Nursing Against Stigma

Intuition whispers goals and dreams. Such a lovely sentiment, and one that describes the center of a passionate belief. A belief that may or may not blossom into change. For me, that change has been reflected only in my personal nursing career. My disappointment is that I haven't known how to take this belief out of my personal career. I believe it is an idea that could affect nurses in their comfort and ability to do their jobs.

Missing from my career is the development of this principle in a much deeper sense. My career was born in hospitals where I continued for twenty years. I floated from unit to unit, hospital to hospital. Besides illness, recovery and death there was one condition becoming increasingly obvious. Active addiction. Alcohol. Prescription drugs. Illicit drugs. And many, many combinations. For the last 19 years I have worked in detox facilities in the critical area of withdrawal management. The beginning of recovery.

Now, towards the end of my career, that intuitive thought - that kernel of an idea - has never gone away. My belief has never diminished. Those with alcoholism are living longer, yet with more severe medical effects. Those with drug addiction are susceptible to more and more powerful drugs. More simply, anyone - any age - any gender - any economic bracket - anyone affected at even the lowest levels by drugs and/or alcohol will be in the care of a nurse. Nurses in any area of our health care systems, focused on the individual, their needs and their abilities, can support that very important part of recovery. The beginning. Just as we support the recovery of those with heart conditions, cancer, diabetes and epilepsy - other ‘socially acceptable’ conditions and diseases. 

Nurses have replaced their stethoscopes and manual blood pressure machines with digital up to date machines that record more than just blood pressure. Today, to the best of my ability, I practice my patient care with the intuitive belief residing in my heart that nurses, and the education about basic health they provide in times of illness, are an incredibly important key for addictions care.

“Reality is that which, when you stop believing in it, doesn’t go away.”

~ Philip K. Dick, I Hope I Shall Arrive Soon

Crisis of Care

In 1966, I stood in a linen closet crying because I was just too scared to do a bed bath…..on a man….kind of old - probably about 40. That was the crisis I had to deal with. 

Telling my dad that I was quitting nursing was the alternative. Just over twenty years later, there was another critical point in my nursing career. Yes, I continued in nursing. That crisis was on a medical unit in Regina. I wanted to know how, with nursing process, to care for patients in alcohol withdrawal. So I moved to Texas. There was no nursing education specific to alcoholism, however I did get experience in a treatment center. Nurses were in treatment centers, not hospitals. And yet, alcoholics and those with drug addiction frequently require medical care for the medical effects of alcoholism and/or drug addiction.

Today, there is another crisis in the world of nursing. In the world of health care workers at any level.  On the streets, in the ambulances, in emergency rooms. Fentanyl, prescription opiate and illicit opiate abuse. I’m not sensationalizing when I say the people are dying out there. Withdrawal management, better known as detox, is alive and well whether in hospitals or detox facilities. I have told many patients over these last many years that I will take care of them as many times as is needed. I have told them that relapse is not a shame but part of the process of addiction. This brings me to the next crisis in the world of active addiction. It has become so much bigger than that first bed bath. And it really is not my crisis.

We, within health care, have the knowledge, tools and abilities to treat the medical effects of this dreadful condition that spirals into so many other medical conditions. We are saving lives…..over and over again. For those that still have loving families, employment and community support systems there is some hope. Hope that a new life, a good life, is a possibility. And then there are those whose bridges have all been burned or are at least severely damaged. Those that are homeless, jobless, with no family. And yet we save lives.

I am reminded of Ebenezer Scrooge when he relegates them to ‘work houses and prisons’ and ‘if they would rather die then let them’. Is that where we are now? And yet we still ‘save lives’. And where do these lives go? The ones that are homeless, jobless, and with no family. Has society even thought about the personal addiction treatment that is needed alongside valuable medical management? In five decades, my limited view of how we have progressed past the stigma, to identify the chronicity of this condition, is that we are still blinded by the brilliance of controlling substances. We seem to have completely forgotten the individuals, the families that have been devastated by the conditions of alcoholism and addiction. 

