Harm Reduction: Compassionate Care Of Persons with Addictions

Addiction is defined as the need for and use of a habit-forming substance despite knowledge the substance is harmful. Addicted persons experience tolerance (more and more of the substance is required to achieve the same effect) and in the absence of the drug, they experience withdrawal symptoms (Merriam-Webster, 2009). Addictions of all kinds (e.g., drugs, alcohol, nicotine, gambling, and eating disorders) result in substantial costs to individuals, families, and society. They may lead to crime and violence, and they cost employers and taxpayers approximately $590 billion annually in lost productivity and medical treatment (Addiction Treatment Magazine, 2012). While significant, however, these financial costs do not begin to approach the personal costs to individuals and families who struggle with addiction.

The Harm Reduction Coalition (n.d.a), a national advocacy group for persons affected by drug use, has noted that social inequality affects persons from different groups in different ways, and works to insure even those with drug addictions have their rights honored, including the right to health care. Nurses and other health care professionals can play a vital role in the care of persons with addiction. When persons with addiction are approached by providers with disdain and rejection, no matter how subtly, they may reject the care offered by these providers. In fact, negative behaviors such as these may result in a missed opportunity for the addicted person to learn about important treatments. Incorporating harm reduction strategies and evidence-based interventions in working with persons with addiction yields the best opportunities for helping them get the care and treatment they need (Copenhaver, Lee, Margolin, Bruce, & Altice, 2011; Dutta, Wirtz, Baral, Beyrer, & Cleghorn, 2012). In this article, the science of addiction will be reviewed, with discussion of how nurses can be helpful to persons with addiction by taking a compassionate approach to their care.

Addiction

While addiction has been viewed historically as a moral failing or lack of individual self-control, it is now recognized and treated as a chronic brain disease often associated with relapses (Courtwright, 2010; Ersche, Williams, Robbins, & Bullmore, 2013; Vrecko, 2010). Although addiction is influenced by environmental, genetic, and behavioral attributes, after initial exposure to a substance, addiction is driven by neurochemical changes in the brain that occur as a result of substance exposure (Kreek et al., 2012). Under the influence of many drugs, including nicotine, opioids, and alcohol, the level of available dopamine in the brain increases, creating the “high” associated with drug use. With continued use, tolerance for the substance increases and the person requires more and more drug to achieve the same feeling or even to achieve normal functioning (Goforth, Murtaugh, & Fernandez, 2010). Thus, once a person is addicted, the person's brain and its natural functions are affected markedly by drugs and the desire to obtain them (Ersche et al., 2012).

Addiction results in organ function changes similar to other chronic diseases. Addiction affects the circuitry of the brain in many ways, including those circuits involving reward, memory, learning, motivation, motor activity, and the ability to inhibit behavior. Addictions also affect several neurotransmitter pathways (e.g., dopamine, serotonin), and the changes can result in inability to stop the drug use, even when life is affected negatively. With proper care, many addicted persons can be treated successfully (National Institute on Drug Abuse [NIDA], 2008), but some persons may struggle with their addiction throughout life (Markel, 2011).

The majority of addicted persons began their illness trajectory in adolescence. Adolescents' brains react differently to substances than do adults' brains. Also, individuals differ in their susceptibility to drug addictions. Research has confirmed 40%-60% of the predisposition to addiction can be attributed to genetics (NIDA, 2008). A person's environment and level of development are also important factors. Adolescents are more apt to engage in risk-taking behaviors, including experimenting with drugs, and thus experience marked risk for addiction (NIDA, 2011).

Attitudes of Health Care Providers and Others

Addiction is often an emotional and uncomfortable topic for health care providers. Even popular media sometimes portray addicted individuals negatively. Persons who struggle with addiction often are depicted as criminals or prostitutes, weak, lazy, and morally corrupt.

Current society stigmatizes addiction, and nurses are susceptible to the same ways of thinking about persons with addiction. Howard and Chung (2000a; 2000b) reviewed 30 years of research on nurses' attitudes toward persons with addiction. While some improvement had occurred over time, many nurses still held negative views of individuals who abuse substances. In fact, nurses were more judgmental than were other health care workers. In a newer study of nurse and physician attitudes regarding injection drug users in New Zealand (Brener, Von Hippel, Kippax, & Preacher, 2010), care providers who believed users were in control of their addictive behavior attributed other health care conditions suffered by the user to the drug use. In a study of nurses in the United Kingdom, Monks, Topping, and Newell (2013) found most of the interviewed nurses had negative views of injection drug users.

Hamdan-Mansour, Mahmoud, Asqalan, Alhasanat, and Alshibi (2011) found nurses in emergency departments in Jordan had negative attitudes toward individual behaviors they interpreted as being feigned in order to obtain drugs (also known as drug-seeking behavior). Negative attitudes by caregivers toward persons with addiction may affect a caregiver's willingness to assess patients for substance problems, affect caring relationships with persons suffering from addictive diseases, and exacerbate avoidance of health care by those with substance problems (Howard & Chung, 2000a).

