Drug Wars, Drug Addiction, and Social Justice Issues


I have been reading Johann Hari’s Chasing the scream: The first and last days of the war on drugs. 

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This book provides a very detailed account of how we came to be an anti-drug and pro-prohibition nation that lead the way toward making criminals out of people who struggle with use of substances and millionaires out of people/ cartels who sell drugs on the black market. I have found the book in some aspects hard to read because the political manipulation of our global population and the injustices that have arisen from this global movement. I get angry about what has happened as I read and I have to step away for awhile.

Some key points from this text for nurses to consider:

  • The dominant medical establishment (in particularly the AMA) was initially very against “drug” prohibition, but key vocal players were forced into silence by the government.
  • Overall, 90% of people use substances we call “illicit drugs” without having addiction issues, yet we continue to think that people need to be cautious with drug use. For instance, many (not all) soldiers used heroin in Vietnam to get through the hellish experiences, yet many (not all) had no issues with heroin addiction when they returned stateside.
  • There is a clear connection between lack of social support, childhood abuse, and adverse childhood experiences (ACEs: see the CDc website for more info on this) with addiction. We need to be compassionate toward those who are suffering, because these childhood experiences literally changed how their brains function, making them very vulnerable toward addiction. Adverse childhood events impact young people across the socio-economic spectrum, and many people who came from “good families” have also experienced a lot of childhood trauma.
  • When it comes to death and illness, our two leading “drug use issues” are likely nicotine and alcohol, both legal, and both toxic and deadly. Yet, we simply put warning labels on these drugs and let folks self-determine their fate. Why are these drugs okay, but others are not? Because they are socially acceptable? Because they are “cheap”?

When we think of the opiate crisis, one of the biggest issues of course is people not having safe and affordable access to opiate medications: when people are cut off from safe supplies (ie, their pain prescriptions which the medical establishment has endorsed and prescribed, with potentially some of the cost covered by their medical insurance ), they may turn toward heroin and other “street” opiate medications. These drugs are expensive, sometimes hard to find, and in many ways they force or perhaps support people to live a life of crime in order to maintain their habits, if people have gone that far they must get help. And people overdose because they have no idea what is in the products they are obtaining.

Maybe, we have created an addiction monster in our society.

However, Portugal has found a way out of the addiction monster’s clutches. In 2001, with a growing heroin addiction problem, Portugal decriminalized all drugs and began to consider addiction to be a public and personal health issue. Drug addiction was viewed for what it is:  a chronic, debilitating illness. People caught with a 10 day supply of any drug are referred to a sociologist who helps to determine their treatment options. And what Portugal has realized is that not only is this a more humane approach, it is also far less expensive to provide adequate medical care and treatment to addicts versus incarcerating them. Portugal has experienced a 75% drop in addicted persons from the 1990’s, and their addiction rates are 5 times lower than the rest of the EU. Meanwhile, drug related HIV infections have dropped by 95%, and the stigma around addiction has lessened dramatically.

http://www.npr.org/sections/parallels/2017/04/18/524380027/in-portugal-drug-use-is-treated-as-a-medical-issue-not-a-crime

As nurses, we are concerned about social justice issues and public health issues. I would posit that nurses and politically active nursing organizations should be taking action around the opiate crisis in several ways:

  • Calling for safe injection sites and distribution of clean needles (or needle exchange centers) and free condoms.
  • Looking at prevention and early identification of at risk persons (both ending early childhood trauma through supporting parents at risk for enacting trauma and assessing for early childhood trauma both across the lifespan and across all populations to determine risks for addiction).
  • Supporting harm reduction techniques.
  • Supporting a view of addiction as a public health issue, and a chronic disease issue.
  • Considering a call toward decriminalization of drugs and ending incarceration for addicts (the Portugal Model).
  • Acting compassionately toward all addicts (even the “drug seeking” ones).

If you are interested in this topic, I do recommend reading Chasing the scream. This text provides great historical insight into how we came to where we are at with the global  “war on drugs” and the escalating issue of for-profit prisons.

We have become the nation with the greatest number of incarcerated individuals (not %, but sheer number!): though we only have 5% of the world’s population, we incarcerate 25% of the world’s total prison population (this link looks at the complexity of these numbers and supports the idea of the truth that in the land of the free, we incarcerate a much higher percentage of people due to lack of alternative ways to provide help https://www.washingtonpost.com/news/fact-checker/wp/2015/07/07/yes-u-s-locks-people-up-at-a-higher-rate-than-any-other-country/?utm_term=.1ca70c3620af).

