Heroin Abuse: Nurses Confronting a Growing Trend

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Renee N. Bauer, PhD, MS, RN, is Assistant Professor, Program Director for Accelerated Track, Indiana State University, Terre Haute, IN.

Erik P. Southard, DNP, FNP-BC, CME, is Associate Professor, Chair, Department of Advanced Practice Nursing, Indiana State University, Terre Haute, IN.

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Andreas M. Kummerow, MS, RN, CNE, is Instructor, Program Director for the RN to BS Track, Indiana State University, Terre Haute, IN.

Heroin Abuse: Nurses Confronting a Growing Trend

T he use of heroin is alarming-ly high in the United States.The Centers for Disease Control and Prevention (CDC, 2015) estimated nearly 700,000 Americans used heroin in 2013. The number of persons addicted to hero- in doubled between 2002 and 2013, from a rate of 1 per 1,000 people in 2002 to just over 2 per 1,000 people in 2013; young adults ages 18-25 demonstrated the greatest increase. The CDC noted heroin-related deaths nearly tripled over this same time (see Figure 1). Heroin addiction is considered a chronic disease (Fatseas et al., 2015); although no cure exists, many treatment options are available (e.g., Medication Assisted Treatment [MAT] and cog- nitive behavioral therapy) (Tetrault & Fiellin, 2012; Zhuang, An, & Zhao, 2013).

The background of heroin use, classification of substance, individ- ual effects, withdrawal from heroin, and health complications will be addressed in this article. Barriers to treatment will be highlighted, as well as current best practices, screening patients for heroin use, and the need for interprofessional alliances working toward heroin eradication.

Background Heroin is a class 1 opioid (Nat –

ional Institutes of Health [NIH], 2014). Processed from the resin of poppy plants and refined to mor- phine before being processed fur- ther into various forms of heroin, this illegal substance is highly

addictive (Goldberg, 2014). Heroin can be smoked, snorted, or injected (NIH, 2014). Intravenous use pro- duces almost instantaneous effects, while snorting produces a feeling of euphoria less quickly; smoking or snorting may be more alluring to users than injecting because of the stigma associated with intravenous (IV) drug use. Heroin Abuse: Nurses Confronting a Growing Trend

Abusers report feeling euphoria with use, describing the sensation as a rush. Intensity of feeling depends on how much is taken, which route is used, and how rapid- ly the drug enters the brain. Preceding the rush, a feeling of warmth in the skin, dry mouth, and heaviness of the extremities com- monly are described (NIH, 2014). Nausea, vomiting, and extreme itching frequently follow the initial high; however, tolerance to these effects is attained quickly. Accord – ing to the NIH, when initial effects subside, users may be drowsy for hours and have a clouded mental function, as well as slowed heart

rate and breathing (sometimes to the point of life-threatening re – sponse).

The stereotypical heroin user injects the drug intravenously, like- ly evident from multiple sclerosed veins and puncture marks at injec- tion sites (U.S. Drug Enforcement Agency [USDEA], 2015). This may result in a railroad track appearance to limbs; abscesses also are common while bacterial endocarditis, hepati- tis, human immunodeficiency virus (HIV) infection, and positive results from purified protein derivative testing are all possible complica- tions (Liebschutz et al., 2014). Not all heroin users and addicts are IV drug users. Much of the drug readily available on the market today is of such high purity that IV use is no longer a necessity. Purity levels of heroin in 1981 were around 10%; by 1999, purity levels increased to an average of 40% (USDEA, 2015). Increased purity contributed to greater lethality and more use-relat- ed deaths. Inhalation and subcuta-

Renee N. Bauer Erik P. Southard

Andreas M. Kummerow

The use of heroin is alarmingly high in the United States. Through education and advocacy, nurses can make a difference in treat- ment. Screening and interprofessional care are ways to combat this problem.

Instructions for Continuing Nursing Education Contact Hours appear on page 235.

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neous injection (known as skin pop- ping) are also common methods of heroin administration (Wooten & Guthrie, 2012).

Heroin is extremely addictive regardless of how it is administered. However, injecting and smoking increase the risk of addiction; these methods also allow the drug to reach the brain faster (NIH, 2014). With addiction, brain chemistry changes and affected persons con- tinue to try to achieve the euphoria previously experienced. Usage con- tinues, but attaining the initial euphoria is not possible.