In general, negative attitudes of health care providers have a negative impact on the care these patients receive (Brener et al., 2010; van Boekel, Brouwers, van Weeghel, & Garretsen, 2013). In addition, persons who experience stigmas are more likely to have negative attitudes toward treatment for their problems (Conner & Rosen, 2008). According to Sellman (2009), the old approach toward addicts of “Come back when you're motivated” (p. 105) is not acceptable and not helpful. The Harm Reduction Coalition (n.d.b) encourages a nonjudgmental attitude on the part of the care provider as the best approach when working with persons with addiction and also as a way to help affected persons avoid harm from their addiction.

Effective Interventions

Replacing negative attitudes with evidence-based interventions to treat persons with addiction is key in helping them achieve the highest level of health possible. Cleary, Hunt, Malins, Matheson, and Escott (2009) found the knowledge and attitudes of caregivers and family members toward persons with co-morbid psychiatric illnesses and substance abuse could be improved through education on substance use/abuse and strategies to support those experiencing these conditions. However, even among trained substance abuse counselors, resistance is evident to adoption of evidence-based practices in the treatment of persons with addiction. Thus, education of all care providers about the nature of and treatment for addiction may be needed to improve health care (Ducharme, Knudsen, Abraham, & Roman, 2010). According to Anton (2010), recognizing addiction as a disease much like diabetes or asthma is the only way addictions and its sequelae will be addressed adequately, with more effective treatment approaches or even cures found.

Research indicates addictions/substance use and abuse are preventable, particularly by intervening with children and adolescents early before problems develop and before brains are altered (Fang, Schinke, & Cole, 2010; Schwinn, Schinke, & Di Noia, 2010). The National Institute on Drug Abuse (2010) has a useful booklet that contains research-based information about how to prevent abuse/addiction. Evidence also indicates persons with addiction are ill, just as persons with heart disease or kidney disease are ill (Roy & Miller, 2010). Acknowledging addiction as an illness and applying evidence-based treatments/interventions in working with an ill individual are critical to proper care. A person with an addiction can recover if given the proper care and treatment, but an addicted person is unlikely to recover alone (NIDA, 2008).

Because about one-third of injection drug users ages 18-30 and 70%-90% of older or even former injection drug users are infected with the hepatitis C virus (HCV) (Centers for Disease Control and Prevention [CDC], 2011), health care providers should give these persons information about the disease (transmission, symptoms, course of the illness, treatment) and ways to keep their loved ones safe from the infection. Nurses also can give persons with addiction information about hepatitis A and B (transmission, symptoms, course of the illnesses, need for vaccines), and identify any sources where persons at high risk may obtain vaccines at no cost. Most injection drug users know not to share syringes, but they do not know the HCV can live outside the body and remain infectious for up to 4 days (CDC, 2009). This knowledge can help addicted persons understand they should not share supplies (e.g., cookers, cotton balls, tourniquets) or needles.

Harm reduction information also can be given to addicted persons (Winstock, Nittis, Whitton, & Lea, 2009). Nurses can provide information about basic wound care, overdose prevention, intervention in case of overdose, phlebotomy skills, and sexual health and human immunodeficiency virus prevention strategies. In the community of persons with addiction, many myths exist about what to do in case of an overdose. Some of these are potentially dangerous. Providing accurate information about response to overdose could save lives. Teaching basic phlebotomy skills may help persons with addiction because they may not know simple anatomy, such as the difference between veins and arteries, and what to do in case an artery is accessed with a needle. Providing basic knowledge to persons with addiction could not only help these persons more safely use their drug of choice, but could help in the development of a trusting relationship that might lead the person to seek help to overcome the addiction. Persons with addiction also need information on how to dispose of syringes and other drug administration items safely. Lack of information not only puts these individuals at risk, but also others. These suggestions come from a harm reduction perspective (Harm Reduction Coalition, n.d.b).

Motivational interviewing is one intervention with some evidence to support its effectiveness in reducing the abuse of substances (Livingston, Milne, Fang, & Amari, 2012). Through therapeutic communication with a trained counselor, the addicted person is guided to identify the problem and make decisions about goals for the future. The focus is not on convincing the person to follow a particular course, but rather to examine the consequences of current behaviors and potential behavior changes (Smedslund et al., 2011). Even though persons with an addiction may not be ready to seek treatment, nurses and other health care providers can offer information about self-help groups (e.g., Alcoholics Anonymous, Narcotics Anonymous) and drug treatment programs. According to the National Institute on Drug Abuse (2012), self-help groups can be very useful to the person recovering from addiction by adding to the effects of other professional treatment programs. These groups provide support to the recovering person, promoting abstinence and other aspects of healthy living. Even if the person is not prepared to embrace any of the options when information about potential treatment is presented, the authors' experience indicates the person will have at least some knowledge of treatment for potential use at a time when he or she is more amenable. Toward that end, nurses in all settings should have access to a list of potential local treatment options to provide to persons with addiction.

