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Kentucky Addiction Disorders

Introduction   

The United States is facing an epidemic of opioid-related mortality and morbidity that has an unparalleled impact. Drug overdoses are the leading cause of accidental deaths in the U.S. (13). Roughly two-thirds of drug overdose deaths were caused by opioids – both legal and illicit (18). There are two intertwined epidemics: the excessive use of opioids for both legal and illicit purposes, and unprecedented levels of consequent opioid use disorder (OUD). 

Addiction remains one of the most critical public health and safety issues facing the Commonwealth of Kentucky (8). There is hope on the horizon for those in Kentucky who are impacted by addiction disorders. The data and statistics suggest that the interventions established are having a meaningful impact. Kentucky had a decrease of over 5% of overdose deaths in 2022 from 2021. Significant legislation has been implemented to battle this crisis within the state of Kentucky. 

As we explore addiction disorders, it is meaningful to understand the pharmacology of the most common opioids and the pharmacokinetics of Fentanyl to fully understand how a common treatment, Methadone, is effectively used. 

Etiology and Statistics on Addiction Disorders in Kentucky 

Opioids are the primary culprit of drug overdose deaths. In 2000, opioid overdoses represented 48% of drug overdose deaths in the U.S.; by 2021, they represented 75% of these deaths (11). 

The Office of the State Medical Examiner (OSME) and toxicology reports submitted by Kentucky coroners state that 90% of deaths in 2022 involved opioids (13).  

It is important to look at trends in data. Recent statistics of addiction disorders in Kentucky: 

• In 2020, there were 1,964 overdose deaths in KY 
• In 2021, there were 2,250 overdose deaths in KY (14.5% increase from 2020)  
• In 2022, there were 2,135 overdose deaths (5% decrease from 2021)  

The Office of Drug Control Policy (ODCP) reports that 90% of deaths in 2022 involved opioids. The most prevalent drug contributing to overdose deaths is fentanyl, accounting for 72.5% nationwide in 2022 [See Figure 1]. In Kentucky, of the 2,135 overdose deaths in 2022, 1,548 (73%) were identified from toxicology testing (11). The age group with the greatest number of drug overdose deaths in Kentucky in 2022 included those between the ages of 35 and 44 [See Figure 2] (11). 

Figure 1. Kentucky Fentanyl-Related Drug Overdose Deaths in 2022 (11) 

Figure 2. Kentucky Drug Overdose Deaths by Age 2020-2022 (11) 

Terminology Related to Addiction and Misuse 

These terms are similar, but providers and clinicians should be aware of the differences (6). 

• Addiction - the constant need for a drug despite harmful consequences. 
• Pseudoaddiction - constant fear of being in pain, hypervigilance; usually there is a resolution with pain resolution. 
• Dependence - physical adaptation to a medication where it is necessary for normal function and withdrawal occurs with lack of the medication. 
• Tolerance - lack of expected response to a medication resulting in an increase in dose to achieve the same pain relief, resulting from central nervous system (CNS) adaptation to the medication over time. 

Opioid Use Disorder (OUD) 

An opioid use disorder (OUD) is defined as a problematic pattern of opioid use that leads to serious impairment or distress (5). 

In the late 1990s, prescription opioid use increased in all regions of the U.S. Unregulated prescription opioid use was promoted, in large part by the pharmaceutical industry (5). Misuse and diversion of these medications became widespread; by 2017, an estimated 1.7 million people in the U.S. suffered from substance use disorders related to prescription opioid pain medications (5).  

The DSM-5 Criteria is an excellent guide for diagnosing OUD. To be eligible for methadone treatment, patients must meet DSM-5 criteria for opioid use disorder. According to the DSM-5, the presence of at least two of the following symptoms indicates OUD (1). 

• Opioids are often taken in larger amounts or over a longer period than was intended 
• There is persistent desire or unsuccessful efforts to cut down or control opioid use 
• A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects 
• Craving or a strong desire to use opioids 
• Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home 
• Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids 
• Important social, occupational, or recreational activities are given up or reduced because of opioid use 
• Recurrent opioid use in situations in which it is physically hazardous 
• Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by opioids 
• Tolerance as defined by either of the following:  
  • Need for markedly increased amounts of opioids to achieve intoxication or desired effect  
  • Markedly diminished effect with continued use of the same amount of opioid 
• Withdrawal as manifested by either of the following:  
  • Characteristic opioid withdrawal syndrome. 
  • Same (or a closely related) substance is taken to relieve or avoid withdrawal  

The severity of OUD is defined as (1):  

MILD: The presence of 2 to 3 symptoms  

MODERATE: The presence of 4 to 5 symptoms  

SEVERE: The presence of 6 or more symptoms 

Opiates and Opioids 

Opiates are chemical compounds that are extracted or refined from natural plant matter (poppy sap and fibers).  

Examples of opiates: 

• Opium 
• Morphine 
• Codeine 
• Heroin 

Opioids are chemical compounds that generally are not derived from natural plant matter. Most opioids are synthesized.  

Though a few opioid molecules — hydrocodone (e.g., Vicodin), hydromorphone (e.g., Dilaudid), oxycodone (e.g., Oxycontin, Percocet) — may be partially synthesized from chemical components of opium, other popularly-used opioid molecules are designed and manufactured in laboratories. 

The pharmaceutical industry has created more than 500 different opioid molecules.  

Common opioids used in the U.S. for treatment of pain: 

• Fentanyl/fentanyl (e.g., Ultiva, Sublimaze, Duragesic patch) 
• Dextropropoxyphene (e.g., Darvocet-N, Darvon) 
• Hydrocodone (e.g., Vicodin) 
• Oxycodone (e.g., Oxycontin, Percocet) 
• Oxymorphone (e.g., Opana) 
• Meperidine (e.g., Demerol) 

Pharmacokinetics of Fentanyl 

Fentanyl is a synthetic opioid agonist that is 80-100 times stronger than morphine and is often added to heroin to increase its potency (6). It can cause severe respiratory depression and death, particularly when mixed with other drugs or alcohol. It has high addiction potential. 

Drug Class 

Opioid, narcotic agonist (Schedule II).  

Uses 

Pain relief, preop medication; adjunct to general or regional anesthesia. Management of chronic pain (transdermal).  

Mechanism of Action 

Opioids can be classified according to their effect on opioid receptors and can be considered as agonists, partial agonists, antagonists, and agonist-antagonists.  

• Agonists - interact with an opioid receptor to produce a maximal response from that receptor. 
• Antagonists - bind to receptors but produce no functional response, while at the same time preventing an agonist from binding to that receptor (naloxone).  
• Partial agonists - bind to receptors but elicit only a partial functional response regardless of the amount of drug administered  
• Agonist-antagonists - act as agonist to a certain opioid receptor, but have antagonist activity to another opioid receptor  

Fentanyl is an μ-opioid agonist that binds to μ-opioid G-protein-coupled receptors, which prevents the release of pain neurotransmitters by decreasing the cellular calcium level. These receptors bind opioids, so they are also commonly referred to as mu-opioid receptors (MORs). 

The connection between the receptor and the first stage of signal transduction becomes established through the G proteins (alpha, beta, and gamma subunits). The main targets of G proteins include the adenyl cyclase, which is the enzyme responsible for the formation of the second messenger, and cyclic adenosine monophosphate (cAMP) (10). 

The phospholipase C is the enzyme responsible for the formation of several ion channels such as the calcium and potassium channels (10). Essentially, GPCRs can directly control the activity of ion channels through mechanisms that do not involve the second messengers. Opioids reduce neuronal excitability by opening the G protein-dependent and rectifying potassium (irk) channels (GIRK) and subsequent cell membrane hyperpolarization (10). 

The opening of the channel occurs by the direct interaction between the subunits of the G protein and the potassium ion channel.  

Endogenous and exogenous opioids operate through both inhibitory and excitatory action at the presynaptic and postsynaptic sites. In particular, the MORs interact with a G protein of the inhibitory type (10).  

In the resting state, G-alpha-beta-gamma complex and the subunit α causes the bind, guanosine diphosphate (GDP). The binding of the opioid agonist (endogenous or exogenous) to the extracellular N-terminus domain of the MOR induces dissociation of GDP from the G-alpha subunit, which is replaced by guanosine triphosphate (GTP). 

Because the enzymatic GTP turnover lasts approximately two to five minutes, a new signal may find the receptor still not ready to respond, so the regulator of G-protein signaling (RGS) protein speeds up the GTP hydrolysis up to 100-fold; this protein binds the G-alpha subunit and removes the active G-alpha-GTP and beta-gamma species (10). 

MORs are present in the CNS and are the most highly expressed of all opioid receptors. These receptors are expressed in neurons throughout the dorsal horn of the spinal cord and in different regions or the brain (10). Within the spinal cord, MORs are localized (presynaptic and postsynaptic) and receive sensory information from primary afferent nerve fibers innervating the skin and deeper tissues of the body (10).  

Fentanyl Pharmacodynamics/Kinetics 

• Onset of action for adults: 
  • IM: 7 to 8 minutes 
  • IV: Almost immediate (maximal analgesic and respiratory depressant effects may not be seen for several minutes) 
  • Transdermal patch (initial placement): 6 hours 
  • Transmucosal: 5 to 15 minutes 
• Duration:  
  • IM: 1 to 2 hours 
  • IV: 0.5 to 1 hour 
• Distribution: Highly lipophilic, redistributes into muscle and fat 
  • Note: IV fentanyl exhibits a 3-compartment distribution model 
  • Changes in blood pH may alter ionization of fentanyl and affect its distribution between plasma and CNS 
• Vdss: Adults: 4 to 6 L/kg 
• Protein binding: 79% to 87%, primarily to alpha-1 acid glycoprotein; also binds to albumin and erythrocytes. 
• Metabolism: Hepatic, primarily via CYP3A4 by N-dealkylation and hydroxylation to other inactive metabolites. 
• Half-life elimination: 
  • IV: Adults: 2 to 4 hours; when administered as a continuous infusion, the half-life prolongs with infusion duration due to the large volume of distribution (Sessler 2008) 
  • Sub-Q bolus injection: 10 hours  
  • Transdermal device: Terminal: ~16 hours 
  • Transdermal patch: 20 to 27 hours  
  • Transmucosal products: 3 to 14 hours (dose dependent) 
  • Intranasal: 15 to 25 hours (based on a multiple-dose pharmacokinetic study when doses are administered in the same nostril and separated by a 1-, 2-, or 4-hour time lapse) 
  • Buccal film: ~14 hours 
  • Buccal tablet: 100-200 mcg: 3 to 4 hours; 400 to 800 mcg: 11 to 12 hours 
• Time to peak: 
  • Buccal film: 0.75 to 4 hours (median: 1 hour) 
  • Buccal tablet: 20 to 240 minutes (median: 47 minutes) 
  • Lozenge: 20 to 480 minutes (median: 20 to 40 minutes) 
  • Intranasal: Median: 15 to 21 minutes 
  • SubQ bolus injection: 10 to 30 minutes (median: 15 minutes) 
  • Sublingual spray: 10 to 120 minutes (median: 90 minutes) 
  • Sublingual tablet: 15 to 240 minutes (median: 30 to 60 minutes) 
  • Transdermal patch: 20 to 72 hours; steady state serum concentrations are reached after two sequential 72-hour applications 
• Excretion: Urine 75%; feces ~9% 

Fentanyl Side Effects 

• IV: Postop drowsiness, nausea, vomiting.  
• Transdermal (10%– 3%): Headache, pruritus, nausea, vomiting, diaphoresis, dyspnea, confusion, dizziness, drowsiness, diarrhea, constipation, decreased appetite (12) 

Occasional:  

• IV: Postop confusion, blurred vision, chills, orthostatic hypotension, constipation, difficulty urinating.  
• Transdermal (3%–1%): Chest pain, arrhythmias, erythema, pruritus, syncope, agitation, skin irritations (12) 

Fentanyl Adverse Effects 

Overdose or too-rapid IV administration may produce severe respiratory depression, skeletal/thoracic muscle rigidity. This muscle rigidity may lead to apnea, laryngospasm, bronchospasm, cold/clammy skin, cyanosis, coma. Tolerance to analgesic effect may occur with repeated use (12).  

Transdermal Fentanyl 

Mechanism of Action 

As mentioned, Fentanyl is nearly 100 times more potent than morphine, resulting in an estimated conversion ratio of 1 to 100 to provide an equal degree of analgesia. It has low molecular weight, high potency, and lipid solubility, which makes it ideal for use with the transdermal route.  

Fentanyl is a 4-anilidopiperidine compound, it exerts its effect by acting as a high-affinity agonist on selective Mu-opioid receptors in the brain (17). It also has effects on delta and kappa receptors. The activation of Mu-opioid receptors causes analgesia and stimulates areas of the brain responsible for addictive potential.  

The transdermal route eliminates the first-pass metabolism of fentanyl by the liver, increasing bioavailability to 90%, making it possible to use lower doses of the drug, thus reducing the incidence of adverse effects. 

Fentanyl can be detected in serum after about one to two hours after first application but does not reach the therapeutic index until approximately 12 to 16 hours due to the need for fentanyl to saturate the epidermis before more efficient absorption (17). The patches are designed to deliver fentanyl at a constant rate. 

Fentanyl is available in various doses: 12, 25, 50, 75, and 100 mcg/hour; requiring replacement every 72 hours.  

Fentanyl metabolism occurs via cytochrome P450 (CYP34A) enzymes into inactive metabolites; hence drugs that enhance or inhibit cytochrome P450 will affect its metabolism (17).  

The elimination half-life after patch removal is 13 to 22 hours; this is due to the slow release of fentanyl from the skin (16).  

Several studies have shown that when compared to sustained-release oral morphine (SROM), transdermal fentanyl has a 30% lower incidence of adverse effects such as constipation and sedation (p<0.05). (16) 

Administration 

The patch has an adhesive side that contains an active ingredient that must be applied directly flat on the skin, and it should be applied to intact, clean, and healthy skin. Skin with scars, rashes, or open wounds should be avoided. Areas with excess hair require clipping if applying the patch in that location. 

The ideal areas to apply the adhesive patch are the chest, back, and arms. Patches should not be applied consecutively in the same location (17). The transdermal fentanyl patch must be removed after 72 hours. Proper disposal is important to avoid intentional abuse and misuse of the discarded patch. 

Adverse Effects 

The most common adverse drug reactions of transdermal fentanyl are nausea, vomiting, and constipation (17). Adverse side effects are manageable with stool softeners and antiemetics. There is a higher incidence of respiratory depression in patients who have not previously been exposed to opioid analgesics. Additional adverse effects include rash and erythema at the application site of the patch that abates after removal or with antihistamine therapy (17). Hypoventilation has been noted as an adverse effect. 

Withdrawal symptoms of transdermal fentanyl may cause adverse side effects such as nausea, vomiting, diarrhea, and shivering. These symptoms may occur when decreasing dosage, abrupt cessation of use, or changing to an alternative opioid medication (17).  

Contraindications 

Contraindications of transdermal fentanyl include patients who experience hypoventilation, respiratory compromise (including acute or severe asthma) or respiratory depression should not take transdermal fentanyl. Also, fentanyl transdermal should be avoided during the acute postoperative pain period for short term pain control, intermittent pain control, or mild pain (17).  

Pediatric patients under 12 or children under 50 kgs and under 18 should not use this drug. Avoid use in patients with a history of sensitivity or reactions to adhesives. 

Prescriber Monitoring 

Fentanyl is an extremely potent opioid and requires prescriber monitoring to maintain a safe therapeutic concentration. The gold standard method of assessing fentanyl concentration is Liquid chromatography-mass spectrometry. A blood concentration of 0.6 ng/ml to 3.0 ng/ml is appropriate for analgesia.  

Monitoring Fentanyl is increasingly important when the patient is taking multiple medications. Drugs that are important review carefully are those which inhibit CYP3A4 metabolism, which causes an increase in Fentanyl concentration and can lead to toxicity. Examples of these drugs include azole class antifungals and macrolide antibiotics (17). CYP3A4 inducers, such as rifampin, phenytoin, and carbamazepine, may also reduce the level of fentanyl to a non-therapeutic level (17).  

Antidote for Fentanyl: Naloxone  

Nursing Considerations (12): 

• Prepare: Resuscitative equipment and opiate antagonist (naloxone 0.5 mcg/kg) should be available for initial use.  
• Establish baseline blood pressure, pulse rate, and respirations.  
• Assess type, location, intensity, duration of pain.  
• Assess fall risk and implement appropriate precautions.  
• Assist with ambulation and encourage patient to turn, cough, deep breathe every two hours. 
• Monitor respiratory rate, B/P, heart rate, oxygen saturation.  
• Assess for relief of pain.  
• For patients with prolonged high-dose use, continuous infusions (critical care, ventilated patients), clinicians should consider weaning the drip gradually or transitioning to a fentanyl patch to decrease symptoms of opiate withdrawal. 

Medication-Assisted Treatment (MAT) for OUD 

Medication-assisted treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, in the treatment of opioid use disorders (OUD). The goal is sustained recovery. Often, individuals have actual pain and became dependent on prescription narcotic drugs, then switch to illicit opioids or the opiate heroin when the medically supplied narcotics run out. 

The U.S. Food and Drug Administration (FDA) has only approved three medication assisted treatments (MATs) for opioid use disorder (OUD): methadone, buprenorphine, and naltrexone. 

We will discuss the pharmacokinetics of Methadone in this course.  

FDA-approved methadone products approved for the treatment of OUD include: 

• Dolophine (methadone hydrochloride) tablets 
• Methadose (methadone hydrochloride) oral concentrate 

Buprenorphine and methadone have been shown to decrease mortality among those with OUD. A recent study reported that buprenorphine was associated with a lower risk of overdose during active treatment compared to post-discontinuation. 

Methadone 

Methadone is a medication approved by the Food and Drug Administration (FDA) to treat OUD, as well as for management of chronic pain. Methadone is safe and effective when taken as prescribed. Methadone is a component of a comprehensive treatment plan, which includes counseling and other behavioral health therapies to provide patient-centered care. 

Definition  

Methadone, a long-acting opioid agonist, it can help relieve cravings and withdrawal, while also blocking the effects of opioids (15). It is available in liquid, powder, and diskettes forms. Patients taking methadone to treat OUD must receive the medication under the supervision of a medical provider, but after a period of stability and consistent compliance, patients may be allowed to take methadone at home between program visits (15). 

Drug Class 

Opioid agonist (Schedule II). CLINICAL: Opioid analgesic. Opioid dependency management. (12) 

Uses 

Methadone is a first-line Opioid Addiction Treatment (OAT) option, along with buprenorphine. Methadone may be preferable to buprenorphine for patients who are at high risk of treatment cessation and subsequent fentanyl overdose. It also alters processes affecting analgesia, emotional responses to pain, and reduces withdrawal symptoms from other opioid drugs 

Mechanism of action 

Methadone hydrochloride is a mu-agonist, which is a synthetic opioid analgesic with multiple actions that are similar to those of morphine (7). The most prominent actions impact the central nervous system and organs composed of smooth muscle.  

Methadone binds to opiate receptors in the CNS, causing inhibition of ascending pain pathways and altering the perception of and response to pain (12). It also produces generalized CNS depression (12). Methadone has also been shown to have N-methyl-D-aspartate (NMDA) receptor antagonism. The contribution of NMDA receptor antagonism to methadone’s efficacy is unknown.  

Methadone binds to plasma proteins in circulation, most predominantly α1-acid glycoprotein (9).  This is an important consideration as certain conditions or medications may alter plasma protein levels. There is considerable tissue distribution of methadone, and it is possible for tissue levels to exceed plasma levels. 

The lipophilic nature of methadone allows for rapid absorption, long duration of action, and slow release from tissues into the bloodstream. This accounts for the wide variation in half-life, recorded as a range from two to 65 hours. 

Methadone is metabolized into inactive molecules by the liver CYP450 enzyme and the intestinal CYP3A4/CYP2D6 enzymes before elimination in the feces or urine. 

Methadone Pharmacokinetics  

Figure 3. Pharmacokinetics of Methadone (12) 

• Well absorbed after IM injection.  
• Protein binding: 85%–90%.  
• Metabolized in liver. Primarily excreted in urine.  
• Not removed by hemodialysis.  
• Half-life: 7– 59 hrs.  
• Crosses placenta and found in breast milk.  

Respiratory issues may occur in neonates if mother received opiates during labor.  

Elderly patients are more susceptible to respiratory depressant effects.  

Age-related renal impairment may increase the risk of urinary retention.  

Caution: Renal/ hepatic impairment, elderly/debilitated patients, risk for QT prolongation, medications that prolong QT interval, conduction abnormalities, severe volume depletion, hypokalemia, hypomagnesemia, cardiovascular disease, depression, suicidal tendencies, history of drug abuse, respiratory disease, and biliary tract dysfunction. 

Drug Interactions  

Alcohol, other CNS depressants (e.g., Lorazepam, morphine, zolpidem) may increase CNS effects, respiratory depression, and hypotension.  

CYP3A4 inducers (e.g., carbamazepine, phenobarbital) may decrease concentration/effects; CYP3A4 inhibitors (e.g., rifampin, clarithromycin) (12). 

Methadone Side Effects 

As with other opioid medications, general side effects of methadone are related to excessive opioid receptor activity, including but not limited to: 

• Diaphoresis/flushing 
• Pruritis 
• Nausea 
• Dry mouth 
• Constipation 
• Sedation 
• Lethargy 
• Respiratory depression 

Adverse Effects 

Cardiovascular: Bigeminy, bradycardia, cardiac arrhythmia, cardiac failure, cardiomyopathy, ECG changes, edema, extrasystoles, flushing, hypotension, inversion T wave on ECG, palpitations, phlebitis, prolonged QT interval on ECG, shock, syncope, tachycardia, torsades de pointes, ventricular fibrillation, ventricular tachycardia 

Central nervous system: Agitation, confusion, disorientation, dizziness, drug dependence (physical dependence), dysphoria, euphoria, hallucination, headache, insomnia, sedation, seizure 

Dermatologic: Diaphoresis, hemorrhagic urticaria (rare), pruritus, skin rash, urticaria 

Endocrine & metabolic: Adrenocortical insufficiency, altered hormone level (androgen deficiency; chronic opioid use), amenorrhea, antidiuretic effect, decreased libido, decreased plasma testosterone, hypokalemia, hypomagnesemia, weight gain 

Gastrointestinal: Abdominal pain, anorexia, biliary tract spasm, constipation, glossitis, nausea, vomiting, xerostomia 

Genitourinary: Asthenospermia, decreased ejaculate volume, male genital disease (reduced seminal vesicle secretions), prostatic disease (reduced prostate secretions), spermatozoa disorder (morphologic abnormalities), urinary hesitancy, urinary retention 

Hematologic: Thrombocytopenia (reversible, reported in patients with chronic hepatitis) 

Neuromuscular & skeletal: Amyotrophy, bone fracture, osteoporosis, weakness 

Ophthalmic: Visual disturbance 

Respiratory: Pulmonary edema, respiratory depression 

Warnings 

• May prolong QT interval, which may cause serious arrhythmias.  
• May cause serious, life-threatening, or fatal respiratory depression.  
• Monitor for signs of misuse, abuse, addiction.  
• Prolonged maternal use may cause neonatal withdrawal syndrome.  

Do not confuse methadone with Mephyton, Metadate CD, Metadate ER, methylphenidate, or morphine 

Serious adverse effects: pancreatitis, hypothyroidism, Addison’s disease, head injury, increased intracranial pressure.  

Methadone Dosing and Titration for APRNs 

The following are tips for nurse clinicians in dosing and titrating Methadone (3): 

• The clinician should attempt to reach an optimal dose of methadone safely and quickly (3).  
• Starting methadone at 30mg is recommended.  
• The starting dose of methadone can be increased by 10–15mg every three to five days. 
• Slower titration is recommended for patients at higher risk of toxicity (e.g., older age, sedating medications or alcohol, patients new to methadone).  
• Patients who have recently been on methadone dosing at higher doses (i.e., in the previous week) can be considered for more rapid dose increases based on their tolerance. 
• Once a dose of 75–80mg is reached, the dose can then be increased by 10mg every five to seven days.  
• If four consecutive missed doses, the dose of methadone should be reduced by 50% or to 30mg, whichever is higher. If five or more consecutive doses are missed, methadone should be restarted at a maximum of 30mg and titrated according to patient need.  
• Sustained-release oral morphine (SROM), at a maximum starting dose of 200mg, can be added on the day of a restart as long as the patient has not become completely opioid-abstinent.  
• For patients who use fentanyl regularly, methadone doses of 100mg or higher are often appropriate.  
• Use prescription practices that promote treatment retention, including phone visits, check-ins, extending prescriptions, or leaving longer duration methadone prescriptions for 30mg at the pharmacy so patients can restart treatment.  
• Be aware of the limitations of urine drug testing.  
• Provide treatment for concurrent psychiatric illnesses and substance use disorders. 

Pregnancy and Methadone  

Opioid withdrawal is associated with a high risk for spontaneous abortion and preterm labor, so pregnant patients with OUD should be started as soon as possible and titrated to avoid withdrawal symptoms (3). Hospital admission for rapid up-titration of methadone with augmenting opioids is recommended if possible. When caring for a pregnant patient using fentanyl, it is vital to contact an obstetrical team early. Use of opiates during pregnancy produces withdrawal symptoms in neonate, including irritability, excessive crying, tremors, hyperactive reflexes, fever, vomiting, diarrhea, yawning, sneezing, seizures (12). 

Guidance for Kentucky APRNs 

Prescribing Opioids 

Before prescribing opioids, complete a detailed patient history and assessment that includes: 

• Indication of pain relief request 
• Location, nature, and intensity of pain 
• Prior pain treatments and response 
• Diagnostic testing 
• Comorbid conditions 
• Potential physical and psychologic pain impact on function 
• Family support, employment, and housing 
• Leisure activities, mood, sleep, and substance use 
• Signs of emotional, physical, or sexual abuse 

When considering opioids, weigh the benefits with the risks of abuse or addiction, adverse drug reactions, overdose, and physical dependence. 

Assessment Tools 

Screening tools can assist in determining risk level and the degree of monitoring and structuring required for a treatment plan. Examples include: 

• Brief Intervention Tool 
  • 26-item "yes-no" questionnaire used to identify signs of opioid addiction or abuse.  
• Current Opioid Misuse Measure (COMM) 
  • The Current Opioid Misuse Measure is a 17-item patient self-report assessment. 
• Diagnosis, Intractability, Risk, and Efficacy (DIRE) Tool 
  • The Diagnosis, Intractability, Risk, and Efficacy is a clinician-rated questionnaire used to predict patient compliance with long-term opioid therapy.  
• Opioid Risk Tool 
  • The Opioid Risk Tool is a five-item assessment to evaluate for aberrant drug-related behavior. 
• Pain Assessment and Documentation Tool (PADT) 
  • The U.S. Centers for Disease Control and Prevention (CDC), the Federation of State Medical Boards, and Joint Commission stress documentation from both a quality and diagnostic perspective.  
• Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) 
  • The Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) is a screening with questions addressing the history of alcohol or substance use, cravings, mood/psychological status, and stress. 
• Urine Drug Tests (UDT) 
  • The CDC recommends drug testing before starting opioid therapy and routinely to detect unanticipated drug use. 

Checklists For Prescribers and Dispensers 

• Dose, frequency, and length prescribed consistent with the indication - avoid long-acting opioids for acute pain 
• Age, weight, height, and sex considered 
• Evaluate for potential drug interactions 
• Evaluate for potential allergic reactions 
• Patient informed and verbalized understanding of the risks and benefits 
  • Warnings about addiction, abruptly halting, use of power equipment, side-effects, respiratory depression, avoid sharing or using not as prescribed. 
• Medication use agreement in place. 
• Instructions for storage and disposal of unused opioids. 

