Addiction for Nurses E-Book

G. Hussein Rassool

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 375

Veröffentlichungsjahr: 2011

Beschreibung

Nurses are acknowledged as key agents in addressing alcohol and drug misuse at individual, family, and community levels. Addiction nursing is central to the assessment, management, and care of people with problematic use of psychoactive substances (both legal and illegal). Work takes place in a wide range of settings, from traditional hospital clinics and wards to community locations such as police custody suites and needle exchange facilities. Addiction for Nurses is a comprehensive textbook for students, explaining the role of the nurse at each stage of intervention. Early chapters approach the subject from sociological, historical, and cultural perspectives, covering significant topics such as the nature of addiction, its social context, and addiction theory. The book then presents vital information about each of the main areas of addiction (nicotine, alcohol, opiates, cannabis, psychostimulants, and hallucinogens) with clinical and practical guidance on recognition, assessment, and treatment intervention strategies. Further chapters consider dealing with emergencies, blood-borne viruses, harm reduction, and work with specific client groups (for instance, black and ethnic minority communities, or those with special needs). This book is an essential resource for all those who come into contact with alcohol and drug misusers and for specialist addiction nurses preparing for practice in this complex and rewarding field.

Leseprobe

Contents

Preface

Acknowledgments

1 Introduction: Nursing Roles and Challenges

Standards of conduct, performance and ethics for nurses and midwives

The need to work with substance misusers

The role of the nurse

Confidentiality

Record keeping: case notes and electronic care records

References

2 Myths, Attitudes and Confidence Skills in Addiction

Myths a bout alcohol and d rugs

Personal use of psychoactive substances

Attitudes and stigmatisation

Intervention confidence s kills

References

3 Addiction and Society

Historical perspective

Different cultures and alcohol and drug use

Prevalence and patterns of alcohol and drug misuse

The alcohol and drug scenes today

Policy initiatives and strategies

Conclusions

References

4 Introduction to Alcohol and Drugs

Problem drug users and problem drinkers

Psychological and physical dependence

The dependence syndrome

How people take drugs (routes of drug administration)

References

5 Nature and Pattern of Addiction

The drug experience

Why do people use drugs?

Patterns of substance use and misuse

Chaotic use

Binge drinking

Harm

References

6 Causes and Maintenance of Addiction

Moral theory

Disease theory

Neuropharmacological theories

Genetic theory

Psychological theories

Sociocultural theories

Bio-psychosocial theory

References

7 Models of Care and Change

Models of care: drugs

Models of care: alcohol

Transtheoretical model of change

Stages of change

Nursing model

References

8 Alcohol

What is a unit of alcohol?

Health consequences of alcohol use

Alcohol withdrawal syndrome

Assessment

Care planning

Detoxification and management of withdrawal

Intervention strategies

Structured aftercare

Alcoholics Anonymous

Harm reduction

References

9 Nicotine

Strategy on tobacco smoking

Nicotine addiction

Harmful effects of tobacco smoke

Nicotine withdrawal symptoms

Assessment and intervention strategies

Health gains and benefits of smoking cessation

References

10 Opiates

Opiates

Assessment of opiate dependence

Intervention strategies

References

11 Cannabis

Cannabis as a gateway drug

Cannabis withdrawal syndrome

Assessment

Intervention strategies

Assistance with withdrawal symptoms

References

12 Psychostimulants

Amphetamines

Cocaine

Stages in cocaine withdrawal

Khat

Ecstasy

Amyl and butyl nitrite

Mephedrone

Assessment of psychostimulants

Intervention strategies

References

13 Other Psychoactive Substances

LSD (lysergic acid diethylamide)

GHB (gammahydroxybutyrate)

Ketamine

Psilocybin

PCP (phencyclidine)

Hypnosedatives

Volatile substances

Over- the- counter drugs

Smart and eco drugs

References

14 Nursing Emergencies and Care in Addiction

Acute intoxication

Risks of alcohol and drug intoxication

Nursing interventions in acute intoxication

Overdose of psychoactive substances

Nursing interventions in drug overdose

References

15 Blood-Borne Viruses

Human immunodeficiency virus

Tuberculosis

Hepatitis C

Hepatitis B

References

16 Prevention and Harm Reduction in Addiction

Prevention

Framework for classifying prevention

Prevention approaches and interventions

Substance misuse and the workplace

Rational use of psychoactive substances

Harm reduction approaches

Principles of harm reduction

Needle exchange schemes

References

17 Complex and Special Needs in Addiction

Physical health

Dual diagnosis: substance misuse and psychiatric disorders

Relationship of alcohol, drugs and mental health problems

Patients with complex needs

Nursing interventions with dual diagnosis patients

18 Women, Ethnic Minorities and Vulnerable Populations

Women and substance misuse

Black and ethnic minority communities and substance misuse

The elderly and substance misuse

Homelessness and substance misuse

Young people and substance misuse

References

Index

This book is dedicated to Yasmin Soraya, Adam Ali Hussein, Reshad Hassan, Leyla, Isra Oya, Mariam Safi an and Hassim.

There is no wealth like knowledge, no poverty like ignorance.

Ali Ibn Abi Talib (RadiAllah Anhu)

This edition first published 2010

© 2010 G. Hussein Rassool

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The Library of Congress has cataloged the printed edition as follows:

Rassool, G. Hussein.

