Is it wise to enter alternative-to-discipline programs for substance use disorders?

By | 2019-08-21T15:33:18-04:00 August 19th, 2019|18 Comments

A reader said she was reported to her board of nursing for an apparent substance use disorder.

After a hearing, the board recommended that to maintain her license, she would need to get into a treatment program sponsored by the board. The reader responded to the board she did not want to voluntarily participate in the treatment program. She wonders what will happen next.

As I discussed in my blog, “Should Nurse Accept Reprimand Offer from Board of Nursing,” boards have the authority to propose professional disciplinary options to nurse licensees. Although it is always best not to be in a situation where you have to make the choice to accept a professional discipline, in most instances the recommendation from the board requires careful, thoughtful consideration.

If an offer is reasonable based on your specific circumstances, and your attorney counsels you that the offer is the best option for you, you should accept your attorney’s advice.

In this instance, it sounds as though participating in a treatment program will allow the reader to keep her license, which is a critical point. By not accepting the offer to get into treatment, she will continue with her substance use disorder and will most likely face a possible suspension of her license and need to petition the board for reinstatement at a future time when she is “clean and sober.”

The reader did not indicate the type of treatment program in which the board was requiring her to participate. Because she would be able to keep her license if she enrolled, it sounds as if it may well be an alternative-to-discipline program.

What are alternative-to-discipline programs?

Alternative-to-discipline programs are used by boards of nursing to help nurse licensees receive needed treatment and maintain an unencumbered professional nursing license. They provide a “non-punitive, nondisciplinary and usually confidential approach” to the nurse licensee. Treatment and aftercare are included in alternative-to-discipline programs.

The “confidential” approach is a crucial benefit of an alternative-to-discipline program that offers this protection. A board of nursing disciplinary action is accessible to the public through the board’s reporting mechanisms and is reported to the National Practitioner Data Bank and other banks.

However, successfully completing an alternative-to-discipline program and its aftercare requirements allows the nurse licensee to obtain treatment confidentially, no (reported) discipline occurs, and the nurse can return to nursing practice and safely provide care to patients.

Alternative-to-discipline programs vary from state to state. Variability includes how the program is administered (e.g., by the state board or another state agency), eligibility and continued nursing practice during treatment.

Alternative-to-discipline programs have been highly successful in treating nurses with substance use disorders. Moreover, the long-term recovery rate for nurse licensees undergoing treatment in these programs is high. Last, but by no means least, the public is protected because the nurse licensee is practicing unimpaired.

Boards of nursing that administer alternative-to-discipline programs include Delaware, Iowa, Maryland, Michigan and North Carolina. To check if your state board offers these programs, click here.

Examples of other nursing board disciplines

The following are a few reported disciplines by state boards where an alternative-to-discipline program was not applicable, was not available or was not requested by the nurse:

  1. Maine Board of Nursing — Registered professional nurse license revoked due to diversion of scheduled drugs from place of work resulting in criminal conviction and falsifying medical records in diverting the scheduled drugs.
  2. Illinois Board of Nursing — RN license placed in “refuse to renew” status after a sister-state violation due to drug diversion. An audit found narcotic withdrawals with discrepancies and the nurse admitted to diversion of medications.
  3. Missouri Board of Nursing — RN license suspended and placed on probation after diverting oxycodone and hydromorphone, and a positive drug screen for amphetamines, marijuana and methamphetamine.
  4. Connecticut State Board of Nurse Examiners — Registered nurse license revoked because her practice “posed a threat to public safety” after her license was previously suspended for using marijuana, cocaine and heroin for almost two years.

Considerations to weigh carefully

Nurses are not immune to drug and alcohol misuse. If you have been reported to your board of nursing for drug or alcohol problems, you need to seek treatment as soon as possible.

Boards of nursing are well-versed in substance use disorder, and when there is the option of treatment and aftercare in a confidential manner, an offer to participate in such programs is one that should be accepted.

