COVID-19 Impact on Teaching Substance Use Disorders

Abstract

Vulnerable populations such as those with substance use disorders (SUDs) are at a higher risk for early morbidities and mortalities yet are less likely to receive primary care and other necessary psychosocial services essential for comprehensive care of these clients. This need has been magnified by the COVID-19 pandemic. Evidence supports an increase in alcohol sales in 2020, and overdoses from illicit drugs have been reported to have more than doubled by May 2020 from the 2018 and 2019 baseline rates, and one reason for these increases is because of COVID-19. The healthcare system is overwhelmed with the cost of treating and addressing the impact of SUDs. Individuals with SUDs often meet providers who are not sufficiently prepared to address their complex issues that include co-occurring mental and physical health disorders. In addition to changes in practice, nursing education must change their curricular approach to meet the challenges in health services across the life span, and nursing education should include lessons being learned during the COVID-19 pandemic. Nurses must be prepared to recognize and screen individuals for SUDs at the undergraduate level as well as assess and treat individuals with SUDs at the advanced practice level in all areas of healthcare services. SUDs should not continue to be siloed and separated into the psychiatric–mental health nursing course within the nursing curriculum but should be addressed in multiple specialties across the curricula and include health responses in regard to the impact that the COVID-19 pandemic is having on SUDs.

The current opioid epidemic is driving the change of focus on substance use disorders (SUDs) in the healthcare system today. According to the 2018 National Survey on Drug Use and Health (NSDUH), an estimated 164.8 million people aged 12 years or older in the United States (60.2%) were past-month substance users of any drug of abuse. The 164.8 million past-month substance users in 2018 include 139.8 million people who drank alcohol, 58.8 million people who used a tobacco product, and 31.9 million people who used an illicit drug (Substance Abuse and Mental Health Services Administration [SAMHSA], 2019). In 2018, about 946,000 adolescents aged 12–17 years needed substance use treatment in the past year; however, 787,000 adolescents between the ages of 12 and 17 years did not receive any substance use treatment in the past year. In addition, 5.2 million young adults aged 18–25 years in 2018 needed treatment for a substance use problem in the past year; however, 4,653,000 young adults aged 18–25 years did not receive any substance use treatment in the past year. Furthermore, about 15.1 million adults aged 26 years or older in 2018 needed substance use treatment in the past year, but 12,100,000 million adults did not receive any substance use treatment in the past year (SAMHSA, 2019). Currently, there is a call for increased integration of primary care services and SUD services by Health and Human Services and SAMHSA for medication-assisted treatment (MAT) and opioid use disorder (OUD) services (Pace, 2017). Although SUDs are identified as a major health concern both nationally and internationally, there are few healthcare providers who have adequate education and experience in providing care to patients with SUD.

In a recent issue of the Journal of Addictions Nursing, the Guest Editorial provided by Moller and Fornili (2016) states that the all-time-high need for treatment of SUDs is now. According to SAMHSA (2014), an estimated 20.2 million Americans (8.4%) experience SUDs. Moller and Fornili note that, for this population to receive care, a sea change is needed in the current healthcare system. In addition to this, it is noted that those with both SUDs and mental health disorders need to be treated in the criminal justice system. This is because of drug arrest rates growing by over 90% between 1980 and 2014. It is important to note that drug arrests are far more because of nonviolent crimes than of violent crimes and that intervening with this population would not only be humane but that treatment would save money over incarceration (Granfield & Eby, 1997). In addition, emerging research shows that longer spells of incarceration increase the recidivism rate (Moller & Fornili, 2016).

According to SAMHSA (2019), most people with SUDs are at a greater risk for having co-occurring disorders including mental health and chronic medical disorders. In addition, there is a shift in focus to prevention and early intervention (Strobbe, 2013). Currently, at this junction in time, there is a lack of consistency in practice of integrating SUDs and co-occurring disorders in primary care. According to evidence practice, there is a need to identify a standard of care that is of the optimal degree of integration to ensure patients with SUDs and co-occurring disorders receive the care that addresses their multidimensional needs. In addition, barriers to implementing integration must also be identified and addressed (Sterling et al., 2011). In addition to these changes needed in clinical practice, nursing education must change their curricular approach to meet the changes in health services across the life span and include lessons being learned during the COVID-19 pandemic. The purpose of this article is to identify the components of integrated care for SUDs so we may better prepare nurses during their education to operationalize this new standard of care.

CO-OCCURRING DISORDERS

Substance use co-occurring disorders include various medical and psychiatric disorders, gender differences, and age group differences. Tables 1 and 2 provide highlights of theoretical and research literature addressed in this review. Persons with severe mental illness (SMI) and addiction are at a higher risk for early morbidity and mortality than the general population but are less likely to receive care and preventative health services. According to the 2018 NSDUH (SAMHSA, 2019), adults aged 18 years or older who had both a mental disorder and an SUD in the past year are referred to as having co-occurring disorders. In NSDUH, the presence of mental disorders is defined as having either any mental illness (AMI) or SMI, and SUDs refer to the presence of either alcohol use disorder or illicit drug use disorder.

TABLE 1.

