SUPPORTING ROLE Mr. Garcia spoke at OR Excellence 2017 about his addiction, recovery and mission to help healthcare professionals who are battling substance abuse.

I was the last person you'd suspect of being a drug diverter. I was the hospital's hardworking, well-liked chief anesthetist, the team player who didn't mind staying late and taking on extra cases. I walked right past you every day for 6 months as I hid and fed my irresistible and irrational fentanyl addiction, which had gotten to the point where I didn't need the drug to feel good; I needed it to feel normal.

"I didn't need fentanyl to feel good; I needed it to feel normal."

Day after day, case after case, nobody noticed that I was giving patients a little less fentanyl and pocketing the waste so I could slip it under my tongue or inject myself. I was spiraling out of control, yet I appeared perfectly normal, a top OR performer even when I was diverting and using large amounts of opioids.

But here's what most people don't get. As clear as the mask on my face, the signs that I was diverting drugs were there all along, from the dramatic spike in my fentanyl ordering and my manic mood swings, to my 60-pound weight loss and my wearing long sleeves on warm days to conceal my track marks. But nobody saw the signs because I wasn't a disheveled, dysfunctional addict. I was happy-go-lucky Rigo.

I can tell you the signs of addiction you never thought to look for, and I can tell you what it feels like to go through this hell, what if feels like to scheme every day to stay a step ahead in my game of catch me if you can. What you might not know is that there are countless other addicts hiding in plain sight, the types like me with a flourishing career as a healthcare provider. The reason most can't see addiction in these roles is because most don't know what addiction feels like. Well here's the scary truth of addiction: It feels normal.

THE TIME TO STRIKE Diverters strike when peers are distracted, dipping into wasted supply or replacing medication with placebo substitutes like saline. Keep a watchful eye where drugs are stored.

Innocently enough
I've harbored the makings of a drug addict my entire life: Type A personality, driven, successful, craving validation and chasing thrills. It began innocently enough when I took my first pain medication in 2009. I was prescribed Vicodin after breaking my ankle. I used my prescription heavily right from the start, throughout recovery and the 3 months of rehab that followed. I never felt alarmed. I never felt I had a reason to worry because, as an anesthesia provider, I was confident that I was taking the appropriate steps to manage my pain. This self-certainty is partly what fuels the risk of healthcare providers falling prey to addiction. We're taught that we know what we're doing at all times, that we get results, and that mindset clouds our judgment when it comes to any issues of our own that arise. Not until my first day back at work, after 3 months of healing and physical therapy, did I realize I had a problem.

On that day, I couldn't get through half a shift without popping a Vicodin because the withdrawals were all-consuming: migraines, nausea, chills, sweats, any kind of ache you can imagine. I felt like I had the flu, only I knew exactly what the cure was and, to me, putting pain meds into my body was not just the easy thing to do, but the right thing to do to be normal again. I needed to function; without meds in my system, I couldn't. The longer I needed them to keep working as a CRNA, the more of them I needed, and the more I needed, the more I lied to conceal this underbelly of my day-to-day being.

I realized I'd become physically dependent, not because of any euphoric high that consumed me when I took opioid medication, but because of how horrible I felt without it. What I didn't know was to raise my hand and say I needed help at that very moment. I couldn't do that, though, without feeling that I'd be marked forever with a scarlet letter of addiction, and so I plowed through the next 6 months as my problem began to spiral. I got myself another 2 Vicodin prescriptions. They quickly ran out.

RECOVERY
Now I Help Other Addicts Recover

ADDICTED HEALTHCARE PROFESSIONALS An advertisement for a rehab facility called the Parkdale Center for Professionals.

After I entered treatment and began the road to recovery, I started to think of ways I could give to others in similar circumstances, and as a founding member of a rehab facility called the Parkdale Center for Professionals (parkdalecenter.com), that is exactly what I do now. At Parkdale, we specifically treat medical and legal professionals who are struggling with drug addiction, with a focus on career reentry afterward. We combine 12-step modalities with alternative therapies to ensure that everyone in our care receives the most comprehensive treatment possible to tackle the myriad issues associated with substance abuse.

We also facilitate a program for healthcare executives called H.E.L.P. —Healthcare Experts in Loss Prevention — to assist facilities in tackling drug-diversion issues. With our guidance, executives learn how to prevent, identify and manage diversion in every department, and close gaps where need be.

— Rodrigo Garcia, APN, MBA, MSN, CRNA, ACIT

From Vicodin to fentanyl
Once my pills ran out, my eye wandered to my work, and I realized that half the fentanyl I was using to sedate patients was wasted at the end of every procedure. The fentanyl I was throwing away could easily become the fix I needed. And it did.

