About

Cultural Competence in Nursing

The purpose of this course is to outline and explore the most common or serious disparities, address ways in which healthcare delivery needs to be adjusted, and start the conversations needed to create a new generation of healthcare that will close these gaps.

Introduction   

There is no doubt that modern medicine has made many technological advancements over the last few decades, forging the way for highly intricate diagnostic and treatment methods and improving the quality and longevity of many lives. In order to truly keep up with changing times however, healthcare professionals must consider much more than the technical aspects of healthcare delivery. They must take a closer look and a more conscientious approach to the way in which care is delivered, particularly across a wide variety of demographics and characteristics. Ensuring care is delivered with empathy, respect, and equity, noting and honoring a patient’s differences, is how care transforms from good to truly great. Practicing diversity, equity and inclusion (DEI), as well as cultural competence in nursing professions must become a standard.  

Health Disparities

When covering cultural competence in nursing, it is vital that a provider knows that each patient is a unique individual. However, there are some characteristics such as race, gender, age, sexual orientation, or disability that can create gaps in the availability, distribution, and quality of healthcare delivered. These gaps can create lasting negative impacts for patients mentally, physically, spiritually, and emotionally and even lead to poorer outcomes than patients not within a special population. Modern healthcare professionals have a responsibility to learn to identify risks, provide sensitive and inclusive care, and advocate for equity in much the same way that they have a responsibility to learn how the human body, medications, or hospital equipment works.  

Epidemiology

In order to understand the importance of cultural competence in nursing as well as the best practices for DEI in healthcare, let’s turn to data.  

Healthy People 2020 provides a myriad of data that includes countless implications for changes that need to occur in healthcare settings for equitable care of all populations. The data includes statistics such as: 

• 12.6% of Black/African American children have a diagnosis of asthma, compared to 7.7% of white children (16).  
• The rate of depression in women ages 65+ is 5% higher than that of men of the same age, across all races (16). 
• Teenagers and young adults who are part of the LGBTQ community are 4.5 times more likely to attempt suicide than straight, cis-gender peers (16). 
• 16.1% of Hispanics report not having health insurance, compared to 5.9% of white populations (16) . 
• The national average of infant deaths per 1,000 live births is 5.8. The rate for Black/African American infants is nearly double at 11 deaths per 1,000 births (16). 
• 12.5% of veterans are homeless, compared to 6.5% of the general U.S. population (16).  

Additional disparities are seemingly endless and point unquestionably to the fact that cultural competence and DEI awareness is no longer something that healthcare professionals can be uniformed about. The purpose of this course is to outline and explore the most common or serious healthcare disparities, address ways in which healthcare delivery needs to be adjusted, and start the conversations needed to create a new generation of healthcare professionals that will close these gaps.  

The importance of understanding DEI best practices in the health setting, as well as possessing cultural competence in nursing, is vital in making positive changes for all populations. 

Race & Ethnicity

One of the most significant disparities in healthcare, and the one garnering the most attention and campaigns for change in recent years, is race and ethnicity. However, when covering the best practices for cultural competence in nursing, it is essential that we go over this topic. Studies in recent years have revealed that minority groups, particularly Black Americans, are sicker and die younger than white Americans. Examples include:  

Current data shows that Black men are more likely to be diagnosed with prostate cancer and 2.5 times more likely to die from it than their white peers. A 2019 study through University of Michigan Rogel Cancer Center explored prostate cancer outcomes when factors such as access to care and standardized treatment plans were controlled. They found that outcomes were comparable and Black men experienced similar mortality to the white men in the study, implying that they did not “intrinsically and biologically harbor a more aggressive disease simply by being Black” (11). 

A 2020 study found that Black individuals over age 56 experience decline in memory, executive function, and global cognition at a rate much faster than their white peers, often as much as 4 years ahead in terms of cognitive decline. Data in this study attribute the difference to the cumulative effects of chronically high blood pressure, more likely to be experienced by Black Americans (20). 

Black women experience twice the infant mortality rate and nearly four times the maternal mortality rate of non-Hispanic white women during childbirth. One in five Black and Hispanic women report poor treatment during pregnancy and childbirth by healthcare staff. Studies indicate that in addition to biases within the healthcare system, some of these poor outcomes may also be attributed to cumulative effects of lifelong inferior healthcare (1). 

Lack of health insurance keeps many minority patients from seeking care at all. 25% of Hispanic people are uninsured and 14% of Black people, compared to just 8.5% of white people. This leads to lack of preventative care and screenings, lack of management of chronic conditions, delayed or no treatment for acute conditions, and later diagnosis and poorer outcomes of life threatening conditions (4). 

Emerging data indicates that hospitalizations and deaths from COVID-19 are disproportionately affecting Black and Hispanic Americans, with Black people being 153% more likely to be hospitalized and 105% to die from the disease than white people. Hispanic people are 51% more likely to be hospitalized and 15% more likely to die from COVID-19 than white people (21).

The potential reasons are many, from genetics to environmental factors such as socioeconomic status, but data repeatedly shows that these factors are not enough to account for the disproportionate health outcomes; it eventually comes down to inequity in the structure of the healthcare systems in which we all live. For example:  

Medical training and textbooks are mostly commonly centered around white patients, even though many rashes and conditions may look very different in patients with darker skin or different hair textures (13). 

There is also a lack of diversity in physicians; in 2018, 56.2% were white, while only 5% were Black and 5.8% Hispanic. More often than not, patients will see a physician that is a different race than they are, which can mean their particular experiences as a minority person, and how that relates to their health, are not well understood by their physician (2). 

While the Affordable Care Act increased the number of people who have access to health insurance, minority patients are still disproportionately uninsured, which leads to delayed or no care when necessary (4). 

Minority patients are also often those living in poverty, which goes hand in hand with crowded living conditions and food deserts due to outdated zoning laws created during times of segregation. This means less access to nutritious foods, fresh air, or clean water which has overall negative effects on health (21). 

Potential solutions to these problems are in the works across many fronts, but the breaking down and resetting of old institutions will likely require change on a broader, political level.  

Medical school admission committees could adopt a more inclusive approach during the admission process . For example, paying more attention to the background and perspectives of their applicants and the circumstances/scenarios in which they came from as opposed to their involvement in extracurriculars (or lack of) and former education. Incentivizing minority students to choose careers in healthcare as well as investing in their retention and success should become a priority in the admissions process (13). This is one of the main drivers and only possible paths to having minority representation in healthcare systems nationwide.  

Properly training and integrating professionals like midwives and doulas into routine antenatal care and investing in practices like group visits and home births will give power back to minority women while still giving them safe choices during pregnancy (1).  

Universal health insurance, basic housing regulations, access to grocery stores, and many other socio-political changes could also work towards closing the gaps in accessibility to quality healthcare and may vary by geographic location.  

Understanding the inequalities that currently exist in the healthcare system for those of minority races is essential in this lesson on cultural competence in nursing.

It is the healthcare provider’s duty to be an advocate for the patient, and the ability to recognize and identify practices that are not diverse, equitable, or inclusive to all races and ethnicities is vital in improving care delivery methods.

LGBTQ

Another highly at risk group for healthcare inequity are members of the Lesbian, Gay, Bisexual, Transexual, and Queer (LGBTQ) community. When practicing cultural competence in nursing, the provider must become aware of how vulnerable this population is, especially in healthcare settings. Risks and examples of disparities within the LGBTQ community include:  

• Youth are 2-3 times more likely to attempt suicide  
• More likely to be homeless 
• Women less likely to get preventative screenings for cancer 
• Women more likely to be overweight or obese 
• Men are more likely to contract HIV, particularly in communities of color  
• Highest rates of alcohol, tobacco, and drug usage 
• Increased risk of victimization and violence 
• Transexual individuals are at an increased risk for mental health disorders, substance abuse, suicide, and more likely to be uninsured than any other LGB individuals (17) 

Current data suggests that most of the health disparities faced by this group of people are due to social stigma, discrimination, lack of access or referral to community programs, and implicit bias from providers leading to missed screenings or care opportunities.  

Support systems and social acceptance are strongly linked to the mental health and safety of these individuals. Lack of support and acceptance in the home, workplace, or school leads to negative outcomes. Also, a lack of social programs to connect LBGTQ individuals to each other and build a community of safety and acceptance creates further gaps.  

There is currently still discrimination in access to health insurance and employment for this population which can affect accessibility of quality health care as well as affordable coverage. 

Following this, a compilation of recent data showcases that there are significant issues with the quality and delivery of care provided to those in the LGBTQ community. This data includes: 

• In a 2018 survey of LGBTQ youth, 80% reported their provider assumed they were straight and did not ask (18).  
• In 2014, over half of gay men (56%) who had been to a doctor said they had never been recommended for HIV screening (14).  
• A 2017 survey of primary care providers revealed that only 51% felt they were properly trained in LGBTQ care (25).  

Although it is unclear as to whether this data stems from a lack of education or social awareness from the provider, it is evident that change needs to be made. 

In order to improve these conditions and close the gap for LGBTQ individuals, much can be done on the community level and in medical training: 

• Community programs should be available to create safe spaces for connection and acceptance. 
• Laws and school policies can focus on how to prevent and react to bullying and violence against LGBTQ individuals. 
• Cultural competence training in medical professions needs to include LGBTQ issues. 
• Data collection regarding this population needs to increase and be recognized as a medical necessity, as it is largely ignored currently. 

It is essential for providers to stay up-to-date on changes and health trends among the LGBTQ populations, as healthcare delivery methods may require adjustments over time; this is critical when learning about cultural competence in nursing.

Gender & Sex

Gender and sex play a significant role in health risks, conditions, and outcomes due to a combination of factors, including biological, social, and economic elements. Among the differences in health data related to gender are:  

• Women are twice as likely to experience depression than men across all adult age groups (7).  
• About 12.9% of school aged boys are diagnosed and treated for ADHD, compared to 5.6% of girls, though the actual rate of girls with the disorder is believed to be much higher (9).  
• A 2010 study showed men and women over age 65 were about equally likely to have visits with a primary care provider, but women were less likely to receive preventative care such as flu vaccines (75.4%) and cholesterol screening (87.3%) compared to men (77.3% and 88.8% respectively) (5).  
• In the same study, 14% of elderly women were unable to walk one block, as opposed to only 9.6% of men at the same age (5).  
• Heart disease is the leading cause of death in women, yet women are shown to have lower treatment rates for heart failure and post heart attack care, as well as lower prevalence but higher death rates from hypertension than men (6).  

It is also important to differentiate the difference between gender and sex when practicing cultural competence in nursing.  

Sex is the biological and genetic differentiation between male and female, whereas gender is a social construct of difference in societal norms or expectations surrounding men and women. For someone looking to better practice cultural competence in nursing and provide both equitable and inclusive care, it is essential that you know this differentiation.  

Some health conditions are undeniably attributable to the anatomical and hormonal differences of biological sex; for example, uterine cancer can only be experienced by those who are biologically female. But many of the inequalities listed above disproportionately burden women due to the social and economic differences they experience in society; for example, 1 in 4 women experience intimate partner violence as compared to 1 in 9 men (22).  

What are the reasons for this? A lot of it has to do with how women are perceived in society, how their symptoms may present differently than male counterparts, or how their symptoms are presented to and received by medical professionals.  

• For centuries, any symptoms or behaviors that women displayed (largely mental health related) that male doctors could not diagnose fell under the umbrella of hysteria. The recommended treatment for this condition was anything from herbs, isolation, sex, or abstinence and it is only in the last one hundred years or so that more accurate medical diagnoses began to be given to women. Hysteria was not deleted from the DSM until 1980 (27). 
• The Cameron study found that women were more verbose in their encounters with physicians and may not be able to fit all of their complaints into the designated appointment time, leading to a less accurate understanding of their symptoms by their doctor (5).  
• The same study also indicated that women tend to have more caregiver responsibilities and feel less able to take time off for hospitalizations or treatments (5).  
• Symptoms of mental health disorders like ADHD may look different in girls than in boys. Girls who are having difficulty focusing may be categorized as “chatty” or a “daydreamer” by teachers, whereas boys are more likely to draw attention for being hyperactive or disruptive, when both are actually experiencing symptoms of ADHD and could benefit from treatment (10).  

In order to close these gaps and ensure equitable care for men and women, the way that teachers, doctors, and nurses view and respond to girls and women must be adjusted.  

• Children who are struggling in school should be looked at more comprehensively and the differences in learning styles widely understood.  
• Screening questionnaires and standard preventive care used when caring for clients in primary care.  
• Social services should be utilized to help determine if women are pushing aside their own healthcare needs due to responsibilities at home.  
• Medical professionals must be trained in the history of inequality among women, particularly in regards to mental health, and proper, modern diagnostics must be used.  
• The differences in communication styles of men and women should be understood when caring for patients.
  

Religion

Religion can impact when patients seek care, which treatments they will participate in, and how they perceive their care. Even advanced technology in healthcare can be perceived as unsatisfactory if it violates religious preferences for patients, so it is very important for healthcare professionals to be aware of certain religious preferences to provide the most competent and sensitive care possible. Consequences of culturally incompetent care include:  

• Negative health outcomes due to not participating in care that violates their religious beliefs. 
• Patient relationships with healthcare professionals can suffer if they feel disrespected or misunderstood, causing patients to delay or avoid seeking care altogether.  
• Dissatisfaction with care which can even lead to long term trauma surrounding major events like birth, death, or chronic disease if a patient felt uninvolved or disrespected in their care (26).  

There are many religions with different practices and ordinances, but we will cover some of the more major and common implications regarding health practices here. Typically, views on pregnancy/birth, death, diet, modesty, and treatment for illness are the most important areas for healthcare professionals to understand. Providers must continue to educate themselves on the practices and preferences of various religions; it is essential in practicing cultural competence in nursing.

Disclaimer: Please note that each religion has many variations and that not all practices may be the same. The following information has been sourced from “Cultural Religion Competency in Clinical Practice,” written by Drs. Diana Swihart, Siva Naga S. Yarrarapu, and Romaine L. Martin (26). 

Buddhism

Study and meditate on life, cause and effect, and karma, working towards personal enlightenment and wisdom. They believe the state of mind at death determines their rebirth and prefer a calm and peaceful environment without sedating drugs. Have ceremonies around birth and death. Their diet is usually vegetarian (26).  

Christian Science

Based on the belief that illness can only be healed through prayer. They typically choose spiritual healing for disease or illness prevention and treatment. Often refuse vaccines and delay treatment for acute illnesses. They avoid tobacco and alcohol but have no other dietary restrictions (26). 

The Church of Jesus Christ of Latter Day Saints/Mormon 

Heavily family-oriented, involvement of family in major health/life events is important. Strict abstinence outside of heterosexual marriage. Fasting required monthly, exempt during illness. Blood or blood products are accepted. Abortion is prohibited unless it as a result of a rape or the mother’s life is in danger. Two elders present for the blessing of those ill or dying (26). 

Hinduism

Centers on leading a life that allows you to reunite with God after death. Believes in reincarnation and so the environment around dying people must be peaceful. Presence of family and priest during end of life is preferable. After death, the body is washed and not left alone until cremated. Euthanasia is forbidden. Often vegetarian and the right hand is used for eating (26). 

Islam

Belief in God and the prophet Abraham. Prayer is required five times daily. Observe Ramadan, a month of fasting and abstinence during daylight (children and pregnant women are exempt from fasting). Autopsies should only be performed if legally necessary. Must eat clean, halal, food and excludes pork, shellfish, and alcohol. Female patients require female healthcare providers. Abortion is prohibited (26). 

Jehovah’s Witness

Belief destruction of the present world is coming and true followers of God will be resurrected. Do not celebrate birthdays or holidays. Believe death is a state of unconscious waiting. Euthanasia prohibited. Refuse blood and blood products. Abortion is prohibited. Pregnancy through artificial means (IUI, IVF) is prohibited (26). 

Judaism

Belief in all powerful God and varying levels of interpretation/observance of laws and traditions. Cremation is discouraged or prohibited. Prayer is important for the sick and dying, after death the body is not left alone. Must eat kosher foods, excludes pork. Amputated limbs must be saved and buried where the person will one day be buried. Abortion allowed in certain circumstances (26). 

Protestant

Christian faith formed in resistance to Roman Catholicism. Autopsy and organ donation are acceptable. Euthanasia is not acceptable. No restrictions on diet or traditional western medicine treatments (26). 

Roman Catholicism

Christian faith steeped in tradition and observance of sacraments. Clergy present at end of life for the sacrament of Last Rites. Avoid meat on Fridays during Lent. Mass and Communion on Sundays is an obligation and they may require a clergy member visit during hospitalization. Abortion and birth control (other than natural family planning) prohibited. Artificial conception discouraged. Newborns with a grave prognosis need to be baptized (26). 

In order to better practice cultural competence in nursing and improve the quality of care given that respects a patient’s faith and religious boundaries, one should focus on:  

• Understanding basic differences and preferences with various religions and providing training for staff.  
• Encouraging family to participate in health decision making where appropriate.  
• Providing interpreters where needed. 
• Promoting an environment that allows for clergy, healers, or other religious figures of comfort to visit and participate in care if desired.  
• Providing dietary choices that are considerate of religious dietary preferences.  
• Recruiting staff that are minorities or of various religions.  
• Respecting a client’s views on controversial topics such as pregnancy/birth, death, and acceptance or declining of treatments even if it conflicts with staff members own beliefs (26). 

Age

As the Baby Boomer generation ages, there is a growing number of older adults in the U.S. In 2016, there 73.6 million adults over age 65, a number which is expected to grow to 77 million by 2034. As of 2016, 1 in 5 older adults reported experiencing ageism in the healthcare setting (24). As the number of older adults needing healthcare expands, the issue of ageism must be addressed. For providers looking to improve cultural competence in nursing practices, it is vital that ageism is addressed, as it flies under the radar. Ageism is defined as stereotyping or discrimination against people simply because they are old. Ways in which ageism is present in healthcare includes:  

• Dismissing a treatable condition as part of aging. 
• Over-treating natural parts of aging as though they are a disease. 
• Stereotyping or assuming the physical and cognitive abilities of a patient purely based on age. 
• Providers being less patient, responsive, and empathetic to a patient’s concerns or even talking down to patients or not explaining things because they believe them to be cognitively impaired. 
• Elderly patients may internalize these attitudes and seek care less often, forgo primary or preventative screenings, and have untreated fatigue, pain, depression, or anxiety  
• Signs of elder abuse may be ignored or brushed off as easy bruising from medication of being clumsy (24). 

There are many reasons why ageist attitudes in healthcare may occur, including:  

• Misconceptions and biases among staff members, particularly those that have worked with a frail older population and assume all elderly people are frail.  
• Lack of training in geriatrics and the needs and abilities of this population. 
• Standardizing screenings and treatments by age may help streamline the treatment process but can lead to stereotyping. 
• Changing this process and encouraging an individual approach may be resisted by staff and viewed as less efficient. 

In order to combat ageism and make sure healthcare is appropriately informed to provide respectful, equitable care:  

• Healthcare professionals can adopt a person-centered approach rather than categorizing care into groups based on age. 
• Facilities can adopt practices that are standardized regardless of age. 
• Facilities can include anti-ageism and geriatric focused training, including training about elder abuse. 
• Healthcare providers can work with their elderly patients to combat ageist attitudes, including internalized ones about their own abilities (24). 

Veterans

Veterans are a unique population that face many health concerns unique to the conditions of their time in service. Much of veteran health care is provided through the Veteran Affairs (VA) facilities, a nationalized form of healthcare involving government owned hospitals and clinics and government employed healthcare professionals. Again, the purpose of this course is to educate providers on how to practice cultural competence in nursing; however, let’s introduce the disparities found within this population by utilizing a few statistics.

• 1 in 5 veterans experience persistent pain and 1 in 3 veterans have a diagnosis related to chronic pain (8).  
• Approximately 12% of veterans experience symptoms of PTSD in their lifetime, compared to 6% of the general population and 80% of those with PTSD also experience another mental health disorder such as anxiety or depression (8). 
• More than 1 out of every 10 veterans experiences some type of substance use disorder (alcohol, drugs), which is higher than the rate for non-veterans (8).  
• In 2019, around 9% of homeless adults were veterans (28).  
• Veterans account for 20% of all suicides in the U.S, despite only about 8% of the U.S. population serving in the military (8).  
• Disparities also exist within the veteran population and veterans who are a minority race or female experience these issues at an even higher rate.
  
• For example, veteran women are twice as likely to experience homelessness than veteran men (28).  

The causes of these troubling issues for veterans are multifaceted; some of it relates to the nature of work in the U.S. Military and increased exposure to trauma (particularly with those involved in combat), and some of it relates to the care of veterans and their mental health during and after their service.  

• 87% of veterans are exposed to traumatic events at some point during their service (8). 
• Current data suggests fewer than half of eligible veterans utilize VA health benefits.
  
• For some this means they are receiving care at a non-VA facility and for others it means they are not receiving care at all. 
• Care at civilian facilities means healthcare professionals who may not have a full understanding of veteran issues (12).  
• Less than 50% of veterans returning from deployment receive any mental health services (23).  

All service members exiting the military are required to participate in the Transition Assistance Program (TAP), an information and training program designed to help veterans transition back to civilian life, either before leaving the military or retiring. The program is evaluated annually for effectiveness and currently includes components about skills and training for civilian jobs and individual counseling regarding plans after exit.  

• Adding or strengthening components of TAP surrounding mental health care and utilization of VA healthcare services would be beneficial and could help reduce disparities. 
• Changing the military culture surrounding mental health to strengthen and mandate training and usage of debriefing for active duty military could be beneficial as well. 
• Incentivizing usage of the VA healthcare system for routine preventative and mental health care would help reach more veterans who may be in need. 

Additional training for healthcare professionals working within the VA with an emphasis on cultural competence and mental health disorders would ensure high quality of care for veterans utilizing their services.

Mental Illness & Disability

Disabilities are emerging as an under-recognized risk factor for health disparities in recent years, and this new recognition is a welcome change as more than 18% of the U.S (15) population is considered disabled. Disabilities can be congenital or acquired and include conditions that people are born with (such as Down Syndrome, limb differences, blindness, deafness), those presenting in early childhood (Autism, language delays), mental health disorders (bipolar, schizophrenia), acquired injuries (spinal cord injuries, limb amputations, change in hearing/vision), and age related issues (dementia, mobility impairment).  

Public health surveys vary from state to state, but most categorize a condition as a disability based on the following: 1) blindness or deafness in any capacity at any age, 2) serious difficulties with concentrating, remembering, and decision making, 3) difficulty walking or climbing stairs, 4) difficulty with self-care activities such as dressing or bathing, 5) and difficulty completing errands, such as going to an appointment, alone over the age of 15 (19).  

Health disparities affecting people with disabilities can include the way they are recognized, their access and use of care, and their engagement in unhealthy behaviors. In order to practice cultural competence in nursing, understanding the disparities that those with disabilities face is essential.

• Due to variations in the way disabilities are assessed, the reported prevalence of disabilities ranges from 12% to 30% of the population (19). 
• People with disabilities are less likely to receive needed preventative care and screenings (15). 
• Only 78% of women with disabilities were up to date with their pap test, while over 82% of non-disabled women were up to date with this preventative screening (19). 
• People with disabilities are at an increased risk of chronic health conditions and have poorer outcomes (15). 
• 27% of people with disabilities did not see a doctor when needed, due to cost, as opposed to only 12% of non-disabled peers (19). 
• 21% of children with disabilities were obese, compared to 15% of children without disabilities (19). 
• People with disabilities are more likely to engage in unhealthy behaviors such as cigarette smoking and lack of physical exercise than people without disabilities (15). 
• During Hurricane Katrina, 38% of the people who did not evacuate were limited in their mobility or providing care to someone with a disability (19). 

Much of the health differences between those with and without disabilities comes down to social factors like education, employment (finances), and transportation which significantly affect access to care.  

• 13% of people with disabilities did not finish high school, compared to 9% of non-disabled peers. 
• Only 17% of people over the age of 16 with disabilities were employed, compared to nearly 64% of non-disabled peers. 
• Only 54% of people with disabilities had at-home access to the internet, compared to 85% of people without disabilities. 
• 34% of people with disabilities reported both an annual income <$15,000 and access to transportation, compared to 15% and 16% respectively for people without disabilities. 
• Fewer than 50% of people with disabilities have private insurance, while 75% of people without disabilities have private health insurance. 
• Even for those insured, 16% of people with disabilities have forgone care due to cost, compared to only 5.8% of insured people without disabilities (19). 

If access to necessary preventive and acute health care is to be increased for those with disabilities, much must be changed in regards to the social determinants affecting this population. Policy change on a community, state, and federal level will be needed to provide the social and economic support these people need. Potential solutions include:  

• Streamline and standardize the process of identifying people with disabilities so they can be eligible for assistance as needed. 
• School programs to help people with disabilities graduate and find jobs within their ability level.  
• Community participation in making sure transportation, buildings, and facilities are accessible to all. 
• Make internet access a basic and affordable utility, like running water and electricity. 
• Address the inequities in health insurance accessibility and coverage. 
• Provide social and economic support programs for parents of children with disabilities and provide transitional support as those children become adults (15). 

Conclusion

In short, cultural competence in nursing means that although a provider may not share the same beliefs, values, or experiences as their patients, they understand that in order to meet the patient’s needs, they must tailor their care delivery. Nurses are patient advocates, and it is on them to ensure that they are providing equitable and inclusive care to all populations. 

However, cultural competence in nursing is ever changing and it is the responsibility of the provider to stay up-to-date in order to offer the best experience for all patients.

