Expert: Forget Detox for Substance Use Disorder

LAS VEGAS — There’s a lot more to substance abuse disorder than physical dependence, which means that acute detox treatment by itself isn’t an effective therapy, a researcher said here.

The real key, said Debra Gordon RN, DNP, of the University of Washington in Seattle, in a talk here at the annual PAINWeek conference, is establishing a relationship with patients so that behavioral changes can be implemented.

Withholding opioids from patients with substance use disorder will not cure their addiction, she said. Moreover, providing them with opioids will not necessarily worsen their addiction and may help them accept behavioral therapies.

“There is no evidence that detoxing someone in an acute situation or hospital setting is going to impact that disease,” Gordon said in a presentation. “In fact, the evidence seems to be they will be more at risk for using at their discharge and having an overdose, some of that being in the prison system, but you see that in hospitals too.”

Patients with substance use disorder continue to use drugs despite recurrent problems in their social, workplace, or familial spheres that occur because of their use. Many take multiple substances and have underlying mental health disorders, both of which need to be screened for, Gordon said.

These patients have a higher pain threshold and the prevalence of chronic pain is also much higher in patients with drug abuse disorder. As such, using the Numeric Rating Scale (NRS-11) to define their pain will be insufficient, and providers should determine whether the source of pain is acute, chronic, or related to the patient’s addiction.

Clinicians should also anticipate that patients with substance abuse disorder may have had negative experiences with the healthcare system previously, Gordon said, and asking open-ended questions without judgment may mitigate feelings of shame or fear that prompt them to withhold information.

Seemingly obvious physical comforts, like turning off the lights or keeping a room quiet, also go a long way as well, Gordon said. Cognitive behavioral therapy can also help patients change their perception of pain and help with sleep, mood, and anxiety issues co-occurring with substance use disorder.

Still, some patients may not be willing to change, and others may try to use within the hospital. When encountering patients who deny having a problem, or who recognize the disorder but are unwilling to change, providers should focus on helping them transition out of the hospital when the time comes and providing naloxone emergency overdose kits to patients who may return to illicit drug use.

“Failure to engage in treatment is not a failure,” Gordon said. “It’s part of the process and it’s part of the disease.”

But despite the treatment options available for patients with substance abuse, some providers may be unaware they exist, or may be unsure of what they are authorized to provide, Gordon said.

“There are barriers in the healthcare system in terms of the way we’ve traditionally been trained and traditionally work in silos, and to care for this population we have to really have a team approach,” Gordon told MedPage Today. “It’s one thing to say stuff on paper and another to try and find out how it works in the real world.”

Gordon did not report any disclosures.

by Elizabeth Hlavinka, Staff Writer, MedPage Today

Primary Source: PAINWeek
Source Reference: Gordon D “Acute pain in patients with active substance use disorder” PAINWeek 2019; Abstract ACU-01.

The Rules of Verbal Jiu-Jitsu With Patients: how to deflect and defuse manipulative conversations

The Rules of Verbal Jiu-Jitsu With Patients: how to deflect and defuse manipulative conversations

You are seeing a newly booked patient in your jail medical clinic. He states that the last time he was in jail, he was given a second mattress because he had surgery on his back many years ago. You note that the patient has not seen a doctor on the outside for many years, that the patient walks and moves normally, and that he has a normal neurological examination. You tell the patient that medical does not give out passes for extra mattresses. The patient angrily erupts in a blaze of obscenities and threatens a lawsuit.

Manipulation happens when a patient wants something that they should not have (like an extra mattress and pillow) and will not accept “NO” for an answer. There are several strategies patients may employ in an attempt to force practitioners to change a “No” to a “Yes.” This patient started with the “other doctors gave me what I want” strategy and when that didn’t work, he employed the “threatening” strategy. (I covered this in more detail in a post last month.)

Verbal Jiu-Jitsu is what I call the technique of deflecting and defusing such manipulative confrontations. The first and most important rule of Verbal Jiu-Jitsu is to remember that this is not a war or a contest! There should be no “battle of wills” between you and your patient. There is no winner or loser. Instead, you and your patient are having a conversation. The whole goal of Verbal Jiu-Jitsu is to avoid any kind of verbal battle.

I know that it is tempting to think of an unpleasant verbal exchange as a debate-style contest, with a winner and a loser at the end. But even if you “win” a verbal battle, you’ve actually really lost because you have not accomplished your goal of getting your patient to understand and accept your treatment plan! Your patient is still not happy and will simply renew the verbal battle at another time in another way — and maybe more effectively next time.

The second rule of Verbal Jiu-Jitsu is to have compassionate understanding of your patient. That person in front of you is not an opponent to be defeated. He is your patient. Like everybody else, inmates are just trying to get by as well as they can in a very tough environment — they’re in jail! It’s just that many inmates (and people on the outside, for that matter) have poor interpersonal skills and resort to pathological social habits. This is what they know and what works for them. If a patient has successfully gotten his way throughout his life by bullying and threatening others, that is how he is going to interact with you, too.