Columbia University’s CASA group has released multiple reports that link drug addiction issues to crime, incarceration, and repeat offenses. Sadly, while 65% of our prison population qualify for addiction treatment, only 11% actually receive treatment. Meanwhile, the majority of violent crimes are committed by those suffering from addiction. https://www.centeronaddiction.org/newsroom/press-releases/2010-behind-bars-II

Poverty, race, and income inequality also play a role in both addiction and incarceration, and as nurses, we are ethically obligated to advocate for change in healthcare and system wide policies that impact vulnerable populations. Raising awareness is a first step, but perhaps nursing organizations need to also start taking stances and lobbying for more humane treatment of those who struggle with addiction.

 

 

What is “best nursing care?” Deconstructing the business model driving healthcare


The current feature on the AJN blog “Off the Charts” is a post titled “The Limitations of Rating Nursing Care by Customer Surveys.”  Since I have, for many long years, decried the practice of basing the evaluation of nursing care on patient satisfaction surveys, I jumped at the opportunity to read this post!  Of course we need and want to know how patients perceive the care we provide, but how we obtain this information, and what we do with this, is a key factor.  Since this approach derives fundamentally from the corporate business model, and is now practiced in the context of this model, the substance, use and outcomes of this practice are deeply flawed when examined from a NurseManifest perspective.  The example the author, Juliana Paradisi gives as an example of her best safe and compassionate nursing care involves a woman in extreme distress who “fired” her as her nurse –  a situation in which she could not break through the barriers inherent in the patient’s distress, but provided a level of care that was exemplary.

Even though the overarching business model that governs healthcare now is probably not going to go away soon (Ha!) – we can raise awareness of the limitations that this imposes on our practice, select specific actions to take to place these practices into context, and work to achieve whatever changes we can make.  We can start with addressing the question: “What is best nursing care” from the perspective of the values in the Nursing Manifesto.  There is no single answer to this question – but there are insights to be gained by thinking, talking and writing the ideas that arise from it. Once we have expressed our ideas, we can examine new and better ways to document our care, and continue to address the limitations of the existing practices that fail to document and support our best practices.

We welcome your ideas here – and stories about the times you provided what you think is the best nursing care!

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Full Practice Authority for APRNs in the U.S. Veteran’s Administration


On December 14, 2016 the U.S. Department of Veteran’s Affairs issued a final ruling authorizing full practice authority of Certified Nurse Practitioners (CNP), Clinical Nurse Specialists (CNS), or Certified Nurse-Midwifes (CNM) in the VA system.  This final ruling does aprn-scales_lgnot include Certified Registered Nurse Anesthetists (CRNA), but is inviting commentary on “on whether there are access issues or other unconsidered circumstances that might warrant their inclusion in a future rulemaking.”  This is a huge victory – one that serves the interests of the patients who receive care through the V.A.  As stated in the ruling:

This rulemaking increases veterans’ access to VA health care by expanding the pool of qualified health care professionals who are authorized to provide primary health care and other related health care services to the full extent of their education, training, and certification, without the clinical supervision of physicians, and it permits VA to use its health care resources more effectively and in a manner that is consistent with the role of APRNs in the non-VA health care sector, while maintaining the patient-centered, safe, high-quality health care that veterans receive from VA. (https://www.federalregister.gov/documents/2016/12/14/2016-29950/advanced-practice-registered-nurses)

Various physician groups, including the American Medical Association, have registered strong opposition to this ruling, which in part is responsible for the exclusion of CRNAs (see Forbes report here).  Part of the objection from some physicians is the claim that full practice authority for APRNs (i.e. APRNs can practice without physician supervision within the scope of APRN practice) is that physician-nurse collaboration is undermined. Those of us who follow the politics of this relationship recognize the absurdity of this claim, but nonetheless, this very current situation reminds us that we still have a long road ahead in establishing nursing’s sovereignty over our own practice.  For more about the long-standing physician opposition to initiatives such as this, see the excellent 2012 report on the ‘Truth About Nursing

If you are inclined to comment on the exclusion of CRNAs from this ruling, you must do so by January 13, 2017. Here are details about how to comment:

Written comments may be submitted: Through http://www.Regulations.gov; by mail or hand-delivery to Director, Regulations Management (02REG), Department of Veterans Affairs, 810 Vermont Avenue NW., Room 1068, Washington, DC 20420; by fax to (202) 273-9026. Comments should indicate that they are submitted in response to “RIN 2900-AP44-Advanced Practice Registered Nurses.” Copies of comments received will be available for public inspection in the Office of Regulation Policy and Management, Room 1068, between the hours of 8 a.m. and 4:30 p.m., Monday through Friday (except holidays). Call (202) 461-4902 for an appointment. (This is not a toll-free number.) In addition, during the comment period, comments may be viewed online through the Federal Docket Management System (FDMS) at http://www.Regulations.gov.

Have you ever considered being on a Board?


Here at the NurseManifest project, we have tended to emphasize grass roots, “on the street” kinds of activism to bring our deepest nursing values into everyday experience.  But manifesting nursing values needs to happen everywhere, and one of the spheres whereconference-table this is vitally important is in the Board Rooms, large and small.  Lisa Sundean, who is one of our NurseManifest bloggers, is embarking on her dissertation project to explore nurses on Boards, and in the interest of sharing her work wide and far, she has established website and blog – SundeanRN.org!  Her first blog post is now available, explaining why this is vitally important!  I highly recommend that you read her post: What do Boards Have to do with Nursing?  And if you have never considered serving in this capacity, think about it now!  We need to be manifesting nursing everywhere – at the bedside, the chairside, the curbside, and yes, the board side!

The Power of Nursing


On January 24th in the early morning hours my husband Brian woke me up because he said his left arm was hurting and he was nauseated.  After I gave him two aspirin we rushed to the ED of our regional hospital….He had a myocardial infarction in process.  The cardiac cath team was called, and an amazing interventional cardiologist performed a balloon angioplasty to open up the blocked artery.  After Brian was stabilized in the CVICU he was transferred to the CV Step Down unit to wait for surgery.  On January 29th the cardiothoracic surgeon performed a CABG x 4 and Brian was discharged on February 3rd.  It was quite an ordeal.  There are always lessons we learn when we are the recipients of health care.

As you can imagine this has been a life-altering event for both of us. During this critical time every person that we encountered and every circumstance that occurred, big and small, mattered to us.  I can honestly say that Brian and I experienced the most excellent care that I could ever imagine, and this made a significant difference in his healing and my experience as a family member.

The nursing staff at this hospital were wonderful. We know that nurses are the heart and soul of any hospital. Every single nurse that we encountered was knowledgeable, skilled, attentive and compassionate.  They were truly person and family-centered.  Every one of them asked how she/he could be helpful to us.  Watching the nurse caring for Brian immediately after surgery in the CVICU was amazing to me.  It was like watching the conductor of a symphony.  Her technological competence was incredible…she monitored everything moment by moment, while continuing to focus on Brian as a person experiencing this critical event, and on me as a wife fearful of what was happening.  When I was waiting for news of Brian’s condition during surgery, several of the staff stopped in to encourage me and to give me updates if they could.  This was so meaningful to me.  When Brian was recovering, the CVICU staff pushed and encouraged him and did anything they could to make me comfortable.  All the staff on the step-down unit exquisitely cared for Brian, supported us and made us feel “at home”.  I’m so grateful to the nursing staff for creating the healing environment where this level of care happens.

We often hear about the horrors of poor nursing care, so I wanted to share this story of hope and encouragement with everyone.  I am so proud to be a nurse because of the profound difference we make in the lives of people in the most vulnerable moments of their lives.  Yes, our cardiologist and surgeon saved Brian’s life, but the nurses were equally biogenic (life-giving) to both of us.  They preserved our dignity, prevented complications, prepared us for discharge, facilitated a smooth transition, allayed our anxieties, relieved our pain, provided comfort, lifted our spirits with laughter, gave us critical information, challenged him to do more than he thought possible, instilled hope for the future, involved us in choices, and took the time to listen to our fears and rants.

P.S. Brian is in cardiac rehab now and is recovering.

Never ever ever underestimate the power of nursing. We transform lives by healing through caring.

Celebrating recovery with Brian!

Celebrating recovery with Brian!