Nurses Drug Guide
An alcohol and drug education program for nursesBernadine T. Markey Alcoholism and drug abuse are serious problems in the United States. Alcoholism is a widespread biophysiologic and psychosocial problem with serious implications for the alcoholic's physical health, economic well-being, psychological equilibrium, and family and social relationships. Consider these startling statistics.
* Approximately 43% of all American adults have been exposed to alcoholism in the family.(1)
* It is estimated that 10% of the population in the United States are problem drinkers.(2)
* There are approximately 10 to 13 million alcoholics in this country, with an estimated seven million alcohol abusers.(3)
* As a result of alcohol abuse, problem drinkers suffer impaired performance on the job, accidental injuries, and medical disorders.
* Fifty percent of hospital beds are occupied by people whose illness is -- in some way -- associated with alcohol abuse or alcoholism, and 40% of the admissions to psychiatric hospitals are because of various psychological and psychiatric ramifications of alcoholism.(4)
* The prevalence of alcoholism places family members at risk for development of highly dysfunctional patterns, a variety of dependencies, and emotional illnesses.(5)
* Alcoholism is involved in 60% of reported cases of child abuse and in the majority of cases of spousal abuse.(6)
* It is estimated that there are 38 million people who are children of alcoholics.(7)
The statistics concerning drug use and abuse in the United States is also dramatic, with American society being described as a drug-oriented, addicted, and chemically dependent.(8) It is estimated that 60% of the world's production of illegal drugs is consumed in the United States.(9) The American drug problem involves the use of legal medications, illegal drugs, and the recreational use of drugs intended for medicinal purposes. Social consequences of drug abuse are similar to those of alcohol abuse (eg, crime, violence, homelessness, automobile injuries and deaths, falls, drownings, suicides, abuse and neglect in families, early sexual activity, adolescent pregnancies, sexually transmitted diseases with AIDs being specific for drug users). Drug abuse is believed to have surpassed mental illness as the most serious health problem plaguing the urban homeless.(10)
USING AND ABUSING POPULATIONS
Substance abuse spans all geographic regions, ethnic groups, and social classes.(11) Overall, in terms of general alcohol abuse, the following has been found to be true.
* Men are more than four times more likely to be heavier users than women.
* People 44 years of age and older are more likely to be abstainers than younger people.
* Caucasians, more than any other ethnic group, have the highest proportion of members who consume alcohol.
* Alcohol use increases for both men and women with higher levels of education than people with lower education levels.
* The proportion of drinkers in a family rises with family income.(12)
Multiple substance abusers. Today, multiple substance abuse -- which refers to simultaneous abuse of different mood-altering drugs, either with one another or in combination with alcohol -- is becoming the norm for alcoholics and drug abusers.(13) Caucasian males have the highest lifetime use of cigarettes, alcohol, stimulants, and hallucinogens. Rates of the use of illicit drugs are greater among African-Americans than for either Caucasians or Hispanics in all age groups except for people 12 to 17 years of age.(14) It has been reported that in US households 37% of the population 12 years of age and older have used illicit drugs one or more times in their lives.(15) Alcohol is the intoxicant most widely used, followed by marijuana, which has been used at least once by 25% of the US population.(16)
Adolescents. Adolescents are a population for whom substance use and abuse is a significant problem. The following statistics illustrate this fact.
* Two out of three adolescents try nicotine.
* At least 92% of adolescents have used alcohol at least once.
* Forty-seven percent of adolescents try marijuana, 20% try cocaine, and 10% to 15% try sedatives.(17)
Other. Alcohol-related mortality and fetal alcohol syndrome is higher for Native Americans than for all other groups, and alcoholism is 5% greater in this group than in the general population.(18) It should be noted that more people die annually from prescription drugs obtained legally but used improperly than from all illegal substances combined.(19)
NURSES AND SUBSTANCE ABUSE
Nurses are not immune to the ravages of substance abuse, either in themselves or in their colleagues, their family members, or their neighborhoods. The precise number of chemically dependent nurses is difficult to ascertain due to the associated social stigma and to denial, which is a characteristic defense.(20) Although there are no accurate statistics on the prevalence of alcohol abuse among nurses, the incidences of alcoholism or alcohol-related problems have been estimated to include 6% to 20% of all practicing nurses; instances of drug dependency have been estimated to include 3% to 5% of practicing nurses.(21) Some health care professionals who have easy access to legal medications (eg, nurses, physicians, pharmacists) are guilty of obtaining these medications to alter their moods.(22) These professionals use multiple medications in an effort to achieve different and particular states of feeling (eg, they use stimulants in the morning to awaken; depressants at night to unwind; other medications counteract fatigue, promote sleep, or just feel better).
