I recently wrote a posting related to nurses caring for patients with addictions in response to a Facebook posting exchange. Below is the exchange, followed by my response.

I wish I could honestly say that I have always been the nurse who has taken the high road, but I can’t. Perhaps that is why I felt compelled to reach out to this nurse. It is time that we as nurses channel our anger directed at vulnerable patients and give voice to the complex issues that fuel or frustrations and sense of powerlessness.

A.K.: I don’t like to use fb to vent n I’m sorry if I’m offensive but as a nurse I HATE addicts. They are unreasonable, demanding and abusive. Just because u made a poor choice in ur life does not give u the right to call me a bitch because I was 5 minutes late with ur damn oxycodone and shame on the doctor and family who prepetuate this kind of behavior. This is the first time I have truly hated my job and all because of one person.

MF: ‎:( you need a beer

ALA Just smile and walk away

SO Oh my dear…it will pass. Where are you working?

A.K. XXX and I really love the work I do except for today. At least I only have two more days with this person n they are being sent to another facility.

MF Hopefully not to mine!

SO Gotcha…I work with adiicts…they are very hard.

DG (my response) So sorry A that you cannot see addiction for the disease that it is.

MF: A disease is one thing but a self-induced disease is another. Even most people who are in the final stages of cancer are able to understand that unfortunately nurses have to take care of many people at once. My experience w…ith addicts says that most of them are so focused on getting the next “fix” that they are unwilling to take into account that other people may take priority over them. “Pain” whether real or imagined does not kill you, the cause behind it may, yes, but getting a pain pill to that person as soon as they ask for it wont fix the cause of the pain anyways. And I highly doubt A.K. doesn’t understand what addiction is. Nurses deal with it every day.

Dear AK.

First off, I want to say I am sorry for my short and somewhat “flip” response to your status post on your wall. Your comment hit me at time when I have been feeling even more passion than usual about the stigma and the health disparities that plague many of the people we serve as nurses. I hope that you will take the time to read this letter and allow me to explain. Just a few days prior to reading your Facebook comment, I saw another remark on Facebook by a nurse from another state referring to “the drug seeking trolls” in the emergency department. That statement has eaten away at my heart like a cancer. So after reading your post, I felt compelled to respond. Please understand that I certainly don’t believe that nurses must be victims of abuse by patients, families, co-workers or employers. Nurse violence is a well-documented problem in health care settings and whether it is a physical or a verbal attack, nurses have a right to work in environments that are both supportive and safe. I do however believe that in our work settings, we must do more to help nurses cope with the stressful situations that can lead to blaming the patients and to burnout.

Addiction may be a self-induced problem because it began with a poor choice or series of poor choices. When I look around me I see friends, family and colleagues that have made the same poor choices and yet they have not ended up addicted. This leads me to believe the research findings supporting a genetic predisposition to addiction are plausible. This also helps me better understand why one person may end up being a highly functioning member of society while his/her best friend lies in a gutter. By the grace of God there go I.

There are many other diseases that also begin with making poor choices. Consider for example, people who suffer and die from emphysema, heart disease, type two diabetes, stroke or cancers of the lip, throat and lung. A good case could be made that these patients also brought their disease on themselves because of choices to smoke, chew tobacco, eat too much and exercise too little. Why is it that when patients with these diseases suffer, we show compassion and caring and do everything we can to try to alleviate their misery; as we are called to do and as we should do!

It really is unfortunate that the primary symptoms of the disease of addiction are denial, irritability, selfishness, aggression and manipulation. All of these symptoms make the patient difficult to like and to care for. These same behaviors are also symptoms of many patients with untreated mental illnesses. The reality is though, that no matter how many times we hear in nursing school, “don’t take it personal this is not about you.” it still hurts. When the words or the fists are directed at us, it is hard NOT to take it personal! It is hard to see aggression as a classic manifestation of the disease, especially when there are no outward signs of injury, like there is with the head injured patient who we expect to act aggressively.

Just like aggression is a hallmark of an addict needing a fix, I believe that your venting on Facebook about how you “hate addicts”, is also a symptom of System disease. I have become increasingly frustrated over my 38 year career with how little treatment for both mental illness and addiction have changed despite the increasing body of knowledge supported by research. Our medical care system has recognized addiction and a number of mental illness as diseases for many years. Yet when it comes to diagnoses and treatment, the addicted and or the mentally ill, rarely get the same level of care as people with other more “socially acceptable” diseases. I, like you, come from a family who has had members who have suffered from addiction. I have also cared for patients who lived with psychosis, addiction or both. I have been spit on, hit and called every name in the book. I have feared for my own safety. I have feared for the safety of my unborn child. My experience with addiction does not end there. In every nursing position I have held, I have shared in the difficult task of having to report nurse colleagues for substance use and then experienced the deep sadness of watching nursing credentials and careers silently and sometimes publically be stripped away. So I am not some ivory tower do-gooder who doesn’t know what it is like in the trenches. I am just frustrated at our profession’s lack of progress in the ability to care safely and humanely for some of our most vulnerable AND some of our most violent patients. And I am just as frustrated with the lack of support and resources for nurses who must live with the day-to-day realities of addiction; their own and their patients.

There may be many variables that lead to addiction and the downward spiral that often results in death. These are just my thoughts about four major flaws in our current health care environment that contribute to the development and the progression of disease.