Potential Signs of Drug Misuse 

The following are red flags of misuse: 

• Only drugs prescribed are controlled substances 
• Early refills 
• Pays cash, although insurance is present. 
• Lost prescriptions 
• Remote address 
• Multiple prescribers 
• Concerning PDMP or KASPAR (Kentucky All Schedule Prescription Reporting) results 

Prescription Drug Monitoring Programs (PDMPs) 

Kentucky has mandatory PDMP Use Laws for clinicians who prescribe certain medications. APRNs are required to use and apply the information gained from this database into practice. 

Prescription drug monitor programs (PDMPs) are in place in various methods and degrees in all states. These databases assist prescribers and dispensers in working together to decrease drug misuse.  

The key benefits include (6): 

• Assists in monitoring opioid prescriptions. 
• Identify if multiple providers are providing prescriptions for the same individual (avoids "doctor shopping"). 
• Assists regulatory boards, Medicaid, medical examiners, law enforcement, and research organizations in gathering data on the effectiveness and enforcement of regulations. 
• PMP Interconnect allows the sharing of prescription information across state lines. 

KASPAR (Kentucky All Schedule Prescription Reporting) 

KASPER is a controlled substance prescription monitoring system designed to assist practitioners and pharmacists. KASPER also provides an investigative tool for law enforcement and regulatory agencies to assist with authorized reviews and investigations. The report shows all Schedule II through V controlled substance prescriptions a patient has received and a list of prescribers who prescribed them (6). 

Practitioners can request this report to review data on controlled substances administered or dispensed to their patient prior to prescribing. This is also a tool to assess the prescriptions obtained by a birth mother of an infant being treated for neonatal abstinence syndrome or prenatal drug exposure. 

To obtain the report, go to the Kentucky Online Gateway website or call KOG Help Desk at 502-564-0104) 

Requirements for an initial prescribing of a controlled substance for pain or associated with the same primary complaint (201 KAR 9:260 Section 3): (6) 

• Appropriate medical history and physical exam. 
• Obtain KASPER report for the previous 12-month period. 
• Do not prescribe or dispense long-acting or controlled-release controlled substances for acute pain not associated with recent surgery. 
• Explain that the medication is intended to treat acute pain for a time-limited use, and to discontinue when resolved. 
• If Schedule II Controlled Substance or Schedule III Controlled Substances with hydrocodone:  
  • Make a written plan stating the objectives of the treatment and further diagnostic examinations required 
  • Discuss the risks and benefits of controlled substance use. 
  • Obtain written consent for treatment 

Conclusion

When designing a treatment strategy to battle this addiction and abuse crisis, it is important to look at common addiction disorders, the pharmacokinetics of opioids, prescribing guidance and laws, and pharmacological interventions that clinicians can use to help improve this crisis. Kentucky is facing poor outcomes in the battle against opioid use disorders (OUD), but with broader research and education, healthcare policy initiatives, and support of those impacted, there is significant hope! 

Kentucky Pharmacology and Addiction Disorders

Introduction   

Individuals struggling with an addiction often feel powerless and hopeless in the battle. Thankfully, there are effective tools to empower and provide hope to these individuals, including initiatives for support, medications, counseling, behavioral therapies, as well as regulations to prevent inappropriate prescribing.  

This course will provide pharmacology of opioids and drugs that can be an effective treatment tool, including buprenorphine and naltrexone. It is meaningful to explore the etiology of addiction disorders impacting the state of Kentucky and review laws and prescribing regulations.  

Understanding Kentucky Addiction Disorders 

The United States is facing an opioid crisis. The number of overdose deaths involving opioids, including prescription opioids, heroin, and synthetic opioids (like fentanyl), is currently roughly 10 times the number in 1999 (2). Opioid overdoses took the lives of 80,000 people in 2021 in the U.S., and nearly 88% of those deaths involved synthetic opioids (2). 

Kentucky ranks in the top 10 states for drug overdoses in the U.S. (5). In 2022, there were 2,135 overdose deaths in Kentucky approximately 90% of those deaths involved opioids (5). Fentanyl causes more overdose fatalities than any other type of drug and in Kentucky, fentanyl was present in 70% of overdose deaths last year (5). 

In 2021, a total of 12,946 Kentucky residents visited an ED for a nonfatal drug overdose (5).  

Legislators in Kentucky have recognized the devastation of addiction disorders and created many initiates to prevent, identify, and treat addiction disorders, specifically opioid use disorders.  

Opioid-Related Laws and Prescribing Regulations for APRNs in Kentucky 

Several laws and policies are in place to mitigate the impact of increased opioid addiction and deaths. These include regulations for prescribers, legislation permitting the operation of syringe exchange programs, and Good Samaritan laws that provide legal protections to bystanders who seek help in the event of an overdose. 

APRNs should be aware of the state laws, regulations, guidance, and policies related to oversight of opioid prescribing and monitoring of opioid use.  

Kentucky’s Controlled Substances Act governs all controlled substances and has many provisions to be aware of (8). 

• Kentucky’s Senate Bill 192, enacted in 2015, provided substance abuse treatment funds and amended KRS 218A.500 to permit communities to set up syringe exchange programs (8).  
• Kentucky’s Good Samaritan Law (KRS 218A.133) protects individuals from prosecution if they seek medical attention while experiencing a drug overdose in certain circumstances (8). It also protects individuals from prosecution when they report a drug overdose if they stay with the individual who has overdosed until first responders arrive.  
• Kentucky Administrative Regulations (KAR) KRS 218A.172 addresses prescribing and dispensing Schedule II controlled substances and Schedule III controlled substances containing hydrocodone. 
  • It requires prescribers to obtain the patient’s medical history and conduct a physical or mental health examination, obtain patient data in the prescription drug monitoring program (PDMP), make a written plan of treatment, discuss the risks with the patient, obtain written consent for treatment, and review data and modify treatment when needed (8).  
  • KRS 218A:205, limits the prescribing of a Schedule II controlled substance used for acute pain to a 3-day supply (8).  
• Kentucky’s prescription drug monitoring program, Kentucky All Schedule Prescription Electronic Reporting (KASPER KRS 218A.172) requires prescribers to check KASPER. 
  • Required prior to the initial prescribing or dispensing of any Schedule II or Schedule III controlled substance containing hydrocodone  
  • Every three months thereafter 
  • Prescribers are required to complete continuing education relating to the use of KASPER, pain management, addiction disorders, or a combination of two or more of these subjects (KRS 218A.205).  

The exceptions for an APRN to prescribe greater than a 3-day supply of hydrocodone combination products include only the following (4). 

• In the professional judgment of the APRN, more than a 3-day supply is needed. The need must be thoroughly documented. 
• Treating chronic pain. 
• Treating cancer pain. 
• Treating a patient at end of life or in Hospice. 
• Treatment of pain after major surgery or significant trauma as defined by the licensing Board and the Office of Drug Control Policy. 
• Administered directly to the patient in an inpatient setting.  
• Scenarios authorized by the licensing board.  

Basic Pharmacology of Opioids 

Opioids are a group of analgesic agents commonly used in clinical practice. Opioid receptors are G-protein-coupled receptors which cause cellular hyperpolarization when bound to opioid agonists (3). 

As long ago as 3000 BC the opium poppy, Papaver somniferum, was cultivated; followed by morphine being isolated from opium in 1806 by Serturner (3). 

Opioids can also be classified according to their effect on opioid receptors and can be considered as agonists, partial agonists, antagonists, and agonist-antagonists (3). 

• Agonists – interact with an opioid receptor to produce a maximal response from that receptor. 
• Antagonists – bind to receptors but produce no functional response, while at the same time preventing an agonist from binding to that receptor (naloxone).  
• Partial agonists – bind to receptors but elicit only a partial functional response regardless of the amount of drug administered  
• Agonist-antagonists – act as agonist to a certain opioid receptor, but have antagonist activity to another opioid receptor  

Naturally occurring opioid receptors are present throughout the body, both centrally (e.g., in the brain and spinal cord) and peripherally (e.g., in the heart and gut). The primary opioid receptors that have been identified are the mu (μ), kappa (κ), and delta (δ) subtypes (1). All of the opioid receptor subtypes are seven-transmembrane G protein–coupled receptors (GPCRs) that can exist in both active and inactive states.  

Opioid agonists bind to inhibitory G proteins, which ultimately activate various signaling cascades. When opioid receptors are activated, release of the neurotransmitter γ-aminobutyric acid (GABA) is decreased (1). GABA produces a tonic inhibition of dopamine release, so this inhibition of GABA causes an increase in dopamine release. In the past few years, several important advances have occurred in our understanding of opioid receptor functioning, including biased signaling, allosteric regulation, and heteromerization (1). 

Pain can be categorized as nociceptive, neuropathic or nociplastic pain (a combination of both that cannot be entirely explained as nociceptive or neuropathic). Nociceptive pain is generated as a warning signal transmitted to the brain about the possible damage of a non-neural tissue (9).  

Neuropathic pain typically results from damage to neural tissue caused by a disease, toxin, or infection. The next type, called nociplastic pain, is a chronic and complex pain, not completely defined but probably caused by an alteration of neurons’ pain response and an increased sensitivity of the central nervous system (CNS). This pain sensations and is commonly observed in patients with cancer and other long-term chronic disorders (9). 

The opioid system is a physiological control system that facilitates communication among a significant number of endogenous opioid peptides and several types of opioid receptors in the CNS and peripheral nervous system.  

This system also significantly modulates numerous sensory, emotional, cognitive functions, as well as addictive behaviors (9). It is also involved in other physiological functions, including responses to stress, respiration, gastrointestinal transit, endocrine, and immune functions (9).  

Figure 1. Effects of Opioids on the Body. Designed by Author. Information retrieved from (15).  

This design was created and copyrighted by Abbie Schmitt, RN, MSN and may not be reproduced without permission from Nursing CE Central. 

Medication-Assisted Treatment (MAT) for Opioid Use Disorder (OUD) 

An opioid use disorder (OUD) is defined as a problematic pattern of opioid use that leads to serious impairment or distress (1). Medication-assisted treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, in the treatment of opioid use disorders (OUD). The goal is sustained recovery.  

The U.S. Food and Drug Administration (FDA) has only approved three medication assisted treatments (MATs) for opioid use disorder (OUD): buprenorphine, methadone, and naltrexone. 

FDA-approved buprenorphine products approved for the treatment of OUD include: 

• Brixadi (buprenorphine) injection for subcutaneous use 
• Bunavail (buprenorphine and naloxone) buccal film 
• Cassipa (buprenorphine and naloxone) sublingual film 
• Probuphine (buprenorphine) implant for subdermal administration 
• Sublocade (buprenorphine extended release) injection for subcutaneous use 
• Suboxone (buprenorphine and naloxone) sublingual film for sublingual or buccal use, or sublingual tablet. 
• Subutex (buprenorphine) sublingual tablet 
• Zubsolv (buprenorphine and naloxone) sublingual tablets 

FDA-approved methadone products for the treatment of OUD include: 

• Dolophine (methadone hydrochloride) tablets 
• Methadose (methadone hydrochloride) oral concentrate 

FDA-approved naltrexone products for the treatment of OUD include: 

• Vivitrol (naltrexone for extended-release injectable suspension) intramuscular 

The FDA requires that prescribing information for medicines that are intended for use in the outpatient setting include how to safely decrease the dose. Prescribers should not abruptly discontinue opioids in a patient who is physically dependent, but slowly decrease the dose of the opioid and continue to manage pain therapeutically.  

Buprenorphine 

Buprenorphine should be used as part of a comprehensive treatment program to include counseling and psychosocial support. 

Definition 

Buprenorphine is a synthetic opioid developed in the late 1960s and is used to treat opioid use disorder. This drug is a synthetic analog of thebaine, which is an alkaloid compound derived from the poppy flower (6).  

Buprenorphine is categorized as a Schedule III drug. This schedule includes drugs that have a moderate-to-low potential for physical dependence or a high potential for psychological dependence (6).  

Buprenorphine is approved by the U.S. Food and Drug Administration (FDA) to treat acute and chronic pain and opioid use disorder. 

Drug Class 

• Analgesic, Opioid 
• Analgesic, Opioid Partial Agonist 

Uses 

Buprenorphine is used to treat opioid use disorder (OUD) and to manage pain that is severe enough to require long-term opioid treatment, and in patients for which alternative treatment options (e.g., nonopioid analgesics) are ineffective, not tolerated, or inadequate enough to provide sufficient management of pain (13). 

Buprenorphine should be used as part of a complete treatment program to include counseling and psychosocial support. 

Mechanism of Action 

Buprenorphine has an analgesic effect by binding to mu opiate receptors in the CNS. Due to it being a partial mu agonist, its analgesic effects plateau at higher doses and it then behaves like an antagonist (13). This is a meaningful attribute, and this plateauing of its analgesic effects at higher doses, causes it to have ceiling, or limited, effects on respiratory depression (6). This is a positive attribute, signifying its safety superiority. 

Buprenorphine exhibits high-affinity binding to the mu-opioid receptors and slow-dissociation kinetics. In this way, it differs from other full-opioid agonists such as morphine and fentanyl, which results in milder and less uncomfortable withdrawal symptoms for the patient (6). 

Essentially, the benefits of this drug include: (1) higher doses do not lead to greater analgesic effects, thus respiratory depression; and (2) the withdrawal symptoms from buprenorphine are not as intense as full-opioid antagonists.  

The extended-release formulation is injected subcutaneously as a liquid (13). 

Note on absorption: When administered orally, buprenorphine has poor bioavailability due to the first-pass effect, in which the liver and intestine metabolize the drug.  

The preferred route of administration is sublingual, so it can have rapid absorption and circumvent the first-pass effect. Placing the tablet under the tongue results in a slow onset of action, with the peak effect occurring approximately 3 to 4 hours after administration (6). 

Pharmacodynamics/Kinetics 

Pharmacodynamics/Kinetics of buprenorphine include the following (13). 

• Onset of action: Immediate-release IM: ≥15 minutes 
• Peak effect: Immediate-release IM: ~1 hour 
• Duration: Immediate-release IM: ≥ 6 hours; Extended-release Sub-Q: 28 days 
• Absorption: Immediate-release IM and Sub-Q: 30% to 40%.  
  • Application of a heating pad may increase blood concentrations of buprenorphine 26% to 55%. 
• Distribution: Cerebral spinal fluid (CSF) concentrations are 15% to 25% of plasma concentrations 
• Protein binding: High (~96%, primarily to alpha- and beta globulin) 
• Metabolism: Primarily hepatic via N-dealkylation by CYP3A4 to norbuprenorphine (active metabolite), and to a lesser extent via glucuronidation by UGT1A1 and 2B7 to buprenorphine 3-O-glucuronide; the major metabolite, norbuprenorphine, also undergoes glucuronidation via UGT1A3; extensive first-pass effect 
• Bioavailability (relative to IV administration): Buccal film: 46% to 65%; Immediate-release IM: 70%; Sublingual tablet: 29%; Transdermal patch: ~15% 
• Half-life elimination in adults: 
  • IV: 2.2 to 3 hours 
  • Buccal film: 27.6 ± 11.2 hours 
  • Sublingual tablet: ~37 hours 
  • Transdermal patch: ~26 hours 
• Time to peak, plasma:  
  • Buccal film: 2.5 to 3 hours 
  • Extended-release Sub-Q: 24 hours, with steady state achieved after 4 to 6 months 
  • Subdermal implant: 12 hours after insertion, with steady state achieved by week four 
  • Sublingual: 30 minutes to 1 hour  
  • Transdermal patch: Steady state achieved by day three 
• Excretion: Most of the drug and its metabolite are eliminated through feces, with less than 20% excreted by the kidneys (6) 
• Clearance: Related to hepatic blood flow 
  • Adults: 0.78 to 1.32 L/hour/kg  

Adverse Effects 

Buprenorphine has anticholinergic-like effects and may cause CNS depression, dry mouth, dizziness, hypotension, drowsiness, QT prolongation, and lower seizure threshold (6).  

Additional adverse effects of buprenorphine include: 

• Nausea 
• Vomiting 
• Headache 
• Memory loss 
• Orthostatic hypotension 
• Urinary retention 

Following buprenorphine treatment, a patient's tolerance to opioids decreases, increasing risk for harm if they resume their previous opioid dosage. Patients should be strongly advised against using opioids without prior consultation with their healthcare provider. 

Warnings 

Prescribers should exercise caution when prescribing buprenorphine to patients with hepatic impairment, morbid obesity, thyroid dysfunction, a history of ileus or bowel obstruction, prostatic hyperplasia or urinary stricture, CNS depression or coma, delirium tremens, depression, anxiety disorders, posttraumatic stress disorder, and toxic psychosis (6).  

Concerns related to adverse effects: 

Hepatic Impairment 

• In individuals with hepatic impairment, such as patients with hepatitis B and C, the dose of buprenorphine has to be modified to prevent toxicity (6). As buprenorphine metabolism takes place in the liver, individuals with liver impairment should undergo close monitoring of their liver function and drug levels. Clinicians should educate patients with hepatitis about the correlation between IV use of buprenorphine and hepatotoxicity (6). 
• For buccal film and sublingual tablets in patients with severe hepatic impairment, it is advisable to reduce the dose by 50% and closely monitor for signs and symptoms of toxicity.  

• Subcutaneous injections are not recommended.  

CNS Depression 

• Due to side effects and CNS depression, patients must be cautioned about performing tasks that require mental alertness (e.g., operating machinery, driving). 

Hypersensitivity Reactions 

• Hypersensitivity, including bronchospasm, angioneurotic edema, and anaphylactic shock, have been reported. The most common symptoms include rash, hives, and pruritus. 

Hypotension 

• Clinicians must be aware of possible hypotension (including orthostatic hypotension and syncope); use with caution in patients with hypovolemia, cardiovascular disease, or if patient takes drugs that may exaggerate hypotensive effects (including phenothiazines or general anesthetics).  
• Monitor for symptoms of hypotension following initiation or dose titration.  

Infection from Subdermal Implant 

• Infection may occur at the site of insertion or removal (6). 

Figure 2. Buprenorphine Injectable (13) 

Naltrexone 

Naltrexone is a pure opioid antagonist, it acts as a competitive antagonist at opioid receptor sites, showing the highest affinity for mu receptors (14).  

Naltrexone was developed in 1963 and patented in 1967 and is used for treatment of alcohol use disorders (6). In 1984, naltrexone received approval for medical use in the U.S.  

Drug Class 

• Antidote 
• Opioid Antagonist 

Uses 

• Alcohol use disorder: FDA-approved 
• Opioid use disorder: For the blockade of the effects of exogenously administered opioids; FDA-approved 
• A fixed-dose combination of naltrexone and bupropion is FDA-approved for obesity (6) 
• Researchers are studying its use in patients with stimulant use disorder, particularly patients with polydrug dependence on opioids, heroin, and amphetamine (6)  

Mechanism of Action 

Naltrexone (and its active metabolite 6-beta-naltrexone) is pharmacologically effective against opioids by blocking the mu-opioid receptor.  

Naltrexone blocks the effect of opioids and prevents opioid intoxication and physiologic dependence on opioid users. Naltrexone helps with alcohol dependency because it modifies the hypothalamic-pituitary-adrenal axis to suppress ethanol consumption (14) . 

Opioids act mainly via the mu receptor, although they affect mu, delta, and kappa-opioid receptors. Naltrexone competes for opiate receptors and displaces opioid drugs from these receptors, thus reversing their effects (14). It is capable of antagonizing all opiate receptors. (14). Exogenous opioids include the commonly prescribed pain relievers such as hydrocodone, oxycodone, and heroin. These typically induce euphoria at much higher doses than those prescribed by medical providers to relieve pain. If naltrexone occupies the receptors, the opioids are not going to provide these euphoric effects.  

According to guidelines by the American Society of Addiction Medicine (ASAM), a combination of buprenorphine and low doses of oral naltrexone is effective for opioid use disorder for managing withdrawal (14).  

Pharmacodynamics/Kinetics 

• Duration: Oral: 50 mg: 24 hours; 100 mg: 48 hours; 150 mg: 72 hours; IM: 4 weeks 
• Absorption: Oral: Almost complete 
• Distribution: Vd: ~1350 L; widely throughout the body but considerable interindividual variation exists 
• Metabolism: Extensively metabolized via noncytochrome-mediated dehydrogenase conversion to 6-beta-naltrexol (primary metabolite) and related minor metabolites; glucuronide conjugates are also formed from naltrexone and its metabolites 
• Oral: Extensive first-pass effect 
• Protein binding: 21% 
• Bioavailability: Oral: Variable range (5% to 40%) 
• Half-life elimination:  
  • Oral: 4 hours; 6-beta-naltrexol: 13 hours 
  • IM: naltrexone and 6-beta-naltrexol: 5 to 10 days (dependent upon erosion of polymer) 
• Time to peak, serum:  
  • Oral: ~60 minutes 
  • IM: Biphasic: ~2 hours (first peak), ~2 to 3 days (second peak) 
• Excretion: Primarily urine (as metabolites and small amounts of unchanged drug) 

Side Effects 

Commonly reported side effects of naltrexone include: 

• Abdominal pain 
• Gastrointestinal Distress 
  • Constipation  
  • Nausea and vomiting 
  • Diarrhea 
• Insomnia 
• Joint and muscle pain 
• Fatigue 
• Loss of strength and energy 
• Tooth pain 
• Dry mouth 
• Increased thirst 

Warnings  

Patients should be opioid-free for a minimum of 7 to 10 days prior to taking naltrexone (14) 

Prescribers must be aware that patients who had been treated with naltrexone may respond to lower opioid doses than previously used, which could result in potentially life-threatening or fatal opioid intoxication. Patients should be educated that they may be more sensitive to lower doses of opioids after naltrexone treatment is discontinued, after a missed dose, or near the end of the dosing interval (14).  

Opioid withdrawal may be noted in patients, and symptoms include pain, hypertension, sweating, agitation, and irritability; in neonates: shrill cry, failure to feed (14). 

Cases of eosinophilic pneumonia have been reported and should be assessed in patients presenting with progressive hypoxia and dyspnea. 

Hepatotoxicity can occur, and clinicians should note that elevated transaminases may be a result of alcoholic liver disease, hepatitis B and/or C infection, or concomitant use of other hepatotoxic drugs; abrupt opioid withdrawal may also lead to acute liver injury. Clinicians should discontinue this drug if any signs or symptoms of hepatotoxicity are found.  

Drug-Drug Interactions: 

• Bremelanotide- Contraindicated to administer with naltrexone due to reduced therapeutic effect of naltrexone (10). 
• Thioridazine – Contraindicated to administer with naltrexone due to the risk of lethargy and somnolence (10). 
• Methylnaltrexone: May enhance the adverse/toxic effect of opioid antagonists; the risk for opioid withdrawal may be increased (14).  
• Naldemedine: Opioid Antagonists may enhance the adverse/toxic effect of naldemedine; the risk for opioid withdrawal may be increased (14).  

Treatment Resources  

The KY HELP Call Center is available to those with a substance use disorder, or their friends or family members, as a resource for information on treatment options and treatment providers.  

Individuals may call 833-8KY-HELP (833-859-4357) to speak one-on-one with a specialist who will connect them with treatment as quickly as possible (5).  

The Kentucky Injury Prevention and Research Center (KIPRC) at the University of Kentucky College of Public Health manages a vital website, www.findhelpnowky.org, for Kentucky health care providers, court officials, families and individuals seeking options for substance abuse treatment and recovery (5).  

The Kentucky State Police (KSP) Angel Initiative is a proactive program designed to help those who battle addiction. There are 16 posts located throughout the commonwealth that will connect individuals with a local officer who will assist with locating an appropriate treatment program. The Angel Initiative is completely voluntary, and individuals will not be arrested or charged with any violations if they agree to participate in treatment.  

Figure 3. Substance Use Disorder Call Center Contact Information (5) 

Conclusion

A common theme among individuals who struggle with OUD is a loss of power to this addictive substance. There is significant opportunity to help this population gain back control, including legislation and supportive initiative, and appropriate combined use of medications, counseling, and behavioral therapies. Knowledge on the pharmacology of opioids, as well as buprenorphine and naltrexone is critical. Although the opioid crisis is substantial, there is hope on the horizon. 

Kentucky Pharmacology of Medical Cannabis

Introduction   

With the recent legalization of medical cannabis in Kentucky, healthcare professionals are at the forefront of new treatment possibilities for patients. This course offers a deeper understanding of the pharmacology, clinical applications, and legal landscape surrounding medical cannabis in the Commonwealth of Kentucky.

As the demand for alternative treatments grows, medical cannabis has shown potential in managing chronic pain, epilepsy, and a variety of other conditions. However, understanding how to responsibly prescribe, monitor, and educate patients on its use is crucial.

Prepare to explore the science behind cannabinoids, the legal requirements specific to Kentucky, and the ethical considerations that accompany this emerging treatment option. Whether you are new to cannabis medicine or looking to expand your knowledge, this course will empower you to provide your patients with safe and informed access to medical cannabis.

Kentucky Prescribing Laws

​Kentucky is faced with an overwhelming crisis of addiction and deaths related to opioids. Medical cannabis can be a powerful tool to fight against this crisis. Governor Andy Beshear signed Senate Bill 47 on March 31, 2023, which legalizes medical cannabis effective Jan. 1, 2025 (6). The Office of Medical Cannabis in the Cabinet for Health and Family Services is responsible for implementing and administering Kentucky's Medical Cannabis Program (6).

There are several FDA-approved medical cannabis products are used for specific medical conditions. Beyond these FDA-approved products, certain states within the U.S., now including Kentucky, have legalized the use of medical cannabis products (containing THC, CBD, or both) for specific medical conditions. These products are not FDA-approved but are regulated by state laws.

Medical providers may choose to prescribe FDA-approved medications and/or give qualifying patients a written certification for medical cannabis and guide them in purchasing at dispensaries based on their condition and unique medical needs.

Key aspects of the law regarding prescribing medical cannabis in Kentucky can be organized by (1) prescribing guidelines, (2) qualifying conditions, (3) regulation, (4) prescribing limits, and (5) business licensing regulations.

Prescribing Process

To obtain medical cannabis, patients must visit a Registered Medical Cannabis Practitioner to receive a written certification. This certification is then submitted to the state, and if approved, the patient will be issued a medical cannabis card allowing them to legally purchase and use cannabis.

To become a Registered Medical Cannabis Practitioner in Kentucky, healthcare providers must follow specific steps per Senate Bill 47 and guidelines established by the Kentucky Office of Medical Cannabis.

These criteria and steps (6):

1. Hold a Valid Medical License 
   • Applicants must be licensed medical providers, such as a physician (MD/DO) or advanced practice registered nurse (APRN), in good standing with the Kentucky Board of Medical Licensure or the Kentucky Board of Nursing. 
2. Complete Required Training 
   • Kentucky requires practitioners to complete specialized training or continuing education on medical cannabis, including its therapeutic uses, legal requirements, and potential risks.  
   • The Cabinet for Health and Family Services has developed the program’s regulations. 
3. Register with the Kentucky Medical Cannabis Program 
   • Practitioners must register with the Kentucky Office of Medical Cannabis to become authorized to recommend medical cannabis to patients.  
   • The application process verifies your licensure and completion of any required training. 
4.  Comply with Medical Cannabis Certification Requirements 
   • Once registered, practitioners can issue medical cannabis certifications to patients with qualifying conditions.  
   • Practitioners must follow state laws, including appropriate documentation, patient education, and ensuring compliance with the specific qualifying conditions outlined by Kentucky law. 
5. Maintain Compliance with State Regulations 
   • Providers must comply with ongoing legal and ethical standards.  
   • The Cabinet for Health and Family Services will monitor compliance, and practitioners may be required to submit records or documentation for review.

