Addressing issues related to addictive behaviors and diagnoses
Substance use disorders (SUDs) are considered chronic health conditions with a relapse or exacerbation rate of approximately 50%, which is similar to other chronic disorders such as diabetes, asthma, and hypertension (National Institute on Drug Abuse [NIDA], 2018a). SUDs are considered a disease related to a dysfunction in dopamine levels. When substances are taken, they dramatically increase dopamine levels. After time, the brain responds by reducing the amount of dopamine produced and absorbed in an effort to maintain homeostasis (NIDA, 2018a). Therefore, people with SUDs have low dopamine levels in key brain regions, which results in an impairment in brain functioning with resultant symptoms including poor decision making and oppositional behavior (NIDA, 2018a). Normalizing this chemical imbalance to other chronic health disorders is helpful to reduce stigma, guilt, shame, and anger. For example, asthma is a chemical imbalance in the lungs that causes coughing and wheezing, and, in SUDs, there is a chemical imbalance in the brain that causes poor decision making and recklessness.
It is important to remember that recovery from SUDs is possible (NIDA, 2018b). Many experts agree that a person can be considered to be recovered from SUDs after 5 years of not using a substance, because after 5 years the relapse/exacerbation rates decrease significantly (White, 2005; Worley, 2017). There are evidence-based, nonpharmacological therapy strategies that work to treat SUDs. Nurses are in a prime position to either implement or recommend therapy strategies for SUDs. Although most nurses are not therapists, simple strategies from therapy models can and should be used by nurses when working with patients with SUDs. Nurses should also advocate for patients by educating them about therapy models and referring patients to therapists or advanced practice nurses (APNs) with expertise in these therapy models. In addition, psychiatric nurses are often able to get training and certification in these therapy models, which can further prepare them to implement these interventions.
Cognitive-behavioral therapy (CBT) focuses on how thoughts affect behavior, which, in turn, impacts emotions (Beck Institute, 2019b). Evidence-based CBT strategies to combat SUDs include learning how to delay and distract cravings by engaging in constructive activities, journaling, communicating with supportive others, going to meetings, and other positive means by which to ride out the wave of craving until it subsides. In CBT, there is a focus on identifying negative thinking and getting into the habit of thinking and writing more effective responses. For example, patients learn to spot the thought of thinking they have not used in 90 days, so they deserve a little holiday and to replace it with a thought such as thinking what they really deserve is to keep their sobriety streak alive to support recovery one day at a time and to stop trying to be fooled into believing drug thinking thoughts (Beck Institute, 2019a).
Other CBT strategies include exploring the positive and negative consequences of continued drug use, recognizing cravings early, identifying situations that might put one at risk for use, and developing strategies for coping with cravings and avoiding those high-risk situations. These strategies include planning how to turn down offers to use substances, such as by responding and saying no thanks, I'll just have a ginger ale, doctor's orders (NIDA, 2018c; National Association for Alcoholism and Drug Abuse Counselors [NAADAC], 2017). In addition, there is a focus on learning how to solve problems rather than using substances to try to cope with problems, which only serves to worsen the problem (NAADAC, 2017). Patients are encouraged to practice behaviors and attitudes of self-respect, including counteracting beliefs that otherwise undermine oneself and lead to helplessness and hopelessness. An example of these behaviors and attitudes is thoughts of being a bad person and having messed up in life as reasons to keep using substances (Beck Institute, 2019a).
In addition, in CBT, there is a focus on interacting with healthy social support, such as peer support groups, engaging with friends and family who support sobriety, and staying away from those who would undermine therapeutic goals. There is an emphasis on healthy lifestyle changes that support sobriety and self-efficacy, including having a healthy daily routine, refraining from cursing and raging, engaging in meaningful hobbies, doing things that promote spirituality and serenity (e.g., yoga), and daily exercise. Exercise is important because it naturally increases dopamine levels, which results in a general positive feeling (Beck Institute, 2019a).
