According to the National Institutes of Health’s National Institute of Drug Abuse, researchers have determined that drug abuse and overdoses have increased during the pandemic. For an addictions nurse, this isn’t surprising. It’s an incredibly stressful time. And more stress results in more cravings for those struggling with addiction.
Hughes took time to answer our questions about being an addictions nurse.
Stephanie Hughes, MSN, APRN
How did you get interested in being an Advanced Nurse in the addiction treatment field? What drew you to it? How long have you been doing it?
My nursing career started in 1998. My first job was in a Behavioral Medicine Unit at King’s Daughters Medical Center in Ashland, Kentucky, where I cared for patients with substance use disorders. I learned how the disease of addiction affects the entire family unit as well as loved ones, and how addiction is unbiased toward socioeconomic status, level of education, or age. This disease affects people of all walks of life.
In 2002, I became the nurse manager of this unit. My leadership role at this medical center extended to the Pre-operative Cardiac Catherization/Intervention Unit. It was approximately two years later when I realized my love for behavioral medicine and returned to it. In 2008, I completed my Master’s in Nursing with an emphasis on leadership and education. This led me to serve as an adjunct clinical instructor at Ashland Community and Technical College, where I worked with RN students in their Psych rotation. I now have been a nurse for 23 years and the disease of addiction along with dual diagnosis (depression, anxiety, PTSD/trauma) continues to be my passion and calling. I continue to learn every day from colleagues and mentors, and, most of all, my patients.
Explain to me briefly what you do as an Advanced Nurse in addiction treatment. Did you have to get additional training/education to do it?
In 2014, I graduated from Frontier Nursing University in Versailles, Kentucky, with a post Master’s degree as a board-certified family nurse practitioner. I also am a buprenorphine waivered practitioner, which means I can prescribe one of the three FDA-approved medications used to treat opioid use disorder. To become waivered, you have to be a qualified practitioner, such as a nurse practitioner or clinical nurse specialist, and apply through and be approved by the Substance Abuse and Mental Health Services Administration (SAMHSA). It also helps to have practice experience in the different levels of care for substance-use disorders, from detox, residential, and partial hospitalization to intensive outpatient and outpatient opioid treatment programs. Having worked in the full continuum allows me to truly meet patients where they’re at and willing to accept care.
What types of people/clients do you serve?
Together with a specialized medical and clinical team, I serve adult men and women who suffer from substance use disorders and their families. Patients who seek treatment for addiction to drugs or alcohol are looking for the same thing any other patient is looking for—they want to be seen by qualified professionals who are engaged with them and they want to be treated with dignity and respect. It’s no different than in a hospital or other care setting; our patients appreciate and remember a friendly smile, a warm blanket, a hot meal, and their hygiene needs being met. As a nurse, I think it’s very important to remember that basic needs are just as important as passing medications and medical treatments. Many of our patients come to us lost or forgotten. Some are homeless, jobless, or estranged from their families due to their addiction. But they still deserve our care, and we help them get their lives back. The treatment we provide not only heals their brains and bodies, but gives them life skills, coping skills, and relapse prevention strategies. And we connect them to other resources in the community as well as our own alumni recovery network for support.
What do you like most about working as an Addictions Nurse?
I get to be the friendly face that greets patients during their first days of treatment. Some days I work to physically stabilize patients and treat the symptoms of detox, and others I just offer a calm, compassionate atmosphere and listen to my patients. Seeing the freedom of recovery through my patients is absolutely amazing. These individuals are some of the strongest people I have ever had the pleasure of meeting. The work they put in to their recovery is unfathomable to many.
What are your biggest challenges in this position? What are your greatest rewards in it?
The biggest challenge for me is having an up-close and personal view of the effects of this terrible disease. One exacerbation/relapse could very well result in death. The loss of so many lives is absolutely devastating.
The greatest reward for me is seeing patients who are working hard and making progress in their recovery—like seeing a patient who now has a relationship with their children and family. They may have gained employment and are able to live independently. I get to help people who will continue to work on their recovery and do amazing things. Many will stay in this field and go on to help others. It’s an amazing dynamic.
What advice would you give to someone considering this type of nursing work?
Nurses who care for people suffering from substance use disorder must empathize with our patients and families. When nurses are able to practice empathy, they are able to treat their patients as people, not diseases, and focus on a person-centered care approach.
