Anita Bertrand doesn't remember much about the first time she stole narcotics she was supposed to administer to surgical patients. She doesn't remember exactly when she installed the intravenous port in her ankle so she could inject the drugs more efficiently. And she doesn't remember how many patients she may have put at risk before getting into treatment.
But she remembers how easy it was to get away with it.
"I was absolutely impaired, using narcotics while working. … And no one ever noticed," says Bertrand, 49, a nurse anesthetist in Houston. "Did I make mistakes? I don't know, and that's the scary part. I'm not aware of any, but I certainly would not say I was immune to that."
America's prescription drug epidemic reaches deep into the medical community. Across the country, more than 100,000 doctors, nurses, technicians and other health professionals struggle with abuse or addiction, mostly involving narcotics such as oxycodone and fentanyl. Their knowledge and access make their problems especially hard to detect. Yet the risks they pose — to the public and to themselves — are enormous.
A single addicted health care worker who resorts to "drug diversion," the official term for stealing drugs, can endanger thousands. Nearly 8,000 people in eight states needed hepatitis tests after David Kwiatkowski, an itinerant hospital technician, was caught injecting himself with patients' pain medicine and refilling the syringes with saline. He infected at least 46, mostly in New Hampshire.
It was the third hepatitis outbreak since 2009 linked to a health care worker using patients' syringes (the others were in Denver and Jacksonville, Fla). And for each of those worst-case scenarios, there are countless more practitioners whose drug-related errors are more isolated — a botched surgery, an incorrect dose of medication, a worrisome vital sign missed.
Much of the damage goes unnoticed or undocumented; oversight mechanisms to detect, report and address drug problems in health care settings are haphazard and limited. Still, a USA TODAY review of state and federal records identified hundreds of cases in recent years in which physicians and other health care practitioners were disciplined or prosecuted for drug diversion or other medical misconduct related to substance abuse.
The toll also can be brutal for the medical professionals who suffer with addiction — often in high-stress jobs with little help. Many struggle with guilt and despair, physical and mental health ills, and indifferent professional environments. Last year, New York's Supreme Court ruled that a hospital was not liable for the overdose death of a physician who, after returning from drug rehabilitation, was given operating room duty, where she had ready access to the propofol that killed her.
"Drug diversion affects so many people, and the systems for dealing with it are completely broken," says Lauren Lollini, 45, who was infected with hepatitis C in the Denver outbreak and now works with HONOReform, a patient safety group.
Bertrand, who returned to practice after treatment, now counsels other health care professionals with drug problems.
"The medical community thinks it's immune from this disease, but that's not true," says Bertrand, who had no history of drug use until she got hooked on pain medication after an abdominal surgery. "There are so many practitioners working impaired and we have no idea. ... We're doing a terrible job addressing this problem."
USA TODAY reviewed an array of government data and independent studies on drug use among health care practitioners, including records on hundreds of doctors, nurses and others caught diverting drugs. The newspaper also interviewed medical professionals, addiction specialists, regulators and law enforcement officials. Findings:
• Pervasive problem: The latest drug use data from the U.S. Substance Abuse and Mental Health Services Administration, released in 2007, indicated that an average of 103,000 doctors, nurses, medical technicians and health care aides a year were abusing or dependent on illicit drugs. Various studies suggest the number could be far higher; an estimated one in 10 practitioners will fall into drug or alcohol abuse at some point in their lives, mirroring the general population.
• Easily hidden: Safeguards to detect and prevent drug abuse in other high-risk industries rarely are employed in health care. No state has universal drug testing requirements, and hospitals, nursing homes and other facilities almost never do so on their own. Many institutions also lack video surveillance and high-tech systems to track dangerous drugs.
• Poorly policed: Many states lack rules to ensure that medical facilities alert law enforcement or regulatory agencies if they catch employees abusing or diverting drugs, so those staffers often are turned loose to find new jobs without treatment or supervision. Disciplinary action for drug abuse by health care providers, such as suspension of a license to practice, is rare and often doesn't occur until a practitioner has committed multiple transgressions.
"We certainly see gaps in the system; the examples are many," says Joseph Perz, an epidemiologist at the U.S. Centers for Disease Control and Prevention.
