On its own, addiction can feel isolating. When coupled with “stay-at-home” mandates put in place to help quell the spread of COVID-19, living with addiction becomes even more challenging. Health professionals must evolve with mandated changes in order to better help the more than 21 million Americans living with a substance use disorder (SUD).
Yet, that number isn’t even close to the entire story when it comes to addiction treatment. Of those who have an SUD, only about 1.4 percent of those aged 12 or older receive treatment during any given year. That glaring treatment disparity stems from a number of factors including access to economic, medical, and social support. The biggest hurdle to comprehensive addiction treatment isn’t lack of insurance or clinic inaccessibility. Ultimately, a struggling addict must want to recover and be ready to do what it takes to achieve their goals.
As addiction varies significantly among individuals, addiction treatment can look very different depending on the person and their preferred substances. SUD treatment can occur in inpatient or outpatient settings. Sometimes, more clinical support is needed, especially among opioid addicts and those dependent on alcohol. In most cases, support groups are crucial to the recovery process, and the sudden onslaught of COVID-19 has completely upended the support system for recovering addicts across the world.
What We’re Up Against
Even if you know firsthand what it’s like to work at an addiction treatment center, COVID-19 has changed everything. Now, health care professionals must work to provide holistic care in what amounts to a vacuum, but addiction treatment involves every aspect of patient care, from mind to body and beyond, and human interaction is a cornerstone of recovery.
Depending on an addict’s substance(s) of choice and the severity of his or her condition, addiction treatment can include a variety of factors. In the wake of COVID-19 and widespread social isolation mandates, treatment may be even more crucial to those vulnerable to relapse. Accessing treatment facilities and medications may inadvertently put many addicts at risk, especially opioid users who may require access to methadone as part of their treatment plan.
Isolation itself can even be a relapse trigger, making social isolation mandates a real threat to recovering addicts. It’s important to note that triggers among opioid users may be similar to those of alcoholics. These triggers include isolation, stress, and anxiety. Furthermore, both opioid addicts and alcoholics may face dangerous withdrawal symptoms when attempting to quit on their own. Without addiction treatment clinics as an option, opioid addicts and alcoholics may fall through the cracks, unable to break free from their addiction. Telemedicine may offer a solution, even in the face of a global pandemic.
Embracing Telehealth in the Wake of Disaster
Telemedicine isn’t new in the realm of addiction treatment, but its use has surged in popularity during the first few months of 2020. Using telemedicine, patients can access care and various clinical services via telephone or video chat. For many recovering addicts and those with co-occurring disorders who are practicing social isolation, telemedicine is a vital aspect of the healing process.
Even without the threat of a pandemic, telemedicine is beneficial to patients from all walks of life, especially for those in rural areas with limited transportation options. The elderly and infirm may also find benefit in telemedicine, which is just as viable as traditional care. In fact, a 2019 survey found that 61% of patients believe they received the same quality of care via telemedicine as with traditional in-person visits. Telemedicine combines quality care with human interaction, benefiting addicts in all stages of recovery.
Especially for those in early recovery, support from one’s peers and treatment providers is integral to the process; however, social distancing has eliminated that lifeline virtually overnight. Telemedicine is poised to bridge the gaps. Early recovery is defined as an addict’s first year of recovery, and it’s considered a crucial time for those looking to change their life for the better. During this time, addicts are learning how to cope with their emotions in a healthy manner while also avoiding relapse triggers and behaviors.
Adaptation and Perseverance Against Addiction
While deaths and illnesses related to COVID-19 are headline news among the general population, health care providers in the realm of substance abuse have additional concerns. Scrambling for solutions, addiction treatment providers worry that social isolation will result in increased relapses and overdoses.
Recovery clinics are urging addiction treatment providers to perform regular wellness checks via remote channels and telemedicine. Health care providers can also encourage their patients to attend virtual support groups and 12-step meetings. Alcoholics Anonymous, for example, is utilizing various meeting apps such as Zoom to facilitate online meetings for those in recovery, and all addicts are welcome to participate.
Fighting opioid addiction and other forms of substance abuse can be an uphill battle, and social distancing mandates are further compounding the issue. It’s essential that health care providers don’t overlook their vulnerable patients with SUDs. Those who are in recovery often rely on group support and find social isolation to be a relapse trigger, so it’s imperative that treatment clinics and providers offer alternatives so their patients feel supported in these trying times.