Treatment is personalized for each patient. This is not cookie cutter treatment. Being a team player and having good communication is critical. Personalized treatment is delivered through a multi-disciplinary treatment team approach with the patient being the focal point. Many patients enter treatment confused, disoriented, and emotionally defeated. We must be the voice of our patients during these times. We as nurses have to have a strong passion for patient advocacy. This ensures we are always fighting for the very best care for our patients.
When vaping first began, many smokers saw it as a godsend: if they couldn’t quit, they could take up vaping, which wasn’t as toxic as smoking.
Or so they thought.
Karen Goldschmidt, PhD, MSN, RN, CNE, Associate Clinical Professor and Department Chair RN-BSN Degree Completion Program, College of Nursing and Health Professions at Drexel University, says, “E-cigarettes were introduced to the market in 2006-2007 as a lower-risk alternative for adults who smoke tobacco and as an aid in smoking cessation. At the time, because e-cigarettes were not considered tobacco products they were not regulated by the Food and Drug Administration.”
In fact, it seems that vaping is causing more problems—and ones that health care providers don’t yet fully understand. “In the last several weeks, hundreds of possible vaping-related illnesses and 18 deaths have been reported. The number of cases has been increasing at an alarming rate. Symptoms of the mysterious illness include shortness of breath, fever, fatigue, and vomiting. Some patients have experienced respiratory failure, ending up in the intensive care unit or on a ventilator,” explains Goldschmidt.
Unfortunately, Goldschmidt states that U.S. youth are the ones who use e-cigarettes the most. And it’s serious. “Today the U.S. faces a public health crisis of epidemic proportions. The use of e-cigarettes among teens has the potential to create another generation addicted to nicotine. Both youth and young adults identify flavors as a primary reason for e-cigarette use. Today there are over 7,000 flavors available. Advertising is another factor,” she says. “Exposure to e-cigarette vapor condensate is toxic to lung cells and shows similar cellular changes to chronic smokers and people with chronic obstructive pulmonary disease (COPD). The exposure increases the risk of infection and chronic lung disease.”
As nurses, you can try to help these patients by encouraging them to quit vaping, as just this kind of intervention could make a difference. According to Goldschmidt, “Studies have shown that receiving counseling regarding tobacco use has been linked with 47 percent better odds of an attempt at quitting smoking within the year. Unfortunately, only a third of adolescents’ report being asked about tobacco use by their provider.”
There are also other steps you can take to help your patients. “I recommend that nurses, nurse practitioners, and physicians screen patients for vaping/e-cigarette-use and educate patients about the risks of using these products. It’s not enough to just ask if people they smoke, drink, or use drugs. E-cigarettes and vaping are seen by people as being completely different, and many are misinformed—thinking that they are safer than smoking,” explains Goldschmidt. “Health professionals need to change their language to keep up with substance use/device use. For instance, Vaping is different than e-cigarettes and ‘Juuling.’”
Goldschmidt suggests that you give support, education, and resources to help your patients who are vaping. “Of course any nurse working with a patient with a substance use disorder needs to be aware that it is just that—that patients are most likely addicted to the Nicotine or THC and a plan of care must include caring for a patient who may decide to continue to use or helping the patient through withdrawal. Education is the key. In the end the patient needs to be ready to give up the substance,” she says. “Providing support and resources for the patient to eliminate vaping/e-cigarettes any substance is very important. I would suggest the Truth Initiative and SmokefreeTXT for Teens as resources to help teens or adults quit e-cigarettes.
“See the CDC website for the most up to date statistics. Also, the FDA, as these products may soon be regulated. Some states have already banned flavored e-cigarettes.”
So many times, nurses treat patients whose lives have been touched by drug or alcohol abuse. But what happens when the nurses themselves are addicts? Sadly, this happens more often than you might think. The American Nurses Association (ANA) has estimated that 10% of nurses suffer from a drug dependency, which could amount to around 300,000 addicted nurses.
Why do nurses abuse drugs and alcohol? For the same reasons other people abuse drugs and alcohol. One of these reasons is stress. Nursing can be a highly stressful profession. People with stressful jobs sometimes turn to alcohol and drugs to try to cope. Of course, using drugs and alcohol to deal with such stress can lead to dangerous repercussions for nurses and their patients.
