Nursing in Addictions Services
Konrad, Sandra
Registered nurses (RNs) who work in addictions services are integral to the treatment people receive as they try to break free from the harmful effects of alcohol and drugs. They care for clients with single addictions, dual and even poly-addictions to illicit and pharmaceutical drugs, and addictions coupled with mental illness in a challenging and ever-changing practice. Practice settings include detoxification centres, residential treatment settings and opiate dependency programs. “While clients are in treatment, we teach the physical aspects of chemical dependency, the body in recovery, and is much health promotion as possible,” says Janice Bonsant, who worked for more than 30 years in addictions nursing.
In 1974, Bonsant thought she would try something new and accepted a position at the Alberta Alcohol and Drug Abuse Commission’s (AADAC) detoxification centre in Edmonton. Her idea was to “try it for a year.” RN skills were being introduced to detoxification, which was becoming an increasingly important phase of treatment. Detoxification is the management of physical withdrawal from a drug of dependence to minimize associated risks.
Bonsant worked at the “detox” centre for nine years before she moved to the Henwood Treatment Centre, a 72-bed residential treatment centre in northeast Edmonton providing intensive treatment for adults with serious alcohol or drug problems. Five years ago, she retired from her position as supervisor of health services and took on a casual position at the centre. This summer, she closed the door on a 30-year career in addictions treatment, a career that has been challenging, ever changing and satisfying.
When Bonsant started her practice in the early 1970’s, alcohol was the primary substance of abuse while a few clients were admitted for heroine and cocaine addictions. Today, RNs care for clients who may be addicted to pharmaceutical drugs that include designer or club drugs such as ecstasy and GHB (gamma hydroxybutyrate), cocaine, amphetamines and more recently, Oxycontin, a painkiller for chronic pain sufferers.
Detox
Operating with lengthy standing orders, RNs supervise treatment for physiological withdrawal in detoxification centres, a common entry point for treatment. RNs apply their extensive knowledge of medications to manage and medicate withdrawal, a process that lasts an average of five days. Monitoring the somewhat predictable detoxification pattetn and outcome, they use keen assessment skills to identify liver, heart, kidney, and skin diseases and a wide range of mental health problems while supervising client care assistants. Identification of complications from addiction-related illnesses such as acute pancreatitis may require RNs to refer clients for further medical assessment and admission to hospital.
“Well-developed assessment, organizational and supervisoty skills are a must,” says RN Sheila Rissling, the adult treatment supervisor at the AADAC Recovery Centre in Edmonton. The Recovery Centre is a 24-hour residential detoxification unit for individuals who are experiencing withdrawal from alcohol or other drugs. According to nurse position descriptions posted on AADAC’s website, RNs operate in a team environment and are responsible for direct client care including client intake/ assessment, observation, case management, medication administration and evaluation, as well as some supervision, coaching and support to other staff. RNs work in partnership with a host of professional disciplines and organizations including addictions counsellors, social workers, doctors, psychiatrists, the Alberta Mental Health Board, regional health authorities, families, 12-step groups, and residential treatment programs.
The work is fast-paced and crisis-oriented. Rissling credits a well-trained staff, a strong team and personal self-care for her ability to mnnnge it all. RNs also need strong interpersonal skills to provide clients with the support they need in a safe environment. At this critical juncture in clients’ lives, emotions are volatile and interpersonal dynamics can be intense. Clients experiencing crises and the health consequences of addiction must be stabilized physically and mentally before they move from detoxification to residential treatment.
Residential Treatment Programs
RNs in residential treatment programs support clients while they undergo psychotherapeutic treatment to learn how to maintain abstinence. The team of RNs and registered psychiatric nurses assess all applications and screen for conditions that can derail the three-week treatment process-the use or abuse of prescription drugs and untreated medical and mental health concerns. Follow-up care includes patient education or counselling and RNs may refer clients for other additional health-care services.
Clients in residential treatment often suffer from a host of medical concerns, a consequence not only of substance abuse but also a result of neglecting basic health-care needs. Dental problems, liver, thyroid or lung dysfunction, out-of-control diabetes, endometrial pain or gynecological problems resulting from working in prostitution are common. While in treatment for their primary addiction, clients can also take part in smoking cessation programs. Research has shown that smoking cessation contributes to success in abstaining From other addictive substances and RNs assess and provide support for nicotine replacement therapy to clients.