To begin to mend this crisis, treatment centers, outpatient clinics and more importantly affordable homes are required. Housing and funding. For those that have housing, their ability to maintain clean and sober time increases, the quality of recovery is improved. Is this an easy task? No. It will require a complete restructuring of our attitudes and our ways of thinking in our increasingly complex system of health care.

“Sometimes you need a little crisis to get your adrenaline 

flowing and help you realize your potential.”

~ Jeannette Walls, The Glass Castle

HOPE: My Definition ~ HOPE ~ Theme for December 2016

In the last month, both in Canada and in the United States there have been political changes that have unbalanced the worlds of many people. The details are political, environmental, cultural and ultimately about territory and the almighty dollar. Personally, my nursing career, spanning  several decades, is in nursing individuals through substance withdrawal. Many of them have burned most of their personal bridges, homes, employment and thus the money to pay their bills. Many have severe medical effects of alcohol and other substances. And yet whether activist on a grand scale or taking care of one person at a time, we each still have hope that there will be a brighter day. Hope that just by taking one more step, one more time, we will be able to facilitate change in life circumstances. It would have been too easy for me to choose Christmas for this December theme when I see hope all around me. Stubborn hope, persistant hope, in the face of barriers that seem insurmountable. So here is my definition of HOPE.

Hints about belief
Open to new directions
Perfectly willing
Enthusiastic about each moment

“There is a crack in everything. That’s how the light gets in.”

~ Leonard Cohen, (Selected Poems, 1956-1968)

Challenging Belief - Essay

I was challenged today to write about an experience that had changed my way of thinking. I flipped through a few decades of memories. So many things to review. There was one experience, or I should say, a set of experiences that came to the fore. These experiences changed the way that I saw addiction within family life, within my nursing career and within my community. None are ‘most important’. But it was my experience as a nurse caring for a patient in the late 1980’s that really shifted my thinking.

I do not remember her name, but I do remember the situation. This tiny, frail woman with fine white hair was one hundred years old. She was one of the patient’s assigned to my care in a general hospital in Saskatchewan. She was psychotic, extremely agitated and so unmanageable she required physical restraints at her ankles and wrists. I’m certain I had taken care of patients in alcohol withdrawal before, but none as dramatic as this woman. 

I had recently been interested in alcoholism and it’s social and family effects, but had not seen such dramatic medical effects until looking after this frail elderly lady. She did not die, she did not get particularly ill. In fact within days was up and was discharged home to her sons. Her twin sons, both mentally challenged and in their 60's, were still in her care. Was there contact with social work? That I do not recall. The physician, Dr. Saul Cohen, a family practioner in Regina, had established a medical regime that treated the symptoms of alcohol withdrawal. He also ran certain blood tests to confirm any medical issues resulting from alcohol abuse. Medically there was protocol and a quasi specialty. But for nursing, I realized there was no preplanned care plan providing specific care for the medical effects of active alcoholism - either withdrawal management or follow up discharge planning.

Although small bits of information had been coming to me about this condition, my thinking changed with this elderly woman and the wonderful physician who treated her. A workshop that he provided the staff opened my budding ideas even more. My own resistance to stigma so obvious at that time created the environment for me to continue in the field of addictions - specifically withdrawal management. I had seen, at the bedside, the neurological effects and the incredible changes wrought by alcohol.

“Do not think that what your thoughts dwell on 

does not matter. Your thoughts are making you.”

 ~ Bishop Steere (from Overcoming Addiction)

Author's note: Edited January 31, 2024

Failure to Recognize

Not a good way to begin the month of June.
Anger and huge frustration about addictions health care
And I do use those three words with great caution
The health care of patients and clients on the frontlines
The health of health care workers on the frontlines

I have devoted the last several decades to this work
I also became aware of the neurobiology of addiction
Always expecting that the bizarre behaviours of our clients
will be seen as a symptom,
that the approaches taken 
in nursing, in social work and in medicine 
and in health care systems will be developed;
that brain trauma of any kind changes an individual’s behaviour,
and such behaviour can be unpredictable and extremely dangerous  to any of us on the front lines charged with the individual's care.