Although alcohol and drug abuse have significant effects on people's health specifically and their lives in general, nurses historically have received little education on alcoholism and drug abuse.(23) Nurses may not learn that substance abuse is a primary illness. When content in nursing curricula is included, the focus has been on physiologic and toxic effects of alcohol and has included little that would help nurses in understanding the psychological process of addiction. They do learn that cirrhosis is secondary to alcoholism, and they learn the effects of alcohol on the heart. Such topics on how to recognize the symptoms and what to do when problems arise with patients, colleagues, and family members who are addicted may be neglected. If any content is offered, it may be during the mental health clinical rotation when nursing students briefly study addictive behaviors.
Many authorities feel that nurses are not only poorly educated about alcoholism and drug abuse, but they also are miseducated.(24) This knowledge deficit inhibits the ability of practicing nurses, including perioperative nurses, to effectively identify and intervene with those patients who present with these major health problems. Efforts are being made to improve nurses' understanding of addictions, especially for those nurses working in alcohol and drug treatment centers. Many nurses who work in general hospitals or clinics, however, are not prepared to deal effectively with chemical dependency.
COURSE CONTENT
Staff development faculty members, or whoever is presenting this material, may want to conduct a needs assessment of the nurses or other health care professionals in their institutions or regions to determine more specific education needs related to alcohol and drug use and abuse.
Keeping abreast of all the new information on health and illness is increasingly difficult for all nurses. Following is a description of our course on drug and alcohol use and abuse, in which we provide an comprehensive overview of the subject. We also offer suggestions to help guide those giving a course or continuing education (CE) program on alcohol and drug education. An adaptation of our course as described in this article is currently a three-credit course for undergraduate students from all disciplines at Bloomsburg (Pa) University. Although the course in this article was designed for nurses, it can be modified to meet the needs of nurses in specialty practices, as well as other health care professionals.
During the course, students examine the nature of alcohol and drug problems as well as sociocultural attitudes toward alcohol and drug use and abuse. Course content includes
* addressing the effects of alcohol and drugs on behavior and the body;
* identifying nursing assessment criteria, the resulting nursing diagnoses and care and the implications of providing this care for substance-abusing nurses;
* discussing the impact of alcoholism and drug addiction on the general population, special populations, and family members;
* reviewing prevention, intervention, referrals, treatment modalities, and support groups; and
* identifying the spiritual, moral, and legal aspects of substance abuse. Implications for nurses of all disciplines are identified. See Table 1 for overall course objectives. The course content can be broken into small segments depending on the needs and time frame of the staff members in your institution or area.
Table 1
COURSE OBJECTIVES
* Discuss the use of moral reasoning to clarify individuals' values, ethics, and attitudes regarding alcohol and drug use.
* Identify the effects of alcohol and drugs on behavior.
* Describe the effects of alcohol and drugs on the body and medical complications associated with their use.
* Identify methods used in the assessment of alcohol and drug use and abuse.
* Identify the legal implications of alcohol and drug use and abuse.
* Identify the methods used for intervention and referrals for alcohol and drug problems.
* Outline the treatment and rehabilitation options for individuals with alcohol and drug problems.
* Describe the role of Alcoholics Anonymous and other support groups in the treatment of alcoholics and drug addicts.
* Identify strategies to provide nursing care to individuals with alcohol and drug problems.
* Explain the effects of alcohol and drugs on fetuses.
* Describe the effects of family members' use and abuse of alcohol and drugs on children.
* Discuss dysfunctional patterns that may develop in families in which alcohol and drugs are used and abused.
* Discuss teaching measures nurses can use to help prevent alcohol and drug-related problems.