The first flaw. Addiction prevention for our children and youth is not a priority. Further the prevention efforts that are in place have historically supported bombarding youth with information and with scare tactics. The research will support that adolescence is a time of restructuring and “rewiring” of the brain. To simply give youth the information about why alcohol and drugs are bad for them is not enough to prevent the “bad choice”. One of my favorite authors, Andrew Robinson who works with teens in the prevention arena wrote a book titled: The Teen Age, 40 Reflections on Relating with Teen. In his book he discusses the research on the adolescent brain and how it relates to adolescent behavior, “Does a teen know that if he gets into the car with someone who’s been drinking, he may be at risk of dying? Yes. Does a teen know that if she comes home after her curfew she won’t be able to drive for a week? Yes. Does it really make a difference whether a teen knows something? Does knowing something change teen behaviors? No. Because the difference between a good decision and a bad one is not a lack of knowledge. It’s something else” (p.12). I could elaborate on the evidenced based approaches that work for prevention from SAMHSA and the NIH but I will not go into it here as that is a topic for a whole other letter. My point here is emphasize that when many bad decisions are made that start people down the path to addiction just educating and scaring is not enough.

The second flaw. Drug addiction can also be the consequence of poor medical management of chronic pain. Sometimes it is our own dysfunctional health care practices that light the fuse of addiction. I wonder how many physicians and nurses could differentiate between acute and chronic pain management standards of care and protocols. I wonder how many nurses or physicians could identify even one resource for treatment of chronic pain in this community or even the whole state. I wonder how many nurses or physicians could accurately assess the difference between acute and chronic pain in their patients.

The third flaw. We still disguise the problem of addiction by focusing on the secondary medical/and surgical problems that arise because of substance use. It would be interesting to know how many people are screened for chemical use using SBIRT, CAGE or other simple to use tools. The irony of this is that one of the biggest risk factors for an ED visit is chemical use. Sometimes this may be the patient’s use or the patient may be ill or injured because of someone else’s use. How many of our ED visits for motor vehicle accidents, gunshot wounds, family violence or suicide attempts are related to chemical use? When we fail to recognize the primary problems that contribute to illness, injury and death, we allow addicts to continue to harm themselves and others.

The fourth flaw. When we do recognize the need for addiction treatment, the cost of care is prohibitive for many on fixed incomes or those lacking social and family support. Yes, we have some good resources in Montana to treat addiction. However, I know of several families who have had to take out second mortgages on their homes so they could pay the upfront $12,000 deposit required for admission of their loved one into treatment. What a blessing when the addict has someone in their corner that cares and has a credit card. Then they hope and pray treatment is successful and that the relapses are infrequent and identified early. Exacerbations and remissions are common in most types of chronic disease but when the disease is addiction or mental illness, relapse is often seen as a personal failure or evidence to support that addiction treatment does not work.

Clearly, I am not advocating that people who have an addictive disease should not have to accept the responsibility for managing their health. Indeed the person is the only one who can initiate recovery. Sadly for some, there comes a time when family and friends must make the agonizing decision to terminate a relationship with an addict for their own well being and safety. I do believe there would be far fewer people who would have to make this choice if our system had better community based prevention and more comprehensive diagnosis and treatment opportunities for people from all walks of life for addiction, mental illness and chronic pain and more support for families. Wouldn’t it be nice if everyone who needs it could afford to pay for six months at a major prestigious clinic like Betty Ford’s? Care for addiction is long term and it is expensive. With our current economic crises we are looking at how to spend less not more. But what are the long-term ramifications to not funding addiction prevention and treatment? How many other medical and surgical hospital stays would not be necessary if we treated the primary problem?

Finally, stigma and shame are barriers for many addicts and families to reach out for help. They know they will be judged. And, as nurses we feel powerless to change anything so we blame the victims. The list of names we use to describe them goes on and on; drug seekers, drunks, druggies, frequent flyers, gomers, losers and yes even trolls. Many patients and families have no choice but to suffer in silence while living with, abuse, trauma and financial ruin. What other chronic disease support groups feel the need to use “anonymous” in their name. There are no community benefits/fundraisers for families needing help with treatment for an addicted member, even though addiction treatment is not funded as well as cancer care or heart disease. I would love to see a donation jar at Safeway or Wal-mart that asks for money to fund addiction care. I’m not expecting that any time soon.

I am frustrated that as nurses we all continue to feel powerless to change ANYTHING for the patient, for ourselves and for our communities. I am frustrated that people who suffer from these diseases are considered second-class citizens and are not given the resources they need to change their life trajectory and reach their full potential. I am frustrated that health practitioners rarely are allowed adequate  time to build the relationship of  trust to explore the origins of the presenting  health problem and feel powerless to do anything other than “treat ‘em and street ‘em”.

Only when we as health care providers begin to utilize our collective voice to speak out and advocate for our patients will our institutions, our insurance companies and our policy makers begin to listen. How long can we continue to afford to be penny wise and dollar foolish? I think it is time we ask the hard questions and they all begin with: How can we empower ourselves to do things differently for the future of our children and our grandchildren and our communities?

Again A. I apologize if I sounded condescending in my response but I thank you for giving me the nudge to say some things I have been wanting to say for a long time.

Blessings and peace to you in your nursing career. I hope that you too can see this is an opportunity for us as nurses to find new ways to support each other so taking care of the difficult patients, isn’t so difficult. Your faculty here at Carroll, is always here for you.

Sincerely,

Donna Greenwood

Donna Greenwood is an associate professor of community and public health nursing and the Monsignor Joseph Harrington Endowed Professor in Nursing at Carroll College in Helena, Montana.