Connecticut Mental Health Conditions

Introduction   

Mental health conditions are common in the United States, with one in five adults suffering symptoms ranging from mild to severe each year. Despite this fairly high prevalence, 2020 data indicates that only 46% of adults with a mental health condition received medical services related to those symptoms (10). Furthermore, experiencing one mental health disorder increases the risk of developing a second or third disorder by two to three fold (13). Comorbid mental health diagnoses also increase the severity of symptoms, negative impacts on quality of life, and risk of suicidal ideations (3)  

Current practices surrounding mental health leave many people at risk of being undiagnosed or untreated and increased awareness and education is needed for medical professionals to help close these gaps in care. This Connecticut mental health training aims to provide a thorough understanding of certain common mental health disorders, how to screen for them and coordinate resources for clients in need, and how to navigate suicide prevention for optimum client safety.  

Epidemiology

Every year, millions of people nationwide suffer from mental health related symptoms that impact their ability to work, attend school, maintain relationships, and enjoy their lives. Recent data indicates that one in five United States adults experiences symptoms of mental illness each year and one in twenty experiences severe symptoms (6). One in six United States children experiences mental illness symptoms each year and suicide is the second leading cause of death in the 10-14 year age group (6).  

As of 2020, anxiety disorders were the most prevalent, with 19.1% of all US adults experiencing some form of anxiety annually. Depression is next, with a prevalence of 8.4%, Post-traumatic Stress Disorder (PTSD) experienced by 3.6%, and bipolar disorder experienced by 2.8% of adults (6).  

There is mild variance among races, with annual prevalence among races outlined as follows:  

• Non-Hispanic multiracial people: 35.8% 
• Non-Hispanic white: 22.6% 
• Non-Hispanic American Indian: 18.7% 
• Hispanic or Latino 18.4% 
• Non-Hispanic black: 17.3% 
• Non-Hispanic Asian: 13.9% 

(6) 

Women are more likely to experience mental illness than men, with 25.8% of women 15.8% of men reporting symptoms annually (NIH). Being part of the LGBTQ community is one of the greatest risk factors, with 47.4% of LGBTQ people experiencing mental illness (6).  

In addition to the factors that increase risk of mental health disorders, experiencing mental health issues also increases other health related risks. Suffering depression increases the risk of cardiovascular and metabolic disorder by 40-50% over the rest of the population, depending on severity. Thirty-two percent of people with mental illness also experience substance abuse disorders, as compared to 10% of the general population (6).  The rate of academic struggles and dropping out of school are 2-3 times higher for children and teens with mental health diagnoses, which in part contributes to the higher rates of unemployment (6.4% vs 5.1%) experienced by people with mental health disorders (6). On a more global scale, it is estimated over $1 trillion is lost in productivity due to depression and anxiety disorders each year (6).  

On the severe end of mental health consequences is suicide, currently the 12th leading cause of death nationwide (12). Overall, there has been a slight decrease in suicide rates in recent years, declining from 14.2 per 100,000 people annually in 2000 to 13.5 per 100,000 people in 2020 (12). Still, suicide is a devastating problem with twice as many people dying by suicide as homicide in recent years. Risk varies by many demographic factors with men being about 4 times more likely to commit suicide than women across all ages. Among women, suicide rate is highest for those ages 45-64, at 7.9 people per 100,000. And among men, the rate is highest for those age 75 and older, at 40.5 per 100,000. By race, American Indians and White men are significantly more affected (12).  

When looking at younger populations, the biggest risk factor seems to be sexuality and gender identity. Gay, Lesbian, and bisexual teens are 4 times more likely to attempt suicide than straight peers and transgender teens are 9 times more likely to attempt suicide than cis-gender peers. Each year, 45% of LBGTQ teens report experiencing serious thoughts of suicide at least once (6).  

Despite these serious implications and high rates of prevalence, less than half of affected people receive appropriate, regular mental health services. These statistics are staggering. This is the reason of why the Connecticut Department of Public Health implemented the Connecticut mental health training CE requirement to improve mental health outcomes. Lack of proximity to resources, prescription problems, delayed or canceled appointments, and complications due to the pandemic or even just symptoms causing poor compliance all serve as barriers to appropriate treatment (6). Healthcare professionals are guaranteed to encounter patients with mental health needs no matter what area of healthcare they work in, and universal improvements in education and preparedness to deal with mental health concerns is desperately needed and can serve to improve outcomes for patients everywhere.

Signs, Symptoms and Criteria for Common Mental Health Diagnoses

Unless you work specifically in mental health, you may only have a vague understanding of what exactly certain mental health diagnoses mean, how they are treated, or what symptoms your clients are dealing with. A more in depth understanding of how mental health problems present and diagnostic criteria is one of the first steps towards better detection and treatment for vulnerable clients. The Connecticut Department of Public Health added this CE requirement of Connecticut mental health training in order to better serve the patient population.

Depression

Known as Major Depressive Disorder (MDD) or Clinical Depression, this is one of the most common mental health disorders. While this disorder may stereotypically be known as being sad or down, the actual criteria for depression is much more detailed and nuanced (9). According to the Diagnostics and Statistics Manual for mental health (DSM-5), MDD is defined as experiencing at least five of the following symptoms for at least a two week time period and at least one of the symptoms must be one of the first two on the list:  

• Sad, depressed, or even flat or detached mood most days, for the majority of the day 
• Decreased or lack of interest or pleasure in any activities throughout the day 
• Decrease in appetite or significant weight loss without trying to lose weight 
• Slowed thought process and movement, noticeable by others 
• Fatigue or low energy levels most days 
• Feeling worthless or unnecessarily guilty most days 
• Decreased ability to think, concentrate, or make decisions most days 
• Recurrent thoughts of death, with or without a plan, or thoughts that things would be easier if one was dead (9)
  

The number, combination, and severity of symptoms will vary by individual. Typically symptoms are severe enough to interfere with a person’s ability to work, attend school, or maintain their relationships as well as they would like. People with depression may also experience excessive worries about their health or increased rates of general physical complaints like headache or abdominal pain. MDD may occur as a single episode, but often occurs in recurrent episodes, lasting for a few weeks to months and then resolving for a period of time before returning. Persistent symptoms lasting two years or more, though often less severe in intensity, is known as dysthymia. Depression can also occur from hormonal changes during or after pregnancy and is known as perinatal depression. Some individuals suffer from depressive symptoms only at certain times of year, typically in the dark and cold months of fall and winter in the northern hemisphere; this is known as seasonal depression (9).  

It is important to separate depression from grief which is a response to loss with similar, often overlapping, but distinguishably different from depression symptoms. In grief, there is an identifiable loss, whereas depression can occur without any particular precipitating event (for “no reason”). Grief involves sad or hopeless feelings intermixed with feelings of joy or peace, whereas depression is persistently low mood. Being close to loved ones often offers comfort or healing in grief, but isolation and withdrawing are more common with depression. And with grief, thoughts of death may occur as a person desires to reunite with a deceased loved one, while in depression thoughts of death center around feeling worthless or hopeless and no longer wishing to live (4).  

Risk factors for depression include personal or family history of any depressive disorder, certain medical conditions that negatively impact quality of life, or even medications taken for other conditions. Major life events or traumas, including death of a loved one, divorce, moving, job changes, birth of  child, abuse, or traumatic events can all increase the risk of subsequent depression (9).  

Anxiety

All people experience worries or stress over things throughout their lives. But anxiety disorders extend beyond normal worries in their frequency and intensity, occurring often enough and at a severity level that interferes with a person’s ability to function at work, school, or in their relationships with others.  There are several distinct disorders that fall under the umbrella of anxiety and the differences lie in the triggers and the expression of symptoms, but the criteria of excessive worry is a common theme across all anxiety disorders (8).  

Generalized anxiety disorder (GAD) is a common form of anxiety that involves a general sense of dread of anxiousness, typically about anything and everything rather than specific events. People with GAD may feel restless, on edge, have difficulty concentrating, become tired easily, be irritable or have difficulty regulating their emotions, have difficulty sleeping, or have frequent general physical complaints like headaches or stomach aches (8).  

Panic disorder involves more extreme physical symptoms of anxiety, known as panic attacks. Sudden, intense bursts of anxiety involving a racing heart, chest pain, shortness of breath, shaking, intense feelings of dread, or an intense desire to flee a situation are considered panic attacks. They may occur in relation to stressful events or for no reason at all. Anyone can experience a panic attack, but experiencing them frequently and being unable to function at work, school, or home because of them is considered panic disorder (8).  

Social anxiety disorder is anxiety triggered by situations with people outside of one’s home. This can be people you know, like classmates or extended family, or strangers like cashiers or healthcare professionals. Symptoms include feeling judged or watched by others, racing heart, being unable to speak up or speak clearly to others, avoiding eye contact, or feeling very self conscious (8).  

Phobias are anxiety related symptoms that center on a very specific trigger or event. People with phobias will do everything they can to avoid the trigger, including refusing to go to a certain place or leave home. Common phobias include agoraphobia (fear of leaving home), blood, heights, airplanes, vomit or vomiting, certain animals (such as snakes, spiders, or dogs), needles or injections, or separation from parents (for children) (8).  

Risk factors for anxiety include exposure to traumatic events (especially early in life), drug or alcohol use, frequent exposure to a stressful environment (at job or school), and family history of anxiety disorders. Certain medications and stimulants like nicotine and caffeine can increase the symptoms of anxiety (8).  

Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder (PTSD) is a type of mental health disorder that develops as a response to experiencing a particularly dangerous, scary, or shocking event. An extreme response of “fight-or-flight” during a high stress event is very normal, but many people recover quickly, within a few days to weeks, and do not experience continued distress after the event is over. For other people, the intense symptoms of fear or anxiety continue long after the danger has resolved (11).  

Symptoms that occur in response to an identifiable event, last more than a month, and are interfering with a person’s ability to function at work, school, or in relationships are considered to have PTSD. Symptoms include:  

• Re-experiencing the event such as through flashbacks or nightmares 
• Avoidance symptoms such as staying away from certain people, places, objects, or even music that serves as a reminder of the event 
• Arousal symptoms of feeling on edge, angry, tense, easily startled, or having difficulty sleeping 
• Cognition and mood symptoms such as difficulty remembering details surrounding the event, negative outlook on the world or about self, feelings of guilt or blame, lack of interest in things 
• Children may experience symptoms of regression such as bedwetting or daytime accidents when previously continent, being unable to speak, acting out the event with toys, increased clinginess or fear of separation from parents or caregivers (10)
  

Risk factors for PTSD include experiencing war (both as a member of the military or a civilian), physical or sexual assault/abuse, car accidents, natural disasters, seeing someone be seriously injured or die, history of mental illness or substance abuse, and having few to no support systems in place during times of stress (11).  

Suicide

Suicide by definition is the death of an individual from self-injurious behaviors and the intent to die from those behaviors. Reckless behaviors resulting in unintentional death are not considered suicide because there was no intent to die. People who attempt or commit suicide often feel worthless, hopeless, or that their life is a burden to others and the only escape from their symptoms or guilt is to end their life (12). Warning signs that individuals may be planning or preparing for suicide include increase agitation and substance use, withdrawing from others, researching methods of suicide, stating they have thought about or have the ability to commit suicide, sleeping too much or not at all, giving away possessions or calling/writing letters to say goodbye to loved ones, or a sudden and extreme improvement in depression symptoms (usually from the resolve to commit suicide) (2).  

A suicide attempt is any self-injurious behavior engaged in as an attempt to die but which ultimately is non-fatal. Suicide attempts can be actions which do not even result in injury, but if death was the individual’s intent, it is considered a suicide attempt. Suicidal ideations are any thoughts, considerations, or detail planning related to ending one’s own life (12).   

The leading method of suicide in recent years is firearms, accounting for more than half of all suicides (11).  

Risk factors for suicide include existing mental illness (especially depression, anxiety, bipolar disorder, or schizophrenia), substance abuse problems, terminal health diagnosis (particularly those that are very painful), persistent bullying or relationship problems, unemployment, highly stressful life events like divorce, family history of suicide or personal past attempts, and childhood trauma or neglect. Having access to guns, knives, pills, or other potentially lethal materials increases the risk of suicide as well (2).  

Case Study

Jason is a 78 year old male who presents at the Internal Medicine office for his annual physical. When the nurse is collecting vitals, she chats with him about his plans for the summer. He states that he and his late wife used to garden together and he has kept up with it for the last 3 years since her death but this year he does not feel up to planning it or doing the work. The nurse asks if he has other plans for how to occupy his time and he states he usually has a group of friends he gets coffee with twice a week, but he hasn’t been waking up early enough to go to it and has decided to sleep in instead. The nurse documents his vitals and reports off to the physician, attributing his “slowing down” to his advancing age. During the visit, his doctor asks how he is coping with his wife’s loss to which Jason replies, “I’m okay. It never gets easier, but you do get used to it.” The physician orders labs to check his iron levels for fatigue and provides a pamphlet for a support group for widows and widowers at the end of the visit. He recommends Jason follow up in another 3-4 months if his fatigue hasn’t improved. 

Screening

Regardless of which area of healthcare you work in, there will always be clients who are struggling with mental health symptoms, even if that is not their primary reason for seeking care at your facility. Routine and standardized screening for these symptoms can help ensure more clients who need help are identified and prevent many from falling through the cracks. Earlier detection of symptoms ultimately leads to better mental health outcomes as well, so simple and routine screenings serve to improve identification and distribution of care to those in need. Improving mental health outcomes is the primary goal of Connecticut implementing this CE requirement of Connecticut mental health training. So who should undergo screening, when should the screenings occur, and what are some of the best or most common screening tools available?  

Let’s start with children since over 50% of all lifetime mental health disorders first appear by age 14.. At every wellness visit, it is recommended to ask general questions about family psychosocial wellness such as childcare resources, availability of food, parent coping with the stressors of parenthood, and normal psychosocial development in the child such as language, eye contact, bonding with family members, play, and age appropriate response to praise and consequences. Families where problems are suspected should be evaluated further. Starting at age 11, the use of more streamlined screening tools is recommended by the American Academy of Pediatrics. The Patient Health Questionnaire (PHQ-9) and/or Pediatric Symptoms Checklist (PSC) should be used annually to detect increased risk of depression, anxiety, or suicidal thoughts. The CRAFFT questionnaire is recommended annually for screening of substance use, starting at age 11. For children who seem anxious or where excessive worries or behavior problems are a concern, a SCARED questionnaire can assess more specifically for anxiety disorders (1).  

Once into adulthood, the PHQ-9 is still a reliable and easy to use tool and should be administered at all annual wellness visits. The General Anxiety Disorder (GAD-7) tool is also quick to administer and can pick up on clients who may be experiencing excessive worries (5). In more acute settings like urgent cares or emergency departments, a simple screening question such as “Do you feel safe at home?” can determine situations that may need acute interventions for clients who may not be receiving regular primary care.  

In addition to annual screening, healthcare providers should be aware of life events that may increase a person’s risk of experiencing a mental health disorder and perform additional screening as needed.  In obstetrics and gynecology settings, women should be screened throughout pregnancy and postpartum for perinatal mood disorders using an Edinburg Questionnaire. Pediatric offices can also screen mothers of infant clients since women often see their child’s pediatrician much more frequently than their own obstetrician or midwife (5). Older adults are more likely to be experiencing declining health, chronic medical diagnoses, or life events such as retirement or the loss of a spouse that increase their risk of depression or anxiety. Assuming their age alone is the cause of certain symptoms should be avoided, while energy and activity levels may indeed decline in later life, a lack of interest or pleasure in things or feelings of hopelessness are not normal signs of aging and should not be brushed off. Updated information on recent life events is important and increased screening should be done accordingly. War veterans, disaster or abuse survivors, and others may find themselves seeking care for physical symptoms related to trauma, but their mental health should be considered and assessed immediately after the event as well as regularly for several months afterwards (5). 

Taking Action

The next step in closing the gap for early detection of mental health disorders is knowing what to do when clients screen positive or when they come to you specifically with a mental health concern or symptoms. A primary goal of the Connecticut mental health training is to prepare nurses with the knowledge and resources needed to get paitents on the right plan of care. Many facilities are surprised once they begin screening, just how many clients present with positive results or the need for further help.  

The first thing to do is gather more information directly from the client. Ask about symptoms they have been feeling, how long it has been going on, recent life events that may be contributing to these feelings, and ways in which the symptoms have been impacting their performance at work, in school, or in other aspects of life. Gather a family history that focuses specifically on mental health disorders to better assess disorders for which a client is at risk. Determine the client’s overall safety; the best way to do this is to ask directly if they are having thoughts of wanting to harm themselves or others. This will help determine if intervention is needed urgently or if a more routine connection with resources is appropriate (2).  

Once more thorough information has been gathered about a client’s particular scenario, providers can determine the best course of action and what resources to connect them with. It is useful for facilities to have a list of resources available. Appropriate resources include providers who can diagnose and prescribe treatment for mental health disorders (this can often be done in primary care settings, but specialists like psychiatry may be more appropriate), therapists or counselors, group therapies or support groups with common themes, and crisis resources like suicide hotlines or facilities that can be accessed 24/7 in the event of a crisis. When connecting clients with resources, plan for appropriate follow up as well to ensure they received the help they needed (2).  

Suicide Prevention

On a broad scale, healthcare professionals can participate in suicide prevention by advocating for screening and early detection of mental illness, as well as identifying risk factors and protective factors for their clients to determine who may need connection with available resources. On a community health level, strengthening available resources and the community’s access to them can promote social change needed for prevention (7).  

On a more individual level, familiarity with what to do when encountering suicidal clients is always useful, though the actually frequency at which you encounter such clients may vary greatly depending on where you work. If you have concerns or a client fails a screening tool, it is always okay to ask them outright if they have thoughts of wanting to hurt themselves. It is a myth that asking someone this will give them the idea and no studies indicate asking this would contribute to suicide risk. If a client indicates they are having thoughts of suicide or self harm, the next steps should be to determine how often these thoughts are occurring and if they have a plan. It can feel awkward to ask these types of questions, but it is extremely important for client safety and studies indicate that most people would like the help and support extended to them. If they admit to having a plan, the next step is to determine if they have the means to enact the plan. If they say they want to take a lethal dose of pills, determine what medicines they have available to them; if they say they have thought about using a firearm, determine if firearms and ammunition are accessible to them (7).  

Clients with an active plan and the means to enact said plan will need crisis intervention and likely involuntary hospital admission. Anyone with thoughts of suicide, even passive ones with no plan, will require further evaluation with a counselor or provider experienced in mental health. Specific plans moving forward for these clients is beyond the scope of this course, but often involve the development of Safety Plans, initiation of psychiatric medication, and connection with resources such as individual or group therapists. The important thing for healthcare professionals in general is to be able to determine when clients are a risk to themselves or others and ensure they are connected with resources before leaving your care (7).  This is what the Connecticut Department of Public Health wants to educate nurses on and is why they implemented a CE requirement of the Connecticut mental health training.

Revisit Case Study

Let’s take a look at Jason’s case again and consider how things might have gone differently with better mental health protocols for the facility.  

Jason is a 78 year old male who presents at the Internal Medicine office for his annual physical. When the nurse is collecting vitals, she chats with him about his plans for the summer. He states that he and his late wife used to garden together and he has kept up with it for the last 3 years since her death but this year he does not feel up to planning it or doing the work. The nurse asks if he has other plans for how to occupy his time and he states he usually has a group of friends he gets coffee with twice a week, but he hasn’t been waking up early enough to go to it and has decided to sleep in instead. The nurse notes the PHQ-9 questionnaire Jason completed at check in and sees the score is 20/27, which is indicative of depression.  

The nurse documents his vitals and reports off to the physician, mentioning Jason’s PHQ score and his lack of interest in his usual activities. During the visit, his doctor asks how he has been feeling lately and if he has been sad or lonely. Jason discloses that he has been feeling down lately and not wanting to do the usual things that he enjoys. His doctor asks if he has any thoughts of suicide or wanting to hurt himself which Jason denies. After a thorough assessment, Jason is diagnosed with MDD and given a trial of fluoxetine. His doctor also recommends Jason establish with a therapist. Follow up is scheduled in 3 weeks to check in on how the new medication is going.  

Alzheimers Nursing Care

Introduction   

Alzheimer’s disease is a destructive, progressive, and irreversible brain disorder that slowly destroys memory and thinking. Alzheimer’s is the most common cause of dementia in older adults (1). For most people who have Alzheimer’s disease, symptoms first appear in their mid 60’s (1).  

Studies suggest more than 5.5 million Americans, most 65 or older, may have dementia caused by Alzheimer’s (1). It is currently listed as the sixth leading cause of death in the United States. It is essential to understand the signs and symptoms of Alzheimer’s dementia and how to manage the care of a patient, family member, or friend suffering from the disease. 

Dementia is the loss of cognitive functioning, such as thinking, remembering, reasoning, and behavioral abilities, such as a decreased ability to perform activities of daily living (1). The severity of dementia ranges from mild to severe. Dmentia’s mildest stage often begins with forgetfulness, while its most severe stage consists of complete dependence on others for general activities of daily living (1).  

History of Alzheimer’s 

Alzheimer’s disease is named after Dr. Alois Alzheimer. In the early 1900s, Dr. Alzheimer noticed changes in the brain tissue of a patient who had died of an unknown mental illness. The patient’s symptoms included memory loss, language problems, and unpredictable behavior.  

After her death, her brain was examined and was noted to have abnormal clumps known as amyloid plaques and tangled bundled fibers, known as neurofibrillary or tau tangles (1). These plaques and tangles within the brain are considered some of the main features of Alzheimer’s disease. Another feature includes connections of neurons in the brain. Neurons are a type of nerve cell responsible for sending messages between different parts of the brain and from the brain to other parts of the body (1).  

Scientists are continuing to study the complex brain changes involved with the disease of Alzheimer’s. The changes in the brain could begin ten years or more before cognitive problems start to surface.  

During this stage of the disease, people affected seem to be symptom-free; however, toxin changes occur within the brain (1). Initial damage in the brain occurs within the hippocampus and entorhinal cortex, which are the parts of the brain that are necessary for memory formation. As the disease progresses, additional aspects of the brain become affected, and overall brain tissue shrinks significantly (1).  

Signs and Symptoms & Diagnosis of Alzheimer’s Disease  

Memory problems are typically among the first signs of cognitive impairment related to Alzheimer’s disease. Some people with memory problems have Mild Cognitive Impairment (MCI) (2). In this condition, people have more memory problems than usual for their age; however, their symptoms do not interfere with their daily lives. 

Older people with MCI are at increased risk of developing Alzheimer’s disease. The first symptoms of Alzheimer’s may vary from person to person. Many people display a decline in non-memory-related aspects of cognition, such as word-finding, visual issues, impaired judgment, or reasoning (2).  

Healthcare providers use several methods and tools to determine the diagnosis of Alzheimer’s Dementia. Diagnosis and evaluation involve memory, problem-solving, attention, counting, and language tests. Healthcare providers may perform brain scans, including CVT. MRI or PET is used to rule out other causes of symptoms.  

Various tests may be repeated to give doctors information about how memory and cognitive functions change over time. They can help diagnose different causes of memory problems, such as stroke, tumors, Parkinson’s disease, and vascular dementia. Alzheimer’s disease can be diagnosed only after death by linking clinical measures with an examination of brain tissue in an autopsy (3).  

Stages of Disease  

Mild Alzheimer’s  

People experience significant memory loss and other cognitive problems as the disease progresses. Most people are diagnosed in this stage (1). 

• Wandering/getting lost  
• Trouble handling money or paying bills  
• Repeating questions  
• Taking longer to complete basic daily tasks 
• Personality/behavioral changes (1) 

Moderate Alzheimer’s  

In this stage, damage occurs in the area of the brain that controls language, reasoning, sensory processing, and conscious thought (1).  

• Memory and confusion worsen.  
• Problems recognizing family and friends  
• Unable to learn new things  
• Trouble with multi-step tasks such as getting dressed  
• Trouble coping with situations 
• Hallucinations/delusions/paranoia (1) 

Severe Alzheimer’s 

• Plaques and tangles spread throughout the brain, and brain tissue shrinks significantly. 
• Cannot communicate  
• Entirely dependent on others for care  
• Bedridden – most often as the body shuts down  

Prevention  

Many aging patients worry about developing Alzheimer’s disease and dementia. Especially if they have had a family member who suffered from the disease, patients may worry about genetic risk. Although there have been many ongoing studies on the prevention of the disease, nothing has been proven to prevent or delay dementia caused by Alzheimer’s disease (2).  

More research suggests that women are more likely to develop dementia and Alzheimer’s compared to men. Further research is needed to determine the role between genetics, sex, and Alzheimer’s risk (4).  

A review led by experts from the National Academies of Sciences, Engineering, and Medicine found encouraging yet inconclusive evidence for three types of interventions related to ways to prevent or delay Alzheimer’s Dementia or age-related cognitive decline (2):  

• Increased physical activity  
• Blood pressure control  
• Cognitive training  

Treatment of the Disease  

Alzheimer’s disease is complex and is continuously being studied. Current treatment approaches focus on helping people maintain their mental function, manage behavioral symptoms, and lower the severity of symptoms. The FDA has approved several prescription drugs to treat those diagnosed with Alzheimer’s (3).  

Treating symptoms of Alzheimer’s can provide patients with comfort, dignity, and independence for a more significant amount of time while simultaneously assisting their caregivers. The approved medications are most beneficial in the early or middle stages of the disease (3). 

Cholinesterase inhibitors are prescribed for mild to moderate Alzheimer’s disease; they may help to reduce symptoms. Medications include Rzadyne®, Exelon®, and Aricept® (3). Scientists do not fully understand how cholinesterase inhibitors work to treat the disease; however, research indicates that they prevent acetylcholine breakdown. Acetylcholine is a brain chemical believed to help memory and thinking (3). 

For those suffering from moderate to severe Alzheimer’s disease, a medication known as Namenda®, which is an N-methyl D-aspartate (NMDA) antagonist, can be prescribed. This drug helps to decrease symptoms, allowing some people to maintain certain essential daily functions slightly longer than they would without medication (3).  