Why waste it, I thought. I had a responsibility that I couldn't let collapse by sinking into withdrawals and felt I had no choice but to stay normal by staying medicated, albeit in secret.

Dipping into waste is a tricky business, but experienced anesthesia providers know how to skirt the noticeable methods of getting into the stock. I knew I couldn't over-order supplies before every procedure; red flags would be raised. I could, however, take on more cases, show up earlier and stay later, and while I was able to get by with this strategy for a time, I was caught 6 months later by my colleagues and confronted. My usage patterns and workload had drastically spiked in under a year. There was no more hiding, not with signs this obvious.

Eventually, my situation was uncontrollable. I began by staying medicated in order to function, but by the end, I was functioning in order to stay medicated. My addiction had won, and through what I now recognize was good fortune, I was pushed into seeking treatment.

How to spot a diverter
One of the first things I tell people about drug diversion is to keep an eye on the overachievers, not just the slackers. Culturally, we affirm and reward workaholic, overzealous behavior, but more often than not, these trademarks are the high-stakes symptoms of someone at risk of addiction.

Other clues that were less obvious were easier to hide from my peers, but they're important to note. My girlfriend, Claudia, who was an OR charge nurse at the time, noticed changes from the beginning. I'm happy to report that we're married now and raising a family. Those days, though, strained our relationship, to say the least. Because she was so close to me, hiding my issues from her was the most difficult part, and I knew she wasn't totally unaware of something wrong in my life. As the months rolled by, Claudia voiced her suspicions.

Naturally, I'd lie and deny. For her, the balancing act was especially rough because she didn't want to see me harming myself, but she also didn't want to turn me in outright and potentially destroy my life and career. Without my willingness to get help, she was nearly powerless. More time passed and she shared concerns and hints with close friends of ours, hospital peers we trusted. Throughout this time, I was drug tested twice as the suspicions around me grew, but I passed the first time because I knew very well that fentanyl was not a substance the lab would include in their screening. Claudia, though, picked up on the signs that were less obvious to others. By the second test, she alerted the hospital to test for fentanyl. These were the final days before I had to seek treatment. These are the signs Claudia saw, the ones you need to know.

SELF-INJECTION IS A DANGEROUS STAGE Providers who self-inject are at a dangerous point in their addiction. Be on the lookout for long sleeves in warm weather.

1. Overloading on work. I couldn't simply order more stock for my cases when I began needing fentanyl because I knew I'd draw attention. Instead, I took to taking on extra patients, working longer days and even relieving coworkers of their own cases because I knew that more exposure meant more opportunity to siphon drugs from the wasted supply. (I did my best to avoid pediatric cases because there wouldn't be any waste fentanyl left over for me.) Documenting waste requires 2 signatures. My strategy usually involved getting someone distracted, someone busy, to sign with me to record what was thrown away. Being a trusted figure on my staff helped, too. Knowing I could easily get other signatures, I felt free to slip the fentanyl under my tongue and keep my withdrawals at bay. The problem with this workaholic behavior is that I was often praised and rewarded for it, and my peers were consistently coming to me when they needed help. The workload was unusually heavy, though, even for someone in a leadership role like me, and while it's not a guarantee, it is a clue that someone might be battling addiction.

2. Spike in usage. My pharmacist noticed that the amount of fentanyl I was ordering overall had seriously spiked in less than a year, and since she rarely dealt with me one on one, her suspicions were black and white from the start, totally objective. On paper, changes in my schedule and medication load were dead giveaways. All she had to do was speak up, which she eventually did, and state her concerns, and these concerns were factually based, a crucial factor in the approach that we'll turn to later.

3. Weight loss. My weight dropped about 60 pounds in the time from my first prescription to when I was caught at work, and that was a telltale sign that Claudia was quick to pick up on. Not only was I overworked, exhausted and more secretive than ever, but my body was showing the signs of my disease as well, and like everything else in the process, I'd lost control. Weight loss isn't the surest sign of someone who's addicted. For some, though, it's part of the package.

4. Unusual clothing. Wearing long sleeves on a warm day is never a good sign. I didn't start shooting fentanyl intravenously until the final stages of my spiral, but when I did, I began covering my track marks with long-sleeve shirts, another item on Claudia's list of suspicions. She'd ask and I always had a lie ready to go, usually something about having the flu and hooking myself up to an IV at work. Before, I'd been slipping the drugs under my tongue, but as any recovered addict will report, you develop a tolerance very quickly and intravenous injection is usually the last stop before the abuse becomes dangerous and unmanageable. I began injecting my supply at the end of a long day, usually the last to leave, alone and at serious risk.