Addiction for nurses / G. Hussein Rassool.

p.; cm.

Includes bibliographical references and index.

Summary: ‘PRIMARY READERSHIP Student nurses (mental health branch) Postgraduate nursing students of addiction SECONDARY READERSHIP Addiction Nurses Community Nurses Mental Health Nurses’-Provided by publisher.

ISBN 978-1-4051-8746-6 (pbk. : alk. paper) - ISBN 978-1-4443-2782-3 (e-book) 1. Substance

abuse-Nursing. 2. Compulsive behavior-Nursing. I. Title.

[DNLM: 1. Substance-Related Disorders-nursing. 2. Behavior, Addictive-nursing.

WY 160 R228a 2010]

RC564.R356 2010

616.86′0231-dc22

2010016814

Preface

Addiction to alcohol and drugs is the foundation of this book. Alcohol and drug misuse is now regarded as a public health problem. The main aim is to promote understanding of the issues and strategies surrounding drug and alcohol use and misuse. It also aims to introduce nurses to the recognition, assessment, prevention and intervention strategies that can be used to support patients in their early identification and management of drugs and alcohol.

The book provides an overview of the approach to addiction and underpins a number of current policy initiatives as applied to current practice. It crystallises the nature of addiction, the health consequences of alcohol and drugs, and makes the complexity of the issues associated with addiction more accessible. It is designed to help nurses and generic health and social care professionals to understand the extent and nature of addiction and provides a framework to assist practitioners in working with alcohol and drug misusers. It provides a timely and practical introduction to the field of addiction.

Acknowledgments

I would like to thank all the staff at Wiley-Blackwell for their support and patience throughout the process of writing and publishing this book.

I am also particularly grateful to Professor Robert West, Addiction Press, who mooted the idea of writing a practical and no-nonsense book on addiction for nurses. To Emily Meir who gave me the opportunity to teach nurses. My thanks also go to Professor James P. Smith, Professor John Strang, Professor A. Hamid Ghodse and Dr. Nek Oyefeso for their guidance in my professional development. Special thanks go to Professor Margarita Villar-Luis, Escola De Enfermagem de Ribeir ã o Preto, Universidade de Sao Paulo, Brazil for our collaboration and development in publishing, teaching and research activities in addiction and mental health.

I am beholden to my patients and students for teaching me about practice in the addiction field. Thanks also go to all the ‘Mousquetaires’-‘Barbiers de Seville’ and my brothers and sisters at Al-Furqaan, Les Guibies for their friendship and support. I would like to acknowledge the contributions of my teachers who enabled me, through my own reflective practices, to follow the path.

My special thanks also to Mariam for all the help and support during the writing of the book. Finally, I owe my gratitude to my family, Yasmin, Adam Reshad, Leyla and Isra for being here.

1

Introduction: Nursing Roles and Challenges

Standards of conduct, performance and ethics for nurses and midwives

The need to work with substance misusers

The role of the nurse

Hospital-based nurses

Community-based nurses

Addiction nurses: specialist alcohol and drug workers

Confidentiality

Record keeping: case notes and electronic care record

Summary of key points

Nurses and other health care professionals form a core component of many health care systems so their roles in responding to the challenges set by the increase in the use of psychoactive substance use are crucial. Nurses in both primary health care and residential settings are usually the first point of contact with many who misuse alcohol and drugs. Nurses are often reluctant to work with alcohol and drug misusers, mainly because of anxieties concerning role adequacy, legitimacy and lack of support.

This chapter will examine the role of nurses in hospital and primary health care settings in relation to intervention and management of substance use and misuse. It will also look at the rationale for working with substance misusers, confidentiality and the contribution that nursing practice can provide.

Standards of conduct, performance and ethics for nurses and midwives

Nurses have a shared set of values, which find their expression in The Code: standards of conduct, performance and ethics for nurses and midwives (NMC 2007). Nurses have the following responsibilities:

To make the care of people their first concern, treating them as individuals and respecting their dignity.

To work with others to protect and promote the health and wellbeing of those in their care, the patients’ families and carers, and the wider community.

To provide a high standard of practice and care at all times.

To be open and honest, act with integrity and uphold the reputation of their profession.

Alcohol and drug misusers must be able to trust nurses with their health and wellbeing. The Code also states that ‘as a professional, you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions’ and that ‘you must always act lawfully, whether those laws relate to your professional practice or personal life’. Those with early substance use problems, chronic problem drinkers and drug users have the same rights vis -à-vis other patients in receiving appropriate health care from the National Health Service (NHS). Every member of the health care profession has an important role to play in responding to substance misuse problems.

The need to work with substance misusers

Given the extent and nature of the normalisation of psychoactive substances in society, only a minority of drug and alcohol misusers is likely to come into contact with specialist drug and alcohol agencies. Most of them will invariably have first contact with primary care services, medical and psychiatric services, social services and voluntary agencies, and the criminal justice system. The need for the management and treatment of substance misuse problems is no longer confined to the specialist services. Nurses, in different specialities and settings, are also likely to come into contact with alcohol and drug misusers.

