Secret program lets nurses get drug treatment on the job

Nurse Kenneth Matsko brushed aside a doctor's misgivings at finding him asleep in the operating room.

Matsko said he was tired because he had just eaten a turkey sandwich. The tryptophan, you know?

But the doctor soon discovered bloody gauze, hypodermic needles and other signs that Matsko, a nurse anesthetist, had injected himself with a powerful sedative during a procedure with a cosmetic-surgery patient.

The doctor didn't know Matsko was in a state program for nurses with drug problems - a confidential program that allows nurses to continue working while shielding them from discipline and public exposure.

Matsko was supposed to tell his employers he was in the program. But he didn't. And because the program is confidential, there was no public record of his drug problems, no way to know, even, that he had recently suffered a relapse.

"I can't sleep when I think about it," Matsko said recently. He's out of nursing for now after finally facing the state Board of Nursing.

"What if I had really hurt somebody?"

The Matsko case is extreme. But it represents the single-biggest reason nurses face disciplinary action in Florida: repeated abuse of drugs, mostly prescription narcotics.

A Tampa Tribune analysis of cases brought against Bay area nurses by state regulators shows nurses relapsing, missing required drug tests, even tampering with their urine samples while under the protection of the state program.

More disturbing is that many of these breaches result in public records only after repeated offenses - and that the records reflect only a fraction of the nurses known to be struggling with drug abuse.

The nurturing approach Florida adopted, with its confidentiality provisions, means patients can't know whether to trust the people who bear chief responsibility for their safety.

Alternative to punitive board

The confidential program, called the Intervention Project for Nurses, is run by a private, nonprofit contractor that is paid about $1.5 million a year by the state Department of Health. It started 25 years ago as an alternative to the harsh punishment of the state Board of Nursing, offering nurses a chance to get treatment without losing their licenses.

Most importantly, it makes it easier for health care professionals to report their drug-using colleagues so they can get help, said Tampa doctor David Myers, an addiction specialist who evaluates nurses for the program.

The majority of Florida's 280,000 nurses don't have drug or alcohol problems. About 11,000 have been through IPN in 25 years, and the majority of those have completed the program successfully and gone on to unblemished nursing careers, IPN officials say.

It's a national model for alternative discipline programs, said Todd Monroe, a nursing researcher at the University of Tennessee Health Science Center. "There are many, many success stories."

But the failures, even if they are few, have the potential to be devastating.

"It's all very hush, hush. No one wants to talk about this," said former nurse Jack Stem, who runs a support program for nurse addicts in Ohio and has battled addiction himself. He favors alternative programs but doesn't like the secrecy that surrounds the topic of nurses and narcotic abuse.

"This is a disease, just like any other physical disease," he said. These drugs, the opiates, alter the way the brain functions. "They change the part of the brain where we make decisions. But if you've never felt it, you think it's just a matter of willpower."

What bothers Stem the most is that so many nurses don't learn this in school.

"They're health care professionals. You'd think they, of all people, should know what these drugs do."

Matsko's problems started when he fell off a chair and injured his shoulder in 2001. He started taking Vicodin.

In 2004, he was reported to the IPN when a co-worker saw him sniffing nitrous oxide; he insisted he was checking the mask to make sure it fit. He was still using the narcotic and a muscle relaxant called Soma and smoking marijuana. He saw a program psychiatrist who said he should sign an IPN agreement.

He was hesitant but went along when he was assured it would be confidential.

It's not an easy program, he said. Nurses must agree to attend support group and relapse-prevention meetings, submit to random urine tests and inform IPN every time they get a new job. At each job, they are supposed to have a supervisor who will monitor them and report to IPN.

Before that, though, Matsko was required to go through drug rehabilitation. Program counselors recommended six weeks of intensive outpatient treatment. Three months after finishing the treatment he was back on the job, with IPN monitoring him.

That's typical, according to the disciplinary reports on Tampa-area nurses. They generally went through six to eight weeks of outpatient treatment, which they paid for themselves. Many were back to work less than three months later. In severe cases, they were prohibited from handling narcotics for a year.

That's not enough, Stem said - not enough rehab and not enough time away from work. A nurse who has been using narcotics for a while can take months to think rationally again.

And if they were getting their drugs from work, he said, "They are being set up to fail."

Art Zwerling, president of the Philadelphia Recovering Nurses Association, works with drug-addicted nurses, particularly nurses who have used intravenous narcotics.

They need "a minimum - a minimum" of three months of inpatient treatment, he said. The American Association of Nurse Anesthetists says they should stay away from work for at least a year.