Theoretical Articles: Substance Use Co-Occurring Disorders

Integration of Substance Use and Behavioral Health Into Primary Care
Author, Year	Issue	Recommendations
Daley (2017)	- Opioid epidemic led medical providers to focus on SUDs. - Alcohol and nicotine also leading to medical problems - Care for SUDs often disconnected from medical practice - Providers have limited skills - Too few people with SUDs receive help	- Screen for substance use with brief screening instruments (Drug Use: Opioid Risk Tool, CAGE, DAST, AUDIT-C) - Full assessment by licensed addiction providers - Educate patients and families to get help and medication-assisted therapy (MAT); naloxone - Consider impact on family and alternative treatment for chronic pain
Pace (2017)	- American Surgeon General report on alcohol, drugs, and healthcare for increased integration primary care and substance use/services (strongly integrated with other medical conditions) - Insufficient training of healthcare professionals to identify and treat SUDs - Over 42,055 Americans died from drug overdose in 2014. - Addiction is a chronic disease that makes a person at risk for other diseases. - Addiction costs U.S. $442 billion annually.	- All of us can play a role in preventing substance use and intervening before tragedy. - Evidence-based public health approach: prevention, treatment, and recovery as top priority - MAT; NPs and PAs for opioid use disorder treatment with buprenorphine - Increasing use of naloxone to reserve overdoses
Strobbe (2013)	- Substance use disorder as the leading healthcare concern nationally and internationally - Few primary care providers have sufficient education to address the problem - One in four deaths in the United States attributable to substance use - One in four children in the United States exposed to alcohol abuse before 18 years old, and more than half of all adults have an alcoholic family member.	- Shift to prevention and early intervention - Screen for heavy drinking - Alcohol screening and brief intervention for youth (increased risk for alcohol dependence later in life) - Screening for drug use in general medical settings - Screening, brief intervention, and referral for treatment
Sterling et al. (2011)	- Most people with alcohol and drug use disorders have co-occurring disorders of mental health and medical problems. - Integrated care is the exception. - Barriers include differences in provider education, organizational factors, financial issues, and stigma. - Methodological problems such as small sample sizes	- Few studies done, but opinion is that integrated care can improve outcomes. - Optimal integration still unknown and barriers remain - Recent research provides some evidence that integrated treatment improves outcomes.

Substance Use and ED
Author (Year)	Issues	Recommendations
Bernstein et al. (2017)	- Boston Medical Center has a 3-year grant to hire outreach workers to work with medical team to identify patients with substance misuse needs, intervene, and offer resources.	- First nationally cited program in an emergency department - Project Assert successful in improving alcohol and substance use disorder services, education, and referral to treatment

Substance Use and Women
Author (Year)	Issues	Recommendations
Terplan et al. (2015)	- Stigma against individuals with SUD is magnified for pregnant women. - Punishing pregnant women is counterproductive and not based on scientific evidence.	- Both the pregnant woman and the fetus benefit from supportive environment. - Pregnant women who use substances deserve care, not punishment. - SUD should be treated as a medical condition.
Nurse Practitioners in Women's Health (2017)	- National Association of Nurse Practitioners in Women's Health concerned about use of opioid pain relievers (OPRs)	- Use of OPRs should be reserved for acute pain. - Use of risk mitigation strategies should include checking state prescription drug monitoring programs, avoiding concurrent prescriptions of benzodiazepines, and considering co-prescribing of naloxone when appropriate and education to use it - Use MAT, which includes counseling and behavioral therapies - A recovery-oriented treatment approach to improve retention in treatment and birth outcomes - Screen all women at least annually for substance use.
Jones (2015)	- Substance-using pregnant women often feel like social outcasts. - Research indicates positive outcomes can result from coordinated care of multiple service providers. - Recent research suggests no long-term consequences of prenatal exposure to cocaine. - It is estimated 50% of infants exposed prenatally to opioids will experience neonatal abstinence syndrome (NAS) - NAS symptoms include central nervous system, gastrointestinal, respiratory, and autonomic dysfunction - Case study of a pregnant woman with a urine positive for opioids and marijuana who felt treated “like a drug addict” during her pregnancy - Both cigarette smoking and alcohol use can harm a fetus. - Cigarette smoking increases risk of intrauterine death, preterm delivery, lower birth weight, respiratory distress, cardiac malformation, and neonatal death. - Alcohol use can lead to fetal alcohol spectrum disorders. - Fetal alcohol syndrome is the most severe form. - Fetal, infant, and child exposure to marijuana is poorly understood.	- Treatment includes nicotine patch and naltrexone. - Treatment during pregnancy includes opioid antagonists (methadone and buprenorphine) and opioid antagonists (naltrexone). - Behavioral treatment for addiction was in an outpatient program. - Psychological services focused on psychoeducation and counseling, parental relationship skills, family planning, nutritional counseling, and healthy lifestyle.
Decker et al. (2017)	- A literature review shows there are several limitations: a general lack of available research, possibility of underreporting prenatal drug use, limitations in assessments used, and the prohibition of medication-assisted treatment by Medicaid. - No studies have been published on the long-term effects of buprenorphine. - Time and more research are needed to evaluate infant development implications. - Most are underreporting opioid use. - Hospitals often do not use same assessments for NAS. - Training to use scoring is extensive, leading to reliability problems. - Some assessment measures are outdated. - Low-income mothers often have trouble maintaining Medicaid coverage, which interrupts access to MAT.	- Research shows methadone is an ideal treatment for OUD and NAS and is being phased out by newer treatments. - Research suggests morphine is better for postnatal treatment for NAS whereas buprenorphine lessens effects of NAS on infants.

