Nurses should learn to recognize signs of drug or alcohol addiction in patients

It can be a sticky situation when a nurse notices that a patient’s medication is disappearing faster than it should. It may be a sign of a problem home care agencies across the country are grappling with: addiction. And while experts have different opinions about how addiction problems should be handled, they agree that staff education is a good first step.

Education becomes more crucial as scientists create more effective painkilling drugs that also cause physical dependence — compounding the confusion among staff. Society has escalated the debate about how to handle chronic pain. In the past, many health care professionals feared allowing patients to take pain medication indefinitely because of the potential for addiction and abuse; now some experts say medication abuse isn’t a problem for many patients.

Arguments also continue over what kinds of drugs should be given to people in pain. At one extreme, the voters in California made it clear last year that they want marijuana to be available to ease pain and discomfort. Others advocate speeding up the nation’s drug approval process so some strong painkillers used by other countries could be sold here.

Your addiction inservice needs to include the latest research on pain management and drug addiction, experts say. Here are some other tips on how to set up such an inservice:

1. Ask local experts to talk with staff about addiction and the illegal drugs being used in your area.

"Get your local substance abuse expert in for a team meeting because that’s the most effective way to teach staff," suggests Jeanne Dennis, MSW, director of hospice program services for Hospital Home Health Agency of California, a nonprofit home health and hospice agency that serves the greater Los Angeles area.

The local expert will be able to talk about the illegal drugs that are available in the area. "What’s on the street in Los Angeles might not be on the street in Chicago," Dennis adds.

"Go to the social worker on your staff and ask who is doing substance abuse treatment in your area," she says.

Typically, these experts do not charge for the service, Dennis says. They can be contacted through local substance abuse support groups, such as Alcoholics Anonymous or Narcotics Anonymous or through a substance abuse treatment center, a hospital that has a substance abuse unit, and certain police departments that have professionals who can talk about drug abuse.

Dennis notes that it’s best to use an outside expert who also is a health care professional.

2. Teach staff what signs to spot in identifying a patient or family member who has a drug or alcohol addiction.

Consider these signs:

A patient’s medication begins to disappear faster than it should.

This kind of issue arose for a home care professional in South Carolina. A patient was in severe pain after having hip replacement, and the patient began to use more medication than was prescribed, recalls Leslie Lander Orr, LMSW, a medical social service supervisor for Home Health, Inc. of Rock Hill, SC. Orr handled this case prior to working for Home Health.

"There was real pain there, but with a history of addiction, the patient could do the same thing with pain medication that the patient had been doing with alcohol," Orr says.

"Immediately, the nurse spotted it because she was monitoring the medication," she adds. The nurse notified the agency. The physician and a mental health professional also were told about the situation.

The mental health professional increased home visits to the patient because the patient couldn’t go to an office. The physician began to reduce the patient’s prescribed dosage and rotate different types of pain medication to avoid the risk of physical addiction to one drug.

Eventually, the patient’s hips healed, and the pain stopped. So the medication was no longer prescribed.

"This case took a team approach," Orr says. "The patient was involved with different agencies, and all the agencies needed to work together in order to solve the problem."

If a patient’s medication is disappearing faster than expected, the nurse can show the patient a medication sheet and ask the patient to check off the times he or she took the medication, suggests Victoria Fletcher, RN, NCAC, NCCDN, clinical representative for the Talbot-Marsh Recovery Campus in Atlanta. The treatment center was founded 20 years ago to help impaired health professionals but has since expanded to include others.

"If the patient doesn’t think he or she has been taking more than prescribed, then limit the amount. Leave only a couple of days worth in the home, and see what happens," Fletcher adds.

"I’ve even labeled bags with the patient’s doses on them and put the time on the bags. A lot of little tricks can help," Fletcher says.

There is physical evidence of substance use.

"When nurses go into the home they might find empty liquor bottles in the trash can," says Mary Schoen, RN, MSN, MPH, director of education services for Visiting Nurses Association of Greater Philadelphia. The full-service nonprofit agency conducts 500,000 visits a year to Philadelphia and surrounding counties.

Patients exhibit behaviors that are not a result of the patient’s normal decline because of illness or a result of prescribed medications.

A nurse might be able to discover this abuse by assessing the patient. They need to note what kinds of medication and dosages are prescribed. Then they should learn the typical effects of the prescribed medication. If the patient is exhibiting behavior that’s different from what is expected, the patient might be using some other drug as well, Dennis says.

An example of this would be a patient with unexplained drowsiness, an unfocused gaze or blank stare, slurred speech, or an unstable gait.