You don’t have control over this — but you do have control over your reaction. When patients confront you with threats, they will expect you to respond the way that most other people would — which is either to fight back or to give in. You should do neither.

Take, for example, the case of this patient in your clinic who has angrily threatened to sue you plus has lobbed in a few F-bombs for good measure. There he is, red faced, fists clenched, and LOUD. Nurses, deputies, and other inmates are watching. How are you going to handle this? How will you accomplish your goal of defusing the situation and facilitating reasonable communication with your patient?

The single worst thing you could do would be to respond to anger with anger: “You can’t talk to me like that! Get the hell out! Who do you think you are?” First of all, the patient is accustomed to this type of response and will be far more comfortable and effective with a loud confrontation than you.

Second, the patient (and everyone watching) have now learned that a verbal confrontation is an effective way of getting under your skin — very useful information! Also, since you (hopefully) are not practiced and adept at angry shouting, your heart will be jack-hammering and you’ll develop a monster headache — at least that’s what would happen with me. You will have ruined your own mood for the rest of the day. How effective are you then going to be with the rest of your clinic schedule?

Finally, the fight is not over! The patient can (and will) renew the attack at another time.

Another wrong response is to compromise: “There is no reason to be angry! Calm down and we can work something out.” This is a mistake! If you compromise, you have established the precedent that becoming angry is an effective strategy with you. Other inmates will learn this and you will inevitably have to endure many more confrontations like this.

Instead, defuse and deflect. One way would be to say: “I see that you are angry, so we are done for now. Security will take you back to your dorm. We’ll talk again later after you’ve calmed down.” It’s important to say this without raising your voice and, if possible, to betray no emotion on your face or body language. The lack of any reaction goes a long way to defusing such situations. No compromise, no bargaining, no reaction.

The next day — or even in an hour or two — you can call the patient back to medical and confidently expect a more productive conversation. It is important at this second interaction not to upbraid or belittle the patient. You should act as if the last incident is forgotten.

It takes training, practice, and time to master verbal defense skills. The best way to learn is through role-playing scenarios. The response to angry outbursts happens to be one of the easiest Verbal Jiu-Jitsu skills to learn. The principles are: betray no reaction or emotion, end the session (if the patient will not calm down immediately), but make sure that such patients know that they are welcome back as soon as they calm down. Bring them back later and act as if the incident is forgotten.

Jeffrey E. Keller, MD, FACEP, is a board-certified emergency physician with 25 years of experience before moving full time into his “true calling” of correctional medicine. He now works exclusively in jails and prisons, and blogs about correctional medicine at JailMedicine.com.

Originally published in MedPage Today

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Top Nursing Podcasts

Top Nursing Podcasts

Please note that all links are for iTunes.

1.    Johns Hopkins Health Newsfeed

Stay up-to-date with short podcasts on top medical storiesopens in new window from Johns Hopkins.

Each podcast is only about a minute, but provides nurses with the latest info in medicine. There are other subscription options from Johns Hopkins, such as Cancer News Reviewopens in new window and Brain Mattersopens in new window, which run a bit longer and offer information on specific topics.

2.    The Nursing Show

Tune into this weekly podcastopens in new window for news, tips, education and more for nurses at all levels.

The Nursing Show offers a wide range of content that spans nursing news, commentary and interviews from guest nurses and medication information. The host of the show is Jamie Davis, a nationally recognized medical educator whose programs and resources have been downloaded more than 6 million times by listeners and viewers.

3.    Medical Spanish

Receive interactive audio Spanish lessonsopens in new window to further develop your skills for medical settings.

These podcasts help you acquire medical vocabulary, learn correct pronunciation and understand native speakers. Many podcasts are free, while some podcasts and supplemental materials require a paid subscription. Host Molly Martin, a hospitalist in Minneapolis, Minnesota, also produces a Spanish Grammar Reviewopens in new window podcast.

4.    Travel Nursing Insider Podcast

Get the latest insightsopens in new window into the career of travel nursing.

These podcasts provide a wide range of information and advice for the travel nursing specialty. Learn more about this unique career and how to succeed from insiders who know the industry.

5.    A Cup of Health with CDC

Listen in to learn about interesting health factsopens in new window from the CDC.

The podcasts are presented in short, accessible chunks of two to six minutes and cover a wide range of statistics or facts. While basic, they can be useful when presenting this kind of information to patients to educate them about their health.

6.    The Oncology Nursing Podcast

Learn how to care for patients in different life and cancer stagesopens in new window.

These podcasts let listeners join oncology nurses as they discuss topics relevant to nursing practice and treating patients with cancer. Produced by the Oncology Nursing Society, episodes last about 20 minutes.

7.    Health Focus

Reinforce your health and medical knowledge with these short podcastsopens in new window.

This series of weekly interviews on South Carolina Radio features, doctors, nurses and other medical professionals. It presents a wide range of topics presented by award-winning public broadcaster Bobbi Conner.

