Final Reflection

This course made me aware of judgements and prejudices that I didn’t realize I had. As I completed the assignments, I had occasion to reflect on past experiences. Becoming more educated on the subject helped me become aware of some of my faulty viewpoints. For example, I gained a much greater appreciation for the grip that addictions can have on people. I am grateful for the shift in perspective that naturally happened as my awareness grew. I believe it will help me to more effectively care for patients afflicted with SUD. I’ve felt my sympathy and my desire to help those struggling with SUD increase throughout this course.

The explanations on the brain reward system were fascinating to me. I specifically found the video about addiction that explained the intensity of cravings for those addicted to opioids to be the most interesting and impactful. Learning about the high effective rate of MAT was very encouraging. However, the extremely low percentage of people who have access to it was equally discouraging. Overall, it did still leave me hopeful that there are strategies to help people with SUD and progress is being made to increase awareness of the problem and availability of treatment.

The most uncomfortable topic was also one of the most helpful. As we explored the topic of stigma, I was made more aware of the damaging effects on those who struggle with substance use. As I watched videos, some assigned and some not, from those who had struggled in the past, my eyes were opened to the ease with which this disorder can develop in a person’s life. I also realized that some attitudes and terminology that don’t seem to be offensive could still subtly cause patients to feel discouraged or shameful.

No matter where I end up practicing as a nurse, I hope to be able to raise awareness about the importance of preventing SUD and the availability of treatment. In order to more effectively do that, I would like to become adept at screening those at risk with one of the several tools we learned about. I especially liked one of the questionnaires in a toolkit on the MOMSOhio website I research for my project. Another part of that website that I would love to emulate as a practicing nurse was from the decision-making module. A MOMS care coordinator was shown having a conversation with a young pregnant mother about her opioid use. The coordinator’s tone was empathetic and non-judgmental, and she was effectively able to instill hope so that the client felt empowered and more optimistic about her potential for change. Instructional videos showing the ideal can sometimes be discouraging when real practice is often so far less than ideal; however, the techniques and attitude demonstrated would certainly help me to more effectively care for all patients regardless of their particular challenges.

Podcast Reflection

One of the biggest barriers to OUD treatment historically has been the limited number of physicians with the buprenorphine prescribing waiver. Two years ago, a significant step toward improving access was made as nurse practitioners and physician assistants were permitted to obtain waivers after 24 hours of training. It was surprising to learn that for the physicians surveyed in Massachusetts, insufficient nursing and office support were the top reasons they weren’t treating more patients with OUD. At the same time, I found this statistic encouraging because it seems like a barrier that can be addressed much more easily than some others. In fact, the Boston Medical Center has already come up with specifically designed training for nurses similar to the 24-hour training required for NPs and PAs to apply for a buprenorphine waiver. This kind of training would equip nurses with the knowledge, insight and ability to help treat the medical side of this complex disease as well as ancillary issues such as relapse, pregnancy, overdose, pain, stigma, criminal justice and other social barriers. Educating nurses about the physiology behind opioids and addiction can also help to reduce stigma. My perception of people with OUD has changed significantly because of the education I’ve received just in the past few weeks.

The collaborative care model makes sense considering the complexity of this disorder. In Boston, providers found that this approach was a more efficient use of the physician’s time. They were able focus their attention on medical issues such as dose changes and maintenance versus tapering decisions because the nurses were equipped to handle more of the psychosocial needs like housing, employment and health insurance. Since nurses have more interaction with patients, they are likely better able to recognize other barriers and issues that need to be addressed.  Because it’s placed in a primary care setting, the Boston’s OBAT (Office Based Addiction Treatment) model has the added benefits of increasing access and reducing stigma. Most patients can more easily visit their primary care physician’s office than an opioid treatment center which may be some distance away. It is also pleasing to know that patients can experience less stigma because more privacy about the nature of their visit can be afforded in a primary care setting than at an opioid treatment center.

The more I learn about OUD, the more I feel drawn to want to want to offer support to those suffering. I’m anxious for the psychiatric clinical next year to see if I find working with patients with mental health issues to be more rewarding than draining. I’ve thought a lot about my cousin’s husband lately. He was a coal miner in West Virginia. He was a good provider for his wife and 2 daughters. They had a home with some land and a couple horses. At one point, he suffered a back injury in the mines and had to have surgery. Years later we learned that he had never overcome his addiction to the pain medication he had been prescribed after his back injury. The transformation was heartbreaking to watch as we saw them slowly lose all they had worked for. He became mean, verbally and even physically abusive. He doesn’t work and lives alone in a rental. Their kids are grown, and my cousin lives in a mobile home on her parents’ property. I haven’t seen her husband in years. I’ve always felt bad for him, but I also always wondered how he could have thrown away such a nice life and caused so much hurt and pain for my cousin and their girls. I have a much different perspective now because of what I’ve learned. I find myself wondering instead about what his experiences with pain management were like. I wonder what other drugs he used over the years and what kind of addiction recovery help he has had. I wonder how different their lives might be if his healthcare providers then had known what we know now, and I wonder if there is yet hope for recovery. I think I’ll have a conversation with my cousin when I go back to visit over the holidays.