Instead, repeated use of heroin causes many individuals to experi- ence irreversible negative health effects (NIH, 2014). Fatal overdose, infectious diseases such as hepatitis and HIV, kidney disease, sponta- neous abortion, and pulmonary complications occur frequently in heroin users. Coma and permanent brain damage have been reported in persons who have abused heroin (NIH, 2014; O’Malley, 2015).

Heroin Withdrawal, Disease Transmission, and Health Complications

Chronic use of heroin leads to physical dependence, and symp- toms of withdrawal are unpleasant. Symptoms may begin as early as a

few hours after the last drug admin- istration to as many as 3 days later, depending on usage patterns (Wooten & Guthrie, 2012). Symp – toms include restlessness, bone and muscle pain, insomnia, diarrhea and vomiting, cold flashes with goose bumps, kicking movements, and severe craving. Individuals go to great lengths to avoid the unpleasant experience of withdraw- al. Fortunately, medications such as buprenorphine (Buprenex®) and methadone (Dolophine®) work by binding to the same receptors as heroin and thus assist users in the weaning process (NIH, 2014). Being aware of the signs and symptoms related to withdrawal also may clue nurses to the use of heroin. Yawn – ing, aching muscles, runny nose, sweating, fever, insomnia, nausea, and vomiting are the most fre- quently reported symptoms (Woot – en & Guthrie, 2012).

Injecting heroin increases the risk of bloodborne pathogen trans- mission by contaminated needles. For example, users are at risk for contracting HIV as well as hepatitis B and hepatitis C (HCV), which are transmitted by needle sharing. HCV is the most common bloodborne infection in the United States (NIH, 2014). In addition, because HIV can be contracted during unprotected sex, heroin use makes infection more likely because impaired indi-

viduals are more likely to engage in high-risk sexual behaviors (Gold – berg, 2014; NIH, 2014).

Heroin has been known to pro- duce immediate and long-term con- sequences (NIH, 2014; Tetrault & Feillin, 2012). Overdose as an imme- diate consequence of heroin use may result in death. Overdose sup- presses the mechanism of breathing, resulting in hypoxia (Boyer, 2012). Coma and permanent brain damage may occur from diminished oxygen reaching the brain. Chronic heroin use may lead to collapsed veins, abscesses, infection of the heart lin- ing and valves, constipation and gastrointestinal cramping, and kid- ney and liver disease (NIH, 2014). Permanent organ damage may result from toxic contaminants or additives blocking major vessels. Pulmonary obstructions frequently arise due to the poor health of the user and heroin’s effects on breath- ing. Diseases such as pneumonia may result from the addict’s com- promised condition. Research of changes in the brain with heroin abuse has found deteriorations in the brain’s white matter, interfering with decision making and the abili- ty to regulate behavior (NIH, 2014; Tetrault & Fiellin, 2012). Heroin Abuse: Nurses Confronting a Growing Trend

Heroin use among women is increasing (CDC, 2015). Pregnant mothers using heroin may sponta- neously abort, and babies often are

FIGURE 1. Number of Heroin Related Overdose Deaths per 100,000 People

3

2.5

2

1.5

1

0.5

0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Source: CDC, 2015.

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born at low birth weights. Infants also may be physically dependent on the drug and suffer neonatal abstinence syndrome (NAS). Fort – unately, mothers treated with buprenorphine can reduce NAS in their infants and decrease hospital length of stay (NIH, 2014).

Practice Barriers and Solutions

Behavioral and physical health- care providers have a long history of functioning separately; this may be reflected in treatment of heroin addiction, especially in the primary care setting and the hospital (Crowley & Kirschner, 2015). For example, primary care physicians and nurse practitioners may lack extensive training in addictions management during medical illness. Due to the stigma of co-occurring addiction problems, many patients also experience prejudice from socie- ty, family, and providers. As a result, fragmented care frequently leads to poor patient outcomes (McNeeley et al., 2012). This dilemma may be addressed by cross-training health- care providers to work with persons with addictions.