Enhancing Your Career in Nursing

Podcasts, books and articles are all helpful ways to develop your knowledge and skills. However, one of the best ways to boost your career opportunities is with a degree.

The online RN to BSN program from Aurora University can help nurses take a leadership role in their field. Nurses are able to learn how to be an asset in their current role and to pursue advanced career opportunities. The program takes place in an online learning environment, allowing students the flexibility and convenience to complete their degree while maintaining their work and personal schedule.

10 Big “Do’s” and “Don’ts” of Interviewing

10 Big “Do’s” and “Don’ts” of Interviewing

Interviewing has a basic set of standards that should be foundations for every interview and permeate every aspect of the interviewing process. From your preparation to your final contact with HR or a hiring manager, you should adhere to these “do” and “don’t” principles.

5 Do’s

Be Honest

Character is one of the most important aspects any employee can have. No matter how good a liar you might be or how much you may stretch the truth, you give off cues that you are not telling the truth or the whole truth. If a potential employer gets the feeling that you are not being completely honest, it will be a huge red flag.

Hold Yourself Well

Posture says a lot about your personality and your attitude. Hold a professional posture that exudes professionalism, self-confidence, and a positive attitude. Don’t get too casual with how you sit or the language you use. Make solid eye contact and be actively engaged in listening.

Dress Professionally

If you are not sure how to dress, do some research. If you aren’t sure if you are over- or underdressed, err on the side of being overdressed. Never do the opposite. Most organizations post a general dress code. Be professional. You might have to invest in a nice business suit that fits you well. Don’t walk in looking unprofessional because of your clothes. Be sure you are well groomed and that your clothing looks professional.

Admit Weaknesses

As mentioned previously, we all have weaknesses. Acting as though you don’t is essentially lying or having a huge ego, neither of which is good during an interview. Remember that a weakness doesn’t mean you’re completely failing in a particular area—it just means that you are not as fluent in that area as in others. Weaknesses can be overcome, but character issues most likely won’t be.

Communicate Well With Human Resources

Human resources has a direct relationship with hiring personnel. If you are not professional in your interactions with HR or prove difficult to work with, that information will surely be communicated to the hiring team. Oftentimes an HR representative will sit in on the interview as well. Any interaction with someone involved in the hiring process should be taken seriously and handled professionally.

5 Don’ts

Fake It Till You Make It

To a certain extent you need to be able to back up everything you say during an interview. Sure, you could argue that you won’t lose a position after obtaining it if you can’t back up everything that was said during an interview. There is a level of cheating yourself you do with that mentality. To say you have something that you don’t actually possess shows a lack of integrity. This is why plagiarism is frowned on and so harshly punished. If you didn’t actually do the work for your degree, you are lying about your credentials and don’t possess the skills that your degree implies you do have. You are lying through the means of a degree because you can’t actually back up what that degree symbolizes or entails. To those who actually put in the work and possess the skills, that attitude is highly offensive. Make sure you can back up what you say.

Exaggerate

We all know people who dramatize every story to make themselves look as innocent as a dove and someone else as evil as Satan himself. Don’t be that person—don’t exaggerate a situation to make yourself look flawless. Don’t demean other people. This is not a healthy sign of a professional. Be clear, objective, and truthful. Talk more about actions and less about personalities. Oftentimes things can come across as gossip. Employers will not knowingly want to bring that into the workplace.

Bring Ego

This “don’t” could really wrap up a few others more generally. Bring your personality to the interview in a professional way, not your ego. Let the interviewers get a feel for who you are and what your likes and dislikes are. But don’t bring ego. People are almost automatically turned off by people with a “big head.” Ego could practically look like an overconfidence in oneself—a failure to admit any real weakness, never being able to admit you’re wrong, or that you think more highly of yourself than you do of others.

Be Irresponsible

There are so many things to say in this section. Be sure to take anything you need with you. Have an extra sheet of paper and a writing utensil to take notes. Show up at least 15 minutes early but don’t arrive at the interview more than 15 minutes early. If you are unfamiliar with how to get to the interview or how bad traffic might be, get there with plenty of time to spare. But if you are 20 or 30 minutes early, don’t let them know you are there. Wait until it’s between 10 to 15 minutes before the scheduled time and then show up to your appointment spot.

Take extra copies of your resume or any other documents, such as a letter of recommendation. If you carry a folder or writing utensil, be sure that they are in good condition as well. Make good eye contact and be sure to greet everyone in the room who is interviewing you.

Forget to Follow Up

Follow-up is an important aspect of an interview. It gives you one last opportunity to influence the interview panel or those making the hiring decision. During a follow-up, by phone or email, be as professional as possible. Thank them for the opportunity to interview for the position. Express how you think you’d be a great fit for the role. Let them know that you will wait to hear back regarding their decision. Don’t make them feel as if they need to respond to your email or that you are expecting a response from them. That is not appropriate for a follow-up. If you want a response to something, do it through HR.

Anything you can do to help increase your chances of getting a new job should be taken seriously. Implementing these ten foundational “do” and “don’t” principles will help set you apart from other candidates.

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