Addictions nursing is a specialty that integrates strong med/surg and mental-behavioral health nursing along with knowledge of addictive diseases and treatment modalities to optimize patient care and recovery outcomes. The nature and complexity of addictive disorders coupled with the prevalence of this patient population in various healthcare settings make it essential that every nurse, especially the emergency department nurse, has a basic knowledge of the disease of addiction.
The CDC reports the cost of substance abuse to the nation's taxpayers to be more than $484 billion per year.1Despite public health efforts, substance dependence, including use of licit and illicit drugs, alcohol and smoking, remains a serious societal burden and a leading preventable cause of morbidity and mortality.2
Addiction is a chronic, incurable, but treatable brain disease. Patients with this disease undergo recurrent cycles of relapse and recovery. Much like other chronic diseases, such as diabetes, hypertension and heart disease, patients usually receive care during an acute phase of the illness and are stabilized with the aid of medication. Pharmacotherapy during the acute care stage aims at interrupting the addictive process through medically supervised detoxification and relieving withdrawal symptoms and discomfort.
Continuing care involves counseling and behavior modification with hope of guiding the patient toward a recovery lifestyle. Depending on the diagnosis and most recent assessment, referral is made for inpatient or outpatient care. Addictions nurses work in partnership with patients and in collaboration with the interdisciplinary treatment team to foster patients' understanding of how the disease of addiction affects their physical, mental, emotional, spiritual and social health.
Sustained sobriety is achieved through continued monitoring, compliance with prescribed medication, lifestyle changes and avoidance of people, places and things that link the individual to addictive behaviors. Only a small percentage of patients are able to maintain lifelong recovery after one treatment episode. The majority need multiple treatment episodes and treatment systems. Interventions address the long-term aspects and cyclical dynamics of the disorder.3 Prolonged participation in self-help support groups often is recommended as well.
Research has shown support group participation to be a major predictor in maintaining abstinence.3
Most of the support groups use the 12-step plan with the exception of LifeRing, which uses a "3S" philosophy based on sobriety, secularity and self-help. The recovery process is based on the "S-to-S" connections with other human beings.4
Addictions nurses employ a person-centered approach in caring for their patients. Shared decision-making, protecting self-determination and ensuring informed consent are all characteristics of this treatment philosophy. Nurses, as well as other addictions clinicians, have the task of engaging patients in these specific aspects of treatment, which requires a connection with the patients. This connection is built on trust, respect and the ability to convey to the patients that the ultimate outcome - recovery - is in their best interest. These efforts take time, a commodity often not afforded to the caregiver.
Person-centered care also requires caregivers to set aside personal prejudice and biases and be willing and prepared to accept the patient's unique goals, wishes, spiritual beliefs, culture and hopes. That is not an easy task, as the patient's addictive behavior may pose roadblocks to the recovery process. For instance, a patient struggling with addictions may use substances during treatment. Although the behavior is well-documented in the research to be symptomatic of addictive disorders, if discovered, this patient would be offered a possible referral to an alternate care setting to protect the sobriety of the other patients in treatment. However, the patient in the acute state of a relapse may decide to give up entirely. This hypocrisy, where treatment systems admit to medically accept the disease but social policy does not support some of the symptoms of the disease, threatens the recovery process for patients during the time they are most in need of treatment.
Further complicating the treatment of patients with addictive disorders is the interrelation they share with criminal behavior and mental illness. There seems to be a trilogy, an alliance, among the three elements. Few patients presenting for addiction treatment have addiction as their only concern. Patients with addiction either have a co-occurring medical/psychiatric diagnosis or have criminal justice involvement requiring the addictions nurse to have knowledge of both mental health and criminal justice processes. As each disorder or problem intermingles, impacts and complicates the other, this knowledge helps the addictions nurse in planning holistic care for the patient.
Research findings have shed light on this alliance, but more is needed in terms of developing effective treatment strategies. Strategies that consider the conundrum of this trilogy are essential to improve recovery outcomes for patients with addiction and co-occurring complications. Current systems address these issues primarily and singularly in a number of settings. However, lack of collaboration among systems and social policies again fail many patients in their attempts at recovery.
In addition, the aging process has its own effect on addictive disorders and the care setting. When the normal aging process blends with decades of substance use, the risks of health complications for the patient rise, resulting in a drastic increase in patient acuity.
For example, the patient who started using drugs at the age of 13 and is now in his 50s has spent decades ignoring his self-care to maintain his addiction. This patient may present with many diagnoses such as diabetes, hypertension, hepatitis, pancreatic disease, heart failure, HIV, mental illness and polysubstance abuse.
Addictions nursing is challenging, rewarding and a necessity society simply cannot do without. Patients with addiction are much more impaired today than they were only a decade ago. The addictions nurse is often the only medical person on duty during the off-shift hours in many inpatient settings as treatment centers try to manage healthcare cost constraints.
During the early phase of recovery, patients are often discovering physical and mental health symptoms for the first time. Although these symptoms may not be new, they were either masked or relieved by drug use. Keen assessment skills and the ability to work under pressure are requisite for this nursingspecialty. The addictions nurse employs a unique blend of motivational interviewing techniques, critical thinking and the nursing process to facilitate patient care. The field is in dire need of nurses to care for this neglected segment of the patient population. n
References for this article can be accessed at www.advanceweb.com/nurses. Click on Education, then References.
Berthilde Dufrene is nurse administrator at R.E. Blaisdell Addiction Treatment Center, Orangeburg, NY, and adjunct nursing faculty at SUNY Rockland Community College, Suffern, NY.
International Nurses Society on Addictions
Substance Abuse and Mental Health Services Administration
Addictions nursing is a relatively young field in comparison with other nursing specialties. It requires a combination of nursing and counseling skills to meet the holistic needs of patients with addiction.
There are two available certifications: certified addictions registered nurse (CARN) and certified addictions registered nurse-advanced practice (CARN-AP).
The first certification was granted in 1989 by the Addictions Nursing Certification Board. Today, there are 369 CARNs and eight CARN-APs nationwide. CARN-APs hold a master's degree or higher in nursing.
The 4-hour computerized certification examinations are offered twice a year. Nurses who wish to apply for CARN and CARN-AP certifications may request an application from email@example.com. At times, a paper-pencil exam is offered during the International Nurses Society on Addictions (IntNSA) annual educational conference. The IntNSA held its 32nd annual conference Oct. 1-4 in Atlanta.
Nurses are eligible to sit for the exam when they have at least 3 years of experience as an RN of which a minimum of 4,000 hours or 2 years are addictions related. Current CARNs or nurses who meet eligibility criteria for CARN and hold a master's degree or higher in nursing with a minimum of 500 hours of supervised direct client contact in advanced clinical practice in addictions/psychiatric/mental health nursing may sit for the CARN-AP examination.