* Outline the primary, secondary, and tertiary prevention methods for alcohol and drug abuse.
* Identify the major categories of drugs that are abused and the consequences of drug abuse.
* Identify the use and abuse of alcohol and drugs on an international level.
* Describe the effects of alcohol and drug abuse on nurses and other professionals.
* Describe the effects of alcohol and drug abuse on elderly people.
* Describe the effects of alcohol and drug abuse on adolescents and college students.
* Describe the effects of alcohol and drug abuse on minorities.
* Describe the ramifications of alcohol and drug use and abuse on all members of society.
Basic framework. We present the basic framework for a substance abuse education course in Table 2. As previously mentioned, content can be adjusted to better serve the needs of individual staff members and institutions (eg, only alcohol use and abuse is taught, only drug use and abuse is taught). The program's goals do not include developing the students into experts. At the completion of the course, however, students should be able to think critically about these topics and be able to help patients, family members, friends, and colleagues with substance abuse problems.
Table 2
COURSE CONTENT
Alcohol and drug use and abuse
* Pharmacologic properties of alcohol and other drugs
* Definitions of social drinking, drunkenness, alcohol abuse, and alcoholism
* The disease concept of alcoholism
* Phases of alcoholism
* Distinguishing between the typologies of alcohol and drug use
* The myths associated with alcoholism
* Identifying why people drink alcohol and use drugs
* Definitions and characteristics of drug addiction (eg, experimental, social, recreational, circumstantial, intensified, compulsive)
Prevalence of alcohol and drug use, misuse, or dependence in America
* Who the alcoholics and drug addicts are
* Drinking in America -- indulgence and abstinence
* Economic cost of alcohol and drug use and misuse
Sociocultural aspects of substance abuse
* Historical and social influences
* Ethnicity and environmental factors of use and abuse
* Attitudes of business, industry, governments, religions, and medical and social services
Philosophies of alcohol and drug use and abuse
* Personal attitudes and values regarding alcohol and drug use and abuse
* Societal values of alcohol and drug use and abuse
Effects of alcohol and drugs on behavior
* Absorption and tolerance
* Blood alcohol and drug concentrations
* Personality traits of alcoholics and drug addicts
Effects of alcohol and drugs on health
* Metabolism of alcohol and drugs
* Pathophysiology of alcoholism and drug addiction
* Multisystem health implications
* Withdrawal syndromes
Etiology of alcoholism and drug addiction
* Research of the causes of substance abuse
Nursing assessment for alcohol and drug abuse
* Implications for specific specialties in nursing
Nursing diagnoses for people with alcohol and drug use and abuse problems
Nursing care for people with alcohol and/or drug problems
Legal implications of alcohol and drug use and abuse
* Drinking and driving
* Crime and violence
* Laws regarding alcohol and drug use and abuse
Methods of intervention for people with substance abuse problems
* Employee assistance programs
Treatment and rehabilitation for substance abusers
Alcoholics Anonymous and other support groups
Family aspects of alcohol and drug use and abuse
* Fetal alcohol syndrome and neonatal addiction
* Children of alcoholics (ie, young children, adolescents, adult children)
* Concept of codependency
* Effect on families
* Support groups for family and friends of abusers
Substance abuse education
Prevention of alcohol and drug abuse
* Primary, secondary, and tertiary methods of prevention
Global view of alcohol and drug use and abuse
Nursing care of drug and alcohol abuse in special populations
* Nurses and other health care professionals
* Elderly people
* Adolescents and college students
* Minority groups
Nursing specialty content. Nurses in specialties deal with the effects of substance abuse directly and indirectly, and educators should take this into consideration while developing course content. For example, perioperative nurses care for patients in a variety of settings. Nurses in the OR may deal with the physiologic effects of alcoholic patients, while nurses in surgical clinics or physicians' offices may deal with the psychological aspects of alcoholism in patients and their family members.