Why Nurses Shouldn’t Try to Treat Themselves
Nurses are accustomed to achieving things and getting things done. Many nurses assume they can treat their addictions just as they handle other things in their lives. They treat other people in the course of their jobs, so they assume they can treat themselves as well.
This could be a mistake – a grave mistake. If nurses are drinking heavily and stop drinking abruptly – if they go cold turkey – their bodies could revolt. The symptoms could include DTs (delirium tremens), which can cause confusion, hallucinations, heart problems, and even death.
Instead, nurses with addictions might want to consider seeking help at dual diagnosis treatment centers. (A dual diagnosis occurs when people have both a substance abuse problem and a condition such as bipolar disorder, anxiety, or depression.) Such treatments might help their clients address their drug and alcohol abuse. Why shouldn’t nurses try to seek the same help themselves?
Addiction Also Hurts Patients
Unfortunately, health care workers’ addictions can hurt more than the health care workers themselves. It can also hurt their patients. If nurses abuse alcohol or drugs, the nurses might:
Take frequent absences from work. This could create staffing shortages where not enough nurses are available to care for patients at a doctor’s office or medical facility.
Not be physically present when patients need them. This could be because the nurses are occupied using drugs or alcohol and not in the office or on the floors of the hospital.
Be too distracted by hangovers or drug cravings to focus on their patients’ needs.
Forget to administer their patients’ medications, give them the wrong dosages, or give them the wrong medications entirely.
Steal medications from their patients.
This last consequence points to the widespread nature of opioid addiction. According to the National Institute on Drug Abuse, around 1.9 million Americans struggled with problems related to prescription opioids in 2013. Nurses seem especially vulnerable because they often have ready access to such drugs. But addiction does not discriminate. It harms all types of people from all walks of life, hurting their health, relationships, jobs, and other areas of their lives. It’s simply the nature of the beast.
Opioids’ qualities can also contribute to this abuse. As we’ve said, nursing is stressful. Opioids are drugs that can relax people and produce effects that temporarily relieve stress, so nurses might turn to these drugs in times of crisis. A popular television show, Nurse Jackie, depicted a fictitious nurse using drugs in this way.
In real life, there is help for such drug use. Professionals at rehab centers acknowledge that stress and addiction often go hand-in-hand. The professionals can work with their clients to find ways to relieve stress that don’t involve drugs.
Opioids also provide painkilling effects. Since nursing can be incredibly physically demanding, many nurses struggle with pain. Some nurses turn to opioids to handle this pain. Some become addicted to them.
Doctors are also prescribing large numbers of opioids, increasing the likelihood of addiction even more. The Centers for Disease Control and Prevention (CDC) reported that in 2012, medical professionals issued 259 million prescriptions for painkillers. Nurses are just some of the millions of Americans who have access to such powerful drugs and have experienced their effects.
What Can Nurses Do?
Fortunately, addicted nurses can find help. On a state level, nurses can contact state boards of nursing and state nursing associations, such as the Massachusetts Nurses Association. They can direct nurses to programs and other treatments to help address their addictions. They could also help nurses if they are facing discipline for their actions.
Other help is also available. On a national level, websites such as AddictedNurse.com can help nurses with substance abuse and other issues. Other nursing and medical organizations offer resources for nurses who are dealing with substance abuse or recovering from it.
Nursing can be a tough profession. Substance abuse is also tough. But there are different kinds of resources and care, such as dual diagnosis treatment centers, that can help nurses seek the treatment they need to help themselves and their patients.
Overdose deaths related to prescription opioids have quadrupled since 1999, according to the Centers for Disease Control and Prevention (CDC), which has made it a topic of dinner conversation as well as a top priority in health care. Nurses can play an important role in reducing these deaths, as well as addiction problems, through their assessments and monitoring of patients. But it’s also important for nurses to be well aware of steps they can take to help protect themselves from possible legal action stemming from opioids.
Scope of the Problem
The depth and breadth of prescription opioid abuse is far reaching. In 2014, almost 2 million people in the United States abused or were dependent on prescription opioids. At least half of all opioid overdose deaths involve a prescription opioid. Every day, more than 1,000 people are treated in emergency departments for misusing prescription opioids.