For example, this medication could help a person in the later stage of the disease maintain their ability to use the bathroom independently for several more months, benefiting the patient and the caregiver (3). This drug works by regulating glutamate, an essential chemical in the brain. When it is produced in large amounts, glutamate may lead to brain cell death. Because NMDA antagonists work differently from cholinesterase inhibitors, these rugs can be prescribed in combination (3).  

Medications to be Used with Caution in those Diagnosed with Alzheimer’s  

Some medications, such as sleep aids, anxiety medications, anticonvulsants, and antipsychotics, should only be taken by a patient diagnosed with Alzheimer’s after the prescriber has explained the risks and side effects of the medications (3).  

Sleep aids: They help people get to sleep and stay asleep. People with Alzheimer’s should not take these drugs regularly because they could make the person more confused and at a higher risk for falls.  

Anti-anxiety: These treat agitation and can cause sleepiness, dizziness, falls, and confusion (3).  

Anticonvulsants: These are used to treat severe aggression and have possible side effects of mood changes, confusion, drowsiness, and loss of balance. 

Antipsychotics: they are used to treat paranoia, hallucinations, agitation, and aggression. Side effects can include the risk of death in older people with dementia. They would only be given when the provider agrees the symptoms are severe enough to justify the risk (3).  

Caregiving  

Coping with Agitation and Aggression  

People with Alzheimer’s disease may become agitated or aggressive as the disease progresses. Agitation causes restlessness and causes someone to be unable to settle down. It may also cause pacing, sleeplessness, or aggression (5). As a caregiver, it is essential to remember that agitation and aggression are usually happening for reasons such as pain, depression, stress, lack of sleep, constipation, soiled underwear, a sudden change in routine, loneliness, and the interaction of medications (5). Look for the signs of aggression and agitation. It is helpful to prevent problems before they happen.  

Ways to cope with agitation and aggression (5):  

• Reassure the person. Speak calmly. Listen to concerns and frustrations.  
• Allow the person to keep as much control as possible.  

• Build in quiet times along with activities. 
• Keep a routine. 
• Try gently touching, soothing music, reading, or walks. 
• Reduce noise and clutter.  
• Distract with snacks, objects, or activities. 

Common Medical Problems  

In addition to the symptoms of Alzheimer’s disease, a person with Alzheimer’s may have other medical conditions over time. These additional health conditions can cause confusion and behavior changes. The person may be unable to communicate with you about their circumstances. As a caregiver, it is essential to watch for various signs of illness and know when to seek medical attention for the person being cared for (6).  

Fever 

Fever could indicate potential infection, dehydration, heatstroke, or constipation (6).  

Flu and Pneumonia 

These are easily transmissible. Patients 65 years or older should get the flu and Pneumonia shot each year. Flu and Pneumonia may cause fever, chills, aches, vomiting, coughing, or trouble breathing (6).  

Falls 

As the disease progresses, the person may have trouble with balance and ambulation. They may also have changes in depth perception. To reduce the chance of falls, clean up clutter, remove throw rugs, use armchairs, and use good lighting inside (6). 

Dehydration 

It is important to remember to ensure the person gets enough fluid. Signs of dehydration include dry mouth, dizziness, hallucinations, and rapid heart rate (6).  

Wandering  

Many people with Alzheimer’s disease wander away from their homes or caregivers. As the caregiver, it is essential to know how to limit wandering and prevent the person from becoming lost (7).  

Steps to follow before a person wanders (7) 

• Ensure the person carries an ID or wears a medical bracelet.  
• Consider enrolling the person in the Medic Alert® + Alzheimer’s Association Safe Return Program®. 
• Alert neighbors and local police that the person tends to wander and ask them to alert you immediately if they are seen alone.  
• Place labels on garments to aid in identification. 

Tips to Prevent Wandering (7) 

• Keep doors locked. Consider a key or deadbolt. 
• Use loosely fitting doorknob covers or safety devices.  
• Place STOP, DO NOT ENTER< or CLOSED signs on doors.  
• Divert the attention of the person away from using the door.  
• Install a door chime that will alert when the door is opened.  
• Keep shoes, keys, suitcases, coats, and hats out of sight.  
• Make sure not to leave a person who has a history of wandering unattended.  

Conclusion

Alzheimer’s is a sad, debilitating, progressive disease that robs patients of their lives and dignity. As research continues on the causes, treatment, and prevention of the disease, healthcare workers and caregivers need to know the signs and symptoms of a patient with Alzheimer’s disease and potential coping mechanisms and management strategies of the disease. More information on the disease is available through several various resources, including:  

Family Caregiver Alliance  

800-445-8106 

NIA Alzheimer’s and Related Dementias Education and Referral Center  

800-438-4380 

Nursing Care in Lewy Body Dementia

Introduction   

Lewy body dementia is one of the more common causes of dementia. Currently it is the second most common dementia disorder following Alzheimer’s disease [2]. This condition is shown to affect more than 1.4 million people in the United States [1] [2]. Of dementia cases in older adults, Lewy body dementia is said to make up 5% of people with dementia [2]. Lewy body dementia is a disorder that progresses over time [1]. The progression of the disease differs between individuals and the severity of the symptoms [1].  

On average an individual lives between five to eight years after diagnosis [1]. Currently there is not a cure for this disease [1]. This course will examine the causes of this disease, signs and symptoms patients might experience, diagnostic tests, types of management, and educational resources for family members. This course is designed to inform nurses about this common disease and to use this information in their daily practice to care for their patients.  

Definition

Lewy body is an umbrella term that includes two separate diagnoses: Dementia with Lewy bodies and Parkinson’s disease dementia [5]. As these diseases progress, they develop together and are seen as one entity, not two separate conditions [4]. Lewy body dementia is a condition that involves neurocognitive disorders that include hallucinations, memory loss, behavior changes, and parkinsonism features [2]. This disease can also affect intellectual abilities and cause individuals to act out dreams during REM (rapid eye movement) sleep [2]. REM sleep behavior disorder sometimes may be experienced before any other symptoms are exhibited [2].   

Lewy body dementia is known for a buildup of deposits of alpha- synuclein proteins called Lewy bodies [1]. Diagnosing this condition can be difficult because many neurological disorders have similar symptoms. Lewy body dementia and Parkinson disease dementia are very similar. For a diagnosis of Lewy body dementia, there must be a cognitive impairment with motor symptoms occuring in less than 12 months [3].  Parkinson’s disease dementia affects an individual’s movements; cognitive symptoms appear later (greater than one year) [5].  

Lewy body dementia is known to affect older adults generally between the ages of 50 and 85 [2]. This disease is said to be underdiagnosed due to a large number of diagnoses occuring post-death during autopsies [4]. Several medications used to treat neurocognitive and behavioral symptoms in other conditions can worsen the symptoms of Lewy body dementia [4]. Therefore, an accurate diagnosis can impact an individual’s quality of life.  

Epidemiology 

Lewy body dementia affects a significant number of individuals in the United States. This condition is found more often in men than women [4]. Age is thought to be the greatest risk factor for an individual developing this disease [4]. An individual who has a family history of Lewy body dementia and Parkinson’s disease is at a higher risk for developing this condition [3].

Lewy Body dementia is more widespread in European, Asian, and African ethnic groups [3].  In individuals with Parkinson’s disease, the incidence of Parkinson’s disease dementia is said to be around 25-30% [4]. The incidence of individuals with Parkinson disease developing this type of dementia after having Parkinson’s for more than 20 years increases to around 83% [4].  

Pathophysiology 

There is a buildup of alpha- synuclein proteins that causes neurons to die in Lewy body dementia [2] [5].  As mentioned above in this course, this buildup of proteins is called Lewy bodies. The death of neurons that produce dopamine result in problems with movement, cognitive impairment, a decline in cognition, and sleep disturbances [4].  In Lewy body dementia there is a deficiency of acetylcholine [3]. There is also a decrease in acetylcholine with Alzheimer’s disease, but the deficiency is greater with Lewy body dementia [3]. The decrease in neurons that produce acetylcholine causes memory loss and learning impairment [4].  

The mutation of synuclein alpha and synuclein beta genes can cause dementia with Lewy bodies [2]. Mutations in apolipoprotein E and GBA genes are potential risk factors for developing the disease [2]. There have been cases where a buildup of alpha-synuclein was found during an autopsy, but the individual did not show any clinical signs of Lewy Body dementia when alive [4]. The function of these proteins in this condition is still undetermined [5]. 

Etiology 

The exact cause of Lewy body dementia is still unknown. While research is ongoing and new developments are occuring, the specific cause has not been determined. The accumulation of Lewy bodies cause cell death which causes symptoms, however, the reason for the buildup of Lewy bodies is still under research [5]. As mentioned earlier, there are specific gene mutations that have been shown to increase the likelihood of producing altered alpha- synuclein proteins, in turn causing them to clump together (forming the Lewy bodies) [2].  

The mutation of the GBA gene interferes with the function of lysosomes, which can affect the breakdown of the alpha- synuclein proteins, causing the proteins to accumulate [2]. The e4 allele type of the APOE gene has been shown to increase the risk of developing Lewy body dementia [2]. These clumps of Lewy bodies form inside and outside of neurons in different areas of the brain, where they can alter the function of the cell and can cause the cell to die [2].

The neurons that develop the neurotransmitter dopamine are especially impacted by these clumps of Lewy bodies, which was addressed earlier in this course [2]. Further research is required to find out why these Lewy bodies develop in certain individuals. Currently, age, genetics, and environmental factors are some of the greatest risk factors [3]. 

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Clinical Signs and Symptoms 

Lewy body dementia is a progressive disorder – the signs and symptoms worsen over time. The symptoms that are more common are sleep changes, impaired behavior, movement, and cognition [5]. Research shows that the location of Lewy body accumulation impacts the clinical signs and symptoms the individual experiences [3]. If Lewy bodies develop in the brainstem and cerebral cortex first, the condition is called dementia with Lewy bodies, and the onset of the dementia is early [3]. If Lewy bodies accumulate in the brain stem and then develop into the cerebral cortex as time passes, the onset of dementia appears later, and this condition is called Parkinson’s disease dementia [3].  

Rapid Eye Movement Sleep Behavior Disorder 

Rapid eye movement (REM) sleep behavior disorder is sometimes the first clinical sign of dementia with Lewy bodies [2]. Individuals with this disorder move and talk while dreaming in their sleep [2]. The movements can be violent and cause the individual to fall out of bed [5]. Individuals may kick, punch, and scream in REM sleep (the second half of their sleep) [4]. REM sleep behavior disorder is seen in 76% of patients with dementia with Lewy bodies [4].   

This disorder can cause fractures and contusions in some individuals resulting from falling out of bed [4]. This can not only affect the individual, but also the sleep partner of the patient [4]. In some cases, separate sleeping arrangements are needed for the safety of the individual and their sleeping partner. A questionnaire by the patient and sleep partner is part of the diagnosis of REM sleep behavior disorder [14]. If the individual does sleep next to someone, this questionnaire can be helpful as most of the time the patient cannot recall the events while asleep [14]. Video polysomnography is required for a complete diagnosis of this disorder [14]. These events while asleep must be repeated to meet the diagnostic criteria [14]. 

Other Sleep Disorders 

Other disorders of sleep include sleepiness in the daytime, restless leg syndrome, confusion when awakened, and obstructive sleep apnea [4]. 

Visual Hallucinations 

Visual hallucinations are present in about 80% of individuals with Lewy body dementia [1]. Visual hallucinations are a core clinical symptom of dementia with Lewy bodies [4]. They are more common in women than in men [4]. Individuals are aware of these hallucinations and can tell others what they experienced [4]. Visual hallucinations are vivid to individuals and have been said to range from people walking around the house to seeing people that have died sitting next to them [6]. During the beginning stages of the disease, the hallucinations do not seem to affect the patient as much as when the disease progresses [6]. Patients are said to be afraid of these hallucinations in the later stages of the disease [6]. Nonvisual hallucinations are less common, however can occur in some patients [1]. These hallucinations include smelling or hearing something that is not in their surroundings [1]. 

Fluctuation in Cognition 

Fluctuation in cognition is also a clinical sign that is associated with dementia with Lewy bodies [4]. This symptom includes changes in attention, concentration, and alertness [5]. These changes are random and can differ day-to-day [1]. Symptoms can include delirium, and mimic symptoms that are caused by metabolic diseases, which can further the difficulty with identifying the correct diagnosis [4]. To diagnose dementia with Lewy bodies, one of the episodes must be confirmed [4]. These fluctuations can be present in other forms of dementia in their later stages but when present in earlier stages, they point to dementia with Lewy bodies [4].  

Memory loss that impacts activities of daily living can be found in later stages of Lewy body dementia [1]. Memory loss early on is more often a characteristic sign of Alzheimer’s dementia [1]. Confusion about the individual’s whereabouts, and inability to multitask can also occur in dementia with Lewy bodies [4]. 

Problems with Movement 

Problems with movement are signs of Lewy body dementia. Bradykinesia (slow movements) and rigidity occur in about 85% of individuals with dementia with Lewy bodies [4]. Tremor at rest is less common in individuals with this condition [4]. Loss of coordination and difficultly swallowing can occur [1]. Problems with movement greatly increase the risk of falls for these individuals [4]. This can place strain on the individual’s caregivers [4]. 

Autonomic Dysfunction 

Autonomic dysfunction can be present in dementia with Lewy bodies and Parkinson’s disease dementia. This symptom is seen in about 90% of patients with Lewy body dementia [4]. The symptoms that result from autonomic dysfunction can be constipation, urinary incontinence, orthostatic hypotension, erectile dysfunction, and dizziness [1] [4]. Orthostatic hypotension appears as early as five years prior to the diagnosis of Lewy body dementia [4]. Syncope and falls are usually the result of orthostatic hypotension [4]. Constipation can also occur earlier in the disease process [4]. 

Diagnostic Tests and Evaluations  

Throughout this course, it has been mentioned that Lewy body dementia is significantly underdiagnosed. Individuals are usually diagnosed as the disease progresses due to the symptoms that overlap with other forms of dementia and other neurological and psychiatric disorders [3]. An autopsy of the brain after death is one of the only ways to have a conclusive diagnosis of Lewy body dementia [16]. There are certain diagnostic criteria and diagnostic tests that are used to diagnose an individual with Lewy body dementia. 

Diagnosis by Symptoms 

Lewy body dementia is probable when an individual experiences dementia and two main features of the disease. Lewy body dementia is a potential diagnosis if the individual experiences progressive dementia and one main feature of the disease [3]. As discussed in the clinical signs and symptoms section of this course, key features of Lewy body dementia are cognitive fluctuations, dementia that progresses, problems with movement (signs of parkinsonism), REM sleep behavior disorder, and visual hallucinations [3] [16].  

Timing of symptoms is relevant for distinguishing between the two forms of Lewy body dementia [3]. Currently healthcare providers use the time span of one year to distinguish the two forms [3]. If dementia occurs within one year of the appearance of movement problems, then a diagnosis of dementia with Lewy bodies is used [3]. If an individual is diagnosed with Parkinson’s disease and starts experiencing symptoms of dementia more than one year after their Parkinson’s diagnosis, then Parkinson’s disease dementia is used [3]. Some indicative biomarkers in addition to clinical symptoms are used in diagnosis [4]. Some of these biomarkers can be found in cerebral spinal fluid (CSF) and are still under research [4].  

Cognitive Tests 

Cognitive testing can be used to show the cognitive impairment of patients with Lewy body dementia [3]. The Mini-Mental State Examination can be used as an initial screening test [4]. This exam tests cognitive function by focusing on concentration, orientation, and memory [15]. This test can be limited since symptoms of these patients can fluctuate day to day [3]. Another cognitive function test is the Montreal Cognitive Assessment (MoCA) [15]. Providers do not usually diagnose based on a single test; instead, they use the results to look for other signs and symptoms of Lewy body dementia [4]. 

Imaging Tests 

There are certain imaging tests that can help with diagnosis and distinguishing between other dementia disorders. A single-photon emission computerized tomography (SPECT) scan can help support a diagnosis [16]. This is a nuclear scan that can sense radioactivity [16]. If the SPECT scan shows a reduced dopamine transporter uptake in the basal ganglia, this can be a sign of Lewy body dementia [16]. This will separate the diagnosis between Lewy body dementia and Alzheimer’s disease [4]. Performing this scan alone will not lead to a possible diagnosis of Lewy body dementia; however, in combination with other diagnostic tests, the scan can lead to a more certain diagnosis [4]. Results from these scans can appear normal initially, and the scan may need to be repeated [4].  

An iodine- MIBG myocardial scintigraphy can be performed to support Lewy body dementia [16]. This would show decreased communication of cardiac nerves [16]. The results may be skewed by heart disease or certain drugs [4]. A CT or MRI may be used but these imaging tests can present mixed results [4]. With Alzheimer’s disease, significant atrophy is seen in the medial temporal lobes [4]. There is normally minimal atrophy in Lewy body dementia [4].  

As mentioned earlier in the course, video polysomnography is needed for the diagnosis of REM sleep behavior disorder [14]. This sleep study without the loss of muscle tone can also point towards a diagnosis of Lewy body dementia as REM sleep behavior disorder has now moved to a key feature of this disease [14]. 

Case Studies 

Case Study #1 

A 74-year-old male presents to his primary care provider after his wife reports abnormal behavior over the past several months. His wife reports the patient kicks and screams during sleep. The patient reports seeing little people walking around the living room during the day. The wife states the patient some days will fall asleep throughout the day while completing activities.  The patient states difficulty walking and muscle stiffness.  

The wife states last week the patient was supposed to go to the local grocery store to buy milk. After two hours passed, the wife called her husband as she was worried about him. He states he got lost finding the grocery store and did not know where he was. The wife said she had to drive to find her husband and bring him home. The patient also reports dizziness when standing. After the nurse obtained an orthostatic blood pressure, the patient was positive for orthostatic hypotension. 

• Which form of dementia is the patient most likely experiencing? 
• What type of symptoms is the patient experiencing that would point to that diagnosis? 
• What diagnostic tests or evaluations should the patient undergo? 
• What types of supportive treatment should the healthcare provider include in the treatment plan for this patient? 

Case Study #2 

A 70-year-old female presents to the emergency department via EMS after falling at home. The patient’s daughter called 911 after finding her on the floor when going to visit her. Upon arrival at the emergency department the patient is oriented to self. The patient does not know where she is or what happened to precipitate the fall. The patient has a past medical history of hypertension, diabetes type II, and Parkinson’s disease.  

The patient was diagnosed with Parkinson’s disease two years prior. The daughter states the patient has been forgetful lately and not acting like herself. The daughter reports that her mom’s behavior is different from day-to-day. An MRI and the National Institutes of Health Stroke Scale (NIHSS) are used to rule out a cerebrovascular accident. A complete blood count (CBC), a complete metabolic count (CMP), and urinalysis are obtained. The patient suffered a contusion to her right cheek and a right radius fracture. The patient states that she sees figures dancing in the room and smells popcorn. The patient appears to be frightened by the hallucinations. The patient’s daughter states for the last six months the patient has had difficulty swallowing and a reduced appetite.  

• Which form of dementia is the patient most likely experiencing? 
• What would the MRI of the patient most likely show? 
• What clinical signs of dementia is the patient exhibiting? 

Management 

Currently there is not a cure for Lewy body dementia, only supportive treatment. The management of this disease involves a multifaceted approach, including therapies, pharmacological treatments, and family support. 

Therapies 

Specific therapies can help with symptom management and help improve the individual’s quality of life. Occupational therapy can help improve a patient’s ability to complete activities of daily living. Speech therapy can help with swallowing coordination and improve the clarity and volume of speech [5]. Physical therapy can aid patients with problems with movement [5]. Mental health counseling can help individuals and their families with managing behaviors and their emotions [5]. 

Medications 

Pharmacotherapy can help with supportive treatment but can also worsen symptoms if certain medications are taken. Below are some examples of medications that are used by patients with Lewy body dementia. 

• Cholinesterase Inhibitors are used to help cholinergic activity to improve cognitive function [6].  

• Rivastigmine was one of the first of these drugs to be tested [6]. Patients were noted to have improved on their cognitive exams [6]. It is also shown to reduce hallucinations and lessen anxiety [6]. This class of drugs has been said to improve the quality of life for some patients [4].   

• Donepezil and Galantamine are also used to reduce dementia symptoms of hallucinations [6]. These drugs were initially targeted for patients with Alzheimer dementia, however, they are effective for individuals with Lewy body dementia as well [3]. A study was done stating even if there is not a sign of cognitive improvement, this should not be the criteria to stop the medication as this medication has been proven to protect the individual from further impairment of cognition [4]. 

• Atypical Antipsychotics are prescribed to patients that are not seeing a reduction of symptoms while on cholinesterase inhibitors [3]. These types of drugs are seen as controversial due to the many adverse effects that have been seen in patients [4]. Drugs such as haloperidol and olanzapine should be avoided in patients with Lewy body dementia as they can cause neuroleptic malignant syndrome (a life-threatening condition) [5]. Quetiapine, clozapine, pimavanserin, and aripiprazole are atypical antipsychotic drugs that can be used to improve agitation and help prevent cognitive fluctuations [5]. 

• Carbidopa-Levodopa can be used in patients to manage problems with movement [3]. This medication can cause side effects and can result in hallucinations, delusions, and increase confusion [3]. Providers should begin with low doses of this medication [3]. 

• Clonazepam is a benzodiazepine that can lessen the REM sleep behavior disorder that patients with dementia with Lewy bodies can experience [5]. Between 33-65% of patients with REM sleep behavior disorder can experience an injury while sleeping [5]. This medication has been proven to decrease injuries that occur during sleep [5]. Clonazepam can adversely affect individuals with gait disorders or sleep apnea [5]. 

• Melatonin is a hormone that can be used for patients that are affected by REM sleep behavior disorder (5). Studies have shown that the use of melatonin lessened the frequency and the severity of symptoms associated with REM sleep behavior disorder [5]. Melatonin can have side effects such as headaches in the morning, sleepiness during the day, and hallucinations [5]. 

• Memantine is used to treat dementia symptoms [5]. This medication is an NMDA receptor antagonist that stops effects of glutamate in the brain [5]. Memantine has been shown to improve symptoms of patients early in the disease [5]. 

Nursing Care 

As mentioned before, there is not a cure for Lewy body dementia. Caring for patients with Lewy body dementia includes supportive treatment. Nurses can play a significant role in caring for these patients and providing the family with support. Home health nurses can help with frequent assessment of the patient and their environment [3]. Environmental changes may be needed to protect the patient from falls and other accidents. Home health nurses can assess the type of assistance the patient would benefit from.  

Nurses can aid the family by providing education to assist in how to care for the patient. Family members and caregivers must be aware of the changes in behavior, fluctuations in cognition, and hallucinations that the individual might experience [3]. Nurses must also provide education to the caregiver of the patient on the side effects of certain medications, as they can affect an individual with this disease [7]. 

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Family Support 

Lewy body dementia is growing in recognition; however, many people might not be aware of this condition and the disease process. Family members need support from health care professionals to better care for their loved ones. Support can come in the form of education and preparing the family for the symptoms the individual may experience. The cognitive function of patients with this disease can be very limited [3]. Family members must be educated on monitoring the individual closely to promote safety [3]. These individuals are at a high risk for falling and developing aspiration pneumonia (due to swallowing difficulties) [3]. Family members should be educated in preparing for an emergency.  

Individuals with Lewy body dementia may need care and the family needs to know how to inform health care providers of their specific needs. It is important to educate family members that their roles in their past relationship with the patient will likely change due to the disease process. To prevent caregiver burnout, family members must be aware of their limitations and know when they need help [7]. Modifying the patient’s home may be needed for patient safety [3]. Each patient may have specific needs and family members should know what modifications may be necessary [3].  

Prognosis 

The prognosis of Lewy body dementia can be viewed as poor. As mentioned briefly earlier in this course, this disease is progressive and after diagnosis, the life expectancy is five to eight years [3]. The range of expectancy has also been attributed to delay in diagnosis, which can further delay supportive treatment to improve quality of life for the individual [3]. Patients can die from complications from the disease. Complications can include cardiac complications, falls, adverse effects from medications, pneumonia, and suicide [3].  

Compared to Alzheimer’s dementia, the risk of hospitalization or death due to respiratory infections is higher in patients with Lewy body dementia [8]. The median age at death is said to be similar between patients with Alzheimer’s dementia and Lewy body dementia [8]. The life expectancy from diagnosis to death is shorter in patients with Lewy body dementia [8]. The patient’s environment has been shown to play a role in the increased risk of mortality [8]. Patients in nursing homes have been shown to have a higher risk of mortality [8]. Caregivers can decrease the risk of complications by educating themselves on this disease and keeping their loved ones safe. 

Resources for Family Support  

Lewy body dementia is a diagnosis that can affect all aspects of an individual’s life and their family members lives. As nurses we must provide support for family members so they can better care for their loved ones and improve their quality of life. As recognition of this condition grows, family support resources are increasing. The Lewy Body Dementia Association is a nonprofit organization that raises awareness and provides support for families with individuals that suffer from Lewy body dementia [10]. Support groups can be found on their website to help families across the country in their local area [10].  

The Lewy Body Dementia Association was started by caregivers of individuals with this condition. They also focus on education and research into the disease. This association is a resource for family members [10]. 

Another resource for family members is The Lewy Body Dementia Resource Center. This is a nonprofit charitable organization that gives assistance and support to those who care for someone with Lewy body dementia [9]. This organization was founded by caregivers of individuals with Lewy body dementia. They have a support phone line that is available seven days a week to answer questions [9]. They also promote research and early diagnosis of this disease [9]. 

Research Programs 

Lewy body dementia is the second most common form of dementia in the United States [4]. This illness is thought to be underdiagnosed and commonly mistaken for other neurological disorders [3]. Research on Lewy body dementia can decrease the time it takes to diagnose a patient, and can help with management of the condition.  