5. Mood swings. Irritability might seem a less objective clue, but it shouldn't be overlooked. When I was in the throes of my addiction, I was exhausted because my heavy workload became entirely motivated by how and when I could get the meds I needed to allay withdrawal symptoms and stay on task. I was less social and more focused on this one demanding element of my life that I was trying so desperately to hide. My moods were up and down, and I threw myself into my cases not just to get what I needed, but to avoid being noticed, too. Keep an eye on any staff members who seem to be going through rapid mood swings.

6. Isolationism. As I went through my addiction, the focus of my work and entire life started to become the one thing I was trying to conceal. As a result, I became less social with my coworkers than I normally was, and where I was typically gregarious and outgoing, I'd become withdrawn and isolated from my peers. This side of my Type A personality is one that my addiction curbed. The lie I was leading separated me from everyone else, including Claudia, who, about a month before I was finally caught, said to me, "Something's not right with you. You're not right." That phrase stuck with me and bothered me because I knew my sneaky behavior bothered her. If you notice someone withdrawing from everyone else, chances are, you're not alone in what you see, and you're probably not far from the truth. Speak up.

7. Tampered drug tests. I make this note the last one because I personally never had to tamper with my drug screening. I knew fentanyl was not on the lab's radar, so I happily handed over my urine sample the first time I was asked to take a test. It is a known practice, however, among addicts to buy time with a compromised urine sample. Opioids take just a few days to leave the system. Addicts facing a drug test can get to that 2- or 3-day threshold by diluting their urine sample with added substances, like salt or bleach, anything that will nullify the lab's findings. If someone's screening is returned as inconclusive, read the result as a red flag. One way to follow up is to ask for a hair sample. There's typically no escaping this kind of screening and, more often than not, someone who's addicted will come clean before they even take the test.

Drug Diversion a Concern Among Facility Leaders

How concerned are you about staff diverting drugs?
Extremely 15%
Moderately 46%
Not at all 39%

SOURCE: Outpatient Surgery Magazine
(www.outpatientsurgery.net), InstaPoll, November 2017, 275 respondents

Judging by the results of a recent poll of our readers, more than half expressed at least moderate concern with drug diversion on their staff. With the current opioid crisis swelling without any apparent solution, everyone seems to be sensing the dire effects of the epidemic in every facet of society, and the healthcare industry is no exception. What's more, healthcare providers have easier access to powerful medications almost every day of their lives, putting them at greater risk of exposure and developing addictions. Talk to your staff about the risks and consequences of drug diversion and keep the dialogue open. This issue is largely a hidden one, and its clandestine nature is where it draws strength. Keep caution and concern open among your colleagues. Part of tackling diversion is keeping everyone conscious of the danger and knowing what to do when they see it.

— Joe Madsen

How to address it
The best advice I can give you if you're planning to confront someone on your staff is to stay objective. I mentioned that my pharmacist had the most black-and-white suspicions of everyone, and in the end, it was her reasoning that brought down the hammer. I was taken aside by the hospital's CEO, the director of the pharmacy, my department chair and human resources, and they addressed me by sticking to the facts.

Another piece of advice: Share your concerns with trusted colleagues in leadership roles who can join you in any plans to intervene. When I was approached, I was given 2 options. I could resign and enter treatment, but still be reported to the Board of Nursing, the state attorney general of Indiana and a monitoring agency, or I could refuse and possibly face criminal felony charges. With my back against the wall, the choice was obvious. What made it obvious, though, was the way the facts were shown to me. I could see just how much my life's very foundations were on the line and, with a group of facility leaders involved, I knew I'd been flagged on multiple fronts.

After a year of recovering away from health care, I was able to return to my career as a CRNA. One day, I found myself working with a nurse in the ER who was pulling opioids to get prepped and, as she bustled around, I noticed another nurse out of the corner of my eye circling our space like a shark. The nurse who was pulling the meds left the room for a minute, but she'd left herself logged into the dispensing machine. I watched as the second nurse moved in to steal drugs. I confronted her with the same 2 options I'd been given long before, but what moved me most was her reaction: a hug and a deep-felt thank you. For her, the lies and nightmarish spiral were finally over. As tough as the consequences might be, she was no longer alone in need of help. Like me, she would be reported and face potential career and legal consequences, but she no longer had a secret to harbor, one that took up an unmanageable space in her life the way it did in mine. This kind of response, this relief, is not uncommon. Some say recovery is like opening the gates of heaven to let you in, but to me, it's like opening the gates of hell and letting yourself out. The lying makes you lonely, and this kind of lie touches every part of your life. It can even kill you. If you approach someone on your staff with the facts, remaining calm and straightforward, you're not just helping your facility and patients. You're liberating someone. And you're treating the problem directly, the way it needs to be treated. OSM