'It's easy to divert'

Matsko's record was clear for about 21/2 years as he moved from job to job, ending up at St. Petersburg Anesthesia Associates. But in early 2008, his bosses became suspicious that he had been stealing supplies of fentanyl, a painkiller and sedative.

They were right.

"It's easy to divert," he said. "I had a supervisor who was watching me."

Many hospitals have systems to track the narcotics that nurses remove from cabinets containing controlled substances.

"But when you really want something, you can get it," Matsko said.

This time, Matsko's IPN case managers sent him to inpatient evaluation through Shands Health Care in Gainesville.

"He readily admits to diverting fentanyl directly from patients in real-time clinical scenarios," wrote psychiatrist Scott Teitelbaum.

He "never took the patient's entire dose, but would share the dose with the patient," the disciplinary report said. "He started by using the drug sublingually under his tongue, but quickly moved to injecting the fentanyl intravenously."

Matsko was one of about 700 nurses who relapsed in IPN from 2007-09, about 20 percent of the nurses in the program, according to IPN records. Nurses who start using again or violate their contracts in any way are supposed to be reported to the board, said Eulinda Smith, spokeswoman with the state Department of Health.

They're not.

Fewer than 500 nurses statewide came before the board on substance-abuse reports in those three years. And they weren't all program referrals. Some hospitals report nurses directly to the board and don't go through IPN.

Linda Smith, who helped create IPN and now is a consultant, said the program is tough on nurses who violate contracts, but a referral to the board isn't always best.

Program managers can help the nurse and protect the public, Smith said, when they pull the nurse from practice, "immediately place the nurse in an evaluation and treatment process ... then determine the next best steps."

Breaking the contract

This time, Matsko spent three months in partial hospitalization at Shands. And less than a month after he finished, IPN approved his return to work.

Teitelbaum wrote, "I believe he is making a solid effort, although he has fooled people before."

To help him after he got out of the hospital, doctors gave him a drug, Vivitrol, to tamp down his opiate cravings. But it made his head hurt and kept him from sleeping.

"I was miserable and in pain," he said.

He lost one job because of what a supervisor described as "a personality clash." Matsko said his bosses were wrongly suspicious of him because he was on an IPN contract.

"There's a tremendous bias against you when you go into IPN," he said. "Some people don't want to work with you."

So Matsko broke his contract. In mid-2009, he took a job with Premier Center for Cosmetic Surgery, the state disciplinary report said.

He didn't tell IPN. He didn't tell his employer he was in IPN. And there was no public record that would alert Premier to his drug history.

An officer manager contacted at the cosmetic surgery center said she was not working there at that time and declined to make anyone else available for an interview.

Matsko stopped taking the Vivitrol, and his cravings returned. He turned to narcotics, including the sedative propofol.

"They give you tools in recovery to deal with that and you have a choice. You can call and tell them and get help, or you can go to your drug of choice," he said.

"I don't know why I did it. I guess I tried the propofol to make myself feel different. I hate even thinking about it."

Matsko rigged up a system that enabled him to deliver propofol into a vein in his foot during anesthesia procedures at the cosmetic surgery center, the disciplinary report said.

One afternoon, while a patient was having surgery, Matsko dropped into a nearby chair and seemed to be asleep.

The center's medical director, who was doing the procedure, took pictures of him for evidence. After the procedure, the medical director began asking questions and learned Matsko was in the program. He wrote IPN immediately.

His patient wasn't harmed, the medical director wrote, but "there was definitely potential for a catastrophic outcome."

Getting out of nursing

Matsko realized he was a menace, he said. He had a four-year nursing degree and two-year master's degree for anesthesia. He was married with a child.

"If someone had told me 10 years ago where I'd be today," he said, "I wouldn't have believed them. I would have said they were crazy."

He moved from the legal Vicodin prescription to fentanyl injections, then propofol.

"You go to work, all of a sudden you're diverting from work. You ask yourself, 'Why?' but don't get any answers."

People don't understand what prescription narcotics do to the brain, Stem said. The addiction can happen quickly or slowly, but with some people, "the brain literally begins to see the chemical as necessary for life."

Some nurses should never return to a workplace where they are surrounded by narcotics, he said. Stem eventually gave up his license.

"I knew I couldn't stay in practice and work around drugs ever again," Stem said.

The board permanently revoked Matsko's anesthesia license but gave him a chance to return to the IPN, which he did.

Now he's working for a time-share company and in treatment.

"I don't know what's going to happen," he said. "I loved nursing, but I'm not interested in the medical field or nursing right now. I'm not comfortable.

"Maybe in a couple of years, after I get some clean time under my belt."