The 57-year-old woman is standing in the hall outside of the exam room. She is agitated. “I’m waiting for the doctor. I’m freezing! My back is killing me!” I note she is pale, unable to stand still, and has a sheen of perspiration on her forehead. She is in withdrawal. I get her a blanket and ask her to wait in her room. The pain clinic nurse is downstairs at the pharmacy getting the patient’s prescription for Suboxone for induction. Induction is the process of starting the patient on medication and finetuning the dose.
An hour later the patient is back in the hall calling me, “Thanks for the blanket!” She is smiling. Her color is back. She is clear eyed, calm, and collected. What happened? Suboxone. Suboxone is a combination of buprenorphine and naloxone that is used to treat opioid addiction. Buprenorphine is a partial agonist of the μ-opioid receptor with a high affinity and low rate of dissociation from the receptor. In English, the buprenorphine molecule sticks to the opioid receptor in the brain, but only partially activates it. Then it stays there for a long time, blocking it from opioids, before dissociating. What this means for the addict is that they get enough opioid receptor activation that they don’t get sick from withdrawal. They can function normally with less of the problematic effects of a full agonist like morphine or heroine.
The addition of naloxone, a full opioid antagonist (blocker), keeps the Suboxone pills from being crushed and injected. Though naloxone has a strong effect when given parenterally (by injection), its effect when given by mouth is negligible because it is poorly absorbed sublingually. Suboxone disintegrating tablets are given under the tongue.
So, what is this wonder drug all about? In 2000, federal legislation (Drug Addiction Treatment Act of 2000) made office-based treatment of narcotic addiction with schedule III-V drugs legal. Until then, the only option for addicts was abstinence-based treatment or methadone clinics. The ever-increasing rates of drug overdose deaths in the United States showed this was not working. At first, only MDs specially approved by the Department of Health and Human Services could prescribe medications to treat addiction. In 2016, President Obama signed the Comprehensive Addiction and Recovery Act allowing nurse practitioners and physicians assistants to prescribe schedule III-V drugs for the treatment of addiction. Previously, they could prescribe these medications to treat pain but not to treat addiction.
What does this mean for the addict? For starters, Suboxone and similar drugs are now more widely available. Until recently, the only way for a heroin addict to keep from getting withdrawal sickness was to use more heroine. These patients were considered toxic to regular doctors because their disease lead to ever-increasing doses, seeking medications from multiple providers, decreasing levels of health, and ultimately death. Now that there is an option other than going cold turkey, the addict without some kind of pain diagnosis can get access to health care whereas before they would avoid it because of the stigma of being an addict. Because Suboxone is a partial agonist with high affinity to the μ-opioid receptor, it decreases the ‘high’ if the patient continues to use narcotics causing the patient to lose interest. It offers the benefit of allowing the addict to function in life, decreases the likelihood of death from respiratory depression, and increases the quality of life because there is no need for the addict to ride the wheel of withdrawal—drug seeking, using, running out, and then seeking again to the exclusion of every joy of life.
What happens when a person starts buprenorphine? After a largish battery of tests, the prospective recovering addict will be asked to abstain from narcotics before induction to Suboxone. How long before the first dose the addict has to abstain depends on the person’s addiction. Longer acting drugs like methadone could be 24 hours. Shorter acting drugs like morphine could be as little as six hours. The person should be in the early stages of withdrawal. The reason for this is the “partial” part of partial agonist. The buprenorphine molecule will muscle other narcotics off the receptor site where it was fully activating the receptor. Now, the higher affinity buprenorphine is sitting there doing half the work that the heroine was doing and this leads to symptoms of withdrawal. Giving a person a drug that puts them immediately into withdrawal will turn them off to it completely. You won’t see that person again. Higher success rates are tied with higher levels of symptoms of withdrawal before induction. Now instead of precipitated withdrawal, the person has relief from symptoms of withdrawal even if they are not getting high.
A person who has been successfully inducted to Suboxone therapy will find almost immediate relief. The terrible body aches, muscle pain, abdominal pain, depression, diarrhea, and cravings evaporate. Our patient might just have found a new way to live, free from the constant need to find more narcotics. She can focus on her life instead of her disease. Most of the clinic patients have jobs. They want desperately to be productive members of society for themselves and for their families. Buprenorphine therapy coupled with lifestyle interventions provided by mental health professionals, self-help groups like Narcotics Anonymous, and patient-initiated interventions (like taking a class or going back to school) are part of the success story of a growing number of recovering addicts.