Substance Use Disorders compared with other Chronic Diseases

It would be ideal if healthcare workers could treat each patient with the same degree of respect and excellent quality of care. While this is the standard we strive for, inequities undeniably exist when it comes to treating patients with substance use disorder compared to other chronic diseases. There are some similarities starting with the reality that no one seeking treatment in emergency departments will be turned away because of the nature of their condition. Another likeness has to do with the treatability. In general, chronic disease even when not curable are treatable to one degree or another. Depending on the substance being used, SUD is highly treatable. In the case of methadone treatment of opioid addiction, successful treatment can be as high as 75%. A final example of the comparable treatment of patients is in the area of patient education. Nurses certainly spend a good deal of time and effort to teach patients about the best ways to manage their chronic diseases. Likewise, a considerable amount of advice is imparted to those addicted to substances including safer drug administration practices and treatment preparation in case of accidental overdose.

It is interesting to note some other similarities between substance use and chronic disease not directly related to healthcare worker treatment. Both conditions can result in similar organ function changes. Additionally, both can have long-term health consequences, and both can be a life-long struggle. Sadly, the Hazelden Betty Ford Foundation reported in 2015 that healthcare providers had a significantly high rate of opioid abuse than the general population. Equally surprising, according to a National Institute of Health article from 2013, nurses were found to be more judgmental than other healthcare workers in treating those with SUD.

Differences in treatment are certainly more numerous than similarities. Persons seen at emergency departments for opioid overdose are more apt to be treated and released quickly while patients with other chronic diseases are more likely to be admitted with a long-term treatment approach. Subtle disdain and rejection can more often be felt by SUD patients from healthcare workers who see addiction as a moral failing. Conversely, little or no judgement is projected on patients with cancer or heart disease even though their life’s choices may have had as much an impact on their current condition as the person struggling with SUD. In some states, it is a criminal offense to be using drugs while pregnant. As they’re required to report their patients, healthcare workers in these states would naturally have a different attitude toward these patients than those in states without legal implications. Finally, because of repeat visits and relapses, healthcare providers might begin to see their patients with SUD as lost causes while patients with other chronic diseases are generally given continued and multiple treatment options. While the reaction to those affected by SUD might on one level be understandable, the effect is counterproductive and with sufficient self-awareness and education, nurses and other healthcare workers can respond in more appropriate and effective ways.

Stigma and Personal Bias

It’s no challenge at all to quickly come up with a list of characteristics of “drug abusers.” The more thought provoking and sobering task is to consider the effect of those judgements on the attitudes of healthcare workers and in turn, on their patients who struggle with additions.

A common perspective is that drug addicts are weak, immoral and deserving of the difficult situations in which they find themselves. Their cause is hopeless because they’re not capable of change even if they wanted it. Without checking oneself in these thoughts, a healthcare worker could be less sympathetic and rationalize that help is less deserved because the situation is the result of poor choices. This could even lead to the nurse or physician, for example, providing insufficient pain control or focusing on a short-term fix without addressing the issue of long-term treatment. The unfortunate effect of these actions could be to reinforce in the patient’s mind that they do deserve the bad things in their life. He or she may lose hope of ever regaining control.

Another stigma is that users are criminals.  Their drug-seeking behaviors make them dangerous people. This attitude may result in healthcare workers being disgusted with or fearful of a patient and question their motives and intentions. They may try to reduce their contact with the patient by speeding up visits and interactions. This could leave the patient feeling isolated and like a misfit that shouldn’t be trusted.

Especially when lacking steady employment, drug abusers are often considered non-productive and incompetent to manage their own lives. They might be talked down to by health professionals who feel superior and consequently offer little respect. Likely already feeling a lack of control in their lives, patients belittled in this way could end up feeling more irresponsible. They may leave a visit with lower feelings of self worth, especially in comparison to their provider.

As I thought about the limited experience I’ve had with patients, two instances came to mind. Neither involved addictions as fas as I know, but the lesson I learn about myself could be applied to a variety of circumstances including substance use. During one of my clinical shifts, I overheard a nurse on the unit trying to encourage a new mother. I had learned in morning report that the mother had absolutely no family support. The mother was trying to breastfeed her baby and had been having issues with clogged ducts and mastitis. She sounded worried, overwhelmed and exhausted. As I listened, I felt a great deal of sympathy for that young mother. I wished that I had been assigned to her baby so that I could have been part of helping her. The nurse spent a lot of time with her providing her with tips and words of encouragement.

A few weeks later, another mother of one of the patients was described in morning report as being less-than-stellar. The nurses obviously had not had good interactions with her in the past, and they didn’t like her attitude or the way she treated her children. I was not assigned to her baby, and the nurses instructed me to avoid her. When she came for a visit later in the day, I was able to hear through the curtain what the nurses were talking about and found their descriptions to be accurate. I was relieved that they had instructed me keep my distance, and I really had no desire to even meet that mother, let alone get involved enough to help her. The nurses didn’t have a lot of interaction with her that day, but when they did, I could sense a good deal of tension and defensiveness.

As I read and watched the material about stigma this week, I wanted to think that I would be the nurse that wouldn’t judge and would treat every patient respectfully with a positive attitude. The experiences just described help me realize how much education and effort will be required to provide the kind of service I would want to receive if I were struggling with an addiction. And yet, we all have personal bias and human emotions, and we all have to exercise some judgement. One tip from the readings that I liked was the “person first” language idea. Some dignity and self worth is restored when one can be referred to as a “person with an addition” rather than an “addict” or as a “person with a substance use disorder” rather than a “substance abuser.” Using this preferred language in writings, in conversations and even in our thinking will help to retain the value of the person so that we can more effectively address the problems with which they struggle. Additionally, in the past when I’ve found myself making judgements about people too quickly, I remind myself that everyone is a child of God with tremendous value and potential. This technique helps me personally as I remember that each of us is loved and that our worth is not determined by the choices we make.