Bobbie Sage thought nursing would be her salvation. She was trapped in an abusive relationship with four kids and looking for a steady income. The day she graduated vocational nursing school, she took the kids and left their father.

Kristen Hwang

CalMatters

Five years later, a DUI ruined her carefully crafted stability. Sage was waiting for a taxi outside a bar with another partner when he began hitting her, she said. She fled in her own car. A mistake with enduring consequences.

Sage was charged with a misdemeanor for driving under the influence of alcohol in 2014. She paid a fine and completed three years of criminal probation without incident, according to court documents. She thought that tumultuous period of her life was over until her state licensing board ordered her to complete an additional probation program for health professionals with substance use problems.

Sage couldn’t afford the drug tests at $300 a month or a fine of $3,140. She dropped out. She surrendered her vocational nursing license in 2019 and blames the program for ending her career.

Now, Sage is among dozens of health care workers who allege they’ve been mistreated under a California law governing workers with addiction and mental health problems. They say state regulations are needlessly punitive, overly bureaucratic and based on faulty addiction science. They call it a trap that prevents them from working and leaves many of them with thousands of dollars of debt.

“One misdemeanor is costing my entire life,” Sage said. “Punish me for something with my (nursing) license that I’ve done with my license.”

2008 Law’s Goal: Protect Patients

The 2008 law was supposed to protect patients after a series of audits and legislative hearings suggested licensing boards were doing a poor job of keeping impaired health workers off the job. It created uniform regulations for each board to follow that stipulate exactly how to deal with these workers, including extensive drug testing, travel restrictions and psychiatric evaluations meant to catch anyone who relapsed.

Some boards created recovery programs as an alternative to discipline. Workers could volunteer to join as a step toward their recovery, or be asked to join by their licensing board as a substitute for public punishment. Others, including Sage, were ordered into a parallel probation program after an incident such as a DUI or other licensing violation.

Nurses say those provisions have become so burdensome and expensive that health care workers avoid the recovery program outright unless a licensing board asks them to join. As a result, the state is monitoring fewer workers than ever. Fewer than 400 people are enrolled, down from a peak of more than 900 in 2010.

The recovery program has never included doctors, whose lobby resisted it because members believed it was too punitive, according to Gail Jara, executive director of California Public Protection and Physician Health, an organization dedicated to creating a new recovery program for doctors. The California Medical Board, which licenses most doctors, plans to push for an alternative program in the Legislature in the coming year.

“It’s living hell,” said an emergency room nurse interviewed by CalMatters who joined voluntarily. The nurse asked for confidentiality because she could lose her license for speaking out under the terms of her contract.

The nurse has been unable to find a job that meets the program’s strict work limitations for nearly two years despite clean tests. She has spent more than $8,000 on drug tests, according to receipts, several thousand more on medical and psychological evaluations, and more than $20,000 paying for health insurance because she lost her work insurance.

Dentists, physical therapists, veterinarians and other health workers whose professional licensing boards are overseen by the California Department of Consumer Affairs are subject to the state law. Nurses make up the majority of the participants, and complaints about the program have erupted at recent Board of Registered Nurses meetings.

Many say they’ve followed all the rules and still see no way out even after years of demonstrated sobriety.

Onerous Consequences

Officials at those meetings faulted minor changes they made to increase oversight, suggesting they went too far. Participants and addiction experts interviewed by CalMatters, however, say the law itself is the root of the issue.

“We’ve built systems that are completely onerous and agnostic of the value of a human life,” said Amanda Choflet, dean of nursing at Northeastern University in Boston and an expert in nursing addiction programs. “It’s not even that the systems themselves are actively trying to keep people from being able to recover. It’s that the systems aren’t built for humans. They’re built in order to enact legislation.”

A group of consumer advocates that pushed for the law argues that it is doing exactly what it is meant to do — impose consequences on workers who can’t stay sober. Michele Monserratt-Ramos, a patient advocate with Consumer Watchdog, said licensing boards’ first duty is to protect the public, not shield health workers with substance use or mental health disorders.