Dennis suggests nurses handle this problem by asking non-judgmental questions, such as "What kind of medication are you using? Is there something you’re using to give you additional relief? Do you feel comfortable letting me know what it is? I’m concerned because I have observed some things in your physical condition that are not in line with what I would expect given your medication and prescribed dosage."

The patient’s family has a history of addiction.

Patients might not share that information, but Orr suggests nurses ask indirect questions that could draw out information indicating a family history of addiction. Nurses and home health workers need to be aware of basic patterns of addiction, including family history, Orr says.

"We assess the types of social problems they may have had as a result of their drinking," Orr says. These could include denial that there are any problems, behavioral changes, personality changes, depression, memory problems, isolation, anger, confusion, nervousness, and malnutrition.

Another sign might be if the family has a strong moral overtone about drinking and engages in teetotalism. Sometimes these families have histories of alcoholism and are at high risk, Fletcher says.

Look for physiological symptoms, Fletcher suggests.

"You would find increased tolerance; blackouts; some withdrawal symptoms, such as the shakes; and physical complications," Fletcher says.

3. Review with staff your agency’s policies and procedures for dealing with addicted patients or family members.

First, you should make sure your agency has policies in place for how to handle instances of substance abuse in patients and their families, Dennis says.

These could include:

The guidelines should tell staff what steps they need to take if they suspect or know a patient or caregiver is addicted.

These steps could include having the employee first notify a supervisor. Then the employee could meet with a case management team to discuss the problem, experts say.

If there is an immediate physical danger to the patient or caregiver, then the employee could be directed to call the police.

An agency’s policies should include procedures for handling ethical issues that arise when staff are treating patients who live with addicts.

If a patient’s caregiver is abusing drugs or alcohol, this could result in elder neglect. Some states require health care professionals to report suspected cases of elder neglect; others require reporting only when there’s evidence of physical abuse. Experts say agencies should have a policy that advises employees to notify an ethics committee of these types of cases.

Make it clear that no employee should stay in a home where the patient or caregiver is selling or using illegal drugs.

When there is suspected substance abuse, Hospital Home Health Agency has nurses notify families and patients that the agency staff will leave the home if the patient is using or selling drugs or is under the influence. The same is true if the patient’s family member is using or selling illegal drugs.

No surprises!

The patient and family members are told about this policy upfront if there is some suspected or known illegal drug use in the home. The nurse might say, "We suspect you’re using, and you still want to be your mother’s caregiver, so we must ask you not to use while we’re here. No one is buying or selling drugs while our staff is here."

Then, if the family violates the policy while a home care employee is visiting, the employee is expected to call a supervisor, explain the situation, and leave the home. The employee can tell the patient that he or she will see the patient when the illegal drug use has stopped.

An agency’s policy also might be to accept patients’ drug addictions and help the addicted patients prevent infections caused by the drug use. (See story on helping addicts keep needles clean, p. 68.)

4. Teach staff that addiction is a disease.

Some people have a biogenetic predisposition to alcoholism and chemical addiction.

"Offspring of alcoholics are twice as likely to become chemically addicted," Fletcher says.

Fletcher suggests nurses treat an addicted patient with dignity. "People have a lot of moral judgment about drug addiction and alcoholism," she notes. "They think people have a choice, but people who are addicted don’t have a choice anymore; they can’t just buck up and not do it anymore."

Sam Orr, MAE, CAC, director for the Men’s Community Residence in Columbia, SC, says that many health care professionals believe addiction is a habit, rather than an illness.

"It hasn’t been that long that insurance companies have recognized alcohol addiction as a disease, and it’s understandable because it’s a very unorthodox disease," Orr says.

5. Differentiate between stereotypical drug addiction and physical dependence to necessary medication.

A national expert on chronic pain and addiction says medical professionals worry too much about patients becoming addicted to their pain medication.

"One of the biggest problems with addiction is people don’t understand the definition of an addict, and they don’t distinguish between addiction and an ongoing need for analgesia," asserts J. David Haddox, DDS, MD, medical director of the Pain Rehabilitation Program, which is part of the Center for Pain Medicine of the Emory Clinic in Atlanta.

Haddox defines addiction as a condition that causes a person to use a drug or alcohol compulsively and destructively. He says physical dependence can occur when patients use certain drugs that improve their quality of life. The patients might suffer physical withdrawal symptoms when they stop using the drug, but they are not psychologically dependent on the drug.

Although medical dictionaries define addiction as physiological or psychological dependence on some agent, Haddox argues that some patients can become physiologically dependent on a drug and still not be destructively addicted to it. (See related story on addiction vs. dependence, below.)

For example, most people who are taking opioid-type pain medication do not become addicted even when they are physically dependent on the drug, Haddox says. This means, they could easily stop taking the drug once the pain has ended.