Substance use is at epidemic proportions in the United States. Substance use disorders (SUDs) are difficult to treat and considered to be chronic with a high mortality rate. Nurses are in a prime position to help patients with SUDs in a variety of settings, but they often lack knowledge about the disorder and the skills to provide effective care. The identification and treatment of co-occurring disorders, such as trauma, are important when providing care for patients with SUDs. Empathy and perspective taking were once thought to be helpful when working with patients, but evolving thought is that compassion is more effective as it involves feeling for, and not with, patients and includes taking action to help another. Harm reduction strategies, such as accepting people where they are, as well as the use of motivational interviewing strategies are also effective when working with patients with SUDs. Involving patients with SUDs in their treatment plans through shared decision making is also effective in building a therapeutic relationship and improves outcomes. [Journal of Psychosocial Nursing and Mental Health Services, 57(9), 11–15.]
Addressing issues related to addictive behaviors and diagnoses
Substance use disorders (SUDs) are a significant problem in the United States. In 2017, 19.7 million Americans age ≥18 had a SUD (Substance Abuse and Mental Health Services Administration [SAMHSA], 2018). Today, more people die from overdose deaths than motor vehicle accidents or gunshot wounds (National Safety Council, 2019). Relapse or exacerbation rates of SUDs are approximately 50% and are similar to other chronic health disorders, such as diabetes and hypertension (National Institute on Drug Abuse [NIDA], 2018b). Despite the high relapse rates, recovery from SUDs is possible (NIDA, 2018b). Factors associated with recovery include quality of life, employment, spirituality, and self-efficacy (Worley, 2019). The purpose of the current article is to provide information on effective strategies for nurses working with patients with SUDs.
What Doesn't Work
Lack of Knowledge About the Neurobiology of Addiction
Studies have shown that health care professionals lack education about SUDs and training in treating them (Van Boekel, Brouwers, Van Weeghel, & Garretsen, 2013). Nurses must have working knowledge of the underlying neurobiology of addiction to provide evidence-based care and educate patients and families. In SUDs, the brain's reward system is activated, which increases dopamine in key areas of the brain, including the ventral teg-mental area, nucleus accumbens, and prefrontal cortex (NIDA, 2017). When dopamine levels are elevated due to substance use, the brain attempts to maintain balance by responding with decreased dopamine production and downregulation of dopamine receptors, which causes negative changes in emotion and behavior (NIDA, 2018a). People with SUDs experience low mood, low motivation, and lack of enjoyment, which often drives them to keep using substances to feel better (NIDA, 2018a). Low dopamine causes negative behaviors in people with SUDs, such as impulsiveness and poor decision making, rather than a moral failure or choice (NIDA, 2018a).
Singling Out SUDs as Different
Although the initial use of a substance is a choice, the impact of the neurobiological changes combined with withdrawal and craving symptoms impede the ability for individuals with a SUD to stop their substance use. This pattern of exacerbation and remission is similar to other chronic health conditions, such as diabetes and hypertension, which also involve patient behavior in how adherent they are to the lifestyle changes that are recommended. For example, patients with diabetes may choose not to adhere to the diet they were prescribed, may not take their medication as ordered, and may not show up consistently for appointments with their primary care provider. Similarly, patients with high blood pressure often do not lose weight or exercise as prescribed. It is not uncommon for patients with a variety of health conditions to be non-adherent to medical advice, yet health care professionals do not respond to them with the same level of disdain that is often directed at people with SUDs. Another example of how people with SUDs are singled out as different is that the term abuse is not applied to people with obesity to describe their relationship with food, but it has been used to describe someone with a relationship to substances.
Although some individuals may start using prescribed substances and develop a SUD and some may use substances to self-medicate, many people use substances because they like how they make them feel and for the thrill (NIDA, 2017). Dangerous thrill-seeking is not uncommon in society and takes place in other more acceptable forms such as skiing, mountain climbing, and car racing. When harm or injury occurs as a result of other thrill-seeking activities, the level of blame is not present as it is with SUDs. It is important to treat all patients equally, and not single out patients with SUDs as being different than patients with other chronic health disorders.