Many of the requirements that nurses and other workers say are intolerable such as work prohibitions were designed to protect patients, said Monserratt-Ramos, whose fiance died after an operation with a doctor who had a history of substance abuse. If health workers know addictive behaviors and other impairments will be scrutinized by their licensing boards, they’ll be less likely to do something harmful, she said.

“The safety net now is the consequences,” Monserratt-Ramos said.

The Department of Consumer Affairs did not make anyone available for an interview, stating that the regulations governing the program were written by a committee years ago and no experts were available. In a statement, the department said each health care board is independently responsible for implementing the program, and eight boards contract with an outside vendor, Maximus Inc., to do so.

The Board of Registered Nursing refused several times to make executive staff or board members available for an interview to address participants’ complaints. Individual board members also failed to return calls or emails from CalMatters. In a statement to CalMatters, board staff said they have already addressed such complaints and are working to address more.

Maximus, a publicly traded company worth $4.5 billion, did not respond to several interview requests. The vendor’s $12.4 million state contract expires at the end of December. The company did not bid for a new contract, and the Department of Consumer Affairs did not provide a reason why.

Sage says she worked hard to transform her life and move on from past abuse. She’s a licensed esthetician now and runs a successful studio in the Bay Area. Family and colleagues describe her as a hard worker, a natural caregiver and someone who doesn’t complain.

She admits she made a mistake, but says she never had an addiction problem. CalMatters reviewed a letter Sage provided from a doctor confirming that she did not meet the criteria for alcoholism and has never been diagnosed as an alcoholic. Under state law, any medical professional with a DUI is presumed to have a substance abuse problem even if it is a one-time offense. The Department of Consumer Affairs said the Board of Vocational Nursing and Psychiatric Technicians, which oversees Sage’s license, does not offer a recovery program, only a disciplinary track.

“I haven’t been a perfect person in my life, but I’ve been a good person,” Sage said. “I’ve taken full responsibility, and I don’t believe we should keep punishing someone for a misdemeanor that happened 10 years ago.”

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Nurse Demand Changes at Board Meetings

CalMatters spoke with six nurses in the recovery program, all of whom asked not to be named for fear of retaliation from their case managers and the Board of Registered Nursing, which authorizes their licenses. The nurses said while some of the policies they regarded as arbitrary have been rolled back — including a requirement to administer narcotics to patients — many of the problems are longstanding and systemic.

The nurses provided documents that supported their descriptions, including their contract agreements, medical records, and recordings of individual meetings with enforcement committees.

Common problems outlined by interviewed nurses include:

• Moving goal posts — All of the nurses interviewed by CalMatters said the requirements to complete the program kept changing, including work requirements and the need for clinical evaluations that could take months for the board to review, prolonging their time in the program. “I felt like I was going to be in this program indefinitely,” said a former acute care nurse who dropped out with what she says were five years of sobriety.
• Retaliation — Nurses said they felt like they were constantly in trouble and forced to stay silent for fear of losing their licenses. They were not allowed to travel to see family or attend their children’s sports games without approval from case managers. They would be held liable if no testing centers were open even on holidays and weekends, and the inability to pay for a drug test counted as a positive result. “I felt so small. I didn’t feel supported. Every time I saw my case manager calling me, I felt like I was going to throw up,” a second nurse interviewed by CalMatters said.
• Forced attendance at religious recovery meetings — A third nurse who started using drugs after escaping a religious cult said her case manager made her go to a faith-based 12-step meeting despite state law prohibiting such a requirement. “I go. I sit on a church pew. I feel like I’m back in my church, and I have palpitations,” she said.
• Interference with personal medical decisions — A fourth nurse who was admitted to the program for alcohol and mental health struggles said she was prohibited from taking prescribed medication for attention-deficit disorder despite demonstrated sobriety and a medical evaluation showing her cognitive performance improved with medication. Another who was prescribed suboxone, a drug commonly used to treat people with opioid dependency, said she was forced to stop by program officials against the advice of her doctor.
• “Cookie-cutter” requirements — A sixth nurse who was addicted to opiates said it took two-and-a-half years for a complaint about her drug use to be processed by the nursing board. In the meantime, she put herself through rehab and stayed sober. The board told her to “voluntarily” join the recovery program or be stripped of her license despite letters from her addiction specialist, the nurse said. According to documents reviewed by CalMatters, the frequency of her random drug testing and other restrictions were substantially similar to requirements imposed on nurses who were not sober at the time of joining the program.