It allows you to get the treatment you need and, more importantly, allows you to continue to practice as a licensed nurse once that treatment is successfully completed. Consider these points:

  1. Review your state nurse practice act for the possibility of an alternative-to-discipline program.
  2. Obtain legal counsel to represent you through the board’s process for getting into an alternative-to-discipline program.
  3. Comply with all requirements for admission into an alternative-to-discipline program and its obligations while in treatment (e.g., group therapy, individual therapy, drug screens).
  4. When returning to practice, accept any suggested conditions that allow you to practice safely and without impairment (e.g., no night duty, no home healthcare).
  5. Remember that being “clean and sober” is a lifelong responsibility that benefits your well-being and safe patient care.
  6. If an alternative-to-discipline program is not an option in your state, seek treatment through alternative programs with the approval of the board of nursing.
  7. Underscore the importance of working with your board of nursing and don’t consider simply not cooperating with that board or “handing in the towel” in the face of allegations of substance misuse.

Take these courses related to substance use disorder:

Recognizing Signs of the Misuse or Abuse of Controlled Substances
(1 contact hr)
Many state medical licensing boards have already or will require healthcare professionals to complete mandated continuing education that addresses prescribing controlled substances. Misuse and abuse of prescribed controlled substances can lead to serious consequences, such as addiction and overdose. Understanding the signs of abuse of medications such as opioids and sedatives is important to safe prescribing of controlled substances. This module will teach healthcare providers about substance use disorder and how to identify signs and symptoms of misuse and abuse. The module will also discuss a safe and effective approach to managing patients with substance use disorder.

Controlled Substance Prescribing for Chronic Pain Management
(1 contact hr)
Many states now or will in the future require continuing education specifically addressing controlled substances. Chronic pain is a fairly common disorder for which healthcare providers often prescribe controlled substances, such as opioids. Prescription opioids can alleviate pain in certain patients, but the risk of misuse, abuse, addiction, and overdose means that providers need to evaluate the risks and benefits for each patient. This course will educate healthcare providers on the role of prescription controlled substances along with other therapies for chronic pain using recommendations from current national guidelines. Upon completion of this course, providers should be able to identify which patients can benefit from chronic opioid therapy along with ways to evaluate them for misuse during the course of their treatment.

The Nurse With Substance Use Disorder
(1 contact hr)
The American Nurses Association has long estimated that misuse of chemical substances among nurses parallels that of mainstream society; however, recent statistics from the CDC reveal that mainstream society substance abuse of illicit drugs or misused prescription drugs is higher. Research indicates nurses with substance use disorder often begin misusing drugs, including alcohol, before finishing their nursing education and can make an entire work group dysfunctional. Use of labels such as impaired can result in stigmatization of the behaviors, making it more difficult for the nurse to seek help or for peers to report them for intervention. All but 7 states in the U.S. have programs to address substance abuse and impaired practice in nursing stressing alternatives to traditional disciplinary actions and criminal prosecution. This activity will help you to recognize and support colleagues who may be suffering from substance use disorder while protecting patient safety.


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About the Author:

Nancy J. Brent, MS, JD, RN
Our legal information columnist Nancy J. Brent, MS, JD, RN, received her Juris Doctor from Loyola University Chicago School of Law and concentrates her solo law practice in health law and legal representation, consultation and education for healthcare professionals, school of nursing faculty and healthcare delivery facilities. Brent has conducted many seminars on legal issues in nursing and healthcare delivery across the country and has published extensively in the area of law and nursing practice. She brings more than 30 years of experience to her role of legal information columnist. Her posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state. Visit The American Association of Nurse Attorneys website to search its attorney referral database by state.


  1. Avatar
    Wendy Herschberger August 25, 2019 at 10:45 am - Reply

    This article is very vague and generalized.
    The alternative programs are VERY expensive to the point most nurses lose their homes and families. This article makes it sound like these programs are easy to do they are not. Yes I agree there are definitely nurses who need help and can benefit from the programs but it seems nursing always places everyone under the same umbrella whether you are a 1 or a 10 on the scale you get treated like the 10. A member of the Florida program made a comment on you tube that most nurses who complete the program usually end up with an anxiety/depression disorder and financial difficulties. Of course they say that is part of the disease.