Infants and Children
Author/Year	Issues	Recommendations
Ko et al. (2017)	- NAS is drug withdrawal in infants after in utero exposure to opioids. - NAS usually occurs within 48–72 hours of birth. - Symptoms of CNS irritability (tremors), gastrointestinal dysfunction, and temperature instability - Incidence of NAS from 2000 to 2012 has increased approximately 400% nationally. - Burden on neonatal intensive care units - Hospital charges for all infants with NAS in 2012 were approximately $1.5 billion with probably 80% charged to Medicaid.	- Primary prevention includes responsible opioid prescribing. - Need increased availability of treatment for opioid use disorder to prevent infants with NAS

AUDIT-C = alcohol use disorders identification test; CAGE = cutting down, annoyance by criticism, guilt feeling, eye-opener; CNS = central nervous system; DAST = drug abuse screening test.

TABLE 2.

Research Articles: Co-Occurring Disorder

Author/Year	Issues	Results/Recommendations
Ede et al. (2015)	- Quantitative study by surveys given to n = 51 patients, n = 27 support staff, and n = 11 providers in an integrated setting in three primary health centers Limitations: - Variations in timing and procedures to collect data from different groups - Low response rate because of homeless shelter site; convenience sample - Limited range of scales - Did not capture spectrum of psychiatric disorders	- High-level satisfaction with integrated primary and behavioral health - Education increased collaboration, and diagnostic tools increase satisfaction and access to mental and substance use care for patients with chronic medical conditions.
Gleason et al. (2014)	- Studied N = 311 adults with severe mental illness and addiction at a higher risk for early morbidity and mortality - Gender may play a role in engaging in programs. - 46% women (n = 144), 54% men (n = 167) - Limitations: self-report measures, amplified rates of morbidity for serious mental illness, do not include transgenders	- One-way ANOVAs - Men had a higher rate of hypertension and triglycerides. - Women had higher rates of at-risk BMI.
delaCruz et al. (2016)	- N = 302 adult men and women in STimulant Reduction Intervention using Dosed Exercise (STRIDE) trials - Valid and reliable instruments, self-administered comorbidity questionnaire, and mental health scales Limitations: - Sample excluded patients with serious medical conditions that prevented exercise. - Participants may have undiagnosed conditions. - Exclusion of opioid-dependent patients; limited sample size of those with medical conditions	- Hypertension more common with cocaine use disorder - Liver disease more common in cocaine-plus-stimulant use - Coordinated care may optimize outcomes with medical comorbidity.

Psychiatric Consults by Medical Teams
Author/Year	Issues	Results/Recommendations
Pezzia et al. (2018)	- Exploratory study of psychiatric consultation requested by inpatient medical teams - N = 536 patients, N = 40 psychiatric consults - Inpatient medicine physician teams in two teaching hospitals from 2008 to 2013 Limitations: - Small team and patient sample - Only two hospitals and two medical teams - Did not examine missed new-onset behavioral conditions - Discussions outside observations	- Substance use, affective disorder, or suicide ideation most common (41.7%) - Requests for medication review being second (30.6%) - Cirrhosis with active substance abuse was the most common medical diagnosis (15), followed by alcohol withdrawal - Inpatient physicians need skill-building for management of medication and substance use management.

Other Co-Occurring Disorders
Author/Year	Issues	Results/Recommendations
Leeman et al. (2016)	- National Epidemiologic Survey on Alcohol and Related Conditions - Total (N = 839): cocaine only (n = 144), opioid only (n = 622), cocaine/opioid co-users (n = 73) were compared - Opioid-only users were largest Limitations: - Analyses were cross-sectional; whether participants received pain treatment, differences between opioid and heroin users, military affiliation	- Co-users did not have significantly higher incidence of psychiatric medical conditions - Opioid-only users were at the lowest risk of negative outcomes but less likely to seek treatment - Conclusion: Over the past 12 months, cocaine and/or opioid users had greater involvement with other substances and more psychiatric conditions than the general population.
Farris et al. (2015)	- Randomized controlled trial of two smoking cessation interventions (N = 395), treatment-seeking smokers Limitations: - Data analyses primarily cross-sectional; homogeneous sample highly educated and middle-to-upper socioeconomic groups' self-report BMI	- In men and women, older age, stronger expectancies about weight control effects of smoking, greater smoker-based avoidance because of smoking-related sensations, and less problematic alcohol use were associated with being overweight.

Substance Use and Emergency Department
Author/Year	Issues	Results/Recommendations
Woodruff & Shillington (2016)	- Exploratory study of N = 292 consecutively enrolled exclusive marijuana-only users visiting the ED; 17% (n = 107) reported using marijuana on medical advice, and 63% (n = 185) were nonmedical users - Participants denied using any other drugs with the exception of alcohol. - They completed the Addiction Severity Index Lite, which has satisfactory validity and reliability. Limitations: - Lack of information about participants' medical conditions, pain, reason for visit, and disability - Small sample size - Selection bias, cross-sectional data; generalizability limited because of low socioeconomic group	- In a multivariate model, compared with nonmedical marijuana users, medical users reported a higher frequency of use. - Medical marijuana users had higher severity scores for drug use, medical problems, and psychiatric problems, although nonmedical users had higher alcohol severity scores.