The challenge in addressing the problem is finding a "balanced approach," Perz adds. "We recognize that addiction is a disease and we recognize the value in … (rehabilitating) a provider. At the same time, we need to be thinking about the potential harm to patients. That balance is difficult."
On the job, 100 pills a day
Only a sliver of the health care practitioners who use drugs get caught.
Stephen Loyd, doctor of internal medicine, turned to narcotic pain relievers to cope with stress during his residency. By 2004, practicing in Tennessee, he was gobbling up to 100 pain pills a day — Percocet, Vicodin, whatever he could steal or finagle. But no patients complained; no colleagues raised concerns. It wasn't until his father intervened that he got help.
"I worked impaired every day; looking back, it scares me to death, what I could have done," he says. "I thought I was doing a pretty good job keeping it hidden. There were signs, behavioral changes. I canceled appointments, my paperwork was behind, I started dressing poorly, doing (hospital) rounds at odd hours. But no one ever reported me."
Harris Silver, a head and neck surgeon, was a resident in Pennsylvania when he started using narcotics in the 1990s for pain from a neck injury. Eventually, he began getting prescriptions from multiple doctors — and forging his own. It was his pharmacist who grew suspicious, contacting a mutual friend who got Silver into treatment.
"Sometimes I'd go to the bathroom in the middle of a long surgery to take medication," says Silver, now a drug policy consultant in New Mexico. "Addiction distorts your thinking. … You reach a point where you can't get through a long day without withdrawal, so you say, 'I'll just take a little to get through ...' I never had complications, and no one complained. At the time, I didn't think I was impaired. But I was."
Anita Bertrand evaded detection even as addiction consumed her. She had two car accidents after leaving work and shooting up. She was found passed out in a hospital break room. But she kept working until a doctor happened to see her passed out in her car in a hospital lot, an empty syringe on the seat, the port in her ankle in plain sight.
Like Silver and Loyd, Bertrand entered a special rehabilitation program for health care practitioners. All but a few states have such programs, typically run under the auspices of state licensing boards or medical professional societies. Practitioners who enroll voluntarily often can keep practicing with supervision after treatment. And those who complete rehabilitation usually are not subject to disciplinary action, so there's no public record of their drug problem.
The structure and success of the professional assistance programs vary, but they have one thing in common: They enroll only a fraction of the doctors, nurses and other health care providers who struggle with substance abuse.
Illness vs. crime, varied approaches
Based on widely accepted estimates of substance abuse among medical professionals, the programs typically aim to enroll 1-3% of a state's health care practitioners.
Even at 1%, that adds up to some 50,000 people nationwide: Nearly 9,000 of the nation's 878,000 licensed physicians, 27,000 of 2.7 million working nurses, and 15,000 or so medical technicians, nurse assistants and other clinical staff. And the programs aren't reaching anywhere near that many.
When Richard Fantozzi became president of the Medical Board of California in 2007, the state had 126,000 licensed physicians. But only about 250 (less than 0.2%) were in the board's substance abuse treatment and monitoring program — far less than the 1,260 that would be a minimal estimate of the population needing assistance.
What's more, independent audits in 2004 and 2006 had identified myriad problems with the program. Enrolled physicians often were allowed to continue in supervised practice, but there were repeated instances in which participants relapsed without alerting their monitors, cheated on drug tests and worked impaired.
"The question for us was, did it work? And it didn't," says Fantozzi, a surgeon. "We weren't getting people into the program who needed it. And when we did get people in, too many were able to game the system. How does that protect patients?"
In 2008, the Medical Board of California closed its physician assistance program. Doctors with drug and alcohol problems still can enroll in private, confidential treatment. But if the medical board verifies a substance abuse complaint, the conduct is punished and noted on the doctor's public record.
Many physician advocates and substance abuse counselors condemn California's approach. They say practitioners needing treatment won't come forward if they face discipline with no option of being diverted to a sanctioned rehabilitation program. And they note that most private treatment programs aren't equipped to monitor physicians' practices when they return to work.
California "is applying a crime and punishment model, which is appropriate in cases where a crime has been committed, where someone has been injured," says Warren Pendergast, president of the National Federation of State Physician Health Programs. "But most of these people haven't injured patients or committed a crime."