Am I angry about the uncontrolled behaviour of a client with severe brain trauma?
Organic, substance affected, mental illness, in withdrawal or all of the above?
And did I mention anything else ~ oh say like poor nutrition, poverty, ……
Or angry about the systems that appear to continue utilizing ineffective models of care?
And did I mention under-funding and under-educating systems that are in place?

I think that’s enough venting for now.
I won’t stop working for and caring for these clients, these patients ~ my fellow human beings.

“Compassion is all inclusive. Compassion knows no boundaries. Compassion comes with awareness, and awareness breaks all narrow territories.”

~ Amit Ray, Nonviolence: The Transforming Power

Final Day of Addictions Nurses Conference

A much shorter day of speakers today. I am writing this on the bus returning us from Biltmore Estate where we have spent the afternoon. (The bus has wifi so hopefully I'll get this posted before returning to the hotel).

The final two sessions were presented by the same speaker.

08:40am
The Opioid Problem
Stephen Wyatt, DO, Medical Director Behavioural Health Services, Carolinas HealthCare System

Much of this session was similar to previous sessions about the seriousness and the wide spread nature of the use and abuse of opioids. While much blame has been put on physicians for over prescribing, and while much of this is also an issue, the blame needs to be shared.  The other area of blame or fault is placed at the feet of those individuals who are drug addicted. This speaker, a physician of many years, who has worked long term in various areas of medicine and osteopathy, provided us with two main issues related to The Opioid Problem. One statistic is that 55% of overdoses have resulted from family and friends sharing medication that should have been discarded.  The other issue is the nature of pain and the vicious circle of uncontrolled pain:  pain - avoidance - decreased mobility - altered functional status - diminished self efficacy - social limitations - pain. This is enhanced if opioids are over used because pain has not been accurately and effectively assessed, provided with appropriate treatments or if patient's do not understand the nature of this drug.

10:40am
Integration of Addiction Medicine in Primary Care
Stephen Wyatt, DO, Medical Director Behavioural Health Services, Carolinas HealthCare System

After a short break, Dr. Wyatt spoke about a critical change in the primary and medical care community for addictions care. That being, alcoholism and drug addiction being treated as any other chronic disease is treated. It i in fact a chronic brain disease. This would include accurate assessment, recommended treatment of a multimodal nature by the physician that include followup review and discussion of the patient's progress. Much to my pleasure he used an analogy that many of in addictions nursing have used for years:  If a patient with diabetes doesn't follow the regimen prescribed, he or she is not punished and care withheld. There is followup to determine how to help this patient.

There was one other session and I believe it was between these two. Now understand, my brain is kind of on overload, so the exact time I'm not certain. However we had an opportunity to sit with different board members to discuss different areas of the organization. I sat at the table with Stephen Strobbe, our president elect, to discuss position papers. He outlined what they are and his ideas for the upcoming year.

Then it was off to the Biltmore Estate. An amazing piece of architecture and forward thinking of George W. Vanderbilt in Asheville, North Carolina. Furniture, immense wall tapestries, a winter garden indoors,  a heated swimming pool and gymnasium. A vast library. A billiard room and bachelors quarters. An entire floor for guests. Huge kitchens and walk in refrigeration. Separate and beautifully appointed bedrooms and quarters for Mrs Vanderbilt and for any female guests (Even separate change rooms in the pool area.) This all in the early 1900's.

"There is no real ending. There's just the place where you stop the story."

~ Frank Herber

Day Three of the Addictions Nurses Conference

Another full day with a twist!

0805- 0935
This morning's keynote address provided me with some answers to a question I've been asking for several years:
Craving:  Etiology, Epidemiology, Management. The presenter was Omar Manejwala, MD, DFAPA of Manejwala Consulting.  Craving is a phenomenon of addiction to drugs or alcohol that has long puzzled me. Having researched this topic, and not finding a definitive written work on craving, this speaker has written his own book Craving  Why We Can't Seem to Get Enough. Most importantly to my mind, cravings are temporary and not as frequent as many of us would believe.