Women and Children
Author/Year	Issues	Results/Recommendations
Sherman et al. (2017)	- A 12-week, double-blind, placebo-randomized controlled multisite trial of N-acetylcysteine treatment of N = 302 patients (n = 86 women and n = 216 men) Limitations: - Inclusion/exclusion criteria limit generalizability; an analysis of baseline differences, not treatment outcomes	- Women reported greater withdrawal intensity (p = .001) and negative impact of withdrawal (p = .00) mostly because of physiological and mood symptoms. - Women were more likely to have lifetime panic disorder (p = .038) and current agoraphobia (p = .022) and reported more days of poor physical health (p = .006) and cannabis-related medical problems (p = .023). - Women reporting chronic pain had greater mean pain scores than men with chronic pain (p = .006). - Cannabis-dependent women may do better in an integrated treatment focusing on co-occurring psychiatric disorder and targeted treatment of cannabis withdrawal syndrome.
Corr & Hollenbeak (2017)	- A retrospective observational study of incidence of NAS in the United States and costs - Data from Kids' Inpatient Database (2003–2012) - Survey weighting used to estimate NAS births - Costs and lengths of stay estimated for NAS versus non-NAS admissions using ICD-9-CM codes - Primarily outcome measures were provider costs and lengths of stay. Limitations: - Use of a national hospital database relying on accurate ICD-9 codes, inability to track individual patients, underestimation of numbers because of missing data from two states with high incidence of NAS	- In 2012, NAS costs nearly $316 million in the United States. - The incidence of NAS is increasing in the United States. - Number of U.S. hospital admissions increased more than fourfold between 2003 and 2012.
Saldana (2016)	- Pilot, N = 31 mothers involved with Child Welfare Services for child neglect and severe substance use - Randomly assigned to standard treatment and experimental treatment for substance use - Instruments: the Parent Daily Report, a 31-item ordinal questionnaire with test–retest and interobserver reliability, the Child Behavior Checklist, the Parenting Stress Inventory, the Brief Child Abuse Potential Inventory, the Addiction Severity Index, the Trauma Symptom Inventory, and the Beck Depression Inventory, all with acceptable validity and reliability - The FAIR treatment program includes counselors, skills coaches, role-play, and new parenting skills. - Program of over 8 months while treating substance use disorder Limitations: - Small sample size; FAIR components evolved over the study period; limited grant resources prevented use of more advanced methods to track participants; state had changes in reporting procedures, sample geographically	- Mothers who received FAIR treatment were retained and more likely to complete treatment. - Treatment of co-occurring parenting and substance use needs might reduce the number of children in CWS and increase family reunification.

ED = emergency department; NAS = neonatal abstinence syndrome; ICD-9-CM = International Classification of Diseases 9th revision Clinical Modification; FAIR = families actively improving relationship; CWS = child welfare system.

In 2018, 47.6 million adults aged 18 years or older had an AMI in the past year. Approximately 9.2 million adults had both AMI and SUD, and this corresponds to 3.7% of adults. This 2018 percentage of adults with both AMI and an SUD was higher than the percentages in 2015 and 2016, but it was similar to the percentage in 2017.

Distinct treatment needs exist because of gender differences; women have more mood and anxiety disorders, whereas men have more psychosis and SUDs. Women are more at risk than men for physical illnesses such as metabolic syndrome and death from cardiovascular disease and diabetes mellitus than men (Gleason et al., 2014). In the STimulant Reduction Intervention using Dosed Exercise (STRIDE) trial for psychostimulant disorders, older patients with two or more conditions reported more pain, psychiatric disorders, and more physical function problems (de la Cruz et al., 2016). In a national survey on alcohol and related conditions (National Epidemiologic Survey on Alcohol and Related Conditions), Leeman et al. (2016) found that, over a 12-month period, cocaine and/or opioid users had greater involvement with other substances and more psychiatric and medical conditions compared with the general population. Cigarette smoking and obesity are two major public health problems. Older age, pressure to maintain a designated weight, and appetite control are all variables that are associated with being overweight (Farris et al., 2015). Pezzia et al. (2018) found that substance use, affective disorder, or suicidal ideation were the most common reasons for psychiatric consults by inpatient medical teams. Cirrhosis and alcohol were the second most common psychiatric consults by inpatient medical teams. Pezzia et al. concluded that physicians need training in medication and substance use management.

SUBSTANCE USE AND EMERGENCY DEPARTMENT

Drug use is a significant burden on the healthcare system because people who abuse drugs are very likely than nondrug users to use the emergency department (ED) as a source of primary healthcare (Woodruff & Shillington, 2016). An innovative initiative to address the needs of patients who have SUDs who come to the ED for their medical needs and SUD issues is Project ASSERT (Alcohol & Substance abuse Services, Education and Referral to Treatment) at Boston Medical Center, which is the first nationally cited program to provide alcohol and substance use services in the ED (Bernstein et al., 2017). This program is recognized as a major breakthrough for substance use treatment that meets the patients where they are in the ED. Historically, patients with SUDs who come to the ED are viewed as “med seeking” and were frequently turned away from the ED without being provided comprehensive treatment. Project ASSERT that was started in 1993 has provided care for over 80,000 patients and continues to evolve to meet the comprehensive needs of patients with SUDs (Greene et al., 2019).