An early intervention in the lifestyle and behaviour of substance misusers helps to limit the associated health, social and familial harms (Rassool 2009). Early intervention strategies from health and social care professionals can have a dramatic impact on preventing substance misuse becoming a long-term problem. The management of those with established substance use problems and those at an early stage of use is not the sole responsibility of specialist workers and addiction specialists. An active involvement of the different cadres of health workers in managing problems of substance misuse is necessary because of the sharp increase, in recent times, in the number of users of psychoactive substances with abuse potential (Rassool & Oyefeso 1993).

A broad range of health, social work and criminal justice system workers have a key role to play in addressing substance misuse and the reduction of substance misuse should be regarded as a core business for many services. Every role in the drug and alcohol field requires a particular set of competences. Some of these will be generic, others more specific to the substance misuse field, and the required competences will vary from one role to another (Home Office 2005). Examples of the types of role that might fall within each category are presented in Table 1.1.

Table 1.1 Working with substance misusers

Source: Home Office (2005) Work Force Briefing, Tackling Drugs Changing Lives. Recruitment guidance for employers. Home Office, London.

Generic workers with an occasional substance misuse portfolioGeneric workers with a substance misuse portfolioSpecialist workersNurseMental health nurseAddiction nursesHospital pharmacistAmbulance staffAlcohol and drug workerTeacher/lecturerConnexions workerYoung people’s substanceEarly years workerYouth workermisuse workerCitizens’ Advice Bureau WorkerPupil Referral Unit teacherDrugs and employment coordinatorSocial workerHousing officerDrugs unit police officerPrison visitorCare Leavers Team social workerCustody suite-based drug workerMagistrateHM Customs workerHomelessness workerProgress2work advisorSolicitorProbation officerSubstance misuse commissionerPrison officerPsychologistDrug Action Team coordinatorCommunity support OfficerCARAT (counselling, assessment, referral, adviceand throughcare) workerEducation drug advisor

The role of the nurse

In relation to substance misuse, nurses must assume a multitude of roles that focus on the provision of effective care, prevention and education (Rassool 1993). Such roles have been discussed in a document from the World Health Organization/International Council of Nurses (WHO/ICN 1991) and are: provider of care, counsellor/therapist, educator/resource, advocate, health promoter, researcher, supervisor/leader and consultant. A brief description of the roles is shown in Table 1.2.

Nurses are uniquely positioned to enhance prevention and intervention strategies. For example, nurses have the opportunity and competence to assess smoking status, advise on the ill health effects of smoking, and assist in smoking cessation. The International Council of Nurses urges nurses around the world to be in the forefront of tobacco control. Nurses should develop partnerships with a broad range of other professional groups, women’s and youth associations, the media, schools, government, and others committed to the prevention of substance misuse and reducing the harm resulting from the consequences of alcohol and drug misuse.

Table 1.2 Nursing roles in relation to substance misuse.

Source: WHO/ICN (World Health Organization/International Council of Nurses) (1991) Roles of the Nurse in Relation to Substance Misuse. ICN, Geneva. Reproduced with kind permission of the World Health Organization.

Nursing roleResponsibilitiesProvider of careCaring for those who misuse or are affected by psychoactive substancesCounsellor/therapistFocusing on the needs of individuals, their families and colleaguesEducator/resourceProviding health information to community groups, schools, families, individuals and to professional and non-professional groupsAdvocateLobbying for change and improved careHealth promoterCampaigning for policy and legislation to reduce demand for abused drugsResearcherDetermining the most effective method of helping, caring and preventing substance misuseSupervisor/leaderGuiding professionals and non-professionalsConsultantProviding consultancy to professionals in this speciality

Hospital-based nurses

Patients who misuse psychoactive substances may be admitted to a variety of hospital-based settings and their health problems may or may not be related to alcohol and drug misuse. Patients attending hospital with alcohol-related problems fall into two broad categories: (i) those with a less severe drinking problem who may be amenable to brief interventions; and (ii) patients with features of alcohol dependence, requiring detoxification and ongoing treatment (Owens et al. 2005). The ranges of medical, surgical and psychiatric problems nurses are likely to encounter and their intervention strategies are shown in Table 1.3.

It is reported that up to 30% of male admissions and 15% of female admissions to general surgical and medical wards have alcohol-related problems (UK Alcohol Forum 1997). One in six people attending accident and emergency (A & E) departments for treatment have alcohol-related injuries or problems, rising to eight out of ten at peak times (HEA 1998), and one in seven acute hospital admissions are misusing alcohol (Canning 1999). For many drug misusers, A & E departments may be the first or only point of contact with health services, most often because of accidental overdoses and other crises (Gossop et al. 1995).

There has been a marked increase in the number of patients attending A & E departments following binge drinking and drug misuse. An increase of overnight alcohol-related emergencies to A & E after the introduction of new UK alcohol licensing legislation has also been reported (Newton et al. 2007). It is estimated that up to 5% of patients attending A & E departments present with primary psychiatric problems, whilst another 20-30% have psychiatric symptoms in addition to physical disorders (Ramirez & House 1997). The most common presenting psychiatric problem in most A & E departments is self-harm, typically constituting one-third of the total.

Table 1.3 Addiction problems encountered by hospital-based nurses.