The National Institute of Neurological Disorders and Stroke provides support for a variety of research endeavors for Lewy body dementia [11]. In 2021 The National Institute of Health spent $93 million dollars on Lewy Body dementia research [11]. One program is the Biomarkers for Lew body dementias program. This program aims to increase clinical data collection from patients with this condition, find biomarkers to expand further research, and allow access to the science community to help with further studies [11]. Another program is the Parkinson’s Disease Biomarkers Program. This program’s purpose is to collectively research with healthcare professionals, patients and family members, and technology professionals to increase biomarker research [11]. 

Biomarker research has been increasing in Lewy body dementia. A biomarker is a feature that can specifically indicate a certain disease [12]. For quite some time there were not any identified biomarkers for Lewy body dementia. There are certain biomarkers that aid in distinguishing Alzheimer’s disease from Lewy Body dementia [13]. These biomarkers can be assessed through imaging or in cerebral spinal fluid [13]. Currently these biomarkers are only helpful if another disease is doubtful [13].  

New biomarkers are needed to separate Alzheimer’s dementia from Lewy Body dementia and other neurological disorders [13]. Biomarkers that can help with early diagnosis would be beneficial for early treatment [13]. 

Conclusion  

Lewy Body dementia affects 1.4 million Americans [2]. The disease is underdiagnosed and often diagnosed incorrectly. Incorrect diagnoses can lead to worsening of symptoms and the administration of drugs that can lead to adverse effects.  

Educating healthcare providers and the community about Lewy body dementia can improve quality of life for individuals with the disease. As nurses, we must be informed about this disease to better educate our patients and their caregivers, and to know how to advocate for our patients.  

Sexual Harassment Prevention

Introduction   

Sexual harassment is a serious issue within the healthcare workplace. One systematic review research study found that sexual harassment rates against female nurses was as high as approximately 43% (5). According to an article published in the American Journal of Critical Care in 2021, recent studies estimate around 60% of female nurses and 30% of male nurses have reported sexual harassment (3).  

For both student and registered nurses, patients were the most likely perpetrators. However, this varies, and some research suggests that physicians and patient relatives were also at an increased likelihood of being perpetrators of sexual harassment toward registered nurses (8). It is important to remember that sexual harassment is not limited to female registered nurses; male nurses are also at risk of experiencing sexual harassment in the workplace. 

The impacts of sexual harassment affect nurses in many negative ways. There are obvious psychological consequences, but there is also evidence to suggest that work performance and productivity can also be negatively affected (12). Many states have recognized the significant impact of this issue and have taken measures to empower nurses to prevent and/or address sexual harassment. 

What Is Sexual Harassment?

Sexual harassment is commonly thought to be unwelcome contact. However, sexual harassment takes many forms. It can be defined as unwelcome sexual behaviors or actions which may be verbal, physical, mental, or visual (13). 

Listed below are some common examples of potential sexual harassment: 

• Actual or attempted rape or sexual assault 
• Pressure for sexual favors 
• Deliberate touching, leaning over, or cornering 
• Sexual looks or gestures 
• Letters, telephone calls, personal e-mails, texts, or other materials of a sexual nature 
• Pressure for dates 
• Sexual teasing, jokes, remarks, or questions 
• Referring to an adult as “girl,” “hunk,” “doll.” “babe,” “honey,” or other similar terms 
• Whistling at someone 
• Turning work discussions to sexual topics 
• Asking about sexual fantasies, preferences, or history 
• Sexual comments, innuendos, or sexual stories 
• Sexual comments about a person’s clothing, anatomy, or looks 
• Kissing sounds, howling, and smacking lips 
• Telling lies or spreading rumors about a person’s sex life 
• Neck and/or shoulder massage 
• Touching an employee’s clothing, hair, or body (4, 13) 

The U.S. Equal Employment Opportunity Commission defines sexual harassment as “unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature.” Sexual harassment can also include offensive remarks about an individual’s gender or sexual orientation. No matter the type or amount of harassment, it can disrupt the workplace and potentially create a hostile work environment (10,11) As you can see, the definition of sexual harassment is broad and can encompass many situations. 

Why Are Nurses Vulnerable to Sexual Harassment?

Nurses are vulnerable to sexual harassment by the very nature of their position. The role of nursing surpasses many societal norms regarding physical contact and involves intimate care of patients both physically and emotionally. This role is often exploited by perpetrators – they may take advantage of a nurse’s position and caring demeanor as a means to harass them (8). 

Staff-on-staff harassment is also commonly reported by nurses (8). Nurses are potentially predisposed to this type of harassment due to their subservient position to many staff members (physicians, administration) and the subsequent power imbalance that results. 

Key Points for Sexual Harassment

Sexual misconduct vs. sexual harassment – Sexual misconduct is a type of sexual harassment. Sexual behavior can turn into sexual harassment when the recipient receives the behavior in an unwelcome manner. The term “unwelcome” refers to unsolicited or uninvited behavior and undesirable or offensive behavior (11). 

Females and males can both be victims – Any unwelcome sexual behavior may be considered sexual harassment, regardless of the gender of the perpetrator and recipient. Male-on-male, female-on-female, female-on-male, and male-on-female types of harassment may occur (11). 

Sexual harassment can affect witnesses – Anyone who is affected by the sexually offensive conduct may be a victim. This may include a person witnessing or overhearing sexually-harassing behavior (1). 

It can occur outside the working environment – The “working environment” is not limited to the physical location of work. A “working environment” may be extended to any location where work occurs, such as remote locations, off-site locations, and temporary working locations (1, 11). 

It doesn’t only occur in person – Sexual harassment can occur on and off the clock. It can occur physically and virtually. Unwelcome sexual conduct through email, phone calls, texts, social media postings, and other mediums may constitute sexual harassment (6). 

Two Types of Sexual Harassment

1. Quid pro quo – Quid pro quo means “a favor for a favor.” In this sense, it refers to an authority figure (manager or supervisor) requesting a sexual favor in exchange for preferential treatment. This could be in the form of a promotion, raise, preferred assignment, or any other job benefit which they may affect (7).
2. Hostile work environment – Another method by which an individual may coerce sexual favors is through the threat or actuality of a hostile work environment. This refers to creating or threatening to create an intimidating, hostile, or offensive work environment in order to influence sexual favors or behavior (7).

What Should Nurses Do If They Experience Sexual Harassment?

If you feel you have been the victim of unwelcome sexual behavior (sexual harassment) there are avenues available to you for support and to report the behavior. 

• While it may not be an easy thing to do (or even possible), try to make it known that the sexual behavior is unwelcome and unwanted. It is your right to inform the person of your stance and to demand the behavior cease. Though this can be difficult and uncomfortable, it is often the most effective method (2). If you decide to confront the perpetrator, try to remain calm and de-escalate the situation as much as possible.   
• You should be explicit in explaining the behaviors that are unwelcome so that the perpetrator can fully understand his/her actions. If you are uncomfortable confronting the perpetrator, consider confiding in a close friend, coworker, or supervisor who can accompany you or advise you on the next steps. 
• Another way is to interrupt the harasser to distract them from the situation (2) 
• Next, make sure to document the scenario. Write down all of the details that you can recall; including any witnesses. This can be helpful in the future. 
• Reporting the issue through the appropriate channels is the next step. Oftentimes, this involves speaking with your supervisor and someone in human resources. While discussing the situation, do not make excuses for the perpetrator or try to “shrug it off.” 

How or whether you report sexual harassment is a personal choice, and you are not limited. However, you should strongly consider reporting the incident because it could escalate further in the future. The perpetrator may also be sexually harassing others. Every workplace should be free from sexual harassment and many states have laws protecting nurses against workplace sexual harassment, including harassment received from patients and family members. There are several options for reporting sexual harassment, and there are several nuances with jurisdiction and handling of complaints. However, you should not be discouraged from reporting through the appropriate avenues. 

 1. Within your organization.

You may contact your supervisor or human resources representative to report an incident. This is often a more comfortable route for nurses as they may be familiar with these individuals. Your organization should have policies and procedures for handling sexual harassment reports which may include escalation to law enforcement as necessary. This is often the fastest method for reporting. Remember that reporting to your supervisor, ethics officer, or human resources official does not preclude you from reporting to other agencies as appropriate. If you wish to remain anonymous, check with your organization to see if they have a policy that gives you that option. 

2. Law enforcement.

Criminal incidents of sexual harassment may be reported to law enforcement as appropriate. Oftentimes your human resource officer can assist in determining if this is necessary or required by state law. If you ever feel that your physical safety is threatened, do not hesitate to contact law enforcement. 

3. Office of Executive Inspector General (state government employees).

State employees may file a report directly with the OEG. To initiate a report, it is best to contact your ethics officer for guidance. 

4. U.S. Equal Employment Opportunity Commission (EOCC).

Sexual harassment is a violation of section 703 VII. The EOCC is charged with administering this statute and provides another option of relief for those who have experienced sexual harassment. The statute for reporting an offense to the EOCC is 180 days from the date of the incident. Of note, the EOCC may hold employers responsible for taking all steps to create an environment free of sexual harassment and can offer an additional avenue for support. This law may be extended up to 300 days depending in the state laws surrounding sexual harassment (10). 

Whistleblower Protections

Retaliation for reporting sexual harassment is illegal under both federal and state statutes. The U.S. Equal Employment Opportunity Commission prohibits retaliation aimed at employees who assert their rights to be free of harassment (9). 

Concluding Points

• Sexual harassment can take place in many venues and formats. It is broadly defined as any unwanted or unwelcome sexual behavior or advances. 
• Sexual harassment is experienced frequently by nursing professionals due to the nature of their positions. 
• You have a right per federal and state laws to be free of sexual harassment in the workplace. 
• If you experience sexual harassment, you should tell the harasser to stop and report the incident in one of the various methods listed above. Do not forget to document provide a thorough report of the incident. 
• You have a right to report sexual harassment without retaliation per federal laws. 

Connecticut Domestic and Sexual Violence

Introduction   

Each year, more than 10 million men and women in the United States experience physical abuse from an intimate partner. One in three women and one in four men have experienced some form of physical violence from an intimate partner in their lifetime and one in 10 women has been raped by an intimate partner (18). Such experiences have a lasting impact on physical and mental wellbeing, employment and economic status, effects on children who may witness such abuse, and, in severe cases, may even result in death.  

Healthcare professionals are on the front lines of screening and prevention for domestic and sexual abuse and may be able to recognize early signs of abusive relationships, improve client connections to resources, and reduce the overall incidence of acute and long-term injury from abuse. This course aims to educate healthcare professionals on risk factors, signs of abuse, characteristics of abusers, and the role of healthcare in interrupting the abuse cycle.

Defining Domestic Abuse 

The Department of Justice defines domestic violence, or intimate partner violence, as “a pattern of abusive behavior in any relationship that is used by one partner to gain or maintain power and control over another intimate partner.” Violence involving intimate partners accounts for 15% of all crime (18). There are various categories of abuse.  

• Physical 

Physically harming a partner by any manner, including hitting, slapping, shoving, etc. Can also involve denying medical care to someone in need as well as forcing drugs or alcohol use upon someone so as to alter their cognition. 

• Sexual 

Attempted or successful coercion to participate in sexual contact without consent. Includes rape (including within marriage), sexually demeaning, harming genitals, or forcing sexual acts after physical violence.  

• Emotional 

Patterns of chronic criticism, name-calling, or demeaning behaviors that damage a person’s self-worth.  

• Economic 

Use of coercion, fraud, or manipulation to restrict a person’s access to money, assets, or financial information. Or unethically acquiring and/or using someone’s economic resources through exploitation or improper conducting of power of attorney, guardianship, or conservatorship roles.  

• Psychological 

Threats or intimidation, forced isolation, destruction of property.  

• Technological  

Use of technology, such as online platforms, computers, mobile phones, cameras, apps, etc. to threaten, harm, control, harass, stalk, impersonate, or monitor another person (22). 

Each of these categories has its own nuances and examples, but all consist of acts or threats that influence the weaker or subordinate partner. For the purpose of this course, we will mostly cover physical and sexual abuse, but all forms of abuse are valid and many times overlap with each other. Abusers use tactics such as (22): 

• Intimidation 
• Manipulation 
• Humiliation 
• Isolation 
• Fear 
• Coercion  
• Blame 
• Injuries/pain 

Further information about the epidemiology of domestic violence will be covered below, but it is important to note that anyone can become a victim of domestic violence, including people of all races, ages, sexual orientations, and gender identities. People of all socioeconomic and education levels can be affected, and all types of relationships can be involved; including couples who are opposite-sex, same-sex, married, dating, co-parenting, or living together.  

Affected individuals include not only the abused, but also family members (particularly children), coworkers, friends, and other members of the abused person’s community. Frequently witnessing domestic violence as a child increases the risk of becoming a victim of domestic abuse or an abuser in adulthood by demonstrating this as a “normal” way of life (22).

Epidemiology of Abuse 

As discussed above, anyone can be a victim of domestic violence, however there are particular populations who are at an increased risk and more likely to be victimized. Awareness of these demographics is useful for healthcare professionals when trying to detect situations where abuse may be more likely. An overview of domestic violence prevalence for at-risk populations is discussed below. 

Gender 

Women are much more likely to be affected by domestic violence than men.  

• 1 in 3 women has experienced some form of physical violence form an intimate partner, though the severity varies widely. 
• 1 in 4 women has experienced severe intimate partner violence either of a physical or sexual nature, compared to 1 in 9 men.  
• 1 in 7 women have experienced a physical injury from an intimate partner, as opposed to 1 in 25 men.  
• 1 in 7 women has been stalked by a partner to a point where they feared harm; conversely 1 in 18 men have had this experience.  
• 1 in 10 women have been raped by an intimate partner. 
• 72% of all murder-suicides involve intimate partners and 94% of the victims of murder-suicides are women (18). 
• Women are at risk for contraception coercion, where a partner pressures them to become pregnant or tampers with contraception to cause pregnancy (1). 

Pregnant Women 

Pregnant women are particularly vulnerable, and their risk of abuse is higher during this time, further complicating the health risks of abuse. 

• 1 in 6 abused women is first abused during pregnancy 
• Over 320,000 women experience domestic violence during pregnancy annually (14) 

Ethnicity/Race 

Minority race groups are more at risk for experiencing domestic violence. Department of Justice (DOJ) survey data indicates that 51.3% and 17.7% of white women report having experienced physical and sexual violence respectively, while non-white women report experiencing these at 54% and 19.8% respectively (26).  

Among minorities, American Indian and Alaskan Natives are among the most at risk. This group experiences high poverty rates, particularly on reservations, increased drug and alcohol use, and minimal resources for Natives seeking culturally specific shelter or safety from abuse, all of which increases the risk and prevalence of domestic violence, particularly among Native women (26)​​​​ 

• Over 84% of Native women experience some form of violence during their life 
• American Indians are 3 times more likely to be a victim of sexual violence than all other ethnic groups 
• 55.5% of Native women experience domestic violence in their lifetime 
  • 66.6% experience psychological abuse from a partner 
  • Over half have experienced sexual assault (26) 

For the Black community, factors like racist societal and legal structures have created gaps in economic opportunities, education, access to healthcare, and access to safety/resources that puts Black men and women at higher risk of domestic violence than their white peers. Due to stereotypes and inconsistent cultural competence among law enforcement, jurors, and judges, Black victims of abuse are more likely to be arrested and less likely to be believed by the legal system than white victims (13). 

• 45.1% of Black women and 40.1% of Black men experience domestic violence of a physical or sexual nature in their lifetimes 
• 53.8% of Black women and 56.1% of Black men have been victims of psychological abuse in their lifetime 
• 8.8% of Black women have been raped by a partner in their lifetime 
• Homicide involving domestic partners was highest among Black women in 2017, at 2.5 per 100,000 (16) 

Age 

Opposing ends of the age spectrum are both at increased risk of victimization, with teens and young adults as well as elderly people being at higher risk than the rest of the population.  

Teens are at an increased risk due to their inexperience with dating and relationships and susceptibility to peer pressure. They may also feel hesitant to tell an adult about abuse for fear of consequences or punishment. They may not recognize behaviors as abusive right away and may perceive controlling or jealous behaviors as signs of love. Teens who have witnessed repeated domestic violence among parents or other family members may also believe that this is how normal relationships function.  

According to 2023 data, one in 12 high school students report physical violence and one in 12 report sexual violence in a dating relationship (5). 

• 1.5 million high school students are abused in a dating relationship annually (only 33% ever tell anyone about it) 
• 26% of teens are victims of cyber dating abuse; female teens were twice as likely to experience this as male teens 
• 57% of teens report knowing someone who has been physically, sexually, or verbally abused in a relationship (19) 

Older adults are also at an increased risk, often due to impaired physical or cognitive abilities that require them to rely on a caretaker. They may be isolated, with limited social support or without the ability to tell someone what is happening to them.  

• It is estimated more than 10% of older adults who live in communities experience physical, psychological, sexual, or financial abuse from a caretaker 
• Only about 1 in 14 of these incidents are reported 
• A spouse or intimate partner is the perpetrator in 57% of physical abuse, 87% of psychological abuse, and 40% of sexual abuse cases 
• 39% of firearm homicides involving older adults were committed by a domestic partner (21) 

LGBTQ Community

Though it is well-known that members of the Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) community are at increased risk of violence or harm. In the general population, awareness of domestic violence rates for the LGBTQ community is just beginning to rise, as most existing data is based on heterosexual relationships. Emerging data is revealing that people in the LGBTQ community experience domestic violence at equal or greater rates than their straight and cis-gender peers (20).  

*Note: A basic understanding of sex, gender, and sexual orientation is necessary when caring for members of the LGTBQ community so as to offer comprehensive and competent care. These common terms and their definitions are included below for anyone needing clarification.  

Quick Terminology Lesson 

Sex: A label, typically of male or female, assigned at birth, based on the genitals or chromosomes of a person. Sometimes the label is “intersex” when genitals or chromosomes do not fit into the typical categories of male and female. This is static throughout life, though surgery or medications can attempt to alter physical characteristics related to sex.  

Gender: Gender is more nuanced than sex and is related to socially constructed expectations about appearance, behavior, characteristics based on gender. Gender identity is how a person feels about themselves internally and how this matches (or does not match) the sex they were assigned at birth. Gender identity is not related to who a person finds physically or sexually attractive. Gender identity is on a spectrum and does not have to be purely feminine or masculine and can also be fluid and change throughout a person's life.  

• Cis-gender: When a person identifies with the sex they were assigned at birth and feels innately feminine or masculine.  
• Transgender: When a person identifies with the opposite sex they were assigned at birth. This can lead to gender dysphoria or feeling distressed and uncomfortable when conforming with expected gender appearances, roles, or behaviors.  
• Nonbinary: When a person does not feel innately or overwhelming feminine or masculine. A nonbinary person can identify with some aspects of both male and female genders or reject both entirely.  

Sexual orientation: A person’s identity in relation to who they are attracted to romantically, physically, and/or sexually. This can be fluid and change over time, so do not assume a client has always or will always identify with the same sexual orientation throughout their life.  

Types of sexual orientation include: 

• -Heterosexual/Straight: Being attracted to the opposite sex or gender as oneself 
• -Homosexual/Gay/Lesbian: Being attracted to the same sex or gender as oneself.  
• -Bisexual: Being attracted to both the same and opposite sex or gender as oneself 
• -Pansexual: Being attracted to any person across the gender spectrum, including non-binary people 

(11) 

There are elements of domestic violence that are specific to the LGBTQ community. One example is “outing” or threatening to disclose a person’s sexual orientation or gender identity without their consent. Threatening to out someone can be used as leverage or a power dynamic in psychological abuse, and actually outing someone can lead to an increased risk of rejection and physical or sexual harm depending on who the information is revealed to.  

Additionally, members of the LGBTQ community may be afraid to seek help in abusive situations or may even experience discrimination when they do seek help, putting them at greater risk of significant harm. Poorly trained staff, implicit biases of staff, and even gender-specific resources such as women’s shelters can be difficult to navigate for LGBTQ victims (20). Statistics about domestic violence in LBGTQ relationships include the following:  

• 61.1% of bisexual women and 43.8% of lesbian women report experiencing rape, physical violence, or stalking by a domestic partner at some point in their life; compared to 35% of heterosexual women 
• 37.3% of bisexual men and 26% of gay men report experiencing rape, physical violence, or stalking by a domestic partner at some point in their life; compared to 29% of heterosexual men 
• 26% reported experiences of near-lethal violence in male-male relationships 
• Fewer than 5% of all LGBTQ domestic violence victims seek orders of protection 
• Transgender people are more likely to experience domestic violence in a public setting compared to cis-gender individuals 
• Transgender individuals experience unique forms of psychological/emotional abuse such as being called “it” or being ridiculed for physical appearance 
• Bisexual individuals are more likely to experience sexual violence than other sexual orientations 
• Black LGBTQ individuals are more likely to experience physical violence from a partner than other races 
• White LGBTQ individuals are more likely to experience sexual violence from a partner than other races (20) 

Disabled Populations 

Nearly a quarter of all U.S. adults have some type of physical, cognitive, or emotional disability. People with disabilities are particularly vulnerable to domestic violence.  

• Nearly 70% of people who have a disability experience domestic abuse 
• People who have a disability are three times as likely to be sexually assaulted than their non-disabled peers (23) 

People with disabilities relying at least partially on others to function in their daily life are particularly vulnerable to being intimidated, isolated, or controlled by someone they trust (power imbalance). Some 75% to 80% of domestic abuse of people with a physical disability and 95% of abuse of those with a cognitive disability goes unreported. The types of abuse are often unique to the disability as well, including:  

• Invalidation or minimization of disability 
• Shaming or ridiculing for disability 
• Refusal to help with daily tasks such as bathing, dressing, or eating 
• Over or under medicating 
• Sexual acts without consent 
• Denying access to healthcare services/appointments or medications 
• Limiting access to mobility devices such as walkers, wheelchairs, or prosthetics 
• Withholding finances 
• Threatening abandonment (23) 

Certain populations with disabilities are more at risk than others.  

• Women who have a disability:  

• • 80% of women who have a disability report sexual assault 
  • 40% higher rates of domestic abuse  
  • Violence experienced by women with disabilities may be more frequent or of greater severity  
  • More likely to experience reproductive coercion, stalking, or psychological abuse 

• People in the LGBTQ community who have a disability: 

• • LGBTQ facilities may not be accessible for those with disabilities 
  • Disability services may not be competent with issues of the LGBTQ community 

• Black, Indigenous, People of Color (BIPOC) with disabilities:  

• • Increased risk for police brutality 
  • Half of Black people with disabilities have been arrested at least once by age 28 
  • Half of people killed by law enforcement have disabilities (23)​​​​

Geographic Location  

A person’s location also plays a role in the risk of domestic violence, with rural locations and homelessness increasing the risk.  

Twenty percent of U.S. residents live in a rural location (17). U​​​​nique characteristics of rural living increase the prevalence and severity of domestic violence in the following three ways.  

Geographic Isolation 

• 80% of rural counties do not have a domestic violence program 
• >25% of rural communities are more than 40 miles from the nearest domestic violence program 
• Rural communities lack robust public transportation, and many people are without a car 
• Decreased likelihood that a neighbor or community member will see or hear abuse occurring  
• Significantly increased time needed for first responders to arrive after an emergency call 
• Scarcity of housing options, especially of lower cost, make it difficult to leave (17) 

Social/Cultural Barriers 

• Rural regions are often more conservative with traditional gender roles (physical or sexual violence against women may be viewed as “normal”) 
• Physical and sexual violence or assault may be viewed as private matters not to be discussed outside of the home 
• Friends or family may encourage victims to stay in abusive relationships to avoid divorce or for children 
• Women may be shamed or not believed for reporting abuse 
• Small-town gossip or lack of anonymity may keep victims from pressing charges or seeking assistive services 
• Women may be less likely to have a job or financial independence from their partners (17) 

Poor or Impartial Criminal Justice Response 

• Domestic violence may be seen as commonplace and low priority among law enforcement 

• Law enforcement, prosecutors, or judges may have relationships with perpetrators or their families that impede their ability to be impartial 
• Law enforcement may hold a patriarchal sense of loyalty to other men and put that above the safety of women in the community (“Good ol’ boys club” attitude) (17) 

Due to geographic isolation and lack of resources, as well as potential lack of income or financial independence, many victims in rural locations wind up homeless if they leave an abusive relationship. This comes with its own significant struggles and risks and is often not sustainable, leading the victims back to live with their perpetrators rather than continue being homeless, essentially creating a vicious cycle between homelessness and abuse.  

• A 2003 survey revealed 46% of homeless women reported being a victim of physical or sexual abuse in the last year. 
• In 2005, 50% of U.S. cities cited domestic violence as a leading cause of homelessness. 
• Some landlords have a zero-tolerance policy for domestic violence and will either evict or refuse to rent in the first place to victims of domestic violence. This was as high as 28% in a survey in New York City (27)

Socioeconomic Status and Education Level

Though people of any socioeconomic status are susceptible to domestic abuse, those with a low socioeconomic status or education level are at an increased risk. This is in part due to the increased isolation and lack of available resources to people in poverty or with low education. Particularly, women who do not work outside of the home or do not have any professional skills with which to get a job are at risk of being more easily isolated or kept from utilizing resources. Those with lower education levels are also more likely to view physical or sexual violence within a relationship as “normal” and tolerate the abuse without attempting to leave.  

Women with household incomes below $75,000 annually are seven times more likely to experience physical or sexual violence than women whose household incomes are above $75,000 (27). 

There is also a circular relationship between low socioeconomic status and domestic violence, as victims of abuse are both more likely to be poor and also more likely to experience economic loss or financial insecurity due to the abuse. Access to money or work can also be restricted by the abuse as part of the attempt to maintain power and control.  

• Between 21-60% of abuse victims lose their jobs from abuse-related reasons (missing work, distracted or poor job performance, etc.) 
• Domestic abuse victims lose a combined eight million days of paid work annually due to injuries or home conflict (18). 