Practitioners can stay updated on regulatory changes by visiting the official website: Kentucky Medical Cannabis Program.

Qualifying Conditions

Medical cannabis can be prescribed to patients diagnosed with conditions such as cancer, multiple sclerosis, chronic pain, epilepsy, PTSD, and other serious ailments. The Cabinet for Health and Family Services will regulate the full list of qualifying conditions.

The conditions allowed for medical cannabis prescription in Kentucky include (6):

• Cancer 
• Chronic pain 
• Epilepsy 
• Multiple sclerosis (MS) 
• Post-Traumatic Stress Disorder (PTSD) 
• Chronic nausea 
• Muscle spasms 
• For other medical conditions, the Kentucky Center for Cannabis will grant allowance if sufficient scientific data and evidence are presented supporting that an individual diagnosed with that condition is likely to receive medical, therapeutic, or palliative benefits from the use of medicinal cannabis.

These conditions are deemed severe enough to warrant medical cannabis as a treatment option to help manage symptoms such as pain, nausea, seizures, and muscle spasms. The state may update or expand this list based on future regulations and medical findings (6).

Patients must obtain a certification from a registered medical provider, after which they will be issued a medical cannabis card to legally purchase and use cannabis within the prescribed limits (6).

Regulation

The Cabinet for Health and Family Services will oversee the implementation of the medical cannabis program, ensuring that products are contaminant-free, accurately labeled, and that dispensaries and other businesses operate safely. Regulations will emphasize precautions to keep cannabis away from minors and unauthorized users.

Prescribing Limits

There is a limit on the amount of medical cannabis an individual can possess. For example, within 30 days, a patient may hold up to 4 ounces of raw cannabis, or 28 grams of concentrate.

Business Licensing

Medical cannabis will be dispensed through licensed and regulated dispensaries. There will be a limited number of cultivation and dispensary licenses issued throughout the state to ensure a controlled distribution of cannabis products. Regulations for cannabis dispensary businesses outline how cultivators, processors, producers, safety compliance facilities, and dispensaries can apply, become licensed, and operate in Kentucky. (6)

Steps for Patients to Obtain Medical Cannabis in Kentucky

1. Obtain a Medical Cannabis Card: After receiving a written certification from a registered healthcare provider, patients must apply to the Kentucky Office of Medical Cannabis to get a medical cannabis card. 
2. Visit a Licensed Dispensary: Once a medical cannabis card is obtained, patients will be able to purchase cannabis products from one of the licensed dispensaries operating throughout Kentucky. 
3. Follow Purchase and Use Guidelines: Patients can purchase medical cannabis products within the legal limits set by the program (e.g., certain amounts of raw plant material, concentrates, or THC-infused products).

Overview and Definitions

Cannabis is one of the most commonly used substances worldwide. It has been used for centuries for recreational and medical use. Cannabis comes in a variety of strains with different concentrations of phytocannabinoids.

Cannabis is becoming more popular due to research supporting therapeutic effects on medical conditions with fewer safety issues. For example, it is not associated with fatal overdoses (1). The human lethal dose is estimated at over 15 g of THC, which is well above the recommended dose. The lethal dose is 750 times greater than a typical intoxicating dose of 20 mg (1). Additionally, unlike opioids, cannabis does not cause respiratory depression due to low cannabinoid receptor expression in the brainstem.

Cannabis has been known by many names, including marijuana, weed, pot, ganja, and Mary Jane. The primary product is the dried flowers of the Cannabis Sativa plant.

Cannabis has been used in various forms, the most common being (13):

• Pulmonary Route
  • Smoking and vaping  
• Gastrointestinal Route 
  • Edibles, tea, and other food products  
• Dermal Route 
  • Creams and ointments

The Cannabis Plant and its Components

The cannabis plant is a complex organism that has been used for medicinal, recreational, and industrial purposes for centuries. It belongs to the Cannabaceae family and contains a variety of chemical compounds that contribute to its effects on the human body (11).

Medicinal cannabis encompasses a diversity of products. Cannabis contains approximately 500 molecules that create about 100 plant-derived cannabis compounds (phytocannabinoids), terpenes, and flavonoids. Widely used phytocannabinoids include A9-tetrahydrocannabinol (THC) and cannabidiol (CBD).

THC is responsible for the intoxicating effects of recreational cannabis, whereas CBD is not intoxicating (1). There are unique therapeutic properties, which are attributed to its chemical components, including cannabinoids, terpenes, and flavonoids. Below is a description of the key components of the cannabis plant:

Cannabinoids

• THC (Tetrahydrocannabinol): This is the primary psychoactive compound in cannabis, responsible for the “high” associated with its use. THC affects mood, perception, and cognitive functions. It also has therapeutic uses, such as pain relief and appetite stimulation.
• CBD (Cannabidiol): Unlike THC, CBD is non-psychoactive and has other therapeutic properties, including anti-inflammatory, analgesic, anti-anxiety, and anti-seizure effects.
• Other Cannabinoids: CBG (Cannabigerol), CBN (Cannabinol), and THCV (Tetrahydrocannabivarin), each with unique effects and potential therapeutic benefits.

Terpenes

• Terpenes are aromatic compounds found in cannabis and many other plants. They contribute to the plant’s distinct scent and flavor profiles. Beyond aroma, terpenes also have therapeutic effects and work synergistically with cannabinoids in what is known as the “entourage effect.”  
• Some of the key terpenes found in cannabis include: 
  • Limonene: This terpene has a citrus-like aroma, and it’s shown to often have anti-anxiety and mood-enhancing properties. 
  • Myrcene: Has a musky, earthy scent and is believed to help with sleep. 
  • Pinene: Found in pine trees, it may improve focus and memory and has anti-inflammatory properties. 
  • Linalool: Has a lavender-like scent, this terpene is believed to reduce anxiety and stress.

Flavonoids

Flavonoids are not a well-known group of compounds found in cannabis. They are responsible for the color and pigmentation of the plant, while they also have antioxidant and anti-inflammatory effects (13).

Plant Structure

• Leaves: Cannabis leaves are uniquely shaped and used to identify the plant. They contain trichomes (small glands) that produce and store cannabinoids and terpenes. 
• Flowers (Buds): The flowers or buds of the female cannabis plant contain the highest concentration of cannabinoids and terpenes. This is the part of the plant that is typically harvested for consumption. 
• Seeds: Cannabis seeds do not contain cannabinoids but are used for industrial purposes, such as producing hemp oil and protein. 
• Stalks and Fibers: In industrial applications, the fibers of the cannabis plant are used to make textiles, paper, and building materials. Hemp, a variety of cannabis, is particularly known for its durable fibers.

Types of Cannabis Plants

There are several types of cannabis plants, and they are typically classified based on their species, characteristics, and effects. Dispensaries may offer products based on types of cannabis plants.

The most common types of cannabis plants include (11):

• Cannabis Sativa 
  • Native to equatorial regions such as Central and South America, Southeast Asia, and Africa. 
  • Sativa plants are tall, often growing over 10 feet, with narrow, light green leaves. 
  • Known for providing an energizing and uplifting high, Sativa strains are often used to enhance focus, creativity, and productivity. 
  • Uses: Commonly recommended for treating conditions like depression and chronic fatigue. 
• Cannabis Indica 
  • Commonly found in colder, mountainous regions such as Afghanistan, Pakistan, and India. 
  • Indica plants are shorter, bushier, and have broad, dark green leaves. They tend to grow faster and have shorter flowering periods. 
  • Indica strains are known for their sedative and relaxing effects. 
  • Uses: Managing chronic pain, insomnia, anxiety, and muscle spasms. 
• Cannabis Ruderalis 
  • Native to Central and Eastern Europe and Russia. 
  • It is generally used for medicinal use, as its low THC content makes it less psychoactive but still useful in treating certain medical conditions. 
• Hybrid Strains of Cannabis 
  • Hybrids are made by crossbreeding Sativa, Indica, and sometimes Ruderalis to combine the best effects of both Sativa and Indica for specific therapeutic or recreational needs. 
  • Sativa-dominant hybrids: Uplifting and energizing effects. 
  • Indica-dominant hybrids: Calming, relaxing effects. 
  • Balanced hybrids: A mix of mental and physical effects. 
  • Hybrids are tailored to meet individual needs, often used for managing conditions like pain, anxiety, insomnia, and lack of appetite.

Pathophysiology

Cannabinoid receptors are G protein-coupled receptors that regulate the activity of neurotransmitters that maintain homeostasis. Activation of cannabinoid receptors occurs when the endocannabinoids produced by the body, or compounds derived from the cannabis plant or synthetic cannabinoids, bind to them. Activation of cannabinoid receptors inhibits the action of adenylyl cyclases and blocks specific calcium voltage-gated channels while stimulating selected mitogen-activated protein kinases and potassium channels (7). The cannabinoid receptors are modulated by fatty acid neurotransmitters called endocannabinoids or endogenous cannabinoids.

G-protein coupled receptors (GPCRs) are a large family of receptors on the surface of a cell that play a crucial role in transmitting signals from the outside of a cell to the inside. These receptors respond to a variety of external stimuli, such as hormones, neurotransmitters, and sensory signals (like light or odor molecules). Once activated by these signals, GPCRs interact with G-proteins inside the cell, which then trigger various cellular responses, including changes in enzyme activity, ion channel function, or gene expression.

There is widespread distribution of 2 G-protein-coupled receptors (GPCRs) – cannabinoid (CB) CB1 and CB2 – throughout the human body (12). CB1 receptors are primarily concentrated in the central nervous system, but CB1 receptors have also been identified in other areas, including in cardiac tissue, reproductive organs, and the gastrointestinal tract (12). CB2 receptors are concentrated in the immune system and other peripheral regions and organs (12).

CB1 receptors are found throughout the nervous system.

• Effects of this receptor include: 
• Euphoric effects 
• Hypotension 
• Anti-inflammatory response 
• Immunosuppression 
• Analgesia 
• Appetite stimulant

CB2 receptors are found in tissues of the immune system, liver, and some neurons.

• Associated with anti-inflammatory effects and immune modulation.

The Endocannabinoid System

The endocannabinoid system (ECS) comprises a large neuromodulator network throughout the central nervous system (CNS) and body. Essentially, this system is a mediator to regulate a harmonious balance between the brain and the body. The ECS is an extensive network of receptors, their endogenous ligands, and enzymes that synthesize and degrade those ligands (12). Major problems arise when the nervous system and body are out of synch – imagine the ECS is a language translator between two individuals, relaying either positive or negative messages.

The ECS affects biological functions, including sleep, memory, mood, learning, hunger and feeding, and pain (9).

The endogenous or exogenous activation of CB1 and CB2 receptors from the cannabis plant has a significant influence on the regulation of diverse systems throughout the body, which points toward numerous possible clinical implications for the therapeutic use of cannabis in managing chronic conditions.

Clinical Application and Use

Cannabis for medical conditions is being actively researched. Cannabis does not cause respiratory depression like opioids, which would be an ideal alternative or adjunct to opioids.

Pharmaceutical products may be obtained with a valid prescription at pharmacies in the United States. However, whole-plant and artisanal formulations are available from stores only in states that have legalized cannabis for medical or recreational use since cannabis is largely still illegal at the federal level at this time. Kentucky is legalizing it only for appropriate medical purposes with guidelines and restrictions.

Qualifying conditions include any type or form of cancer, chronic pain, epilepsy or other seizure disorder, spasticity, multiple sclerosis, chronic nausea or vomiting, and post-traumatic stress disorder. There are other medical conditions or diseases for which the Kentucky Center for Cannabis may find medical cannabis appropriate if research supports its effectiveness.

Patients under 18 cannot purchase cannabis, their parents or legal would need to pick up and administer their medical cannabis.

Remember, prescribers must understand the varying ratios of THC and CBD in medical cannabis and that different ratios are more effective for certain medical conditions.

Cannabis cultivators classify the products under the following chemotypes:

• Chemotype I – THC: CBD ratio is ≥10 
• Chemotype II – THC: CBD ratio is between 0.2 and 10 
• Chemotype II – THC: CBD <0.2 
• Chemotype IV is predominantly Cannabigerol

THC is responsible for most of the pharmacological outcomes of cannabis, including analgesic, antioxidant, anti-inflammatory, bronchodilator, antipruritic, and anti-spastic activities (4). However, THC has a psychoactive effect and can promote dependency among chronic users as it interacts with the dopaminergic system (4). CBD is reported to reduce inflammation, muscle spasms, seizures, and anxiety, which can also be helpful in therapeutic cancer management.

Cancer

Pain is very common among those with cancer. Roughly 30% to 50% of people with cancer will experience moderate‐to‐severe pain. Pain can be a consequence of the tumor itself or treatment interventions, including surgery, chemotherapy, and radiotherapy (4). This can have a major negative impact on their quality of life. However, pain is not sufficiently relieved by opioid medications in 10% to 15% of those with cancer, so alternatives are needed to effectively and safely supplement or replace opioids. Currently, an increasing number of patients with chronic cancer pain are seeking alternative treatment options. 

Nausea and vomiting can also have a significant impact on cancer patients, as they are common side effects of chemotherapeutic agents. 

Poor appetite and nutrition can result from cancer treatments. Tumors can also release molecules that mimic natural hormones involved in satiety. 

Research on medicinal cannabis in simulating appetite has been tried in cancer patients with positive outcomes (13). 

Chronic Noncancer Pain

The ECS is intricately involved in pain perception and pain modulation, with endocannabinoids and CB receptors found in peripheral tissues, the spinal cord, and areas of the brain associated with nociception. Endocannabinoids and phytocannabinoids have demonstrated antinociceptive effects for acute pain, inflammatory pain, and neuropathic pain (12).

A systematic review published in 2022 reviewed placebo groups and various THC: CBD ratios (high, comparable, or low); the studies found that synthetic products with high THC: CBD ratios were associated with a moderately beneficial effect on pain and an increased risk for sedation (12).

Given the increasing consequences of the use of opioids for the treatment of chronic pain and the risk for opioid abuse and diversion, there is considerable interest in whether medical cannabis could replace or reduce opioids in these patients. A recent systematic review found evidence from observational studies suggesting that cannabis-based medicines are associated with a reduction in opioid use. However, additional longitudinal studies are needed.

Epilepsy and other Seizure Disorders

The ECS regulates neuronal excitability and is used for the treatment of epilepsy. There is high-quality evidence that medical cannabis has been shown to decrease the frequency of seizures compared to placebo (13).

The only approved purified CBD formulation in the U.S. is Epidiolex, which is a form of purified CBD (~99%) with minimal <1% THC (13). Epidiolex is the first and only FDA-approved drug derived from the cannabis plant and is used to treat seizures associated with three rare and severe forms of epilepsy: Lennox-Gastaut syndrome (LGS), Dravet syndrome, and Tuberous Sclerosis Complex (TSC).

Multiple Sclerosis

Multiple sclerosis (MS) is a chronic disease of the CNS and is characterized by demyelinating plaques in grey and white matter that leads to progressive neuroaxonal loss.

The most distressing and challenging to treat symptoms of multiple sclerosis are spasticity, painful spasms, and neuropathic pain.

Nabiximol was developed to treat MS symptoms, including neuropathic pain and spasticity.

Post-Traumatic Stress Disorder

The cannabinoid-1 receptor (CB1) and endocannabinoid anandamide have been implicated in the etiology and pathophysiology of PTSD (10). However, research studies have found varying results on the effectiveness of this treatment. One study found an increase in suicidal ideation among veterans diagnosed with PTSD following the use of medical cannabis (10). Essentially, further research and close monitoring are needed.

Pharmacokinetics

As of 2024, several FDA-approved medical cannabis products are used for specific medical conditions. The drugs are derived from cannabis or synthetic cannabinoids and have been approved for use in treating certain conditions.

Medical providers can prescribe these medications or guide patients in purchasing medical cannabis at dispensaries based on their condition and unique medical needs. Prescribers need to carefully consider the A9-tetrahydrocannabinol (THC) and/or cannabidiol (CBD) content of the products, essentially the ratios of each compound and the use for specific medical conditions. Essentially, medical cannabis is not a “one size fits all”.

CBD is not intoxicating and has fewer adverse effects than THC. However, THC has increased analgesia effects. Meta-analysis of studies found that synthetic products with high THC: CBD ratios (e.g., dronabinol, nabilone) were associated with a moderately beneficial effect on pain severity but had an increased risk for sedation (12).

It is recommended to prescribe relatively low doses and slowly increase the dosage to minimize dose-related toxicities and the potential for drug-drug interactions with concomitant medications (1).

FDA-Approved Medical Cannabis Products: 

• Epidiolex (Cannabidiol) 

• Marinol (Dronabinol) 

• Cesamet (Nabilone)

Cannabidiol (Epidiolex)

Cannabidiol is an oral cannabinoid indicated for the treatment of seizures associated with Lennox-Gastaut syndrome, Dravet syndrome, and tuberous sclerosis complex (3).

Cannabidiol is a derivative; however, it lacks the psychoactive properties commonly associated with delta-9-tetrahydrocannabinol (THC). Adjunctive cannabidiol treatment significantly reduced seizure frequency in this population with a reduction in seizures observed within 4 weeks of initiation (3).

Drug Class

• Anticonvulsant 
• Cannabinoid 

Uses

Cannabidiol is an oral cannabinoid indicated for the treatment of seizures associated with Lennox-Gastaut syndrome, Dravet syndrome, and tuberous sclerosis complex (3, 14).

Mechanism of Action

The precise mechanisms of action of this drug's anticonvulsant effect are unknown. Epidiolex does not appear to bind with cannabinoid receptors (3). It is suspected to be effective in epilepsy by modulating the endocannabinoid system by preventing the degradation of anandamide, which is an endocannabinoid that may have a role in seizure inhibition. Epidiolex is also believed to regulate T-type calcium channels and nuclear peroxisome proliferator-activated receptor gamma, which are both involved in seizure activity (3).

Pharmacokinetics

Pharmacokinetics (3):

• Cannabidiol is administered orally.  
• Protein binding of cannabidiol and its metabolites is more than 94%. 
• Cannabidiol is metabolized by the liver (primarily) and the gut.  
• The active metabolite, 7-OH-CBD, is further converted to an inactive metabolite, 7-COOH-CBD.  
• Half-life ranges from 56 to 61 hours after twice-daily dosing for 7 days.  
• Plasma clearance after a single 1,500 mg dose is 1,111 L/hour.  
• Excretion occurs in the feces with minor renal clearance.

Adverse Reactions

Adverse reactions (14):

• Elevated hepatic enzymes, hyperammonemia 
  • Serum creatinine elevations of approximately 10% were observed within 2 weeks of starting cannabidiol.  
  • Cannabidiol causes elevated hepatic enzymes (8% to 25%). Promptly measure serum transaminases and total bilirubin and discontinue if the patient develops clinical signs or symptoms suggestive of liver injury (e.g., unexplained nausea, vomiting, right upper quadrant abdominal pain, fatigue, anorexia, jaundice, and/or dark urine). 
• Anemia, eosinophilia, thrombocytopenia 
  • Cannabidiol can cause decreases in hemoglobin and hematocrit. Anemia (7%), decreased platelet count/thrombocytopenia (5%), and increased eosinophil count/eosinophilia (5%) were reported in cannabidiol-treated patients during tuberous sclerosis complex (TSC) trials.  
• Agitation and irritability 
• Insomnia and sleep disturbance 
• Drowsiness and lethargy 
• Hypersalivation 
• Angioedema, erythema, pruritus, rash 
• Suicidal ideation and behavior 
  • Monitor all patients beginning treatment with AEDs or currently receiving such treatment closely for emerging or worsening suicidal thoughts/behavior or depression. Patients and caregivers should be informed of the increased risk of suicidal thoughts and behaviors and should be advised to immediately report the emergence or worsening of depression, the emergence of suicidal thoughts or behavior, thoughts of self-harm, or other unusual changes in mood or behavior.  
• Anorexia (16% to 22%), diarrhea (9% to 31%), vomiting (17%), nausea (9%), weight loss (3% to 7%), gastroenteritis (0% to 8%), and abdominal pain/discomfort (3%) were reported during clinical trials.

Warnings / Contraindications

THC found in medicinal cannabis may acutely impair cognitive function. It should not be prescribed for children or adolescents unless the benefits outweigh the risks. THC-containing cannabis products should not be prescribed to individuals with angina or a history of myocardial infarction, or to those who have a personal or family history of psychosis, depression, or suicidal ideation. (3)

Cannabidiol is contraindicated in patients with a history of cannabidiol hypersensitivity, sesame oil hypersensitivity, or hypersensitivity to any of the ingredients in the product.

Cannabidiol dosage adjustment is recommended in patients with moderate or severe hepatic disease. Obtain serum transaminase (ALT and AST) and total bilirubin concentrations before starting cannabidiol treatment, at 1 month, 3 months, and 6 months after initiation, and periodically thereafter or as clinically indicated (3). Patients taking valproate or clobazam are at greater risk, so consider more frequent monitoring of serum transaminases and bilirubin in patients who are taking valproate or who have elevated baseline hepatic enzymes.

Patients should avoid abrupt discontinuation, cannabidiol should be discontinued gradually. As with all antiepileptic drugs, abrupt discontinuation of cannabidiol can increase the risk of seizure frequency and status epilepticus (14).

Pregnancy and breast-feeding: There is not enough data on the developmental risks associated with cannabidiol use during pregnancy or lactation. This drug is highly lipophilic, and it is expected to be secreted in human milk. Consider the developmental and health benefits of breastfeeding along with the mother's clinical need for cannabidiol and any potential adverse effects on the breast-fed infant from cannabidiol or the underlying maternal condition. (14)

Oral Dosage

• Adults: 2.5 mg/kg/dose PO twice daily; increase in weekly increments of 2.5 mg/kg/dose twice daily as tolerated. The recommended maintenance dosage is 5 mg/kg/dose PO twice daily. Max: 10 mg/kg/dose PO twice daily.  
• Children and Adolescents (1 to 17 years): 2.5 mg/kg/dose PO twice daily; increase in weekly increments of 2.5 mg/kg/dose twice daily as tolerated. Continue to the recommended maintenance dosage of 5 mg/kg/dose PO twice daily. Max: 10 mg/kg/dose PO twice daily.  
• If rapid titration is necessary, increase the dosage no more frequently than every other day.

Alternatives

Antiepileptic drugs (AEDs) would be an appropriate alternative, as well as sodium channel blockers, calcium channel blockers, and GABA drugs.

Dronabinol

Dronabinol is a synthetic oral preparation of delta-9-tetrahydrocannabinol (delta-9-THC) and is a cannabinoid (3).

Brand Names: Marinol, SYNDROS

Drug Class

Cannabinoid 

Uses

Dronabinol is FDA-approved for:

• Nausea and vomiting secondary to cancer chemotherapy or HIV/AIDS 
• Appetite stimulant

Mechanism of Action

Dronabinol is an orally active cannabinoid (a synthetic form of THC). As mentioned earlier, the majority of effects of cannabinoids and endocannabinoids are completed by the two inhibitory G-protein coupled receptors (GPCRs): CB1 (present in high levels in several brain regions, including the prefrontal cortex, hippocampus, amygdala, basal ganglia, and the cerebellum) and CB2 (present in a minimal distribution in the brain stem and periphery including immune cells and neurons) (8). Dronabinol has effects on the CNS, including central sympathomimetic activity.

Dronabinol, like THC, is a partial agonist to the CB1 receptor. Cannabinoid signaling impacts pain modulation, cognition, appetite stimulation, nausea, and others (8). The anti-emetic and appetite stimulation effects of the CB1 receptor appear to mediate the therapeutic effects of dronabinol.

Cannabinoids exert a wide range of CNS effects including short-term memory deficits, sense of time-lapse, increased sensation, and cognitive reasoning. Cannabinoids also produce both euphoria and dysphoria, which depends on prior use and the dose administered. The brain distribution of CB1 receptors and receptor-activated G-proteins correlates with exhibited behavior (3).

Cannabinoids also exhibit CNS-mediated effects on thermoregulation, feeding behavior, nausea, and reward mechanisms. It is now hypothesized that the antiemetic effects are mediated by cannabinoid receptors in the vomiting center of the medulla (3). Cannabinoids may act in the vomiting center to combat the effects of serotonin to block the release of neurotransmitters from vagal afferent terminals, which help to produce emesis (3). Essentially, the neurological impact of the drug can impede messages of nausea and vomiting response.

Appetite stimulation effects are believed to be mediated by cannabinoid receptors in the lateral hypothalamus (3). Cannabinoids impact body temperature directly at brain regulatory centers by inhibiting noradrenergic activity in the hypothalamus.

Pharmacokinetics

Metabolism: Liver via extensive first-pass, cytochrome P450 2C9, and cytochrome P450 3A4.

Onset of Action: Typically, 0.5 to 1 hour

Half-life: 4 hours

Bioavailability: 10 to 20%

Adverse Effects

Adverse effects (8):

• Hypersensitivity to Dronabinol or Sesame Oil; reported signs commonly include lip swelling, hive, rash, oral lesions, skin burning, and throat tightness. 
• Abdominal pain 
• Dizziness 
• Euphoria 
• Paranoia 
• Somnolence 
• Psychiatric and cognitive changes. 
• Possible mental and physical impairment and delay in reaction. Patients should not operate heavy machinery or motor vehicles until it is ruled out that the drug impairs their ability to operate.  
• Hemodynamic Changes 
  • Dronabinol can cause hemodynamic instability in patients with existing cardiac disorders. 
  • Decreased or increased blood pressure, syncope, or rapid heart rate.  
  • Monitor for these changes after initiating treatment and modifying doses.  
• Seizures in patients with a prior medical history of seizures.  
• Drug misuse and abuse risk (especially in those with a substance abuse history).  
• Paradoxical Nausea and Vomiting

Warnings

This drug is contraindicated in patients who have a history of hypersensitivity reactions to sesame oil or THC derivatives (8).

Signs and symptoms of toxicity include (8):

• Mild Intoxication: sleepiness, feelings of joy, heightened sensory vigilance, time perception difficulties, conjunctival injection, dry oral cavity, and elevated heart rate. 
• Moderate Intoxication: Memory difficulty, feelings of detachment, mood changes, retention of urine, and decreased bowel motility. 
• Severe: Decreased coordination of motor function, lethargy, slurring of speech, and orthostatic hypotension.

Panic attacks in those with anxiety and seizure activity in those with a history of seizures can also occur.

Nabilone (Cesamet)

Nabilone is a synthetic cannabinoid that mimics the effects of THC (8).

Drug Class

Antiemetic

Uses

The treatment or prophylaxis of nausea and vomiting associated with chemotherapy in patients who have not responded adequately to other treatments.

Mechanism of Action

Nabilone acts as an agonist at endogenous cannabinoid receptors, CB1 and CB2, which decreases the excitability of neurons (13). The antiemetic effects are thought to be mediated by cannabinoid (CB1) receptors in the “vomiting center” of the medulla. Cannabinoids may act in the vomiting center to oppose the effects of serotonin (5-HT3) and block the release of neurotransmitters from vagal afferent terminals that produce emesis.

Pharmacokinetics

Absorption: Rapid and complete

Distribution: ~12.5 L/kg

Metabolism: Extensively metabolized to several active metabolites by oxidation and stereospecific enzyme reduction; CYP450 enzymes may also be involved

Half-life elimination: Parent compound: ~2 hours; Metabolites: ~35 hours

Peak, serum: Within 2 hours

Excretion: Feces (~60%); renal (~24%)

Adverse Effects

• Central nervous system (similar to other cannabinoids) 
  • Dizziness (52% to 59%) 
  • Drowsiness 
  • Ataxia 
  • Euphoria 
  • Headache 
  • Difficulty concentration  
  • Sleep disturbance  
• Hypotension 
• Anorexia 
• Cardiac arrhythmias 
• Syncope 
• Tachycardia 
• Flushing 
• Cough and/or wheezing

Warnings

Warnings (15):

Nabilone is a schedule II-controlled substance, which is considered to have a high potential for abuse. Prescribers should limit prescriptions to the amount necessary for a single chemotherapy cycle. Monitor patients for signs of excessive use, abuse, and misuse. Use with caution in patients with a history of substance abuse.

