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Nursing

How Nurses Can Foster Positive Interactions with Patients who have Substance Use Disorders

Institute for Research, Education & Training in Addictions (IRETA) Webinar: June 20, 2018

Katherine Fornili, DNP, MPH, RN, CARN, FIAAN Assistant Professor, University of Maryland School of Nursing

Charon Burda, DNP, MS, PMHNP-BC, CARN-AP Assistant Professor, University of Maryland School of Nursing

Director, Psychiatric Mental Health Nurse Practitioner Specialty

Victoria Selby, PhD, PMHNP-BC, CRNP Assistant Professor, University of Maryland School of Nursing

© Fornili, Burda & Selby, 2018

PURPOSE: • To help nurses foster positive

relationships with patients that have substance use disorders (SUDs) in order to provide high quality healthcare

© Fornili, Burda & Selby, 2018

OBJECTIVES: • Identify nurses’ attitudinal barriers and

knowledge deficits related to substance use disorders. • Suggest specific values and skills that nurses can adopt

to improve their interactions with patients with substance use disorders.

• Describe preliminary research that informs the University of Maryland's School of Nursing curriculum, and its goals of providing more effective healthcare and reducing health disparities.

© Fornili, Burda & Selby, 2018

ASSUMPTIONS: • If addiction is seen as a moral failing, it will be condemned. • If seen as a deficit in knowledge, it will be educated. • If the addiction is viewed as an acceptable aberration, it

will be tolerated. • If the addiction is considered illegal, it will be prosecuted. • If viewed as an illness, it will be treated. • Social policies mirror these different views with strategies

ranging from prohibition and criminalization to hospitalization and mandated treatment.

– DiClemente, 2006, p. vii

© Fornili, Burda & Selby, 2018

ASSUMPTIONS: • All nurses encounter patients with SUDs on a daily

basis, in all practice settings • Patients with SUDs can be challenging to treat • Nurses require more evidence-based training

& skills in the treatment of SUDs

© Fornili, Burda & Selby, 2018

In one year, drug overdoses killed more Americans than the entire Vietnam War did

• 2015 was the worst year for drug overdose deaths in US history. Then 2016 came along .

• 19 percent increase between 2015 and 2016 alone (largest known increase in drug overdose deaths for any single year yet)

Leading cause of death for Americans under age 50

© Fornili, Burda & Selby, 2018

© Fornili, Burda & Selby, 2018

Every day, more than 115 people in the United States die after overdosing on opioids.

© Fornili, Burda & Selby, 2018

“Treatment Gap”—Needing but not receiving treatment

It’s much easier in America

to get high than it is to

get help.

© Fornili, Burda & Selby, 2018

National Curriculum Committee Addictions Counseling Competencies Model (CSAT, 2017)

• Defines the knowledge, skills, attitudes (KSAs) and competencies needed by all disciplines, in order to: • Identify individuals with SUDs;

• Assess their condition;

• Intervene on their behalf; and/or

• Refer them to treatment.

• Discusses roles of other healthcare professionals (but not so much about nursing)

© Fornili, Burda & Selby, 2018

National Curriculum Committee Addictions Counseling Competencies Model (CSAT, 2017)

© Fornili, Burda & Selby, 2018

Addictions Nursing: Scope and Standards of Practice (Amer. Nurses Assoc. & the Int’l Nurses Society on Addictions, 2013)

• “The chance that a nurse will meet a person whose substance use puts him or

her at risk for adverse health consequences is high.”

(ANA-IntNSA, 2013, p. 14)

© Fornili, Burda & Selby, 2018

Addictions Nursing: Scope and Standards of Practice (Amer. Nurses Assoc. & the Int’l Nurses Society on Addictions, 2013)

“Focusing nursing education on treatment of substance use and addictive disorders alone results in nurses being unprepared to intervene with patients with risky substance use or those engaging in risky behaviors… such as a single episode of risky alcohol use that could lead to serious health outcomes such as motor vehicle crash, drowning or alcohol poisoning.” (ANA-IntNSA, 2013, p. 14)

© Fornili, Burda & Selby, 2018

Recommended Addictions Content for All Nurses  Stigma: Non-Judgmental Approaches & Patient-First Language  SBIRT: Screening , Early Intervention & Referral to Treatment  Pain: Safe Opioid Prescribing and Diversion  Recovery-Oriented Care: Effective, Integrated Prevention & Treatment  Trauma: Trauma-Informed Care & Avoidance of Re-Traumatization  Gender-Specific Services: Women, LGBTQ  Perinatal Substance Use: Pregnancy & Neonatal Abstinence Syndrome  Medication-Assisted Therapy & Behavioral Interventions  Care Coordination: Care Continuum; Post-Treatment Recovery Support  Psychopharmacology: Co-Occurring Disorders (psychiatric & somatic)  Occupational Health & Safety: Clinicians with SUDs, Workplace Violence