  2. Avatar
    Rosemary Smentkowski MSN, RN, PMHNP-BC, CARN August 25, 2019 at 3:33 pm - Reply

    Pleased to see this information on this site. Nurses also need to understand their best choice of attorney would be someone who understands the language of their BON. The nurse’s legal issues are separate from their license.
    In many states if you choose not to participate in ATD you will be a “former nurse” as one participant shared with her peers.
    The peer connection is vital in ATDP!
    One other benefit as someone who hired nurses and facilities ATDP Peer Meetings, advocacy in positions for future practice when granted permission to do so. Nurses with BON sanctions need advocates!
    One last comment, always carry your own malpractice insurance! Always!
    Great article!

  3. Avatar
    Irene August 25, 2019 at 7:38 pm - Reply

    These programs are nothing but humiliating potty training excercises that cost thousands of dollars and you never get your reputation back. No one is on the nurses side. Don’t ever report yourself for anything.

  4. Avatar
    Paul Cox August 26, 2019 at 4:12 am - Reply

    Ms. Brent, I am curious to know if you have any conflicts of interest, including any relationship with one of these programs or with a Board of Nursing.

    I think we both know that almost any basic Google search of these programs would certainly paint a VERY different picture than what your article paints.

    Thus, I believe this article is very misleading as to the actual nature of these programs. As such, it may be very damaging for a healthcare professional to infer that an “alternative-to-discipline” program is necessarily as beneficial as it sounds. It is the duty of another JD to argue the other side.

    These “alternative-to-discipline” programs in many cases are utilized as discipline against the person, the license, or BOTH. The Florida Board of Nursing routinely refers to it’s State-approved program as “discipline” and gives the program various codes as defined in it’s “Summary to Discipline”. Even if other States do not use the word, these programs are, in effect and in practice, disciplinary. In very many (all?) cases, the participants are required to refrain from nursing altogether, or major aspects of nursing, such that the participant has severely reduced or no disposable income to afford the “treatment”. Thus, he/she may be effectively forced out of the program AFTER he/she has spent all of their disposable income and cannot afford more psychiatric assessments or an even attorney to help them.

    Further, these programs across the US can be so disruptive to a professional’s life that it is practically impossible for the participant to remain anonymous. In a very basic example, simply signing up for an initial evaluation can require a witness and an emergency contact with the nurse’s entrance paperwork. Rumors fly. The program may further justify requiring involvement of friends/family as necessary to “recovery”. Explaining one’s absence from work requires either lying or admitting to being in such a program.

    I am familiar with individuals who have involved themselves with such programs — nurses and administrators alike — and I am certain that very many participants could talk at great length about how the programs are NOT “alternative-to-discipline” but are in fact just another means of discipline against the person, the license, or BOTH.

    Given that both the author and I hold JD degrees, and because a professional license is an actual property right, I feel it is professionally responsible for the author to advise the healthcare professional to seek the advice of a licensed attorney who specializes in these cases, BEFORE signing any paperwork or even SPEAKING to any representative of these self-proclaimed “alternative-to-discipline” programs.

    In all things, follow the money.

    Paul Cox, RN, JD, MBA

    • Avatar
      peter peil September 2, 2019 at 10:20 pm - Reply

      Paul I am very interested in your commentary. I have yet to meet some one that has had a good experience with these programs. How do we find a lawyer versed in the BON process? How do we stay under the rader and not get referred to a program. Were are the advocates for nurses? Can nurses seek treatment and not be at the mercy of he board? Would be grateful for a reply.
      Pete Peil , RN

  5. Avatar
    Leanne Meier August 26, 2019 at 11:15 am - Reply

    This could be an excellent opportunity for the nurse, in theory. In Practice I have found that my board was not at ALL on the side of the nurse. Im a teacher for a RN Refresher course and had the opportunity to hear from students on there experiences. They were 98% NOT positive. It all depends on those in charge and how it is run. In my experience, it was punative, deceptive, dictatorial, and generally not helpful. Being connected to the board, automatically makes nurses wary and reluctant to speak honestly. Im aware of a program in my community run by recovering nurses, for the sole purpose of supporting the addicted nurse. FAR better choice, if available!