What’s it like to come off Suboxone? Eh, probably a lot like getting off heroine. Same withdrawal profile or pretty close. Patients wanting to get off all narcotics, including Suboxone, can be weaned off gradually depending on their desired treatment goals. Someone facing a jail sentence or travel overseas that needs to detox from opioids quickly may be on a tapered dose of Suboxone for just a few days or weeks. Other people may decide that the burden of staying on Suboxone is worth not having to go through withdrawal and choose to stay on a maintenance dose for the rest of their life. The addiction specialist will help guide the patient through the decision process. Many patients decide to stay on the medication as a hedge against relapse since buprenorphine has a higher affinity for opioid receptors than street drugs. This coupled with the very slow rate of dissociation means that a person would have to stop the buprenorphine well in advance of restarting heroine or other opioid in order to get high.
What does this mean for health care? For one, at least some addicts who eschewed health care in the past can now get treatment for this disease. At some point, most addicts will desire to get off narcotics. Having a real treatment option available instead of a far-away methadone clinic or withdrawal will work to drive these patients into recovery. Another thing is that it’s possible that some of the stigma of addiction will be lifted, at least slowly, as treatment becomes available and success stories become commonplace. As the DEA and FDA work to get a handle on the 70,000 overdose deaths per year by educating doctors and enforcing distribution laws, these drugs will become harder to get. During the 12 months prior to July 2017, overdose deaths fell in 14 states for the first time during the opioid epidemic, according to the Centers for Disease Control and Prevention. In the rest of the nation, at least the numbers have leveled off. Greater access to Narcan (brand name of naloxone, one of the drugs in Suboxone), and more treatment options for addicts will hopefully drive these numbers lower over time. It’s not time to celebrate, but at least there is a glimmer of hope. The priority is to keep addicts alive until they can (or they are ready to) get treatment for their disease.
Opioids are a type of narcotic pain medication that is used to control pain. Examples include meperidine, methadone, morphine, oxycodone (OxyContin), oxycodone with acetaminophen (Percocet), and hydrocodone with acetaminophen (Vicodin). There is an increasing number of patients with pain addicted to opioids. According to the Centers for Disease Control and Prevention, opioid overdoses have quadrupled since 1999. Nurses play a vital role in preventing opioid addiction in patients with pain through nursing assessments and monitoring of their patients.
Here are 4 essential steps that nurses can take to help prevent opioid addiction.
1. Perform a comprehensive assessment of pain by using a standardized pain assessment tool.
Nurses need to assess the individual patient’s pain location, characteristics, onset, duration, frequency, intensity or severity, precipitating factors of pain, and how the individual manages his or her pain.To learn more about pain assessment tools, visit www.paincommunitycentre.org/article/pain-assessment-tools.
2. Assess the patient’s pain management and medications used.
Pain medication should be matched to the individual patient’s needs. It is important that nurses assess the patient’s detailed medical history, including a list of currently prescribed and past medications, as well as a history of substance use or substance use disorders in the patient and the patient’s family. Keep monitoring patient use of medications and opioids to avoid overdependence or potential addiction.
3. Evaluate the effectiveness of the pain management through ongoing assessment of the individual patient’s pain experience.
Proper evaluation of pain management requires that all patients have a treatment entry diagnosis that is defined, standard, and objectively determined. An ongoing assessment of the patient’s pain experience during and after treatment is vital for preventing pain medication misuse. Patients can become addicted if they take pain medications or opioids too much or for a long period of time.
4. Educate your patients about pain management.
A better patient understanding of the nature of pain, its treatment, and the side effects and complications is one of the most important steps toward improved control of pain and pain medication use. Nurses should provide written instructions about dosage, adverse effects, how long the medication should be taken, and how to store and dispose of unused medication. Opioids can be dangerous if patients take them with alcohol, or with certain drugs such as antihistamines, sleeping pills, and some antidepressants. Nurses can also introduce the use of non-pharmacological techniques (e.g., relaxation, guided imagery, music therapy, distraction, massage, lifestyle modifications, and heat and cold application) before, during, and after feeling pain to control and reduce pain.
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