Community Health Project Part I

Clinical Application-Community Health Project Part I

Clinical Application Assignment/Community Health Project Part 1

NURS 492

Old Dominion University

ASSESSMENT

Aggregate

The aggregate I have chosen for my community health project are individuals 18+ years and older struggling with substance use disorder (SUD). There is a great need throughout the nation, state and local communities for increased assistance in addressing the knowledge deficit related to substance misuse and behavior modification through lifestyle change. The growing SUD problems are currently being described as a national epidemic by our public health officials (Palombi, St Hill, Lipsky, Swanoski, and Lutifiyya, 2018). In 2017, the President of the United States declared the SUD problem a national emergency allowing states to access additional resources temporally relieving some of the strains on their communities (Johnson, 2016; Rutkow, and Vernick, 2017; Palombi et al., 2018).

I am personally familiar and involved in the 12-step recovery and work with individuals seeking assistance in recovery from SUDs. Within the last year my own extended family lost a 25-year-old male to a heroin overdose, two other individuals also expired in the same home within days of each other due to heroin overdose. Culpeper County, where I am currently employed, has a higher than state average mortally rates due to illicit opioid drug use.

Aggregate Characteristics

Substance abuse and opioid addiction, has two sides. One side is the over use of prescription opioid pain relievers (OPRs), and the other side is the use of illegal heroin or synthetic opioids such as Fentanyl. About half of the overdose deaths in the U.S. are due to OPRs (Rutkow and Vernick, 2018).

The age range of this population of individuals is between 18 to 70 years old with the average being in their late twenties to early forties (Virginia Opioid Addiction Indicators, 2017). The disease of SUD can affect individuals from all walks of life from any socio-economic background. Education levels range between high school drop outs to college graduates. Many individuals with SUD have limited support systems due to the disease likely affecting others in the family and/or the family is unwilling to help the individual any longer (Treatment Improvement Protocol (TIP), Series, No. 39, 2013). This disease can bring out the worst in individuals which may have left them homeless or in unstable living situations. Many maybe having trouble at their place of work, unemployed or are unemployable due to criminal backgrounds by the time they are researching out treatment options (Morano, Steege, and Luckhaupt, 2018).

According to the National Institute of Drug Abuse (NIDA) the average relapse rate is 40 – 60%, showing a low level of aspiration or motivation to change (Treatment and Recovery, 2018). Typical coping mechanisms characteristic of this population is escapism and avoidance of anything uncomfortable or unpleasant. Individuals withdrawing from substances during the initial period of abstinence varies in severity displaying signs and symptoms of fluid volume deficit/dehydration, GI upset, tremors, yawning, restlessness, frustration, agitation, and heighted anxiety levels (Hedden, Kennet, Lepari, Medley and Tice, 2014).

I am currently a night shift nurse working full time on the detox unit at Boxwood Recovery Center allowing me regular access to this aggregate group along with my participation within the 12-step fellowship. Boxwood Recovery Center is affiliated with the Rappahannock Rapidan Community Services Board (RRCSB). The RRCSB directly servers the communities of Fauquier, Rappahannock, Culpeper, Madison, and Orange counties.

The facility provides a combination of medical detoxification services and a 28-day residential substance treatment program. It is a coed facility for individuals age 18+ years and older offering 26 residential treatment beds and six detox beds (Residential Substance Use Disorder Services, para 1, 2018). The facility accepts individuals from all over the state of Virginia through a relationship between community service boards. These are individuals who have voluntarily chosen to participate in treatment. Part of the daily schedule is an hour for special interest topics presentations. Physicians discuss medically assisted treatment (MAT), a health department nurse reviews HIV and Hepatitis C information, and Accu detox is performed. I will be allowed to present information to the aggregate group during this allotment of time by my facilitator.

Compare/Contrast

The most current data available from the Substance Abuse and Mental Health Services Admission (SAMHSA), 2014, reports 27.0 million people aged 12 or older used an illicit drug in the past 30 days, which equals about every 1 in 10 Americans (Hedden et al., 2014). The total number of opioid-related deaths in the United States has climbed from 9,489 in 2001 to 42,245 in 2016 for an increase of 345%. The nation mortality rate due to opioid deaths in 2016 was 5.2 per 1000 population, the majority being males (Gomes, Tadrous, Mamdani, Paterson and Juurlink, 2018). The Virginia Department of Health (VDH) Opioid Indicators for 2016 shows the states mortality rate from Fentanyl and heroin at 11%, and OPRs at 5.9%. The same VDH report shows Culpeper County having an overdose mortality rate of 28% from Fentanyl and heroin, 17% over the states average and their mortality rate due to OPRs at 14%, 8.1% over the state average.

