Let’s talk about the alcoholics and the drug addicts…

Do I have your attention?  I know, you’ve heard it all before.  Nothing new here.  And I’m sure you’ve heard about the “stigma” that surrounds alcohol and drug use.  You may still have this feeling that it’s the abusers fault anyways so it’s not your problem or your concern.  Or perhaps you struggle with these issues or know someone who struggles with this and you blame yourself/them because it’s so obvious that it’s a preventable problem.  I personally have fallen victim to the belief in this stigma.  I mean after all, the chose to start using substances, didn’t they?


What is a stigma?  A stigma is “a mark of disgrace associated with a particular circumstance, quality, or person”.  But who cares about if you hold this stigma?  In the healthcare setting, this stigma causes discrimination of patients based on their substance use issues and inhibits effective care management.  As nurses, it causes sub-par care for these patients.  The foundation of nursing is the ability to feel empathy for your patients.  If you, as a nurse, cannot empathize due to an underlying stigma which is held, effective care cannot be given.  Patients may develop feelings of inferiority and may lead to them not seeking help when help is needed.

A common theme with psychiatric patients and patients with substance abuse problems is health-seeking behavior.  This is then therefore highly overlooked by nurses and the healthcare staff.  However, issues arise when patients seek care and the staff is not willing to provide care.  The patients problems may be dismissed and this health-seeking behavior which leads to adverse outcomes, including overdose and suicide leading to death.  Within the past three years, death by synthetic opioid overdose has increased 530%.  No, that is not a typo.  That is more than a five times increase in the number of deaths related to opioid overdose.

Substance use is very non-selective – anyone has the potential to fall victim to its consumption.  The very definition of substance abuse is fluid and the problem does not just fall on those who are diagnosed with substance use disorders.  In fact, remember that aforementioned 530% increase in synthetic opioid related death?  Well, 70-90% of these people who die of opioid abuse actually do not meet the criteria for the diagnosis of having a substance use disorder.

This significant problem comes back to a failure on the part of the healthcare system in 1) identifying patients with or at risk for substance abuse problems, and 2) employing proactive and interventional support to prevent further progression of the addiction or adverse outcomes.  In the hospital setting patients are likely to present whether due to an injury/ condition secondary to substance abuse or patients obtain opioid pain medication for acute/ chronic conditions.  The presence or risk for substance abuse is brushed under the rug in this setting.  On the inpatient unit, as well as in the emergency department, the focus is primarily on treating the acute condition and ignoring the underlying problems.  There are screening measures which are intended to identify these patients, but their use is ineffective.  The screening process includes an interview upon admission asking about substance us (including alcohol as well as illicit substances).  Often, this interview is carried out in a way which poses the questions to the patient in a leading way, favorable to the socially acceptable response.  For example, a person might ask: “You don’t use alcohol or illicit drugs, do you?” or “You only drink socially, right?”.  This sounds like such a basic and blatant mistake, but it happens everyday in the hospital, doctors office, emergency department, wherever!

So how do we approach this problem?  The first thing we must do is recognize the true problem which we are facing as well as the scope of this problem, the implications, and its relevance to each and every person.  As I mentioned above, “substance use is very non-selective – anyone has the potential to fall victim to its consumption”.  This means it is your problem too.  It could be yourself, your mother, your brother, you cousin, your friend, your neighbor, etc who may become trapped with this problem.  Be aware of its existence, and “fight the stigma”.

Next, optimizing screening procedures is essential for the identification of patients at risk for or with substance abuse problems.  This means having an open, honest conversation with patients upon admission to “wherever” and approaching the topic in a nonjudgemental, compassionate manner.  Non-leading questions are crucial to the identification of these patients.  Furthermore, asking about facts rather than open-ended, subjective questions regarding a person’s substance use can be profoundly beneficial.  For example, asking “how many drinks do you have in a day?”  as appose to “do you drink a lot?” (there are much less obvious ways this question is posed but I can’t think of any right now so..) can give a lot more information about a patients substance use and guide the healthcare team to identifying problems more directly.

The next way we can approach this problem is through effective education.  Following screening, particular attention should be given to those deemed at risk for developing a substance use disorder.  Sometimes, patients fall into this problem because they simply did not know enough about its existence and they thought everything was fine.  Opioids are significantly over-prescribed and patients may think just because it is prescribed, they have to take it and there is no risk with taking it as the doctor orders.  This is not at all the case.  Pain is a subjective experience and it is the doctor’s goal to minimize pain as the presence of pain is linked to negative health outcomes.  However, these type of pain relievers should be discontinued as soon as is possible for the patient to manage their pain without them.  This is another point which falls on the nurses identifying the need for them on a patient-by-patient basis and advocating for what is best for the patient to manage pain and prevent bigger issues, like addiction.  The issue with prescribing them is that there is no standard protocol for their use for pain since pain is different for each and every person – some people may need them longer than others.  Another important note regarding this is that pain does not need to be gone for the discontinuation of these drugs.  Alternative drug therapies which have less abuse potential should be utilized to manage pain following their discontinuation.  Education can also regard alcohol use.  The standard for casual drinking is classified as 1 drink a day for women with no more than 7 drinks in a week and 2 drinks a day for men with no more than 14 drinks a week.  Binge drinking is defined as more than 4 drinks in a 2-hour period for women or more than 5-drinks in a 2-hour period for men.  Heavy alcohol use includes binge drinking on five or more days in the past month for both men and women.  (Also, believe it or not, alcohol withdrawal is one of the most deadly substance use withdrawals there is.)  Most people do not know these limits.  I certainly didn’t before this semester when I learned it in class!  Educating patients about the guidelines for these issues, the complications and risks with them as well as the adverse outcomes related with them can significantly decrease the prevalence of substance use disorders.

Finally, we can combat this problem with effective intervention for patients who are suffering from substance addiction.  This may include tapering drugs or the referral to a methadone clinic, tapering alcohol use over time, or the referral to treatment programs which may help the patients quit their addiction.

There is no denying there is an issue with substance abuse and effective intervention to help those suffering from substance abuse problems.  Knowing the problem exists is the first step.  You have already taken the first step by reading this post!  Now, it’s time to act.  It’s time to spread the word, fight the stigma that exists, and cut out the judgement related to those who struggle with addiction.  Specifically for the healthcare team, it is crucial that we improve screening and intervention for these patients.  Within the community, you can do your part by sharing the facts and supporting those you may know battling addiction, reserving judgement and expressing empathy.

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