Acceptance and Commitment Therapy
Acceptance and commitment therapy (ACT) is an evidence-based therapy model that includes strategies of detaching from inner experiences by relating to them differently; learning how to accept thoughts and feelings without trying to change their form or frequency; mindfulness to stay in the present moment; self-understanding to let go of concrete and inflexible thoughts or ideas about oneself; learning what is important to oneself in regard to values; and committed action and empowerment for behavioral change (Lee et al., 2015; NAADAC, 2017). ACT principles emphasize that life involves a polarization between choosing to escape feelings and moving toward suffering versus accepting feelings and moving toward values (NAADAC, 2017). For people with SUDs, strategies include encouragement to open up and consider the fact that they are stuck to ideas, people, and substances and to move toward being more flexible and getting unstuck from self-invalidation. Addiction is seen as self-invalidation, which leads to emptiness and a need to escape the emptiness by using substances, which only results in greater suffering. ACT fills a role in preventing relapse by providing a framework for individuals to understand that escape from one's feelings leads to suffering and substance use (NAADAC, 2017).
Specific strategies include having patients identify the most bothersome feelings that they experience regularly and then have them identify where in their body they actually feel the feeling and to describe that feeling and how they handle it. A “beach ball” analogy can help understand the feeling: If you push down a beach ball, it uses your energy to push itself back up. On the other hand, one has the choice of letting the ball float around without adding any energy. Therefore, as with negative and bothersome feelings, if you do not struggle or try to push or control them, you do not have to give them energy (NAADAC, 2017). Another strategy is Tobias Lundgren's bull's eye (Dahl, 2015; NAADAC, 2017), in which people identify their values and then graph how closely their behavior matches their values. The difference between behavior and values is thought to be representative of the amount of suffering experienced and the unease in trying to escape it (Dahl, 2015; NAADAC, 2017).
Mindfulness-based interventions (MBI) can be used to train individuals to be present in the moment with purpose in a nonjudgmental way (Shapero et al., 2018). A goal of mindfulness is to improve self-regulation of attention to the present moment while maintaining openness and acceptance to respond to distressing thoughts and emotions in a nonjudgmental way (Shapero et al., 2018). Mindfulness has been shown to have a significant positive impact on the brain, including decreasing the size and activity of the amygdala, which is the worry and anxiety center of the brain, and by causing prefrontal cortex thickening and greater activity in the prefrontal cortex, anterior cingulate, and insular cortex (Garland & Howard, 2018). There are many MBIs, including concentrating on a sensory object (often the sensation of breathing or other bodily sensations or an image) while one acknowledges and then disengages from distracting thoughts and emotions or open monitoring by which a metacognitive state of awareness is achieved that involves monitoring the content of consciousness while reflecting back on the process or quality of consciousness itself. MBIs are thought to reduce emotional reactivity (Shapero et al., 2018).
MBIs are evidence-based strategies to reduce cravings for substance use and relapse by modulating cognitive, affective, and psychophysiological processes integral to self-regulation and reward processing and by targeting techniques that address addictive behaviors (Grant et al., 2017). One example is the chocolate exercise—an experiential mindfulness practice designed to increase awareness of cravings. In this exercise, patients hold a piece of chocolate close to their nose and lips and become mindful of the arousal of craving as they refrain from eating the chocolate. A comparison is then made between the urge to swallow the chocolate and craving for substances. Patients are then guided to focus on how the senses, thoughts, and feelings about the chocolate subside over time. Other MBI strategies include mindful breathing, body scan meditations, as well as stopping to breathe and imagining future consequences, and then making choices. Another exercise is to have patients visualize the last time they used substances and focus on the scene; where it is, what friends are there, and then think of themselves stopping what they are doing physically, taking a breath, imagining the possible consequences of their actions, and then choosing what to do next (NAADAC, 2017).
Dialectical Behavioral Therapy
Dialectical behavioral therapy (DBT) includes evidence-based strategies that help patients with SUDs learn several skills that can be effective in reducing or stopping substance use, including mindfulness, distress tolerance, interpersonal effectiveness, and emotional regulation (Stotts & Northrup, 2015). In DBT, patients are encouraged to seek environments and peer groups that discourage substance use; remove triggers, such as drug paraphernalia or unhealthy relationships from their daily lives; remove social and environmental triggers for drug use, such as people, places, or events; and bolster self-esteem and confidence to help them stay sober through stressful periods (NAADAC, 2017). Emotional regulation skills are emphasized, which help patients decrease vulnerability to painful emotions and change emotions they want to change, including dysfunctional emotional triggers for substance use, and to reduce self-medication with substances to manage emotions. In addition, relationships are a focus because in SUDs, substances take a priority above almost everything else. In DBT, patients learn to ask others for what they need and to say no while maintaining self-respect in their relationships with others. DBT also focuses on distress tolerance, which helps patients stay in the moment, tolerate pain in difficult situations, and not exhaust themselves by fighting to change things (University of Washington, 2019).
