Patients with substance use disorder have high rates of hospitalization, readmission, and long lengths of stay. All healthcare providers must understand the connection between trauma and addiction. Because some addicts in a hospital setting may feel stigmatized, it’s also important to:
• perform more care management;
• coordinate with local resources;
• develop a comprehensive treatment plan.
While opioid-related morbidity and mortality is an epidemic that dominates the news, the ripple effects of substance abuse among hospitalized patients are felt throughout healthcare facilities nationwide.
People with substance use disorders (SUDs) experience high rates of hospitalization, readmission, and long lengths of stay, according to the American Hospital Association.1
So how can nurse case managers best serve patients with SUDs, both during their stay and after discharge?
Without recovery services planned in advance, patients with addiction issues who are discharged are more likely to simply continue using drugs, explains Lydia Anne Bartholow, DNP, PMHNP, CARN-AP, associate medical director for outpatient substance use disorder services at Central City Concern in Portland, OR.
As an expert in addiction treatment, she recently spoke to the American Case Management Association’s Oregon chapter to teach an introduction to the brain science of addiction from a trauma-informed, health equity lens. Part of her presentation was teaching an overview of the basic neurobiology of all substance use disorders, as well as a population-based look at who struggles with addiction and why.
She says there are two important steps hospital nurse case managers can take to support these patients:
• First, work on the connection around trauma and addiction. What is the link between trauma and substance use disorders?
• Second, try to frame it as a disease and not a moral failing. What are some neurobiological processes that occur in all substance use disorders?
Step 1: Understand Trauma and Addiction
Until healthcare providers understand the connection between trauma and addiction, some addicts in a hospital setting may feel stigmatized.
Bartholow says children who experience trauma are 46 times more likely to develop SUD as an adult. The understanding of addiction, and subsequently how case managers work to treat SUDs, must reflect this knowledge.
“You’re less likely to think ‘can’t she just get herself together?’ if you understand the background of substance abuse. The fact is, there’s a 4,600% increase in developing substance abuse as an adult in patients with six or more ACEs — that means you’re dealing with a population 46 times more likely to have this disease,” she says.
But what, exactly, is the correlation between high Adverse Childhood Experiences (ACEs) scores and addiction? The original ACEs study asked a series of questions about incidents that occurred before the age of 18. Three questions focused on abuse — sexual, verbal, and physical — while other questions addressed types of family dysfunction — a parent who’s mentally ill or alcoholic, for example. The ACEs include the following2:
• physical abuse;
• sexual abuse;
• emotional abuse;
• physical neglect;
• emotional neglect;
• intimate partner violence;
• mother treated violently;
• substance misuse within household;
• household mental illness;
• parental separation or divorce;
• incarcerated household member.
The original ACEs study showed a direct link between childhood trauma and adult onset of chronic disease as well as the following statistics:
• ACEs rarely happen in isolation. For example, 87% of survey respondents had experienced two or more types of trauma.
• Compared with someone with zero ACEs, people with four or more ACEs were twice as likely to be smokers, 12 times more likely to have attempted suicide, seven times more likely to be alcoholic, and 10 times more likely to have injected street drugs.
• For every additional ACE score, the rate of prescription drug use increased by 62%, according to a 2017 study of adverse childhood experiences and adolescent prescription drug use.3
Not all hospitals track patients’ ACEs score when they come in for services, but Bartholow says it can open up so much compassion.
“Patients with ACEs scores that are seven or eight? That makes you sit back and realize what you’re dealing with. You can step back and say, ‘I really had no idea.’”
Step 2: Have Compassion for Addiction as Disease
It’s also important for nurse case managers and their teams to really understand substance abuse as a disease, says Bartholow.
“We would never say to someone with uncontrolled diabetes, ‘Just control your diabetes better.’ Instead, we would arrange for them to see an endocrinologist and give them enough support to make sure they’re getting their needs met,” she says.
There often is a stigma around addiction as disease. For patients, it can be incredibly difficult to admit they have a problem and call on professional help.
“Extreme substance users who end up in the hospital — without a comprehensive treatment plan — go straight back to using because they don’t have the skill set to not use. For people that have addiction issues, it’s stigmatizing,” Bartholow says.
“I’ve had a vision that we do more care management and coordination with local resources so when someone presents to the ER, perhaps an opiate overdose or IV wound, whatever it is, my dream would be that emergency rooms or inpatient providers have the skills to refer to treatment,” she says.
“I think the hospital impetus is to treat the medical illness that is comorbid and get them out as quickly as possible with a lecture to never inject again,” she explains, using the analogy of a patient presenting with signs of a heart attack. “In that case, we immediately connect them to a cardiologist. We never just give them a list of cardiologists and say, ‘Don’t ever have a heart attack again.’”
The Next Frontier: Addiction Medicine
Is it possible that addiction medicine will be one of the next big frontiers?
As addiction medicine grows, so too will systems of care that are easy to navigate, nonshaming, and patient-centered. This system also will provide immediate access to pharmacotherapies for SUDs.
“What we’ll see is a focus on creating systems of care, much of what we saw in primary care post-implementation of the Affordable Care Act,” Bartholow says. “One of the things we see is that people are incredibly vulnerable in the gaps of care. If people are coming to the emergency room but never finding primary care, do intensive case management to get them to use those expensive treatments less,” she says.
“Where we’re seeing a lot of federal funding is around the opiate crisis; thus, we’ll see people coming up with more creative ways to provide interventions that are also better care, [and] it’ll save money and provide better care for patients. I hope there’s more funding into intensive case management,” she adds.
1. American Hospital Association. Addressing the Opioid Epidemic: Resources. Available at: https://bit.ly/2uIP6UF.
2. Substance Abuse and Mental Health Services Administration. Adverse Childhood Experiences. Available at: https://bit.ly/2xzBIFJ.
3. Forster M, Gower AL, Borowsky IW, McMorris BJ. Associations between adverse childhood experiences, student-teacher relationships, and non-medical use of prescription medications among adolescents. Addict Behav 2017 May;68:30-34. doi: 10.1016/j.addbeh.2017.01.004. Epub 2017 Jan 6.