Course content for perioperative nurses includes alcohol-drug interactions with anesthetic agents and postoperative analgesics. In this portion of the course, for example, perioperative nurses are reminded that alcohol and drug abuse cause liver alterations and that the presence of alcohol or drugs in patients' bodies may alter the liver's ability to metabolize other drugs. This process is significant when patients are given medications (eg, anesthetics, analgesics) that are dependent on the liver for their metabolism. Anesthetic agents and analgesics may be present in the body in lower or higher than expected doses, depending on liver function and whether patients are heavy or moderate drinkers. Doses appropriate for patients with normal liver function have to be adjusted for patients whose liver function is compromised.(25)
Alcohol is a central nervous system (CNS) depressant; therefore, health care providers must use caution when using other medications that depress the CNS -- especially those that cause cardiac or respiratory depression. Patients' prolonged excessive use of alcohol may produce irreversible cardiomyopathies or other cardiovascular alterations that perioperative nurses must assess before administering these medications to surgical patients who abuse alcohol.(26)
Patients admitted for most elective surgeries should arrive in the OR in a sober state. Patients admitted for surgery in emergency or traumatic circumstances, however, may be in acute states of intoxication. Even if patients are not acutely intoxicated, perioperative nurses need to remember that sober alcohol abusers have physiologic and psychological deficits that must be considered during the entire perioperative period.
Nurses' roles. Overall, in our various settings, nurses have identifiable roles related to people who abuse substances. These roles include
* providing care to patients throughout the life cycle;
* counseling patients, family members, and colleagues in a variety of settings;
* being educators and resource people for schools, communities, and professional groups;
* advocating for effective treatment and care for patients and colleagues;
* promoting legislation to help reduce substance abuse; and
* conducting research to help determine the most effective methods of helping, caring, and preventing alcohol and substance abuse.(27) At the completion of the course, nurses will have gained insight into all of these roles as they relate to substance abuse in nursing and in the general population.
COURSE MATERIALS
When preparing a course on alcohol and drug use and their ramifications, nurse educators will need to ensure that all facts are scientifically correct and up-to-date. Information from both printed and other media can be used.
Printed material. There is a rich resource of printed material on the subject of alcohol and drug use and abuse. There are many health care professionals who treat patients with substance abuse problems; therefore, nurses studying alcohol and drug use and abuse need to remember to look outside of as well as in the nursing literature. Educators from other disciplines (eg, medicine, social welfare, psychology, sociology, psychiatry, criminology, health education, physical education, employee assistance programs, substance abuse counseling) who teach content related to substance abuse are also excellent resources.
Other media. In addition to the wealth of printed material on the subject, there are many audiovisual materials related to substance abuse for people of all ages as well as for nurses and other health care professionals. Cost is always a factor, but it is possible to borrow videotapes or movies from various agencies and to acquire handouts, pamphlets, or booklets that are provided at no charge.
Many state and national organizations offer valuable information for nominal fees. Table 3 lists some places to look for pertinent materials. In addition, television documentaries on substance abuse are timely and well researched by the producers. Educators can send for copies of these programs at reasonable cost from television stations or networks.
Table 3
PLACES TO LOOK FOR LEARNING AND TEACHING MATERIALS
* Employee assistance programs either in your institution or nearby
* The medical library in your institution it separate from the nursing library
* Other hospitals' medical or nursing libraries
* Clinics (eg, a family planning clinic may have material on fetal alcohol syndrome or neonatal addiction)
* A drinking and driving program in your community
* A college or university in your community
* A local high school
* Mothers Against Drunk Drivers
* Alcoholics Anonymous or other support groups
* Public health departments
* Local, state, and national law enforcement agencies
* American Nurses Association
* Your state nursing organization and state board of nursing
* American Hospital Association
* National nursing organizations that specialize in substance abuse (eg, Drug and Alcohol Nursing Association, National Consortium of Chemical Dependency Nurses, National Nurses Society on Addictions)
* National organizations that specialize in substance abuse (eg, National Clearinghouse for Alcohol and Drug Information, National Institute on Alcohol Abuse and Alcoholism)
TEACHING STRATEGIES
The type of teaching strategies used depends on the size of the class and whether the course is taught in a formal or an informal setting. These strategies include
* lectures,
* class discussions,
* student presentations,
* question-and-answer sessions,
* debates,
* small group projects,
* simulations,
* guest speakers,
* printed handouts,
* overhead transparencies, and
* videotapes.