Contingency management is another strategy in DBT, such as identifying people, places, and activities that can reinforce non-substance-use behavior, which is seen as a reward. Patients are also encouraged to burn bridges and build new ones when indicated by identifying people, places, and activities that trigger substance use and get rid of them and learn strategies to manage cravings. Other DBT strategies include alternative rebellion, whereby patients are encouraged to find alternative ways to rebel if drug use functions as a way for them to rebel against society, and adaptive denial, whereby cravings and urges to use are denied by telling oneself instead that one is craving something benign, like lemonade or a bubble bath (NAADAC, 2017).
Eye Movement Desensitization Reprocessing
Eye movement desensitization reprocessing (EMDR), developed by Francine Shapiro, a therapist with a background in hypnosis (EMDR Institute, 2019a), is based on an adaptive information processing (AIP) model. The AIP model predicts that dysfunctionally stored and unprocessed memories are the cause of a number of mental disorders, including posttraumatic stress disorder (PTSD), mood disorders, chronic pain, eating disorders, addiction, and various others (Hase et al., 2017). EMDR can only be performed by psychiatric nurses or therapists with training. Evidence for EMDR for a variety of mental health conditions, including trauma, depression, eating disorders, and addiction, is overwhelmingly positive (EMDR Institute, 2019b; Valiente-Gómez et al., 2017). EMDR stimulates stagnant unprocessed information through dual attention by eye movement, tapping, or sound, and promotes balance in processing that information by forming more functional memory networks, leading to a more adaptive response and reaction. EMDR uses bilateral stimulation so that both the left, logical side of the brain and the right, emotional side of the brain process the memory and create new neural pathways for coping (EMDR Institute, 2019b). Trauma and PTSD commonly co-occur in people with SUDs, and this combination is considered a barrier to recovery (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). People with SUDs also have higher rates of experiencing trauma because they are exposed to dangerous situations as part of their use of substances (SAMHSA, 2014). The effect of trauma in the brain is similar to using substances in that it impairs executive brain functioning, decision making, and emotions and leads to disturbing memories that cause hyper-reactivity (Gisquet-Verrier & Le Dorze, 2019). Therefore, trauma-focused care principles are an important strategy when working with patients with SUDs. Specific EMDR protocols have been developed for SUDs, including the feeling state addiction protocol (FSAP) by Miller (2011), which is based on the theory that addictions are created when positive feelings become linked with specific objects or behaviors, which then need to be reset. The desensitization of triggers and urge reprocessing (DeTUR) protocol by Popky (n.d.) focuses on targeting triggers, thereby lowering the level of urge to use as a response to the triggers. The CRAVEx protocol targets addiction memories and the level of urge to use substances (Carletto et al., 2018), and the level of positive affect (LOPA) protocol addresses avoidance in treatment and unrealistic positive investment in destructive behavior (Markus & Hornsveld, 2017). Nurses can offer support to patients with SUDs by referring them to an EMDR therapist or nurse to help them in their recovery journey. EMDR therapists can be found through a search at http://www.emdr.com/SEARCH/index.php or other search engines.
Several evidence-based therapy models are available for SUDs. Simple strategies within the therapy models can be used by nurses when working with patients with SUDs. In addition, nurses can function as advocates for patients when they gain an understanding of therapy models and strategies and provide this education to patients and refer them to therapists or APNs who having training and expertise in providing care for people with SUDs. Nurses should adopt a positive, hopeful attitude and belief that there are effective treatments for SUDs and that recovery is possible. Patients with SUDs should be offered and receive evidence-based care that includes nonpharmacological therapy approaches.
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