NursesProblemsInterventionsMedical unitsUnexplained fever. Acute or chronic infections of skins and joints. Unexplained cardiac murmurs. Endocarditis. Venous and arterial thrombosis. Jaundice. Abnormal liver function. Lymphadenopathy features of immunosuppression. Munchausen syndromeProvision of total care. Screening. Taking a drug and alcohol history. Dealing with withdrawal symptoms and withdrawal. Harm reductionSurgical unitsAbscess. Acute abdominal pain. Intestinal obstruction (body packers). Vascular problems. Trauma (such as road traffic accidents or burns). Rhinitis. RhinorrhoeaPsychiatric nurseDrug-induced psychosis (stimulants and alcohol). Drug-withdrawal psychosis (hypno-sedatives). Alcohol psychosis. Suicidal behaviour and depression as a result of substance misuse. Withdrawal symptoms. Dual diagnosisAssessment of substance misuse and high-risk behaviours. Brief interventions. Cognitive therapy. Relapse prevention. Harm reductionAccident and emergency nurseComplications of substance misuse. Accidental overdoses. Intoxication. Withdrawal. Self-harm. Primary psychiatric symptomsBrief assessment. Brief interventions. Dealing with self-harm. Management of overdose and withdrawalPrison health care nurseAlcohol and drug addiction. Self-harm. Dual diagnosis. HIV/AIDS and injecting drug useAssessment of substance misuse and high-risk behaviours. Management of withdrawal. Harm reductionObstetric nurse/midwifePregnant substance misusersHarm reduction. Screening for cervical cytology. Smoking cessation. Maternal health, antenatal screening (hepatitis C, B and HIV), antenatal counselling, antenatal care and aftercare

The ‘Models of Care’ (NTA 2002) recommend that staff at A & E departments should include interventions strategies such as screening, provision of drugrelated information and advice and referral to specialised alcohol or drug agencies. The key points of reducing drug-related deaths by A & E staff are presented in Table 1.4.

Table 1.4 Key points in reducing drug-related deaths.

Source: adapted from NTA (National Treatment Agency) (2004) Reducing Drug-related Deaths. Guidance for drug treatment providers. NTA Publications, London.

Responses/InterventionsNeeds/ProblemsInjectors should be given injecting equipmentIf needle exchange services are closed and they need injecting equipmentEncourage drug users to seek treatmentReduce overdose and blood-borne infectionsHepatitis B immunisation for injectors who attend A & EShould be a routine procedureRisk of overdose due to loss of toleranceLoss of tolerance after detoxification, rehabilitation or prison. Homeless injectors are a high-risk groupLong-term users and poly-drug users are at high risk of overdoseThe more they overdose, the greater the risk of one of the overdoses being fatalProvision of health information literatureOverdose preventionViral transmissionLocal drug or alcohol servicesLinking with local drug or alcohol agenciesEstablish relationship with substance misuse servicesEncourage drug or alcohol users to attend A & ENon-judgmental and non-hostile attitude would be a positive experience for substance misusers and their friends or families

During the past decade, there has been a significant increase in the number of dedicated alcohol nurse specialists in hospitals (Owens et al. 2005). Alcohol nurse specialists have a multidimensional role ranging from providing advice on detoxification, screening for alcohol-related problems and optimising medical management through to providing ongoing support and information for referral for specialist alcohol treatment (Hillman et al. 2001).

Substance misuse is common among people with mental health problems and such dual needs should be met by mainstream services with the support of specialist advice (Department of Health 2002). Problems associated with alcohol/drug use are more common in mental health services, particularly in acute admission services. Mental health nurses in all settings should be able to respond to the needs of people with mental health and substance misuse problems (Department of Health 2006).

Prison health care services deal with the health needs of the prison population through the provision of general medical services and psychiatric treatment. Prison populations have a high concentration of people with a history of drug misuse: over one-third of the people received into British prisons each year are treated for opiate dependence (Home Office 2003).

Midwives provide support to women, their babies, their partners and families, from conception to the first phase of post-natal care. It is acknowledged that for some women this may be their only contact with the statutory health services. Late booking for antenatal care by women with problem drug and/or alcohol use is variously attributed either to lack of awareness of pregnancy, due to the menstrual disturbances and amenorrhoea that are common features of drug use, or else simply to lack of motivation (Hepburn 2004). Midwives can play an important role in nudging women who are misusing substances to make a positive change to substance-misusing behaviour. Another aspect of intervention includes the observation of babies undergoing withdrawal symptoms if they were born with a high degree of dependence on opiates.

Community-based nurses

A summary of the problems encountered by community-based nurses and their intervention strategies is presented in Table 1.5.

With the new NHS system focusing on identifying the needs for local services and on primary prevention with health improvement programmes, practice nurses are ideally placed to screen for drug misuse and for those with at-risk alcohol consumption, to deliver health information and brief interventions. There is some evidence suggesting that 13% of men and 2.5% of women having an alcohol use disorder consult their general practice (McMenamin 1997). In a study by Owens et al. (2000), the findings showed that practice nurses are happy to give advice regarding sensible drinking and routinely and appropriately take a history of alcohol intake, usually within well-woman and well-man clinics.

Community mental health nurses are exposed to a wide range of clients with varying degrees of psychiatric disorders and substance misuse. Community drug and alcohol teams may include community psychiatric nurses. Their work may cover the recognition of substance misusers, liaison with primary health care workers, for example general practitioners, in detoxification, motivation and relapse prevention, counselling, alcohol, drug and HIV (human immunodeficiency virus) education, and other harm minimisation work (Royal College of Psychiatrists 1997).