Textbooks can be used, but they may not be suitable for short courses or CE programs. In these cases, self-study guides, handouts, and copies of journal articles are more helpful. In addition, if the educator distributes outlines or lesson plans, students will find it easier to follow along, take notes, and remain aware of assignments and examinations.
Out-of-class projects. We assign students taking our course two out-of-class projects -- both of which students have rated highly after completion. We assign the first project early in the course when the students are learning about behavioral changes that result from drinking alcohol. The students are assigned to be in a drinking environment (eg, party, picnic, football game, wedding, neighborhood or family barbecue, tavern) and observe the changes in behavior of a person who is drinking alcoholic beverages. The student abstains while he or she observes. The person to be observed can be a family member, friend, or a stranger. The students are asked to observe the person's behavior before drinking and then for several hours while the subject is drinking so that comparisons can be made. The amount of alcohol consumed is also a factor. For some students, this is the first time they are in a drinking environment without drinking themselves. We require the students to write a reaction paper about this experience.
Our other out-of-class assignment requires the students to attend an open Alcoholics Anonymous (AA) meeting. Some nursing students or nurses may already have attended such a meeting while in nursing school; however, we recommend that they attend another meeting because it is difficult to grasp the depth of support that AA offers to fellow alcoholics by attending only one meeting. We also require students to write a reaction paper about this experience.
Alcohol and drug awareness day. As educators, we have found that having students conduct an alcohol and drug awareness day on campus is a worthwhile project. This type of project also lends itself well to hospital settings where nurses taking the course can designate an alcohol and drug awareness day at their institution. On the designated day, the students set up a table in a place that is easily accessible to either students or employees, depending on the site (ie, campus, health care institution). On the table are displays and pamphlets or handouts about alcohol and drug abuse.
At our university, we have undertaken this project with the cooperation of the local state department of health nurse and health educator. The state health department has provided us printed material at no charge related to alcohol and drug education. We have also invited mothers from Mothers Against Drunk Driving (MADD), who brought printed materials from their organization. The students, as well as the nurse from the state health department, the health educator, the MADD representative, and the course instructor, help staff the table. In the past, we have also invited law enforcement officers to work at the display because many people have questions about alcohol and drug abuse and the law.
The response on our campus to an alcohol and drug awareness day has been favorable. It is important to market the alcohol and drug awareness day before the event; this is especially important in a hospital setting so that the hospital employees are aware of the program. The students who conduct this project should contact the editors of the hospital newsletter and local newspapers so that an article can be written on the topic.
Guest speakers. Inviting guest speakers to lecture about substance abuse is beneficial for the students' course. Guest speakers may include
* police officers or lawyers to discuss legal issues,
* murses who work in drug and alcohol treatment centers,
* murses who care for drug-addicted infants, and
* drug and alcohol counselors.
We also discovered that guest speakers who are recovering alcoholics and drug addicts can be powerful educators. For nurses in particular, it is helpful to invite nurses who are recovering alcoholics or drug addicts. A lasting impression is made on the students when recovering alcoholics and drug addicts share their experiences of abusing alcohol and drugs, the impact of these abuses on their lives, and how they found treatment and recovery. It is very important for students taking this course to realize that there is no cure for alcoholism or drug addiction, but there is hope and recovery by abstaining from these substances. It is vital that everyone know the methods alcoholics and drug addicts use daily to stay in recovery.
EVALUATION
As with all CE programs or courses, student evaluations are very important because they alert educators to the effectiveness of their teaching efforts. In addition, positive evaluations may justify the continued existence of the program. Your institution may have a standard evaluation form that is used for all programs; if not, you can develop one specifically for the program that you teach. Although educators hope that effective teaching leads to increased knowledge and behavioral changes, this is not always the case. Nurse educators should review the evaluations and seriously consider students' suggestions to improve course presentation.
SUMMARY
Alcohol and drug use and abuse present serious problems for health care professionals, both as clinicians and users. These topics need to be addressed in nursing curricula. In this article, we have offered the framework for a course of study that reviews these problems and applies the nursing process to these issues so that educators can provide interesting, stimulating, and timely programs on alcohol and drug use and abuse. Educators must remember, however, they cannot make decisions for their students in regard their alcohol and drug use. The educator's role is that of a teacher and guide who is fully aware that all people are responsible for their own behaviors and the consequences of their choices.