Negative Attitudes Toward People With SUDs
Stigma among health care professionals, including nurses, toward people with SUDs is well documented and a barrier to diagnosis, treatment, and recovery in patients with SUDs. Researchers who conducted a systematic review of stigma among health care professionals found that health care professionals have negative attitudes and beliefs toward patients with SUDs, including that people with SUDs are violent, manipulative, and lack motivation. Researchers also found that negative attitudes of health professionals are barriers to effective treatment for people with SUDs and lead to less personal engagement, diminished empathy, and suboptimal health care (Van Boekel et al., 2013).
Empathy and Perspective Taking
The role, meaning, and significance of empathy in health care is evolving. Empathy is the ability to share in the feelings of others, which then enables one to resonate with the other person's positive and negative feelings (Singer & Klimecki, 2014). Taking on the feelings of others, particularly in the field of mental health, can be draining. Researchers who conducted a review of studies on predictors of compassion fatigue in mental health professionals found that the more empathetic professionals were, the greater their level of compassion fatigue (Turgoose & Maddox, 2017). A problem with empathy is bias, which can be difficult to moderate. In one study, researchers found that less empathy was exhibited toward people who contracted HIV through substance use versus a blood transfusion (Decety, Echols, & Correll, 2010).
Although it may be assumed that nurses are empathetic to the experiences of all their patients, it has been established that being exposed to the pain of others does not always result in empathy (Chierchia & Singer, 2017). The expectation that nurses either show neutrality in their emotional response or have empathy and take on patient's feelings is likely unrealistic, and it could be particularly challenging when working with patients with SUDs due to the negative behaviors resulting from brain dysfunction.
Another common approach to working with challenging patients is the idea of perspective taking, whereby a person overcomes his/her own perspective by putting him/herself in the shoes of another to perceive a situation with greater understanding (Eyal, Steffel, & Epley, 2018). However, perspectives taken are often inaccurate. Researchers looked at 25 studies on understanding the mind of another and found that perspective taking did not increase one's ability to accurately understand the mind of another person compared with a control condition and that perspective taking actually led to decreased interpersonal accuracy (Eyal et al., 2018).
Thinking about compassion is evolving; it is seen as either building on empathy or as being different from empathy. Compassion can be described as a feeling of concern for another person's suffering, which includes feeling with the person and not for the person, accompanied by motivation to help (Singer & Klimecki, 2014). Compassion is also described as including a sense of warmth toward a person and a motivation to alleviate suffering (Chierchia & Singer, 2017). Compassion puts caring into action, with an emphasis on an effort to help change the person's situation (Singer & Klimecki, 2014).
In a qualitative study, researchers who interviewed patients with SUDs about what they need from providers found that patients reported wanting to be treated with care and valued providers who portrayed that they were deserving of care (Press, Zornberg, Geller, Carrese, & Fingerhood, 2016). In another study, patients were able to distinguish compassion from empathy from their health care providers and valued compassion over empathy (Sinclair et al., 2017).
A benefit of using compassion as a strategy with patients is that it can be learned. In a review of studies related to compassion training that included neuroimaging studies, researchers concluded that compassion can be trained and used to help cope with the distress that can be associated with empathy (Chierchia & Singer, 2017). One evidence-based strategy for developing compassion is through loving kindness mindfulness meditation, in which one directs positive thoughts, well-being, and kindness toward oneself or others (Chierchia & Singer, 2017; Germer & Barnhofer, 2017). There are several mobile applications as well as websites that include guided recordings to aid in this practice (Berkeley, University of California, 2019; Brach, 2019; Insight Timer, 2019).
A Therapeutic Relationship and Embracing Harm Reduction
Developing a therapeutic relationship is crucial and to do that nurses need to get to know patients and listen to their stories. According to interpersonal neurobiology concepts, positive brain changes occur through this relationship when the patient feels understood (Solomon & Siegel, 2017). It is important to hear about a person's journey with substances, both good and bad, and to respect and acknowledge that using substances is to some degree positive for people with SUDs.