Use with caution in patients with cardiovascular disease, it may cause tachycardia and/or orthostatic hypotension.

It may impair physical or mental abilities; patients must be cautioned about performing tasks that require mental alertness (e.g., operating machinery or driving).

Use with caution in patients with mania, depression, or schizophrenia; cannabinoid use may enhance symptoms of psychiatric disorders.

Use with caution in the elderly, it can cause postural hypotension.

Alternatives to Medical Cannabis

Alternative treatments for patients whose pain is partially responsive to opioids include antidepressants, anticonvulsants, local analgesics, and corticosteroids (4).

Cannabis Use Disorder

Cannabis Use Disorder (CUD) is a medical condition that is broadly defined as the inability to stop consuming cannabis even when it is causing physical or psychological harm (2). This disorder is estimated to affect roughly 10% of cannabis users worldwide (2).

CUD is in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a substance use disorder, highlighting how some individuals develop a dependency or addiction to cannabis.

Endocannabinoids and the Reward System

Building on our knowledge learned earlier on the ECS, it is important to recognize that CB1 receptor stimulation can also indirectly activate the dopaminergic system that mediates the rewarding effects of many drugs (2). It is most likely that THC indirectly increases dopaminergic activity by encouraging the firing of dopaminergic neurons in the midbrain. (2).

Essentially, this release of dopamine can lead to addiction to this sensation and continued use for this purpose rather than the initial purpose intended (e.g. pain or anxiety).

Risk Factors

• Using cannabis at a younger age increases the likelihood of developing CUD. 
• Daily or frequent cannabis use heightens the risk of dependency. 
• Using cannabis in conjunction with other substances, like alcohol, illicit drugs, or nicotine, can increase the likelihood of developing CUD.

Manifestations of Cannabis Use Disorder

Individuals with CUD may use cannabis in larger amounts or for longer than prescribed. They may express a desire to stop but are unable to do so. Significant time is usually spent obtaining, using, and recovering from cannabis use, often interfering with responsibilities and social obligations. Tolerance and withdrawal are also major characteristics of CUD. Over time, the individual may need more cannabis to achieve the same effects due to reduced sensitivity (2).

Treatment

The optimal treatments for most substance use disorders) combine psychosocial and pharmacological interventions.

Psychosocial-based interventions:

• Cognitive behavioral therapy (CBT) 
• Motivational enhancement therapy (MET)
• Abstinence-based contingency management combined with CBT and MET

Nursing Considerations and Follow-Up

When teaching patients to safely use medical cannabis, nurses and healthcare providers should emphasize several key points, ensuring patients understand how to use the medication effectively while minimizing potential risks.

Important Considerations

Dosage and Titration

• Start Low and Go Slow 
  • Educate patients on beginning with the lowest effective dose and gradually increase as needed. This minimizes side effects such as dizziness, fatigue, or psychoactive effects from THC. 
• THC vs. CBD Ratio  
  • Providers should explain the difference between THC (which can be psychoactive) and CBD (which is non-psychoactive) to help patients choose a product with the appropriate balance of cannabinoids based on their condition and tolerance.

Administration Methods

• Inhalation (e.g., vaping, smoking) 
  • Although inhalation provides rapid onset, smoking should generally be discouraged due to the health risks associated with inhaling combusted material. 
• Edibles and Oral Forms 
  • Edibles and tinctures take longer to take effect (30 minutes to 2 hours), but the effects last longer.  
  • Patients should be advised to avoid consuming too much too quickly due to the delayed onset.  
• Sublingual tinctures are absorbed faster than edibles and allow for more precise dosing. 
• Topicals 
  • Topicals can be helpful for localized pain (e.g., arthritis) without causing systemic psychoactive effects.

Potential Side Effects and Safety

Patients using products with THC should be informed about potential psychoactive effects like euphoria, drowsiness, delayed physical or mental abilities, altered judgment, or anxiety. Prescribers should discourage activities such as driving or operating heavy machinery while taking medical cannabis. Medical cannabis can interact with other medications, so it is important to review the patient’s medications and adjust as necessary.

Although cannabis has a low risk of addiction compared to opioids, patients should still be given education on the potential risk of abuse, particularly with high-THC products.

Legal Use and Safe Storage

Providers should ensure that patients understand the legal status of medical cannabis in their state and the need for a valid medical cannabis card to purchase products from licensed dispensaries. Patients should be instructed to store cannabis in a secure, childproof container and out of reach of children and pets to avoid accidental ingestion.

Patient Monitoring and Follow-Up Providers should follow up regularly to assess pain levels, side effects, and the effectiveness of the treatment. Adjustments to dosage or formulation may be needed. Providers should help patients choose the right strain or product (indica, sativa, hybrid). Prescribers should encourage patients to keep a journal of daily symptoms and to set realistic goals.

Upcoming Research and Legislation

There are challenges to using cannabis for medical purposes as well as developing clinical trials. This often stems from the legal issues as well as the stigma associated with cannabis use. Some of the challenges in building the evidence for cannabis use include (13):

• Difficulty in designing the clinical trials (randomization, source of cannabis, security measures, etc.). 
• Approval to use cannabis for research (e.g., in the US, it would require FDA approval, registration with the Drug Enforcement Agency, and approval from the research ethics board). 
• Finding agencies that will fund the study.

Researchers are overcoming these barriers and widening the span of cannabis for medical therapy. For example, there is significant research on the use of medical cannabis for the treatment of Alzheimer’s Disease and dementia, as well as other cognitive-related disorders (5).

Sativex is not yet FDA-approved in the U.S., but it’s used in other countries (e.g., Canada and the UK) for the treatment of multiple sclerosis-related spasticity and neuropathic pain (13). Sativex is under clinical trials in the U.S., particularly for treating multiple sclerosis and certain types of cancer pain, but it is still pending FDA approval. Clinical trials are ongoing to evaluate its safety and efficacy under U.S. regulatory standards (4).

Conclusion

The cannabis plant is a multifaceted organism with various chemical compounds contributing to its medicinal uses. Its cannabinoids, terpenes, and flavonoids work together to provide therapeutic effects, making it an increasingly popular option in modern medicine, especially as research continues to uncover its potential benefits. By providing education and ongoing follow-up, healthcare providers can help ensure that medical cannabis is used safely and effectively for medical conditions while minimizing risks and side effects.

Kentucky Medical Cannabis Laws and Prescribing for APRNs

Introduction

In 2023, The Governor of Kentucky signed a bill legalizing the use of medical cannabis for its residents with certain medical conditions beginning January 1, 2025 [7]. This law affects the prescribing authority of both physicians and advanced practice registered nurses (APRNs). However, what we think of as “prescribing” (i.e. writing a prescription for a medication and handing it to the patient) is not the process for prescribing medicinal cannabis.

Instead, when a patient has a qualifying medical condition and a practitioner determines the patient is eligible for medical cannabis, the practitioner provides the patient with a certification through an online state registry (this “certifies” the patient’s eligibility). The patient can use the certification to obtain a registry identification card, granting them access to medicinal cannabis at dispensaries.

​According to the new Kentucky law, APRNs who seek authorization to provide these certifications must complete specialized continuing education and apply to become a Medical Cannabis Practitioner in the state.

This course will begin with the history of medical cannabis legalization in the U.S. and transition into the responsibilities of the Medical Cannabis Practitioner, including diagnosing qualified medical conditions. The course will end with an overview of clinical guidelines for treating qualifying medical conditions with medicinal cannabis.

History of Medical Cannabis Legalization

Historically, the legalization of medical cannabis did not always align with its cultural acceptance. Let’s explore the history of cannabis in the United States.

Informal Use of Cannabis

Historically, cannabis was not considered dangerous. A bag of cannabis was found buried alongside a Siberian mummy with breast cancer believed to be from 500 BCE [3]. Before the 1930s, U.S. import and export of cannabis (termed “marihuana” or “hemp” at the time) was legal, and many people bought the plant to treat a variety of ailments [15].

However, in the 1930s, a media campaign linked criminality and insanity with cannabis use [3]. States began to restrict its possession. Furthermore, the government passed the 1937 Marihuana Tax Act which placed a tax on imports and exports of cannabis, and anyone who violated the new law would be fined and imprisoned [3][19]. This changed the cultural acceptability of cannabis.

Hesitation of Medicinal Cannabis

Fast forward to the 1960s, when society began to develop an interest in cannabis again – particularly cannabis research. This prompted the U.S. to assign a formal grower of cannabis for research purposes [3]. A decade later, cannabis was deemed “not acceptable” for medical use (Schedule I drug) according to the 1970 Controlled Substance Act. Schedule I drugs are those that have a high potential for abuse and are not acceptable for medical use [21].

It took another 15 years before the U.S. Food and Drug Administration (FDA) approved the drug dronabinol (a synthetic drug modeled after a substance within the cannabis plant) for medical use, particularly to treat nausea and vomiting related to cancer. California was the first state to legalize cannabis for medicinal purposes in the late 1990s. However, the government prohibited physicians from “prescribing” medical cannabis and instead allowed physicians to “recommend” it [15].

Final Consensus on Medicinal Cannabis

The cannabis plant was identified as containing both cannabidiol (CBD) and tetrahydrocannabinol (THC). CBD is a substance in the cannabis plant that has medicinal benefits but does not cause psychoactive effects (the “high” feeling). THC is also a substance in the cannabis plant, but it’s known to cause psychoactive effects.

In September 2018, drugs containing CBD were labeled as Schedule V drugs (a significant jump from the previous Schedule I label) as long as they did not contain more than 0.1% THC [5]. Schedule V drugs have a lower potential for abuse but contain a limited number of certain narcotics [21]. In December of the same year, the 2018 Farm Bill identified the THC threshold as 0.3% for cannabis research [4].

Current Numbers

Most recently, medical cannabis has become culturally acceptable. As of September 2024, medical cannabis is legal in 47 states [17]. Of this number, 38 states have a medical-only cannabis program. Nine of the 38 states allow only CBD or products containing a low amount of THC for qualifying medical conditions. These nine states are [17]:

• Georgia
• Indiana
• Iowa
• North Carolina
• South Carolina
• Tennessee
• Texas
• Wisconsin
• Wyoming

States that do not have a medical cannabis program:

• Idaho
• Kansas
• Nebraska

How to Become a Medical Cannabis Practitioner

A Medical Cannabis Practitioner, also referred to as a Medicinal Cannabis Practitioner, is a physician or APRN who is authorized to prescribe controlled substances and provide written certifications for medicinal cannabis [9]. The journey to becoming a Medical Cannabis Practitioner in Kentucky is a four-step process that includes [9]:

1. Confirming you meet the eligibility requirements
2. Completing the continuing education requirements
3. Applying for authorization through the Kentucky Board of Nursing
4. Registering with the Kentucky Office of Medical Cannabis to access the Medical Cannabis Practitioner Authorization Registration Portal

Let’s discuss these steps in further detail.

Am I Eligible?

Although this course will prepare you for the role of Medical Cannabis Practitioner, it is important to ensure you meet the qualifications before applying for authorization. Confirm you meet the following qualifications, and you are that much closer to your new role! [8]

1. Hold an active unrestricted Kentucky license as an APRN that is in good standing.
2. Have a valid Drug Enforcement Administration (DEA) registration and a current registration certificate is on file with the board.
3. Have an active account with the Prescription Drug Monitoring Program (PDMP) with a current PDMP registration certificate on file with the board. (the PDMP is the state-based electronic database used to track prescriptions for controlled substances) [18]
4. Has not engaged in inappropriate prescribing, personally furnishing, dispensing, possessing, diverting, administering, supplying, or selling a controlled substance or other dangerous drug for which a license (to prescribe, possess, dispense, personally furnish, administer, supply, or sell a controlled substance) has been denied or restricted, or for which disciplinary action has been taken.
5. Have completed the continuing education requirements (detailed in the next section).
6. Have no ownership or investment interest in or compensation agreement with a licensed cannabis business.

Am I Meeting the Continuing Education Requirements?

Per the new law, an applicant for an initial authorization shall have completed within the immediate 12 months a one-time requirement of 6 contact hours in the following subjects [8]:

1. Diagnosing qualifying medication conditions
2. Treating qualifying medical conditions with medicinal cannabis
3. The pharmacological characteristics of medicinal cannabis and possible drug interactions
4. Indications of cannabis use disorder

Thereafter, an APRN renewing the authorization shall have obtained during the earning period 3 continuing education hours in the subjects above.

In summary, APRNs who desire to provide written certifications for medicinal cannabis in Kentucky need an initial 6 CE hours and 3 CE hours at each renewal.

How Do I Apply?

After confirming your eligibility and completing the CE requirement, you can apply for authorization through the Kentucky Board of Nursing (https://kbn.ky.gov). Take these steps to submit your initial application. The same steps apply for renewal applications.

1. Submit an “Authorization to Provide Written Certifications for the Use of Medicinal Cannabis” Initial Application or Renewal Application.
2. Submit a copy of your DEA registration certificate.
3. Submit proof of completion of the continuing education requirements.
4. Pay a nonrefundable fee of $100.

Submit all supporting documentation via your account in the Kentucky Board of Nursing Nurse Portal. Your application will be valid for 6 months. If requirements are not within this time, your application will expire, and you will need to start the process over.

How Can I Access the Authorization Registration Portal?

After receiving authorization from the Kentucky Board of Nursing, you must register for an online account with the Kentucky Office of Medical Cannabis to access the Medical Cannabis Practitioner Authorization Registration Portal (https://kymedcan.ky.gov). It is through this portal that you will provide patients with written certifications for medicinal cannabis.

What is the Process for Writing an Initial Certification for My Patient?

The State of Kentucky has outlined Professional Standards of Care that APRN Medicinal Cannabis Practitioners must follow when writing certifications for patients in the state. You must practice these standards at all times. When providing written certifications to your patient, you must perform the following tasks [8][10].

1. Establish a Practitioner-Patient Relationship
2. Use the Right Form
3. Obtain a Medical History
4. Perform a Physical Exam
5. Perform Diagnostic Tests If Needed
6. Diagnose Qualifying Medical Conditions
7. Provide Education
8. Obtain Consent
9. Include a Statement
10. Document
11. Follow Up
12. Keep Records

Let’s discuss these steps in further detail.

Establishing a Practitioner-Patient Relationship

Establish a bona fide practitioner-patient relationship with the patient. This is required before you write the certification and must occur in-person. You may also establish the relationship after receiving a referral from the patient’s primary care provider and the relationship may be maintained via telehealth. However, the relationship should not be established via telehealth.

Using the Right Form

Make sure to use a form prescribed by the cabinet (refers to the Cabinet for Health and Family Services – the commonwealth of Kentucky). Keep in mind, the certification will be issued through the registration portal.

Obtaining a Medical History

You must obtain the following basic information about the patient:

• Name
• Date(s) of office visits or treatments, and responses to treatments
• Medical history, including relevant prescription history and diagnostic results
• History of drug use, including a documented review of the patient’s current medications to identify possible drug interactions, including benzodiazepines and opioids
• Psychiatric history
• Social and family history

You should also gather information about the patient’s experience with cannabis as well as their values, preferences, needs, and knowledge related to using cannabis [15].

Performing a Physical Exam

Your examination of the patient must occur in-person for the initial certification. You must not perform a telehealth examination of the patient for the initial certification. The physical examination should be relevant to the patient’s current medical condition and should include a focused physical examination.

Performing Diagnostic Tests If Needed

You must obtain a drug screen on the patient if there is evidence or behavioral indications of addiction or drug abuse. It is within your discretion to decide the nature of the screen and which type of drug will be screened.

Diagnosing Qualifying Medical Conditions

Diagnose the patient with a qualifying medical condition for which you believe the patient is likely to receive safe and effective therapeutic or palliative benefit from the use of medicinal cannabis. You may also confirm a diagnosis if the patient has been previously diagnosed with a qualifying medical condition by another health care provider. In this case, you must review the current treatment for the qualifying condition and the patient’s response to the treatment [15].

While research about the medicinal benefits of cannabis is limited, some evidence does show a benefit to certain health conditions. Drugs that contain cannabinoids (substances found in the cannabis plant), may help improve symptoms, such as tics and sleep impairments, in patients with mental health disorders [14]. However, research suggests cannabinoids may be most helpful in treating rare forms of epilepsy and nausea and vomiting associated with cancer chemotherapy [14]. For these reasons, qualifying medical conditions have been established to help you determine which of your patients would benefit most from medicinal cannabis. Qualifying medical conditions may vary across states.

Qualifying medical conditions in Kentucky include [12]:

• Any type or form of cancer regardless of stage
• Chronic, severe, intractable, or debilitating pain
• Epilepsy or any other intractable seizure disorder
• Multiple sclerosis (MS), muscle spasms, or spasticity
• Chronic nausea or cyclical vomiting syndrome that has proven resistant to other conventional medical treatments
• Post-traumatic stress disorder (PTSD)
• Any other medical condition or disease for which the Kentucky Center for Cannabis, or its successor, determines that sufficient scientific data and evidence exists to demonstrate that an individual diagnosed with that condition or disease is likely to receive medical, therapeutic, or palliative benefits from the use of medicinal cannabis

Diagnosing patients involves using diagnostic reasoning to synthesize and analyze data from health histories, physical examinations, and diagnostic information [1]. Diagnostic reasoning is a cognitive competency under the domain of clinical reasoning that is more than simply defining a clinical problem [16].

It also involves reducing diagnostic errors (by making sure you don’t miss something) and determining the best treatment available based on the patient’s needs. Diagnostic errors are associated with poor patient outcomes and are linked to practitioners’ insufficient knowledge, data-gathering flaws, and suboptimal approaches to information processing [16]. This is why you need to develop excellent diagnostic reasoning skills as an APRN.

For example, a patient may report symptoms associated with the above qualifying medical conditions, such as loss of appetite, depression, anxiety, sleep deprivation, and mobility issues secondary to chronic pain [2]. These symptoms alone may not be considered qualifying medical conditions (as they can easily be associated with non-qualifying medical conditions). However, medicinal cannabis for chronic pain may alleviate these symptoms if they are secondary to the pain.

This is also the case for MS-related symptoms (such as sleep disorder) and PTSD-related symptoms (such as intrusion symptoms, sleep disturbance, and mood imbalances) [2]. This is why it is important to perform a thorough evaluation of the patient’s medical history as well as primary and secondary symptoms before diagnosing or failing to diagnose a qualifying medical condition. This is part of diagnostic reasoning. Your goal is to ensure the patient receives the most appropriate treatment for their condition.

When writing certifications for medicinal cannabis, you may confirm a diagnosis once you:

• Obtain a copy of the medical records or detailed written summary indicating the diagnosis
• Are satisfied that those records confirm a diagnosis of a qualifying condition
• Maintain a copy of any record or report of any Medicinal Cannabis Practitioner on which the practitioner relied for purposes of meeting the requirements in this section
• Document a plan to obtain the patient’s consent to obtain and discuss the patient’s prior medical records within 30 days of initiating a treatment. Upon receipt of the medical records, you must review and incorporate the information from the records into the evaluation and treatment of the patient. If you are unable to obtain the patient’s prior medical records despite your best efforts, you must document those efforts in the patient’s chart
• Obtain and review a Prescription Drug Monitoring Program (PDMP) report for that patient for the 12-month period immediately preceding the initial patient encounter and appropriately utilize that information in the evaluation and treatment of the patient.
• Explain treatment, alternative risks, and the benefits of medicinal cannabis with the patient (more on this in the next section)
• Obtain written informed consent from the patient for treatment
• Discuss and document the patient’s treatment with the patient’s other providers
• Meet the requirements for providing certification to patients assigned female at birth who are of childbearing potential and age (more on this in the next section)

Providing Education

Consult with the patient (or the patient's custodial parent or legal guardian responsible for providing consent to treatment if the patient is a minor child). In the consultation, explain the treatment, benefits, alternatives, possible risks, and side effects associated with medicinal cannabis, including possible interactions between medicinal cannabis and any other drug or medication the patient is taking at the time. This includes any risk to fertility, or risks to fetal harm for patients assigned female at birth who are pregnant or breastfeeding.  

Before prescribing medicinal cannabis treatment, you must recommend all patients assigned female at birth and who are of childbearing age submit to a pregnancy test. If any patient declines to take a pregnancy test, you must document the patient’s declination and the stated rationale for their decision.  

If a patient assigned female at birth is pregnant or breastfeeding, you must provide counseling. If the patient declines consultation, you must document the patient’s declination and the stated rationale for their decision. This must be completed prior to providing a written certification. 

Obtaining Consent

After thorough education has been provided, obtain written informed consent from the patient for treatment (or the patient’s custodial parent or legal guardian, if the patient is a minor child). 

Including a Statement

Before you issue the written certification, make sure it includes a statement from you certifying that: 

1. A bona fide practitioner-patient relationship exists between you and the patient. 
2. The patient has been diagnosed with at least 1 qualifying medical condition for which you believe the patient may receive medical, therapeutic, or palliative benefit. 
3. In your professional medical opinion, the patient may receive medical, therapeutic, or palliative benefits from the use of medicinal cannabis. 

Documentation

Include a documented review of whether standard medical treatment has been attempted or considered. If standard medical treatment is not attempted, you must document the reasons that standard medical treatment is not appropriate for the patient. Also document findings from your evaluation of the patient, such as medical history obtained or reported, physical exam findings, diagnostic test results, and patient declinations. Finally, record that you issued the certification in the electronic monitoring system within 24 hours of providing the patient with the certification. 

Follow Up

Be available to provide follow-up care and treatment to the patient, including physical examinations relevant to their condition to determine the efficacy of medicinal cannabis in treating their qualifying medical condition. If the qualifying condition was indicated as a terminal illness in the prior 6 months, you must confirm whether the patient’s condition continues to be a terminal illness.  

Terminate or decline to issue a new written certification if: 

• The patient no longer has the diagnosis of, or symptoms of, the qualifying medical condition 
• You are no longer authorized to issue a written certification 
• Based on your clinical judgement, the patient or caregiver is abusing or diverting medicinal cannabis 
• The patient is deceased 

Be sure to notify the cabinet in writing within 30 days the name of any patient for whom you terminated or declined to issue a written certification. 

Keeping Records

Keep all records required for the recommendation for a written certification for at least 5 years following the last office visit by the patient. The records may be kept with the patient’s other medical records.

What Happens When My Patient Needs a Renewal Certification?

You may provide subsequent or renewal certifications, including for registry identification card renewals, electronically or during a telehealth consultation [8][10]. You may renew a certification for no more than 3 additional periods of no more than 60 days each (180 days total). After that, you may issue another certification only after an in-person or telehealth examination. For renewing a registry identification card, the certification is valid for a maximum of 60 days.

What are the Limitations of My Role When Writing Certifications?

While following the above rules regarding writing certifications ensures you are practicing according to Kentucky law, limitations of your role exist. You must not [10]:

• Dispense medicinal cannabis
• Provide a written certification to a family member or for yourself

Dispensing refers to the delivery of a prescription drug or product to a patient [23]. Dispensaries are responsible for dispensing medicinal cannabis. Your role is to write the certification in the registry, which allows the patient access to a dispensary with their registry identification card.

Additionally, if you fail to renew your authorization or are otherwise unable to legally practice as a registered nurse or APRN, you are legally prohibited from practicing as or using the title of Medicinal Cannabis Practitioner until you have been reissued authorization by the Kentucky Board of Nursing.

What Happens if I Violate the New Law?

The Kentucky Board of Nursing may probate, restrict, suspend, or revoke your authorization to provide written certification for the use of medicinal cannabis and practice license for violations of the above rules [8][10]. An investigation may be made against you, and you may be required to undergo substance use evaluation or be subject to immediate temporary suspension [8].

Treating Qualifying Medical Conditions with Medicinal Cannabis

In this final section of the course, we will discuss treatment of qualifying medical conditions with medicinal cannabis as recommended by medical experts through clinical practice guidelines. Although this information is meant to guide your practice, you should follow your workplace’s policy on prescribing medicinal cannabis.

Qualifying medical conditions discussed in this section include:

• Cancer
• Chronic Pain
• Epilepsy
• Multiple Sclerosis and/or Spasticity
• Chronic Nausea and Vomiting
• Post-Traumatic Stress Disorder

Medicinal Cannabis and Cancer

The American Society of Clinical Oncology (ASCO) developed guidelines in 2024 to guide clinicians on how to use medicinal cannabis as a treatment in adult patients with cancer [3]. The organization developed the guideline after a review of multiple research studies, although the evidence is limited.

Guidelines are as follows [3]:

• The ASCO strongly recommends against using cannabis and/or cannabinoids in place of cancer-directed treatment. Cannabis/cannabinoids used as cancer-directed treatment may cause significant clinical problems (fatigue, confusion, feeling high) without good evidence of clinical benefit.
• The ASCO recommends against using cannabis and/or cannabinoids to augment cancer-directed treatment. The ACOS categorizes this recommendation as weak, meaning the undesirable effects probably outweigh the desirable effects, but appreciable uncertainty exists.
• The ASCO recommends against the use of 300 mg or more per day of oral CBD to manage symptom burden in adults with cancer due to lack of proven efficacy and risk for reversible liver enzyme abnormalities. The ACOS categorizes this recommendation as weak, meaning the undesirable effects probably outweigh the desirable effects, but appreciable uncertainty exists.

In summary, the ACOS is most certain that cannabis and/or cannabinoids should not be used in place of cancer treatments. The above recommendations are only applicable to adults who are not part of a clinical trial.

Medicinal Cannabis and Chronic Pain

An expert review panel developed “Clinical Practice Guidelines for Cannabis and Cannabinoid-Based Medicines in the Management of Chronic Pain and Co-Occurring Conditions 2024” to guide clinicians on how to use medicinal cannabis in adults with chronic pain [2]. Below are the panel’s recommendations.

For chronic pain alone [2]:

• The panel recommends cannabinoid-based medicines (CBM) as monotherapy, replacement, or adjunct treatment, in people living with chronic pain, for the management of chronic pain including central and/or peripheral neuropathic pain to improve pain outcomes.
• The panel recommends CBM as an adjunct treatment, for the management of chronic migraine or chronic headache, in those not achieving adequate response to other modalities. However, the panel categorizes this recommendation as weak as some patients experience headache caused by cannabis. On the contrary, the panel places a high value on CBM benefit of migraine and headache relief over the risk of adverse events (which are mostly non-threatening). To mitigate the risk of headache caused by cannabis, starting with a low dose, titrating slow, and choosing the best route for the patient’s needs is recommended.

For chronic pain among patients using opioids [2]:

• The panel recommends CBM as adjunctive treatment to opioids, for the management of chronic pain in those experiencing unsatisfactory analgesia from opioid treatment.
• The panel recommends CBM as adjunct treatment among people using moderate/high doses of opioids (>50 morphine equivalent) for the management of chronic pain and/or to increase opioid sparing.
• The panel recommends CBM as adjunct treatment for chronic pain among people using any dose of opioids who are not reaching chronic pain goals, are experiencing opioid-related adverse events, or display risk factors for opioid-related harm.

For chronic pain in patients with certain medical conditions [2]:

• The panel recommends CBM for the management of muscular and neuropathic pain in people living with HIV who are not achieving adequate response, or those experiencing adverse effects to other treatment modalities.
• The panel recommends CBM as adjunct treatment, for the management of chronic pain in people living with arthritic conditions in those not achieving adequate response to other modalities.
• The panel recommends CBM as adjunct treatment, for management of back pain, fibromyalgia pain, or other chronic pain in people with fibromyalgia who are not achieving an adequate response to standard analgesics.

