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Today let’s talk about how to treat substance abuse! I’m calling it “The Pathway to Recovery.” I find many psychiatric nurse practitioners shy away from treating addiction. I was weary of it in the beginning as well, but you know what? It’s a niche I just kind of fell into and I really enjoy it. It’s a wonderful subspecialty in psychiatry and understanding how to treat addiction can open up a whole new patient population to you! I’m going to give you 5 steps to treat substance abuse patients! If you follow these 5 steps you can’t go wrong! I use this approach with my patients and, guess what? It works! I’m attaching the patient handout portion and an explanation of how to use the handout. Below I will explain my methods in more detail!
Step 1: Assess Motivation
Assess whether the patient is motivated to get sober. Yes, patients will walk into your office and NOT be ready to commit to treatment! Their partner, friend, or relative convinced them to come and they are trying to appease them. When working with the unmotivated patient, you will feel their resistance throughout the assessment. They will often deny that their substance use is really a problem. They will also REALLLLLLY resist medication. When this starts to happen LISTEN TO YOUR GUT! Ask the patient right away, “Do you want to get sober?” Because this process is going to be hard. It’s going to take commitment. They must be ready and motivated! Some of your patients will be ambivalent (remember the Transtheoretical or Stages of Change model in nursing school… yup, here it is!). These patients may partially engage and be willing to do some of the treatment plan, but not all. Maybe they will take a medication but not go to therapy. Meet the patient where they are. When I have an ambivalent patient who is only partially engaged I like to say, “Okay, let’s try it your way first for a month. When you come back next month if you aren’t sober we will try it my way.” They usually agree! You must get the patient to buy in and build rapport and this is part of that. If your patient is ready and committed, you are ready to jump onto the pathway to recovery!
Step 2: Assess Whether the Patient Needs to Detox Inpatient
Always ask yourself, is it safe for this patient to detox and achieve initial sobriety in an outpatient setting? MOST of the time, the answer is yes. In three years, I can only think of a handful of patients I recommended inpatient detox for. What may be an indicator that a patient needs inpatient detox first? Lack of support at home, moderate-severe withdrawal symptoms, medically unstable (particularly if their blood pressure is elevated or they are high risk for seizure), or psychiatric instability (psychosis, mania, suicidal thoughts). All the patients I sent inpatient for detox were medically unstable and/or having moderate-severe withdrawal symptoms. Blood pressures were sky high, they appeared extremely unwell, and had severe tremors. If your patient appears unwell and you are concerned for their physical health DO NOT IGNORE YOUR GUT! Patients detoxing from alcohol or benzodiazepines are your most medically high-risk patients. Opioid detox is uncomfortable, but not deadly. Alcohol and benzodiazepine detox can be deadly. If I am concerned and really feel strongly the patient needs inpatient detox first, I am very straightforward about how serious the detox process is. I say, “Detoxing from alcohol (or benzos) is extremely serious. You can have seizures, hallucinate, and be very ill. If you go inpatient you will be prescribed medications that will make your detox a lot safer and more comfortable.” If your patient is hitting close to 48 hours without alcohol they know what you’re saying is true and often they will take your advice. Once they detox, they can return to you and resume outpatient care.
I have found inpatient detox to be the fastest, safest, most reliable way to get patients to detox. They have no access to alcohol or other substances, they are medically monitored, and they are getting introduced to group therapy and support groups. Going inpatient is a significant event for most patients and leaves a major impact on them which also provides good motivation not to relapse in the future.
Step 3: Prescribe Relapse Prevention Medication
Your primary role in this treatment plan is 1) Get your patient to the right treatment setting and 2) Make sure your patient is on the right medication. If they go inpatient to detox they may come back to your office on the right medications, but you need to be sure! Substance abuse patients are more likely to stay sober with medication to prevent relapse. I like to explain to my patients “Medication is a very small, but important part of the treatment plan. The right medication can give you the foundation to move forward.” Take a look at the corresponding handout to see more about when to use each medication. In the handout I don’t go in depth on how to treat benzodiazepine abuse. That is a whole other topic that I have a really great handout for. You will most commonly treat alcohol, opioid, and cocaine dependence. Marijuana dependence is extremely common, but there are no medications studied or approved for marijuana dependence at this time. Some BIG KEY POINTS to keep in mind are DO NOT START NALTREXONE UNLESS THE PATIENT HAS BEEN OFF OPIATES FOR 7-10 DAYS and DO NOT START ANTABUSE UNTIL 24 HOURS AFTER THEIR LAST DRINK. Be sure to give your patient a list of products and foods to avoid while taking Antabuse. On that note, though, let me add that I have NEVER had a patient say, “Oh man I accidentally used too much aftershave and had the worst reaction” or “I ate chicken marsala and got so sick.” It doesn’t usually go that way. So, reassure your patients that as long as they avoid alcohol and do their best to avoid the things on the list they will be just fine. Antabuse takes 1-2 weeks to completely leave the body. So, having your patient on Antabuse provides an excellent long-lasting safety net.
Be sure to assess for comorbid psychiatric conditions. In my experience, 20% or less of patients presenting with a substance abuse disorder ONLY have a substance abuse disorder. The other 80% of patients have a comorbid psychiatric disorder. Make sure you prescribe the appropriate medications for these co occurring psychiatric disorders as well.
Step 4: Refer the Patient to a Substance Abuse Counselor
This part is so important. First, this adds an additional layer of accountability. Your patients need as many points of accountability as possible. Second, your patient doesn’t know it yet, but they are going to experience multiple phases during their recovery. The first phase (we call it the “pink cloud phase”) everything feels so wonderful and the patient is over the moon they are sober. That phase eventually evolves into a more ordinary phase where reality settles in and the excitement of sobriety has worn off. Patients need a lot of help working through this phase and onto the next ones. Patients who don’t have a therapist and aren’t anticipating this get caught off guard and are very high risk for relapse during this time. A good therapist will help the patient anticipate this new phase and can give your patient the tools to navigate through it.
Step 5: Pick a Support Group and Start Attending ASAP
Here is another layer of accountability. I am a big advocate of “90 in 90” which means a patient will attend 90 meetings in 90 days. These meetings keep their sobriety at the forefront. There are different types of meetings for everyone. The corresponding handout lists the most common support groups, their websites, and the theoretical basis for each group. If your patient attends meetings they are significantly more likely to stay sober. Also encourage your patient to get a sponsor! If your patient can only see a therapist OR go to meetings, I would encourage them to go a support group every time! This part of the puzzle is absolutely critical. Best of all, the meetings are free.
Now you are ready to treat substance abuse patients like a pro! Don’t shy away from it! Follow these steps and you will be able to have the joy of helping so many people achieve sobriety and change their lives! Now I need your feedback. The attached handout is a sampling of the type of handouts I plan to make in the future. My goal is to make a blog post that explains a concept in detail and make a handout you can use in an appointment with the patient (that will hopefully save you time explaining things) and a quick reference sheet you can put in a binder. Does this handout have too much information? Too little? Is this post too in depth? I want to provide you with the most practical information and tips to give you confidence in your practice. Let me know how I could make this information better for you! I’m looking forward to your feedback! I probably won’t leave this handout up permanently if I decide to include it as part of the Psych NP Resource File. So download it now!!