Safe Opioid Prescribing: —Avoiding diversion and iatrogenic drug dependence — Maintaining access to pain mediations for those in need

© Fornili, Burda & Selby, 2018

Addictions Nursing: Standards of Practice (ANA-IntNSA, 2013)

STANDARD ADVANCED PRACTICE COMPETENCIES

1. Assessment Initiates and interprets diagnostic tests and procedures; assesses the effect of interactions among individuals, family, community & social systems

2. Diagnosis Integrates data; develops differential diagnoses

3. Outcome Identification

Identifies outcomes based on the evidence and implementation of EBP

4. Planning Plans for multi-faceted needs of complex consumers; current evidence

5. Implementation Facilitates utilization of systems and resources; Collaboration; Treatment; prescriptive authority

6. Evaluation Outcomes

7. Ethics Risks, benefit & outcomes; informed consent and refusal

8. Education Utilize current research

© Fornili, Burda & Selby, 2018

Addictions Nursing: Standards of Practice (ANA-IntNSA, 2013) STANDARD ADVANCED PRACTICE COMPETENCIES

9. EBP & Research Conducting/synthesizing research & other evidence

10. Quality of Practice Quality improvements, practice changes, design innovations

11. Communication Discussions with patients, families & inter- professional team

12. Leadership Improve practice environment; model expert practice

13. Collaboration Partner with other disciplines to enhance outcomes

14. Professional Practice Evaluation Seeking feedback on professional practice

15. Resource Utilization Formulates innovative solutions and evaluation strategies

16. Environmental Health Practices in environmentally safe and healthy manner

© Fornili, Burda & Selby, 2018

Standards of Practice (ANA, 2015; ANA-IntNSA, 2013)

STANDARD COMPETENCIES

GENERALIST RN ADDICTIONS RN ADVANCED PRACTICE

Assessment Collects data not limited to demographic, social, physical, functional, psychosocial, emotional, cognitive, sexual, cultural, age-related, etc.

Collects information on the amount frequency, and pattern of alcohol consumption, drug use, tobacco use, and behaviors that may be maladaptive behaviors.

Initiates and interprets diagnostic tests and procedures; assesses the effect of interactions among individuals, family, community & social systems.

© Fornili, Burda & Selby, 2018

Medication Assisted Treatment (MAT): Nicotine Use Disorder*

• Nicotine replacement – (patches/gum) • Prescription Medications –

(Bupropion & Varencicline)

*Combined with behavioral treatment such as CBT

(CDC, Smoking…, n.d.; Fiore et al., 2008; NIDA, 2018, Principles. Of Drug Addiction Treatment…; SAMHSA, Behavioral health treatments and services, 2017; WHO, n.d.)

© Fornili, Burda & Selby, 2018

Medication Assisted Treatment (MAT): Alcohol Use Disorder (AUD)*

• Naltrexone – opioid antagonists, also used to treat alcohol use disorder

• Acamprosate – to stabilize chemical signaling in the brain (neurotransmitter function)

• Disulfiram – Patient experiences unpleasant side effects when he or she consumes alcohol.

(Reus et al., American Psychiatric Association practice guidelines…, 2018)

*Combined with behavioral treatment such as CBT

© Fornili, Burda & Selby, 2018

Medication Assisted Treatment (MAT): Opioid Use Disorder (OUD)*

• Methadone - full agonist synthetic opioid – Federally regulated clinic

• Buprenorphine - partial-agonist synthetic opioid – Office-based treatment – DATA 2000 – Office-based treatment – Schedule III, IV, and V narcotics

by waivered physicians – CARA - expanded waiver eligibility to NPs and PAs

• Naltrexone – opioid antagonist – Outpatient – Not a controlled substance – PLUS behavioral treatment

*Combined with behavioral treatment such as Contingency Management

and/or substance use disorder (SUD) counseling

© Fornili, Burda & Selby, 2018

NIDA Principles of Effective Treatment 1. Addiction is a complex but treatable disease, affects brain function and behavior

2. No single treatment is appropriate for everyone

3. Treatment needs to be readily available

4. Effective treatment attends to multiple needs of the individual, not just drug use

5. Remaining in treatment for an adequate period of time is critical

6. Behavioral therapies – including individual, family, or group counseling – are the most commonly used forms of treatment

7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies

(NIDA, 2012)

© Fornili, Burda & Selby, 2018

NIDA Principles of Effective Treatment 8. An individual’s treatment and a services plan must be assessed continually &

modified as necessary to ensure that it meets his or her changing needs

9. Many drug-addicted individuals also have other mental disorders

10. Medically assisted detoxication is only the first stage of addiction treatment and by itself dose little to change long-term drug abuse