0945
Then the twist:  I was given the opportunity to share my beliefs and opinions about the geriatric population and addiction in an interview. The interview was conducted out by the pool in cushioned shaded comfort. A Board member doing a project for educational purposes, is interviewing several of us about this topic. I should have more information in a few months about this recorded interview.

I had a few minutes to be able to catch the last ten minutes of
Biopsychosocial-spiritual Management for Persons with Coexisting Pain and Substance Use Disorders presented by Deborah Matteliano, PhD, FNP, ANCC Certified in Pain Management; University of Buffalo
(She and I had had supper together last night - a new friend and colleague)

Before lunch the next presentation was:
11:10 - 12:10
SBIRT Plus Recovery Management (SBIRT + RM) Enhanced Model for Substance Use Disorder Interventions within Primary Care Settings
Katherine Fornilli, MPH, RN, CARN, University of Maryland School of Nursing

Don't you just love the acronyms! Assessments of our clients for referral to treatment centers and followup care are sparse and require a slightly different focus. This speaker has designed such an assessment process to provide improved followup. A new development, this will soon be tested in the speaker's area.

Luncheon from 12:30p to 1:30pm was another 'working' lunch and the Annual Business Meeting of the International Nurses Society on Addictions. As with all business meetings, committee reports, financial statements and goals were discussed. The largest conference in our history many new members were welcomed - more from Canada! And while a small organization, we are slowly expanding globally in the U.K., Europe, Australia and New Zealand.

1:35pm - 2:35pm was another Keynote Address:
Developmental Model of Recovery
Tammy Bell, LCSW, MSW, MAD
I thoroughly enjoyed this speaker. She opened by telling us what her position is on substance abuse treatment - abstinence based, having worked with Father Joseph Martin who did Chalk Talks for the U.S. military many years ago. Her other influence was Terence Gorski who has written and spoken about The Post Acute Withdrawal Syndrome.  Both of these people are part of my own initiation into Addictions care.

2:40pm - 3:40 pm
NADA Ear Acupuncture Protocol: Opportunities and Challenges for Integrating In Addiction Treatment
Michelle Olshan-Perimutter, PMHCNS-BC, FNP-BC; Carolinas Healthcare System
The NADA protocol is practiced at Victoria Detox, my day job, Monday to Friday. This speaker would love to see nurses able to freely practice this low cost and effective modality, however there is variable responses to this practice. This was also another brush with my past as she mentioned Dr. Libby Stuyt, another of my early influences and a mentor in my journey into the field of  addictions nursing.

4:10pm-5:10pm
Harm Reduction: Differing Points of View
Bonnie Franckowiak, DNP, FNP-BC, CARN-AP
From abstinence based treatment now to harm reduction I have come full circle. This speaker, who shared that her experience was initially abstinence based, defined harm reduction and spoke of the need for this care for many clients. Our small group enjoyed good discussion about the pros and cons of these diametrically opposed theories. The nub is that alcoholism and addiction, defined as achronic relapsing diseases, should be treated like any other chronic disease, the most common example being diabetes. Rather than a punitive rigid approach, harm reduction provides a more humane approach to the individuals in our care.

To change the tone of another long and satisfying day, I took a short walk in the warm dry afternoon. In the park across the street, a lovely young couple were being photographed. She in a creamy soft sari, he in a maroon tunic. Geese floated calmly on the still pond.  Mowers were trimming and a worker with a leaf blower was cleaning sidewalks and corners. Traffic moved steadily and busily in front of my hotel.

After a lovely evening meal of gnocchi, apples, squash and garlic mushrooms I returned to my room. Although not able to visit my brother Larry in person, we talked for almost an hour on the phone.  Skype is a blessing!

"What we find changes who we become."

