health and healing week 6 - chapter 7

three competing lenses of addiction

1. during the victorian era addicts were viewed as morally flawed

2. brain disease model of addiction - middle of the 20th century

3. development/learning model

developmental model

• Draws on the same neuroscience of the brain as the disease model but provides a different interpretation

• heavy substance use is learned and that the brain changes are responses to life experiences including trauma, interpersonal and structural violence, and substance use itself

what does the developmental model consider

• the potent impact of social factors, such as isolation and dislocation, and adversity in early childhood development

why do people think substance abuse is a choice

• the rise in individualism

• military languages (the war on drugs)

• criminalizing approaches to dealing with substance use

how does the developmental model view substance abuse

• away from the “choice” model and the “disease” model to view substance use as something that is learned and can be unlearned

moral failing model

• cause

  • moral weakness

• solution

  • shame and punishment

• role of choice

  • immoral by choice

brain disease model

• cause

  • drugs cause the brain changes underlying addiction

• neurobiology

  • damage caused by drug use reduces cognitive control, increases compulsivity in drug seeking

• solution

  • external control, follow advice

• role of choice

  • unable to make choices

developmental learning model - general

• cause

  • learned responses brain changes are normal responses to life experiences, including substance use

• neurobiology

  • People learn addiction through neuroplasticity; repeated experiences establish patterns, forming habits

• solution

  • Individual learning and development

• role of choice

  • new choices learned

the term addiction

• carries the greatest stigma and is perhaps the most overused

addiction definition

• generally refers to compulsion and dependence

• there is considerable disagreement regarding the meaning and usefulness of the term addiction

substance use disorder

• the term that is now used

• replaced the terms substance abuse/dependence

DSM-5 direction

• that people with substance use issues receive a diagnosis of mild, moderate, or severe substance use disorder.

why was there a shift in language

• to reduce the labelling of patients experiencing normal levels of tolerance and withdrawal symptoms as “addicts”

• to improve the clinical assessment, management, and treatment of pain

dependence

• is limited to physiological dependence, which is an expected, anticipated, and normal response to repeated doses of many medications including:

  • beta-blockers

  • antidepressants

  • opioids

  • antianxiety agents

  • other drugs and substances.

dependence characteristics

• tolerance

• withdrawal

tolerance

• needing more amounts of the medication or substance to produce the desired effect

withdrawal

• physiological symptoms that occur when the medication or drug is withdrawn, requiring care to manage and mitigate withdrawal symptoms

what is heavy use responsible for

changes in the brain and other physiological characteristics of substance use disorders.

intoxication and for the withdrawal and tolerance phenomena regarded as central to current definitions of addiction or dependence.

main social consequences of substance use disorders, such as problems in fulfilling social roles.

majority of the substance-attributable burden of disease and mortality.

Heavy use over time as a definition better fits the empirical data and may diminish stigmatization and avoids pointing attention away from highest-risk categories.

how should nurses react to substance use

• use the term substance use

• specify the types of substances (e.g., THC, CBD, or high-content THC such as shatter), patterns and amount of use, and the physiological and social effects of such use as they are experienced by individuals.

goal of substance use health

• a way to expand beyond harm reduction to promoting health in relation to substances.

• Harm reduction is a philosophy and a set of programs and services

• focus on preventing the harms of substance use, not reducing substance

substance use health

• the achievement of self-defined goals of well-being across the spectrum of substance use ranging from no substance use to substance use disorder

harms associated with substance use

• from the frugs themselves

• legal

• economic

• social

what should health care providers recognize

• wider context not just the harms

  • their own knowledge and biases and how they convey them

  • how they act

  • both with PTS and other staff

substance use health scale

• no use

  • no use of substances

• beneficial

  • positive health or social effects

• lower risk

  • occasional use that has negligible health or social effects

• problems occurring

  • use that has negative consequences for individuals families or communities

• substance use disorder

  • diagnosable chronic medical condition based on 11 criteria listed in the DSM-5

political orthodoxy

• the distinguishing of drug addiction and drug habituation

  • with illegal drugs deemed addiction-producing

  • alcohol and tobacco were deemed habit-forming

Abstinence

• completely no use of a given substance

AA effectiveness

• has been shown to be as effective or more effective than other established treatments for heavy alcohol use

National Anti-Drug Strategy

• preventing illicit drug use;

• treating patients with dependencies on illicit drugs

• and combatting the production and distribution of illicit drugs

• with no mention of harm reduction

downstream harm reduction policies

• providing access to safe substances

  • providing heroin that is not cut with more harmful substances such as fentanyl; drug-checking services

• safe supplies

  • clean needles or crack pipes that will not cut people’s lips

• safe places to use substances

  • safe injection sites

• overdose care

  • public distribution of naloxone [Narcan] kits

goal of harm reduction

• the reduction of the harms of substance use but not the reduction of use

three harm reduction paradigms

1. Conservative paradigm, in which harm reduction measures (e.g., needle exchanges) are seen as temporary, with an ultimate goal of abstinence;

2. Liberal paradigm, in which informed choice is supported and a safety net provided; and

3. Structural paradigm, in which empowerment, advocacy, and emancipation of people using substances are embraced.

perspectives on harm reduction

• a technical solution

  • decontextualized interventions aimed at “facilitating behavior changes that are deemed necessary to reduce the harms associated with drug use”

    • ex. supervised consumption sites

• contextualized social practice

  • interventions contextualized within economic, political, and social contexts.

harm reduction vs abstinence

• opposition to one another

alcohol use

• about 78% of Canadians (23.3 million people) drank alcohol in the past year, which was the same as in 2015. Alcohol use was similar between males and females, but more females were drinking compared to 2015.