Immigrants, in particular, may be affected by this as they may be of lower education (or at least unable to fluently speak the language of the new country), often poor or without any assets, and may be unable to work or earn money. They may rely on an abusive partner for money, a place to live, and even communication, keeping them isolated in a relationship that feeds on control/power (25).​​​​

Health Implications of Abuse 

There are many health implications for people in abusive relationships. Acute or short-term injuries are typically physical in nature and include things like (9):  

• Cuts 
• Bruises 
• Broken bones 
• Concussions 
• Burns 

Additionally, only 34% of people who sustained a physical injury from domestic violence sought medical care for those injuries, meaning many may have poorly healed injuries or long-term sequelae from lack of proper treatment (18). 

There are also long-term consequences or chronic health conditions that result from domestic violence, including:  

• HIV or other sexually transmitted infections (STIs) from sexual abuse 
• Bladder and kidney infections  
• Circulatory/cardiovascular conditions 
• Asthma 
• Unintended pregnancy, including teenage pregnancy 
• Chronic pain 
• Arthritis or joint disorders 
• Gastrointestinal disorders or nutritional deficiencies 
• Neurological disorders including migraines and neuropathy 
• Sexual dysfunction (9) 

Mental health effects are also significant with victims experiencing increased rates of:  

• Anxiety 
• Depression 
• Post-traumatic stress disorder (PTSD) 
• Suicidal thoughts and attempts 
• Addiction to drugs or alcohol (9) 

Certain populations, such as individuals in the LGBTQ community, are already at an increased risk for mental health issues and suicidal ideations. Therefore, abused members of this population are at a further increased risk.  

Additionally, victims of abuse may experience social or economic consequences that in turn worsen their overall health through poorer living conditions, nutrition, and access to healthcare. Economic consequences include (9):  

• Interrupted or lost educational opportunities 
• Lost professional opportunities 
• Damage or destruction to property or items of value 
• Medical or legal debt 

Health implications may be dependent on age or situation as well. Among the unique risks are pregnant, very young, and very old victims.  

Abuse during pregnancy can result in intrauterine hemorrhage, preterm labor, or miscarriage. Chronic stress during pregnancy, lack of prenatal care, or trauma to the fetus can lead to long-term health effects of the infant once born (14). S​​​​ome women may also be victims of contraceptive or reproductive coercion, where an abuser pressures them to become pregnant or tampers with their contraception to cause pregnancy. Unwanted pregnancy puts these women into a more vulnerable position to be victims of abuse and the above complications (1).  

Surveys of youth show that 50% of teens and young adults who have experienced dating violence or rape have also attempted suicide compared to 12.5% of youths without a history of abuse (19). Domestic violence also increases the risk of pregnancy and STIs which can have a more extreme and lasting impact on teens, affecting reproductive or sexual health for the rest of their lives.  

For older adults, the risks are increased as well, with elderly victims of abuse having a shorter lifespan than their peers who are not abused. Mental health effects such as depression, anxiety, fear, isolation, loss of self-esteem, and feelings of shame, powerlessness, and hopelessness may be exacerbated because people in this age group are already struggling with a lack of independence or isolation from a social network. Overall, this can reduce quality of life and dignity in an already difficult period of decline (21).  

Exposure to domestic violence, even when not directly victimized, also has a lasting impact on health. Children are particularly vulnerable to witnessing or being exposed to abuse:  

• 1 in 15 children are a witness to domestic violence during childhood (of those, nearly 60% experience maltreatment themselves). 
• Homes with both child maltreatment and intimate partner violence often have more severe levels of abuse.  
• 1 in 5 child homicides between ages 2-14 are related to domestic violence cases (15). 

Children who are exposed to domestic violence may experience acute symptoms such as:  

• Anxiety 
• Aggression 
• Sleep disruption 
• Nightmares 
• Bedwetting 
• Concentration deficits or poor school performance 

Over time, children who are exposed to domestic violence are:  

• 3 times as likely to engage in violent behavior as their peers 
• More likely to be either perpetrators or victims in their own future relationships 
• At greater risk of health conditions like obesity, cancer, cardiovascular disease, substance abuse, depression, and unintentional pregnancy (15)

Perpetrators of Abuse 

It is important for healthcare professionals to not only recognize risk factors for victims of abuse, but also risks for becoming a perpetrator of abuse. Truly mitigating risks and reducing the prevalence of domestic abuse requires recognizing and offering services to victims, but also identifying potential abusers and providing interventions to stop abuse at the source.  

Risk Factors 

The conditions that lead to perpetrators becoming abusers are nuanced and multifaceted, involving individual experiences, past relationships, attitudes of the person’s community, and societal implications (4).  

Individual 

Individual risk factors are based on lived experiences, existing mental health conditions, and individual stressors. Individual risk factors include:  

• Poor self esteem 
• Low education level 
• Young age 
• Problem behaviors in youth 
• Drug or alcohol abuse 
• Depression or anxiety 
• Poor coping or problem-solving skills 
• Poor impulse control 
• Personality disorders 
• Isolation or few friends, small support network 
• Economic stress such as unemployment or low income 
• Hostile/misogynistic attitudes towards women and strict gender role of male dominance 
• Being physically or emotionally abused as a child 

Relationship 

Relationship risk factors are based on the characteristics of the people involved in the relationship and their attitudes and behaviors within the relationship. Relationship risk factors include: 

• Relationships with frequent jealousy, possessiveness, tension, or divorces and separation 
• One partner with clear dominance or control the majority of the time 
• Families undergoing economic stress or low income 
• Network of peers in aggressive or violent relationships 
• Parents with low education levels 
• Witnessing violence between parents during childhood 

Community 

Community risk factors are based on the attitudes and social norms of people in the neighborhoods, workplace, or schools a person is involved in. Community risk factors include:  

• High poverty and low education rates 
• High unemployment rates 
• High crime/violence rates 
• High drug use 
• Low sense of community among neighbors 

Societal 

Societal risk factors are based on the attitudes and political policies where a person lives on a broader scale, including city and state level. Societal risk factors include (4):   

• Emphasis on traditional gender roles (women at home/unemployed/submissive, men work and make family decisions) 
• Cultural norms of aggression 
• Weak education, health, and social policies or support 

Protective Factors 

There are some factors that are protective against becoming a perpetrator of abuse, even for people who may have grown up around domestic abuse. Protective factors include (4):  

• A strong social support network 
• Exposure to strong, positive relationships 
• An involved and neighborly community 
• Available services and resources within a person’s community 
• Access to stable and safe housing 
• Access to medical and mental health care 

The Cycle of Abuse 

In addition to recognizing who may become or be an abuser, it is important to understand and recognize the pattern or cycle of abuse and how perpetrators maintain control in the relationship. While each abuse scenario is unique, the overall patterns are the same and exist in a cycle which may progress quickly or over longer stretches of time. The four main stages are tension, incident, reconciliation, and calm (10). 

Tension Phase 

During the tension phase, there is a slow increase in the frequency and intensity of irritability, short temper, emotional outbursts, and impatience. There may be external factors such as life stressors, financial strain, work struggles, etc. that make the abuser feel out of control, adding to this rising tension. Victims may report “walking on eggshells” during this time, as they feel the tension build (10).​​​​ 

Incident Phase 

Once the tension builds to a breaking point, one or more abusive incidents will occur. Abuse perpetrators do not have an “anger problem” as they are able to control their emotions in places like work, school, or in public. The anger and aggression displayed by a perpetrator is an intentional use of power to regain or maintain control over the weaker partner in the relationship. Incidents can look like (10):  

• Intimidation 
• Threats 
• Physical violence 
• Sexual violence 
• Verbal violence (insults, name calling) 
• Shaming/humiliation 
• Blaming 
• Social isolation 
• Manipulation 

• Financial abuse 
• Emotional abandonment  

Abusers can use many methods of violence and a variety of tactics within each of those methods. The ultimate goal of all behaviors is to maintain control over the victim and remain in a position of power. Figure 1 below provides examples of specific behaviors within each type of violence.  

Figure 1. Domestic Abuse Intervention Programs (3) 

Reconciliation Phase 

Once the incident is over, the perpetrator feels a relief of tension, though the victim likely is at peak anxiety. The abuser may seem to show remorse in the form of apologies, affection, or promises to never become violent again. Victims are often willing to give abusers another chance during this stage because they seem to show genuine remorse or intent to reform (10).​​​​ 

Calm Phase 

Next the relationship moves into a calm phase where the perpetrator’s remorse dissipates, and they may begin to dismiss the incident by shifting blame or saying things like “it wasn’t really that bad.” For the victim, this can be confusing or feel like a letdown when the abuser’s previous intent to make changes fades. This eventually shifts back into rising tension and the cycle repeats itself (10).​​​​ 

Role of the Healthcare Professional in Abuse 

Given all of this knowledge about who is at risk and what goes on in an abusive relationship, you may be wondering how healthcare professionals can help or what your role entails. The responsibility of the healthcare professional lies in a few main areas of identifying and handling abuse situations.  

Risk Identification 

One of the first steps in disrupting the abuse cycle is identifying those most at risk. Part of this is through knowledge of risk factors and vulnerable populations and signs of abuse, as already covered in this course. Another means of identification is through routine screening of certain populations. Unfortunately, there is a limited number of screening tools available, and tools are almost exclusively targeted at women of reproductive age. Available tools assess for domestic abuse within the last year; there is no recommended appropriate interval to administer screening and it is at the provider’s discretion, though at least annually is typical (24). S​​​​ome examples of available screening tools include: 

• HARK (Humiliation, Afraid, Rape, Kick): A four-question tool that assesses emotional and physical violence 
• HITS (Hurt, Insult, Threaten, Scream): A four-item tool that assesses the frequency of domestic violence 
• E-HITS (Extended version of HITS): Includes an additional question to assess the frequency of sexual violence 
• PVS (Partner Violence Screen): A three-item tool that assesses physical abuse and safety 
• WAST (Women Abuse Screening Tool): An eight-item tool that assesses physical and emotional abuse from domestic partner (24)​​​​ 

The above screening tools are well studied in women and have been shown to be effective. Currently, there is a lack of studied and effective domestic violence screening tools in the primary care setting, especially for teens, men, clients in the LGBTQ community, and the elderly. More work is needed in this area. Even for women, screening is not often conducted outside of the obstetrics/gynecology (OB/GYN) setting (24).​​​​ 

Simply asking “Do you feel safe at home?” or “Is there any history of violence in your home?” is also a basic way to cast a wide net among large volumes of patients and reduce the chance of domestic violence going unnoticed. Asking questions like these on admission in the emergency department (ED) or hospital, or during the intake process for office visits can easily be implemented as part of facility policy. Many offices or hospitals will also have signs up in bathrooms, changing areas, or exam rooms that encourage clients to disclose abuse in a confidential and safe way during their visit (24).​​​​  

Screenings of any kind are most effective when the client is separated from their partner, even briefly. If the abuser is with them, they can be asked to step into the waiting room or, if it is necessary to be more subtle, clients can be asked to leave the room for something inconspicuous, like providing a urine sample, and then lead to a separate room for further, private discussion (24).  

Appropriate Response 

Timely referral to appropriate ongoing services has been shown to reduce physical and mental harm from violence and abuse. When domestic violence has been disclosed or a screening has come back positive, the attitudes and behaviors of the healthcare professional are important and can have a big impact on the client’s feelings about their care. Appropriate and sensitive behaviors include:  

• Listening to clients actively and objectively 
• Believing the client 
• Validating the client’s feelings and fears 
• Avoiding asking “why” questions or placing blame like “Why didn’t you call the police?” or “Why do you stay?” 
• Respecting a client’s decision to stay or leave 

Plan of Action 

Interventions and next steps include (6):  

Gathering Additional Information 

• Getting a detailed history 
• Assessing symptoms 
• Taking photographs if necessary (bruise patterns, burns, cuts, etc.) 

Assessing Safety 

• Verbal/physical threats 
• Weapons in the home 
• Frequency of violence 
• Children or others in the home 

Develop a safety plan together with client 

• Signs of rising tension 
• Who to call or where to go 
• Available resources in community 

Provide referrals as desired by client 

• Police (for order of protection or to press charges) 
• Hotlines 
• Shelters 
• Counseling 

Documentation and Reporting 

​​Appropriate documentation of abuse, including detailed history, exam, and any pictures, as well as a safety plan and any resource connection should be included in the client’s chart​.​​ Laws about mandated reporting vary by state and healthcare professionals may need to report the documented abuse to authorities. ​​​​​​ 

​​​​In Connecticut, there is no requirement to report domestic violence or abuse. Mandated reporting is reserved for abuse of children, disabled people, residents of long term care facilities, the elderly, and healthcare professionals who are impaired or negligent (8). ​​​ 

​​​​For situations which must be reported, the report must be made within 12 hours of when a clinician first suspects abuse or becomes aware of an abuse situation. Reports may be made through the Connecticut State Department of Public Health which has various resources and care lines depending on the type of suspected abuse being reported. Examples can be found in the table below (8). ​​​ 

​​​​​​​ 

​​​​​ 

If you are required to report an incident, it is best to notify the client prior to reporting so that they are aware and prepared and can utilize their safety plan if they feel this will anger the perpetrator (6).​​​​ 

Counseling/Therapy 

When considering counseling, individual therapy is always recommended and beneficial, but it is important to note couples therapy may be contraindicated. If the goal is to maintain the relationship and address abuse cycles, couples therapy should be approached cautiously as this type of treatment may increase the abusive behaviors. Couples therapy may elicit a different viewpoint or information about the relationship that threatens the abuser's desire for control and may increase anger, minimization of abuse, or victim blaming as the abuser now has to work harder to maintain control. This can increase abusive behaviors outside of therapy sessions and put the victim at greater risk.  

There is some evidence to suggest couples therapy can be helpful in breaking abuse cycles, but it should only be undergone with an experienced therapist with special knowledge of how to identify and address abuse in a manner that does not exacerbate the abuse (​12​​     ​).  

Follow Up 

Often domestic violence reoccurs and increases in frequency or intensity over time. Up to 75% of clients reporting domestic violence will continue to experience abuse. This can be frustrating for healthcare professionals, but it is important to remember that your role is to document the abuse, provide resources to clients, report when required, and not judge or verbalize opinions on what clients should do (2).  

Appropriate follow up for healing wounds or injuries should be scheduled. Information about local domestic violence resources should be provided at each visit with clients. If a client does leave an abusive relationship, it is important to continue screening for violence as they may return to the relationship and are at an increased risk of entering new relationships that are also abusive (2). 

Community Outreach 

​​Healthcare professionals can have an impact on domestic violence in broader ways that direct client interactions as well. Advocacy on a community level can help increase awareness, shift harmful societal views on domestic violence, and create more robust community resources. ​Places where healthcare voices can help shift the narrative on domestic violence include (6): ​​ 

• Parent Teacher Association (PTA) members 
• Church members 
• Community leadership positions 
• Social clubs 
• ​​Political/voter groups​​​ 
• ​​​Connecticut Coalition Against Domestic Violence (CCADV) ​​​​ 

​​​Nursing Education​​ 

​​​RNs with a Connecticut license must apply for renewal every 6 years. They are not required to obtain CEUs specific to domestic or sexual violence for license renewal, though the topic is strongly recommended as these issues can impact clients across a variety of demographics and in many different healthcare settings. Required topics for license renewal include screening for PTSD, depression, and risk of suicide, and training for suicide prevention (7). ​​​​​​ 

​​​​Connecticut APRNs must complete 50 hours of ​​continuing​​ education every 2 years and are required to complete at least 1 hour each on the topics of sexual assault and domestic violence. Having compassionate, ​​knowledgeable​​, and competently prepared providers in delicate situations such as abuse, or violence can increase client safety and improve overall health outcomes (7). ​​​​​ 

Case Studies 

Kimari’s Case 

Kimari is a Black, 22-year-old pregnant woman who presents to the OB clinic for a second trimester visit with complaints of abdominal pain. Kimari’s partner accompanies her to the visit today and the nurse notes that Kimari is unusually quiet and withdrawn compared to her previous visits. Her partner is answering most of the nurse’s questions for her. The nurse asks him to step into the waiting room so Kimari can change into a gown. Once he is gone, the nurse administers the HITS screening tool and opens a discussion with the client. Kimari reveals that her partner had been emotionally abusive in the past but never physically. However, since she has become pregnant, the abuse has worsened and has started to include forced sexual activity and physical violence. She admits her abdominal pain today is due to him shoving her down the stairs in the house the day before.  

The nurse sits with Kimari and listens to her description of the events of the last few weeks. At this time, she wants to stay in the relationship as she does not have anywhere else to go and also has a two-year-old at home to think about. She is interested in individual counseling and develops a safety plan with the nurse which includes hotlines and local resources, as well as a plan to go to her sister’s house if tension seems to be rising again.  

A physical exam reveals a healthy pregnancy with normally developing fetus and no complications from the fall down the stairs. The information from today’s visit is documented in her record and a follow-up appointment is scheduled for the following month.

Kevin’s Case 

Kevin is a 28-year-old gay man presenting to the family practice clinic for an annual wellness visit. Kevin’s provider conducts a thorough physical assessment, orders labs, and administers screening tools for anxiety and depression. Kevin is found to be in good health but does score moderately high on his depression screening. The provider caring for him recommends individual counseling and offers an antidepressant which Kevin accepts. He is scheduled for a follow up in one month and the visit concludes.  

Kevin returns home where he lives with an emotionally abusive husband. When Kevin reveals that he was given a prescription for an antidepressant, his husband ridicules him and calls him “crazy” and “weak.” They get into an argument and Kevin’s husband slaps him.  

Later that evening, Kevin’s husband finds him unresponsive but still breathing in the bathroom with what appears to be an attempted overdose. He calls 911.

Conclusion 

Domestic violence, particularly physical and sexual abuse, is a problem with far-reaching consequences that affects people of all demographics. Identification of those most at risk, early intervention, and connection to resources, as well as prompt treatment of acute injuries and health implications are all important components in reducing the tragic impact of domestic violence. Healthcare professionals in all settings may encounter abuse situations and should be up to date on best practices for screening and management of these cases. Hopefully upon completion of this course, healthcare professionals will feel confident in their role in supporting victims.

HIV/AIDS

This course fulfills the continuing education requirement for the District of Columbia on HIV/AIDS. 

Introduction and Objectives  

An estimated 1.2 million Americans are living with HIV. As many as 1 in 7 of them do not even know they are infected. The others utilize the healthcare system in a variety of ways, from testing and treatment regimens to hospitalizations for symptoms and opportunistic infections. Healthcare professionals in nearly every setting have the potential to encounter patients with HIV as the disease can affect patients of any age or stage of life (4). Proper understanding of HIV is important in order to provide high–quality and holistic care to these patients.

Upon completion of this course, the learner will:  

1. Have an increased understanding of the history of HIV and how stigma around the disease developed and is being combated today.
2. Demonstrate an understanding of how a person is infected with HIV and the various stages of the disease.
3. Demonstrate understanding of transmission modalities and appropriate infection control measures.
4. Have a basic knowledge of treatment approaches, common side effects, and barriers to proper treatment.
5. Understand comorbidities and coinfections common with HIV.
6. Understand ethical issues and confidentiality surrounding the care of HIV patients.

Epidemiology 

In the early 1980s, a series of unusual and aggressive illnesses began popping up in clusters across the United States, affecting previously healthy men. Illnesses such as pneumocystis pneumonia, Kaposi‘s sarcoma, and severe wasting, all related to unexplained immunodeficiency, were suddenly rapidly increasing in prevalence, and the only common link seemed to be that it was occurring in gay men. By 1982, the term Acquired Immune Deficiency Syndrome (AIDS) was being used to describe a “moderately predictive…defect in cell–mediated immunity,“ but the details of disease trajectory and how men were contracting it were still foggy (2). 

Over the next several years, cases continued to rise, and women and children began presenting with the disease, bringing scientists to the realization that it could be contracted through more ways than just homosexual sex. Amid the social panic, the retrovirus responsible was identified and named Human Immunodeficiency Virus, more reliable testing developed, and various other modes of transmission (like needle sharing, contaminated blood products, childbirth, and breastfeeding) were recognized. By 1989, less than a decade after the first cases were garnering attention, 142,000 cases were reported by 145 countries worldwide (2).  

Over the next several decades, more and more information was discovered about HIV and AIDS, and scientists and legislators worked hard to understand and reduce transmission, increase quality and duration of life for those already infected, and fight the stigma and discrimination that had developed during the 1980s (2).  

Today, approximately 1.2 million people in the United States are living with HIV, though 1 in 7 people don‘t know it. Rates of infection are not equal across demographic groups, and certain factors may increase a person‘s risk (10). Patient information to consider when determining someone‘s risk includes:  

• Age: As of 2018, the age group with the highest incidence of new HIV diagnoses is 25-34 years or approximately 36% of new infections. Ages 13-24 are next, though the numbers in this age range are coming down in recent years. From there, the risk seems to decrease as people age, with the 55 years and older group accounting for only around 10% of new diagnoses each year (10).  
• Race/Ethnicity: Currently, the highest rate of new infections is in African Americans, at approximately 45%. This is incredibly high when you consider that African Americans only make up 13% of the general population. This is followed by Hispanic/Latinos at 22% of new infections and people of multiple races at 19% (7).  
• Gender: Men are disproportionately affected by HIV, accounting for five times the amount of new infections as females each year. This data refers to the sex of someone at birth. When looking at the transgender population, there is a nearly equal rate of new infections among those who have transitioned male-to-female and female-to-male. Together, transgender people account for 2% of new cases in 2018 (7).  
• Sexual orientation: Gay and bisexual men remain the population most at risk of HIV, accounting for around 69% of all new infections in 2018 and 86% of all males diagnosed. Similar racial and ethnic disparities affecting all people with HIV still existed among gay and bisexual men (7).  
• Location: Different areas of the country are affected at different rates for a variety of factors, including population density, racial distribution, and access to healthcare. The southern states are unmistakably more affected than other regions, with anywhere from 13-45 people per 100,000 having a diagnosis of HIV. California, Nevada, New York, and D.C. all having similar rates of infection as the southern states and are among the highest in the country. The Midwest and Pacific Northwest are next most affected, with 9-13 people per 100,000. The Northeast and Northwest have the lowest rates nationally at just up to 5 people per 100,000 (7). 

While the effects of HIV and AIDS have resulted in a staggering 32 million deaths worldwide since the start of the epidemic, global and national numbers indicate that it peaked around 2005. Numbers of infections and deaths have been on a slow decline since then, mostly due to earlier and more accurate diagnosis, increased knowledge of how to prevent transmission, and effective and accessible treatments. An estimated 65% of Americans currently diagnosed with HIV are considered “virally suppressed,“ demonstrating that adherence to treatment guidelines means most infected people have virtually no risk of transmitting the virus to their partners and have a life expectancy nearly the same as non-infected people (6).  

HIV/AIDS’s financial impact is also significant, with an estimated $380,000 spent throughout an individual‘s lifetime with the disease. In 2009, it was estimated that $16.6 billion was spent on HIV treatment in the U.S. alone. However, federal prevention programs do more than improve health outcomes and decrease the number of new infections; they also claim financial benefits and saved approximately $129 billion in the last two decades by averting new infections.  

The Ryan White Program is notable and has been in place since 1990. It is a significant source of expanded coverage and funding for patients living with HIV who cannot afford health insurance or proper treatment. This safety net program is federally funded and named after a teenager who died from AIDS after receiving an HIV–contaminated blood transfusion. Ryan‘s story was also a turning point in the public perception of the disease, and the program helps fight the stigma surrounding HIV today (5). 

Etiology and Pathogenesis 

So just what is this virus that can cause so much devastation but took scientists years to understand? HIV is a type of retrovirus known as lentiviruses; these viruses have long incubation periods and lead to chronic and deadly infections in mammals. Studies indicate that the virus may have first infected humans hunting and eating the meat of infected chimpanzees in central Africa as early as the late 1800s. Once the virus jumped to humans, it spread slowly over many decades and across countries before picking up steam and attracting attention in the United States in the 1980s (7).  

Once a host has been infected, the virus seeks out, attaches to, and enters CD4-T cells, immune cells largely responsible for attacking and clearing pathogens in the body. Once inside the cell, viral mRNA (or genetic code) directs the cell to become a factory of more HIV virions, which are then released through a process known as budding. Those virions travel through the body, enter other CD4-T cells, and produce more viruses in a slow but deadly cascade. As part of the body‘s defense against such pathogens, CD4-T cells are programmed for apoptosis (cell death) upon being taken over by a host. Others will experience cell death due to close proximity to infected cells. Still, others will be killed by other types of immune cells. While HIV ravages the body and continues to rise in viral load, the number of CD4-T cells will drop lower and lower until, eventually, the body‘s cell-mediated immunity is no longer viable. Without cell-mediated immunity, opportunistic infections and cancers can take over, and the infected person progresses from HIV infection to full–fledged AIDS (12). 

Typically, the disease progresses in 3 stages.  

• Stage 1 is acute HIV infection. The virus is reproducing rapidly, and affected individuals may experience flu–like symptoms, including fever, chills, headache, and fatigue. Not everyone experiences symptoms during Stage 1, but all are highly contagious during this period.  
• Stage 2 is Chronic HIV infection; viral replication slows, and this stage can last for many years. A person in this stage is still contagious, but they may have no symptoms. Proper use of medication treatment may mean an infected person never moves past this stage.  
• And finally, if the viral load continues to increase and the CD4-T cell count gets below 200 cells/mm, the illness transitions to Stage 3, AIDS. In this stage, even minor opportunistic pathogens can make a person very ill due to the lack of a properly functioning immune system. Symptoms and infections such as thrush, pneumonia, peripheral neuropathy, and Kaposi sarcoma are common. Stage 3 is very contagious and life expectancy is about 3 years if left untreated (7). 

Transmissibility

Perhaps the most elusive part of this virus for many years was how it spreads. We now know that HIV is spread only through certain bodily fluids. An accurate understanding of HIV transmission is important for healthcare professionals to provide proper education to their patients, reduce misconceptions and stigmas, and prevent transmission and protect themselves and other patients (11). 