The most common drugs associated with prescription opioid overdose deaths are methadone, oxycodone, and hydrocodone. According to the CDC, prescription opioid overdose rates between 1999 and 2014 were highest among people aged 25 to 54.
Role of the Nurse
A 2016 study published in the Journal of the American Medical Association (JAMA) by Baker and colleagues notes that there is significant variability in the amount of opioids prescribed, and the most commonly dispensed opioid was hydrocodone (78%), followed by oxycodone (15.4%). Interestingly, a 2015 study in the American Journal of Preventive Medicine reported a decrease in the rate of prescribing opioids (-5.7%), perhaps indicating that more health care providers are becoming aware of the addiction issue.
Screen Patients
Nurses are well positioned to detect patients with substance misuse. One simple screening tool is the National Institute on Drug Abuse (NIDA) Quick Screen. If a substance use disorder is suspected, the nurse should remain nonjudgmental while referring patients for further evaluation and treatment, so they receive the care they need.
One model for follow-up of possible substance abuse is Screening, Brief Intervention, and Referral to Treatment (SBIRT) from the Substance Abuse and Mental Health Services Administration. SBIRT is a method for ensuring that people with substance use disorders and those at risk for developing these disorders receive the help they need.
Assess the Patient Carefully
Pain medication should be matched to the individual patient’s needs. This begins with a detailed history, including a list of currently prescribed and past medications. Ask about a history of substance use or substance use disorders in the patient and the patient’s family. If opioids are being considered, assess the patient’s psychiatric status.
A physical exam should also be completed, keeping in mind signs and symptoms of possible substance abuse such as advanced periodontitis, traumatic lesions, and poor oral hygiene. If patients are already being managed for chronic pain, the nurse should consult with the appropriate provider.
Apply Evidence-Based Pain Management
To provide optimal patient care, as well as to protect themselves from legal action, nurses should practice evidence-based pain management. That includes considering non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, as first-line pain medication.
NSAIDs have been shown to be at least as effective (if not more so) than opioids for managing pain, particularly in combination with acetaminophen. Before patients begin taking NSAIDs, verify that they are not taking other anticoagulants, including aspirin, and check for hepatic or renal impairment.
Nurses should complete continuing education courses in pain management, and document they did so, which can provide evidence of their knowledge in event of legal action.
Educate Patients
Nurses have an opportunity to educate patients about the role of pain medication in their care. This education should include pain medication options and the reasons why non-opioids are preferred.
Verbal and written instructions after the procedure need to contain name of drug, dosage, adverse effects, how long the drug should be taken, and how to store it. Results from a 2016 survey published in JAMA Internal Medicine found that more than half (61%) of those no long taking opioid medication keep it for future use, so patients need to be told to dispose of unused drugs and how to do so. Patients can search for places that collect controlled substance drugs through the Drug Enforcement Administration at www.deadiversion.usdoj.gov.
The same survey found that about 20% shared the opioid with another person, so education material should mention not to do this. Nurses should also discuss the perils of driving or undertaking complex tasks while taking an opioid. Document in the patient’s health record that this information was provided and the patient acknowledged receipt and understanding. An office visit can also provide the opportunity for nurses to address opioid abuse on a larger scale.
Refer Patients as Indicated
Nurses need to closely monitor patient use of controlled drugs to avoid overdependence or potential addiction, and refer chronic pain patients to a pain management center or specialist. Be sure to document the referral in the patient’s health record. Nurses also should consider referral for patients who seek opioids beyond when they are likely to be needed.
Pain Medications Cautions
Below are some considerations for the use of pain medication in patients:
Use non-steroidal anti-inflammatory drugs (NSAIDs) as the first option. Consider a selective NSAID to avoid increased risk of bleeding. Know that using acetaminophen in combination with NSAID may have a synergistic effect in pain relief. (Do not exceed 3,000 mg/day in adults.)
Provide patient education.
Document patient communications, education, and referrals in the health record.
Protecting Patients and Nurses
Nurses who assess and monitor patients for treatment of pain are encouraged to be mindful of and have respect for their inherent abuse potential. Doing so helps protect patients from harm and nurses from potential liability.
Disclaimer:This article is provided for general informational purposes only and is not intended to provide individualized business, risk management, or legal advice. It is not intended to be a substitute for any professional standards, guidelines or workplace policies related to the subject matter.