SUBSTANCE USE IN WOMEN AND CHILDREN

There has been a 375% increase in the number of women seeking OUD treatment during pregnancy (Decker et al., 2017). Cannabis-dependent women may benefit from integrated treatment focusing on co-occurring psychiatric disorders and treatment of cannabis withdraw syndrome (Sherman et al., 2017). Pregnant women with SUDs experience additional stigma. Punishing pregnant women denies the interconnectedness of the mother–fetal dyad. This suggest that women who are pregnant and have substance use disorders are reluctant to seek obstetrical care and SUD treatment (Terplan et al., 2015). Women's health nurse practitioners (NPs) and others who provide healthcare for women should do the following: (a) use evidence-based guidelines for management of acute and chronic pain; (b) use risk mitigation strategies when prescribing opioids for acute and chronic pain; (c) assess pregnancy status, sexual activity, and contraceptive use before prescribing opioid pain medication; (d) use a nonjudgmental approach; and (e) screen all women at least annually for substance use with a valid screening tool (Nurse Practitioners in Women's Health, 2017).

Any amount of smoking can harm the fetus and newborn; fetal alcohol syndrome (FAS) is the most severe of fetal alcohol spectrum disorders. Children with alcohol neurodevelopmental disorder typically have lifelong cognitive and behavioral deficits, which are milder than fetal alcohol syndrome. Fetal, infant childhood effects of marijuana exposure are poorly understood, and research is mixed. Recent research suggest few, if any, long-term effects of prenatal cocaine exposure (Jones, 2015). Neonatal abstinence syndrome (NAS), a constellation of signs and symptoms of central nervous system dysfunction, includes gastrointestinal, respiratory, and autonomic nervous system problems. Opioid agonists (methadone and buprenorphine) and opioid antagonists (naltrexone) are medications that can stabilize pregnant women with OUD (Jones, 2015). The incidence of NAS is increasing in the United States and carries a huge burden on hospital days and costs. In 2012, NAS costs nearly $316 million in the United States; the U.S. hospital admissions increased fourfold between 2003 and 2012 (Corr & Hollenbeak, 2017).

As of March 2016, the Food and Drug Administration requires both sustained and immediate-release opioid medications to include a black box warning that prolonged opioid use during pregnancy, which might lead to NAS (Dowell et al., 2016). Access to treatment for maternal OUD and standardized treatment for NAS might decrease the impact of NAS (Ko et al., 2017). A pilot study of child neglect and parental substance use suggests that women in an integrated program that includes training in parental responsibilities and substance use recovery are likely to complete treatment for substance use and show better outcomes for meeting parental responsibilities (Saldana, 2016).

SUDS AND COVID-19

Stress may lead to increased use of alcohol, tobacco, or other drugs. The COVID-19 pandemic has been identified as causing anxiety and stress for most of the population. The Centers for Disease Control and Prevention (2020) has identified individuals who have an SUD as having a greater risk of relapsing or an increased use of abusing substances in response to the pandemic. Individuals using substances often have impaired judgment, which could include not following COVID-19 precautions of mask wearing, social distancing, and handwashing (NIDA, 2021). People with mental health disorders and SUDs are at a higher risk of having poor coping mechanisms. As a result of the social isolation and other stressors such as including working at home, lost income, or trying to homeschool children connected with COVID-19, there has been a substantial increase in alcohol sales and binging on alcohol or other substances (Dela Cruz, 2020). Evidence supports an increase in alcohol sales in 2020 (Pollard et al., 2020), and overdoses from illicit drugs causing cardiac arrests have been reported to have more than doubled by May 2020 from the 2018 and 2019 baseline rates (Friedman et al., 2020). Individuals who relied on Alcoholics Anonymous and Narcotics Anonymous meetings to maintain their sobriety were not able to attend their in-person meetings because of the restrictions on social gatherings. Attending 12-step Alcoholics Anonymous and Narcotics Anonymous groups fosters sobriety (Dela Cruz, 2020; Wilson et al., 2020). Meetings are now virtually online for those individuals who have access to a computer or smart phone. Unfortunately, there are individuals who do not have access to a computer or have limited broadband access (Wilson et al., 2020).

An additional concern related to SUDs and COVID-19 are the adverse medical complications that can result for those who contract the virus. Because COVID-19 attacks the lungs, it could greatly impact individuals with SUDs. In particular, those who smoke tobacco, marijuana, or vape are at a high risk for severe medical complications if they contract COVID-19. Persons with opioid and/or methamphetamine use disorders may also be at risk for severe medical complications because both of these drugs have negative effects on the respiratory system. According to Volkow (2020), opioids act on the brain stem to slow breathing, which may cause hypoxemia, and methamphetamines constrict the blood vessels contributing to pulmonary damage and pulmonary hypertension. In addition, individuals with SUDs are at a higher risk for contracting COVID-19 because of their vulnerability of being more at risk for homelessness and incarceration (Volkow, 2020).