alcohol use stats

• Young adults (20–24) had the highest alcohol use (83%)

• Adults 25+ were at 79%

• Youth (15–19) had the lowest (57%)

drug use in canada

• Cannabis was the most commonly used illegal drug (before legalization in 2018)

• Use increased from 12% (2015) to 15% (2017)

Use of other illegal drugs (like cocaine, ecstasy, meth, hallucinogens, and heroin):

• Increased from 2% to 3%

• This rise was mainly due to increased cocaine use

opioid crisis - discussions

• supporting harm reduction

• improving data/surveillance

• addressing prevention and treatment options

factors influencing substance use

• social practices and accessibility

• affordability

• trauma, violence, chronic pain

• mental health

factors influencing harm related to substance use

• interrelated - historical, physical, economic, socio-political and ideological contexts

• physical context

  • where people live

• privilege

  • income, racism, ability

• socio-political and ideological

  • different substances are more acceptable than others

how should health care providers view substance use

• must avoid viewing substance use as a primary problem to be targeted

• heavy substance use is a symptom of other pre-existing problems and circumstances.

• should assess substance use in the context of a comprehensive health history, including violence, trauma, and mental health histories, and in the contexts of income, housing, employment, food security, and access to services such as counselling

Five “As” for Integrating Knowledge of Substance Use in Health Assessment

• Acquire knowledge: replace erroneous assumptions. Know yourself: your assumptions, attitudes, values, and beliefs.

• Anticipate harm that may be caused

• Analyze the impact of policies at the level of organizations (e.g., clinical assessment tools) and society (e.g., static social assistance rates in the face of rising costs of living).

• Avoid social judgement about substance use, such as seeing a person as “bad,” deviant, or morally weak.

• Approach all patients respectfully.

why should nurses not only rely on a set list of signs and symptoms of drug use

• there is considerable variation in patient presentation

• many street drugs are tainted with multiple substances

• the mixing of substances in the illegal drug supply is increasingly common

• physical/medical conditions can look like use, intoxication, or withdrawal

how to put harm reduction principles into action

• learn about the context and population you serve

• be clear about why you are gathering information and convey your reasons to PT

• do not gather info that is not needed or used

• assess individuals in context

• start history taking with the least intrusive questions

• consider timing

• use assessment as an opportunity to ask about a PTS health goals, promote health and offer suggestions for harm reduction

• avoid making assumptions

• know and draw on resources

• advocate for adequate resources for yourself and your PTs

TWEAK screening tool

• tolerance

  • how many drinks do you need to feel the first effectt

• worry

  • have close friends or relatives worried or complained about your drinking

• eye opener

  • do you sometimes drink when you first get up

• amnesia

  • Has a friend or family member ever told you about things you said or did that you could not remember

• kut down

  • Do you sometimes feel the need to cut down on your drinking?

TWEAK scoring

• Taking ≥3 drinks to feel high = tolerance.

• Score 2 points each for tolerance and worry.

• Score 1 point each for the rest.

• A low-risk response is ≤1 point.

• ≥2 points = a likely drinking problem.

learn about the context and population you serve

• What are the most common substance use issues?

• What are the common histories?

• What substances are being used?

• What are the differential effects on particular populations within the communities served?

• What resources are available?

Be clear about why you are gathering information, and convey your reasons to patients you are assessing

• introduce the screenings

• explain why its being given

  • We know that many people use alcohol, but we ask everyone about their alcohol use so that we can provide better pain management and anticipate reactions to medications and other problems

Do not gather information that is not needed or will not be used

• when PT know that the info will only be used for health reasons they are more likely to tell you information

assess individuals in context

• what you know about the context of people’s lives in the populations you are serving, you will be better able to listen for and understand individuals’ histories

least intrusive questions

• start with legal substances

• first questions asked should be more general

• questions should show your knowledge about drugs

• some standardized questions may not be clear, change it to a clearer question

timing

• depth of conversations will vary based on presentation of the PT, who is in the room and anything that may happen that day

• strive to obtain as much information as the patient is willing to share, while recognizing that you may have to gather further information at a later time as a relationship develops.

know and draw on resources

• Learn about your in-house and community resources

• Learn whether a given resource is more abstinence based or harm reduction based

• learn the reputation of a given resource from patients who have accessed the resource

Advocate for adequate resources for yourself and your patients

• taking time to pay attention to patients’ answers, acknowledging discomfort (yours and theirs), listening respectfully, following up appropriately, and having resources to offer patients

who experiences withdrawal

• Up to half of people with heavy prolonged use will experience withdrawal

withdrawal

• and signs and symptoms may appear within 6 to 12 hours of the abrupt cessation or decrease in alcohol intake

• signs and symptoms manifest in 4 stages

stage one of withdrawal

• minor withdrawal symptoms

  • tremors

  • diaphoresis

  • nausea/vomiting

  • hypertension

  • tachycardia

  • hyperthermia

  • tachypnea

• 6-12 houes

stage 2 withdrawal

• alcoholic hallucinosis

  • dysperceptions visual (zooscopies),

  • auditory (voices)

  • tactile (paresthesia)

• 12-24 hours

stage 3 withdrawal

• alcohol withdrawal seizures

  • generalized tonic–clonic seizures

  • short or no postictal period

• 24-48 hours

stage 4 withdrawal

• delirium tremens

  • delirium

  • psychosis

  • hallucinations

  • hyperthermia

  • malignant hypertension

  • seizures

  • coma

• 48-72 hours

treatment for withdrawal

• medications