  6. Avatar
    Kathleen Ciberay August 26, 2019 at 9:25 pm - Reply

    I was referred to an alternative-to-discipline program by the Board of Nursing after a complaint against me. The BON said I must have an evaluation by the particular ATDP, which is the only one in my state. At the time this occurred, I was not worried, as what I had done was fairly minor. I cannot go into detail at this point as to what occurred, however I want to point out that the ATDP which “assessed” me was also the ATDP that I had to attend if their evaluator felt I needed treatment/monitoring. The evaluation was not accurate at all. My words were twisted and my “self-report” was totally used against me. The evaluator found that I had a “mental disorder” (I have been diagnosed with ADHD for over 15 years) and said I was not safe to practice without treatment and monitoring. Note that this had nothing to do with the original complaint. There is much more but my issue is: Is it not a conflict of interest for the evaluating agency to also be the ATDP?

    • Avatar
      Rox December 30, 2021 at 9:56 pm - Reply

      What ultimately happened?

  7. Avatar
    Jen August 27, 2019 at 12:05 am - Reply

    Checkout your attorneys political agenda, before you follow her advice. In some states there are alternative to discipline programs for “medical professionals” they allow nurses also but only One Board approved program for “nurses”
    Be VERY aware of the fact that just because your board may allow you to enter the program for “medical professionals” and continue to work as long as you remain in the program, in the end not doing exactaly what the board initially recommended will negatively impact your license. After successful completion….
    Almost every one of the nurses that participate in an approved program that is not Nurse Specific(over seem by the Board) will still end up with an administrative action on their license forever! The Board has the final say, do what they recommend, do not just blindly follow your attorney! An administrative action can GREATLY decrease your ability to get an interview or hired by large healthcare systems or any medical provider.
    – call it discrimination-
    But that will not change reality, a mark on your license, a letter from the BON stating your license is now unencumbered nc you’ve already been placed in the Data Bank. This makes you a high risk employee regardless of how much you may have turned your life around.
    Employers hire nurses in recovery every day without knowing, even nurses that previously diverted and relapsed multiple times…..their saving grace is that once they have successfully completed the orders set forth by their board (signing the private letter agreement).
    These nurses are given a second chance, a clean slate (license) and they never have to provide embarrassing explantations for their past and their resume is not placed in the pile of applicants that will not be offered an interview

  8. Avatar
    Joshua welch August 28, 2019 at 2:18 pm - Reply

    This is a very vague, non insightful, prejudiced article on a heavy topic that involves both medical and legal topics and consequences. The article in no way represents an unbiased point of view, or even addresses the issues, surrounding the topic.

  9. Avatar
    shajib hasan September 19, 2019 at 2:04 am - Reply

    I was referred to an alternative-to-discipline program by the Board of Nursing after a complaint against me. The BON said I must have an evaluation by the particular ATDP, which is the only one in my state. At the time this occurred, I was not worried, as what I had done was fairly minor. I cannot go into detail at this point as to what occurred, however I want to point out that the ATDP which “assessed” me was also the ATDP that I had to attend if their evaluator felt I needed treatment/monitoring. The evaluation was not accurate at all.

  10. Avatar
    molla September 19, 2019 at 2:05 am - Reply

    This article is very vague and generalized.
    The alternative programs are VERY expensive to the point most nurses lose their homes and families. This article makes it sound like these programs are easy to do they are not. Yes I agree there are definitely nurses who need help and can benefit from the programs but it seems nursing always places everyone under the same umbrella whether you are a 1 or a 10 on the scale you get treated like the 10.

  11. Avatar
    NurseA July 4, 2020 at 1:44 pm - Reply

    Hi. This is the first time ever I am making a comment to a forum post. While I am a constant lurker to the bulletin boards, I have never felt strong enough to leave a comment/reply. I am a Nursing Consultant, that at one time had worked in consulting roles in revamping, building and adjusting “alternative-to-discipline” programs for Missouri and NY State BON. While MO and NY ave somewhat differ in requirements and guidelines, a lot of stipulations and monitoring guidelines are “eerie” similar.