In addressing the current impact COVID-19 has had on individuals with SUDs, it is essential that healthcare providers be informed of those changes that have occurred and provide care that is relevant to those changes. In addition to maintaining current on any changes to providing care because of the impact of COVID-19, healthcare practitioners should include providing education to both the family and individuals about the warning signs of relapse and offering tools to address the potential risks. A major area of practice that has changed as a result of COVID-19 includes patients who live in rural communities and who have been treated in person in the offices of primary care providers. These providers are rescheduling patients who have been stable and adherent to their treatment for SUD with MAT. Most providers are using telehealth as an alternative venue for treatment during the pandemic. Unfortunately, many patients in the rural communities have unreliable cell phone service or limited broadband access (Wilson et al., 2020). An additionally significant change has been that SAMHSA has temporarily modified the dispensing of methadone. Patients who are stabilized on methadone may attend the methadone treatment program every second week of the month and obtain a 14-day supple of medication (Dela Cruz, 2020). Some primary care providers who treat patients with SUDs in the rural Appalachian community prioritize the modality of patient visits based on patient acuity. Patients with high acuity must visit in person and increase in frequency of visits, whereas patients with low acuity may receive a phone call (Wilson et al., 2020). Healthcare providers have also been facilitating access to resources of treatment for those individuals having substance use issues during the COVID-19 pandemic (SAMHSA, 2021).

NURSING EDUCATION: INTEGRATION OF SUDS INTO CURRICULUM

Healthcare providers' attitudes and knowledge, especially as it concerns nursing education, will be addressed in this review and highlighted in Tables 3 and 4. Some healthcare providers have negative attitudes toward patients who have SUDs, and it is identified as a barrier to care (Chang &Yang, 2013; Meltzer et al., 2013). Often, healthcare providers stigmatize patients with SUD, which can result in providing less-than-optimal care for patients with SUD (Chang & Yang, 2013; McNeely et al., 2018; Meltzer et al., 2013; Neufeld et al., 2011). Efforts to address the barriers of negative provider attitudes include novel educational programs in both medicine and nursing programs and studies of the outcomes of these programs (Meltzer et al., 2013; Smothers et al., 2018). Education-focused training alone may not be sufficient to improve the overall attitudes and quality of care provided to patients with SUD (Chang & Yang, 2013; Meltzer et al., 2013; van Boekel et al., 2013). Multiple educational strategies that may include clinical supervision, practicing skills more than once throughout the curriculum, and other active learning modalities when designing SUD education were more effective in improving attitudes of nursing students in providing quality of care to patients with SUD (Finnell et al., 2018; Moore et al., 2017; Oermann, 2018). Furthermore, it is imperative to include in the education of nursing students their own self-awareness (which should include an inventory of emotional intelligence) and the impact negative feelings and biases may have on the nursing care provided to patients (Boyatzis, 2018; Coyne, 2020; Madva, 2018), including tools (such as keeping a journal and seeking supervision) of how students can continue to self-reflect and identify potential barriers to caring for patients with SUDs throughout their professional careers.

TABLE 3.

Substance Use Disorders, Attitudes, and Education of Healthcare Provider

Author/Year	Issue	Results/Recommendations
Meltzer et al. (2013)	- Some physicians have negative attitudes toward patients with substance use disorder (SUDs). - Quantitative study of a 10-hour addiction medicine course for improving attitudes among N = 128 internal medicine residents using the Medical Condition Regard Scale	- Mean baseline scores were lower for patients with alcoholism and dependence on narcotic pain medication than for patients with pneumonia and heartburn. - Participation in course associated with modest attitude improvement - Other efforts may be needed to ensure patients with stigmatized disorders are treated with the best care.
Neufeld et al. (2011)	- The Alcohol Medical Scholarship Program developed to improve medical education for SUDs - Mentoring of junior full-time faculty in U.S. medical schools	- Participation was associated with a fourfold increase in yearly SUD lecture time and topics. - An increased number of medical disciplines taught SUDs in clinical rotations and new SUD-related electives. - Increase in medical education committee membership - 60% of scholars received promotion
Chang & Yang (2013)	- A cross-sectional design study of N = 489 nurses working in two medical centers in Taiwan	- Age, total nursing experience, work unit, personal experience, experience of taking care of clients with substance use problems, substance use education in school, and continuing education were significantly associated with nurses' attitudes. - Hierarchical regression showed that continuing education predicted nurses' attitudes but with low variance. - Education not sufficient - Nurses must include multiple strategies such as clinical supervision to improve attitudes.

TABLE 4.