The use of tobacco, alcohol and illicit drugs by young people and school children is the source of much public concern. It is estimated that between 780 000 and 1.3 million children are affected by parental alcohol problems (Prime Minister’s Strategy Unit 2004). School nurses are often asked to play a role in delivering health education/promotion (drug and sex education) under the personal, social and health education (PHSE) curriculum. A toolkit for school nurses has been developed to provide information about the effects of parental alcohol misuse on children and what can be done to support these children, both individually and within the wider school context (Alcohol Concern 2006).

Table 1.5 Addiction problems encountered by community-based nurses.

NurseProblemsInterventionsCommunity psychiatric nurseDual diagnosis problems related to withdrawal from alcohol or benzodiazepines, or opiates, blood-borne infections, amphetamine or cocaine psychosisAssessment of mental health/substance misuse problems. Counselling. Harm reduction. Relapse prevention. Cognitive therapy. Health education. Alternative therapies. Drug prescribing. Home detoxification. Prevention of substance misuseNurses in sexual healthHIV status. Sexually transmitted infectionsTaking a drug and alcohol history. Pre-and post-test counselling. General counselling. Harm reductionPractice nurseGeneral health problems. Wellness programmeScreening. Brief interventions. Provision of health information. Harm reduction. Smoking cessation clinicDistrict nurseDifferent stages of illnessEarly identification. Generic assessment. Health information. Harm reduction. ReferralSchool nurseGeneral health care of school childrenHealth education (drug and sex education). Health counselling. Referral to specialist and non-specialist agencies. Dealing with parental alcohol/drug misuseOccupational health nurseGeneral health care of workersHealth education. Screening for drugs and alcohol. Controlled drinking. Smoking cessation clinic. Harm reduction. ReferralPrimary care mental health workerMental health needsBrief interventions. Health information. Assessment and screening. Cognitive-behavioural therapies. Harm reduction

District nurses usually encounter patients at different stages in their illness and are responsible for the provision of total nursing care. They too have a role to play in prevention and harm reduction in relation to substance misuse.

The misuse of psychoactive substances in the workplace is one of the major concerns of management, professional organisations and occupational health staff. There is evidence to suggest that a policy on tobacco smoking or alcohol use can lead to reduced absenteeism, improved safety performances, lower maintenance costs, lower air-conditioning and ventilation costs, increased productivity, improve morale among non-smokers, fewer accidents and a lowered risk of losing skilled employees through premature retirement or death (McEwen 1991).

Primary care mental health workers provide additional, specialist services in primary care settings for people with mental health needs. One of the key functions is to help facilitate the transition towards primary care becoming the major arena of community mental health care and to facilitate the supply of basic therapeutic interventions such as cognitive behavioural therapies.

Substance misusers may come into contact with genitourinary medicine services as a result of concerns relating to their HIV status or sexually transmitted infections. Nurses working in sexual health need to have close working relationships with substance misuse and general services. Areas of intervention include taking a drug and alcohol history, sexual history, pre- and post-test counselling, general counselling, health education and harm reduction.

Addiction nurses: specialist alcohol and drug workers

Alcohol and drug workers or substance misuse workers come from a variety of professional backgrounds, including nursing, social work and the criminal justice system, and are found in statutory services, statutory and voluntary agencies and the private sector. They are regarded as drug and alcohol specialists. Nurses working in specialist alcohol and drug services have been ascribed occupational labels such as alcohol nurse, drug dependency nurse, chemical substance nurse, specialist nurse in addiction, and community psychiatric nurse (addiction) (Rassool 1997). It was not until the mid-1980s that addiction nursing as a clinical speciality, within the broader framework of mental health nursing, began to put down its clinical and academic roots.

The concept of addiction nursing was introduced in the literature in the UK by Rassool (1996). It is defined as a specialist branch of mental health nursing concerned with treatment interventions aimed at those individuals whose health problems are directly related to the use and misuse of psychoactive substances and to other addictive behaviours such as eating disorders and gambling (Rassool 1997). The scope of professional practice in addiction nursing incorporates the activities of clinical practice, education, policy making, research and an expanded role in the prescribing of drugs (Rassool 2004).

Addiction nurses practice in a variety of settings including smoking cessation clinics, mobile methadone clinics, outreach work with drug-using commercial sex workers, and satellite clinics for homeless drinkers; they are also involved in the development of multiprofessional post-graduate educational programmes in addictive behavior (Rassool 2000). Addiction nurses provide a range of physical and psychosocial interventions in the management and comprehensive treatment of substance misusers. The interventions include total nursing care, management of withdrawal and detoxification, prescribing, support, advice and basic counselling, harm reduction, family therapy and cognitive behavioural therapies such as relapse prevention. They also have a key worker role in the shared care approach, perform risk assessment and act as an advocate. Some nurses practice in a ‘social work model’ and can address family and personal relationships, child care, housing, income support and criminal justice issues (Department of Health 1999a).