Bodily fluids that can transmit the virus include: 

• Blood 
• Semen and pre-seminal fluid 
• Rectal fluid 
• Vaginal fluid 
• Breastmilk 
• Fluids that may contain blood such as amniotic fluid, pleural fluid, pericardial fluid, and cerebrospinal fluid 

If one of these fluids comes in contact with a mucous membrane such as the mouth, vagina, rectum, etc., or damaged tissue such as open wounds, or is directly injected into the bloodstream, then transmission of HIV is possible (11). 

Scenarios where transmission is possible include: 

• Vaginal or anal sex with someone who has HIV (condoms and appropriate treatment with antivirals reduce this risk) 
• Sharing needles or syringes with someone who has HIV 
• Mother-to-child transmission during pregnancy, delivery, or breastfeeding (appropriate treatment during pregnancy, c-section delivery, and alternative feeding methods reduce this risk) 
• Receiving a transfusion of infected blood or blood products (this is very rare now because of screening processes for blood donations) 
• Oral sex with someone who has HIV (though this is very rare) 
• A healthcare worker receiving a needle stick with a dirty sharp (risk of transmission is very low in this scenario) 

HIV cannot be transmitted via: 

• Saliva 
• Sputum 
• Feces 
• Urine 
• Vomit 
• Sweat 
• Mucous  
• Kissing 
• Sharing food or drink 

Reducing Transmission 

Patient education about risk and protection against HIV, testing, and what to do if exposed should be standard practice for healthcare professionals in nearly all healthcare settings. Primary care should include risk screenings and patient education routinely to ideally help prevent infections from even occurring or catch those that have occurred early on in the disease process (11). 

Strategies include: 

• Identifying those most at risk, incredibly gay or bisexual men, minority patients, and those using drugs by injection 
• Ensure patients are aware of and have access to protective measures such as condoms and clean needle exchange programs 
• Provide routine screening blood work for anyone with risk factors or desiring testing 
• Providing access to PrEP medications where indicated (discussed further below) 
• Staying up to date on current CDC recommendations and HIV developments 
• Maintaining a nonjudgmental demeanor when discussing HIV with patients to welcome open discussion (11) 

For patients with a repeated or frequent high risk of HIV exposure, such as those with an HIV+ partner or those routinely using IV drugs, pre-exposure prophylaxis (PrEP) may be a good choice to reduce the risk of them contracting the virus. When used correctly, PrEP is 99% effective at preventing infection from high–risk sexual activity and 74% effective at preventing infection from injectable drug use. Depending on the type of exposure risk (anal sex, vaginal sex, needle sharing, etc.), PrEP needs to be taken anywhere from 7-21 days before it reaches its maximum effectiveness. Most insurances, including Medicaid programs, cover PrEP at least in part. There are also federal and state assistance programs available to make PrEP available to as many people who need it as possible. Some side effects are commonly reported, primarily G.I. symptoms, headaches, and fatigue (11).  

For those who have a confirmed diagnosis of HIV/AIDS, the focus should be promoting interventions that will prevent further transmission. One of the biggest determinants for transmission is the infected person’s viral load. Individuals being treated for HIV can have their viral load measured to ensure viral replication is being controlled as intended. A viral load lower than 20-40 copies per milliliter of blood is considered undetectable, meaning the virus is not transmissible to others. Even for those not receiving treatment, there are methods to reduce transmission (11). 

Important considerations for transmission in patients who are HIV+ include: 

• Referral for treatment and educating on the importance of treatment compliance in order to keep the viral load as low as possible 
• Education on the importance (and possible legal consequences) of proper disclosure to any sexual or needle–sharing partners who may be at risk of exposure 
• Encouraging and assisting with access to condom use and clean needle programs 
• Providing information to HIV+ pregnant women about how interventions such as proper treatment during pregnancy, c-section delivery, and formula feeding can keep the risk of transmission as low as 1% (11) 

Methods of infection control for healthcare professionals include: 

• Universal precautions when handling any bodily fluids 
• Eyewear when at risk for fluid splashing 
• Careful and proper handling of sharps 
• Facilities having a standard plan in place for potential exposures 

If exposure or needlestick do occur for healthcare professionals, the patient would ideally submit to testing for HIV to determine if the staff member is even at any risk. If the HIV status of the patient is unknown or confirmed to be positive, four weeks of post–exposure prophylaxis (PEP) may be advised within 72 hours of exposure (11).  

PEP is meant for emergency use only, such as for healthcare workers with a potential exposure or patients with an exposure that is not expected to become routine. PEP is not meant to replace the use of PrEP or other preventative measures. In order to be effective, PEP must be started within 72 hours of the potential exposure and must be taken for a 28–day course of treatment. When used correctly, it is highly effective and typically well–tolerated, with nausea being the most common side effect. For healthcare professionals taking it due to workplace exposure, your facility should cover the cost. For patients in the general population, insurance will usually cover it, or there are assistance programs available to make it affordable for everyone (11). 

Treatment Considerations

When HIV is appropriately treated, advancement from HIV to AIDS can be significantly reduced, and quality and longevity of life maximized. In 2018, the CDC estimated around 65% of all U.S. citizens living with HIV were virally suppressed, and 85% of those receiving regular HIV–related care were considered virally suppressed. However, an estimated13% of all HIV cases do not know they are infected. Appropriate medical care and keeping viral loads undetectable is one of the single most effective methods of preventing transmission (4, 6).  

For those receiving treatment, a multifaceted and individualized approach can reduce a person‘s viral load, reduce the risk of transmission, reduce the likelihood of developing AIDS, and preserve the immune system. Regardless of how early someone receives treatment, there is no cure for HIV, and an infected person will be infected for life. All individuals diagnosed with HIV (even asymptomatic people, infants, and children) should receive antiretroviral therapy or ART as quickly as possible after a diagnosis of HIV is made. There are seven different classes of antiretroviral medications that disrupt various points in the viral replication process. Most treatment regimens use several of these medications combined with the most effective results; some combination pills are also available for administration ease. Medication regimens are chosen based on a patient‘s health status and history, tolerance or sensitivity to medication, and stage and severity of HIV infection. Patient condition and viral load should be monitored closely, and changes or inadequate response to treatment may indicate the need for a change in medication regimen at any time (1). 

The classes and available medications for ART include (1): 

Nucleoside reverse transcriptase inhibitors (NRTIs): these inhibit the transcription of viral RNA to DNA 

• Abacavir (Ziagen) 
• Emtricitabine (Emtriva) 
• Lamivudine (Epivir) 
• Tenofovir disoproxil fumerate (Viread) 
• Zidovudine (Retrovir) 

Non-nucleoside reverse transcriptase inhibitors (NNRTIs): these inhibit the transcription of viral RNA to DNA 

• Doravirine (Pifeltro) 
• Efavirenz (Sustiva) 
• Etravirine (Intelence) 
• Nevirapine (Viramune, Viramune XR) 
• Rilpivirine (Edurant) 

Protease inhibitors: inhibit the final step of viral budding 

• Atazanavir (Reyataz) 
• Darunavir (Prezista) 
• Fosamprenavir (Lexiva) 
• Ritonavir (Norvir) 
• Saquinavir (Invirase) 
• Tipranavir (Apitvus) 

Fusion inhibitors: prevent the virus from fusing with CD4-T cells 

• Enfuvirtide (Fuzeon) 

Integrase strand transfer inhibitors (INSTIs): these stop HIV from inserting its DNA into cells 

• Dolutegravir (Tivicay) 
• Raltegravir (Isentress, Isentress HD) 

Chemokine receptor antagonists (CCR5 antagonists): prevent the virus from binding to CD4-T cells 

• Maraviroc (Selzentry) 

Entry inhibitors: prevent the virus from binding to and entering cells 

• Ibalizumab-uiyk (Trogarzo) (1) 

These types of medication do not come without side effects or complications. Most side effects fit into a few major groups and may be bothersome but are not life–threatening or serious. More Serious or worrisome adverse effects may occur, and a patient‘s current health status, as well as medical history or existing conditions, should be carefully considered (3). The common categories of adverse medication reactions include:  

• Gastrointestinal: Nausea, vomiting, diarrhea, decrease in appetite, reflux, constipation, damage to liver or pancreas 
• CNS: Headache, dizziness, sleep disturbance, neuropathy, memory problems, hearing impairment or tinnitus 
• Hematological: Anemia, hematuria, hyperbilirubinemia  
• Psychological: Mood swings, anxiety, depression, confusion, nightmares/vivid dreams 
• Dermatological: Rash, face discoloration, pruritus 
• Musculoskeletal: Body aches, abnormal fat distribution 
• GU: Menstrual cycle disruption 

Due to the need to take medications for the rest of one‘s life and the long list of potentially bothersome side effects, medication adherence is a common issue in treating HIV appropriately (3).  

There are several scenarios that increase the likelihood of poor compliance, including:  

• Asymptomatic patients, since side effects of medications, maybe unpleasant and they are in a latent phase of disease without symptoms  
• Young patients, including children or teenagers who may not understand the necessity of taking daily medications and face a lifetime of treatment 
• Patients with substance abuse or mental health issues, as they may be in and out of cognitive and psychiatric crises 
• Poor literacy or education level, as these patients may be easily confused by a complicated medication regimen or simply not understand the importance of lifelong therapy, especially if they are feeling well 
• Social stigma, which may lead people to try and hide medications or not want their diagnosis to be discovered (3) 

Care Considerations for Comorbidities and Coinfections

Caring for patients with HIV or AIDS is a complicated task requiring compassion, patience, and understanding the many potential complications and ways that various body systems are affected. Many infections and comorbidities commonly present alongside HIV/AIDS, particularly as patients age, immune function declines, and effects of long-term medication use develop. The social stigma and psychological impact of such a devastating disease must also be considered to provide holistic care to these patients (9). Common coinfections/comorbidities include:  

Tuberculosis

T.B. is a highly contagious airborne illness that affects the respiratory system. It is an opportunistic infection that frequently affects people with weakened immune systems, like those with AIDS. The bacteria can live in the body without causing symptoms in a latent phase for long periods. As the immune system in HIV weakens, a latent T.B. infection may become active, causing symptoms and deteriorating health. Most common symptoms include cough, hemoptysis, fever, fatigue, night sweats, or poor appetite, and weight loss. Seriously immunocompromised people may even experience disseminated T.B. where the infection affects more than the lungs and can even lead to septic shock and death. Annual PPD tests for T.B., or chest X-ray for anyone with a history of positive PPD, should be conducted on patients with HIV (9).  

Hepatitis

About 1 in 10 people affected by HIV will also have viral hepatitis, as the diseases are spread in much the same way, particularly needle sharing and sexually and vertically (mother to fetus). Hepatitis infections progress quickly in immunocompromised patients and can greatly reduce liver function, which complicates the use of ART medications and can result in poor clearance from the body. All new HIV diagnoses should be screened for Hepatitis A, B, and C, and Hep A and B vaccines should be encouraged in unvaccinated patients (9).  

STIs

Because HIV can be acquired via high–risk sexual activity, infection with other STIs is common. Sometimes, other STIs may even increase the risk of contracting HIV as they result in open sores or breaks in the skin where HIV can more easily enter. Bacterial STIs can typically be cured with antibiotics, but other viral STIs like Herpes and HPV do not have a cure. Routine screening for patients engaging in high–risk sexual activity or those already infected with HIV should be a typical part of care (9).  

Cardiovascular Disease

Studies show that patients with HIV also increase inflammation of the arteries and plaque formations throughout the body due to a complicated effect on macrophages. Some of the ART medications also increase the risk of heart attack or stroke. Concurrent infection with hepatitis can increase cholesterol, which further deteriorates cardiovascular health and increases MI or stroke risk. Patients with HIV should be screened for family history and current heart health, and their plan of care should incorporate ways to reduce risks, including a focus on diet and activity level (9)l.  

Osteoporosis

Bone density has been shown to decrease faster than normal in patients receiving ART medications, and it is recommended that patients over age 50 have annual bone density scans to estimate fracture risk. Treatment for osteoporosis should be added to the plan of care as needed (9).  

Cancer

As science has become better equipped to detect and treat HIV and concomitant infection, cancer has remained a leading cause of death for HIV patients and is a considerable risk for those living with the disease. Most commonly, cancers of the head and neck, anus, lungs, liver, and lymph system occur. Smoking cessation, regular pap tests for women, HPV vaccines, and routine screenings like colonoscopies after a certain age should be heavily counseled in HIV patients to reduce their risk further. Earlier and consistent ART has been shown to reduce the risk of developing cancer (9).  

Mental Health Issues

When considering the long–term and eventually fatal nature of this disease, along with the social stigma and complicated and expensive treatment regimens, it is no surprise that mental health disorders such as anxiety and depression are common for patients with HIV. Upwards of 22% of patients with HIV will suffer from depression, likely higher when you account for substance abuse disorders. In addition to assessing and treating body systems affected by the virus, it is important to screen patients for psychiatric disorders and be aware of the negative effects the diagnosis may be having on mental health. Medication treatment and therapy should be included in care where appropriate (9). 

Ethical Concerns

Maintaining confidentiality under HIPAA laws is essential in the care of patients with any diagnosis, but the social stigma attached to HIV infection–in addition to the frequency and intensity of medical care needed and the responsibility to notify partners and prevent further spread–makes confidentiality particularly challenging with many ethical considerations to navigate.  

The first issue with maintaining confidentiality occurs with testing itself. HIV is considered a reportable disease. Any positive results must be reported to a local health department and then on to the CDC for local and national statistics and to initiate follow–up with the positive person and provide education on the next steps. Patient names and identifying information are included with the positive result when reported to local and state health departments but is removed before it is reported to the CDC. There is an option for anonymous testing where patients are given a special identification number, and their names and identifying information are not included. These are often self–administered tests and are not available everywhere (8).  

Testing for HIV requires informed consent, meaning healthcare professionals must discuss the risks, benefits, and potential consequences of testing for HIV and cannot test someone for HIV without their consent. Minors’ ability to get testing and treatment for HIV without a parent or guardian’s consent varies from state to state (8).   

Once someone tests positive for HIV, the issue of disclosure presents itself. Patients need to inform their past and future sexual partners or anyone they share needles with of their HIV status. Health departments will help contact tracing and notifying past partners and help those potentially exposed with their testing and prophylactic treatment options. In some states, it is considered a criminal offense to withhold a positive infection status when a person may be exposing others. However, the responsibility to disclose falls on the patient, and healthcare professionals may not notify potential contacts without a patient‘s consent. Infected persons are not required to inform friends, family, employers, or others who are not at risk of contracting the disease (8).  

Employers who provide health insurance for their employees may be given information about the costs and benefits of disclosing an HIV diagnosis indirectly. So while insurance companies cannot directly tell an employer about an HIV diagnosis, employees should be aware the information may come out indirectly. However, all workers with HIV are protected under the Americans with Disabilities Act. As long as they can complete their job duties, employers may not discriminate against them (8). 

Finally, and of particular importance for healthcare professionals, is navigating the stigma or negative stereotypes that often accompany an HIV diagnosis. There are some societal misconceptions that HIV infections only occur as a result of immoral or taboo behavior or that those infected should be treated differently or avoided. People with HIV may have internalized these harmful stereotypes and feel a sense of shame around their diagnosis. It is important for healthcare professionals to understand that these stereotypes are untrue and harmful, but to provide non–judgemental and compassion that preserves dignity and views the patient as more than their diagnosis.  

Conclusion 

Professionals in any healthcare setting may encounter patients with HIV or AIDS. A basic understanding of this disease’s many considerations is fundamental to ensure that quality and compassionate care is being provided. Understanding the disease, treatments, and the unique struggles of these patients can significantly impact their healthcare experiences and promote quality of life.  

Controlled Substances

Introduction   

Pain is complex and subjective. The experience of pain can significantly impact an individual's quality of life. According to the National Institute of Health (NIH) (40), pain is the most common complaint in a primary care office, with 20% of all patients reporting pain. Chronic pain is the leading cause of disability, and effective pain management is crucial to health and well-being, particularly when it improves functional ability. Effective pain treatment starts with a comprehensive, empathic assessment and a desire to listen and understand. Nurse Practitioners are well-positioned to fill a vital role in providing comprehensive and empathic patient care, including pain management (23).

While the incidence of chronic pain has remained a significant problem, how clinicians manage pain has significantly changed in the last decade, primarily due to the opioid epidemic. This education aims to discuss pain and the assessment of pain, federal guidelines for prescribing, the opioid epidemic, addiction and diversion, and recommendations for managing pain.

Introduction   

Pain is complex and subjective. The experience of pain can significantly impact an individual's quality of life. According to the National Institute of Health (NIH) (40), pain is the most common complaint in a primary care office, with 20% of all patients reporting pain. Chronic pain is the leading cause of disability, and effective pain management is crucial to health and well-being, particularly when it improves functional ability. Effective pain treatment starts with a comprehensive, empathic assessment and a desire to listen and understand. Nurse Practitioners are well-positioned to fill a vital role in providing comprehensive and empathic patient care, including pain management (23).

While the incidence of chronic pain has remained a significant problem, how clinicians manage pain has significantly changed in the last decade, primarily due to the opioid epidemic. This education aims to discuss pain and the assessment of pain, federal guidelines for prescribing, the opioid epidemic, addiction and diversion, and recommendations for managing pain.

Definition of Pain

Understanding the definition of pain, differentiating between various types of pain, and recognizing the descriptors patients use to communicate their pain experiences are essential for Nurse practitioners involved in pain management. By understanding the medical definition of pain and how individuals may communicate it, nurse practitioners can differentiate varying types of pain to target assessment.

According to the International Association for the Study of Pain (27), pain is "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or terms of described such in damage." The IASP, in July 2020, expanded its definition of pain to include context further.

Their expansion is summarized below:

• Pain is a personal experience influenced by biological, psychological, and social factors.
• Pain cannot be inferred solely from activity in sensory neurons.
• Individuals learn the concept of pain through their life experiences.
• A person's report of an experience in pain should be respected.
• Pain usually serves an adaptive role but may adversely affect function and social and psychological well-being.
• The inability to communicate does not negate the possibility of the experience of pain.

Types of Pain

Pain originates from different mechanisms, causes, and areas of the body. As a nurse practitioner, understanding the type of pain a patient is experiencing is essential for several reasons (23).

• Determining an accurate diagnosis. This kind of pain can provide valuable clues to the underlying cause or condition.
• Creating a treatment plan. Different types of pain respond better to specific treatments or interventions.
• Developing patient education. A nurse practitioner can provide targeted education to patients about their condition, why they may experience the pain as they do, its causes, and treatment options. Improving the patient's knowledge and control over their condition improves outcomes.

Acute Pain

Acute pain is typically short-lived and is a protective response to an injury or illness. Patients are usually able to identify the cause. This type of pain resolves as the underlying condition improves or heals (12).

Chronic Pain

Chronic pain is diagnosed when it continues beyond the expected healing time. Pain is defined as chronic when it persists for longer than three months. It may result from an underlying disease or injury or develop without a clear cause. Chronic pain often significantly impacts a person's physical and emotional well-being, requiring long-term management strategies. The prolonged experience of chronic pain usually indicates a central nervous system component of pain that may require additional treatment. Patients with centralized pain often experience allodynia or hyperalgesia (12).

Allodynia is pain evoked by a stimulus that usually does not cause pain, such as a light touch. Hyperalgesia is the effect of a heightened pain response to a stimulus that usually evokes pain (12).

Nociceptive Pain

Nociceptive pain arises from activating peripheral nociceptors, specialized nerve endings that respond to noxious stimuli. This type of pain is typically associated with tissue damage or inflammation and is further classified into somatic and visceral pain subtypes.

Somatic pain is most common and occurs in muscles, skin, or bones; patients may describe it as sharp, aching, stiffness, or throbbing.

Visceral pain occurs in the internal organs, such as indigestion or bowel spasms. It is more vague than somatic pain; patients may describe it as deep, gnawing, twisting, or dull (12).

Neuropathic pain

Neuropathic pain is a lesion or disease of the somatosensory nervous system. Examples include trigeminal neuralgia, painful polyneuropathy, postherpetic neuralgia, and central poststroke pain (10).

Neuropathic pain may be ongoing, intermittent, or spontaneous pain. Patients often describe neuropathic pain as burning, prickling, or squeezing quality. Neuropathic pain is a common chronic pain. Patients commonly describe allodynia and hyperalgesia as part of their chronic pain experience (10).

Affective pain

Affective descriptors reflect the emotional aspects of pain and include terms like distressing, unbearable, depressing, or frightening. These descriptors provide insights into the emotional impact of pain on an individual's well-being (12).

Case Study

Mary Adams is a licensed practical nurse who has just relocated to town. Mary will be the utilization review nurse at a local long-term care facility. Mary was diagnosed with Postherpetic Neuralgia last year, and she is happy that her new job will have her mostly doing desk work and not providing direct patient care as she had been before the relocation. Mary was having difficulty at work at her previous employer due to pain. She called into work several times, and before leaving, Mary's supervisor had counseled her because of her absences.

Mary wants to establish primary care immediately because she needs ongoing pain treatment. She is hopeful that, with her new job and pain under control, she will be able to continue a successful career in nursing. When Mary called the primary care office, she specifically requested a nurse practitioner as her primary care provider because she believes that nurse practitioners tend to spend more time with their patients.

Assessment

The assessment effectively determines the type of treatment needed, the options for treatment, and whether the patient may be at risk for opioid dependence. Since we know that chronic pain can lead to disability and pain has a high potential to negatively affect the patient's ability to work or otherwise, be productive, perform self-care, and potentially impact family or caregivers, it is imperative to approach the assessment with curiosity and empathy. This approach will ensure a thorough review of pain and research on pain management options. Compassion and support alone can improve patient outcomes related to pain management (23).

Record Review

Regardless of familiarity with the patient, reviewing the patient's treatment records is essential, as the ability to recall details is unreliable. Reviewing the records can help identify subtle changes in pain description and site, the patient's story around pain, failed modalities, side effects, and the need for education, all impacting further treatment (23).

Research beforehand the patient's current prescription and whether or not the patient has achieved the maximum dosage of the medication. Analysis of the patient's past prescription could reveal a documented failed therapy even though the patient did not receive the maximum dose (23).

A review of documented allergens may indicate an allergy to pain medication. Discuss with the patient the specific response to the drug to determine if it is a true allergy, such as hives or anaphylaxis, or if the response may have been a side effect, such as nausea and vomiting.

Research whether the patient tried any non-medication modalities for pain, such as physical therapy (PT), occupational therapy (OT), or Cognitive Behavioral Therapy (CBT). Note any non-medication modalities documented as failed therapies. The presence of any failed therapies should prompt further discussion with the patient, family, or caregiver about the experience. The incompletion of therapy should not be considered failed therapy. Explore further if the patient abandoned appointments.

Case Study

You review the schedule for the week, and there are three new patient appointments. One is Mary Adams. The interdisciplinary team requested and received Mary's treatment records from her previous primary care provider. You make 15 minutes available to review Mary's records and the questionnaire Mary filled out for her upcoming appointment. You see that Mary has been diagnosed with Postherpetic Neuralgia and note her current treatment regimen, which she stated was ineffective. You write down questions you will want to ask Mary. You do not see evidence of non-medication modalities or allergies to pain medication.

Pain Assessment

To physically assess pain, several acronyms help explore all the aspects of the patient's experience. Acronyms commonly used to assess pain are SOCRATES, OLDCARTS, and COLDERAS. These pain assessment acronyms are also helpful in determining treatment since they include a character and duration of pain assessment (23).

Inquire where the patient is feeling pain. The patient may have multiple areas and types of pain. Each type and location must be explored and assessed. Unless the pain is from a localized injury, a body diagram map, as seen below, is helpful to document, inform, and communicate locations and types of pain. In cases of Fibromyalgia, rheumatoid arthritis, or other centralized or widespread pain, it is vital to inquire about radiating pain. The patient with chronic pain could be experiencing acute pain or a new pain site, such as osteoarthritis, that may need further evaluation and treatment (23).

Inquire with the patient how long their pain has been present and any associated or known causative factors. Pain experienced longer than three months defines chronic versus acute pain. Chronic pain means that the pain is centralized or a function of the Central Nervous system, which should guide treatment decisions.

To help guide treatment, ask the patient to describe their pain. The description helps identify what type of pain the patient is experiencing: Allodynia and hyperalgesia indicate centralized pain; sharp, shooting pain could indicate neuropathic pain. Have the patient rate their pain. There are various tools, as shown below, for pain rating depending on the patient's ability to communicate. Not using the pain rating number alone is imperative. Ask the patient to compare the severity of pain to a previous experience. For example, a 1/10 may be experienced as a bumped knee or bruise, whereas a 10/10 is experienced on the level of a kidney stone or childbirth (23).

Besides the 0-10 rating scale and depending on the patient's needs, several pain rating scales are appropriate. They are listed below.

The 0-5 and Faces scales may be used for all adult patients and are especially effective for patients experiencing confusion.

The Defense and Veterans Pain Rating Scale (DVPRS) is a five-item tool that assesses the impact of pain on sleep, mood, stress, and activity levels (20).

For patients unable to self-report pain, such as those intubated in the ICU or late-stage neurological diseases, the FLACC scale is practical. The FLACC scale was initially created to assess pain in infants. Note: The patient need not cry to be rated 10/10.

(21).

Assess contributors to pain such as insomnia, stress, exercise, diet, and any comorbid conditions. Limited access to care, socioeconomic status, and local culture also contribute to the patient's experience of pain (23). Most patients have limited opportunity to discuss these issues, and though challenging to bring up, it is compassionate and supportive care. A referral to social work or another agency may be helpful if you cannot explore it fully.

Assess for substance abuse disorders, especially among male, younger, less educated, or unemployed adults. Substance abuse disorders increase the likelihood of misuse disorder and include alcohol, tobacco, cannabis, cocaine, and heroin (29).