Individuals who misuse heroin have increased morbidity and mor- tality; they also struggle with high rates of acute care hospitalization (McNeely et al., 2012). Nurses must be able to assess these patients and familiarize themselves with prompt, seamless, medical intervention. Additionally, patients with a dual diagnosis of substance abuse and medical co-morbidity must have both health concerns addressed. A better understanding of substance abuse is warranted; this may have substantial implications for care of patients with addictions and lead to increased knowledge of treatment options (Choi, Krantz, Smith, & Trick, 2015).

Initially, patients struggling with addiction need nonjudgmental care from their healthcare team mem- bers (Bartlett, Brown, Shattell, Wright, & Lewallen, 2013; O’Malley 2015). While compassion and car- ing alone will not save the lives of all individuals, more research is

needed to demonstrate the effects of unconditional positive regard on patient outcomes. Stigma attached to drug abuse continues to be perva- sive among nurses and other healthcare providers, resulting in suboptimal care for affected pat – ients in the hospitals they frequent (Bartlett et al., 2013; Sterling, Chi, & Hinman, 2011).

When heroin-using patients are admitted for surgery, they must be treated as high-risk individuals (Lee, Weng, Hsu, & Lin, 2015). They face higher risk of drug withdrawal and complications associated with pain management. In fact, few nurses have been trained to provide care when heroin use accompanies other healthcare problems (Mallia – rakis, 2015). Nurses may be con- cerned that use of analgesics may cause addiction symptoms to reemerge. Thus, addicted patients experiencing pain from surgery have a potential to be under-med- icated (Lee et al., 2015).

Persons who have inhaled hero- in often exacerbate asthmatic symptoms and cause more severe attacks. Of 11,397 hospitalized pat – ients, Choi and colleagues (2015) found 341 (3%) were dependent on inhalational heroin, 260 (2.3%) on cocaine, and 106 (0.9%) on injected heroin. Inhalation heroin users were more than three times as likely to be admitted for respiratory illness as other users.

Approach to Addiction Responding to the heroin epi-

demic has a three-tier approach in the United States: prevent, reduce, and reverse (O’Malley, 2015).

Prevention Nurses can educate the public

and save patient lives by learning about problems with heroin in their communities. Initial screening is imperative; healthcare providers also should be cross-trained regard- ing heroin addiction. Literature sug- gests the primary care setting serves as a platform to promote preven- tion in at-risk patients and address early signs of addiction (Crowley & Kirschner, 2015).

The insidious illness of addiction usually starts benignly. Commonly, an injury resulting in chronic pain can contribute to development of heroin use and abuse (Kanouse & Compton, 2015; O’Malley, 2015). Prescribers need to implement adjunctive measures whenever pos- sible in treating pain. One Danish study tracked patients with chronic pain who were given opioids liber- ally; rather than pain decreasing, researchers found subjects reported more pain and higher healthcare use compared to persons who were not given opioids to manage pain (Stempniak, 2016).

Screening is imperative. When obtaining a medical history, health- care providers also should include questions about substance abuse. Several tools have been developed to help providers assess the likeli- hood of substance abuse disorders or heroin use, including the 10-item Drug Abuse Screening Test (DAST- 10) (Skinner, 1982) to identify drug use in the preceding 12 months. Adopting an appropriate tool for the provider’s purpose and patient group is important.

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a program model of the Substance Abuse and Mental Health Services Administration (SAMHSA) (Harris, 2016). This modality may help providers identify risk for substance abuse among adolescents. SBIRT training should be provided to Emergency Department providers so they become familiar with the intervention referral-to-treatment step (Manton, 2014). They also should be knowledgeable concern- ing treatment facilities in the com- munity. Providers will benefit from use of a printed list with treatment alternatives, including location, contact information, hours of serv- ice, and other information related to patient treatment.

The inpatient setting is an oppor- tune time for nurses to identify like- ly addiction and provide patients with appropriate resources. Inter – ventions can be initiated in the emergency setting or on the inpa- tient unit to ensure holistic treat- ment. In particular, medical-surgi-

Heroin Abuse: Nurses Confronting a Growing Trend

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cal nurses may care for patients who have addiction problems co-occur- ring with medical problems. These patients often demonstrate signs of malnourishment and may be immune-compromised. They may present with more advanced illness and be reluctant to remain hospital- ized. Individualized intervention programs provide opportunities to enhance screening, prompting early identification (Bartlett et al., 2013).