Substance Use Disorders and Nursing Education

Author/Year	Issue	Results/Recommendations
Oerman (2018) (Editorial)	- Because of the opioid crisis, substance use content can no longer be taught by one lecture in the mental health course or one place in the curriculum.	- Integrate substance use education throughout the curriculum - Provide opportunity to practice skills more than once to develop confidence and competence
Smothers et al. (2018)	- A systematic review of the literature	- Numerous professional organizations recognizing the need to increase SUD education for nurses - The American Association of Colleges of Nursing, American Society for Pain Management Nurses, and American Nurses Association
Knopf-Amelung et al. (2018)	- As behavioral health is integrated into healthcare, nurses may assess substance use with the SBIRT model - Baccalaureate students given SBIRT training using three different educational methods	- All three methods showed increased knowledge and confidence and improved attitudes in working with patients with SUDs. - There was no difference in knowledge among the methods. - The groups that used more active learning methods reported more working knowledge of SUDs and right to ask patients about it. - Screening, brief intervention, and referral whether in person (standardized patient) or online gave students hands-on practice. - This learning promoted competence in performing SBIRT.
Finnell et al. (2018)	- Preventive Services Task Force recommends screening adults aged 18 years or older for alcohol use and provide brief behavior counseling. - SBIRT for substance use has not been disseminated; therefore, nurse educators must prepare students at BSN and graduate levels (APRN). - Curricular change included a gap analysis of courses; 2-day SBIRT workshop with role-playing and exemplars - Developed modules for certain courses such as Intro to SBIRT (Health Assessment), Brief Intervention (Specialty Course), Screen (Health Promotion and Public Health), and Medications (Pharm) for SUDs	- Students given pocket reference cards - Each module has applying knowledge such as role-play, interactive case, or simulation. - Next step is use of the Clinical SBIRT Proficiency Checklist by a clinical instructor.
Moore et al. (2017)	- SBIRT content was mapped to 10 courses across an MSN-NP program. - Methods were readings, lectures, case studies, role-playing, tutorials, symposia, and tracking the use of SBIRT during clinical preceptorships. - 139 online and on-campus MSN-NP students were taught SBIRT.	- Students successfully implemented SBIRT in precepted clinical settings. - Faculty and clinical preceptors trained in SBIRT - Course content coordinated - Two screening tools used in advanced health assessment - Lecture on interviewing for SUD in health promotion - During faculty observations, NP students performed histories on patients and found substance use. - During 3 years of training grant, students attended on-campus four 90-minute symposia. - Scaffolding approach across multiple courses and clinical practice provided repeated exposure to facilitate retention. - Modes of teaching were lectures, simulations, case studies, and role-playing. - Faculty need to know SBIRT and motivational interviewing.
Gehrs, Ling, Watson, & Cleverley (2016)	- Impact of SUD on the Canadian healthcare system is huge. - The Centre for Addiction & Mental Health is Canada's largest mental health and addictions academic teaching hospital. - SUDs are the primary diagnoses of 31% of annual inpatient admissions. - CNSs with expertise in addictions are ideally prepared to promote competency development among BSN-prepared nurses caring for these patients.	- Despite recent advocacy to advance the addiction nursing workforce in Canada, recruitment of graduate-level CNSs in this field is still a challenge because of a shortage of candidates with addictive expertise. - Hospital-implemented competency-based professional development framework to increase CNSs with addiction expertise

SUD = substance use disorder; SBIRT = Screening, Brief Intervention, and Referral to Treatment; NP = nurse practitioner; APRN = advanced practice registered nurse; CNSs = clinical nurse specialists.

The nursing education framework of using the constructivism theory of learning is appropriate for this recommended curriculum change. It hypothesizes that individuals construct their own learning by making sense of the information and construct their own meaning. The learning occurs by repeating the principles and situations of substance use disorder treatment in multiple situations throughout the curriculum. Teachers encourage students to apply this learning in clinical situations to gain a better understanding of SUDs and treatment. Students learn how to learn rather than just regurgitate content. The student is the focus of learning, and the teacher facilitates and guides this process (Olusegun, 2015).

As previously identified, opioid misuse is a national public health crisis in the United States (Oermann, 2018), and alcohol ranks among the top five risk factors for diseases, disability, and death worldwide (Finnell et al., 2018). Therefore, substance use content can no longer be only one lecture in the mental health nursing course. There is a need to educate students on skills in screening, motivational interviewing, and intervening through Screening, Brief Intervention, and Referral to Treatment (SBIRT) instructions (Oermann, 2018; SAMHSA, 2017). Active learning methods are more effective in changing students' attitudes in screening for SUDs. Threading the SBIRT skills throughout the curriculum develops students' competence and confidence in working with patients who have an SUD (Oermann, 2018). Rassool (1998) suggests the development of a nonjudgmental and positive attitude toward persons with alcohol problems may be partly related to education. In a study by Murphy-Parker and Martinez (2005), it was reported that for nursing students who had a personal experience of knowing someone with an alcohol addiction, a surprisingly optimistic and high expectation of recovery far exceeds true rates of recovery currently being achieved in substance abuse programs.

Smothers et al. (2018) conducted a systematic review of the literature of substance use education in schools of nursing and identified that the American Association of Colleges of Nursing, American Society for Pain Management Nursing, and American Nurses Association supported the increase for substance use education for nurses that includes outcome assessments. Knopf-Amelung et al. (2018) conducted a study comparing three instructional methods to teach baccalaureate nursing students in the care of patients with SUD. The three instructional methods included (a) narrated slides, (b) an online course, and (c) an in-person role-play with classmates and standardized patient simulations. The authors concluded that all three methods improved attitudes and confidence in working with patients with SUD. However, the group prepared with more active learning (which was the in-person role-play) showed a better working knowledge of SUD and felt it was their role to intervene. Finnell et al. (2018) integrated SBIRT steps and other SUD content throughout the nursing courses and provided role-play to apply the knowledge. The authors recommend that the next step in integrating SUD education is the use of the Clinical SBIRT Proficiency Checklist by clinical instructors. Chang and Yang (2013) similarly recommended multiple strategies such as clinical supervision to improve nurses' attitudes and care of patients with SUD.

Another program studied mapping SBIRT content to 10 courses across an MSN-NP program. They applied multiple methods such as reading, two lectures, case studies, role-play, tutorials, symposia, and test questions. The faculty and clinical preceptors were trained in SBIRT and motivational interviewing. A total of n = 139 online and on-campus MSN-NP students completed the program. The authors concluded that the use of scaffolding across multiple courses and clinical practice led to increased retention of SUD education (Moore et al., 2017).