Inquire as to what changes in function the pain has caused. One question to ask is, "Were it not for pain, what would you be doing?" As seen below, a Pain, Enjoyment, and General Activity (PEG) three-question scale, which focuses on function and quality of life, may help determine the severity of pain and the effect of treatment over time.

(21).

Assess family history, mental health disorders, chronic pain, or substance abuse disorders. Each familial aspect puts patients at higher risk for developing chronic pain (23).

Evaluate for mental health disorders the patient may be experiencing, particularly anxiety and depression. The Patient Health Questionnaire (PHQ4) is a four-question tool for assessing depression and anxiety.

In some cases, functional MRI or imaging studies effectively determine the cause of pain and the treatment. If further assessment is needed to diagnose and treat pain, consult Neurology, Orthopedics, Palliative care, and pain specialists (23).

Case Study

You used OLDCARTS to evaluate Mary's pain and completed a body diagram. Mary is experiencing allodynia in her back and shoulders, described as burning and tingling. It is exacerbated when she lifts, such as moving patients at the long-term care facility and, more recently, boxes from her move to the new house. Mary has also been experiencing anxiety due to fear of losing her job, the move, and her new role. She has moved closer to her family to help care for her children since she often experiences fatigue. Mary has experienced a tumultuous divorce in the last five years and feels she is still undergoing some trauma.

You saw in the chart that Mary had tried Gabapentin 300 mg BID for her pain and inquired what happened. Mary explained that her pain improved from 8/10 to 7/10 and had no side effects. Her previous care provider discontinued the medication and documented it as a failed therapy. You reviewed the minimum and maximum dosages of Gabapentin and know Mary can take up to 1800mg/day.

During the assessment, Mary also described stiffness and aching in her left knee. She gets a sharp pain when she walks more than 500 steps, and her knee is throbbing by the end of the day. Mary rated the pain a 10/10, but when she compared 10/10 to childbirth, Mary said her pain was closer to 6/10. Her moderate knee pain has reduced Mary's ability to exercise. She used to like to take walks. Mary stated she has had knee pain for six months and has been taking Ibuprofen 3 – 4 times daily.

Since Mary's pain is moderate, you evaluate your options of drugs for moderate to severe pain.

Opioid Classifications and Drug Schedules

A comprehensive understanding of drug schedules and opioid classifications is essential for nurse practitioners to ensure patient safety, prevent drug misuse, and adhere to legal and regulatory requirements. Nurse practitioners with a comprehensive understanding of drug schedules and opioid classifications can effectively communicate with colleagues, ensuring accurate medication reconciliation and facilitating interdisciplinary care. Nurse practitioners’ knowledge in facilitating discussions with pharmacists regarding opioid dosing, potential interactions, and patient education is essential (49).

Drug scheduling became mandated under the Controlled Substance Act. The Drug Enforcement Agency (DEA) Schedule of Controlled Drugs and the criteria and common drugs are listed below.

(Pain Physician, 2008)

Listed below are drugs classified by their schedule and mechanism of action. "Agonist" indicates a drug that binds to the opioid receptor, causing pain relief and also euphoria. An agonist-antagonist indicates the drug binds to some opioid receptors but blocks others. Mixed antagonist-agonist drugs control pain but have a lower potential for abuse and dependence than agonists (7).

(41).

Commonly Prescribed Opioids, Indications for Use, and Typical Side Effects

Opioid medications are widely used for managing moderate to severe pain. Referencing NIDA (2023), this section aims to give healthcare professionals an overview of the indications and typical side effects of commonly prescribed Schedule II opioid medications, including hydrocodone, oxycodone, morphine, Fentanyl, and hydromorphone.

Opioids are derived and manufactured in several ways. Naturally occurring opioids come directly from the opium poppy plant. Synthetic opioids are manufactured by chemically synthesizing compounds that mimic the effects of a natural opioid. Semi-synthetic is a mix of naturally occurring and man-made (35).

Understanding the variations in how an opioid is derived and manufactured is crucial in deciding the type of opioid prescribed, as potency and analgesic effects differ. Synthetic opioids are often more potent than naturally occurring opioids. Synthetic opioids have a longer half-life and slower elimination, affecting the duration of action and timing for dose adjustments. They are also associated with a higher risk of abuse and addiction (38).

Hydrocodone

Mechanism of Action and Metabolism

Hydrocodone is a Schedule II medication. It is an opioid agonist and works as an analgesic by activating mu and kappa opioid receptors located in the central nervous system and the enteric plexus of the bowel. Agonist stimulation of the opioid receptors inhibits nociceptive neurotransmitters' release and reduces neuronal excitability (17).

• Produces analgesia.
• Suppresses the cough reflex at the medulla.
• Causes respiratory depression at higher doses.

Hydrocodone is indicated for treating severe pain after nonopioid therapy has failed. It is also indicated as an antitussive for nonproductive cough in adults over 18.

Available Forms

Hydrocodone immediate release (IR) reaches maximum serum concentrations in one hour with a half-life of 4 hours.  Extended-release (ER) Hydrocodone reaches peak concentration at 14-16 hours and a half-life of 7 to 9 hours. Hydrocodone is metabolized to an inactive metabolite in the liver by cytochrome P450 enzymes CYP2D6 and CYP3A4. Hydrocodone is converted to hydromorphone and is excreted renally. Plasma concentrations of hydromorphone are correlated with analgesic effects rather than hydrocodone.

Hydrocodone is formulated for oral administration into tablets, capsules, and oral solutions. Capsules and tablets should never be crushed, chewed, or dissolved. These actions convert the extended-release dose into immediate release, resulting in uncontrolled and rapid release of opioids and possible overdose.

Dosing and Monitoring

Hydrocodone IR is combined with acetaminophen or ibuprofen. The dosage range is 2.5mg to 10mg every 4 to 6 hours. If formulated with acetaminophen, the dosage is limited to 4gm/day.

Hydrocodone ER is available as tablets and capsules. Depending on the product, the dose of hydrocodone ER formulations in opioid-naïve patients is 10 to 20 mg every 12 to 24 hours.

Nurse practitioners should ensure patients discontinue all other opioids when starting the extended-release formula.

Side Effects and Contraindications

Because mu and kappa opioid receptors are in the central nervous system and enteric plexus of the bowel, the most common side effects of hydrocodone are constipation and nausea (>10%).

Other adverse effects of hydrocodone include:

• Respiratory: severe respiratory depression, shortness of breath
• Cardiovascular: hypotension, bradycardia, peripheral edema
• Neurologic: Headache, chills, anxiety, sedation, insomnia, dizziness, drowsiness, fatigue
• Dermatologic: Pruritus, diaphoresis, rash
• Gastrointestinal: Vomiting, dyspepsia, gastroenteritis, abdominal pain
• Genitourinary: Urinary tract infection, urinary retention
• Otic: Tinnitus, sensorineural hearing loss
• Endocrine: Secondary adrenal insufficiency (17)

Hydrocodone, being an agonist, must not be taken with other central nervous system depressants as sedation and respiratory depression can result. In formulations combined with acetaminophen, hydrocodone can increase the international normalized ratio (INR) and cause bleeding.  Medications that induce or inhibit cytochrome enzymes can lead to wide variations in absorption.

The most common drug interactions are listed below:

• Alcohol
• Benzodiazepines
• Barbiturates
• other opioids
• rifampin
• phenytoin
• carbamazepine
• cimetidine,
• fluoxetine
• ritonavir
• erythromycin
• diltiazem
• ketoconazole
• verapamil
• Phenytoin
• John’s Wort
• Glucocorticoids

Considerations

Use with caution in the following:

• Patients with Hepatic Impairment: Initiate 50% of the usual dose
• Patients with Renal Impairment: Initiate 50% of the usual dose
• Pregnancy: While not contraindicated, the FDA issued a black-boxed warning since opioids cross the placenta, and prolonged use during pregnancy may cause neonatal opioid withdrawal syndrome (NOWS).
• Breastfeeding: Infants are susceptible to low dosages of opioids. Non-opioid analgesics are preferred.

Pharmacogenomic: Genetic variants in hydrocodone metabolism include ultra-rapid, extensive, and poor metabolizer phenotypes. After administration of hydrocodone, hydromorphone levels in rapid metabolizers are significantly higher than in poor metabolizers.

Oxycodone

Mechanism of Action and Metabolism

Oxycodone has been in use since 1917 and is derived from Thebaine. It is a semi-synthetic opioid analgesic that works by binding to mu-opioid receptors in the central nervous system. It primarily acts as an agonist, producing analgesic effects by inhibiting the transmission of pain signals (Altman, Clark, Huddart, & Klein, 2018).

Oxycodone is primarily metabolized in the liver by CYP3A4/5. It is metabolized in the liver to noroxycodone and oxymorphone.  The metabolite oxymorphone also has an analgesic effect and does not inhibit CYP3A4/5. Because of this metabolite, oxycodone is more potent than morphine, with fewer side effects and less drug interactions. Approximately 72% of oxycodone is excreted in urine (Altman, Clark, Huddart, & Klein, 2018).

Available Forms

Oxycodone can be administered orally, rectally, intravenously, and as an epidural. For this sake, we will focus on immediate-release and extended-release oral formulations.

• Immediate-release (IR) tablets
• IR capsules
• IR oral solutions
• Extended-release (ER) tablets

Dosing and Monitoring

The dosing of oxycodone should be individualized based on the patient's pain severity, previous opioid exposure, and response. Initial dosages for opioid naïve patients range from 5-15 mg for immediate-release formulations, while extended-release formulations are usually initiated at 10-20 mg. Dosage adjustments may be necessary based on the patient's response, but caution should be exercised. IR and ER formulations reach a steady state at 24 hours and titrating before 24 hours may lead to overdose.

Regular monitoring is essential to assess the patient's response to treatment, including pain relief, side effects, and signs of opioid misuse or addiction. Monitoring should include periodic reassessment of pain intensity, functional status, and adverse effects (Altman, Clark, Huddart, & Klein, 2018).

Side Effects and Contraindications

Common side effects of oxycodone include:

• constipation
• nausea
• sedation
• dizziness
• respiratory depression
• respiratory arrest
• hypotension
• fatal overdose

Oxycodone is contraindicated in patients with known hypersensitivity to opioids, severe respiratory depression, paralytic ileus, or acute or severe bronchial asthma. It should be used cautiously in patients with a history of substance abuse, respiratory conditions, liver or kidney impairment, and those taking other medications that may interact with opioids, such as alcohol (4).

It is also contraindicated with the following medications and classes:

• Antifungal agents
• Antibiotics
• Rifampin
• Carbamazepine
• Fluoxetine
• Paroxetine

Considerations

• Nurse practitioners should consider the variations in the mechanism of action for the following:
• Metabolism differs between males and females: females have been shown to have less concentration of oxymorphone and more CYP3A4/5 metabolites.
• Infants have reduced clearance of oxycodone, increasing side effects.
• Pediatrics have 20-40% increased clearance over adults.
• Reduced clearance with age increases the half-life of oxycodone.
• Pregnant women have a greater clearance and reduced half-life.
• Impairment of the liver reduces clearance.
• Cancer patients with cachexia have increased exposure to oxycodone and its metabolite.
• Maternal and neonate concentrations are similar, indicating placenta crossing (4)

Morphine

Mechanism of Action and Metabolism

Morphine is a naturally occurring opioid alkaloid extracted from the opium poppy. It was isolated in 1805 and is the opioid against which all others are compared. Morphine binds to mu-opioid receptors in the brain and spinal cord, inhibiting the transmission of pain signals and producing analgesia. It is a first-line choice of opioid for moderate to severe acute, postoperative, and cancer-related pain (8).

Morphine undergoes first-pass metabolism in the liver and gut. It is well absorbed and distributed throughout the body. Its main metabolites are morphine-3-glucuronide and morphine-6-glucuronide. Its mean plasma elimination half-life after intravenous administration is about 2 hours. Approximately 90% of morphine is excreted in the urine within 24 hours (8).

Available Forms

Morphine is available in various forms, including.

• immediate-release tablets
• extended release tablets
• oral IR solutions
• injectable solutions
• transdermal patches

Dosing and Monitoring

Morphine is hydrophilic and, as such, has a slow onset time. The advantage of this is that it is unlikely to cause acute respiratory depression even when injected. However, because of the slow onset time, there is more likelihood of morphine overdose due to the ability to “stack” doses in patients experiencing severe pain (Bistas, Lopez-Ojeda, & Ramos-Matos, 2023).

The dosing of morphine depends on the patient's pain severity, previous opioid exposure, and other factors. It is usually initiated at a low dose and titrated upwards as needed. Monitoring pain relief, adverse effects, and signs of opioid toxicity is crucial. Reevaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy or of dose escalation. General recommendations for initiating morphine (Bistas, Lopez-Ojeda, & Ramos-Matos, 2023).

Prescribe IR opioids instead of ER opioids.

Prescribe the lowest effective dosage, below 50 Morphine Milligram Equivalents (MME) /day.

Side Effects and Contraindications

Because morphine binds to opioid receptors in the brain and spinal cord, is metabolized in the liver and gut, and has a slow onset, the following side effects are common:

• Constipation
• Nausea
• Vomiting
• Sedation
• Dizziness
• Respiratory depression
• Pruritis
• Sweating
• Dysphoria/Euphoria
• Dry mouth
• Anorexia
• Spasms of urinary and biliary tract

Contraindications of morphine are:

• Known hypersensitivity or allergy to morphine.
• Bronchial asthma or upper airway obstruction
• Respiratory depression in the absence of resuscitative equipment
• Paralytic ileus
• Risk of choking in patients with dysphagia, including infants, children, and the elderly (8)

Concurrent use with other sedating medications: Amitriptyline, diazepam, haloperidol, chlorpromazine

Morphine interacts with the following medications:

• Ciprofloxacin
• Metoclopramide
• Ritonavir

Considerations for Nurse Practitioners

Assess for medical conditions that may pose serious and life-threatening risks with opioid use, such as the following:

• Sleep-disordered breathing, such as sleep apnea.
• Pregnancy
• Renal or hepatic insufficiency
• Age >= 65
• Certain mental health conditions
• Substance use disorder
• Previous nonfatal overdose

Fentanyl

Mechanism of Action and Metabolism

Fentanyl is a synthetic opioid more potent than morphine and was approved in 1968. Fentanyl is an agonist that works by binding to the mu-opioid receptors in the central nervous system. This binding inhibits the transmission of pain signals, resulting in analgesia. Fentanyl is often used for severe pain management, particularly in the perioperative and palliative care settings, or for severe pain in patients with Hepatic failure (8).

It is a mu-selective opioid agonist. However, it can activate other opioid receptors in the body, such as the delta and kappa receptors, producing analgesia. It also activates the Dopamine center of the brain, stimulating relaxation and exhilaration, which is responsible for its high potential for addiction (8).

Indications for fentanyl are as follows:

• Preoperative analgesia
• Anesthesia adjunct
• Regional anesthesia adjunct
• General anesthesia
• Postoperative pain control
• Moderate to severe acute pain (off-label)

Available Forms

• Fentanyl is available in various forms, including:
• transdermal patches
• injectable solutions
• lozenges
• nasal sprays
• oral tablets (8)

Dosing and Monitoring

Fentanyl is metabolized via the CYP3A4 enzyme in the liver. It has a half-life of 3 to 7 hours, and 75% of Fentanyl is excreted in the urine and 9% in feces.

The dosing of fentanyl depends on the route of administration and the patient's needs. For example, transdermal patches are typically applied every 72 hours, while injectable solutions are titrated to achieve the desired analgesic effect. Monitoring should include assessing pain levels, respiratory rate, blood pressure, and sedation scores (8).

Fentanyl is most dosed as follows:

• Post-operative pain control
• 50 to 100 mcg IV/IM every 1 to 2 hours as needed; alternately 0.5 to 1.5 mcg/kg/hour IV as needed. Consider lower dosing in patients 65 and older.

PCA (patient-controlled analgesia): 10 to 20 mcg IV every 6 to 20 minutes as needed; start at the lowest effective dose for the shortest effective duration - refer to institutional protocols (8).

Moderate to severe acute pain (off-label) 1 to 2 mcg/kg/dose intranasally each hour as needed; the maximum dose is 100 mcg. Use the lowest effective dose for the shortest effective duration (8).

Side Effects and Contraindications

Common side effects of fentanyl include:

• respiratory depression
• sedation
• constipation
• nausea
• vomiting
• euphoria
• confusion
• respiratory depression/arrest
• visual disturbances
• dyskinesia
• hallucinations
• delirium
• narcotic ileus
• muscle rigidity
• addiction
• loss of consciousness
• hypotension
• coma
• death (8).

The use of fentanyl is contraindicated in patients in the following situations:

• After operative interventions in the biliary tract, these may slow hepatic elimination of the drug.
• With respiratory depression or obstructive airway diseases (i.e., asthma, COPD, obstructive sleep apnea, obesity hyperventilation, also known as Pickwickian syndrome)
• With liver failure
• With known intolerance to fentanyl or other morphine-like drugs, including codeine or any components in the formulation.
• With known hypersensitivity (i.e., anaphylaxis) or any common drug delivery excipients (i.e., sodium chloride, sodium hydroxide) (8).

Considerations for Nurse Practitioners

Nurse practitioners prescribing fentanyl should thoroughly assess the patient's pain, medical history, and potential risk factors for opioid misuse. They should also educate patients about the proper use, storage, and disposal of fentanyl. It should be used cautiously in patients with respiratory disorders, liver or kidney impairment, or a history of substance abuse. Fentanyl is contraindicated in patients with known hypersensitivity to opioids and those without exposure to opioids.

Alcohol and other drugs, legal or illegal, can exacerbate fentanyl's side effects, creating multi-layered clinical scenarios that can be complex to manage. These substances, taken together, generate undesirable conditions that complicate the patient's prognosis (8).

Hydromorphone

Mechanism of Action and Metabolism

Hydromorphone is a semi-synthetic opioid derived from morphine. It binds to the mu-opioid receptors in the central nervous system. It primarily exerts its analgesic effects by inhibiting the release of neurotransmitters involved in pain transmission, thereby reducing pain perception. Hydromorphone also exerts its effects centrally at the medulla level, leading to respiratory depression and cough suppression (1).

Hydromorphone is indicated for:

• moderate to severe acute pain
• severe chronic pain
• refractory cough suppression (off-label) (1)

Available Forms

Hydromorphone is available in various forms, depending on the patient’s needs and severity of pain.

• immediate-release tablet
• extended release tablets
• oral liquid
• injectable solution
• rectal suppositories

Dosing and Monitoring

The immediate-release oral formulations of hydromorphone have an onset of action within 15 to 30 minutes. Peak levels are typically between 30 and 60 minutes with a half-life of 2 to 3 hours. Hydromorphone is primarily excreted through the urine.

The dosing of hydromorphone should be individualized based on the patient's pain intensity, initiated at the lowest effective dose, and adjusted gradually as needed. Close monitoring of pain relief, adverse effects, and signs of opioid toxicity is essential. Patients should be assessed regularly to ensure they receive adequate pain control without experiencing excessive sedation or respiratory depression.

The following are standard dosages that should only be administered when other opioid and non-opioid options fail.

• Immediate-release oral solutions dosage: 1 mg/1 mLoral tablets are available in 2 mg, 4 mg, and 8 mg.
• Extended-release oral tablets are available in dosages of 8 mg, 12 mg, 16 mg, and 32 mg.
• Injection solutions are available in concentrations of 1 mg/mL, 2 mg/mL, 4 mg/mL, and 10 mg/mL.
• Intravenous solutions are available in strengths of 2 mg/1 mL, 2500 mg/250 mL, ten mg/1 mL, and 500 mg/50 mL.
• Suppositories are formulated at a strength of 3 mg (1).

Side Effects and Contraindications

Hydromorphone has potential adverse effects on several organ systems, including the integumentary, gastrointestinal, neurologic, cardiovascular, endocrine, and respiratory.

Common side effects of hydromorphone include:

• Constipation
• Nausea
• Vomiting
• Dizziness
• Sedation
• respiratory depression
• pruritus
• headache
• Somnolence
• Severe adverse effects of hydromorphone include:
• Hypotension
• Syncope
• adrenal insufficiency
• coma
• raised intracranial pressure.
• seizure
• suicidal thoughts
• apnea
• respiratory depression or arrest
• drug dependence or withdrawal
• neonatal drug withdrawal syndrome
• Hydromorphone is contraindicated in patients with:
• known allergies to the drug, sulfites, or other components of the formulation.
• known hypersensitivity to opioids.
• severe respiratory depression
• paralytic ileus
• acute or severe bronchial asthma (1).

Caution should be exercised in patients with:

• respiratory insufficiency
• head injuries
• increased intracranial pressure.
• liver or kidney impairment.

Considerations for Nurse Practitioners

As nurse practitioners, it is crucial to assess the patient's pain intensity and overall health status before initiating Hydromorphone. Start with the lowest effective dose and titrate carefully for optimal pain control. Regular monitoring for adverse effects, signs of opioid toxicity, and therapeutic response is essential. Educate patients about the potential side effects, proper dosing, and the importance of not exceeding prescribed doses. Additionally, nurse practitioners should be familiar with local regulations and guidelines regarding opioid prescribing and follow appropriate documentation and monitoring practices.

Additional Considerations

In terminal cancer patients, clinicians should not restrain opioid therapy even if signs of respiratory depression become apparent.

Hydromorphone requires careful administration in cases of concurrent psychiatric illness.

Specific Patient Considerations:

• Hepatic impairment and Renal Impairment: Initiate hydromorphone treatment at one-fourth to one-half of the standard starting dosage, depending on the degree of impairment.
• Pregnancy considerations: Hydromorphone can traverse the placental barrier and induce NOWS.
• Breastfeeding considerations: Nonopioid analgesic agents are preferable for breastfeeding women.
• Older patients: hydromorphone is categorized as a potentially inappropriate medication for older adults (1).

Tramadol

Mechanism of Action and Metabolism

Tramadol is a Schedule IV opioid medication with a higher potential for dependency and misuse than non-opioid medications. It binds to opioid receptors in the central nervous system, inhibiting the reuptake of norepinephrine and serotonin. It also has weak mu-opioid receptor agonist activity.

The liver metabolizes tramadol mediated by the cytochrome P450 pathways (particularly CYP2D6) and is mainly excreted through the kidneys.

Tramadol is used for moderate to severe pain.

Available Forms of Tramadol include:

• Immediate-release-typically used for acute pain management.
• Extended-release-used for chronic pain.

Dosing and Monitoring

Tramadol has an oral bioavailability of 68% after a single dose and 90–100% after multiple doses and reaches peak concentrations within 2 hours. Approximately 75% of an oral dose is absorbed, and the half-life of tramadol is 9 hours (18).

Tramadol dosing should be individualized based on the patient's pain severity and response.

The initial dose for adults is usually 50-100 mg orally every 4-6 hours for pain relief. The maximum daily dose is 400 mg for immediate-release formulations and 300 mg for extended-release formulations (18).

It is essential to monitor the patient's pain intensity, response to treatment, and any adverse effects. Regular reassessment and adjustment of the dosage may be necessary.

Side Effects and Contraindications

Tramadol is responsible for severe intoxications leading to consciousness disorder (30%), seizures (15%), agitation (10%), and respiratory depression (5%). The reactions to Tramadol suggest that the decision to prescribe should be carefully considered.

Common Side Effects of Tramadol Include:

• Nausea
• Vomiting
• Dizziness
• Constipation
• Sedation
• Headache
• CNS depression
• Seizure
• Agitation
• Tachycardia
• Hypertension
• reduced appetite
• pruritus and rash
• gastric irritation

Serious side effects include:

• respiratory depression
• serotonin syndrome
• seizures

Contraindications

Tramadol is contraindicated in patients with:

• history of hypersensitivity to opioids
• acute intoxication with alcohol
• opioids, or other psychoactive substances
• Patients who have recently received monoamine oxidase inhibitors (MAOIs)

Additionally, the following can be observed in tramadol intoxication:

• miosis
• respiratory depression
• decreased level of consciousness
• hypertension
• tremor
• irritability
• increased deep tendon reflexes

Poisoning leads to:

• multiple organ failure
• coma
• cardiopulmonary arrest
• death

Considerations for Nurse Practitioners

Tramadol has been increasingly misused with intentional overdoses or intoxications. Suicide attempts were the most common cause of intoxication (52–80%), followed by abuse (18–31%), and unintentional intoxication (1–11%). Chronic tramadol or opioid abuse was reported in 20% of tramadol poisoning cases. Fatal tramadol intoxications are uncommon except when ingested concurrent with depressants, most commonly benzodiazepines and alcohol (18).

Tramadol poisoning can affect multiple organ systems:

• gastrointestinal
• central nervous system: seizure, CNS depression, low-grade coma, anxiety, and over time anoxic brain damage
• Cardiovascular system: palpitation, mild hypertension to life-threatening complications such as cardiopulmonary arrest
• respiratory system
• renal system: renal failure with higher doses of tramadol intoxication
• musculoskeletal system: rhabdomyolysis
• endocrine system: hypoglycemia, serotonin syndrome (18)

Cannabis

Mechanism of Action and Metabolism

Cannabis is classified as a Schedule I status. It contains various cannabinoids, with delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) being the most studied. THC primarily acts on cannabinoid receptors in the brain, producing psychoactive effects, while CBD has more diverse effects on the nervous system. These cannabinoids interact with the endocannabinoid system, modulating neurotransmitter release and influencing various physiological processes (32).