Confidentiality

Under statutory law and professional codes of practice, nurses, midwives and allied professionals have a professional duty of care relating to respecting and maintaining patient confidentiality. The professional ethical obligations for nurses are set out in the Nursing and Midwifery Council’s Code of Professional Practice (NMC 2002). It is stated that:

To trust another person with private and personal information about yourself is a significant matter. If the person to whom that information is given is a nurse, midwife or health visitor, the patient or client has a right to believe that this information, given in confidence, will only be used for the purposes for which it was given and will not be released to others without their permission. The death of a patient or client does not give you the right to break confidentiality.

Nurses, whether working in the NHS or the private sector, should also observe any government guidelines on confidentiality such as the Department of Health’s (2003) code of practice on confidentiality. Information provided in confidence should not be used or disclosed in a form that might identify a patient without his or her consent (Department of Health 2007). The person’s right to confidentiality means that all clients must have this clearly defined and explained to them before being asked to reveal any personal information. Information can be provided to third parties on their behalf only if their specific written permission is provided before this occurs. Informed consent is an ongoing agreement by a person to receive treatment and undergo procedures (or participate in research), after the risks, benefits and alternatives have been adequately explained to them (Royal College of Nursing 2005). The consent should be documented, accessible in the client’s notes and subject to regular review. For more comprehensive information see Patient Confidentiality (Department of Health 2007) and Guidance for Access to Health Records (Department of Health 2003).

Record keeping: case notes and electronic care records

The keeping of records of patients as part of a care plan is a basic requirement of health and social care practice. A record is ‘anything that contains information (in any media) which has been created or gathered as a result of any aspect of the work of NHS employees’ (Department of Health 1999b). Within the Data Protection Act 1998, a health record is defined as a record consisting of information about the physical or mental health or condition of an identifiable individual made by or on behalf of a health professional in connection with the care of that individual. The Data Protection Act 1998 gives every living person or their authorized representative the right to apply for access to their health records irrespective of when they were compiled. The process of keeping records involves consideration by third parties, including courts of law and other health or social care professionals. Nurses should keep records that are simple, accurate, legible and up-to-date. Clinical records must be kept confidential at all times and stored in a secure place.

Under the NHS Electronic Care Records system, everyone will have a computer based care file with basic information to provide health care staff with quicker access to reliable information. The NHS Care Records Service aims to make caring across organisational boundaries safer and more efficient. This will mean that instead of having separate records in all the different services, key workers will have access to the information they need. The electronic patient records are available to staff whenever a client visits hospital or community-based services. Access to the electronic record is strictly password controlled to maintain patient confidentiality at all times.

Summary of key points

Nurses are usually the first point of contact for patients who have potential or early alcohol and drug problems.

The extent and nature of the substantial health and social problems associated with substance misuse highlight the pressing need for nurses to respond to the needs of substance misusers.

Roles in the substance misuse field are characterised by the level and frequency of contact with substance misuse and substance misusers.

The exchange and sharing of information has to be done whilst observing the code of practice regarding confidentiality and should be underpinned by clear policies and procedures.

Record keeping is a basic health and social care practice and is applicable to all services.

References

Alcohol Concern (2006) Toolkit for School Nurses. Alcohol Concern, London: http://www.alcoholandfamilies.org.uk/documents/SN/sn-tools_index.htm.

Canning U.P., Kennell-Webb S.A., Marshall E.J., Wessely S.C. & Peters T.J. (1999) Substance misuse in acute general medical admissions. Quarterly Journal of Medicine, 92(6), 319–326.

Department of Health (1999a) Drug Misuse and Dependence. Guidelines on clinical management. Department of Health, London.

Department of Health (1999b) For the Record: managing records in NHS Trusts and Health Authorities. HSC 1999/053. Department of Health, London: www.doh.gov.uk/nhsexec/manrec.htm (accessed 10 June 2009).

Department of Health (2002) Mental Health Policy Implementation Guide: dual diagnosis good practice guide. Department of Health, London: www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4009058&chk=sCQrQr.

Department of Health (2003) Guidance for Access to Health Records. Department of Health, London: www.doh.gov.uk.

Department of Health (2006) From Values to Action: the Chief Nursing Officer’s review of mental health nursing. Department of Health, London.

Department of Health (2007) Patient Confidentiality. Department of Health, London: www.doh.gov.uk.

Gossop M., Marsden, J., Edwards C., Wilson A., Segar G., Stewart D. & Lehmann P. (1995) The October Report. The National Treatment Outcome Research Study: a report prepared for the Task Force. Department of Health, London.

HEA (Health Education Authority) (1998) Perceptions of alcohol related attendances in A & E departments in England: a national survey. Alcohol and Alcoholism, 33(4), 354–361.

Hillman A., McCann B. & Walker N. P. (2001) Specialist alcohol liaison services in general hospitals improve engagement in alcohol rehabilitation and treatment outcome. Health Bulletin, 59(6), 420-423.

Hepburn M. (2004) Substance abuse in pregnancy. Current Obstetrics and Gynaecology, 14, 419–425.

Home Office (2003a) An Analysis of CARAT Research Data as at 3 December 2002, Research, Development and Statistics Directorate, London: Home Office.

Home Office (2005) Work Force Briefing, Tackling Drugs Changing Lives. Recruitment guidance for employers. Home Office, London: www.homeoffice.gov.uk/publication-search/drugstrategy/WorkforceBriefing-Jobs?view=Binary.