In May, when nurses began flooding board meetings with sweeping allegations of mistreatment, Executive Director Loretta Melby said “What you heard from Maximus today is there’s, you know, about 250 participants in that program. We don’t have 250 people in public comment.”

But as more nurses called in to raise issues, other board members registered concern. “It sounds like collectively, we the board made, and this program made some errors,” board member Alison Cormack said during a June meeting. In August, the nursing board voted to rescind program changes made by Melby and chief enforcement officer Shannon Johnson, including a requirement that nurses work directly with patients and administer narcotics.

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In response to what nurses told CalMatters about ongoing problems with enforcement committees and employees of Maximus, the board’s staff sent this unsigned statement: “Board staff actively works with the vendor to address all concerns that are brought forth by participants.”

The statement added that “each participant is individually evaluated on a case-by-case basis” to determine the requirements of their recovery contracts, however the unsigned statement also acknowledged that previous participant contracts may not have accounted for an individual’s case history. Case managers and enforcement committee members must now examine each individual participant’s compliance with the program before making changes to their contracts, the statement said.

During a board meeting, Maximus, the program vendor, denied that its staff forced participants to attend religiously based meetings, an objection raised by several people during public comment. In a statement to CalMatters, board staff also denied there was such a requirement.

However, the nursing board’s own website denotes “12-Step Group Attendance” as a program requirement. The 12-step structure was created by Alcoholics Anonymous, and several steps reference God. Recovery agreements provided to CalMatters by participants say they can attend groups other than Alcoholics Anonymous, but program participants say they can’t find non-religious or non-spiritual alternatives that meet the board’s requirements, which also include finding a sponsor, another Alcoholics Anonymous rule.

Program regulations also stipulate that positive drug tests are not dismissed even if they are the result of a valid prescription. Regulations mandate that an approved physician submit monitoring plans for participants to take prescription medication even for chronic conditions such as high blood pressure and diabetes. Some nurses said they avoid medical care outright because of the bureaucratic hoops they are required to jump through.

Workers with Addiction Avoid Program

The majority of recovery program participants, 250, are nurses, Maximus Director of Clinical Services Ginny Matthews testified during a recent nursing board meeting. That means the state nursing board is monitoring less than 0.05% of its roughly 537,000 nurses. Other licensing boards are tracking far less.

The state does not track how many health professionals are disciplined and ordered to probation like Sage because of a drug or mental health impairment, but only 0.1% of the health care workforce is disciplined annually for any reason. Research shows between 10% to 12% of medical professionals will develop a substance use disorder during their lifetime.

That means the vast majority of health workers with addictions are flying under the radar, multiple addiction experts interviewed by CalMatters said.

“Where are all of the people who we know should be getting into these programs, and why aren’t they turning to our programs for help?” said Chloflet, the Northeastern dean of nursing. “That’s the thing that should be the most concerning to these state boards.”

Dr. Karen Miotto, a long-time specialist in substance use disorders and treatment for physicians, said protecting patients should be everyone’s primary concern, but programs that lean heavily on punishment rather than recovery tend to discourage participation. When that happens, regulators are left in the dark.

“If you create it so that no one will come…then you can’t argue we’re doing the safest thing,” Miotto said.

In a 2018 presentation to the nursing board, Matthews of Maximus attributed the decline in participation, which began in 2010, to a drastic drop in self-referrals after the state implemented the current law designed to increase oversight of professionals struggling with addiction or mental health issues.

In a statement to CalMatters, Board of Registered Nursing staff said it “cannot speculate as to the reason(s) that enrollment is low” but some nurses “may not want to participate in this specific program because it is overseen by their licensing agency, entails worksite monitoring, and there are costs associated with it.”