This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 650,000 nurses since 1976. INS endorses the individual professional liability insurance policy administered through NSO and underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to [email protected] or call 1-800-247-1500.
It seems like we see articles and hear news reports about opioid addiction on a daily basis. Unfortunately, many of these stories are no exaggerations.
According to the United Nations Office on Drugs and Crime’s 2015 World Drug Report, it is estimated that 32.4 million people around the world struggle with opioid abuse. Additionally, results from the Substance Abuse and Mental Health Services Administration’s 2014 National Survey on Drug Use and Health estimate that 1.9 million Americans struggle with addictions to prescription opioids and 435,000 more have addictions to heroin, an illegal opioid.
Opioid abuse is clearly a problem in the United States and abroad. Different organizations, institutions, and agencies have taken different approaches to combat this problem, as have individual rehab centers across the country. Several of these approaches involve nurses.
Treating Addictions
If the opioid epidemic is a war, nurses are serving on the front lines. Emergency room nurses often treat people who have overdosed or are suffering from the ill effects of opioids, other drugs, and alcohol.
Nurses work at rehab centers to treat opioid abuse and other forms of abuse. They work at clinics and hospitals that provide medication-assisted treatment (MAT). They work in a wide variety of health care settings to help people recognize and treat their addictions. They also work to educate others about substance abuse and hope that such preventative measures can help people avoid addiction in the first place.
State Efforts
At Boston Medical Center, doctors do not administer programs that treat opioid abuse. Instead, nurses administer such programs. This tactic allows the clinic to see more patients (and ultimately treat more patients). Other health centers in Massachusetts and across the United States are utilizing nurses to administer such programs.
Other programs might provide specific training that relates to addiction. In 2016, the U.S. federal government awarded a grant to train student nurses at the College of Nursing at the University of Massachusetts in Amherst, Massachusetts. This program trains nurses in SBIRT, which stands for screening, brief intervention, and referral to treatment. The program aims to diagnose addictions early and help people find treatment for them.
National Efforts
National organizations are also tackling addiction. The American Nurses Association (ANA), the American Association of Colleges of Nursing, and others have pledged to provide more training for people who prescribe opioids. The ANA has also pledged to encourage more health care providers to register with their states’ drug monitoring programs.
The ANA has also pledged to launch a campaign to raise awareness of opioid addiction. It has already established resources about opioid addiction and other forms of substance abuse. Additionally, ANA provides resources that can help nurses with their substance abuse problems if they are addicted themselves.
Government Efforts
The government has also joined nurses in the fight against opioid abuse. The U.S. Centers for Disease Control and Prevention (CDC) created and published guidelines regarding the prescription of opioids. Several nursing schools across the United States have pledged to teach these CDC guidelines, many of which address the use of opioids for long periods of time.
State boards of nursing have also created similar recommendations. The Michigan Board of Nursing, for example, has issued guidelines for nurses in regards to using controlled substances to treat pain. These guidelines recognize that nurses need to effectively treat pain. They also recognize the potential danger of certain medications.
There are also other government efforts relating to opioid abuse and nurses. The Comprehensive Addiction and Recovery Act of 2016 is a federal law that permits nurse practitioners and physician assistants to prescribe buprenorphine to patients who are addicted to opioids. It also allows doctors to see higher numbers of patients who need such drugs.
Speaking of government action, the U.S. Drug Enforcement Administration (DEA) sponsors National Prescription Drug Take-Back Day. During this event, people bring unneeded prescription drugs to designated areas. DEA agents and other law enforcement agents take these drugs and educate the public about drug abuse. During one such day in April 2016, authorities took back almost 447 tons of prescription drugs.
Nursing Efforts
Nurses educate the public about Prescription Drug Take-Back Day. They also play a vital role in other government efforts to end addiction by participating in community-based opioid overdose prevention programs (OOPPs). As their name indicates, OOPPs work to prevent substance abuse problems from ever occurring. Other nurses and nursing organizations are interested in government matters as advocates. They encourage other nurses to take political action or support candidates who take particular views on health care matters.
These efforts demonstrate that while the opioid epidemic is huge, different organizations, institutions, government bodies, rehab centers, and people are committed to helping fight it. Nurses have played—and will continue to play—a vital role in this battle.