McEwen J. (1991) Interventions in the workplace. In I. Glass (ed.) The International Handbook of Addiction Behaviour, pp. 307–312. Routledge, London.

McMenamin J.P. (1997) Detecting young adults with alcohol use disorder in a general practice. New Zealand Medical Journal, 110, 127–128.

Newton A., Sarker S.J., Pahal G.S., van den Bergh E. & Young C. (2007) Impact of the new UK licensing law on emergency hospital attendances: a cohort study. Emergency Medicine Journal, 24(8), 532-534.

NMC (Nursing and Midwifery Council) (2002) The Code of Professional Conduct. NMC, London.

NMC (Nursing and Midwifery Council) (2007) The Code: standards of conduct, performance and ethics for nurses and midwives. NMC, London. http://www.nmc-uk.org/aDisplayDocument.aspx?documentID=5982.

NTA (National Treatment Agency) (2002) Models of Care for Treatment of Adult Drug Misuers. Parts 1 and 2. NTA Publications, London.

NTA (National Treatment Agency) (2004) Reducing Drug-related Deaths. Guidance for drug treatment providers. NTA Publications, London: http://www.nta.nhs.uk/publications/documents/nta_guidance__for__drug__treatment__providers_drdpro.pdf.

Owens L., Gilmore I.T. & Pirmohamed M. (2000) General practice nurses’ knowledge of alcohol use and misuse: a questionnaire survey. Alcohol and Alcoholism. 35(3), 259–262.

Owens L., Gilmore I.T. & Pirmohamed M. (2005) How do the NHS general hospitals in England deal with patients with alcohol-related problems? A questionnaire survey. Alcohol and Alcoholism, 40(5),409-412.

Prime Minister’s Strategy Unit (2004) Alcohol Harm Reduction Strategy for England. Cabinet Office, London: http://www.cabinetoffice.gov.uk/strategy/work_areas/alcohol_misuse.aspx.

Ramirez A. & House A. (1997) ABC of mental health: common mental health problems in the general hospital. British Medical Journal, 314, 1679–1681.

Rassool G.H. (1993) Nursing and substance misuse: responding to the challenge. Journal of Advanced Nursing, 18(9), 1401–1407.

Rassool G.H. (1996) Addiction nursing and substance misuse: a slow response to partial accommodation. Journal of Advanced Nursing, 24(2), 425–427.

Rassool G.H. (1997) Addiction nursing-towards a new paradigm: the UK experience. In G.H. Rassool & M. Gafoor (eds) Addiction Nursing-perspectives on professional and clinical practice. Nelson Thornes, Cheltenham, UK.

Rassool G.H. (2000) Addiction: global problem and global response complacency or commitment? Journal of Advanced Nursing, 32(3), 505–508.

Rassool G.H. (2004) Prescription for change: perspectives on prescribing authority for addiction nurses in the United Kingdom. Journal of Addictions Nursing, 15(4), 193–197.

Rassool G.H. (2009) Alcohol and Drug Misuse. A handbook for student and health professionals. Routledge, Oxford.

Rassool G.H. & Oyefeso N. (1993) The need for substance misuse education in health studies curriculum: a case for nursing education. Nurse Education Today, 13, 107–110.

Royal College of Psychiatrists (1997) Community Psychiatric Nursing. Occasional Paper No. OP40. Royal College of Psychiatrists, London.

Royal College of Nursing (2005) Informed Consent in Health and Social Care Research. Royal College of Nursing, London.

UK Alcohol Forum (1997) Guidelines for the Management of Alcohol Problems in Primary Care and General Psychiatry. Tangent Medical Education, London.

WHO/ICN (World Health Organization/International Council of Nurses) (1991) Roles of the Nurse in Relation to Substance Misuse. ICN, Geneva.

2

Myths, Attitudes and Confidence Skills in Addiction

Myths about alcohol and drugs

Personal use of psychoactive substances

Attitudes and stigmatisation

Intervention confidence skills

Summary of key points

Statements and responses to Activity 2.1

Our understanding of addiction is based on a lay foundation as much as on our scientific understanding of addiction, which is relatively new. Our understanding of alcohol and drug addiction is embedded in belief systems and attitudes. We have developed a number of myths about addiction and these have been made legitimate. We will need to dispel some of the most popular myths as evidence suggests that they are false. The myths have a significant influence in our understanding of addiction and our interaction with alcohol and drug users and misusers. Many factors impact on nurses and other health care professionals’ willingness to intervene with individuals who use drugs and alcohol. These factors include knowledge, training, organisational structure and policies, and previous positive or negative experiences (Rassool 2009). Interactions with alcohol and drug users and misusers are also tied up with our myths, attitudes and confidence.

In this chapter, there are a number of self-assessed activities to examine the myths of addiction, our personal use of alcohol and drugs, attitudes towards substance misusers and intervention confidence skills in working with substance misusers. In order to understand the nature and reasons behind the use of alcohol and drugs, you will need first to understand your own ‘dependence’. You need also to be more aware of your own attitude towards substance misusers. Understanding why an individual becomes dependent on alcohol or drug may enable you to have a more positive attitude (feeling, thinking and behaviour) about substance misusers and facilitate them to change their behaviour.