For other symptoms associated with chronic pain [2]:

• The panel recommends THC-dominant cannabis for people with problematic loss of appetite in association with chronic pain, over no treatment.
• The panel recommends CBM as adjunct therapy to improve symptoms of depression in people living with chronic pain experiencing unsatisfactory results from standard treatment.
• The panel recommends CBM as adjunct therapy to improve symptoms of anxiety in people living with chronic pain not responsive to, or intolerant of, non-pharmacologic treatment.
• The panel recommends CBM as monotherapy, replacement or adjunct treatment, to improve sleep and symptoms of sleep deprivation in people living with chronic pain not responsive to, or intolerant of, other modalities or pharmacologic treatment.
• The panel recommends CBM as monotherapy, replacement or adjunct treatment, in people living with chronic pain, for mobility in those not achieving adequate response to other modalities. However, the panel categorizes this recommendation as weak because although various forms of CBM show benefits in mobility, adverse events related to the smoked form of CBM are less favorable.

In summary, CBM is recommended as an adjunct, replacement, or sole treatment for chronic pain and some pain-associated symptoms. Although no recommendations were made against the use of CBM for chronic pain, CBM is often recommended as a “last resort” treatment so-to-speak or preferred over no treatment at all. It is also important to note that CBM is recommended as an adjunct treatment for pain in patients who take opioids and never as a replacement.

Medicinal Cannabis and Epilepsy

Consider the following evidence when treating epilepsies. Medicinal cannabis has been shown to be effective in the treatment of some forms of epilepsy, including Dravet syndrome, Lennox–Gastaut syndrome, and tuberous sclerosis complex [24]:

• Darvet Syndrome

A rare, severe childhood-onset myoclonic form of epilepsy, characterized by prolonged seizures often triggered by fever or quick body temperature changes.

• Lennox–Gastaut Syndrome

An epileptic encephalopathy characterized by multiple seizures and severe cognitive impairment.

• Tuberous Sclerosis Complex

A rare genetic disease that causes benign tumors in various organs (including the brain) characterized by varying epileptic seizure types.

CBD is also commonly used as an adjunct therapy for epileptic encephalopathies with clobazam (a benzodiazepine) [13][24]. Additionally, epidiolex (a CBD oral solution) was approved by the FDA in 2018 as treatment for both Darvet syndrome and Lennox-Gastraut syndrome [22].

In pediatric populations, studies have consistently shown purified CBD’s effectiveness in reducing seizure frequency and improved quality of life in children with drug-resistant epilepsy [6]. These reported benefits have been noted in various countries. While this is not a clinical guideline recommendation, it serves as a basis for parental (or legal guardian) education and treatment options.

In summary, follow your workplace’s policy on how to treat epilepsy with medicinal cannabis. Research on this subject is limited to rare and severe forms of epilepsy.

Medicinal Cannabis and Chronic Nausea and Vomiting

The aforementioned expert panel also guides clinicians on how to use CBM to treat nausea secondary to chronic pain in adults [2]. Additionally, the ACOS makes a recommendation regarding the treatment of nausea and vomiting in adults receiving chemotherapy.

Guideline recommendations [2]:

• The panel recommends CBM for the management of HIV-related nausea, in people living with HIV. CBM is for symptom management only and should not replace the use of antiretroviral therapies.
• The panel recommends CBM as a consideration to reduce nausea in people living with chronic pain as monotherapy or adjunct treatment for those not achieving adequate response to other treatment modalities. However, the panel categorizes this recommendation as weak as it does not include cancer-related nausea. On the contrary, the panel places a high value on the benefit of CBM for nausea relief over the risk of adverse events of CBM (which are non-threatening).
• The ACOS recommends dronabinol, nabilone, or a quality-controlled oral 1:1 THC: CBD to augment the antiemetic regimen of adults with refractory nausea and vomiting who receive moderately or highly emetogenic antineoplastic agents with guideline-concordant antiemetic prophylaxis. The ACOS categorizes this recommendation as weak, meaning the desirable effects probably outweigh the undesirable effects, but appreciable uncertainty exists.

In pediatric populations, evidence has shown that synthetic cannabinoids demonstrated benefit in chemotherapy-induced nausea and vomiting when compared with conventional agents [6]. However, this is not a clinical guideline recommendation. Experts advise practitioners to consider the child’s specific condition and prognosis, and the potential benefits and risks, including drug-drug interactions [6]. Additionally, medical cannabis products may require slow titration, and administration should be tailored to the individual child and condition [6].

In summary, CBM is recommended for HIV-associated nausea in adults, but not in place of HIV treatment. CBM is also recommended for refractory nausea and vomiting in adults who receive both chemotherapy and antiemetic prophylaxis concurrently.

Medicinal Cannabis and Multiple Sclerosis and/or Spasticity

The expert panel also addressed CBM as a treatment for symptoms associated with multiple sclerosis (MS) in adults.

Guideline recommendations [2]:

• The panel recommends CBM as an adjunct treatment for pain management in people with MS who do not achieve adequate response to other modalities.
• The panel recommends CBM as an adjunct treatment, for the management of muscle spasms in people living with MS in those not achieving adequate response to other modalities.
• The panel recommends CBM as an adjunct treatment, for the management of sleep disorder in people living with MS in those not achieving adequate response to other modalities.

In pediatric populations, evidence has shown that dronabinol has been used to successfully manage spasticity in children with neurological complexities and receive palliative care [6]. This is not a clinical guideline recommendation. As aforementioned, treatment should consider the child’s specific condition and prognosis, and potential benefits and risks.

In summary, CBM is recommended for the treatment of MS symptoms in adults when other treatments are not effective.

Medicinal Cannabis and Post-Traumatic Stress Disorder

Finally, the expert panel addresses the use of CBM in the care of adults with PTSD. The U.S. Department of Veteran Affairs (VA) also recommended its clinical practice guideline titled “Management of Posttraumatic Stress Disorder and Acute Stress Disorder 2023.”

Guideline recommendations [2]:

• The panel recommends CBM to improve PTSD symptoms in people living with chronic pain not responsive to, or intolerant of, non-pharmacologic treatment [2]. PTSD symptoms include pain, intrusion symptoms, sleep disturbance, and reduced mood and quality of life. However, the panel categorizes this recommendation as weak as studies were limited to one form of cannabis – herbal. On the contrary, the panel placed a high value on the benefit of CBM for PTSD symptoms over the risks of adverse events of CBM (dry mouth, disturbance in attention and memory, and the potential for the patient to use CBM for non-medical purposes).
• The VA recommends against the use of cannabis or its derivatives to treat PTSD due to limited evidence [20].

In summary, CBM is favored for treatment of PTSD symptoms when non-pharmacological treatments are not effective (although it depends on the form of cannabis used). It is important to note that both guidelines showed insufficient evidence as the reason for its recommendation.

To conclude this entire section, your primary goal in treating patients with medicinal cannabis is to achieve therapeutic effects while maintaining the patient’s safety. Clinical practice guidelines can help guide your practice when treating qualifying medical conditions as a Medical Cannabis Practitioner in Kentucky. However, as mentioned earlier, follow your workplace’s policy on prescribing medical cannabis.

Conclusion

This course has provided you with a detailed look into the role of the Medical Cannabis Practitioner, including what it takes to fulfill this role and how to diagnose and treat patients with cannabis per Kentucky law and within your APRN scope of practice. Further details on the new rules surrounding APRN medical cannabis prescribing can be found under the following Kentucky law:

“Title 201 | Chapter 020 | Regulation 067: Professional Standards for Medicinal Cannabis” (https://apps.legislature.ky.gov/law/kar/titles/201/020/067).

Kentucky Alzheimer’s and Dementia Review

Introduction   

Dementia is a broad term that describes a significant decline in cognitive abilities that interferes with a person’s daily life [1]. Alzheimer's disease (AD) is the most prevalent form of dementia, accounting for at least two-thirds of dementia cases in individuals aged 65 and older [1]. AD is a neurodegenerative disorder characterized by an insidious onset and progressive impairment of cognitive and behavioral functions, including memory, comprehension, language, attention, reasoning, and judgment [1][2]. Although Alzheimer's disease (AD) itself is not fatal through direct mechanisms, it increases susceptibility to complications that can lead to premature death including aspiration pneumonia which occurs when the disease causes difficulty in swallowing, leading to the inadvertent inhalation of food particles, liquids, or gastric fluids into the lungs [1]. 

In 2022, Alzheimer's disease was the seventh leading cause of death in the United States, according to the Centers for Disease Control and Prevention (CDC) [3]. This is a decrease from its previous position as the sixth leading cause of death before the COVID-19 pandemic, which ranked fourth in 2022 [3]. Alzheimer's disease often appears after the age of 65, known as late-onset AD (LOAD) [3][4]. However, early-onset AD (EOAD), which occurs before age 65, is less common and affects about 5% of patients with AD [4]. EOAD often presents with atypical symptoms and with aggressive progress, leading to delayed diagnosis and a more severe disease course [5]. 

Over the past decade, there have been significant advancements in identifying biomarkers for the early and specific diagnosis of AD. These include neuroimaging markers from amyloid and tau PET scans, as well as cerebrospinal fluid (CSF) and plasma markers such as amyloid, tau, and phospho-tau levels [6]. 

While there is no cure for Alzheimer's disease, treatments are available to manage and alleviate some symptoms. Recent advancements in medication and the discovery of new biomarkers have shown promise in moderating the disease's progression.  

Warning Signs and Symptoms of Alzheimer’s Disease and Other Dementias 

Alzheimer's disease features gradual and progressive neurodegeneration due to neuronal cell death [1][7]. The neurodegenerative process often initiates in the entorhinal cortex, a region within the hippocampus [1][8]. Genetic factors contribute to both early and late-onset AD. Trisomy 21, for example, presents a risk factor for early-onset dementia [9]. Alzheimer's disease (AD) symptoms vary depending on the disease stage, which classifies into distinct levels of cognitive impairment and disability. These stages include the preclinical or presymptomatic stage, mild cognitive impairment, and the dementia stage, further divided into mild, moderate, and severe stages [1][10].  

This staging system differs from the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) [1]. The initial and most common symptom of typical AD includes episodic short-term memory loss [11]. Individuals often struggle to retain added information while their long-term memories remain intact. As the disease progresses, impairments in problem-solving, judgment, executive functioning, and organizational skills become evident [11]. Early in the disease, instrumental activities of daily living, such as driving, managing finances, cooking, and planning, suffer [1]. 

As cognitive decline advances, individuals may experience language disorders and impaired visuospatial skills. In the moderate to late stages, neuropsychiatric symptoms like apathy, social withdrawal, disinhibition, agitation, psychosis, and wandering become more prevalent [1][12]. Late-stage symptoms can include difficulty with learned motor tasks (dyspraxia), olfactory dysfunction, sleep disturbances, and extrapyramidal motor signs such as dystonia, akathisia, and Parkinsonian symptoms [1][12]. In the final stages, primitive reflexes, incontinence, and complete dependence on caregivers are common [1][12]. 

AD involves multiple factors and includes many known risk factors. Age serves as the most significant factor, with advancing age as the primary contributor. The prevalence of AD doubles with every 5-year increase in age starting from age 65 [13]. Cardiovascular diseases (CVD) increase the risk of developing AD and contribute to dementia caused by strokes or vascular dementia [14]. Recognizing CVD as a modifiable risk factor for AD has become more common. 

Obesity and diabetes are also important modifiable risk factors for AD [15]. Obesity can impair glucose tolerance and increase the risk of developing type II diabetes [1]. Chronic hyperglycemia can lead to cognitive impairment by promoting the accumulation of beta-amyloid (A-beta) and neuroinflammation [1][16]. Obesity further amplifies the risk by triggering the release of pro-inflammatory cytokines and promoting insulin resistance [16]. 

Other potential risk factors for AD include traumatic head injury, depression, cardiovascular and cerebrovascular disease, higher parental age at birth, smoking, family history of dementia, increased homocysteine levels, and the presence of the APOE e4 allele [1][17]. Having a first-degree relative with AD increases the risk of developing the disease by 10% to 30% [18]. Individuals with two or more siblings with late-onset AD face a threefold higher risk than the general population [1][19]. 

Importance of Early Detection, Diagnosis, and Communication for Memory Concerns 

Early detection and diagnosis of Alzheimer's disease (AD) are critical for effective management and care planning [20]. A thorough history-taking and comprehensive physical examination are fundamental in diagnosing AD. Gathering information from family and caregivers is also vital, as patients may lack insight into their condition. Evaluating a client's functional abilities, encompassing both basic activities of daily living (ADLs) and instrumental activities of daily living (IADLs), offers import information about their cognitive and functional status. IADLs require advanced planning and cognitive skills, including tasks like shopping, managing finances, filing taxes, preparing meals, and housekeeping. 

In addition to medical history, inquire about the patient's social history, including alcohol use and any history of street drug use. These factors can influence cognitive function and require consideration in the diagnostic process. 

Conduct a physical exam, including a neurological exam and mental status assessment, to evaluate the AD stage and rule out other conditions. The neurological exam in AD may appear normal except for anosmia. Anosmia also occurs in patients with Parkinson's disease, dementia with Lewy bodies, and traumatic brain injury (TBI) with or without dementia, but not in individuals with vascular cognitive impairment (VCI) or depression [1][21]. 

Perform and document cognitive assessments such as the Mini-Mental Status Exam (MMSE) or the Montreal Cognitive Assessment Exam (MOCA). The MOCA evaluates patients with mild cognitive impairment more effectively than the MMSE [22][23]. Another cognitive screening test, the Mini-Cog exam, involves a clock drawing test and a three-item recall [24]. The results of the Mini-Cog remain consistent regardless of the individual's level of education.  

In the advanced stages of AD, patients may exhibit more focal neurological signs, including apraxia, aphasia, frontal release signs, and primitive reflexes [1] [25]. As the disease progresses, patients may become mute and unresponsive to verbal requests, leading to increased dependence on caregivers and becoming confined to bed and entering a persistent vegetative state. 

During a mental status examination, evaluating multiple cognitive domains is important to determine the extent of cognitive decline in Alzheimer's Disease (AD) [1]. These domains encompass concentration, attention, recent and remote memory, language abilities, visuospatial skills, praxis, and executive functions [1][26]. Regular follow-up appointments for individuals with AD should incorporate a comprehensive mental status examination to monitor disease progression and the emergence of neuropsychiatric symptoms. 

Effective communication techniques are essential when discussing memory concerns with the patient and their caregiver. Clear, empathetic communication helps in building trust and ensuring that the patient and caregiver understand the diagnosis, treatment options, and care plans. This approach fosters a supportive environment, enabling better management of the disease and improving the quality of life for both the patient and the caregiver. 

Tools for Assessing a Patient’s Cognition 

Cognitive assessment uses various tools to evaluate various aspects of cognitive function, which diagnose and manage conditions such as Alzheimer's disease (AD) and other dementias. These tools build a clinical understanding of care needs through ongoing interactions with the patient and caregiver. Customize the choice of assessment tools to fit clinician preferences, practice composition, workflows, and clinical goals. Here are some commonly used tools 

• Mini-Mental State Examination (MMSE): used for a quick assessment of cognitive function. 

• Montreal Cognitive Assessment (MOCA): More sensitive than the MMSE for detecting mild cognitive impairment. 

• Mini-Cog: Involves a clock drawing test and three-item recall, useful in primary care settings. 

• Functional Assessment Staging Test (FAST): For staging dementia. 

• Clinical Dementia Rating (CDR): For staging and evaluating dementia severity. 

Use these tools alongside other diagnostic procedures such as blood tests, imaging (CT, MRI), and neuropsychological testing to evaluate  

Documentation Requirements 

Documentation of cognitive-relevant history should include factors contributing to cognitive impairment, such as psychoactive medications, chronic pain syndromes, infection, depression, and other brain diseases [28]. Medical decision-making documentation should cover the current and progression of the patient’s disease and the need for referrals to rehabilitative, social, legal, financial, or community services. 

Patients without a firm diagnosis need documentation confirming cognitive impairment and a narrative history supporting the suspicion of potential cognitive impairment [28]. Use standardized tools for cognitive assessments and keep the full instrument raw scoring and results available for Medicare Administrative Contractor review if requested. 

Required Tools and Assessments 

Document the following standardized tools within the medical record: 

• Cognitive assessment tools: Mini-Cog©, GPCOG, Short Montreal Cognitive Assessment (s-MoCA) [31]. 

• Functional assessment tools: Katz Index of Independence in Activities of Daily Living, Lawton-Brody Instrumental Activities of Daily Living Scale (IADL) [32]. 

• Dementia staging tools: Functional Assessment Staging Test (FAST), Clinical Dementia Rating (CDR® Dementia Staging Instrument), Dementia Severity Rating Scale (DSRS), Global Deterioration Score (GDS) [33]. 

• Neuropsychiatric assessment tools: Neuropsychiatric Inventory Questionnaire (NPI-Q), BEHAV5+©, Patient Health Questionnaire-2 (PHQ-2) [34]. 

Additional Documentation 

Additional documentation of cognitive-relevant history should include: 

• Medication reconciliation 

• Evaluation of home and vehicle safety 

• Identification of social supports and caregivers 

• Advance care planning and palliative care needs 

Background and Introduction to CPT® Code 99483 

The Alzheimer’s Association advocates for Medicare reimbursement for services to improve detection, diagnosis, and care planning for patients with Alzheimer's disease and related dementias (ADRD). This advocacy led to the approval of Medicare procedure code G0505 in January 2017, later replaced by CPT code 99483 in January 2018 [35]. CPT code 99483 reimburses physicians and eligible billing practitioners for a clinical visit that produces a written care plan [35]. 

Who Is Eligible for Comprehensive Care Planning Services? 

Provide cognitive assessment and care plan services under CPT code 99483 when a comprehensive evaluation of a new or existing patient with signs or symptoms of cognitive impairment is necessary [35]. This evaluation aims to establish or confirm a diagnosis, etiology, and severity of the condition. If any required elements are missing or unnecessary, use the appropriate evaluation and management (E/M) code instead. 

Requirements for CPT Code 99483 

To bill under CPT code 99483, perform the following service elements [28]: 

1. Cognition-focused evaluation, including a pertinent history and examination  
2. Medical decision-making of moderate or high complexity  
3. Functional assessment (e.g., this includes basic and instrumental activities of daily living as well as decision-making capacity).   
4. Use of standardized instruments to stage dementia (e.g., Functional Assessment Staging Test [FAST], Clinical Dementia Rating [CDR]) [30].  
5. Medication reconciliation and review for high-risk medications  
6. Evaluation for neuropsychiatric and behavioral symptoms, including depression, using standardized instruments  
7. Assessment of safety, both within the home environment and in other settings, including considerations for motor vehicle operation if relevant.  
8. Identification of caregivers, their knowledge, needs, social supports, and willingness to take on caregiving tasks  
9. Development and periodic updating of an Advance Care Plan  
10. Develop a comprehensive written care plan that addresses neuropsychiatric and neurocognitive symptoms, outlines functional limitations, and includes referrals to community resources. Document and share this plan with the client and/or caregiver. 

This service involves 50 minutes of face-to-face time with the patient and/or family or caregiver. Do not report cognitive assessment and care plan services if any essential elements are either absent or deemed unnecessary. Instead, use the appropriate evaluation and management (E/M) code [28]. 

Assessment Settings and Documentation 

Evaluate the first nine assessment elements of CPT code 99483 during the care planning visit or across multiple visits using billing codes (often E/M codes) [36]. Include results of assessments conducted before the care plan visit if they remain valid or update them at the time of care planning. Complete assessments that require a care partner or caregiver before the clinical visit and provide them to the clinician for the care plan. 

Cognitive Assessment and Care Planning Billing Codes 

Use Current Procedural Terminology (CPT) code 99483 for a clinical visit that assesses cognitive impairment and establishes a care plan for patients with dementia or other cognitive impairments, including Alzheimer's disease [27][28]. This code applies to patients at any stage of impairment and once every 180 days billed to the insurance company.  

Additional CPT codes related to cognitive assessment and care planning [27][28]: 

• 99324–99337: Home visits for new patients 

• 99341–99350: Home visits for established patients 

• 99366–99368: Medical team conferences 

• 99497: Advanced care planning for the first 30 minutes 

• 97129, 97130: Cognitive functioning intervention services 

Screening and Billing for Cognitive Assessment 

Medicare Annual Wellness Visits (AWV) require screening for cognitive impairment [29]. Identify cognitive impairment during routine visits through direct observation or information from the patient, family, friends, caregivers, and others. Develop a cognitive assessment and care plan during a separate visit. 

Bill CPT code 99483 apart from the annual wellness visit due to the time and medical decision-making [28]. If providing both services at the same visit, use a -25 modifier [28]. 

Eligible Providers and Settings 

Any healthcare professional qualified to report Evaluation and Management (E/M) services can offer this service, including physicians (MD and DO), nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse midwives (CNM), and physician assistants (PA) [28]. Practitioners must provide documentation substantiating a moderate-to-elevated level of complexity in their medical decision-making, following E/M guidelines [28]. Conduct care planning visits in the office, other outpatient settings, home, domiciliary, rest home settings, or via telehealth. Even when using telehealth, include all required service elements for CPT 99483 [36]. 

Utilizing a Care Plan Template 

The required elements for this service may benefit from a standardized care plan template. This template can simplify communication and track patient care and outcomes but must allow for narrative unique to the patient. Discuss and give the written care plan to the patient and/or family or caregiver and document this face-to-face conversation in the clinical note. Share the care plan with other providers involved in the patient's care to ensure continuity and coordination. 

Frequency of Service and Auditing 

A single physician or other qualified health care professional reports CPT code 99483 no more than once every 180 days [28]. Revise the care plan at intervals and whenever the patient’s clinical or caregiving status changes. Ensure that revisions to reports exclude any service elements of CPT 99483 when billed through alternative E/M codes, such as those for chronic care management or non-face-to-face consultation [28][36]. 

The Alzheimer's Association's Cognitive Impairment Care Planning Toolkit is a valuable resource for practitioners, providing comprehensive guidance on creating effective care plans for patients with cognitive impairment. 

Current Treatments Available to the Patient 

The primary approach to treatment manages symptoms of Alzheimer's disease (AD). Two categories of drugs treat AD: cholinesterase inhibitors and partial N-methyl D-aspartate (NMDA) antagonists [1]. 

Cholinesterase Inhibitors 

Cholinesterase inhibitors work by increasing the levels of acetylcholine, a neurotransmitter involved in learning, memory, and cognitive functions [1][37]. Three drugs in this category have received FDA approval for treating AD [1][37][38]: 

• Donepezil: 

• Preferred medication 

• Used in AD with mild dementia 

• Rapid and reversible inhibitor of acetylcholinesterase 

• Administered once daily in the evening 

• Rivastigmine: 

• Used in mild cognitive impairment (MCI) and mild dementia stages 

• Slow, reversible inhibitor of acetylcholinesterase and butyrylcholinesterase 

• Available in oral and transdermal formulations 

• Galantamine: 

• Approved for MCI and mild dementia stages 

• Rapid, reversible inhibitor of acetylcholinesterase 

• Available as a twice-daily tablet or once-daily extended-release capsule 

• Not suitable for individuals with end-stage renal disease or severe liver dysfunction 

Common side effects of cholinesterase inhibitors include gastrointestinal symptoms such as nausea, vomiting, and diarrhea [37]. They may also cause bradycardia, cardiac conduction defects, and syncope due to increased vagal tone [37]. These medications are contraindicated in patients with severe cardiac conduction abnormalities [37]. 

Partial N-Methyl D-Aspartate (NMDA) Antagonist: Memantine 

Memantine acts as a partial NMDA antagonist that blocks NMDA receptors and slows intracellular calcium accumulation [39]. The FDA has approved it for the treatment of moderate to severe Alzheimer's disease. Side effects may include dizziness, body aches, headaches, and constipation [39]. Combine memantine with cholinesterase inhibitors like donepezil, rivastigmine, or galantamine in individuals with moderate to severe AD [39]. 

Disease-Modifying Therapies for Alzheimer’s Disease 

AD treatment managed symptoms. However, understanding AD's pathophysiology and improving diagnostic testing led to new disease-modifying therapies. These therapies target the disease's mechanisms, even in preclinical and presymptomatic stages. 

Recent Therapy Approvals 

• Aducanumab [40]: 

• FDA accelerated approval in June 2020 

• Shown to reduce amyloid-beta plaque in the brain 

• Did not meet the primary phase III trial endpoint of clinical improvement 

• Lecanemab [41]: 

• FDA accelerated approval in January 2023 

• Reduced amyloid-beta burden in the brain 

• Phase III trial showed a 27% slowing of disease progression 

• Donanemab [42]: 

• Expected FDA approval in 2023 

• Reduced amyloid-beta burden in the brain 

• Slowed cognitive decline by 35% 

Amyloid-Related Imaging Abnormalities (ARIA) 

ARIA results from an immune response to amyloid-targeting therapies, causing capillary leakage and hemorrhages in cerebral vascular walls [43]. Two types exist: ARIA edema (ARIA-E) and ARIA hemorrhage (ARIA-H). Key risk factors for developing ARIA include the apolipoprotein E4 allele and cerebral amyloid angiopathy findings in brain MRI [43]. 

Other Management Strategies in Alzheimer’s Disease 

Manage symptoms such as anxiety, depression, and psychosis in the mid to late stages of the disease. Avoid tricyclic antidepressants due to their anticholinergic effects, which worsen cognitive impairment [44]. Use antipsychotic medications with caution for acute agitation when other interventions have failed, and the patient's or caregiver's safety is at risk. Try SSRIs like citalopram and anticholinesterases like donepezil before considering antipsychotics. 

Prefer second-generation antipsychotics over first-generation antipsychotics due to their safer profile and fewer extrapyramidal side effects [45]. Brexpiprazole, approved by the FDA in May 2023 for treating agitation associated with dementia due to AD, serves as an example. Use the lowest effective dose when prescribing antipsychotics [46]. Avoid benzodiazepines as they worsen delirium and agitation [47]. 

Non-Pharmacological Interventions 

• Behavioral Strategies: Establishing a familiar and secure environment is essential. This includes addressing personal comfort needs, offering security objects, redirecting attention when necessary, removing hazardous items, and avoiding confrontational situations. 

• Sleep Disturbances: Addressing mild sleep disturbances through non-pharmacological strategies such as exposure to sunlight, daytime exercise, and establishing a bedtime routine. 

• Exercise: Regular aerobic exercise slows the progression of AD. 

Conclusion

Alzheimer's disease (AD) is the prevalent form of dementia, impacting cognitive and behavioral functions, and is a leading cause of death among the elderly [1]. AD presents with symptoms that progress from mild memory loss to severe cognitive and functional decline [1]. Early detection and diagnosis are critical for effective management, involving a thorough assessment of cognitive and functional abilities [48]. While there is no cure for AD, symptomatic treatments such as cholinesterase inhibitors and NMDA antagonists can help manage symptoms, and recent advancements in disease-modifying therapies offer new hope for slowing disease progression [49].  

Comprehensive care planning, including regular cognitive assessments and tailored interventions, is essential for optimizing patient outcomes and supporting caregivers. Regular follow-ups and a multidisciplinary approach to treatment, incorporating both pharmacological and non-pharmacological strategies, can improve the quality of life for individuals with AD and their families. 

Kentucky Pediatric Abusive Head Trauma

Introduction and Objectives 

Pediatric Abusive Head Trauma (AHT), also known as Shaken Baby Syndrome, includes an array of symptoms and complications resulting from injury to a child or infant’s head and brain after violent or intentional shaking or impact. There are approximately 1,300 reported cases of AHT each year and it is the leading cause of child abuse deaths nationally. For those children who survive, most suffer lifelong complications and disabilities (7).   