In addition to addressing student attitudes to SUDs, it is imperative to also consider faculty attitudes toward SUDs. Nursing faculty have also been identified to lack an understanding in the treatment of SUDs (Voshall et al., 2013). Convincing non-mental-health nursing faculty to teach about SUDs is essential in successfully threading SUD education throughout the nursing curriculum (Puskar et al., 2014). Before SUD education can be integrated into the curriculum, it is important to include the faculty in developing and implementing this endeavor. Empowering the nursing faculty in the participation in the curricular change in SUD education will provide a foundation for successfully implementing the education of students in the care of patients with SUD.

RECOMMENDATIONS FOR FUTURE NURSING SUD EDUCATION

Students and faculty need to know the rationales for the bigger picture of the SUDs in the healthcare system, public health, and the critical role of nurses to intervene. As mentioned above, nursing faculty need to buy in on the integration of SUDs throughout the nursing curriculum in both the undergraduate and graduate programs. This alignment of SUDs is being addressed in primary care and throughout the specialties (Daley, 2017; Ede et al., 2015; Sterling et al., 2011). Substance abuse affects almost every area of healthcare. For example, SUD is addressed in neonatal care as neonatal absence syndrome and fetal alcohol spectrum disorder (Corr & Hollenbeak, 2017; Decker et al., 2017; Jones, 2015). SUD impacts both physical and psychiatric disorders, which is one of the reasons for psychiatric consults throughout the hospital, including trauma patients. Drug screens are done routinely in trauma situations as a contributing factor in accidents and assaults (Pezzia et al., 2018).

Both the alcohol use disorders and the opioid epidemic have been magnified by the COVID-19 pandemic. There has been an escalation of SUDs and relapse as a reaction to the lockdown during the pandemic (Hudson, 2020; Volkow, 2020). Although many 12-step programs are virtual, not everyone has access to a computer or can connect to their treatment programs therapy for their SUDs (Hudson, 2020). Furthermore, there are many people who have difficulty accessing their MAT for treatment of opioid abuse and are at a greater risk for relapse (Wilson et al., 2020). In addition, using alcohol and drugs as a coping method increases the risk for developing SUDs (Dela Cruz, 2020; Wilson et al., 2020).

Another reason for the need to thread the education of SUDs is that the spread of COVID-19 is being influenced by people going to bars and parties that include alcohol and possibly other drugs without wearing masks and social distancing. The public health departments monitor increases of the incidence of COVID-19, and one of the first interventions is to shut down bars, restaurants, and parties with alcohol and drugs (Centers for Disease Control and Prevention, 2020). Healthcare providers need to be educated on this link of alcohol and drug use and the spread of COVID-19 (Parker-Pope, 2020). They also need to be aware of the escalation of substance use when people are lonely and isolated and ineffectively coping with losses such as jobs and homes as well as loss of physical contact with family, friends, and colleagues. In addition, the added stress of some parents needing to homeschool and work simultaneously can add additional stresses that also increase the risk of abuse.

In conclusion, it is essential for nursing curriculum to include all the current issues involving the health issues that are converging on threading SUDs throughout the program. Included in the education is providing resources to the students for referrals and healthy coping mechanisms that should be a part of any nursing intervention with their patients (National Institute on Alcohol Abuse and Alcoholism, 2020). Some examples would include alternative socializations that do not include alcohol and drugs. This is an urgent public health need to break the cycle of COVID-19, increased isolation and loneliness, and ineffective coping with additional stressors (such as losing their homes and jobs, homeschooling, connections), which increases the risk of drug and alcohol use, that results in an increased risk of COVID-19 because of the bars and parties without social distancing or use of masks. We need to replace this illness cycle with a healthy cycle of preventing COVID-19 and SUDs by supporting healthy coping measures such as acceptable socialization (which includes wearing masks and social distancing); providing access to resources for meeting basic needs for housing, jobs, and food; and referrals for addressing treatment of SUDs. Nurses are central to being part of the solution to provide help to those who are struggling with substance use and COVID-19.

There is evidence in the nursing literature that substance abuse education is a key predictor of nurses' knowledge and therapeutic attitudes (Rassool, 2007). Because nurses are the frontline caregivers in this country, nurses must be given the education necessary to accomplish the tasks to screen, assess, and refer, if needed, to addiction specialist for care. Nurses are a huge part of the workforce that can play a major role in decreasing the health and social problems associated with addiction. An important contribution to this subject was written by Fornili (2007). Fornili states that nurses are invisible members of the addiction treatment workforce. Fornili attributes this, in part, to the “critical failure” of nursing to communicate its role within this workforce. Fornili continues to challenge nurses and nurse educators to critically evaluate the role of nurses in the addictions treatment workforce and to promote recognition of the valuable contribution that nursing can contribute, and has contributed, to the quality of care delivered to individuals who experience those disorders. Nurses are well positioned to screen, assess, refer, and, at the advanced practice level, treat clients for substance disorders, provided the knowledge and willingness exist to intervene (Murphy-Parker, 2013). Nurse educators must seriously evaluate the role of nurses in the addictions treatment workforce and promote the invaluable influence that nursing can have and has had on the quality of care delivered to individuals with substance-related disorders.