Myths a bout alcohol and d rugs

In Activity 2.1, you will need to consider whether the statements are fact or fiction. It would be worthwhile to look for evidence to support the statements. The answers appear at the end of this chapter.

Activity 2.1 Please tick the appropriate box to state whether the statement is fact or fiction

Personal use of psychoactive substances

In this section, you will consider your own use of alcohol and drugs. Self-awareness of one’s own drug (legal, prescribed or illicit) or alcohol use should enable you to be more cognisant about the nature and reasons behind the misuse of alcohol and drugs. This activity is based on the ‘addiction’ of substances (alcohol and drugs), things, people or activities (Scottish Drugs Training Project, University of Stirling). For example, people may be dependent on alcohol, coffee, tea, chocolate, a first cigarette on waking up, jogging, horse racing, the internet or soap operas; abstinence from the substances, activities or things would create an emptiness in your daily routine. Please undertake Activity 2.2.

The reasons why people use drugs and continue to use drugs are two different propositions. The reasons may or may not be the same. Physical and psychological withdrawals of psychoactive substances are discussed in Chapters 6–12.

Activity 2.2 Personal use of addictive substances/activities/people/things

Source: Scottish Drugs Training Project, University of Stirling.

1 List your dependence/dependencies:(a) Substances:(b) Activities:(c) People/things:2 (a) What are the reasons you think you may be dependent?(b) Why do you need them?(c) What do they do for you?3 (a) How would you feel if you had to give up your preferred choice of dependence?(b) Would it be easy or difficult?(c) Would you have physical or psychological withdrawal symptoms or both?

Attitudes and stigmatisation

An attitude is the way we feel, think or behave towards an individual or thing. For example, nurses can have a positive or negative attitude towards working with alcohol and drug misusers. That is, they may be reluctant to work with substance misusers because they perceive alcohol and drug misusers as unpleasant and over-demanding. Attitudes are influenced by a variety of factors, including past experiences (positive and negative), knowledge, education, context of the situation, and cultural and religious factors. Changing an attitude is a complex problem as an individual’s attitudes may be closely tied to their personal values, belief system or important aspects of their self-identity (Wood 1998). Attitudes towards substance misusers represent one factor within this wider set that may impact on health professionals’ responses. In this context, attitudes towards alcohol and drug misusers can be broadly categorised as professional or personal views. Professional attitudes refer to beliefs concerning professional practice such as role legitimacy (e.g. is it appropriate for me to respond to alcohol use within my professional role?), confidence (perceived level of skills and abilities) and perceived efficacy of available treatments and interventions (Rassool 2009). Personal attitudes refer to feelings and beliefs that stem from the stigmatised nature of drug use, for example blame and anger.

Attitudes of health care professionals towards substance misusers exert a significant influence on their readiness to intervene and the quality of such interventions. Negative attitudes have been associated with the reluctance of substance misusers to utilise the health services, reduced likelihood to pursue referrals and the reluctance of health care professionals to engage in management and treatment with substance abusers (McLaughlin et al. 2000; Mistral & Velleman 2001).

Complete Activity 2.3 and reflect about your attitudes towards alcohol and drug misusers. Write in your reflective journal about your own substance use and your attitude towards substance misusers.

Activity 2.3 Rassool Attitude Towards Substance Misusers Questionnaire (RATSMQ-10)

The statements below reflect several different opinions, beliefs and viewpoints about substance use and misuse. Please indicate how strongly you agree or disagree with each statement. To complete the instrument please place a tick in the box that best reflects how strongly you agree or disagree with each statement.

Rassool Attitude Towards Substance Misusers Questionnaire, © G. Hussein Rassool 2004. Permission should be obtained from the author for use of the questionnaire beyond personal use.

Activity 2.4 Addiction Intervention Skills Questionnaire

To complete the instrument, please place a tick in the box that best reflects your confidence level.

Addiction Intervention Skills Questionnaire, © G. Hussein Rassool 2004. Permission should be obtained from the author for use of the questionnaire beyond personal use.

Intervention confidence skills

If you have a belief in yourself and in your competences or abilities in providing optimal care to any group of patients, you will have the readiness to work with alcohol and drug misusers. In addition, having a positive attitude or therapeutic optimism will influence your interventions with substance misusers. Nurses will have some areas of their nursing or health activities where they feel quite confident, while at the same time they may not feel at all confident in other areas. By taking a positive attitude this may enable the development of confidence skills in working with alcohol and drug misusers. Please complete the Questionnaire of Intervention Confidence Skills in working with substance misusers (Activity 2.4).

When you have completed the book or a course, you should return and complete this questionnaire for a second time. It would be valuable for you to compare the two sets of answers in relation to your intervention confidence skills.

Summary of key points

Our understanding of addiction is based on a lay foundation and scientific understanding.

Our understanding of alcohol and drug addiction is rooted in myths, belief systems and attitudes.

There is a need to be self-aware about own dependence on substances, things, activities or people.

Reflect on your own attitude towards those with alcohol and drug problems.

It is important to develop a positive attitude in order to enhance the quality of care given to those with alcohol or drug problems.

By taking a positive attitude this may enable the development of confidence skills in working with alcohol and drug misusers.

Statements and responses to Activity 2.1

1Myth: There are no degrees of addiction

Fact