Similar to opioids, cannabinoids are synthesized and released in the body by synapses that act on the cannabinoid receptors present in presynaptic endings (32). They perform the following actions related to analgesia:

• Decrease the release of neurotransmitters.
• Activate descending inhibitory pain pathways.
• Reduce postsynaptic sensitivity and alleviate neural inflammation.
• Modulate CB1 receptors within central nociception processing areas and the spinal cord, resulting in analgesic effects.
• Attenuate inflammation by activating CB2 receptors (32).
• Emerging research shows cannabis is indicated for:
• Migraines
• chronic pain
• back pain
• arthritic pain
• pain associated with cancer and surgery.
• neuropathic pain
• diabetic neuropathic pain when administered early in the disease progression.
• sickle cell disease
• cancer
• inflammatory bowel disease (32)

Available Forms

Cannabis refers to products sourced from the Cannabis sativa plant. There are differences between cannabis, cannabinoids, and cannabidiol (CBD). Cannabinoids are extracted from the cannabis plants. Cannabinoid-based treatments, such as dronabinol and CBD, are typically approved medical interventions for specific indications. THC (9-tetrahydrocannabinol) is the psychoactive component of the cannabis plant. CBD is a non-psychoactive component (32).

Cannabis can be consumed in different forms, each with a different onset and duration. Patients may have individual preferences, including:

• smoking/vaporizing dried flowers.
• consuming edibles
• tinctures or oils
• applying topicals (32)

Dosing and Monitoring

Inhaling marijuana via the lungs by smoking or vaping causes maximum plasma concentration within minutes. Psychiatric effects begin within seconds to a few minutes after inhalation and peak after 15 to 30 minutes. The effect diminishes throughout 2 to 3 hours (32).

Oral ingestion of marijuana causes psychiatric effects that typically occur between 30 and 90 minutes and reach maximum effect after 2 to 3 hours. Ingested marijuana effects last about 4 to 12 hours (32).

Dosing cannabis is challenging due to variations in potency and individual responses. Start with low doses and titrate slowly to achieve the desired effect while minimizing side effects. Regular monitoring is crucial, including assessing symptom relief, adverse effects, and potential drug interactions. Encourage patients to keep a diary to track their cannabis use and its effects (32).

Side Effects and Contraindications

Cannabis can exacerbate mental health conditions such as anxiety and psychosis. Common side effects of cannabis include (32):

• Dizziness
• dry mouth
• increased heart rate
• impaired memory
• psychoactive effects

Contraindications include:

• Pregnancy
• Breastfeeding
• heart disease
• respiratory conditions
• history of substance abuse
• mental health disorders

Case Study

Mary is agreeable to trying an increased dose of Gabapentin. Mary would also like to see a counselor to discuss her past and get help with her anxiety. You made an appointment for Mary to see a Licensed Clinical Social Worker in your clinic.

You read the side effects and warnings for Gabapentin, and it is unsafe to use Gabapentin and Tramadol together since they are both depressants. You order a non-steroidal drug for Mary's somatic knee pain and make a consult for imaging studies on her left knee. You also make a referral to Orthopedics.

You educated Mary about the side effects of Gabapentin and scheduled a follow-up appointment. The day after Mary began her treatment with the increased Gabapentin, you called Mary to follow up on its effect. Mary still has pain, but she is not having any untoward side effects. Gabapentin may not work immediately so you will schedule a follow-up call in 3 days.

Opioid Use, the Opioid Epidemic, and Statistics

The use and misuse of opioids has become a pressing public health concern, leading to a global epidemic. The history of opioid use, the opioid epidemic, and associated statistics provide essential context for healthcare professionals in addressing this public health crisis. More importantly, it is estimated that 1 in 4 patients receiving prescription opioids in primary care settings will misuse them. In addition, 50% of opioid prescriptions are written by primary care providers, including nurse practitioners (22). Understanding the factors contributing to the epidemic and the magnitude of its impact is crucial for effective prevention, intervention, and treatment strategies.

History of Opioid Use

Opioids have a long history of medicinal use, dating back to ancient civilizations. They have been a drug of choice for pain relief for thousands of years. The introduction of synthetic opioids in the 19^th century, such as morphine and later heroin, revolutionized pain management. However, their potential for addiction and misuse soon became apparent (16).

The Opioid Epidemic

The opioid epidemic refers to the surge in opioid misuse, addiction, and overdose deaths. The epidemic gained momentum in the late 1990s with increased prescribing of opioids for chronic pain (43).

No doubt, increased prescribing put opioids in the hands of consumers, but increased prescribing resulted from a multifactorial influence. One of the main influences was aggressive marketing by pharmaceutical companies, which has been well publicized. However, due to the long history of underprescribing pain medications for fear of misuse and addiction, the medical community was primed to expand its opioid prescribing practices (31).

A historical event that increased comfort with prescribing opioids, in the writer's opinion, was the introduction of the Medicare Hospice Benefit in 1986. Medical directors must be contracted or employed by hospices, and these medical directors had or soon gained pain management expertise. To further promote hospice and effective pain management, the hospice medical directors, with newly acquired skills, provided education throughout medical communities about pain management and specifically to decrease the fear of using opioids. Pharmacies and attending physicians grew accustomed to giving opioids for home use. Hospice care is for terminally ill patients, defined as a life expectancy of 6 months or less. Still, the reality is that hospice discharges 12 to 40% of patients for ineligibility and other reasons.

A more prominent factor in increasing opioid prescribing was the 1996 American Pain Society's introduction of pain as "the 5^th Vital sign." Soon after, The Joint Commission promoted pain as "the 5^th Vital Sign" and began compliance surveys in healthcare organizations requiring pain assessment details to be as prominent as blood pressure and heart rate. The Joint Commission cited a quote from 1968 by a nurse from the University of California Los Angeles, Margo McCaffrey, who defined pain as "…Whatever the experiencing person says it is, existing whenever s/he says it does." The Joint Commission accreditation programs pursued pain management as part of the accreditation process throughout its healthcare accreditation programs, including hospice accreditation by 1989 per TJC Timeline (48).

The National Institute of Health published an article about the Joint Commission's role in the opioid epidemic, particularly regarding the definition of pain, "This definition emphasizes that pain is a subjective experience with no objective measures. It also stresses that the patient, not the clinician, is the authority on the pain and that their self-report is the most reliable indicator of pain. This set the tone for clinicians: Patients are always to be trusted to report pain accurately” (45).

Statistics on the Opioid Epidemic

In the United States alone, over 500,000 people died from opioid overdoses between 1999 and 2017. The number of opioid-related overdose deaths continues to increase, with synthetic opioids, mainly illicitly manufactured Fentanyl, playing a significant role in recent years (46). Fentanyl-laced drugs, such as marijuana, are increasingly sold knowing and unknowingly to introduce medications with a high addiction rate, thus creating new consumers. This practice can potentially increase deaths due to the imprecise nature of manufacturing (16).

Opioid-related hospitalizations have also risen substantially. In 2014, there were approximately 1.27 million hospitalizations related to opioids in the United States. These hospitalizations not only place a burden on healthcare systems but also reflect the severe consequences of opioid misuse (3).

Federal Regulations on Opioid Prescribing

The history of substance use disorder prevention that promotes opioid recovery and treatment for patients and communities can be traced back to the early 20^th century. However, the current approach to addressing opioid addiction and promoting healing has evolved significantly in recent times (36).

In the early 1900s, health professionals treated opioid addiction with punitive measures, including incarceration and moralistic approaches. The focus was on punishing individuals rather than providing effective treatment. This approach persisted for several decades until the mid-20^th century when the medical community started recognizing addiction as a medical condition rather than a moral failing (36).

The Controlled Substances Act (CSA), introduced in 1970, was a response to increasing drug abuse and illicit drug trafficking in the United States. The CSA is a federal law regulating the manufacture, possession, distribution, and use of certain substances, including drugs and medications, that can potentially cause abuse and dependence. Its primary purpose is to combat drug abuse, reduce drug-related crimes, and protect public health and safety. The Drug Enforcement Agency (DEA) plays a crucial role in enforcing the CSA by monitoring and controlling controlled substance production, distribution, and use (31).

In the 1990s, the significant increase in opioid prescribing, leading to a surge in opioid addiction and overdose deaths, prompted a shift in focus toward prevention. Efforts were made to educate healthcare providers about the risks of overprescribing opioids and to implement prescription drug monitoring programs to track and prevent abuse (36).

The Comprehensive Addiction and Recovery Act (CARA) was signed into law in 2016 to expand access to treatment and recovery services for opioid addiction. This legislation allocated funding for prevention, treatment, recovery, and support services while promoting evidence-based practices and programs (36).

The Centers for Disease Control and Prevention (CDC) published guidelines in 2016 for prescribing opioids for chronic pain, which was updated in 2022. These guidelines emphasize the importance of non-opioid alternatives, using the lowest effective dose for the shortest duration, and assessing the benefits and risks of continued opioid therapy (13).

Furthermore, the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT) was signed into law in 2018, providing additional resources to address the opioid crisis. This legislation expanded access to medication-assisted treatment (MAT), increased the availability of naloxone, a medication used to reverse opioid overdose, and enhanced support for recovery housing (36).

In recent years, there has been a growing recognition of the importance of a comprehensive approach to opioid addiction, including harm reduction strategies, increased access to naloxone, and the integration of mental health services. Communities and organizations have been working together to address the underlying issues contributing to addiction, such as poverty, trauma, and social determinants of health (50).

Overall, the history of substance use disorder prevention that promotes opioid recovery and treatment has evolved from a punitive approach to a more compassionate and evidence-based model. Efforts are now focused on prevention, early intervention, and expanding access to comprehensive treatment and support services for individuals and communities affected by opioid addiction (36).

The most current federal regulations on opioid prescribing for healthcare providers are the amendments to the CSA in 2018, which added new rules to limit the quantity and duration of opioid prescriptions for acute pain to seven days. In 2022, the CDC updated recommendations to the Clinical Practice Guidelines for Prescribing Opioids for Pain.

The 2022 CDC guidelines are summarized below (13):

1. Non-opioid therapies should be considered the first-line treatment for chronic pain.
2. Establish clear treatment goals with patients, including realistic pain management and functional improvement expectations.
3. Conduct a thorough risk assessment for potential harms before initiating opioid therapy.
4. When opioids are used, start with the lowest effective dose and consider immediate-release opioids instead of extended-release or long-acting opioids.
5. Prescribe the lowest effective dose for the shortest duration possible, typically three days or less and rarely exceeding seven days.
6. Reassess benefits and risks within one day after prescribing opioids, including checking the prescription drug monitoring database.
7. Avoid prescribing opioids and benzodiazepines concurrently whenever possible due to the increased risk of overdose and death.
8. Offer naloxone to patients at increased risk of opioid overdose, including those with a history of overdose, substance use disorder, or concurrent benzodiazepine use.
9. When opioids are no longer needed, taper the dose gradually to minimize withdrawal symptoms.
10. Arrange an evidence-based treatment for patients with opioid use disorder, including medication-assisted treatment (Naltrexone, Buprenorphine, or Methadone).

Safe Prescribing and Prescription Monitoring Program

Prescription Drug Monitoring Programs (PDMP) are state-run electronic databases that track.

the prescribing and dispensing of controlled substances. PDMPs are designed to improve patients.

care and safety by giving clinicians access to patients' prescription histories, allowing them to make informed decisions when prescribing controlled substances. PDMPs help identify patients at risk of substance misuse or prescription drug overdose. They also enable clinicians to identify potential drug interactions and prevent opioid diversion (14).

PDMPs collect and store data from pharmacies and prescribers in a centralized database. Clinicians can access this database to review a patient's prescription history, including the types of medications prescribed, the prescribers involved, and the dispensing pharmacies (14).

In many states, PDMP use is mandated by law, and nurse practitioners may be required to register and use the system. It is essential to understand state-specific laws and regulations regarding PDMP use.

PDMPs have some limitations, such as incomplete data or delays in reporting. The CDC emphasizes that clinicians should use PDMP data for their clinical assessment and other relevant information to make informed decisions about prescribing controlled substances. Still, PDMP cannot be used as the sole basis for denying or providing treatment (14).

Case Study

After five days on Gabapentin, Mary was doing well, and her neuropathic pain had decreased to 3/10. However, Mary suffered a fall after her knee "gave out" and injured her knee and back. She was in severe pain, and her family drove her to the ER. The ER doctors saw Mary, and orthopedics were consulted. Mary has surgery scheduled for a knee replacement a week from now.

Mary was prescribed Vicodin because she was in excruciating pain, but her prescription only allowed enough medication for two days. Mary has made an appointment with you to renew her prescription.

You evaluate Mary because you know that concomitant use of Gabapentin and opioids puts Mary at risk for respiratory depression and possible side effects, including accidental overdose.

Mary stated she has been more alert the past 24 hours and is afraid her functional status will continue to decline if she does not have more Vicodin because the pain in her back and knee makes it difficult to stand. You assess Mary. Mary stated she occasionally drinks alcohol but has not had a drink since she moved. She has no familial history of substance abuse or mental health disorders.

Mary's mother stayed at her house to help her for the first 24 hours after Mary's return from the ER, but Mary is providing her care now.

You check the PDMP database and see that Mary was prescribed eight pills she has taken over the last 48 hours.

Since the Vicodin has been effective without untoward side effects, and Mary's function is improving, you decide to refill the prescription of Vicodin. You will taper the dose to three Vicodin daily for two days and two for one day. Mary will be near her appointment for a knee replacement as well.

Preventing Opioid Use Disorder

As previously discussed, opioid addiction is a growing concern worldwide, affecting individuals from all walks of life. According to the CDC, "Anyone who takes prescription opioids can become addicted to them" (14).

As frontline healthcare professionals, nurse practitioners must recognize the signs of opioid addiction to provide timely intervention and support. This section will outline the key indicators of opioid addiction.

Physical Symptoms

Physical symptoms are often the first noticeable signs of opioid addiction. These symptoms may include constricted pupils, drowsiness, slurred speech, impaired coordination, and increased sensitivity to pain. Additionally, individuals struggling with opioid addiction may exhibit frequent flu-like symptoms, such as a runny nose, sweating, itching, or gastrointestinal issues.

Behavioral Changes

Opioid addiction can significantly impact an individual's behavior. These may include increased secrecy, frequent requests for early prescription refills, doctor shopping (seeking prescriptions from multiple healthcare providers), neglecting personal hygiene, and experiencing financial difficulties due to excessive spending on opioids (37).

Social Isolation

Opioid addiction often leads to social withdrawal and isolation. Individuals struggling with opioid addiction may distance themselves from family, friends, and social activities they once enjoyed. They may exhibit erratic mood swings, become defensive or hostile when confronted about their drug use, and display a general lack of interest in previously important activities (30).

Psychological Changes

The psychological impact of opioid addiction is significant. Individuals with opioid addiction may exhibit increased anxiety, depression, irritability, and restlessness. They may also experience cognitive impairments, memory lapses, and difficulties in decision-making. Healthcare professionals should be attentive to these changes, as they can indicate opioid addiction (51).

Tolerance and Withdrawal Symptoms

The development of tolerance and withdrawal symptoms are critical signs of opioid addiction. Individuals may require increased dosages of opioids to achieve the desired effect, indicating a growing tolerance. Furthermore, withdrawal symptoms such as muscle aches, nausea, vomiting, insomnia, and intense cravings for opioids may occur when the drug is discontinued or reduced abruptly (51).

Opioid Overdose

The management of opioid overdose, withdrawal, and addiction requires a comprehensive approach that combines pharmacological interventions with psychosocial support. Naloxone remains a vital tool for reversing opioid overdose, while medications such as Methadone, buprenorphine, and naltrexone play crucial roles in withdrawal and addiction treatment (National Institute of Health, 2023). Nurse practitioners must stay vigilant and informed about the evolving landscape of medications. This section aims to provide a comprehensive review of medications and treatment strategies for opioid overdose, withdrawal, and addiction and is excerpted from the NIH (40).

Naloxone

Mechanism of Action and Metabolism

Naloxone is an opioid receptor antagonist. It works by binding to opioid receptors and displacing any opioids present, thereby reversing the effects of opioid overdose. It has a higher affinity for opioid receptors than most opioids, effectively blocking their action.

Naloxone is indicated for emergency intervention of opioid overdose. It effectively reverses respiratory depression and other life-threatening effects. Studies suggest the potential benefits of combining naloxone with other medications, such as buprenorphine (see below), to improve outcomes. Initiatives promoting community-based naloxone distribution programs have shown promising results in reducing opioid-related deaths.

Available Forms

Naloxone is available in various formulations:

• Intranasal
• Intramuscular
• Intravenous
• auto-injectors.

The most used form is the intranasal spray, which is easy to administer and requires no specialized training. Intranasal naloxone formulations have gained popularity due to their ease of use and increased availability. A recent study showed that the non-FDA-approved compound spray was far less effective than either FDA compound (15).

Dosing and Monitoring

The recommended initial dose of naloxone for opioid overdose is 2mg intranasally or 0.4mg to 2mg intramuscularly or intravenously. If the patient does not respond within 23- minutes, additional doses may be administered every 2-3 minutes. Continuous monitoring of the patient's respiratory status is essential, as repeat doses may be required due to the short half-life of naloxone.

Side Effects and Contraindications

Naloxone has been shown not to affect individuals without opioids in their system.

Common side effects of naloxone include

• Withdrawal symptoms: increased heart rate, sweating, and agitation
• nausea
• vomiting
• headache

Contraindications include known hypersensitivity to naloxone and situations where the use of naloxone may be unsafe or not feasible.

Considerations for Nurse Practitioners

Fentanyl and other opioids have a rapid onset, and the need to act quickly is paramount. As mentioned previously, the ease of use and higher plasma concentrations using the FDA-approved 4-mg FDANxSpray device compared with the locally compounded nasal sprays should be considered when ordering Naloxone (15).

Fentanyl and other potent synthetic opioids may require multiple administrations of naloxone to achieve reversal of an overdose (Chiang, Gyaw, & Krieter, 2019). As a nurse practitioner prescribing naloxone, it is crucial to assess the patient's risk factors for opioid overdose, such as a history of substance use disorder or chronic pain management. Education regarding the proper administration of naloxone should be provided to the patients and their caregivers. Additionally, it is essential to provide resources for follow-up care, including addiction treatment and ongoing support.

Methadone

Mechanism of Action and Metabolism

Methadone is a long-acting opioid agonist that effectively suppresses withdrawal symptoms and reduces cravings. It binds to the same opioid receptors in the brain as other opioids. It relieves withdrawal symptoms and reduces cravings by blocking the euphoric effects of opioids, thus helping individuals with opioid dependence to achieve stability (33).

Available Forms

Methadone is available in oral tablets and liquid formulations. The oral tablet is the most used form and is typically administered once daily (33).

Dosing and Monitoring

Methadone dosing is individualized based on the patient's response and needs. Initially, the dose often started low and gradually increased until the patient reached a stable dose. Dosing may need to be adjusted based on the patient's response, adherence, and any changes in their overall health. Regularly monitoring the patient's vital signs, urine drug screens, and assessment of their withdrawal symptoms and cravings is essential.

Side Effects and Contraindications

Common side effects of methadone include:

• Constipation
• dry mouth
• drowsiness
• sweating
• weight gain
• respiratory depression

Contraindications include:

• known hypersensitivity to methadone
• severe asthma
• respiratory depression
• certain heart conditions (33).

Considerations for Nurse Practitioners

As a nurse practitioner prescribing methadone, conducting a comprehensive assessment of the patient's medical history, current medications, and substance use history is crucial. Opioid treatment programs or specialized clinics are often involved in methadone treatment, so collaboration and coordination of care with these programs are essential. Regularly monitoring the patient's progress, adherence, and potential side effects or drug interactions is essential. Additionally, providing education on the risks and benefits of methadone and the importance of adherence to the prescribed regimen is crucial for successful treatment outcomes.

Buprenorphine

Mechanism of Action and Metabolism

Buprenorphine is a partial opioid agonist with a ceiling effect that minimizes the risk of overdose while reducing withdrawal symptoms. Buprenorphine is a partial opioid agonist that binds to the same receptors as other opioids but produces a weaker response. It has a high affinity for the mu-opioid receptors, which helps reduce cravings and withdrawal symptoms in individuals with opioid dependence.

Available Forms

Buprenorphine is available in different formulations, including sublingual tablets, buccal films, and extended-release injections. The sublingual tablets have different strengths, such as 2mg, 4mg, 8mg, and 12mg. Buprenorphine is taken as a daily tablet or weekly or monthly injection.

Dosing and Monitoring

The dosing of buprenorphine varies depending on the individual's opioid dependence severity and treatment phase. Initially, a low dose (e.g., 2-4mg) is given, and it may gradually increase to a maintenance dose of 8-24 mg daily. Regular monitoring is essential to assess the patient's response, adherence, and potential side effects.

Side Effects and Contraindications

Common side effects of buprenorphine include:

• Constipation
• Nausea
• Headache
• Insomnia
• Sweating

Serious side effects are rare but can include:

• Respiratory depression
• Allergic reactions

Buprenorphine is contraindicated in individuals with:

• Severe respiratory insufficiency
• Acute intoxication with opioids
• Known hypersensitivity

Considerations for Nurse Practitioners

Nurse practitioners can prescribe buprenorphine for opioid dependence treatment under the Drug Addiction Treatment Act (DATA). To become eligible, they must complete specific training requirements and obtain a waiver from the Substance Abuse and Mental Health Services Administration (SAMHSA). Nurse practitioners should assess patients thoroughly, including their opioid use history, comorbidities, and medication compatibility, while ensuring appropriate counseling and referral for comprehensive treatment (40).

Clonidine + Lofexidine

Mechanism of Action and Metabolism:

Both Clonidine and Lofexidine are alpha-2 adrenergic agonists. They work by stimulating alpha-2 receptors in the brain, which reduces sympathetic outflow and norepinephrine release. This results in decreased sympathetic activity, leading to various effects such as reduced blood pressure, decreased heart rate, and alleviated withdrawal symptoms (28).

Available Forms

Clonidine is available in oral tablets and patches. Lofexidine is available in oral tablets and is taken as needed (40).

Dosing and Monitoring

For opioid withdrawal, the Clonidine dose ranges from 0.1-0.3 mg every 4-6 hours. Lofexidine is usually initiated at 0.53 mg three times daily, and the dose can be increased to 2.88 mg daily. Monitoring blood pressure and heart rate is essential during treatment (40).

Side Effects and Contraindications:

Common side effects of both medications include:

• dry mouth
• sedation
• dizziness
• constipation
• orthostatic hypotension (40).

Both medications are contraindicated in patients with:

• Hypotension
• Bradycardia
• heart block
• history of hypersensitivity to the drugs (40).

Considerations for Nurse Practitioners:

An early study of lofexidine vs. clonidine for withdrawal symptoms showed that treatment with lofexidine resulted in lower withdrawal symptoms, fewer mood problems, less sedation, and hypotension. There were no significant differences in craving levels, morphine metabolites in urine, or dropout rates when both were compared.

Lofexidine can be a safe option for outpatient treatment as it does not lead to hypotension. However, nurse practitioners must closely monitor patients' blood pressure and heart rate during treatment and educate them about possible side effects. If patients experience any concerning symptoms, they should inform their nurse practitioner immediately.

Gradual dose reduction of Clonidine is crucial to prevent rebound hypertension. Before prescribing either medication, nurse practitioners should assess for any contraindications or potential drug interactions (19).

Emerging Therapies for Withdrawal

Extended-release naltrexone: Naltrexone is an opioid receptor antagonist that blocks the effects of opioids, reducing the risk of relapse. It is taken as a monthly injection.

Alpha-2 adrenergic agonists: Emerging evidence suggests the potential use of dexmedetomidine and guanfacine for managing opioid withdrawal symptoms.

Medication-Assisted Treatment (MAT):

Methadone was introduced in the 1960s and marked a significant turning point in opioid addiction treatment or MAT. Along with counseling and behavioral therapies, MAT became the cornerstone of opioid addiction recovery.

Examples of medications used:

• Methadone
• Buprenorphine:
• Naltrexone:

Adjunctive Pharmacotherapies:

Antidepressants: Selective serotonin reuptake inhibitors and tricyclic antidepressants may help manage co-occurring depression and anxiety.

Anticonvulsants:

Medications like Gabapentin and pregabalin show promise in reducing opioid cravings and improving treatment outcomes.

Other Substance Use Disorders

Patients in pain may struggle with Substance Use Disorders other than Opioid Use Disorder. Substance use disorders may often occur with mental health conditions such as anxiety, depression, and bipolar disorder. In addition, many individuals engage in polydrug use. Understanding the most common Substance Use Disorders aids in a comprehensive assessment of the patient and the development of appropriate treatment plans (28).

Alcohol Use Disorder (AUD):

The prevalence of AUD worldwide was estimated to be 9.8% in men and 5.5% in women in 2016 (28).

Cannabis Use Disorder (CUD):

the prevalence of CUD in the United States increased from 2.18% in 2001-2002 to 2.89% in 2012-2013. (28).

Cocaine Use Disorder:

According to the National Survey on Drug Use and Health (NSDUH), in 2019, approximately 1.9 million Americans aged 12 or older had cocaine use disorder in the past year (44).

Methamphetamine Use Disorder:

A study published in Drug and Alcohol Dependence reported that the prevalence of methamphetamine use disorder in the United States was estimated to be 0.2% in 2015-2016 (6).

Drug Diversion and Illegal opioids

Misuse of opioids is facilitated by diversion and is defined as "the transfer of drugs from lawful to unlawful use" (24). Most commonly, this occurs when family and friends share prescribed opioids with other family and friends. Opioids and other controlled drugs are also diverted from healthcare facilities. Statistics show that healthcare facility diversion has increased since 2015 (24)

Diversion affects patients, healthcare workers, healthcare facilities, and public health. Patients experience substandard care due to ineffective pain management and impaired healthcare workers. In addition, affected patients are at risk of infections from compromised syringes (24).

Healthcare employees who divert are at risk of overdose and death. If caught, they face criminal prosecution and malpractice suits. Healthcare facilities also bear the cost of diverted drugs via internal investigations, follow-up care for affected patients, regulatory fines for inadequate safeguards, and declining public trust (24).

Despite the enormous consequences of drug diversion, healthcare facilities have implemented few processes to detect and deter the diversion of controlled substances (24).