Heroin addiction

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Hi there,

I am a psychiatric Nurse working in England, I was the first Nurse prescriber to prescribe substitute drugs to heroin addicts in our country. I was wondering if you have Nurse prescribing in your country and how it works there?.

Hi Simon,

I'm not a Nurse so I don't know if Nurses can prescribe or not. I would just like you to know that Europe is light years ahead of the U.S. in addiction treatment. Although addiction is called a disease in the US, somewhere in the neighborhood of 93% of treatment centers "treat" addiction with 12-step facillitation. Therefore, people with addiction in this country are "treated" for "the disease of addiction" with a moral model of intervention.

Unfortunately, MMT in this country is so tightly regulated that few people can benefit from it. Everyone is shuffled off into re-education called "treatment" and are told that the only possible way for them to overcome and addiction is to spend the rest of their lives "recovering", (the myth propagated here is one can NEVER recover from addiction) while attending 12-step meetings (AA/NA) for the rest of their lives. Once indoctrinated into the recovery subculture, the person is expected to surrender and accept that they are powerless and need divine intervention to keep from using drugs or drinking. Once the person is indoctrinated into the recovery subculture, they are told that if they "work the program" (whatever that means, for there is no criteria to do so) that God will deliver promises upon them. God will remove their character defects, God will intervene in the "strange blank spots" to keep them from drinking or using drugs, so on and so forth. But to receive these promises one must become humble before God and the group, they must confess their sins to God and the group in what they call "sharing" and make amends for their sins. They must cast aside the silly notion that they can think for themselves and direct their own lives, they must give up free will and turn it over to God. They tell the person that the reason they are an "alcoholic/addict" is because they are selfish, liars, cheaters and theives and their only hope for "recovery" is through the grace of God.

So as you have have likely guessed Simon, the success rate of this treatment hovers somewhere around 3-5%. The treatment centers are hard pressed to answer for these miserable stats, and since they are nothing more than very expensive rapid indoctrination of the 12-step religion, they absolve themselves from providing inadequate treatment by blaming the client for treatment failure. Either the client is "in denial, not honest enough, hasn't worked the steps properly (although there is no criteria), hasn't gotten right with God, hasn't went to a meeting everyday, didn't really want to get better, and the list goes on and on.

So yes, what you are doing is helping far more people than all of the 1930's religious psychobable that is done here. What other disease is treated with a moral modality created in the early 20th century ignoring all new research that is available?

I know you must be thinking that I must be joking. Really, I am not. Google, Alcoholics Anonymous+Cult and you will be led to many sites.

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Well, I currently work in substance abuse primarily with ETOH & Heroin/Opiate abusers, and I think someone needs a refresher on the 12 steps, it is not as trite as posted here. I agree you should google AA, the Big Book & read some history behind the prgram & read the 12 steps for yourself

I have seen many addicts successfully beat addiction using a 12 step based program who are not particularly religious per say, but can still apply the basic principles to their situations. AA or NA meetings are extrememly supportive & non-judgemental & if you really want to see it & make your own assessment just attend a open meeting.

Currently we are using Suboxone sublinguil protocol for opiate addiction, we try to make it quick 5 days then off, but for some patients like long term pain patients/ spinal surgery pt.s that have long term pain issues they can be maintained long term on suboxone with fairly good results. Unfortunately like most areas of medicine substance abuse is not cookie cutter & where I am at at least each patient is approached individually, thank goodnesss.

I have to respectfully disagree with Jerseyboy, I have found working in substance abuse on & off the past 18 yr.s that a 12 step based program while not for everyone is not the holy roller judgemental experience his post makes it seem. One thing doesn't work for everyone, but it's a good organization that has been a lifesaver emotionally & physically to countless addicts & families, myself included.

here in MI, physicians are limited to 30 suboxone patients at one time,and must be certified to write rx for suboxone. I don't believe NP's can prescribe suboxone in MI ,but I could be incorrect in that, I know they are not in the treatment facility where I work.

I agree, great thread. I love working with substance abuse patients ;0)

-Sara

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Thought you might be interested in hearing a former addicts point of view on a couple of the different programmes. Personally I don't think the Naltrexone program is an effective treatment in the long term, it didn't work for me and it hasn't worked for anyone else I know. Even people who initially seemed to be doing quite well on the program relapsed within 2 years, including one girl who had orginally been part of the initial program in Israel and receoved a lot of media attention for having "beat her addiction" (she relapsed within 18 months and went onto the methadone program).

The problem with the Naltrexone program by itself is that it takes care of the physical dependance and that is actually the easist part of the process, but it doesn't really address the psychological and environmental issues related to addiction. You go from being an addict to being clean and expected to just continue taking your Naltrexone and get on with your life and that is very hard to do. I remember feeling completely lost after doing a rapid detox with Naltrexone, it was like "ok now what" I had no idea how to cope in the real world, how to handle not being an addict and having my whole life revolve around Heroin.