Nurses say the reason why numbers are dropping is obvious — the program is so intolerable that current participants tell their colleagues with addiction to stay invisible.

“We’re only the tip of the iceberg. When you become an addict you recognize other people,” a nurse who spent three years in the program told CalMatters.

What Does Evidence-Based Recovery Look Like?

Rigorous monitoring and drug testing can be effective even if they are intrusive and inconvenient, experts on health care worker addiction told CalMatters.

Research shows that daily check-ins, random drug tests, attending recovery meetings, and years of monitoring all help health workers stay sober and care for patients safely. Requiring a professional to adhere to these conditions in exchange for keeping their license is known as leveraged treatment — the point being to balance recovery with public safety.

“Leveraged treatment, we know, is enormously successful,” Miotto said.

Some studies suggest more than 90% of health workers who complete recovery and monitoring programs are sober and working five years later. In comparison, about 75% of the general population will recover from addiction. Success among health workers corresponds with random drug tests and lengthier program requirements.

But there are limits to what is effective.

Participants are the most successful with daily check-ins, weekly group meetings such as those held by Alcoholics Anonymous, twice monthly drug testing and nurse support meetings, and at least three years of monitoring, according to the only study to assess nurse monitoring program characteristics.

Requiring nurses to do more did not yield better results, according to the study, which assessed 14 state programs, not including California.

In comparison, California’s requirements are far more stringent.

State law requires all health care professionals to be tested once per week the first year in the program. Minimum test requirements drop in ensuing years but still average three times per month.

Regulations allow an average annual maximum of two tests per week, and many nurses interviewed by CalMatters said they had been subject to two or three tests within a 10-day period despite spending years in the program without violations.

Recovery agreements reviewed by CalMatters also showed that they required nurses to attend chemical dependency support groups several times per week, as often as daily, even after years of proven sobriety.

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‘One Paycheck Away From Disaster’

Shortly after receiving the terms of her probation, which included random drug testing and daily check-ins, Sage was injured in a car accident that prevented her from working for a year. She had three kids at home, and her disability checks didn’t stretch far enough to cover the drug tests. In an email to her probation officer, Sage wrote that she wanted to comply and asked if there were other options available.

“It’s either put a roof over my head or pee for a drug test for something that happened four years ago,” Sage wrote to her probation officer in 2018.

It didn’t matter.

“Failure to submit biological fluid testing will be considered the same as a positive test and will be a violation of probation. There are no other options,” the probation officer responded via email.

Sage testified under oath at an administrative hearing that her probation officer verbally told her to give up her house and live in her car if that was the only way to pay for the terms of her probation. During the eight months she was in the program, Sage said she became suicidal.

“I called my own family and wanted them to take my kids because I didn’t feel like I could take care of them,” she said. “I felt so horribly defeated and desperate by how I was treated.”

Her probation officer listed 148 failures to check in and 15 missed drug tests as part of the reason to revoke Sage’s license. Emails show that all of the violations on Sage’s record happened after she notified her probation officer that she couldn’t afford the costs.

“Most American families are one paycheck away from disaster. The board was perfectly fine to tell me to live out of my car, which I find disgusting,” Sage said.

This year, Sage petitioned to have her license reinstated. During a reinstatement hearing, Sage testified that she did not have a pattern of substance abuse, and instead the 2014 DUI represented the worst of two very difficult years of her life as she tried to escape an abusive relationship.

“I just want to say that I have spent my life trying to change since that day,” Sage testified.

On Monday, the Board of Vocational Nursing and Psychiatric Technicians notified Sage that her license could be reinstated only if she resumed probation for three years and paid an additional $600 processing fee.

“I wish that somebody who has the ability to make a change will look at the whole program and say it’s time to revisit this and make some changes,” Sage said.

About the Author

Kristen Hwang is a health reporter for CalMatters covering health care access, abortion and reproductive health, workforce issues, drug costs and emerging public health matters. Her series on soaring rates of maternal and congenital syphilis won a first place award from the Association of Health Care Journalists.

About CalMatters

CalMatters is a nonprofit, nonpartisan newsroom committed to explaining California policy and politics.