There is growing information identifying rural communities, like Culpeper County, as being at increased risk for opioid misuse due to healthcare disparities and a larger disease burden compared to larger suburban/metropolitan area (Robertson, Walker, Stovall and McCluskey, 2015; Gomes et al., 2018; Palombi et al., 2018). Culpeper County has a population of 48,952 with the median age at 38.9 years (Data USA, 2016). The U.S. Census Bureau report 2017, indicates Culpeper County’s median household income of $66,160, is slightly higher than national average of $59,039. Culpeper County stakeholders identified SUDs as their third highest priority in the community behind childhood and adult obesity. Culpeper’s crime rate is 2.67 per 1,000 residents compared to the Virginia state crime rate of 2.16 per 1,000 residents (Neighborhood Scout.com, 2017).

Professional Literature Review and Resource

Due to the national severity of the SUD problem states have enacted rare emergency declarations typically reserved for natural disasters or communicable disease outbreaks. Virginia was the second state to declare an emergency declaration related to SUDs increasing access of Naloxone to laypeople (Rutkow and Vernick, 2017) (Freeman, Hankosky, Lofwall, and Talbert, 2018). The SUD problem is not limited to the aggregate population of individuals age 18+ years, it is also affecting adolescent children ages 12 to 17 years, possibly even younger children too, this age group had the most rapid increase in opioid overdose deaths in the past decade (Edlund, Forman-Hoffman, Winder, Heller, Kroutil, Lipari, and Colpe, 2015). SUDs of all kinds are a common concern throughout the nation. The younger population have greater involvement with illegal opioid/synthetic drug use, and older individuals suffering from chronic pain issues are more affected by OPRs (Palombi et al., 2018). There are numerous approaches to addiction recovery treatment which makes it difficult to demonstrate consistency related to treatment methods throughout the industry (Robertson et al., 2015). Medication-assisted treatment (MAT) and contingency management treatment (CMT) have shown to be the most effective EBPs in the treatment of SUDs (Guerrero, Padwa, Fenwick, Harris, and Aarons 2016). An interdisciplinary approach is required in the treatment of SUDs including family supports (Imkome, 2018). Individuals may require multiple services during the recovery process to include counseling or psychotherapy, possible inpatient medication treatment, medical services, family therapy, parenting instruction, vocational rehabilitation, social and/or legal services (Principles of Drug Addiction Treatment (Third Edition), 2018) (Imkome, 2018).

Population Needs as Nursing Diagnoses

The first identified nursing diagnosis is denial by the community as related to the rural isolation evidenced by the delayed response to the opioid crisis in rural Culpeper County (Palombi et al., 2018). My second nursing diagnosis is dysfunctional recovery process as related to increased rate of SUDs in the county evidenced by the 11% over states average (VDH, 2017). My third and priority nursing diagnosis is knowledge deficit as related to the disease process, treatment needs, community supports, and follow up care of individuals suffering with SUDs as evidenced by the stigma in the community regarding individuals seeking treatment for SUDs, and the declining anonymous fellowship within the community (Gurewich et al., 2013) (Imkome, 2018).

There is no single theory defining the condition of SUDs and no one single approach to the treatment of SUDs (Gurewich, Prottas, and Sirkin, 2013) (Imkome, 2018). Due to the extreme increase of overdose deaths related to opioid use federal and local governments are now becoming more involved in addressing this epidemic (Edlund et al, 2015) (Rutkow and Verrnick, 2017; Palombi et al, 2018). SUD use is impacting every individual within our society, young and old (Edlund et al, 2015). Even with supported EBPs in the treatment of addiction many of these services are not being delivered in community-based care (Guerrero et al, 2016).

PLANNING

Health Planning/Needs

My priority nursing diagnosis is knowledge deficit as related to the disease process, treatment needs, community supports, and follow up care of individuals suffering with SUDs (Gurewich et al., 2013; Imkome, 2018). My action plan is to provide the aggregate with information related to the disease process, alternative treatments, support within the community, such as AA and NA meetings, and the importance of family involvement for individuals in recovery (Principles of Drug Addiction Treatment, 2018). I will present this information to the aggregate at Boxwood Recovery Center in Culpeper County, Virginia during the one-hour information session provided by my facilitator. I will use a Power-Point presentation and printed hand-out material to convey this information. Also, I will leave hand-out materials for future use in this aggregate population.

Alternative Interventions

One alternative intervention I will be working on this weekend by attending the Virginia Area Conference of Alcoholics Anonymous as a general service representative for a 12-step meeting is becoming involved as a volunteer in the Cooperation with the Professional Community/Public Information committee (CPC/PI) to do outreach in Culpeper and the surrounding rural Counties. Obtaining the information from these committees is simple, the time to travel around to the high schools, social services offices, and physicians’ offices is rather daunting on a volunteer bases, not that it can’t be done by recruiting a group of recovery individuals. That’s how it works, one day at a time, preforming service by carrying the message to those who are still suffering with SUDs.

