I’ve changed many details to protect the identity of the nurse I interviewed. I offered to pay her for her time, but she refused, so I made a donation to the American Nurses Foundation Coronavirus Response Fund in her honor. The Coronavirus Response Fund for Nurses focuses on:
Providing direct financial assistance to nurses
Supporting the mental health of nurses – today and in the future
Ensuring nurses everywhere have access to the latest science-based information to protect themselves, prevent infection, and care for those in need
Driving the national advocacy focused on nurses and patients
Mental Health RN
I interviewed Frannie, a mental health nurse who specializes in addiction medicine. She is a Registered Nurse who works at an outpatient opioid treatment center. I was surprised when she told me that some people wouldn’t describe patients on methadone as being in “recovery” because methadone is still an opioid. Frannie said, “If their story is that they are recovered, then they are.”
I have no experience with this type of nursing, so I was fascinated to learn that about 30% of the patients at the clinic will likely be on methadone for life. “These are stable patients with jobs, families, work. They are highly functional.”
I asked about access – do you have to get referred? Frannie said, “Anyone can walk in off the street. We have an NP there every day and a doctor 2x week.”
For those struggling with addiction to opioids, methadone is prescribed at a low dose. Many start out at 30 mg daily, but some are now at the daily maximum dose. Their tolerance level is extremely high. If they have been doing fentanyl, they need a lot more. You have to not judge a 90 lb. woman who needs 200 mg to function.”
Frannie told me many of her patients have been coming to the clinic for 5 years or more. Many of them are at 80 – 120 mg daily.
I asked how a maintenance dose could max out. I wondered about tolerance. Frannie said, “A lot of it is psychological. If they miss a dose they feel like they have the flu. Most of them come in once a month or every 2 weeks for their supply. They take it the way they are supposed to and then come back for more.”
What about the other 70% of your patients?
“At the bottom of the ladder are the people who are unstable with comorbidities. People with higher levels of care do come in and we are trying to keep them off the street. These are the borderline stability folks. 15-20% of them are never going to get to take home doses. They have to come in every day. They are often also still using methamphetamines, cocaine.
We test them once a month randomly, but even if they test positive, we still treat them. We keep an eye on their dose. Urine tests get sent to a lab. Sometimes we can’t dose them because there are too many other drugs on board.
There’s a small percentage of patients who are freaking out, like they are coming in wearing three masks, but most of them seem to be hanging in there. They’ve already been through some rough S%$#. Even though they are addicts they have some resiliency.”
Unique challenges to those with addiction
According to the National Institute on Drug Abuse, the pandemic presents some unique challenges for people with substance use disorders and those who are in recovery.
I read an interview with Dr. Nora Volkow, the director of the NIDA that focused on the collision of the Covid-19 pandemic and another very real public health crisis – substance use disorder. It really hit home when Dr. Volkow said, “We had not yet been able to contain the epidemic of opioid fatalities, and then we were hit by this tsunami of COVID.”
Issues that are exacerbated by Covid-19
The healthcare system is not prepared to care for those with addiction
Social distancing makes these folks even more vulnerable by interfering with the support systems that help them to recover
The drugs themselves negatively impact human physiology, making those with addiction at higher risk for getting Covid-19.
According to Volkow, it’s harder for patients to get access to treatment. Some clinics are decreasing the number of patients, the healthcare system is less able to initiate people on buprenorphine. If you are socially isolated and you overdose, it is much less likely that you will be rescued with naloxone.
There are no statistics yet on how Covid-19 is influencing fatalities from drug overdoses.
Research into the NIH’s $900 million Helping to End Addiction Long-term (HEAL) initiative came to a halt. Research into bringing medication-assisted treatments to prison inmates has stopped. Some IRBs are closing, making recruitment for research impossible. Dr. Volkow spoke of the need to be creative with virtual technologies to advance the goals of NIDA and the NIH.
How have things changed at Frannie’s clinic since Covid-19?
“For the patient it’s unsettling. They come here every day and it’s different. They are more stressed. They are constantly asking – are you going to close? They are so worried the clinic will close. It’s their life-line.
We’re behind glass. Before we always had half the window open, now we keep it closed.
There’s no paperwork due to pen sharing. We are doing it all on the computer. They used to get their own water from a pitcher, now we pour the water for them.”
What about infection prevention?
“People who in the past didn’t get take home doses are now getting them."
I thought that would be a bonus for folks to not have to come in as often, but Frannie said, “People like coming into the clinic, though it’s hard to be responsible for all the medications. If they don’t live in a home, 14 bottles is hard to keep track of. You can’t get more take out if you can’t be responsible for your medicine.
I’ve been surprised though that most of the ones who have gotten the extra doses to take home have been bringing back all their empty bottles, which is required if they want more doses.
Another change is that we have to call them every other day on the phone to assess how they’re doing. I’m pleasantly surprised. It’s been interesting to call my patients every day. I thought maybe they wouldn’t answer their phones, but they are sober and kind and happy for the check-in.
It’s increased my trust in my patients.
I have to wear a mask and gloves all day and the patients also have to wear them. We keep their masks in plastic bag with name. It’s now the security officer’s job to let in ten people in at a time. He hands out the masks.” Frannie said previously there were between 20-30 people in the room, “being social and seeing each other, they miss the interaction."
I wondered if the patient masks dry out in those baggies. Frannie said, “I have no idea. That’s the policy – it’s what we have to do.
I am getting some skin breakdown from the mask. I switch between my homemade and my surgical mask.
There are four of us nurses in the pharmacy and our desks are not 6 feet apart. No one is changing their masks. Despite that, I think we’re doing a pretty good job.
I think we don’t give them enough credit. We talk about how vulnerable they are, but they are doing okay. They have surprised the crap out of me.”
I’ve written up interviews with two other nurses, so if you enjoyed this one, check them out:
At the Bedside with Covid-19 - Stories from the Frontlines
At the Bedside with Covid-19 Part 2: John
I hope to continue to interview nurses in various roles. Please let me know if you would like to be interviewed, or if you have any requests! Next up is an interview with an ER nurse.