~ Peter Morville

Ordinary

Ordinary

Ordinary. It was just the very ordinary look of her face, her hairstyle, the way she walked. Well maybe not her walk. Her shoulder’s bowed, she didn’t quite shuffle but walked stiffly, head down and even from the back she looked beaten and sad. Even her name was ordinary. Jane. Not Jane Doe at least, but Jane Brown. An ordinary Jane. Sad and yet hopeful. So very hopeful. It was her daughter who called to her. Not literally, but in her look when she saw her mother ‘in her cups’ again, or trembling so badly she couldn’t even hold her cup of coffee to her lips. The pained and worried look on her husband’s face. Her own mother’s set jaw to see her daughter sliding far too quickly down a slippery, rocky slope. And there was the new grandchild to be born. Her son and daughter kept hinting that as long as she was not ‘clean and sober’ - how she hated that phrase - she would be unable to see her first grandchild.

This was her second, or was it her third, attempt to find sanity and purpose in sobriety. It didn’t matter. She was going to stop this time and for good. She didn’t really have much of a plan, but she had a team of people supporting her, and friends that would be honest with her, take her by the hand and lead her carefully over the rocks. Jane Brown wanted to answer her family’s call - and the call of her own heart. Jane wanted to belong again, to live again. As she walked away from me, I saw her straighten, her head up and her step become stronger.

“The things you do for yourself are gone when you are gone, 

but the things you do for others remain as your legacy.”

~ Kalu Ndukwe Kalu

Stepping Out ~ 2

Stepping Out ~ 2

Light seeped thinly from the kitchen under the old wooden door into the level basement. Under a faded and fringed shade yellowed light pooled around his old green reading chair. In that overstuffed chair, he buried himself in travels through fiction and non-fiction. The written word was the only thing that interested him anymore. That the wide and deep basement was not completely finished was of no matter. Richard Gladstone decided that the morning mirror he had seen himself in had lied. His  mood only supported the lies. His beliefs about the ouside world and his family were more opinions than beliefs. Richard had thought them so long that they had taken on the patina of belief. And all of it coloured his attitudes. Richard shook his head slowly as these thoughts layered themselves over the words he was reading. Laying his book aside, he shook both head and hands violently flinging heavy drops of sticky emotion away from him, leaving them on the dusty carpet at his feet.

“What are you going to do!?” his muttered whisper dissolved into the darkness outside of the pool of lights. 

His attitudes were as thin and brittle as his posture. To bend them may be dangerous. On the other hand, his choice to remain seated, reading and ‘testing’ the wines now seemed barely comfortable. Books often slipped noiselessly out of his hands to the floor by the end of any evening.

He rose stiffly and walked toward the side door leading outside. Richard had no use for A.A., any part of it. And he had no use any longer for alcohol - only that there was a malicious craving that he couldn’t explain to anyone. And if Richard tried, eyes glazed over and conversation turned to gossip, weather, politics - anything else. His cell phone rang - a fragile electronic connection to the outside world. He hesitated to answer, but courtesy got the best of him.

‘Coffee? In fifteen minutes? Good, I’ll see you at The Coffee Barn in fifteen.’ 

His decision made, Richard stepped through the door into the open night.

“Courage doesn’t happen when you have all the answers. It happens when 

you are ready to face the questions you have been avoiding your whole life.”

~ Shannon L. Adler

A Calling

Addicts

Alcoholics

Recovered ~ a word with high and hurry up expectations  ~ recovered from what?

bad, sometimes criminal, substance induced behaviour?

emotional distortions also substance induced?

Assumption: their fault ~ 

so, ineffectively throw rotten tomatoes and hurl invectives!

a better choice is calling those folks to be accountable ~

when they are ~  and many, many answer the call to accountability ~ they become invisible

brushing by on the street,

reception and greeting in offices and businesses,

giving medical and nursing care

local grocer or butcher.......the list goes on....and on.....and on.......

“It is wrong and immoral to seek to escape the consequences of one’s acts.”

~ Mahatma Gandhi