Through the RN Practice in Primary Care and Substance Abuse Disorder course I have learned both that I was more knowledgeable on the subject than I thought, but also realize there is a lot more to learn on the subject. I have learned a lot from the class. I have also learned something about myself through the class, I am more passionate about the subject than I realized before taking it.
The most interesting part of the class for me was the module that explained how substance abuse “tricks” your brain. The video “Addiction Neuroscience 101” was amazing. It really explains the effects of substance abuse and the daily struggle of patients to fight the urges of relapsing. I’ve shared this with some of my co-workers and I think as our practice keeps moving forward and expanding our behavioral health/MAT programs this video will be used for staff education.
I think the topic that sometimes gets uncomfortable is debating the expansion or limitation of Narcan. I feel comfortable sharing my view on it but sometimes it gets uncomfortable debating with others. A lot of times people have such “black and white” views on the subject that they do not take any other opinions in consideration. Luckily our class contains professional health care professionals, and everyone was very respectful of varied opinions.
Module 6 also really got me thinking, realizing the skill set of our nurses can limit or expand our provider services. I would like to share what I have learned with my teammates at work. I would like to empower the nurses that have an interest in this subject to learn more and in turn both them and the providers they work with will be more confident treating patients with substance abuse. I also plan to stress the strong linkage between mental health conditions and substance abuse. Our practice does utilize the PHQ9, Audit-C and DAST 10 currently but not consistent enough. In the future I feel every patient that is part of our MAT program should also routinely follow our counselors and based on their screening results also follow up with a Behavioral Health provider as indicated.
I’ve enjoyed this class.
There are so many barriers to substance use disorder treatment. It was interesting to me that the biggest barrier reported was insufficient nursing support. The more I thought about this the more it made sense. In the primary care setting nurses have a heavy influence of what providers do. They organize and set the pace for providers. Based on the nurse’s skills and knowledge can either expand or limit what a practice can offer. Placing nurses that are specialized in substance abuse disorders could potentially change the environment of a whole program. I believe if nurses are placed that are knowledgeable it will help eliminate some of the other barriers. With the correct knowledge they can educate the other staff members to better understand what these patients need and the disease itself, increasing their teammates knowledge. With better understanding of your team and nurses leading the way it can break the office stigma. As far as the insufficient knowledge of the providers, I feel as substance abuse continues to grow more providers will get their waiver. I do feel that to be successful providers need to have an interest and passion to treat substance abuse.
I agree there are critical elements to have a successful nurse management model. Frequent follow ups are a must. Case management is needed to link patients to all needed resources and play a big role in the concrete service support. Patients must feel comfortable with their treatment which means staff must know how to treat/react to issues such as insurance trouble, pregnancy, surgeries just as any other chronic disease. Substance use disorder treatment must always involve counseling, it’s been proven to be more successful. Provider must be supported by their teams and as always integrated care most benefits the patients and provide the best outcomes.
If you would of asked me 3 years ago if I would ever consider this type of nursing role, the answer would have been a 100% no. Even though I thought I did, I had no understanding of these disorders. Today, my answer is different. Working in a practice offering MAT and taking the time and effort to understand and learn the facts, I would consider a role of this type.
I believe substance abuse disorders are a chronic disease. These patients are treated differently in our healthcare system. For many years standard treatment for substance abuse was an intensive 28- day rehab or 12- week treatment as an outpatient and that was the extent of it. I believe this is evolving and will continue to improve. Other chronic diseases such as hypertension and diabetes are monitored continuously and even when at goal periodically reassessed. I believe as providers are more educated about substance abuse treatment and the stigma barrier is broken substance abuse will be treated just as any other chronic disease. Another example of how patients are treated differently is that there are commonly criteria for dismissal from MAT programs related to number of relapses. An article from North Carolina Medical Journal compares this situation with substance abuse and diabetes. “Diabetic patients are not typically fired from a practice from relapsing with donuts.” Studies have shown success in treatment for most is determined by the length of treatment.
When viewed as a chronic illness, treatment is similar for substance abuse and other chronic diseases. We want diabetic patients to follow a diet avoiding foods that are known to increase their blood sugar. To treat diabetes oral medications and/or insulin is prescribed to keep blood sugars under control. Similarly, with hypertension we want our patients to avoid sodium in their diet and decrease stress levels. When needed anti-hypertensive medications are initiated. For substance abuse disorders we want our patients to avoid people, places, and things that might trigger their dependence. Often medication is required to keep the threat of deadly relapses from occurring just as anti-hypertensive medication is prescribed to avoid a heart attack or stroke. Both chronic illness and substance abuse disorders have a hereditary factor involved as well. As healthcare providers we must promote the lifestyle and behavioral changes, monitor/manage disorders with medications if needed and monitor outcomes. Treating chronic diseases successfully requires a team with the patient in the middle.
I believe that stigma is a huge barrier of why patients do not seek treatment for their healthcare. Patients try to hide their disorders because they fear this will become their identity. They fear every medical decision is going to be made based on the fact that they suffer from a substance abuse disorder. They even avoid any general check ups or visits for illnesses or an injury because they feel healthcare staff always assume “they are after something.” They fear if they come in for a cough, “They just want Phenergan with Codeine” when they truly feel they need an antibiotic. If they have a fall with injury “It doesn’t hurt that bad they just want narcotics.” This stigma has a negative impact on the patient’s health not just in relation to substance use but just their general well- being.
The community of which our practice resides has a lot of stigma related to opioid and any substance use in general, but we also have a significant percentage of our population who are suffering from these disorders. Before our practice started our MAT program, a lot of the residents of our community had to travel a long distance for treatment, were on a forever long waiting list, or would not have access at all. Three years ago, our health center and a private practice merged. Our patients and staff both voiced concerns about how the “different” types of patients would react being in the same waiting room together or assumed we would have “conflicts” or “difficult situations” with patients in out MAT program. Which these instances have occurred, but they have also occurred with patients who are not in the MAT program over blood pressure medications.
We all have unconscious bias, maybe not necessarily related to substance use. Its natural, anyone who says they do not is naive. It is important as your work in healthcare to be aware of your own bias to ensure it does not affect the care you give to patients. I think stigma can be a result of lack of knowledge and exposure. Not all people that have a stigma feeling towards someone are trying to be hateful or malicious. I think the hardest part for people is to admit they don’t understand. Even people in healthcare carry stigma related to this issue and they have medical knowledge regarding addiction. As you can imagine someone without medical knowledge doesn’t understand that it’s not just “poor choices”. They don’t realize addiction makes your brain function differently. That being said I think there needs to be A LOT more education for healthcare staff regarding substance use along with community education. The media doesn’t help. Very rarely do you see success stories of patients overcoming addiction, it usually just reinforces the negative stigma that people already have, and also further discourages patients that are suffering from it.
Our practice has future plans to start a needle exchange as part of a harm reduction program. We foresee stigma from our community. We expect to have to defend and give explanations as people will assume, we are “promoting” patients to use by providing needles and we are just “making things worse.” A co-worker explained it in a way giving a good perspective: We are trying to reduce harm. We could go to the beach and pass out sunscreen and it’s the same idea. People are well aware sun exposure has a negative impact and can cause skin cancer. They are going to go to the beach regardless, so we provide sunscreen. Our patients suffering from substance use disorder, if they are participating in a needle exchange they are injecting. They are going to continue injecting until an intervention is done. If they are going to do it regardless at that point in time, its better to use a clean needle rather than a used one. Further, statistics have shown patients who use a needle exchange are more likely to seek treatment. They come to trust the staff that is supporting them and do not feel judged aka providing care WITHOUT stigma!
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