Vol. 1 Issue 8
Treating the Chemically-Dependent
Nurses play numerous, essential roles in caring for patients with substance abuse problems
As in most matters in a hospital setting, nurses take the lead in addressing patient concerns and crises as they arise. At Santa Barbara Cottage Hospital, nurses working with chemical dependency patients are an essential part of the treatment team and are the most agile and versatile in the various roles they are called upon to perform.
For more than 20 years, Cottage Hospital has had a comprehensive program for the treatment of chemical dependency patients, beginning with detox in an acute hospital setting and then providing a variety of treatment options after the detox phase. For example, most patients are admitted to 5-East, Psychiatric and Chemical Dependency Services through the ED. Individuals who come to the ED requesting help with a substance abuse problem will first discuss the matter with a nurse. Once cleared for admission, the first person they meet when they arrive on the unit will be a nurse who continues the admitting process, taking detailed information about medical and personal background and assessing the needs for detoxification.
There has been a long evolution, many additions and changes both subtle and large to the Cottage model for treatment. These changes reflect both local adjustments to the needs of the community and the way drug and alcohol programs have changed nationally over the years.
On the Unit
Psychiatry, these days, is the first step for the chemical dependency patient. With a 20-bed unit, four are devoted to detox patients and these beds are virtually always in use.
"Our nurses are constantly multitasking and are interdisciplinary in their role[s]," said Darcy Keep, RN, nursing director of 5-East and an ADVANCE editorial advisory board member. "They need to be educated psychiatric nurses in the broadest possible sense. They have to be familiar with diagnoses across a large range of mental health issues and work efficiently with patients suffering from depression, schizophrenia, chemical dependency or other problems. They also need to be alert to the individual patient and those occasions when dual diagnosis is present. This is frequently the case, because alcoholism or other dependency issues are so often a component or underlying part of mental health problems."
At Cottage, like any other detox unit, the greatest number of patients are alcoholic. It is well-known that detoxification from alcohol is the most medically dangerous of all forms of detox. There are times when laboratory values checked in the ED are so seriously awry that a patient may be given a bag of IV fluid before coming to the unit. And, on rare occasions, a patient may be sent to a medical floor to be stabilized for a day before coming to 5-East. This happens if the patient has a serious cardiac problem or other condition in addition to alcoholism and requires specialized medical treatment at the onset of detox.
Nurses on 5-East know the detox regime thoroughly, using most often Valium®, Librium, Vistaril® and Restoril® over a few days to a week for the typical alcohol detox. Any number of other characteristic complaints including pain, nausea and vomiting; diarrhea and cramps may arise, and these are generally treated with typical medications like Phenergen®, Compazine®, ibuprofen or Bentyl®. With opiate detox patients, additional medications are used, including clonidine and Robaxin®, which address specific signs and symptoms of opiate withdrawal; and trazadone is used for insomnia. On rare occasions, a patient may present with drug-induced psychosis from substances like cocaine or methamphetamine, and medications like Haldol® or Zyprexa® may be used.
The medical difficulties are most often the less formidable part of the job when compared with individual personal relations with the patients and management of the milieu. Detox patients are not always the most cooperative or willing patients. They may have been compelled into the hospital by family or an employer.
During detox they may suffer from acute cravings. A whole range of stressful components may complicate the patient's situation and nurses become the vanguard of crisis management. They work to calm, educate and encourage the patient, and perform the same function with family members. At almost any hour of the day or night, the nurse is counselor, confidant and recovery guide for the patients, as well as for friends or family most involved with the patients while they are in the hospital.
"Keep in mind," said Keep, "an environment like ours is very social; patients are not just in bed, but are up and around much of the time in common areas or in group meetings. Nurses spend long periods talking with patients, educating or conducting groups. Nurses are the first resource from which the patient receives information about what will happen in detox and what the treatment options are after detox. And they are a continuous part of the therapy the patient receives while on the unit."
A Team Approach
Every day on 5-East the medical director, staff doctors, case management and representatives from the nursing staff meet. During these meetings, treatment plans and the status of every patient on the unit are discussed. Keep likes to point out that on a unit such as 5-East the professional atmosphere is highly collaborative. The whole nature of a unit addressing behavioral health issues requires extensive discussion among all the components of the staff, nursing having a very large voice. A general understanding and consensus about the situation and treatment of each patient is reached through continuous dialogue among the staff members.
"[There is] a genuine team approach with a common understanding of the needs of the patient, and how we are going to address those concerns is a major focus," remarked Billie Pauletto, RN, a nurse on 5-East. "Given the history of our unit, as well, we all have had a good education in listening, learning and being gracious."
5-East, as a unit, has existed for 6 years. Prior to that time, as was almost universally the case, psychiatry and chemical dependency were separate units. Treatment of alcoholism in any kind of organized medical way goes back to at least the 1920s when psychiatry, using standard counseling and analysis, tried to uncover the reasons for the illness. Organized medicine had little success in this approach. Alcoholics Anonymous (AA) became well-known and respected in the 1940s as a support group for alcoholics, but its treatment philosophy was not immediately accepted as the standard treatment model. The Hazelden Foundation and Johnson Institute in the 1950s and 1960s were the pioneers in creating month-long, inpatient programs that incorporated the AA 12-Step philosophy.
Cottage Hospital created a chemical dependency unit in the 1970s when such a department within hospitals was becoming very widespread. Treatment then would include detox and recovery education all within the hospital over the course of a month. Following the new pattern in the 1990s, Cottage separated detox and inpatient recovery. Detox remains in an acute hospital setting and Cottage Residential Center is a separate off-site recovery program. Ideally, chemical dependency patients detox on 5-East and then transfer to the residential program, which happens often.
"To a very large degree, the hospital combined psychiatry and chemical dependency," commented Pauletto. "When I think about it now, it astounds me how really separate we were. In theory, we were all familiar with a large range of diagnoses and treatments, but in practice we tended to be somewhat narrow and doctrinaire. Our approach now is more varied and nuanced, with greater attention focused on the patient as an individual. The patients have greatly profited from this change and the knowledge base of the nursing staff is much broader."
Nursing in a chemical dependency environment carries with it a variety of demanding challenges and some wonderful opportunities to improve the lives of others. Chemical dependency is a very treatable disease and the nurse involved in any level of care soon discovers the patients' gratitude and knows they have begun a process that can lead to a lifetime of recovery.
Dean Stewart is a chemical dependency clinician at Santa Barbara Cottage Hospital.