Harm reduction is an approach to SUDs developed by Marlatt (1996) that can be described as a come-as-you-are approach in which patients are met at the place they are at in their substance use or recovery. Any steps taken in the right direction are valued and accepted, and stopping use completely is not automatically expected or demanded (Worley, 2019). An effective communication approach used with harm reduction is motivational interviewing (MI), which encompasses several strategies, including a nonjudgmental communication approach that focuses on the client's determination to change (Logan & Marlatt, 2010). Although there have been some conflicting studies on effectiveness, there is evidence that MI works to help people change behavior (Lundahl, Kunz, Brownell, Tollefson & Burke, 2010).
Lecturing patients on the facts about harmful effects of using substances and telling them to stop using is not effective, just as this approach does not work with smoking cessation or diet modification. People with SUDs already have extensive and sophisticated knowledge about substances and their effects. One effective MI strategy to facilitate change is to ask what is good about their substance use and then what is not good about it with the goal of guiding patients to self-identify what is causing problems in their lives and then guiding them to decide what they want to change. The readiness-to-change ruler strategy can be used in which patients are asked on a scale of 1 to 10, as on a ruler, how willing they are to cut back or change, ideally using an actual ruler, which can be obtained online (Case Western Reserve University, 2011). Whatever number they give, they are then asked why the number was not lower, or why they are not even less motivated to change, which prompts patients to provide the reasons they want to change. There are numerous other MI strategies to use with people who have SUDs and video examples are readily available online (Boston University School of Public Health, n.d.; SAMHSA, 2013).
Shared Decision Making
When working with patients with SUDs, a collaborative or shared decision making approach is useful. This approach involves clinicians and patients working together to make decisions and treatment plans based on clinical evidence that balances risks and outcomes with patient preferences and values (National Learning Consortium, 2013). When patients with mental health disorders are involved in making decisions about their care via shared decision making, they are more satisfied with their care and more likely to stick to treatment plans (Slade, 2017). Results of a meta-analysis on shared decision making showed that it is beneficial for health care providers to attend to consumers' interest in involvement in actual treatment decisions within the context of a strong therapeutic relationship (Klingaman et al., 2015).
Treatment of Co-Occurring Disorders
Having a SUD along with another mental health disorder such as depression occurs in approximately 50% of patients (NIDA, 2018c). When these disorders go undiagnosed and untreated, patients turn to self-medicating with substances. Posttraumatic stress disorder (PTSD) is a common co-occurring disorder in people with SUDs, which is known to be a barrier to recovery (SAMHSA, 2014). Many people with SUDs have a history of trauma and having a SUD is related to developing trauma because people are exposed to dangerous situations as part of their use of substances (SAMHSA, 2014). The effect of trauma on the brain is similar to using substances in that it impairs executive brain functioning, decision making, and emotions (Cohut, 2017). In addition, memories play a significant role in SUDs and PTSD, which cause hyper-reactivity; therefore, trauma-focused care principles are an important strategy when working with patients with SUDs (Gisquet-Verrier & Le Dorze, 2019).
SUDs are challenging mental health disorders due to high mortality and exacerbation rates. Barriers to providing effective care include lack of knowledge of the neurobiology of addiction and evidence-based strategies for care. In addition, stigma from health care providers is a long-standing barrier to effective care. Although empathy and perspective taking were once thought to be useful, current thinking is showing that compassion, which involves care and concern with the additional component of taking action to help another person, can be learned and is a more effective approach. Developing a therapeutic relationship, embracing harm reduction, including MI, and shared decision making are also strategies that have been shown to be effective. Identification and treatment of co-occurring disorders is also crucial when providing care for patients with SUDs.
When working with patients with SUDs, a variety of effective strategies should be used, as there is no one universal approach that will be effective with all patients.
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