References

Data USA: Culpeper County, Va. (2016). Retrieved from https://datausa.io/profile/geo/culpeper-county-va/

Edlund, M. J., Forman-Hoffman, V. L., Winder, C. R., Heller, D. C., Kroutil, L. A., Lipari, R. N., and Colpe, L. J. (2015). Opioid abuse and depression in adolescents: Results from the national survey on drug use and health. Drug and Alcohol Dependence. Elsevier Journal. Retrieved from http://dx.doi.org/10.1016/j.drugalcdep.2015.04.010

Freeman, P. R., Hankosky, E. R., Lofwall, M. R., and Talbert, J. C. (2018). The changing landscape of naloxone availability in the United Sates, 2011 – 2017. Drug and Alcohol Dependence. Elsevier Journal. (pp. 361-364) Retrieved from http://doi.org/10.1016/j.drugalcdep.2018.07.017

Gurewich, D., Prottas, J., and Sirkin, J. T. (2013). Managing care for patients with substance abuse disorders at community health centers. Journal of Substance Abuse Treatment (pp. 227–231). Retrieved from http://dx.doi.org/10.1016/j.jsat.2013.06.013

Gomes, T., Tadrous, M., Mamdani, M. M., Paterson, J. and Juurlink, D. N. (2018). The burden of opioid-related mortality in the United States. Substance Use and Addiction. JAMA Network Open. Retrieved from http://doi:10.1001/jamanetworkopen.2018.0217

Guerrero, E. G., Padwa, H., Fenwick, K., Harris, L. M., and Aarons, G. A. (2016). Identifying and ranking implicit leadership strategies to promote evidence-based practice implementation in addiction health services. Implementation Science. Bio Med Central. Retrieved from http://doi:10.1186/s13012-016-0438-y

Hedden, S. L., Kennet, J., Lepari, R., Medley, G. and Tice, P. (2014). Behavioral health trends in the United States: Results from the 2014 National survey on drug use and health. Substance Abuse and Mental Health Services Admission (SAMHSA). Rockville, Md. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf

Imkome, E. (2018). Nursing care for persons with drug addiction. Intech Open. Retrieved from http://dx.doi.org/10.5772/intechopen/73334

Johnson, S. R. (2016). The racial divide in the opioid epidemic. Modern Healthcare. Chicago. (Vol. 46, Iss.9). Retrieved from https://search-proquest-com.proxy.lib.odu.edu/docview/1770073946/fulltext/C3949557292248BEPQ/1?accountid=12967

Morano, H. L., Steege, A. L., Luckhaupt, S.E. (2018). Occupational patterns in unintentional and undetermined drug-involved and opioid-involved overdose deaths — United States, 2007–2012. Morbidity and Mortality Weekly Report (MMWR). Center for Disease Control (CDC). Atlanta, GA. Retrieved from http://dx.doi.org/10.15585/mmwr.mm6733a3.

Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) (2018). National Institute on Drug Abuse (NIDA); National Institutes of Health (NIH); U.S. Department of Health and Human Services. Washington, D.C. Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment

Neighborhood Scout (2018). Culpeper, Virginia, crime analytics. Culpeper crime data index. Retrieved from https://www.neighborhoodscout.com/va/culpeper/crime

Palombi, L. C., St Hill, C. A., Lipsky, M. S., Swanoski, M. T., and Lutfiyya, M. N. (2018). A scoping review of opioid misuse in the rural United States. Annals of Epidemiology. Elsevier Journal. (pp. 641-652) Retrieved from http://doi.org/10.1016/j.annepidem.2018.05.008

Residential substance use disorder services. (2018). Rappahannock Rapidan Community Services. Retrieved from https://www.rrcsb.org/adult-services/residential-substance-use-disorder-services/

Robertson, A., Walker, C. S., Stovall, M. and McCluskey, L. (2015). Use of evidence-based substance use treatment practices in Mississippi. Evaluation and Program Planning. Elsevier Journal. (pp.198-204). Retrieved from http://dx.doi.org/10.1016/j.evalproplan.2015.06.002

Rutkow, L., and Vernick, J. S. (2017). Emergency legal authority and the opioid crisis. The New England Journal of Medicine. (pp.2512 – 2514). Retrieved from https://www.nejm.org/doi/pdf/10.1056/NEJMp1710862

Treatment and Recovery (2018). Drugs, brains, and behavior: The science of addiction. National Institute on Drug Abuse (NIDA). Bethesda, Md. Retrieved from https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/treatment-recovery

Treatment Improvement Protocol (TIP) (Series, No. 39). (2013). Center for Substance Abuse Treatment (CSAT). Substance Abuse and Mental Health Services Administration (SAMHSA). Rockville, Md. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK64258/

Virginia Opioid Addiction Indictors (2017). Virginia Department of Health. Retrieved from http://www.vdh.virginia.gov/data/opioid-overdose/

United States Census Bureau (2017). Income -poverty data tables. Retrieved from https://www.census.gov/topics/income-poverty/income/data/tables.html