    While it is true, these programs do help SOME nurses on FEW occasions, MOST of these programs are not individually tailored, very draconian and punitive in nature. Majority if not all of the cases that come up before BON are not properly investigated, or even reviewed. If the licensee is given the option to participate in an alternative program such as IPN, CANDO, the board will impose or “recommend” mandatory 5 to 2 years of monitoring/probation. On many occasions I have seen/reviewed that while Addictionologist or evaluating physician recommends no further monitoring, the BOARD or “Alternative” body will disregard recommendations and impose monitoring, along with testing (Urine, Nails, Hair, Blood).

    While I have heard some have said that everyone involved gets some monetary “kick backs” or incentives, personally, I have never seen or observed anything that would suggest any of this. Professionals who enter these programs often end up in Bankruptcy and with Severe Mental, Psychological Problems. Seems like there is no win/win situations. So, Professionals, especially those who hold Nursing Licenses, should know how truly difficult, unfair and punitive these programs are.

    This article compelled me to write 1st ever reply to a post, because it makes it seem like these programs are easy and very doable. Reality however is quite the opposite.

    • Avatar
      NurseM September 21, 2020 at 11:39 am - Reply

      I am an RN who has to now jump into the Massachusetts state ATD program called SARP. I relapsed (alcohol) one day in June. I had been sober for over 10years. My hospital employer realized this & of course I was fired. They didn’t want to report me to the board-I was told this by the DON, because they believed they could work with me & felt they knew me well enough to trust in a mutually agreed upon contract. They reported me due the hospital lawyer telling them they had to. So now I have to pay dearly for the next 3yrs.

      My question, please to anyone who my know this, Is that I am in my final year of a psych NP program. When I graduate & pass boards, I’m thinking I’m not even going to be able to apply for the NP license? I’m hoping that I can, and still remain in SARP with supervision etc. Any thoughts would be much appreciated. Thanks!

      • Avatar
        jes November 14, 2021 at 10:55 pm - Reply

        So, technically, if your license is unencumbered and active you should still be able to initiate the process, however, I recommend gradually working through the final steps required to graduate, delay the boards for 6-8 months after graduating, and if you are in your final year of SARP (what a lovely acronym -_-). You shouldn’t be prevented from taking the boards based on the requirements.

  12. Avatar
    Mary January 21, 2021 at 4:11 am - Reply

    I’d love the article if there was more specific information. The text is too generalized

  13. Avatar
    Nurse AZ July 7, 2021 at 9:52 pm - Reply

    Yes, this article is very vague. First off Boards of Nursing are NOT well-versed in substance use disorders. It is sad that they have the ATD Programs, who are staffed with people who seem to only have judgements & assumptions regarding Substance Use Disorders. They come across as rude & short, no empathy what-so-ever, and treat nurses in the program like they are a nuisance. In AZ, for the 3 year program, with insurance and no inpatient stay- the program costs (MINIMUM) $25,000. Just be smart with your choices, stay sober and do what is necessary than you should have no issues
    > Don’t forget to check Recovery Trek (drug testing roulette) daily (Missed test can result in additional test for 6+ months or time added to your sentence)
    > Keep copies of ALL reports, including COC for drug tests
    > Send reports to every single email you have for the BON, bc it never fails, you will have a “missing/late” report
    > Have folder in your email to store all communications with the BON
    > Utilize the nurses you meet while in the program that can relate to you
    * because the BON does not care that this can financially destroy you, they don’t care that you are
    overwhelmed, or that you are anxious & wanting guidance – if you voice concerns to the board,
    the typical response is “This program is voluntary, you do not have to be in it.” Even though they
    are holding your license/livelihood hostage by the balls & you really do not have a choice.

  14. Avatar
    jaylyn October 11, 2021 at 10:14 pm - Reply

    the kickbacks go strictly to the third party contracted ATD program and those involved (as in those working for these programs) and the third party drugs screening sites. There were opportunities for them to bring in individuals who could appropriately code and bill to the professionals’ in the program so their insurance would cover a portion of the costs–but that was denied–as it would take away from the profit obtained by the aforementioned, staff that were directly/indirectly working for the Board ADT.

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