This serious and tragic injury may be a challenge to diagnose because obvious signs of injury may not be easily detectable right away, and those responsible for the injuries may avoid taking the child for treatment (4). Therefore, it is incredibly important for healthcare professionals who work in pediatrics or emergency medicine to be able to identify at-risk individuals and recognize signs and symptoms of potential victims of AHT. It is also 100% preventable, and proper training on how to mitigate the risks and situations that lead to AHT can help healthcare professionals reduce the incidence of this horrific injury. Upon completion of this course, the learner will be able to:  

1. Identify risk factors and common mechanisms of injury for pediatric abusive head trauma. 
2. Describe signs and symptoms and diagnostic tools used to identify pediatric abusive head trauma. 
3. List potential outcomes of pediatric abusive head trauma and their prevalence. 
4. Understand the legal considerations of mandated reporters, process of reporting, and penalties for pediatric abusive head trauma perpetrators in the state of Kentucky  
5. Identify ways that societal and healthcare interventions can help reduce the prevalence of pediatric abusive head trauma 

Epidemiology/Risk Factors  

Though pediatric abusive head trauma most often occurs in children under age 5, the majority of these injuries are in children under the age of 1 year. There is a slight difference in incidence between genders, with 57.9% of victims being male and 41.9% being female. There is a peak occurrence of AHT between 3 and 8 months (4). Babies of this age are particularly vulnerable for a multitude of reasons, including large head size, weak neck muscles, fragile and developing brains, and the discrepancy in strength between infant and abuser. Sleep deprivation paired with longer and louder crying spells of very young infants sets the stage for high levels of caregiver frustration, which often precedes AHT injuries. The perpetrator is almost always a parent or caregiver (7).  

Besides infant age, there are many social factors that increase the risk of AHT, including a lack of childcare experience, young or poorly supported parents, single-parent homes, low socioeconomic status, low education level, and a history of violence. These factors paired with a lack of prenatal care or parenting classes often leads to poorly prepared parents who have not been taught to anticipate crying spells or how to deal with the frustration in a safe manner (7).  

Unfortunately, Kentucky has one of the highest rates of child abuse in the country. In 2019, there were more than 130,000 reports of suspected abuse or neglect, and 15,000 of those had substantial evidence to support abuse had occurred. Of those, nearly 76 were nearly fatal or fatal, and 32 of those were due to pediatric abusive head trauma(1).  

Case Study 

A Nursery nurse on a Labor, Delivery, and Postpartum unit is providing discharge information to the parents of a 2 day old baby girl, Violet, who is going home today. This is the first child for both parents. They are 19 years old, living in an apartment together while the mother works part time as a waitress and the father works full time for a lawn mowing company. The child’s maternal grandmother lives nearby and will be helping the mother care for the baby the first few weeks and then watching the baby a few days per week when the mother returns to work.   

Pathophysiology of Pediatric Abusive Head Trauma

While anyone can sustain a head injury, the relatively large size of young children’s heads paired with their weak and underdeveloped neck muscles is what makes them particularly susceptible to AHT. When a child’s head moves around forcefully, the brain moves around within the skull, which can tear blood vessels and nerves, causing permanent damage. Bruising and bleeding may occur when the brain collides with the inside of the skull or fractured pieces of skull. Finally, swelling of the brain may occur, which builds up pressure inside the skull and makes it difficult for the body to properly circulate oxygen to the brain (6).   

It should be noted that bouncing or tossing a child in play, sudden stops or bumps in the car, and falls from furniture (or less than 4 feet) do not involve the force required to mimic the injuries of AHT (7).  

Also important to understand is that AHT is a broad term used to describe the injury, but there are a collection of various mechanisms of injury within AHT. Among these different causes are Shaken Baby Syndrome (SBS), blunt impact, suffocation, intentional dropping or throwing, and strangulation. It is recommended to classify all of these injuries as AHT so as to avoid any confusion or challenges in court if multiple mechanisms of injury were involved (4).   

Diagnosis of Pediatric Abusive Head Trauma  

Parents or caregivers who have inflicted injury onto a child may delay seeking treatment for fear of consequences. It is important to gather a thorough history and be on the lookout for inconsistent stories, changing details, or mechanism of injury that does not match the severity of symptoms (7).   

Symptoms that typically lead caregivers to seek treatment for their child include:  

• Decrease in responsiveness or change in level of consciousness 
• Poor feeding 
• Vomiting 
• Seizures 
• Apnea 
• Irritability 

Upon exam, these children may exhibit:   

• Bradycardia 
• Bulging fontanel 
• Irritability or lethargy  
• Apnea 
• Bruising 

A lack of any external injuries or obvious illnesses when presenting with these symptoms should alert the healthcare professional to the possibility of AHT, particularly in young children or infants. Additionally, unexplained fractures, particularly of the skull or long bones, bruising around the head or neck, or any bruising in a child less than 4 months are red flags (4).   

An ophthalmology consult to assess for retinal hemorrhage should be obtained. The force used with AHT can cause a shearing effect with the retina and is visible with a simple fundal exam of the eye. This type of injury does not typically occur with accidental or blunt head trauma and is typically considered highly indicative of abuse. That same shearing force often causes bleeding within the brain, and subdural hematomas are often revealed on CT or MRI (4).   

Any of the above criteria, or other suspicious story or injuries, should be reported for further investigation. Mild injuries are harder to detect but only occur around 15% of the time. Severe injury from AHT accounts for 70% of cases (4).

Case Study Cont.

Baby Violet is now 5 weeks old and is brought to the ED by her parents. Her mother reports that she has been eating poorly and acting strange since this morning. Her father reports he thinks she has been sleeping excessively for 2 days now. On exam, the baby is found to have a bulging fontanel, slow heart rate, and a bruise on the side of her head. Her mother states she sustained that bruise when she rolled off of her changing table yesterday.  

Outcomes and Sequelae  

For children diagnosed with even mild to moderate AHT, the prognosis is fairly grim. Up to 25% of children with AHT end up dying from their injuries, and for those who survive, 80% will have lifelong disabilities of varying severity (7).    

The most common complications and disabilities include: blindness, hearing loss, developmental delays, seizures, muscle weakness or spasticity, hydrocephalus, learning disabilities, and speech problems. Lifelong skilled care and therapies are often needed for these children, accruing over $70 million in healthcare costs in the United States annually (4).  

Legal Considerations in the State of Kentucky  

In the state of Kentucky, anyone with a reasonable suspicion that abuse or neglect is occurring is mandated by law to report the incident, and there are legal consequences (from misdemeanor all the way to felony) for willfully failing to make a report. For healthcare professionals, this is particularly important to note, as you will come in contact with many different types of families, injuries, and stories, and must remain vigilant in assessing for abuse (5).  

A report of suspected abuse should be made at the first available opportunity and can be made by contacting the child abuse hotline (1-877-KYSAFE1), local law enforcement, Kentucky State Police, or the Cabinet for Health and Family Services. The child’s name, approximate age and address, as well as the nature and description of injuries, and the name and relationship of the alleged abuser should all be included in the report (9).   

Once a report has been made, the Department for Community Based Services will determine if an investigation is warranted. If the home is deemed to be unsafe or there is a threat of immediate danger to a child, the child will be removed from the home, but in all other cases, every effort will be made to maintain the family (5).

Case Study 

It is later determined that Baby Violet was violently shaken by her mother during a crying spell one evening. During legal proceedings for the incident, it is revealed that the grandmother witnessed this abuse.

Prevention  

While accurate detection of AHT is incredibly important, another key consideration for this injury and its poor outcomes, is that these incidents are 100% preventable. Much of the time, AHT is preceded by extreme frustration by a parent or caregiver when an infant is crying for long periods or is inconsolable. Proper education and preparedness about when and why this occurs, and what to do when it does, can help prevent AHT from occurring. For healthcare professionals who regularly care for infants, children, and expecting or new parents, there is a huge potential for positive impact (2).  

Identifying those most at risk is a great starting place and new parenting courses, educational discussion and pamphlets, as well as regular check-ins are extremely beneficial for at-risk families. Young or inexperienced families, families without a lot of external support, or those with low socioeconomic status or poor education should be looked at first.   

Once the most at risk families have been identified, provide them with information and services that may help reduce risks. These interventions are useful for anyone with an infant or small child, but special attention and close follow up should be given to those with more risk factors (8).   

1. Educate about infant crying: The PURPLE Crying program is particularly useful for this and includes facts and common symptoms of excessive or colicky infant crying. PURPLE stands for:   

• Peak of Crying, with crying increasing weekly after birth and peaking around 8 weeks  
• Unexpected, where crying may come and go with no apparent cause 
• Resists soothing, where your baby won’t settle no matter what you try 
• Pain like face, where your baby looks like they are in pain even if nothing is wrong 
• Long-lasting, with crying lasting as long as 5 hours 
• Evening, with excessive crying being more common in the evening or at night (8)

2. Enhance parenting skills: Let parents know it is okay to feel frustrated. Take a deep breath, count to 10, place your infant in a safe place and walk away for a few minutes to collect yourself. Many parents don’t know that this is okay to do (3).   

3. Strengthen socioeconomic support: Make sure families are aware of and utilizing access to supportive services like WIC to help ease financial strain.

4. Emphasize social support and positive parenting: Ask about nearby help in the form of relatives or friends. Encourage them to reach out for emotional support, or even a break from caring for the infant. Connect families with community resources like motherhood support groups or playdates. Schedule for early childhood home visits (2).  

Conclusion  

Though the goal is for there to be no scenarios where children suffer head trauma at the hands of an abuser, there is a long way to go before that objective can be reached. In the meantime, healthcare professionals must be vigilant in maintaining a high level of suspicion for pediatric abusive head trauma whenever they are caring for children. Understanding contributing risk factors, as well as signs and symptoms, and how to properly assess for and diagnose pediatric abusive head trauma will lead to more accurate detection, appropriate treatment, and hopefully better outcomes. On the other end of things, those in a position to influence parenting education and community health standards should consider the ways in which caregiver frustration might be better handled to prevent the abuse from even occurring. There is much work to be done when it comes to AHT, but well informed medical professionals is an essential step in the right direction.  

Kentucky Implicit Bias

Health Equity is a rising area of focus in the healthcare field as renewed attention is being given to ongoing data regarding discrepancies and gaps in the accessibility, expanse, and quality of healthcare delivered across racial, gender, cultural, and other groups. Yes, there are some differences in healthcare outcomes purely based on biological differences between people of different genders or races, but more and more evidence points to the vast majority of healthcare gaps stemming from individual and systemic biases.  

Policy change and restructuring is happening at an institutional level across the country, but this will only get us so far. In order for real change to occur and the gaps in healthcare to be closed, there must also be awareness and change on an individual level. Implicit, or subconscious, bias has the potential to change the way healthcare professionals deliver care in subtle but meaningful ways and must be addressed to modernize healthcare and reach true equity.  

This Kentucky Implicit Bias training meets the “Implicit Bias” requirement needed for Kentucky nursing license renewal.

What is Implicit Bias?

So what is implicit bias and how is it affecting the way healthcare is delivered? Simply put, implicit bias is a subconscious attitude or opinion about a person or group of people that has the potential to influence the actions and decisions taken when providing care. This differs from explicit bias which is a conscious and controllable attitude (using racial slurs, making sexist comments, etc). Implicit bias is something that everyone has and may be largely unaware of how it is influencing their understanding of and actions towards others. The way we are raised, our unique life experiences, and an individual’s efforts to understand their own biases all affect the opinions and attitudes we have towards other people or groups (7). This Kentucky Implicit Bias training course will increase your awareness of implicit bias in your nursing practice.

This can be both a positive or a negative thing. For example if a patient’s loved ones tells you they are a nurse, you may immediately feel more connected to them and go above and beyond the expected care as a “professional courtesy.” This doesn’t mean you dislike your other patients and their loved ones, just that you feel more at ease with a fellow healthcare professional which shapes your thoughts and behaviors in a positive manner.  

More often though, implicit biases have a negative connotation and can lead to care that is not as empathetic, holistic, or high quality as it should be. Common examples of implicit bias in healthcare include:  

• Thinking elderly patients have lower cognitive or physical abilities 
• Thinking women exaggerate their pain or have too many complaints 
• Assuming patients who state they are sexually active are heterosexual  
• Thinking Black patients delay seeking preventative or acute care because they are passive about their health 
• Assuming a chatty college student is asking for ADHD evaluation because she is lazy and wants medication to make things easier
  

On a larger, more institutional and societal level, the effects of bias create barriers such as:  

• Underrepresentation of minority races as providers: in 2018 56.2% of physicians were white, while only 5% were Black and 5.8% Hispanic (2) 
• Crowded living conditions and food deserts for minority patients due to outdated zoning laws created during times of segregation (17). 
• Difficulty obtaining health insurance for minority or even LGBTQ clients, decreasing access to healthcare (3). 
• Lack of support and acceptance for LGBTQ people in the home, workplace, or school as well as lack of community resources leads to negative social and mental health outcomes. 
• Due to variations in the way disabilities are assessed, the reported prevalence of disabilities ranges from 12% to 30% of the population (15). 

Implications

Once you have an understanding of what implicit bias is, you may be wondering what it looks like on a larger scale and what it means in terms of healthcare discrepancies. More and more data stacks up each year with examples that span all types of diversity, from race to gender, age, disabilities, religion, sexual identification and orientation, and even Veteran status. Examples of what subconscious biases in healthcare may look like include:   

• 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. This can lead to missed or delayed diagnoses and treatment for patients of color (9).  
• A 2018 survey of LGBTQ youth revealed 80% reporting their provider assumed they were straight or did not ask (12). And in 2014, over half of gay men (56%) surveyed who had been to a doctor said they had never been recommended for HIV screening, despite increased risk for the disease (10).  
• A 2010 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 (4).  For centuries, any symptoms or behaviors that women displayed (largely related to mental health) that male doctors could not diagnose fell under the umbrella of “hysteria”, a condition that was not removed from the DSM until 1980 (20).  
• When treating elderly patients, providers may dismiss a treatable condition as part of aging, skip preventative screenings due to old age, or overtreat natural parts of aging as though they are a disease. Providers may be less patient, responsive, and empathetic to a patient’s concerns or even talk down to them or not explain things because they believe them to be cognitively impaired (18).  
• Minority, particularly Black or Hispanic patients, are often thought to be less concerned or more neglectful of their health, but minority patients are also most 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 (mude). Minority patients are also still disproportionately uninsured, which leads to delayed or no care when necessary (3).  

Although these are only a few examples, there are obvious and substantial consequences of these biases; which is why it is vital that we address them in this Kentucky Implicit Bias training course.  

This has obvious negative connotations or repercussions at the time of care and can lead to client dissatisfaction or suboptimal treatment and missed preventative care, but over time the effects of implicit bias can add up and lead to even larger consequences. Examples include:  

• 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 and undertreated for Black Americans (16). 
• 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 (3). 
• 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) (4).  
• 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 (5).  
• 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 (11).  

Impact of Historic Racism

In addition to discrepancies in insurance status, representation in medical textbooks, and representation among medical professionals, there is a long history of systemic racism that has created generational trauma for minority families, leading to mistrust in the healthcare system and poorer outcomes for those marginalized communities.  

Possibly one of the most infamous examples is the Tuskegee Syphilis Study. This 1932 experiment included 600 Black men, about two thirds of which had syphilis, and involved collecting blood and monitoring the progression of symptoms for research purposes in exchange for free medical exams and meals. Informed consent was not collected and participants were given no information about the study other than that they were being “treated for bad blood”, even though no treatment was actually administered. By 1943, syphilis was routinely and effectively treated with penicillin, however the men involved in the study were not offered treatment and their progressively worsening symptoms continued to be monitored and studied until 1972 when it was deemed unethical. Once the study was stopped, participants were given reparations in the form of free medical benefits for the participants and their families. The last participant of the study lived until 2004 (6).  

The “father of modern gynecology,” Dr. J. Marion Sims, is another example steeped in a complicated and racially unethical past. Though he did groundbreaking work on curing many gynecological complications of childbirth, most notably vesicovaginal fistulas, he did so by practicing on unconsenting, unanesthetized, Black enslaved women. The majority of his work was done between 1845 and 1849 when slavery was legal and these women were likely unable to refuse treatment, sometimes undergoing 20-30 surgeries while positioned on all fours and not given anything for pain. Historically his work has been criticized because he achieved so much recognition and fame through an uneven power dynamic with women who have largely remained unknown and unrecognized for their contributions to medical advancement (23).  

Another example is the story of Henrietta Lacks, a young Black mother who died of cervical cancer in 1951. During the course of her treatment, a sample of cells was collected from her cervix by Dr. Gey, a prominent cancer researcher at the time. Up until this point, cells being utilized in Dr. Gey’s lab died after just a few weeks and new cells needed to be collected from other patients. Henrietta Lacks’ cells were unique and groundbreaking in that they were thriving and multiplying in the lab, growing new cells (nearly double) every 24 hours. These highly prolific cells were nicknamed HeLa Cells and have been used for decades in the development of many medical breakthroughs, including studies involving viruses, toxins, hormones, and other treatments on cancer cells and even playing a prominent role in vaccine development. All of this may sound wonderful, but it is important to understand that Henrietta Lacks never gave permission for these cells to be collected or studied and her family did not even know they existed or were the foundation for so much medical research until 20 years after her death. There have since been lawsuits to give family members control over what the cells are used for, as well as requiring recognition of Henrietta in published studies and financial payments from companies who profited off of the use of her cells (15).  

When considering all of the above scenarios, the common theme is a lack of informed consent for Black patients and the lack of recognition for their invaluable role in society’s advancement to modern medicine. It only makes sense that these stories, and the many others that exist, have left many Black patients mistrustful of modern medicine, medical professionals, or treatments offered to them, particularly if the provider caring for them doesn’t look like them or seems dismissive or unknowledgeable about their unique concerns. Awareness that these types of events occurred and left a lasting impact on many generations of Black families is incredibly important in order for medical professionals to provide empathetic and racially sensitive care. 

Exploring Areas of Bias

Culture

Cultural competence is a common buzzword used in healthcare training programs and information about various religions, ethnicities, beliefs, or practices is often integrated into medical training. Students and staff members are often reminded that the highest quality of care anticipates the unique cultural needs a client may have and aims to provide care that is holistic and respectful of cultural differences. An awareness of the potential variances in care, such as dietary needs, desire for prayer or clergy members, rituals around birth or death, beliefs surrounding and even refusal for certain types of treatments, are all certainly very important for the culturally sensitive healthcare professional to have (and the distinctions far too many for the scope of this course); however, there is also a fine line between being aware of cultural similarities and stereotyping.  Since this course is a required California Implicit Bias training, it is essential that this topic is covered. 

Clinicians should make sure to understand that people hold different identities, beliefs, and practices across racial, ethnic, and religious groups. Remember that just because someone looks a certain way or identifies with a certain group does not mean all people within that group are the same. Holding assumptions about clients of a particular race or religion, without getting to know the individual needs of your client, is a form of implicit bias and may cause your client to become uncomfortable or offended.  

Simply asking clients if they have any cultural, dietary, or spiritual needs throughout the course of their care is often the best way to learn their needs without making assumptions or stereotyping. Overall, it should be thought of as extending care beyond cultural competence and working on partnership and advocacy for your client’s unique needs. 

Maternal Health

One of the most strikingly obvious places that implicit bias has tainted the healthcare industry is in maternal health. Repeatedly, statistics show that Black women experience twice the infant mortality rate and nearly four times the maternal mortality rate of non-Hispanic white women during childbirth.  

Let those numbers sink in and realize that this is a crisis. Pregnancy and childbirth are natural processes, but do come with inherent risks for mother and baby; but in a modern society, women should feel comfortable and confident in their care, not scared they won’t be treated properly or even survive. Home births among Black women are on the rise as they seek to avoid the biases of the hospital setting and maintain control over their own experiences (21).  

The reasons for this disparity and Black women fearing for their lives when birthing in hospitals are many. This disparity exists regardless of socioeconomic class or education, indicating that a more insidious culprit, implicit bias, is hugely responsible (21).  In order for true change to come, this topic must be addressed in this California Implicit Bias training. A few notes that indicate the prevalence of implicit bias in healthcare throughout history are listed below:  

• False beliefs about biological differences between white and black women date back to slavery, including the belief that Black women have fewer nerve endings, thicker skin, and thicker bones and therefore do not feel pain as intensely.  
• These beliefs are obviously untrue, but subconscious bias towards those beliefs still exists as Black and Hispanic women statistically have their perceived pain rated lower by health care professionals and are offered appropriate pain management interventions less often than white peers.  
• Complaints from minority patients that may indicate red flags for conditions such as preeclampsia or hypertension are often downplayed or ignored by healthcare professionals.  
• Studies show healthcare professionals may believe minority patients are less capable of adhering to or understanding treatment plans and may explain their care in a condescending tone of voice not used with other patients.  
  • One in five Black and Hispanic women report poor treatment during pregnancy and childbirth by healthcare staff. 
  • These patients are less likely to feel respected or like a partner in their care and may be non-compliant with treatment recommendations due to feeling this way, however this just perpetuates the attitudes held by the healthcare providers (21).

Reproductive Rights

Branching off of maternal health is reproductive justice. Biases surrounding the reproductive decisions of women may negatively impact the care they receive when seeking care for contraception or during pregnancy. While some of these inequities may be more profound for women of color, women of all races can be and are affected by biases surrounding reproduction, which is why it is being covered in this California Implicit Bias training course. Examples of ways implicit bias may affect care include:  

• Some healthcare professionals may believe there is a “right” time or way to become pregnant and feel pregnancy outside of those qualifiers is undesirable; this can stem from personal or religious beliefs. While healthcare staff are certainly entitled to hold these beliefs in their personal lives, if the resulting implicit biases are left unchecked, they can lead to attitudes and actions that are less compassionate when caring for their clients. Clients may feel shamed or judged during their experiences instead of having their needs addressed (8). Variables that may be perceived as unacceptable or less desirable include: 
  • Age during pregnancy. Clinicians may feel differently about pregnant clients who are very young (teenagers) or even those who are in their 40s or 50s (8).  
  • Marital status during pregnancy. Healthcare professionals may have beliefs that clients should be married when having children and may have a bias against unmarried or single clients (8).  
  • Number or spacing of pregnancies. Professionals may hold beliefs about how many pregnancies are acceptable or how far apart they should be and may hold judgment against clients with a large number of children or pregnancies occurring soon after childbirth.
    - Low-income and minority women are more likely to report being counseled to limit the number of children they have, as opposed to their white peers (15).  
• Method of conception. Some healthcare professionals may have personal beliefs about how children should be conceived and may have negative opinions about pregnancies resulting from fertility treatments such as IVF or surrogacy (8).  
• Personal or religious beliefs about contraception may also cause healthcare professionals to provide less than optimal care to clients seeking methods of birth control.  
  • Providers may believe young or unmarried clients should not be given access to contraception because they do not believe they should be engaging in sexual activity (8). 
  • Providers, or even some institutions such as Catholic hospitals, may withhold contraception from clients as they believe it to be immoral to prevent pregnancy. 
  • Providers may push certain types or usage of contraception onto clients that they feel should limit the number of children they have, even if this does not align with the desires of the client. This includes the use of permanent contraception such as tubal ligation (15).  
  • Providers may provide biased information about the types of contraception available, minimizing side effects or pushing for easier, more effective types of contraception (such as IUDs), despite a client’s questions, concerns, or contraindications (15). 
    - One study showed Black and Hispanic women felt pressured to accept a certain type of contraception based on effectiveness alone, with little concern for their individual needs or reproductive goals (15).  
• Personal or religious beliefs about pregnancy termination may impact the care provided and counsel given to pregnant clients who may wish to consider termination. Providers who disagree with abortion on a personal level may find it difficult to provide clear and unbiased information about all options available to pregnant clients or may have a judgmental or uncompassionate attitude when caring for clients who desire or have had an abortion (8).  

Case Study

Alexandria is a 22-year-old Hispanic woman who has always wanted a big family with 3-5 children. She met her current boyfriend in college when she was 19 and became pregnant shortly afterward. It was an uneventful pregnancy, and Alexandria had a vaginal delivery to a healthy baby girl at 39 weeks. When that child turned 2, Alexandria and her partner decided they would like to have another baby.

At 38 weeks gestation, Alexandria was at a prenatal appointment when her provider brought up her plans for contraception after the birth. The provider suggested an IUD and stated it could be placed immediately after birth, could be left in for 5 years, and would be 99% effective at preventing pregnancy. Alexandria stated she had an IUD when she was 17 and did not like some of the side effects, mostly abdominal cramping, and that she also might like to have another baby before the 5-year mark.

Her doctor stated “All birth control has side effects, and this one is the most effective. You are so young, do you really want 3 children by age 25 anyway?” 

How to Measure and Reduce Implicit Biases in Healthcare

Assessing for Bias

In order for change to occur, there is a broad spectrum of transitions in individual thought and policy that must occur. Evaluating for the presence, and the extent, of implicit bias is one of the first steps.  This Kentucky Implicit Bias training will cover both individual and institutional level focuses. 

On the individual level, possible action include:  

• Identifying and exploring one’s own implicit biases. Everyone has them and we all need to reflect upon them. This goes beyond basic cultural competence and includes a deeper understanding of how your own experiences or environment may differ from someone else and may have caused you to feel or believe a certain way.   
• Attending training or workshops provided by your job and completing exercises in self reflection will help you better understand where your biases are and the extent to which they may be impacting your behavior or actions at work and in your personal life. 
• Reflecting on how one’s biases affect actions. Once you have recognized the internal opinions you hold, you can examine ways that those opinions may have been affecting your actions, behaviors, or attitudes towards others. Reflect on your care of patients at the end of each shift. Consider if you made assumptions about certain clients early on in their care. Think about ways those assumptions may have affected your interactions with the client. Think about if you cared for your clients in a way that you would want your own loved ones cared for.  
• If you have the time, volunteer at events or in places that will expose you to people who are different from you. Use the opportunity to learn more about others, their lived experiences, and identify how often your implicit biases may be affecting your view of others before you even get to know them.  

On an institutional level, the measurement of biases can be more streamlined and may utilize tools like surveys.  

• Monitoring patient data and assessing for any broad gaps in diagnoses, preventative care and treatment rates, as well as health outcomes across racial, ethnic, gender, and other spectrums. Recognizing gaps or problem areas and assigning task forces to evaluate further and address the underlying issues.  
• Regularly poll clients and employees of healthcare facilities to determine who might be experiencing effects of bias and when. 
• Require employee participation in implicit bias presentations or courses, allowing employees to self identify areas where they may be biased.

Acting to Reduce Bias

Once the presence and extent of bias has been identified, individuals can make small, consistent changes to recognize and address those biases in order to become more self aware and intentional in their actions. Some possible ways to address and reduce implicit bias on an individual level include:  

• Educating oneself and reframing biases. In order to change patterns of thinking and subsequent behaviors that may negatively impact others, you can work on broadening your views on various topics. This can be done through reading about the experiences of others, watching informational videos or documentaries, attending speaking engagements, and just listening to the experiences of others and gaining an understanding of how their lives might be different than yours.  
• Understanding and celebrating differences. Once you can learn to see others for their differences and consider how you can adapt your care to help them achieve the best outcomes for their wellbeing, you are able to provide truly equitable care to your clients. This includes understanding differences in experiences, perceptions, cultures, languages, and realities for people different from yourself, recognizing when disparities are occurring, and advocating for change and equity.  