Reduction MAT for persons addicted to

heroin may be accomplished by combining medications, such as methadone, buprenorphine, or nal- trexone (Vivitrol®), with psy- chotherapy and behavioral thera- pies (O’Malley, 2015; SAMHSA, 2016). MAT can reduce mortality, decrease death from overdose, reduce transmission of infectious disease, increase treatment reten- tion, improve social functioning, and reduce criminal activity (SAMHSA, 2016). Although MAT does not cure the illness and the patient remains addicted to an opi- oid, opioid use is monitored closely by a medically trained individual and risks associated with IV drug use generally are reduced greatly.

Use of treatment agreements also has been successful in addressing heroin addiction. Treatment agree- ments often exist as written, signed, and updated contracts between the prescriber and patient (SAMHSA, 2016). The patient must acknowl- edge and understand benefits and risks of treatment as well as goals.

Use of one physician or pre- scriber rather than many is another strategy to decrease the risk of addiction (SAMHSA, 2016). In addi- tion, using one pharmacy allows easier follow up on prescriptions with communication between serv- ices. Providers may suggest pill counts and pharmacists should deny early refills. Family education, commitment, and social support also are critical to success. Family members should be educated regarding changes in brain chem- istry for the affected person (NIH, 2014).

Participating in additional treat-

ment modalities can contribute to successful rehabilitation. Cognitive behavioral therapy is the therapy of choice (SAMHSA, 2016), enabling individuals to develop healthy cop- ing skills, address life problems, and develop rational thinking. Support groups offer compassion in a non- judgmental setting, allowing per- sons familiar with the illness to help others. Research supports integrated care for persons with co-occurring disorders, finding patients who receive integrated care are more likely to be abstinent at 6 months than those who only received inde- pendent medical treatment (Lieb – schutz et al., 2014).

In the hospital, nurses must communicate therapeutically and nonjudgmentally with the patient with a history of substance abuse. An attitude of unconditional posi- tive regard should be the standard. The patient should be treated with acceptance combined with empath- ic listening (O’Malley, 2015).

Reversing Overdose Given the increase in heroin use

and overdose deaths, more infor- mation now is available about the use of intranasal naloxone for the reversal of opioid overdose. This reversal agent has been used by emergency medical professionals for more than 40 years to reverse respiratory depression caused by opioid use (Clark, 2014). Nurses and other healthcare professionals can advocate for policies that create an expanded cadre of properly trained providers to administer naloxone and increase its availability. Once policies are in place to support naloxone use, nurses also can become involved with training law enforcement officers to recognize signs and symptoms of opioid over- dose and intervene with intranasal naloxone (Purviance, Ray, Tracy, & Southard, 2016).

Nursing Implications Although addiction may be an

uncomfortable topic for healthcare providers, many nurses continue to hold negative views of individuals who abuse substances and have

been known to be more judgmental than other healthcare workers. Providers’ negative attitudes can diminish patients’ feelings of empowerment and thwart positive treatment outcomes (Bartlett et al., 2013). Nurses may have a more task-oriented approach in the deliv- ery of healthcare, resulting in decreased personal engagement and reduced empathy for persons with a history of substance abuse (van Boekel, Brouwers, van Weeghel, & Garretsen, 2013).

Nurses should be able to identify interventions to ensure patients ex – periencing heroin addiction re ceive appropriate care. Healthcare work- ers must act to increase opportuni- ties for persons currently addicted or recovering from addiction to feel safe sharing their history, allowing nurses to support their recovery. By transforming healthcare delivery, nurses provide a dual advantage: improving the health of affected persons and reducing costs for unpaid hospital admissions (Crow – ley & Kirschner, 2015).

Nurses also should familiarize themselves with MAT and under- stand the importance of behavioral treatment (SAMSHA, 2016). Refer – ring a patient for group counseling and community-based services is also critical. Motivational inter- viewing (MI), a component of SBIRT, can be helpful in initiating dialogue with a person experienc- ing substance use. MI involves help- ing the patient examine the conse- quences of current behaviors (Bartlett et al., 2013).

