Opinion ID: 618491
Heading Depth: 2
Heading Rank: 1

Heading: Disabling Effects of Narcotics Use

Text: Maher's medical records confirm that, for nearly a decade, Maher has treated pain with a varying array of powerful narcotics, and she usually has taken multiple drugs at the same time and in significant doses. In a 2007 letter, Dr. Elizabeth Cuevas, Maher's primary care doctor, noted that her patient is treated with narcotics that are prescribed at very high doses, and Dr. Wolfram Goessling, Maher's treating gastroenterologist, has similarly noted that Maher takes impressive amounts of narcotics. Over the course of her treatment, Maher has consulted several pain clinics and periodically changed medications, but her records reveal no success in scaling back the use of narcotic painkillers. According to Dr. Herbert Malinoff, one of Liberty's consulting doctors, Maher's record of treatment supports a diagnosis of -31- chemical dependency relative to opioid and Benzodiazepine use over a long period of time. Maher contends that her drug use, as a matter of law, prevents her from working in any job within the field of nursing, and thus precludes employment in the one area for which she is qualified by education, training, or experience. As Maher notes, Massachusetts' Standards of Conduct for licensed nurses prohibit nurses from practicing while impaired. 244 Mass. Code Regs. § 9.03(36). Maher argues that the sedentary nursing roles that Liberty has suggested she would be capable of filling all necessarily involve the practice of nursing, defined by statute to include coordination and management of resources for care delivery. Mass. Gen. Laws Ann. ch. 112, § 80B. Because she is therapeutically addicted to narcotic medication, Maher suggests that she is legally impaired and cannot serve in the above positions.14 Though Maher tries to segregate this line of reasoning from her alternative argument that the effects of her medications would interfere with her ability to carry out the duties of a nursing job, they cannot be so easily disentangled. The fact of narcotics use does not, by itself, appear to preclude legal 14 Because I dispose of Maher's argument based on the definition of impaired, I do not address her contention that the sedentary nursing roles identified by Liberty involve the practice of nursing under Massachusetts law. -32- function as a nurse. The governing regulations define impaired to mean the inability to practice nursing with reasonable judgment, skill, and safety by reason of alcohol or drug abuse, use of substances, a physical or mental illness or condition, or by any combination of the foregoing. 244 Mass. Code Regs. § 9.02. Thus, whether Maher is impaired turns not on whether she is addicted to narcotics, but on a factual determination of whether her narcotic use is likely to interfere with her judgment [and] skill. Id. The evidence of the effect of Maher's narcotic use on her ability to concentrate and function is mixed. There is, to be sure, an intuitive logic to the notion that we should be wary of entrusting patient care to a medical professional who takes large amounts of narcotic medications. This is a point that Maher emphasizes in her briefs, and it has some basis in fact. Medical authorities warn that narcotics may cause sedation, mental clouding, and impaired psychomotor function. However, according to a publication of the American Medical Association included in the administrative record, these types of side effects usually dissipate with continued treatment, normally within a week with regularly scheduled dosing, and studies have demonstrated that most patients on chronic opioid therapy can safely drive cars. One of Liberty's consulting physicians, Dr. Robert Millstein, makes the same point in his February 2007 report, though he acknowledges -33- very few studies have examined the effects of opioids on selective, divided, and sustained attention. Maher's medical records indicate that she has often complained of the sedation brought on by her regimen of narcotics. However, close scrutiny of these records indicates that many of her reports of somnolence and other drug-related side effects are correlated with a change in medication or an adjustment of dosage. To take one example, Maher saw Dr. Goessling in March 2005 and complained that the morphine she was taking made her loopy and more sleepy than usual. Her medical records reveal that she was started on morphine only a couple of days prior, when she was admitted to the hospital for abdominal pain and the pain clinicians recommended that she transition from OxyContin. Overall, I do not find convincing support in the record for the proposition that Maher's drug use, by itself, would render her incapable of working in one of the sedentary nursing positions identified by Liberty. There is no clear prohibition in Massachusetts on serving as a nurse while on a medically prescribed regimen of narcotics, so long as the drugs do not impair the nurse's judgment, skill, and safety. Maher's doctors have not suggested that her use of drugs would interfere with her judgment or ability to make rational decisions. Indeed, Dr. Goessling and Dr. Cuevas both identify excessive sedation to be the major side effect associated with Maher's medication. I acknowledge that Dr. -34- Goessling has opined that he cannot imagine that it would be in [Maher's] or society's benefit to have her work as a nurse making decisions over other people's lives, but he does not point to any specific effect of the drugs that would render Maher incapable of safely managing the limited nursing roles suggested for her by Liberty. I am not unconcerned by the possibility that narcoticrelated sedation would make it difficult for Maher to complete a regular workday. In one instance in 2005, Maher reported that the somnolence associated with a change from OxyContin to Palladone was causing her to take three naps per day. Such considerable sedation would clearly interfere with most if not all possible employment. However, because Maher's reports of drowsiness and other adverse effects from medication appear largely related to alterations in her drug regimen -- which conforms to the medical evidence that side effects are most pronounced when first starting a narcotic -- I do not see convincing evidence that Maher's ability to concentrate and exercise judgment would be significantly compromised by a regular and stable program of narcotic medications.