11. Treatment does not need to be voluntary to be effective

12. Drug use during treatment must be monitored continuously, as lapses during treatment do occur

13. Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases as well as provided targeted risk-reduction counseling, linking patients to treatment if necessary

(NIDA, 2012)

Patient Factors---40% • STRENGTHS the patient

comes through the door with

Relationship Factors---30% • Patients’ perceptions of EMPATHY,

ACCEPTANCE & HOPE

Expectancy & Hope---15% • Extent to which the patient

BELIEVES or EXPECTS that the counselor’s intervention will be beneficial

Model/Technique---15% • Least Influential Contributors To

Change: What we do as helpers; our strategies and techniques

Mid-Atlantic Addiction Technology Center. Addiction Exchange, Vol. 3, No. 8: Common Factors Research, May 15, 2001

© Fornili, Burda & Selby, 2018

Meta-Analysis: 40 Years of Outcomes Research— COMMON FACTORS

Meta-Analysis: 40 Years of Outcomes Research— TAKE HOME MESSAGES

Patient Factors • Focus on STRENGTHS (talents, beliefs, past problem-solving abilities) • Utilize social supports and resources Relationship Factors • Really LISTEN • Foster good ALLIANCE between patients and staff Expectancy & Hope • Convey the “POSSIBILITY OF CHANGE” • HOPE, OPTIMISM and ENCOURAGEMENT improve outcomes Model/Technique • Instead of finding more “effective” models of treatment, we should

elicit, amplify and reinforce the PATIENT and FAMILY FACTORS.

Mid-Atlantic Addiction Technology Center. Addiction Exchange, Vol. 3, No. 8: Common Factors Research, May 15, 2001 © Fornili, Burda & Selby, 2018

© Fornili, Burda & Selby, 2018

Meta-Analysis: 40 Years of Outcomes Research— TAKE HOME MESSAGES

 All treatment models can be equally effective (TREATMENT WORKS!)

 Biggest engine of change is the PATIENT and FAMILY, not “us” or our intervention models

 Outcomes improve when we INSTILL HOPE and accommodate our patients

Mid-Atlantic Addiction Technology Center. Addiction Exchange, Vol. 3, No. 8: Common Factors Research, May 15, 2001

WHAT DOES NOT WORK:

• Outcomes do not improve when we require patients to “fit” or “conform” to our favorite model or technique

MOTIVATIONAL ENHANCEMENT

© Fornili, Burda & Selby, 2018

Problem Recognition, Readiness for Treatment and Motivation

ADAPTED FROM: Ingersoll, K. and Wagner, C. “Motivational Enhancement Groups for the Virginia SATOE Model,” Va. DMHMRSAS, 1977. © 2002, Va. DMHMRSAS

People who show INSIGHT about: • The RELATIONSHIP between

NEGATIVE CONSEQUENCES and

• Their USE of ALCOHOL AND OTHER DRUGS (AODs)

Will probably: • BE RECEPTIVE to treatment, and

• DO WELL well in treatment.

Problem Recognition, Readiness for Treatment and Motivation

ADAPTED FROM: Ingersoll, K. and Wagner, C. “Motivational Enhancement Groups for the Virginia SATOE Model,” Va. DMHMRSAS, 1977. © 2002, Va. DMHMRSAS

People who: • Are unable to RECOGNISE their problem,

• FAIL TO DISCLOSE that they have an AOD problem, or

• Exhibit DENIAL and MISTRUST---

Will probably be:

• HARDER TO ENGAGE in treatment; and

• MORE LIKELY to “DROP OUT”

Problem Recognition, Readiness for Treatment and Motivation

ADAPTED FROM: Ingersoll, K. and Wagner, C. “Motivational Enhancement Groups for the Virginia SATOE Model,” Va. DMHMRSAS, 1977. © 2002, Va. DMHMRSAS

These persons need to be ASSESSED for:

• TREATMENT READINESS and • MOTIVATION.

BRIEF INTERVENTIONS focused on pre-treatment “MOTIVATIONAL ENHANCEMENT” will help improve likelihood of success.

© Fornili, Burda & Selby, 2018

KEY ASSUMPTIONS about MOTIVATION:

• Most people are not completely ready for change!

• If people are not ready to change, we need to:

• Help PREPARE them for CHANGE;

• NOT PUSH them into changing when they are not ready.

KEY ASSUMPTIONS about MOTIVATION:

SIGNS OF PATIENT RESISTANCE are: • Interrupting; • Denial; • Ignoring; or • Arguing

These are clues to check our own behaviors, plans and expectations.

Are we rushing ahead to action planning without first checking the patient’s level of readiness?

If If so, we may be in a “CONFRONTATION-DENIAL TRAP”— inducing the patient to argue, interrupt, deny the problem, or ignore us.