Discussion and Implications

When a person with addiction perceives a care provider is negatively judgmental, he or she may react in angry and hostile ways that are helpful to neither of them. To help avoid anger and hostility, conversations between addicts and nurses must start with compassion and care. Individuals with addiction may react with less hostility if they do not believe they have to defend themselves. According to Monks and colleagues (2013), lack of knowledge by nurses about addiction and their negative attitudes toward addicted persons perpetuates poor care given by nurses to persons with addiction.

Some nurses may feel uncomfortable with helping a client live an addicted life. Assisting someone to manage the effects of addiction in the healthiest way possible can seem to be abdication of the health-promoting responsibility of the nurse. However, nursing practice acts such as those in North Carolina (North Carolina Nursing Practice Act, 2009), New York (New York State Education Department, 2013), and California (California Board of Registered Nursing, 2013) generally allow the nurse to perform health counseling and teaching to assist all clients toward an optimum state of health. When nurses care for addicted persons with care and compassion, they help these clients live as healthy a life as possible given their circumstances and the life choices they have made. Although a nurse would not suggest a patient use illegal drugs, teaching him or her to reduce the adverse health effects of this practice and avoid spreading infection would not violate ethical standards or nursing laws. For example, in a supervised injection facility in Canada, while clients inject themselves with drugs, nurses do health teaching in an effort to reduce the harm that could come with this behavior. The nurses take the opportunity to promote health services and addiction treatment to clients (Lightfoot et al., 2009). While many cities in other countries have safe injection facilities, and efforts to open them in San Francisco and New York began several years ago, there are no such facilities in the United States (Drug Policy Alliance, 2013). Nurses often provide care in this way for other patient groups. For example, smoking cigarettes during pregnancy is known to be harmful to the fetus. In addition, exposing a newborn to secondhand smoke increases the likelihood of neonatal illness and death (American Cancer Society, 2013). However, if a pregnant woman or new mother refuses to stop smoking cigarettes, nurses do not refuse to treat her. Instead, they may discuss reducing the number of cigarettes smoked during pregnancy, not smoking in the house or car with the baby, and keeping cigarettes out of children's reach. Although the ultimate goal is smoking cessation, nurses treat the woman as she is and help her to make the best possible health choices until she is able to overcome her addiction. The authors suggest the same practices may be useful when working with persons who are addicted to drugs and alcohol.

Regardless of how or why an addiction begins, nurses in medical-surgical settings often find themselves caring for patients who have an addiction and co-morbid medical or psychiatric problems. These nurses often have not had sufficient education about addiction and its treatment (Monks et al., 2013). Persons with addiction are typically more immune-compromised and have poorer nutritional and hydration status than those without addiction. Addicted persons also often are reluctant to seek health care, so they present to a health care facility with more advanced illness. Once admitted to a hospital for treatment for a medical condition, individuals with addiction are often reluctant to remain in the hospital for the required treatment period (Ford, Bammer, & Becker, 2008). Patient self-esteem and treatment outcomes are affected negatively by negative attitudes of health care providers (van Boekal et al., 2013). For example, addicts may leave hospitals without completing treatment because they are denied medications that could help them through the withdrawal process (Monks et al., 2012).

According to the National Institute on Drug Abuse (2008), effective treatment of persons with addiction requires treatment of the whole person. Medications are an effective component of treatment for some substances; behavioral therapies are also important because they can help addicted persons stay in treatment longer. Finally proper social services are a key element. No single effective treatment plan exists for all addicted persons, and entering treatment on multiple occasions may be required for ultimate successful rehabilitation. When a person is in treatment, he or she needs to be treated holistically; that is, other problems must be addressed as well as the addiction. For example, high co-morbidity exists between addiction and mental illness. Because relapse is a common problem for addicts, health care providers need to be alert to signs of relapse and ready to offer resources for treatment.

Conclusion

Persons struggling with addiction its need nonjudgmental care from health care providers in order to help them reduce their risk of harm associated with their addiction (Harm Reduction Coalition, n.d.b). Because nurses have more face-to-face interactions with patients in many treatment settings than any other health care provider, they are in a unique position to affect the health and well-being of persons with drug and alcohol addiction in a positive way. However, they must have knowledge about addiction and the treatment in order to be effective caregivers (Psychiatric Mental Health Substance Abuse Essential Competencies Task Force, 2012). While being nonjudgmental and treating affected persons with kindness and compassion will not save all of them from harm, it could help many who flounder.

The science behind addiction is explored. Strategies for nurses to use in caring for persons with addiction are provided. Harm reduction for persons with addiction is described, and ways nurses can provide care from this perspective are explored.