Community Exam #2 (Part 3)

drug overdose trends

• drug-related overdoses are among leading causes of injury mortality in US

• opioid-related overdose deaths have been primary contributor to mortality

  • multiple waves of opioid epidemic

  • increased potency of synthetic opioids (fentanyl)

  • adulteration of community drug supply with synthetic opioids

• psychostimulant use has recently been increasing

  • contributing to overdose deaths

• emerging substances also contributing to overdose deaths

  • xylazine

  • medetomidine

opioid epidemic: wave 1

prescription opioid overdose deaths

• rates of opioid prescribing increased in late 1990s

  • recognition of pain as fifth vital sign

    • would screen for and treat as aggressively as possible

  • coincided with aggressive marketing of opioid analgesics for the management of acute and chronic pain by pharmaceutical industry

  • opioids promoted and marketed as being associated with low risk of addiction

opioid epidemic: wave 2

heroin-related overdose deaths

• new guidelines recommended against long-term opioid treatment for chronic pain

• did NOT wean or taper off opioids very effectively

  • just stopped prescribing them with no pain management plan or alternative strategies

    • patients experienced withdrawal and rebound pain

• implementation. of prescription drug monitoring programs in select states

• heroin was cheaper and more accessible

opioid epidemic: wave 3

synthetic opioid overdose deaths

• still policies that limited prescription opioids, so obtained opioids from community sources

  • increased demand within community drug supply

    • led to creation of accessible and affordable alternatives

  • fentanyl and associated high-potency analogs flooded community drug supply

• widespread proliferation of synthetic opioids

  • primarily fentanyl

• higher rates of mortality among younger individuals

opioid epidemic: wave 4

psychostimulant-involved overdose dealths

• more widespread proliferation of synthetic opioids

• adulteration of synthetic opioids with psychostimulants

  • cocaine and methamphetamine

• increase in overdose deaths significantly

  • may be due to addition of some foreign unknown substance

harm reduction

set of practical strategies and ideas aimed at reducing negative consequences associated with drug use

policies, programs, and practices that aim to minimize negative health, social, and legal impacts associated with drug use, drug policies, and drug laws

harm reduction: overview

• non-judgemental empathic approach

• meeting patients where they are at

• diverges from traditional authoritarian and medical model of practice

• willingness to provide care and treatment regardless of patient’s willingness to mitigate or eliminate substance use

• focuses on reducing mortality so can seek care if ready

• keeps people safe within systems and environments that typically fail to do so

harm reduction: principles

1. respect autonomy

2. practice acceptance and hospitality

3. provide support

4. connect with the community

5. provide many pathways to well-being across the continuum of health and social care

6. value practice-based evidence and on-the-ground experience

7. cultivate relationships

8. assist NOT direct

9. promote safety

10. engage first

11. prioritize listening

12. work toward system changes

harm reduction: elements

1. humanism

2. pragmatism

3. individualism

4. autonomy

5. incrementalism

6. accountability without termination

humanism

• providers value, care for, respect, and dignify patients as individuals

• important to recognize that people do things for a reason

  • harmful health behaviors provide some benefit to the individual and those benefits mist be assessed and acknowledge

  • understand balance between harms and benefits

• understand why patients make decisions is empowering for providers

pragmatism

• none of us will ever achieve perfect health behaviors

• health behaviors and the ability to change hem are influenced by social and community norms

  • behaviors do not occur within a vacuum

individualism

• every person presents with own needs and strengths

• people present with spectrums of harm and receptivity

  • require a spectrum of intervention options

autonomy

• providers offer suggestions and education regarding patient medications and treatment options

  • individuals ultimately make their own choices about health behaviors to the best of their abilities, beliefs, and priorities

incrementalism

• any positive change is a step toward improved health

  • positive change can take years

• important to understand and plan for backward movements

accountability without termination

• patients are responsible for their choices and health behaviors

• patients are not fired for not achieving goals

• individuals have the right to make harmful health decisions

  • providers can still help them understand that the consequences are their own

implementation: avoid stigmatizing langauge

• associated with adverse health outcomes

  • delays in seeking or receiving appropriate treatment

  • use of punitive or non-evidence based interventions

  • barriers to recovery

  • adverse physical, mental, and psychosocial outcomes

substance use stigma

negative attitudes, beliefs, or behaviors about or towards individuals with substance use disorders or related problems

implementation: avoid stigma language

use non-stigmatizing and person-first/centered language (person with ____)

• when communicating with patients and family members or support systems

• when communicating with other interprofessional members of healthcare team

  • role modeling appropriate language and best practices

• used in clinical documentation

  • role modeling appropriate langauge and best practice

  • can foster trust for patients who might access their electronic health records

motivational interviewing

a patient-centered approach for strengthening a person’s own motivation and commitment to making positive behavior change

motivational interviewing: components

1. partnership

2. acceptance

3. compassion

4. empowerment

partnership

• see the individual as the expert in their own life

• ensure that their expertise and perspective are central to the conversation

• promote a collaborative and respectful relationship

acceptance

• honor the absolute worth of the individual

• respect their autonomy

• cultivate accurate empathy

• acknowledge the understandable and logical reasons for substance abuse

• use affirmation

  • highlight their existing strengths and existing resources

compassion

• prioritize the well-being of the patient

• demonstrate genuine care and concern

• remain non-judgemental

• understand and validate their struggle

• work in behalf of the individual’s best interests and welfare

empowerment

• draw out the patient’s internal motivation to change high risk behaviors

• highlight past instances of reduced or limited substance use

• seek out wisdom of the individual

• elicit ideas and solutions from the patient

transtheoretical model of change

• motivational interviewing should be framed within the context of this model

• meet patients where they are at

• support self-efficacy

• elicit an individuals's own reasons to change

transtheoretical model of change: stages

1. precontemplation: not even aware of problem

2. contemplation: starting to think about making change

   1. nurses can have big impact in this stage

3. determination: make plan for change

4. action: change is made

5. maintenance: change is maintained

motivational interviewing: techniques

1. open-ended questions

2. affirmative statements

   1. support self-efficacy

   2. remind patients of specific strengths

3. reflection

   1. demonstrates engagement

4. summarizing

   1. allows patients to clarify ideas or concepts