are aware of these.”

The NHA offers confidential referrals to help through Employee Assistance Programs. It maintains links to external programs such as the Physicians Health Program co-ordinated by Farnan. And in smaller communities where confidentiality can be more of a challenge, the NHA can sometimes arrange for caregivers to be brought in from elsewhere.

In any case, Butcher says he doesn’t believe there’s any “systemic problem” of intoxication of healthcare professionals.

“[They] are subject to all the concerns, including addiction, that the rest of population is,” he concludes.

1. NHA’s vice-president of medicine, David Butcher, told Northword that he does not know whether the Sept. 2, 2004 memo, which states that the nurse used patches that were “removed from patients,” accurately describes what happened. He said the statement was “based on an assumption,” which has neither been confirmed nor refuted by information from the coroner’s report. Butcher indicated the memo was “not an official NHA memo…[but] may have been distributed on NHA letterhead,” and later added that it was “appropriately sent by a Bulkley Valley District Hospital pharmacist as a policy directive to staff.”
2. Source: 1999 U.S. National Household Survey on Drug Abuse.
3. The Physicians Health Program, co-sponsored by the B.C. Medical Association and B.C. College of Physicians and Surgeons, provides confidential help for physicians dealing with addictions and other issues.
4. A new policy regarding the disposal of Fentanyl was approved and circulated by the NHA in late August 2004. According to NHA vice-president of medicine David Butcher, the lag of nearly two years between the nurse’s death and the communication of the new policy was due to the fact that the coroner’s report was completed in April 2004, then forwarded to professional organizations such as the College of Physicians and Surgeons, before making its way through NHA policy processes.

©Larissa Ardis