I needed a period of adjustment, time to get used to a life without addiction and this is where I think that it has to be imperative that any program is combined with counselling and helping people to reintegrate back into normal society. For me the program that did work was Methadone. I tried Naltrexone, abstinence based rehab programs and Narcotics Anonymous, but with Methadone both the physical and psychological urges were taken care of and it allowed me to start preparing for and learning how to accept a life without addiction. Methadone didn't work straight off though, I made the mistake of asking to be put on a low dosage and to come off very rapidly and I relapsed because I didn't allow myself time to adjust. Once I went back on the program on a decent amount of Methadone and then gradually tapered off over a 2 year period, in conjunction with regular counselling I had a lot more success. I've now been Methadone free for nearly 4 years and drug free for over 4 years.

If you have any questions for me, please feel free to ask...I will answer anything as best I can.

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Saralyn,

Im curious, does the place you work give informed consent about Rational Recovery, SMART Recovery, SOS, or WFS? Or, do you require 12-step meeting attendance?

I'm certain many of your patients have been through treatment more than once and each time have been referred to 12 step meetings, but it did not work for that patient. So which recovery support group do you send them to? You don't send them back to 12-step meetings if they have tried it several times and it didn't work for them, do you? And if you do, why?

And I really don't need a refresher on 12-steps. I have studied them intensely over the years. I agree, people need to go see for themselves. However, one must attend more than one or two meetings, and you must not let the group know you are there to observe. Attend like those coerced into re-education and attend 90 meetings in 90 days. Become part of the subculture, tell them you are an alcohol or addict. Then decide for yourself. If anyone does this experiment, please be very careful with whom you associate. AA is full of predators, criminals and mentally ill people. Choose wisely who you speak to. And if you really want to get them riled up, tell them you're "sober" but you take Methadone.

http://www.orange-papers.org/

http://www.morerevealed.com/library.jsp

Of particular interest here is the book The Real AA: Behind the Myth of 12 Step Recovery. You can read the book online.

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The program I work for is strictly 12 step based. No unfortunately they do not give out information on alternative recovery programs, which I feel is ethically wrong, but that's the way it is there.

I think all methods of recovery should be considered on a case by case basis as it is not a cookie cutter system. My employer requires 90 meetings in 90 days upon discharge (I do not believe they follow up on this however) and for those discharged on suboxone for longer terms, perhaps a long taper over a few months the require the pt to come to a weekly meeting in order to get the rx.

There are most definately flaws in the system, but I believe it's one of the best programs in Michigan. That said they abuse the hell out of the staff, you have to love workig with addicts & psych pt.s to stay, but you already know that. Please pardon any spelling errors, just finished 13 hr.s & I'm pooped! And yes, I have seen lots of frequent flyers but that has declined the past 6 months or so since the new medicaid rules took effect.

-Sara

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Saralyn,

Thank you for your response. I'm just curious about patient advocacy though. As a Nurse, aren't you ethically and legally bound to give patients informed consent on any treatment? If you worked at a Dr. office and you saw a patient returning time after time because the Dr. prescribed antibiotics for their diabetes instead of insulin, wouldn't you question that? Or would you let the patient just keep returning for the wrong treatment?

I'm often amazed, that for some reason, people who present for treatment of addiction are not given the same patient rights as those who present for other problems.

What is the rationale that the facility gives you for prescribing the wrong treatment over and over for people? I have to agree with changes in the Government payor sources. I agree, why pay for the same treatment over and over if it doesn't work. However, I believe they have gone about this all wrong. The patient is the one who gets punished for ineffective treatment, not the facility providing it. Does this occur in any other field?

Thanks for your response

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Well the patients are given informed consent forms that do not address this. They are assessed by a sw/who discusses their case with the insurer & decide if the pt meets criteria. Now they have turned away pt.s that do not meet the criteria for in pt tx, but not specifiallly frequent flyer pt.s

Bear in mind here, if I were to push the issue with I agree with you on by the way, I would be canned. I am the person that holds health benefits for my husband & myself & I have some serious medical issues myself & can't afford to lose it or cobra at this point. Do I tell my frequent flyer pt.s about other alternatives that might suit them better, in private of course.

The facility I work for is very abusive to the staff. I have been physically & verbally threatened by a STAFF member, have even filed incident & police reports (and I am like the 5th person to be threatened by him an write it up) and they just put him on the advisory board for "service excellence", they have Techs (like a patient care tech only no medical training, with at least 1 year in recovery) passing meds including suboxone-very scary, but of course they want the RNs to pull the meds the night before & place them in packetts for the next day, several RN's will not do it nor sign the MARs if they are not dispensing meds. I thought it was illegal to set up meds anyways?

So in my opinion it is not currently a safe environment for pt.s and staff for many reasons. I am currently looking for employment elsewhere, but in the mean time I have to have health ins. I ask the same questions you ask & get poo-pooed or not answered at all.