When enough people have recognized and addressed their own implicit biases, advocacy can extend beyond individual care of clients and reach the institutional level where change is more easily seen (though no more important than the small individual changes). One of the most effective ways to make institutional level changes is through representation of minority groups in positions of power and decision making. Simply keeping structures as they are and dictating change without any evolution from leadership is not likely to be effective in the long term. Including minority professionals in positions of leadership or on decision making panels has the most potential to make true and meaningful change for hospitals and healthcare facilities.

Examples of institutional level changes include:  

• Medical schools will need to take a broader, more inclusive approach when admitting future doctors, incentivise minority students to choose careers in healthcare, and invest in their retention and success (9).  
• 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 can also work towards closing the gaps in accessibility to quality healthcare and may vary by geographic location (3).  
• Community programs should be available to create safe spaces for connection and acceptance for LGBTQ people. Laws and school policy need to focus on how to prevent and react to bullying and violence against LGBTQ individuals (12). 
• Cultural competence training in medical professions needs to include LGBTQ issues and data collection regarding this population needs to increase and be recognized as a medical necessity (12). 
• 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 taught as well (20).  
• Medical facilities should emphasize respect of a client’s views on controversial topics such as pregnancy/birth, death, and acceptance or declining of treatments even if it conflicts with a staff members’ own beliefs (14).  
• Healthcare facilities can adopt practices that are standardized regardless of age and include anti-ageism and geriatric focused training, including training about elder abuse (18). 

Obviously each geographic area will have differing demographics depending on the populations they serve. What works at one facility may not work at another. Hearing from the community is beneficial for keeping things individualized and allows facilities to gain perspective from the local groups they serve.  

• Town Hall style meetings, keeping hospital board members and employees local rather than outsourcing from travel companies (when possible), and encouraging community involvement from staff members are all great ways to keep a community centered facility and keep the lines of communication open for clients who may be having a different experience than their neighbor.
  

There are many things that will need to be done in order for equitable, bias-free healthcare to become a norm nationwide. However, taking the time to learn from this Kentucky Implicit Bias training, apply it to current practices, and continue to learn about others and their respective beliefs and cultures is just the beginning.

Kentucky Suicide Prevention

Suicide risks among nurses is a public health concern. The first and most profound way to address the troubling rates of suicide among nurses is to employ suicide prevention. For that matter, mandatory training, resources, and the establishment of policies and procedures are crucial within the operation of organizations. All healthcare providers are responsible for identifying and addressing situations which warrant intervention.  

This Kentucky Suicide Prevention course meets the “Suicide Prevention” requirement needed for Kentucky nursing license renewal.

Introduction   

According to the Centers for Disease Control and Prevention, suicide is a leading cause of death in the United States, which is subsequently a public health concern (6). As underscored by the CDC (6), “In 2018, suicide took more than 48,000 lives and was the 10th leading cause of death in the United States”. Yet, it has been noted that suicidal ideations and attempts occur more often than suicidal deaths (17). However, suicide is preventable and from a collaborative approach, preventive strategies can help reduce an individual’s risk for a detrimental outcome (6). Some of the warning signs of suicide include, but are not limited to, the following: feeling hopeless or helpless; feeling like a burden to others or unable to find a reason for living; unbearable pain; expressing thoughts of suicide; exhibiting signs of depression or loss of interest in normal activities; aggression, impulsivity, or humiliation; or displaying a sudden sense of peace (4). From a public health standpoint, all ages are affected by suicide (6). Nevertheless, there are higher suicide rates in some groups (e.g., non-Hispanic American/Alaska Native; non-Hispanic White populations; veterans; persons residing in rural areas; individuals who identify as lesbian, gay, or bisexual; and individuals holding certain occupations often considered high stress such as healthcare providers) in comparison to others (6). As stated, individuals requiring intervention are often those with high stressors and/or have a history of other acts of violence (6). One of the most demanding professions is nursing, and nurses are deemed at a higher risk for suicide than the general population. Taking that into account, suicide awareness and prevention programs are fundamental.  This Kentucky Suicide Prevention course will increase your awareness among nurses at risk for suicide and provide tools for screening and preventative measures.

The Significance of Suicide Prevention

As emphasized, suicide is a public health concern due to the nature of its adverse impact on not only the individual, but their loved ones and communities correspondingly (6). Factors such as socioeconomical issues, interpersonal problems, mental or physical health problems, substance abuse, previous suicidal attempts, occupational demands/workplace stressors, and being able to access deadly means may contribute to individuals being at a higher risk for suicide (6). Anxiety, stress disorders, and depression are all increased by the demands of the responsibilities related to the nursing profession, and sadly, those factors are interrelated to higher suicide rates among nurses (7). In saying that, nurses who work on the frontlines are heavily burdened, which is why it is so critical that support is rendered with the goal of yielding a reduction in the risks of suicide. There are many strategies that can be implemented to protect individuals from suicidal thoughts and behavior. Some of those protective factors include the following: coping and problem-solving skills; cultural and religious believes that dissuade suicide; support from friends, family, and communities; supportive affiliations with care providers; access to physical and mental health care; and restricted access to fatal means among persons at risk for suicide (6). 

Suicide Risk Factors Amongst the Nursing Population

With suicide prevention being a public health concern, it is important to identify groups of persons considered at substantial risk for suicide. Nurses are often faced with high demands of responsibilities as well as easy access to fatal means. Primarily, workplace stressors and lack of personal care can lead to burnout which consequently can lead to an increased risk for suicide incidences in the nursing population. Burnout has been noted as one of the most common reasons nurses contemplate suicide, and circumstances such as short-staffing and the most recent pandemic (COVID-19) have brought about a wave of burnout among nurses who work on the front line (11). Nurses are often responsible for the care of all others (professionally and personally) while unintentionally neglecting their own needs; therefore, providing support for nurses is imperative. For example, there have been fifty-eight suicides amongst the nursing population in the state of Kentucky since 2016; however, nurses in the state of Kentucky are required to obtain recurring suicide prevention education and training (15). Hence why the Kentucky Board of Nursing has added a continuing education requirement to address suicide prevention in nursing. Furthermore, Kentucky nurses can obtain additional education on identifying signs of burnout and ways to reduce stress by viewing a suicide prevention video and engaging in a program developed by the Kentucky Nurses Action Coalition in collaboration via the support of the Kentucky Nurses Association (15).  

As previously emphasized in this Kentucky Suicide Prevention course, in comparison to the general population, there is notably a higher risk of suicide amongst nurses (both females and males) (8). There are many suicide risk factors among nurses, but the following are some of the most evident: exposure to frequent trauma and death; working long, consecutive shifts; workplace bullying; neglecting self- care; social isolation or seclusion; and access to as well as knowledge of, lethal substances, such as opioids (5). Case in point, it has been proven that female nurses often opt for pharmacological poisoning (e.g., opioids and benzodiazepines) as a method to complete suicide, whereas their male counterparts utilize firearms in the same nature as the general population (8). Nurses are unlikely to seek mental health assistance in comparison to the general population due to some of the following reasons: concerns with how their careers could potentially be impacted; uncertainties regarding confidentiality; conflicts with taking time off to attend appointments as well as inability to obtain appointments; and fear of potential consequences associated with their professional licenses in the form of reprisals (11). For optimal outcomes, strategies to address suicide risks must aim to properly identify and address those exhibiting signs of burnout and depression as well as to reduce stigma and other barriers to seeking treatment (11). Next we will explore strategies to address suicide risk factors as required by the Kentucky Board of Nursing in this Kentucky Suicide Prevention course. 

Strategies to Address Suicide Risks

Mental health promotion is one of the most critical strategies to help decrease incidences of suicide in the nursing population (2). Upon identifying individuals and/or groups at risk for suicide, it is important to derive pathways for proper intervention. The negative stigma associated with the treatment of mental illnesses is a well-known barrier for those in need of help, especially professionals such as nurses who are obliged to taking care of others, and this stigma prevents individuals from seeking treatment when they lack any type of support system. Organizations can better support individuals who are at risk for suicide by assuring that suicide training and screening tools for suicide risk are available to all employees, making every other member in one’s organization part of their support network. In fact, there are three primary initiative-taking strategies recommended by the Suicide Prevention Resource Center (SPRC) for organizations to implement and those strategies include establishing a respectful, inclusive work environment; identifying employees at risk for suicide; and formulating a responsive plan to enforce (12). Vitally, there should be identifying and reporting methods available for nurses to be screened anonymously (2). For example, individuals enduring a crisis can text “HOME” to 741741 to communicate with a crisis counselor (15). Another example of an anonymous suicide prevention resource is the HEAR (Healer Education Assessment and Referral) screening program (2). The HEAR program is purposed for screening, assessing, and referring nurses at risk for suicide as well as providing education pertaining to mental health, and likewise, it is aimed at removing the stigma associated with the reluctancy in seeking mental health assistance (16). In addition, managers and leaders are equipped with the knowledge necessary for providing support to their staff which, in turn, leads to healthier ways for alleviating stress and avoiding burnout (16). Essentially, organizations must convey the message to their employees that it is okay to seek assistance for mental health concerns as their well-being is priority. This can also be achieved by offering resources such as Employee Assistance Programs or displaying information for crisis hotlines (e.g., National Suicide Prevention Lifeline, Safe Call Now, Disaster Distress Helpline, or the Crisis Text Line) for individuals who are experiencing depression and/or those afflicted by suicidal thoughts/ideations (2). Trainings and in-services are also necessities.  

Oftentimes, an individual may require the assistance of a peer (whether a colleague or a friend) when faced with a crisis (2). Nurses should be educated and aware of suicide prevention strategies which include assessing for risk factors, inquiring about plans (ask direct questions) as well as means, monitoring behavior, and collaboratively creating a safety plan (13). Specifically, some of the strategies recommended to prevent suicide include the following: reinforce economic supports; strengthen access and delivery of suicide care; generate protective environments; encourage connectedness; teach coping and critical thinking skills; identify and support people at risk; and reduce harms and prevent future risk (6). Though suicide prevention strategies may not be 100 percent effective in stopping an individual from executing a plan, peers need to know how to identify signs of suicide risk to properly support their colleagues in obtaining appropriate mental health assistance (2). Besides, the American Foundation for Suicide provides an abundance of suicide prevention resources (3). In essence, suicide awareness and prevention are vital. 

Additional Interventions and Protective Factors to Reduce Suicide Rates

Though assessing and safety planning are crucial in caring for nurses at risk for suicide, it is also important that appropriate referrals and follow-up interventions are implemented. As previously indicated in this Kentucky Suicide Prevention course, the HEAR program is an anonymous program that was designed to assess and refer individuals at risk for suicide. The program interactively screens the individual, categorizes the responses into tiers, then proactively provides options for counseling either online, via telephone, or in-person, and/or referrals are submitted to community providers for continuity in treatment (1). This method is remarkable for nurses who are reluctant to seek help because of the fear of having one’s career and reputation jeopardized, as their organizational safety net does what is supposed to do – recognize and report. What is also more noteworthy is that the HEAR team can be contacted for assistance by employees who have identified colleagues who are at risk (1). Correspondingly, organizations can replicate the HEAR program at their facilities by either modifying their Employee Assistance Programs to incorporate the HEAR service, establishing contracts with local or virtual mental health agencies, or by imitating the program by means of staffing provisions (1). Still, organizations can elicit protection to employees at risk by promoting safety and wellness as well as encouraging teamwork and providing support (18). Similarly, it is important that other preventive and/or protective factors are explored to achieve a reduction in suicide rates. For that matter, Hutton (2015) listed the following as preventive or protective factors for individuals at risk for suicide: “Reasons for living, perceived meaning in life, adaptive beliefs; Social support and feeling connected that may include religious affiliation; Being married, and for women, being pregnant, having children; Restricted access to firearms; Moral objection to suicide; Engaged in treatment or having access to mental or physical health care; Resilience, coping skills; Fear of social disapproval; and Cognitive flexibility”. In the same aspect, following up with an individual at risk is another intervention that can assist in prevention and protection. In this regard, one major advantage of the HEAR program is its unique outreach approach which entails counselors following up with the individual to assist him/her in seeking emergent care or to help the affected individual obtain an appointment for mental health treatment/counseling in a timely manner (10). 

Ethical and Legal Considerations Regarding Care for Suicidal Individuals

As formerly stated, no intervention is 100% certain to prevent an individual from executing a suicidal plan, but with training and resources to help recognize and support, the resulting interventions have proven to be positively impactful in many cases. However, when providing care for suicidal individuals, ethical and legal considerations should be prioritized.

For one’s protection as well as the protection of the individual and the organization, the following legal considerations are notable when caring for persons who are at risk for suicide: become familiar with suicide policies and procedures for your organization; gain awareness regarding state laws associated with advanced directives, involuntary commitment, seclusion and restraint; familiarize yourself with HIPAA regulations and exceptions regarding confidentiality; and if dealing with a patient, document all action in his/her health record (13).

Also, if one is assisting a colleague, organizational protocol should be followed. As a nurse professional, it is crucial that one follows policies, procedures, and protocol to avoid breaching patient confidentiality as well as potentially being sued for negligence or malpractice. It is equally important to consider ethical responsibilities when dealing with individuals at risk or suicide. A nurse can reference the professional Code of Ethics as a guide for dealing with ethical concerns or he/she can consult with an ethics committee. Regarding ethical responsibilities, one should display these key attributes: be respectful and compassionate, serve as an advocate, promote health and safety, encourage autonomy, maintain confidentiality, refrain from conflict of interests, participate in collaborative care, engage in research to remain cognizant of evidence-based practices, and address ethical issues (9).  

Case Study

A 24-year-old novice nurse has been noted to have discrepancies in the narcotic counts of her medication cart on a few occasions. Moreover, it has also been observed by other colleagues that the nurse is often truant, and her mood is very unpredictable. She has episodes of extreme euphoria, and she has become overly generous (i.e., offering a necklace that she inherited from her late mother to a colleague). Even more so, an incident report was recently completed regarding her miscalculation of a critical medication dosage. Although the nurse’s error reflected in the incident report was a “Near Miss,” the nurse’s recent behavioral changes warrant the need for immediate intervention. Regrettably, this error has caused the nurse to feel even more overwhelmed and emotionally detached. All the above occurrences have resulted in her feeling emotionally unstable to the point of her expressing suicidal thoughts and ideations. A colleague who has established rapport with the nurse makes herself available to listen, she asks the nurse direct questions, and she provides encouragement to the nurse as well as supportive resources (i.e., phone numbers for the Employee Assistance Program, the National Suicide Prevention Lifeline, and the Crisis Text Line). What are other strategies that might be valuable to the nurse’s prognosis?

Recommendations

All nurses and healthcare professionals in the same respect should engage in continuing education which addresses suicide prevention. Principally, it takes a collaborative approach to provide individualized and organizational support to a nurse/colleague in crisis. For best results, there should be programs in place and resources available which promote suicide awareness, highlight protocol, and offer ongoing support. Ultimately, the goal of promoting mental health and wellness for nurses is to reduce the likelihood of suicide. 

Kentucky Domestic Violence

Introduction   

Domestic violence continues to be a prevalent topic in media and society. While many partake in conversation, there can be a severe lack of knowledge on how impactful domestic violence can be. Healthcare providers are in a prime position to provide assessment, treatment, and resources to victims of any age. Recognizing the various types of abuse, the populations affected, and the appearance of victims can create confidence in the nurse who has hundreds of patient encounters annually.

What is Domestic Violence?

Domestic violence is a pattern of abusive behaviors that is utilized by one individual within the relationship to gain and maintain control and power over the other individual(s) in a relationship. Domestic violence can include but is not limited to any of the following: sexual, physical, economical, psychological/emotional, and technological (16).

For reference, the Kentucky statute defines domestic violence as: “Physical injury, serious physical injury, stalking, sexual assault, strangulation, assault, or the infliction of fear of imminent physical injury, serious physical injury, sexual assault, strangulation, or assault between family members or members of an unmarried couple” (16).

The relationship of those involved is not always romantic in nature, as it can be between parents and children, friends, roommates, family, and other individuals that live together in the same household (16).

In recent years, domestic violence has taken on a new name: intimate partner violence. While intimate partner violence is used for those experiencing abuse in an intimate/romantic relationship, some individuals use the terms interchangeably. It is important to note the definitions of each term to clearly understand that while the two can overlap they are not the same (11).

To provide a clear picture, here is an example of domestic violence and intimate partner violence:

• Example of Domestic Violence: a 20-year-old male named Sam lives with his 21-year-old roommate Danny. Danny has physically abused Sam by hitting, kicking, and slapping him often. Danny and Sam are not in a romantic/intimate relationship, and they share their apartment with one other person who is attending the same university as them.
• Example of intimate partner violence: Shelly is a 27-year-old who is in a relationship with her 35-year-old boyfriend Marcus. Marcus often forces Shelly to perform sexual acts she does not want to do as well as control her through threats and acts of physical harm. Shelly does not live with Marcus, but she often finds him always around.

If Danny and Sam had been in an intimate/romantic relationship, the abuse could have been classified as intimate partner violence or domestic violence. If Shelly had been living with Marcus the term domestic violence could have been used; however, since they are not, the term intimate partner violence is more appropriate.

Domestic violence can also incorporate elder abuse and child abuse if the victim resides in the household (16).

For child abuse, the age range is from newborn to age 17 and encompasses a recent act or a failure to act as a parent or caretaker, that results in serious physical or emotional harm, exploitation, sexual assault/abuse, or death or an act or failure to act that can lead to an imminent risk of severe harm (9). Age-related considerations will be discussed later in this course. With elder abuse, the victim must be 65 years of age or older and can be carried out the same way as domestic violence (53).

As mentioned, domestic violence, intimate partner violence, elder abuse, or child abuse can occur in a variety of ways. While there is no full comprehensive list, there are many behaviors that the abuser may utilize to ensure the compliance of the victim (Table 1).

Case Study:

Nora and Keith were both born overseas with Nora currently living in the United States. Keith lives overseas and has completed tertiary education. English is Nora’s second language, but she does require an interpreter to assist her for anything other than basic communication. Keith works in a well-paid, professional job.

The two initially met through an online dating website and agreed to meet in the United States where Keith came for a vacation. The relationship progressed quicker than Nora expected. She was willing to assist Keith in obtaining a tourist visa for Keith and within a few weeks of the visa going through they got married. During the sixth month of marriage, Nora became pregnant.

Since their marriage, Keith has changed. Nora is not allowed to leave the house without Keith’s knowledge of where she is going, what she is doing, who she is with, and when she will be home. If she is not home on time, Keith becomes angry and yells at her. He tells her “You’re stupid and can’t remember anything!” Demeaning names are often used in the household and Keith once told Nora she’d never be able to hold a job and is useless. He insists he is the only one who does anything around the house while working a full-time job. He makes it hard for her to access an interpreter when they are conducting financial business, insisting that he will “take care of it” and that she “doesn’t need to worry about that.” Once he took her phone because he didn’t think it was a good idea to use when pregnant.

At one of her obstetric appointments, Keith was not present due to being at work, Nora admitted to the nurse that she felt worried for herself and her unborn child. She wonders if she could continue helping Keith become a United States citizen, but she quickly brushes that idea away. “He’s just worried about the baby,” she says. “He’s never hit me, so it’s not abuse.”

Etiology and Pathophysiology

Etiology: Domestic violence, including child and elder abuse, and intimate partner violence begins because of the abuser’s desire for domination or control of the victim.

Reasons abusers may have the need to control vary, and while this is not a complete list, it does highlight the many reasons why someone may become an abuser in a relationship (8):

• Individual:
  • Jealous
  • Young age
  • Learned behavior from a home where domestic violence occurred or was viewed as acceptable.
  • Lack of nonviolent social problem-solving skills
  • Low self-esteem
  • Anger management or aggressive behavior especially in youth
  • Personality or psychological disorders such as antisocial or borderline personality disorder traits
  • Alcohol and/or drug use (those who are impaired have a more challenging time controlling urges)
  • Low academic success
  • Impulsiveness or poor behavior control
  • Depression and suicide attempts
  • Support/belief of firm gender roles such as male dominance or hostility toward women
  • History of being physically abusive
• Relationship:
  • Desire for dominance or control in the relationship or the partner
  • Unhealthy family dynamics or relationships
  • Financial stress
  • Witnessing violence, physical discipline, or poor parenting during childhood
  • Association with antisocial or aggressive peers
  • Parents with less than a high school degree
• Community:
  • High poverty, unemployment, and crime/violence rates
  • Limited education and economic opportunities
  • Low comradery among the community such as not looking out for each other or intervening during a situation
• Society:
  • Traditional gender roles and inequality
  • Supporting aggression toward others
  • Income inequality

Pathophysiology: Research on domestic violence is not definitive when it comes to the pathological findings in perpetrators, there have been several reoccurring characteristics that are common (8):

• Jealous, possessive, or paranoid
• Controlling every activity such as finances and social events
• Low self-esteem
• High consumption of alcohol and/or drugs
• Emotional dependence is present more often in the abuser but can be present in the victim as well.

Case Study

Dominic started off as a nice guy, that’s how Cara always described him. He was always dotting on her and her younger sister Chloe despite Chloe being nine. Most of Cara’s other boyfriends wouldn’t have found Chloe interesting, nor would they want to date her after they found out Cara was given custody of Chloe since their parents passed away. Dominic had been different, in more ways than one.

After a year of dating, Dominic began pushing boundaries in their relationship. If Cara didn’t want to have sex and Dominic did, she ended up giving in despite not wanting to. They fought more than they ever had and after having one of these fights in front of a few friends, there was talk of breaking up. Dominic didn’t like that and promised to change.

For a while, things were okay. They collaborated with a therapist to help them talk through disagreements and they were able to work together. However, Dominic became jealous of Cara when she got a job promotion and promptly started a fight with her when she went to his home that evening. He had been in the same position at work for years and was taught from a young age that women were expected to stay home and care for the children.

Cara ended up breaking up with Dominic a few days later and moving to a new apartment with Chole when her lease was up for renewal.

The Cycle of Abuse Model

The cycle of abuse is a four-phase wheel that depicts how abuse continues within a relationship (Image 1).

Phase One: Building Tension

In the first stage of the abuse cycle, tension is created and grows. This type of tension can be caused by anything: family, work, financial concerns, catastrophic events, minor to major illnesses, or conflict. These types of stressors are common in everyday life and a majority of individuals are able to cope with them in a healthy manner. Abusers use the stressor(s) as an excuse and as a justification for their actions (19).

Some victims of abuse are likely to try and placate the abuser as a means of avoiding the phase of violence that often follows. They may try to act more submissive or “stay out of the way” or even try and be more helpful to please the abuser. Other victims may do the opposite, provoking the abuser to act and become violent. They are essentially trying to “get it over with” (19).

Phase Two: Incident

The incident phase is where the act of abuse occurs. This can range from physical, psychological/emotional, or verbal abuse and occur in any of the ways listed in Table 1 (please note Table 1 is not a comprehensive list) (19).

As discussed earlier, domestic violence and intimate partner violence are the abuser’s way of gaining and maintaining control and power over the victim. The entire abuse cycle is the abuser’s way of doing that; however, the incident phase is when the abuser is more dangerous and frightening to the victim (19).

Phase Three: Reconciliation

This phase of the cycle is where the abuser may make excuses for the behavior. They may apologize as a way to earn sympathy from the victim: “work has been stressful” or “my mother recently had a stroke, and I don’t know how we will care for her.” Other abusers will blame the victim for their behavior with statements like “don’t make me angry and I won’t have to do this.” Denying the event occurred can be another act the abuser does during the reconciliation phase: “that never happened” (19).

The term gaslighting can be used during the phase and is defined as the attempt of the abuse to create confusion or self-doubt by distorting reality and making the victim question their own intuition, judgment, or memory (40).

Phase Four: Calm

The final stage of the cycle is the calm phase. Often referred to as the “honeymoon phase,” this part of the abuse cycle consists of a period of normality or even better than what life was before the abuse occurred (19).

Love-bombing, defined as an individual manipulating another individual through the act of going above and beyond, may occur as the abuser attempts to “make up for” their actions. This, however, is false as the abuser’s goal is to keep the victim in the relationship and unaware (10).

The cycle remains a cycle because the relationship does not stay in the “calm phase” and instead leads to tension building once again. The cycle will repeat through the relationship with various periods of time between calm and tension building. As the relationship progresses, the time between calm and tension building shortens. This could be attributed to the abuser realizing they can “get away with” their actions since the victim did not leave them or has returned to the relationship/abuser (13).

Breaking the cycle can be extremely difficult for victims. The victim may be ashamed to admit they are a victim of abuse. They may also experience fear due to the violent nature of their abuser; when faced with leaving, the abuser may retaliate and take drastic measures to ensure that the victim does not leave. This can consist of severe physical, mental, or financial abuse. Some acts done by abusers can result in death. Some victims think the abuse is their fault or that they deserve it (13).

Love is a large factor in staying within the cycle. Those who are victims may be or think they are in love with their abuser and that they can “save” the abuser by “fixing them.”

Accepting the abuse as part of an otherwise “good” relationship is another reason why victims may not leave. Other reasons for staying in the relationship can include (19):

• Religion or family pressure
• Lack of financial means
• Lack of knowledge of available services or support network
• Losing children
• Cultural, race, or gender barriers

A Note: Healthcare providers should keep in mind that the abuse cycle model is a simplified version of the complex problem of domestic violence or intimate partner violence.  It is important for healthcare providers to not victim blame those in the cycle of abuse; those in the cycle may not see the patterns that those removed from the situation can and may experience denial. Time, distance from the situation, and a different perspective from the situation are often needed for the victim to realize they are or were in the cycle.

Case Study

Nicole presents to her primary care physician’s office for a routine medical exam. Nicole is 20 years old, unemployed, and has a cat at home. Recently, Nicole has decided to move in with her girlfriend Iris but is hesitant to do so. When prompted to discuss it further, Nicole states that her girlfriend “doesn’t understand personal space, but only when she’s at home.”

Iris comes from a conservative family with traditional values. She has not told her family about her relationship with Nicole, presenting Nicole as a “friend that needs a place to stay for a while.” Despite understanding the situation, Nicole says she feels hurt by this since Iris has admitted to telling her family about other girlfriends in the past.

Nicole admits to bringing this up with Iris after they’d been drinking one night. Iris got mad and hit Nicole in the face, possibly breaking her nose. Nicole was too scared to go to the hospital and was admitted Iris said her nose “looked better” and “wasn’t as crooked as before.”

After the fight, Iris seemed like a different person. She showered Nicole and her cat with gifts, making promises about how things would change and that she would introduce Nicole to her family as her girlfriend soon. Things seemed to be okay for a while and Nicole started looking for jobs. She could tell Iris was frustrated with her lack of “trying” to contribute to the household. However, when Nicole was offered a position, Iris yelled and her and guilted her into not accepting the job.

Those at Risk

While anyone can be at risk for domestic violence or intimate partner violence, there are groups that are at a higher risk.

Children:

The year 2015 produced nearly four million reports of alleged maltreatment to the child protective agencies in the United States. Of that nearly four million, 683,000 children were officially reported to have been maltreated, abuse being second to neglect. Children from birth to the age of three had the highest rate of being victims with 27.7%. This is important to note because infants and young toddlers rely heavily on parents or caregivers to provide them with food, water, hygiene, interaction, and affection. All of which are vital to proper growth and development. Child victims were slightly more female than male at 50.9% which is consistent with adult statistics as females predominantly being the victim (46).

Data on children exposed to abuse varies as there is no national survey that is dedicated to focusing on children and their exposure to domestic violence. However, there are a few statistics that continue to be cited throughout literature. It is estimated that there is between 3.3 million to 10 million children are exposed to severe parental violence annually in the United States. The research for these statistics varied in collection methods, but one study produced interesting results. Approximately 12.6% of adults who were asked to reflect on their teenage years reported that there had been some type of abuse in the house: 50% reported their father hitting their mother, 19% reported their mother hitting their father, and 31% reported both parents hitting each other (46).