NOTES
(1.) T R Syre, About Alcoholism (Dubuque, Iowa: Brown & Benchmark Publishers, 1994) 32.
(2.) J Kinney, G Leaton, Loosening the Grip: A Handbook of Alcohol Information, fifth ed (St Louis: Mosby, 1995) 19.
(3.) R G Schlaadt, Alcohol Use & Abuse (Guilford, Conn: Dushkin Publishing Group, Inc, 1992) 41.
(4.) Syre, About Alcoholism, 33.
(5.) K Louie, :Dysfunctional patterns in families with drug and alcohol problems," in Substance Abuse Education in Nursing, Vol 1: Curriculum Modules, ed M A Naegle (New York: National League for Nursing Press, 1991) 385.
(6.) Schlaadt, Alcohol Use & Abuse, 42.
(7.) Kinney, Leaton, Loosening the Grip: A Handbook of Alcohol Information, fifth ed, 186.
(8.) R G Schlaadt, Drugs, Society, & Behavior (Guilford, Conn: Dushkin Publishing Group, Inc, 1992) 6.
(9.) Ibid, 15.
(10.) Ibid.
(11.) E A Duthie, J S D Arcangelo, "Pharmacology," in Substance Abuse Education in Nursing, Vol I: Curriculum Modules, ed M A Naegle (New York: National League for Nursing Press, 1991) 253.
(12.) Kinney, Leaton, Loosening the Grip: A Handbook of Alcohol Information, fifth ed, 20-21.
(13.) Ibid, 384.
(14.) A H Claus, V P Clarke, "Drug and alcohol problems in special populations," in Substance Abuse Education in Nursing, Vol II: Curriculum Modules, ed M A Naegle (New York: National League for Nursing Press, 1992) 535.
(15.) R P Zahourek, "Attitudes and values about drug and alcohol use," in Substance Abuse Education in Nursing, Vol I: Curriculum Modules, ed M A Naegle (New York: National League for Nursing Press, 1991) 5.
(16.) Schlaadt, Drugs, Society, & Behavior, 54.
(17.) M A Naegle, "The adolescents who uses drugs and alcohol," in Substance Abuse Education in Nursing, Vol I: Curriculum Modules, ed M A Naegle (New York: National League for Nursing Press, 1991) 429.
(18.) Syre, About Alcoholism, 48.
(19.) Duthie, Arcangelo, "Pharmacology," 253.
(20.) G B Smith, "Attitudes of nurse managers and assistant nurse managers toward chemically impaired colleagues," IMAGE -- The Journal of Nursing Scholarship 24 (Winter 1992) 295-300.
(21.) O K Caracci, "The relationship between alcohol use and knowledge among nurses," Journal of Alcohol & Drug Education 37 (Spring 1992) 66-73.
(22.) Kinney, Leaton, Loosening the Grip: A Handbook of Alcohol Information, fifth ed, 389.
(23.) M R Haack, T L Hughes, eds, Addiction in the Nursing Profession: Approaches to Intervention and Recovery (New York: Springer Publishing Co, 1989) 24.
(24.( A M Catanzarite, Managing the Chemically Dependent Nurse: A Guide to Identification, Intervention, and Retention (Chicago: American Hospital Publishing, Inc, 1992) 19.
(25.) A G Goodman et al, eds, Goodman and Gilman's The Pharmacological Basis of Therapeutics, ninth ed (New York: McGraw-Hill, Health Professions Division, 1996) 386.
(26.) Ibid, 387.
(27.) A Sheehan, "Nurses respond to substance abuse," International Nursing Review, 39 (September/ October 1992) 141-144.
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Bernadine T. Markey, RN, PhD, CNOR, is an associate professor (retired), department of nursing, Bloomsburg (Pa) University, Bloomsburg.
Joan B. Stone, RN, DEd, is an assistant professor, department of nursing, Bloomsburg (Pa) University, Bloomsburg.
COPYRIGHT 1997 Association of Operating Room Nurses, Inc.
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