The bottom line is this, if there is a open bed-fill it. If the patient has any substance abuse issues & the insurance company deems them appropriate for treatment they get in, whether it is their 1st or 15th time in our facility. Now I am still very pro- AA & NA for reasons I stated before, it works for many however it doesn't work for everyone I agree.

I mean to me it seems if we keep a revolving door & the patient has been there 10 times aren't we becoming part of the problem & enabling ?

There are not many substance abuse centers left in my state, and almost all of them are 12 step based. I don't know what the answer is for these frequent flyer pt.s, it's so disheartening. Tomorrow I have several on the schedule that have been in multiple times, but if the ins pays they will get in, that's it. It's a viscous circle..the staff gets very depressed over it at times too.

I don't think things will change until after our next inspections. Don't get me wrong , our program is great once the patients are in they get great treatment & counseling, it's just obvious though that there has to be other alternatives for the ones it doesn't work for and where I'm at, there isn't.

Now add to that we take dual dx, substance abuse with a side of schizophrenic or adhd, or whatever. You get the idea.

But, not to sound whiny (which I am) I LOVE working with substance abuse patients! There are tons of management problems & changes going on currently & I think this will all rear it's ugly head soon, but til then I keep my mouth shut, do my job & pray my co-worker doesn't come in with a gun & go postal. No security on days, rent a guard at night, for visual presence only- they are not allowed to touch or restrain a pt in any way..

And God help me if someone reads this board & rats me out, but hey you have to vent somewhere.

So you see, it's a big hairy mess at this point from a nursing standpoint.

But I do see a lot of good happening too, and the staff both nursing & counseling REALLY care, it's just sad to see the same ones falling through the cracks over & over again.

-Sara (pardon my spelling)

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I'm often amazed, that for some reason, people who present for treatment of addiction are not given the same patient rights as those who present for other problems.

Me too, but that's the way it is unfortunately, and we an only advocate for them so far, is has been made crystal clear not only to me but others we are not to "'question" such things.

For example, I had a pt presented to me by the psychologist on staff at the assisted living facility where the pt lived, this Dr. was insistant upon sitting in on my interview/admission of the pt. I refused, strongly & insisted on interviewing the pt alone. The pt then told me he was brought there against his will and told if he did not check in for etoh treatment he would be evicted, as he had fallen on the ice on the sidewalk severely & permanently damaged his arm & leg & had limited ability to walk & use his arm. They wanted him to come to tx so they could fight the lawsuit saying he fell because he was drunk which the pt denied!

I ended up calling my administrator & the pt told the admin the SAME thing & guess what, they talked him into staying & I was flat out old to admit him-period.

I am just waiting to get a supeona for court for that! Now I wrote extensive notes & put them into a file at home just in case- but it was total BS, the admit was completely inappropriate & the pt stated over & over he was there against his will & just didn't want to get evicted from his apt..it's unbelievable, he may have kept his apt, but the psych Dr signed nothing to to sy he could keep livingthere it was all forced.

That's the type of management we deal with.

-Sara

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saralyn,

I pray that you can find a job at a more reputable place before something happens at your current employer and you end up loosing your license. There is no way I would feel comfortable setting up meds for someone else to pass out or signing the mar that you gave them. What if someone gets the wrong meds or to many meds and dies. This could come back to haunt you. I understand the position you are in with medical insurance though I have been there myself. I am glad you opened my eyes to what can go on at drug rehab facilitys. This is a area that I am very intereted in working in after my personal experiance with trying to get my husband to go to rehab.

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Thank you for the concern, I'm not in any danger of losing my license because as a LPN I am not allowed under company policy to pass meds- lol, see the irony. It's the RN's that would be in danger of that, which is why they are refusing to set them up, sign them out. And who could blame them?

I don't work in the areas where they recieve meds at all, in fact if a patient has a seizure or is medically unstable I call 911 & away they go!

So it's not on me , but it's still wrong. Obviously someone got pixxed about it my supervisor told me today that the state will be there weds to inspect, interesting. I'm not worried about my department at all, but am VERY interested to see how the in-patient areas do!

What makes me angry is that I am forced to work near & at times with someone who has been verbally abusive & physically threatening to myself & other employees, even after it's been well documented. They just don't appear to care & let him get away with getting in our face screaming, backing me into a room with no escape, shaking his fists at others. It is ridiculous. Right now it works for me due to the insurance & my schedule, but I won't be staying forever-believe me! As soon as I finish up my RN, I'll be moving along- I need a good retirement 401K & they have just cancelled our pension & match for our self funded retirement so a lot of employees are leaving..

But back to the subject of working with substance abuse, I will probably still stay in that area if possible, depending on where we end up living in the US r/t my hubby's work. Though I wouldn't mind travel nursing when he retires in a few yr.s

-Saralyn

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