Noting that addiction is an illness, Pendergast and other specialists insist that the best way to protect patients is to remove the stigma so practitioners who need treatment won't be afraid to seek it.
"The message we need out there is … we can treat these people and get them healthy," says Jon Shapiro, medical director for Pennsylvania's Physicians' Health Program.
But relying on health care workers to self-refer for treatment is risky and could put lives at risk. Many won't seek help voluntarily. And rooting them out is especially difficult in the medical world, which generally lacks the safeguards used to identify substance abusers in other high-risk jobs, such as flying planes or driving buses.
Drug use in the medical community "can't be treated just as an addiction and treatment problem," says U.S. Attorney John Kacavas, who prosecuted Kwiatkowski. "To protect the patient," he says, "there has to be a law enforcement component."
The case for drug testing
Kwiatkowski wasn't great at hiding his drug problem, but that never stopped him from working in health care.
In 2008, he was caught stealing fentanyl syringes at a hospital in Pittsburgh. In 2010, he was found passed out in the bathroom of a hospital in Phoenix, an empty fentanyl syringe in the toilet. In 2011, co-workers at a hospital in Exeter, N.H., were concerned that he was acting strangely, sweating, running to the bathroom during procedures.
But it wasn't until several patients in Exeter developed identical strains of the debilitating hepatitis C virus that he finally was investigated and stopped. In December, he was sentenced to 39 years in prison.
Along the way, Kwiatkowski had been fired, disciplined by a state licensing board, and investigated by police. In some cases, his problems went unreported; in others, authorities were alerted but the information wasn't readily available to subsequent employers. There are no national databases to track misconduct by medical technicians, as there are for doctors and nurses.
Kacavas is part of a coalition of law enforcement and patient safety groups pushing for state laws to require that medical institutions alert authorities when a caregiver is caught stealing drugs or working impaired. Many also favor random drug testing, which is almost never used in the medical community.
"Any clinician in a hospital should be subject to random toxicology screening," says Art Zwerling, former chief nurse anesthetist at Philadelphia's Fox Chase Cancer Center and a recovering alcoholic and prescription drug addict. Zwerling, a peer assistance adviser, thinks testing would push abusers into treatment and expose the true scope of the medical community's drug crisis.
But questions abound: What drugs should the tests cover? How would practitioners be assured of privacy for medical conditions requiring prescription medication? And who would cover the considerable costs?
"It's an expensive thing to do right," says Pendergast, "and it's really complicated."
Hospital cracks down; drug thefts monthly
When the University of Tennessee Medical Center in Knoxville cracked down on drug diversion with a series of new controls — video surveillance, medication accounting systems, and internal reporting rules — the problem proved larger than anyone expected.
"I was catching at least one health care provider every month stealing medication," says Kimberly New, until recently the hospital's manager of controlled substance surveillance.
Other hospitals that take similar steps find the same, says New, a board member of the National Association of Drug Diversion Investigators. But practitioners who get caught rarely are prosecuted, either because institutions don't report them or because the cases aren't big enough.
"To get a case prosecuted, you have to really push hard," New says.
USA TODAY reviewed more than 200 state and federal prosecutions completed since 2008 for drug diversion by health care providers; just 15% involved practitioners stealing drugs for personal use. Most involved doctors, nurses and others who diverted on a large scale for profit, often using prescription scams.
Disciplinary actions by medical boards and hospitals also are rare. From 2010 to 2013, only about 750 physicians nationwide lost hospital privileges or had their licenses revoked or restricted for being unable to practice safely because of drug or alcohol abuse, according to a USA TODAY analysis of the government's National Practitioner Data Bank public file.
Many addiction specialists and policy-makers believe the more immediate way to address the medical community's drug problem is to give practitioners better education on preventing addiction and spotting potential impairment in colleagues.
"We don't teach our practitioners much about addiction, given how much is out there," says Pendergast. He believes the issue should get more attention during care givers' training and also in continuing education during their careers.
Fantozzi, who left California's medical board in 2009, proposed a continuing education requirement for doctors on drug use and addiction. He wanted malpractice insurers to fund the program.
"The idea was to be constantly educating thousands of people who would be out there watching for (drug use and diversion)," Fantozzi says. "The malpractice companies were fine with it, but we couldn't get interest from the medical societies.
"They didn't see that as a solution."