Unconditional positive regard should be demonstrated for every patient with heroin addiction. Patient advocacy, selflessness, and willingness to suspend judgment are hallmarks of compassionate nursing care. Although nurses may feel uncomfortable about helping a person live an addicted life, helping the patient manage the effects of addiction also may help him or her become less hostile and defensive (Bartlett et al., 2013).

Once heroin addiction identifi- cation strategies are in place, nurses should work with the interprofes- sional team to implement evidence-

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based treatment protocols and algo- rithms. Barriers to the delivery of evidence-based interventions by healthcare professionals, such as time constraints, insufficient train- ing and education, or lack of moti- vation, must be removed (O’Malley, 2015). In a study by Liebschutz and colleagues (2014), linking medically hospitalized patients to buprenor- phine treatment was effective at reducing illicit drug use 6-months after hospitalization.

Conclusion Heroin use is now viewed as a

chronic condition with no easy solution (Fatseas et al., 2015). Screening patients for substance abuse is paramount and can be facilitated by the nurse (Harris, 2016). Cognitive behavioral thera- py and MAT are evidence-based treatments that enhance sobriety (SAMSHA, 2016).

The most successful programs to address addiction will draw on the collective expertise of pharmacists, nurses, physicians, nurse informa – ticists, behavioral health specialists,

and others (Liebschutz et al., 2014). Nurses should be able not only to rec- ognize conditions and treat patients appropriately, but also to advocate for patients and be involved in policy changes related to substance abuse and addiction.

REFERENCES Bartlett, R., Brown, L., Shattell, M., Wright, T.,

& Lewallen, L. (2013). Harm reduction: Compassionate care of persons with addictions. MEDSURG Nursing, 22(6), 349-358.

Boyer, E.W. (2012). Management of opioid analgesic overdose. New England Journal of Medicine, 367(2), 146-155. doi:10.1056/NEJMra1202561

Centers for Disease Control and Prevention (CDC). (2015). Today’s heroin epidemic infographics. Retrieved from https:// www.cdc.gov/vitalsigns/heroin/info graphic.html

Choi, H., Krantz, A., Smith, J., & Trick, W. (2015). Medical diagnoses associated with substance dependence among inpatients at a large urban hospital. PLoS ONE, 10(6), e0131324. doi:10. 1371/journal.pone.0131324

Clark, A. (2014). Legislative: Responding to the fatal opioid overdose epidemic: A call to nurses. The Online Journal of Issues in Nursing 19(3). doi: 10.3912/OJIN.Vol. 19No03LegColO1

Crowley, R.A., & Kirschner, N. (2015). The integration of care for mental health, sub-

stance abuse, and other behavioral health conditions into primary care: Executive summary of an American College of Physicians position paper. Annals of Internal Medicine, 163(4), 298- 299. doi:10.7326/M15-0510.

Fatseas, M., Fuschia, S., Alexandre, J., Debrabant, R., Auriacombe, M., & Swendsen, J. (2015). Craving and sub- stance use among patients with alcohol, tobacco, cannabis or heroin addiction: A comparison of substance- and person- specific cues. Addiction, 110(6), 1035- 1042. doi:10.1111/add.12882

Goldberg, M. (2014). Patient education: 11 common questions on heroin abuse. Psychiatric Times, 31(7), 1-4.

Harris, B.R. (2016). Talking about screening, brief intervention, and referral to treat- ment for adolescents: An upstream inter- vention to address the heroin and pre- scription opioid epidemic. Preventive Medicine, 91, 397-399. doi:10.1016/ j.ypmed.2016.08.022

Kanouse, J., & Compton, P. (2015). The epi- demic of prescription opioid abuse, the subsequent rising prevalence of heroin use, and the federal response. Journal of Pain & Palliative Care Pharmacotherapy, 29(2), 102-114. doi: 10.3109/15360288. 2015.1037521

Lee, W.Y., Weng, C.H., Hsu, Y.P., & Lin, P.H. (2015). The perioperative management of pain in patients who are addicted to heroin. Journal of Nursing, 62(3), 72-77. doi:10.6224/JN.62.3.72

Heroin Abuse: Nurses Confronting a Growing Trend