© Fornili, Burda & Selby, 2018

A New Way of Communicating— Motivational Interviewing and Motivational Enhancement

• Confrontational vs. Motivational Styles— – It is not necessary for patients to “hit rock-bottom;” – It is not helpful to try to force patients to “accept their diagnosis” (label); – It is important for providers to avoid the “Confrontation-Denial Trap.”

• Motivation— – Brief Interventions focused on pre-treatment motivational enhancement

will improve the likelihood of success.

• Readiness—Nurses can: – Help patients gain insight about the relationship between their AOD use

and their medical conditions and negative life consequences (Discrepancy); – Help patients begin to consider or actually make behavior changes

(Stages of change).

WELLNESS & RECOVERY

8 DIMENSIONS of WELLNESS

https://www.samhsa.gov/wellness-initiative/eight-dimensions-wellness

• Emotional—Coping effectively with life and creating satisfying relationships

• Environmental—Good health by occupying pleasant, stimulating environments that support well-being

• Financial—Satisfaction with current and future financial situations

• Intellectual—Recognizing creative abilities and finding ways to expand knowledge and skills

• Occupational—Personal satisfaction and enrichment from one’s work

• Physical—Recognizing the need for physical activity, healthy foods, and sleep

• Social—Developing a sense of connection, belonging, and a well-developed support system

• Spiritual—Expanding a sense of purpose and meaning in life

© Fornili, Burda & Selby, 2018

RECOVERY from Mental Disorders and/or Substance Use Disorders: Not Just ABSTINENCE

• DEFINITION: A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

• 4 DIMENSIONS – Health – Home – Community – Purpose

https://www.samhsa.gov/recovery

© Fornili, Burda & Selby, 2018

RECOVERY: Not Just Abstinence • Recovery emerges from hope • Recovery is person driven • Recovery occurs via many pathways • Recovery is holistic • Recovery is supported by peers and allies • Recovery is supported through relationships and social network • Recovery is culturally-based and influenced • Recovery is supported by addressing trauma • Recovery involves individual, family and community strengths and responsibility • Recovery is based on respect – recovering from addiction and psychiatric issues

require bravery on the part of the individual. Communities and social systems that acknowledge this lessen the stigma associated with these disorders and offer people a healthier atmosphere in which they can get better and give back

PRELIMINARY RESULTS: Using Data Regarding Nurses’ Attitudinal

Barriers & SUDs Knowledge Deficits to Improve Nursing Curriculum

© Fornili, Burda & Selby, 2018

Qualitative Themes and Curricular Revisions (Incomplete Preliminary Data-Not Ready for Prime Time)

Theme Recommended Curricular Revisions • SUDs patients are difficult to care

for • Difficult behaviors and how they may lead to negative feelings in

the nurse

• “Lying” and “manipulation” • Appropriate responses to those behaviors, and how forming safe, trusting relationships help to reduce those behaviors

• Safety and Workplace Violence • Violence prevention in health care facilities

• Nurse-Patient Relationship • How to convey messages that the nurse understands the patient and accepts them

• Stigma & Cultural Competence • Stigma is counterproductive • Words and labels matter • Culturally competent nursing care

• “Drug-seeking” Behavior and Pain Perception

• Safe opioid prescribing • Tolerance & Withdrawal • Pseudo-addiction

• Mothers and Babies • Perinatal substance use & NAS • Parental shame and perceived incompetence • Provider behavior can be counterproductive and interfere with

recovery process and adequate maternal/child bonding

© Fornili, Burda & Selby, 2018

TAKE HOME MESSAGES FOR TODAY: • ALL NURSES and ALL HEALTH PROFESSIONALS must have a

basic understanding of SUDs in order to care for these individuals in their particular practice settings (CSAT, TAP #21)

• ADVANCED PRACTICE NURSES and OTHER MAT PRESCRIBERS need more advanced training (www.samhsa.gov/medication-assisted-treatment)

• Provider attitudes can inhibit one’s ability to provide adequate services to patients with SUDs (Goplerud, Hagle, McPherson, 2017)

• Any door is the right door. In integrated care, treatment must have multiple points of entry. There is no wrong door to recovery (SAMHSA, 2006)

© Fornili, Burda & Selby, 2018

What if behavioral health problems and specialty referrals were addressed like other types of health care problems?

ACUTE CARE

CHRONIC CARE SUBSTANCE

USE DISORDERS

Fornili, 2017

© Fornili, Burda & Selby, 2018

For questions, please contact: Katherine Fornili, DNP, MPH, RN, CARN, FIAAN Assistant Professor, University of Maryland School of Nursing Dept. of Family & Community Health

President-Elect, International Nurses Society on Addictions-IntNSA (2016-2018) (President, 2018-2020) www.intnsa.org

655 W. Lombard Street, Suite 545 D Baltimore, MD 21201 Office: 410-706-5553 EMAIL: fornili@umaryland.edu