Patients experiencing a combination of mental/emotional/ psychiatric problems with the abuse of alcohol or other drugs are increasingly common, says RN Linda Lovett. Lovett has worked in psychiatry for 20 years and now divides her practice time between the residential addictions treatment at Henwood Treatment Centre and the psychiatry unit at the Royal Alexandra Hospital. She hopes that the exposure to the two practice settings will strengthen her proficiency in the concurrent treatment of patients suffering from mental health problems and addictions.
Opiate Dependency Programs
RNs who work in opiate dependency outpatient clinics provide treatment to clients with long-standing addictions to heroin and pharmaceutical opioids. They are often responsible for administering daily doses of methadone, a synthetic narcotic analgesic which alleviates withdrawal symptoms and offers clients a viable alternative to abstinence. Deemed a harmreduction strategy, methadone maintenance programs help clients escape from a criminal lifestyle, and with the emergence of HIV and Hepatitis C, it also reduces the negative health consequences of injection drug use. While administering the medication in the initial phase of treatment, RNs perform rapid physical and psychological assessments of the client and look for indicators of illness, intoxication or drug withdrawal. They are experts at swift assessments, focused education and counseling interventions, says Chris Mayberry, supervisor of AADAC’s Opioid Dependency Program in Edmonton. “We assess clients’ response to the medication, monitor their compliance with the medication regime, assess symptoms related to the disease process or medication, assess other medical and psychosocial issues, and connect clients to health and community resources.”
When treatment is stabilized, RNs help clients link to neighbourhood pharmacists, important partners in the delivery of daily medication. Frequently, clients remain in treatment for years and rely on RNs to support them in emergencies such as hospitalization, incarceration or to maintain their treatment when they travel. RNs need to develop close working relationships with pharmacists in hospitals and correctional facilities to respond to client needs.
Measuring Success
Nursing knowledge and skills, especially in health assessment, overlap from one recovery setting to another as do case and crisis management abilities. RNs are trained and educated to view the person holistically which helps them see other health issues external or related to addiction. Experience working with the plethora of health issues and a broad knowledge of general nursing prepare RNs for the variety in addictions treatment. Various courses, many through AADAC, and specialized conferences and symposiums keep RNs abreast of advances in treatment.
RNs new to addictions treatment sometimes experience a version of culture shock, says Sheila Rissling recalling her introduction to the work in Vancouver’s inner city. “I have learned to believe in my skills, to be more open and accepting of people, their misgivings and accomplishments. I want people to do really well, but that’s not always where they are.”
What about recidivism? It’s a question frequently heard by RNs. After all, isn’t addictions treatment intended to prevent a client’s return to problem drinking or using drugs. “Clients rarely come in, learn a set of coping skills and get straight the first time,” says Rissling. “How we analyze recovery success is crucial to assisting clients.” RNs become familiar with the situations and circumstances that put a client at risk for relapse, help clients to plan for success, and support them if they return to using drugs or alcohol. “You don’t know when a client’s right time is. I always hope this is it,” says Janice Bonsant.
All professionals working in addictions treatment learn to measure clients’ success in degrees, the small steps they take to improve their lives – improved financial stability or housing, better care of their health, increased social supports, resolving legal issues, and attending counselling. A “process of change” framework that incorporates relapse into recovery underlies practice. Offering unrelenting support, RNs help clients who return to identify changes in treatment that can advance them yet another step.
“One client has been on methadone for more than 20 years, longer than I’ve worked in the program,” says Chris Mayberry. “Early in recovery, he upgraded his education and, today, he’s a successful businessman.” Rissling says the person who attained sobriety after detoxifying more than 60 times is the one that continues to inspire her.
Janice Bonsant, now just entering retirement after 30 years of nursing in addictions treatment still feels compassion for those who need treatment and sums up her commitment simply by saying: “You can’t give up on them.”
Resources
Addictions Nursing Resources in the AARN Library
Scope and standards of addictions nursing practice, American Nurses Association and National Nurses Society on Addictions, 2004
Health Canada Resources available online
Best Practices-Substance Abuse Treatment and Rehabilitation 1999
http://www.hc-sc.gc.ca/hecs-sesc/cds/pdf/best_pract.pdf
Best Practices-Concurrent Mental Health and Substance Use Disorders 2002
http://www.hc-sc.gc.ca/hecs-sesc/cds/pdf/concurrentbestpractice.pdf
Copyright Alberta Association of Registered Nurses Dec 2004
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