More recent data supports this research. A study conducted by Dong et al. in 2004 discussed adverse childhood experiences with 8,600 adults. Of those that participated 24% stated they had been exposed to child abuse before the age of 18. In this study, the abuser was often the father or stepfather abusing the mother or stepmother. 550 college students were evaluated in another study that showed 41.1% of females and 32.3% of males witnessing abuse as children (46).

While these statistics are staggering, it is important to note that these numbers are only an estimate and can be assumed to be higher or lower based on reporting rates, definitions of domestic violence (physical as well as psychological/emotional, sexual), and time ranges that the surveyor sets (lifetime versus a specific period in time) (46).

Sexual abuse is another concern that regards children and can be a form of domestic violence. Statistics show that one in four girls and one in 13 boys will experience some form of sexual abuse during childhood, and often the perpetrator is someone the child or family knows. More often than not, this type of abuse is carried out by a parent or stepparent, sibling or stepsibling, or other relative who lives in the home. In contrast to teenage or adult victims of sexual assault, child victims are usually brought to a healthcare provider after injury to the genitalia is noted or signs of a sexually transmitted infection are present (2).

While some sexually transmitted infections are transmitted from mother to infant during the delivery phase and can remain present for some time after birth, there is a general rule that any sexually transmitted infection diagnosis after the neonatal phase is considered as evidence of sexual abuse. Care should be taken when collecting specimens and conducting assessments on children to minimize pain and physical and/or psychological trauma (7).

When determining if a patient should be evaluated for sexual assault, healthcare providers should consider if the patient has a recent, evidence of a recent, or healed penetrative injury to the genitals, anus, or oropharynx. A child could present with signs and symptoms such as pain in the genital region, bleeding, tearing, or bruising. If the child or parent/caregiver reports or suspects that the abuse, sexual or physical, was caused by a stranger is another reason to err on the side of caution and consider a sexually transmitted infection screening (45).

If the perpetrator is known to have a high chance of or is infected with a sexually transmitted infection. This can include members of the household that the child lives with. Children with signs and symptoms of sexually transmitted infections such as genital itching and/or odor, vaginal discharge and/or pain, genital legions ulcers, or other urinary symptoms they should be evaluated. If a parent or child requests sexually transmitted infection testing or if the child cannot verbalize the assault that occurred, the provider should consider it (7).

Tests for sexually transmitted infections should have high specificity due to the nature of the situation. Treatment should wait until all samples have been obtained to prevent false results. Healthcare providers should discuss and collaborate with trained professionals on how to ensure testing and treatment is appropriately carried out. Recommendation for Human Papillomavirus vaccinations are encouraged for children with a history of sexual abuse over the age of nine due to the increased risk of unsafe sexual practices in the future. Human immunodeficiency virus testing may be indicated based on the assailant’s history and circumstances of the abuse (7).

Children may also be victims of domestic violence through Munchausen by Proxy where the caregiver or parent exaggerates or fabricates physical or mental health disorders the child has or does not have; Munchausen itself involves the individual, not someone else. The motivation for this is to gain sympathy and attention from family, friends, and others within the community (21).

Young Adults/Adolescents:

Defined as the ages of 13 to 17, adolescent years are more prone to intimate partner violence than domestic violence as opposed to younger children due to the start of dating; however, domestic violence can co-occur with intimate partner violence. Data shows that 1.5 million United States high school students are the victim of physical violence annually. Of the 1.5 million, only 33% discussed abuse with anyone, meaning only 500,000 adolescents are reporting it. When looking into reasons why this may be, as an addition to all the reasons discussed previously, 81% of parents do not believe that teen dating violence is a concern, or they are unaware that it is an issue. Adolescents may not be willing to share with their parents or caregivers due to fear of not being believed or taken seriously (17).

Technology and social media applications can be unmonitored areas of abuse that family and friends are unaware of. Technology abuse was mentioned earlier in this course, but healthcare providers should be aware of how it can appear. Victims of technology abuse may report that someone they are interacting with or dating is forcing them to share passwords or locations, change information on their profiles, and participate in activities online that can be interpreted as humiliating. There may be comments about posts on social media that are seen as jealous; private photos may be leaked, or the abuser may threaten to leak them (48).

Sexual abuse might be harder to diagnose in the adolescent population. This age range is often associated with risky behaviors such as sexual behaviors and using illicit drugs. Healthcare providers should ensure they are screening adolescents thoroughly when they present to any healthcare facility for treatment regarding suspicious injuries or complaints. They may present with serious changes in emotion—anger, low self-esteem, cries for no reason, withdrawal or scared, confusion about sexual orientation—changes in the way they dress, participation in harmful sexual behavior or using alcohol and/or drugs, or avoiding activities they used to enjoy. Physical symptoms may include swelling or redness in the genital area, difficulty walking or sitting, pain or burning when using the restroom, penile or vaginal discharge, or bruising on the buttocks or thighs (45).

Elders:

Elder abuse consists of financial, sexual, emotional, and physical abuse as well as abandonment and neglect. More often than not, elder abuse occurs in the home of the victim which could be classified as domestic violence if they live together. The abuser in the situation is someone the victim has trust with as they are often in charge of many aspects of the victim’s life. The abuse can consist of children, grandchildren, other family members, friends, or other caregivers; studies show that 76.1% of abusers are a member of the victim’s family (30).

It is estimated that four million older Americans are victims of some form of elder abuse annually. Those who require assistance with activities of daily living have an increased risk of emotional abuse or financial exploitation, over 13% of those have suffered emotional abuse since the age of 60. Emotional abuse can be done through the act of demeaning comments about how the victim is “useless” or “helpless” or “weak.” These comments can be seen as embarrassing or humiliating. Since individuals who require assistance to carry out daily tasks may not be able to leave the house often, financial exploitation can be easy for an abuser to carry out. Those who are victims of financial exploitation lost approximately $2.9 billion in the year 2011 (30).

Most sexual abuse cases with elderly patients consist of female victims and male abusers, with only 15.5% of cases being reported to the police. This could be due to fear, cognitive deterioration—50% of older adults diagnosed with dementia are mistreated or abused in some way—or any other reason discussed previously in this course (30).

Women:

On a national level, one in four women have experienced physical violence in their lifetime—often carried out by an intimate partner while one in seven have been injured by an intimate partner. The most abused women fall in the age range of 18 to 24 years old (36). As 18 years old is when most go to college or university or move out of the family home, this age range may not be surprising to some healthcare providers.

For every seven women, one woman states that she was stalked to the point she feared for the safety of herself and/or her family, worrying she or they would be harmed or killed; 19.3 million women have reported being stalked in their lifetime (55). As covered earlier, stalking can be via technology or in-person, depending on the situation and the abuser involved. It is important to remember that intimate partner violence covers past partners or spouses. Data shows that 60.8% of women who have been the victim of stalking report that the stalker was a former or current intimate partner (36).

The number of women who have been a victim of severe physical violence such as strangulation, burning, beating, etc. in their lifetime is one in four. The same number (one in four) consists of those who have experienced severe intimate partner violence. This type of violence contains any of the following: sexual violence and/or intimate partner stalking that can include injury, use of victim services, post-traumatic stress disorder, sexually transmitted infections, or other effects. On average, three women are killed daily as a result of current or previous intimate partners (36).

One in five women have been raped during their lifetime while one in ten women have been raped by an intimate partner, but rape is not the only part of sexual abuse that women can face. In addition to unwanted touching, kissing, and sexual acts, women can also be the victim of reproductive coercion. This type of sexual assault involves the sabotage of contraception medications or forcing a partner to use them, intentionally expose a partner to sexually transmitted infections or human immunodeficiency virus, refusing to practice safe sex, controlling pregnancy through forcing the woman to continue the pregnancy or terminating it through an abortion, refusing sterilization, or controlling the victim’s access to reproductive health care (36).

Data shows that 20% of the women who seek care in family clinics and had a history of abuse reported that they experienced pregnancy coercion and 15% of them had some form of birth control sabotage. Women who were diagnosed with a sexually transmitted infection were hesitant to notify their partner of the diagnosis for fear of the abuser denying they were infected or that the woman had been cheating. Those who did discuss their diagnosis reported threats of harm or experienced actual harm as a result (36).

Domestic violence or intimate partner violence with pregnancy occurs in approximately 342,000 women annually in the United States. Women who experience domestic violence or intimate partner violence are more likely to not receive prenatal care, or they are waiting longer to seek out care than what is medically recommended. Depression in the postnatal period for those who are victims of abuse is three times more common than those not experiencing abuse in the home. Women may also experience a higher risk of perinatal death; a three time increase from those not experiencing abuse (55).

It is important for healthcare providers to understand that pregnancy may increase or decrease the amount of abuse experienced by a woman. Each situation varies, but one study showed that abuse peaked during the first trimester and tapered off after that in women who recently experienced abuse. Women who did not have a recent history of abuse did not experience it throughout the pregnancy. This same study noted that psychological and sexual abuse rates were high within the first month postpartum (39).

Domestic violence or intimate partner violence can affect the fetus as well. There is a higher risk of low birth weights, fetal injury, early placenta separation, infection, hemorrhage, and preterm birth (27). After birth, infants can display signs of trauma that include feeding problems, high irritability, sleep disturbances, and delays in development. One good thing is that these can be alleviated with a secure relationship with a safe caregiver (39).

Men:

Men as victims of domestic violence or intimate partner violence is a growing topic in society and data varies. Research states that one in nine men experience severe physical violence at the hands of an intimate partner while one in 25 reports being injured by an intimate partner. Those who have been a victim of severe physical violence such as burning, strangulation, beating, etc. is one in seven men. Of males who experienced any form of domestic violence or intimate partner violence or stalking, 97% reported the abuser was female (6).

Five million males in the United States report being the victims of stalking in their lifetime. It is stated that 43.5% of men who reported stalking stated that a current or former intimate partner was stalking them. Of the data collected, 46% of males were stalked by only female perpetrators, 43% were stalked by male perpetrators only, and 8% were stalked by both male and female perpetrators (6).

Sexual violence data for male victims starts with one in four men having experienced some form of it in their lifetime; one in 14 were forced to penetrate someone—sexually penetrating someone without the other individual’s consent as a result of intoxication, unconsciousness, incapacitation—within their lifetime. Victims of rape, completed or attempted, consisted of one in 38 men with 71% of them experiencing this prior to the age of 25 (6).

Of those that were victims of complete or attempted rape, 87% reported only male perpetrators, 79% reported only female perpetrators, sexual coercion was done by female perpetrators as reported by 82% of victims, unwanted sexual contact was reported at 53%, and done by female perpetrators only, and 48% of non-contact unwanted sexual experiences—such as unsolicited photos—were done by male perpetrators (6).

The data collected and reported is important in healthcare due to the seriousness of the situation. As covered previously in this course, gender roles and society’s expectations of how individuals are expected to act based on their gender can lead to a lack of support or recognition within a certain community. It is the job of the healthcare provider to assess all patients they come in contact with and never make assumptions based on appearances. As this section has shown, males can very well be the victims of domestic violence or intimate partner violence (6).

People of Color:

Rates of domestic violence or intimate partner violence are higher among people of color. In the 2010 National Intimate Partner and Sexual Violence Survey, those who identified as Native American/Alaska Native and non-Hispanic Black females reported rates of lifetime abuse at 46% and 43.7% respectively. This was in comparison to non-Hispanic White women’s 34.6% and Hispanic women who had a reported percentage of 37.1 (51)

Intimate partner violence was one of the leading causes of death among Black women. Nearly 50% of Indigenous Americans report that they have been “beaten, raped, or stalked by an intimate partner” while over 50% of Asian women have reported physical and/or sexual violence by an intimate partner during their lifetime (26).

Data on males presented challenging to find. Statistics show that 38.6% of African-American men report domestic violence or intimate partner violence (58).

There are many reasons for the increased statistics among people of color. Discrimination is still prevalent, leading to financial hardships, unemployment, and lack of insurance. This may cause the victim to rely on the abuser for economic support. Oppression may lead people of color to distrust the justice system. They may also be fearful of ending up abused by the system. Stereotypes that depict men and women of color in certain light can lead to conflict between the victim and their depicted “culture.” Women and men may not want to be viewed as weak for being a victim of domestic violence when society depicts them as strong or reinforcing the negative stereotypes about their partners (26).

Religion and spirituality can have certain views on relationships and separation or divorce. Religious leaders may be held in high esteem and be viewed as the only person a couple should go to in order to solve relationship issues (26).

Individuals Classified as Immigrants and Refugees:

Those born outside of the United States have a higher chance of domestic violence or intimate partner violence than other people of color physically born in the United States. One study revealed that 48% of Latinas reported violence from their intimate partners increased after immigration to the United States. Study results ranged from 24% to 60% of women who have immigrated from Asia. Asian immigrant women are at a higher risk for homicide when compared to American-born Asians (47).

Abusers may utilize the legal system to ensure control and hold power over the victim. Legal documents such as passports or identification cards might be taken or destroyed, legal paperwork may not be properly filled out or submitted, or threats of deportation may occur. If the victim has a culture that could be different from the country they are in, there may be some cultural barriers that they are unable to overcome because of the abuser. Victims may not be permitted to learn English (or the primary language of the country they are in) or be prohibited from speaking their native language. The abuser may accuse the victim of abandoning the community, they may use racial slurs against the victim, or they might deny the victim from working or obtaining an education (15).

Domestic violence or intimate partner violence can occur for many reasons within the immigrant or refugee community. Language barriers, difficulty understanding legal rights, and stress in adaptation to a new set of cultural/societal norms can be contributing factors to people of color becoming a victim. Women are at a higher risk due to poverty, disparities in social resources between her and her partner, immigration status, and social isolation (15).

Immigrants or refugees may not be aware that victims of crime, regardless of citizen or immigration status, are entitled to access law enforcement services or the courts. They can receive assistance from government and non-government agencies that can include safety planning, counseling, interpreters, emergency housing, and potentially financial assistance (15).

When services are offered to these individuals they should be focused on the specific and unique needs of the victim. Services are not “one size fits all” and should be tailored to the needs of the victim such as shelters that address specific cultural needs, legal assistance maintaining immigration status or child custody, and access to other victim-specific services (15).

Those that are considered refugees or displaced individuals can experience the same hardships as immigrants. Data about refugees or displaced women who are living in the most forgotten and underfunded locations state that 73% of women reported an increase in domestic violence, a 51% increase in sexual violence, and a 32% growth in early and forced marriage within the first ten months of the COVID-19 pandemic (22).

Members of the LGBTQIA+ Community:

Overall, awareness of domestic violence and intimate partner violence has primarily focused on heterosexual individuals, leaving the members of the LGBTQIA+ community to be underrepresented in the conversations. In recent years, there has been a shift, focusing on all individuals, and data is being collected to provide an accurate picture of how domestic violence and intimate partner violence impacts everyone (35).

Data shows that 43.8% of women who identify as lesbian and 61.1% of women who identify as bisexual have experienced some form of physical violence, rape, and/or stalking by an intimate partner in their lifetime. In comparison, 35% of heterosexual women reported the same experiences (35).

Discussing gay and bisexual men, 26% and 37.7% respectively, reported physical violence, rape, and/or stalking by an intimate partner as opposed to heterosexual males at 29%. Of those who are in male same-sex relationships, 26% reported calling the police for assistance for near-lethal violence (35).

Less than 5% of members within the LGBTQIA+ community sought out orders of protection after experiencing domestic violence or intimate partner violence. The type of violence experienced by this community ranges from physical violence at 20%, threats and intimidation at 16%, verbal harassment at 15%, and sexual violence at 4%. Of the intimate violence cases reported in 2015, 11% of them involved a weapon (35).

White members of the LGBTQIA+ community are more likely to experience sexual violence while Black/African American members of the LGBTQIA+ community are more likely to experience physical violence at the hands of an intimate partner. Transgender victims are more likely to experience acts of domestic violence or intimate partner violence in public spaces as opposed to those who do not identify as transgender. Those who identify as bisexual have higher risks of sexual abuse, and anyone in the LGBTQIA+ community who is on public assistance is more likely to be a victim of domestic violence or intimate partner violence (35).

Members of the LGBTQIA+ community face unique challenges as it pertains to domestic violence or intimate partner violence. Some members of the community do not share their sexual orientation with others and the threat of “outing” could be used as a method of psychological/emotional abuse. This could also be a barrier to seeking help. Those who have experienced hate crimes or have been a victim of physical or psychological abuse in the past may be less willing to request assistance (35).

Other reasons for not seeking services include fear that bringing attention to the problem will set back equality in the LGBTQIA+ community; domestic violence shelters are sometimes listed as “female or male only” and transgender individuals may not be allowed in; healthcare providers may not be trained in assessing and managing LGBTQIA+ domestic violence or intimate partner violence concerns; fear of or experiencing homophobia/transphobia when reporting; low confidence with the legal system as depicted by media or personal experience; and society believes that domestic violence or intimate partner violence does not occur in the LGBTQIA+ community (35).

Individuals in the Military:

The number of active-duty members of the United States military is over 1.3 million individuals with 16% of that number being women. The spouses of those active-duty members consist of an additional 600,000 members; approximately 25% of them are under the age of 25 years old. Data that was collected showed that in the 2018 fiscal year, there were 16,912 reports of domestic violence or intimate partner violence; almost half of those reports (8,039) did meet the criteria for abuse under definitions created by the Department of Defense. Of those 8,039 cases 73.7% were classified as physical abuse, 22.6% were emotional abuse, 3.6% were sexual abuse, and 0.06% were domestic violence (12).

Comparing data to previous years, events that meet criteria based on the Department of Defense’s definitions have not changed much since the 2009 fiscal year. Reporting has fluctuated due to changes in the number of service members during any given time as well as the addition of sexual abuse reports increasing due to the inclusion of it in the Department of Defense’s definitions for domestic violence or intimate partner violence in the 2009 fiscal year (12).

Nearly 50% of those who reported domestic violence and 66% of those who reported intimate partner violence to the Department of Defense were members of the military when the abuse took place. The 2018 fiscal year resulted in 15 deaths caused by domestic violence or intimate partner violence, 13 being spouses and 2 being intimate partners. Three victims who died as a result of this violence had reported the abuse to the Department of Defense while four of the abusers had previous reports of at least one episode of abuse already on their record. Nine of the abusers were actually civilians acting against military victims (12).

Abusers within military relationships are likely to be underreported, especially if the victim is a civilian, they are not married to the abuser, or they do not live in the military space. Those who are not married to the service member cannot get treatment inside military hospitals or other treatment facilities. Coordination between civilian and military officials for reporting domestic violence or intimate partner violence can be challenging and lead to underreporting (12).

As discussed previously, intimate partner violence can begin in adolescents, leading to the increased risk of future events of violence later on.  Those who report sexual violence, domestic violence or intimate partner violence, or stalking do so by the age of 25: 71% of them are females and 58% of them are males. As a note, 23% of women reported their experience occurred by the age of 18. Domestic abuse was prominent in junior enlisted military couples (classified as E-3 and lower), ranging in age from 18 to 24. The 2018 fiscal year showed that 15.1 per 1,000 married couples experienced domestic violence, compared to the overall domestic violence rate of 5 per 1,000 married couples (12).

Data comparing civilian to military populations shows that those within the military sector have lower rates of domestic violence or intimate partner violence overall. Over the lifetime 20% of civilian women and 13.7% of active-duty women report sexual violence; 56.7% of civilian women and 47.2% of active-duty women experience psychological aggression; and 26.9% of civilian women and 21.9% of active-duty women experience severe physical violence. The active-duty women were deployed within three years of the report (12).

Those with Cognitive and/or Physical Disabilities:

Disability is an all-encompassing word to describe individuals with a physical or mental impairment that leads to activity limitation and how they are able to participate in society. This could be termed as participation restrictions.  Types of disabilities and how they affect the individual can vary, ranging from mild, to moderate, and severe in terms of how limited they are in terms of participation.

The list below is not all-encompassing but it does highlight some of the more common impairments (5).

• Physical Impairments:
  • Visual
  • Movement
  • Hearing
• Mental Impairments:
  • Thinking
  • Learning
  • Communication
  • Social Relationship
  • Remembering

These disabilities can present at birth as a result of genetics or the mother’s exposure to something during pregnancy. They can also develop later on in life and present in the form of traumatic brain injuries, illicit substance use, or progressive medical diagnoses (5).

In comparison to women without disabilities, women with disabilities have a 40% greater risk of being victims of violence; these women are at a concerning risk for severe violence. The primary abuser of women with disabilities is their male partners. Sexual abuse is reported to be around 80% of women with disabilities; this is three times more than women without disabilities. A single study reported that 47% of women with disabilities had been sexually abused on more than 10 different occasions (31). Overall, those with disabilities are three times more likely to be sexually abused, and 19% of rapes or sexual abuse were reported to police in comparison to the 36% reported by those without a disability (42).

While those with a disability account for 12% of the population, 26% of the victims of nonfatal violent crimes had a disability. Those with cognitive disabilities had the highest rates of victimization at a rate of 83.3 per 1,000 individuals. Law enforcement responded to 90% of the reports made by victims without disabilities as opposed to the 77% of reports that they responded to as it pertains to victims with disabilities (29). This can lead to mistrust in the justice system that keeps victims from initially reporting the events or seeking assistance in the future. Several studies seem to suggest this view as between 70% to 85% of abuse cases against those with disabilities are not reported. Another study noted that only 5% of crimes committed against those with disabilities were prosecuted; 70% of crimes committed against individuals without disabilities were prosecuted (29).

Those with disabilities face challenges when it comes to leaving domestic violence or intimate partner violence situations. Those providing shelter services may not be trained in disability awareness, studies report approximately 35% have this type of training. Sixteen percent of shelters have an individual dedicated to providing services to women with disabilities. Some individuals may see violence as a way to manage those with disabilities and blame the victim for the abuse, justifying the abuse (42).

Individuals with Mental Illness:

Similar to those diagnosed with disabilities, those who have a severe mental illness—a psychotic disorder such a schizophrenia, schizoaffective disorder, depressive disorder with psychotic symptoms, or bipolar; or being under the case of secondary mental health services—are more likely to be victims of domestic violence or intimate partner violence. Data is limited, but there is some information regarding domestic violence and sexual abuse. A range of 15% to 22% of women diagnosed with a severe mental illness reported recent domestic violence while men had a range of 4% to 10%. Another study produced similar results: 27% for women and 13% for men. Regarding sexual abuse, women had a 9.9% prevalence in the first study and a 10% in the second. Sexual abuse in men was only reported in the first study with a value of 3.1%. One interesting data point is that sexual abuse in adulthood leads to a 53% increase in suicide attempts among women (25).

Studies also showed that those at the highest risk for physical violence were young males with severe mental illness. As they get older, become employed, and live independently or have a family with responsibilities the risk decreases. Some theorize that not having societal roles for those with severe mental illness can cause them to become victims of domestic violence or intimate partner violence as a method to provide for themselves (25).

As highlighted in other groups, those with mental illness can have a difficult time reporting and leaving an abusive or violent situation. As is with those with disabilities, a diagnosis of a severe mental illness may be seen as less credible when giving reports to law enforcement. Others may accuse the victim of being the abuser due to their diagnosis—media often portrays those with mental illness as dangerous, violent individuals because of stigma. Feelings of hopelessness, low self-esteem, increased symptoms of the mental illness can all be causes of stigma and domestic violence or intimate partner violence (25).

Substance use disorders are prominent in those diagnosed with mental illness. More than one in four individuals with a serious mental illness—depression, anxiety, schizophrenia, and personality disorders—also have a substance use disorder. As discussed earlier in this course, substance use can increase an individual’s susceptibility to becoming an abuser, as well as making an individual a victim due to impairment (52).

Individuals Without a Home (Homeless):

For women and children, domestic violence or intimate partner violence is a major cause of homelessness in many communities. It is reported that between 22% to 57% of women who were experiencing homelessness directly attributed domestic violence as the cause for their homelessness. Thirty-eight percent of all domestic violence victims will become homeless at some point; victims may often experience multiple periods of homelessness due to them leaving and returning to the abuser several times before finally escaping the abuser for good. Of women experiencing homelessness, 90% report that they have been sexually abused or have been severely physically abused in their lifetime (37).

The major concern for those experiencing homelessness is safety rating at 85% while finding affordable housing is the second concern rating at 80%. An average stay in an emergency shelter is 60 days, but it takes approximately six to 10 months to secure affordable housing. Only 30 affordable rental units are available for every 100 extremely low income, meaning shelter stays are longer and other victims may be turned away due to a lack of space. These victims who cannot gain access to a shelter may return to their abuser to avoid living on the streets. The 2010 fiscal year revealed that 172,000 requests for shelter were unable to be met due to max capacity (37).

Victims might be evicted or denied housing due to records of domestic violence, regardless of the individual being the victim. Some landlords may not want to risk having violence taken upon them, their families, or their properties by providing housing to the victim. Other landlords have a “zero tolerance” rule when it comes to crime, and they will evict those involved in the crime of violence if it occurs. A Michigan study revealed that women who were victims of domestic violence or intimate partner violence were more likely to be evicted than other women. This can lead to victims failing to report their situation to law enforcement for fear of eviction. A study showed that 65% of test applicants—those seeking housing on behalf of a victim of domestic violence or intimate partner violence—were denied housing or were offered lease terms and conditions that were highly unfavorable in comparison to non-victim applicants (1).

Low-Income:

Individuals who rely on others for financial stability are at a higher risk for domestic violence or intimate partner violence. The lack of financial stability limits the victim’s choice and the ability to escape a violent situation or relationship (49). Women with an income of less than $75,000 are seven times more likely to experience domestic violence than women who have an income over $75,000. Hosing and the neighborhoods that individuals live in can be a contributing factor to domestic violence or intimate partner violence. Women who rent housing can experience intimate partner violence at a rate of three times the amount than women who own their own home. Interestingly, women living in poor neighborhoods and having financial hardship are twice as likely to be victims of domestic violence or intimate partner violence as opposed to women who live in affluent neighborhoods but still have financial hardship (28).

Data suggests that domestic violence or intimate partner violence and finances are related: loss of employment or income can lead to increased stress, both of which have been identified as causes of domestic violence. Difficulty maintaining work can be a contributing factor as well, or relying on part-time, low-paying jobs—as over 70% of low-income parents do now have a high school degree—adds to stress and income instability (28).

Domestic violence or intimate partner violence situations may not lead to unemployment; however, it can be a significant barrier. Physical abuse can lead to missed workdays due to injury, psychological or emotional abuse can lead to poor work performance or severe anxiety, and technology abuse can affect communication with coworkers or management. This creates a cycle that is hard to break; victims may lose jobs due to the increased number of barriers preventing them from working. This can force them to rely on welfare or other assistance programs or their abuser (28).

Individuals Living in Rural Communities:

According to the United States Department of Agriculture the definition of a rural community that has a population density of less than 500 individuals per square mile in open countryside and places with a population of less than 2,500 individuals (54). These locations are significant distances from urban areas and can be an unanticipated place where domestic violence or intimate partner violence can occur (44).

One study evaluated the number of reports of intimate partner violence against women in both small rural and isolated areas—22% and 17.9% respectively—in comparison to women who lived in urban areas at 15.5%. Higher cases of physical abuse were reported among women living in rural settings. This study also evaluated the distance from the rural areas and the closest intimate partner violence program(s) which reported it was three times greater than in urban areas. These services served more counties and limited on-site services or shelters. At least 25% of women in rural or isolated areas live over 40 miles from the nearest program. Less than 1% of women in urban areas are over 40 miles from a domestic violence or intimate partner violence program (44).

As reflected on in this section, many of the individuals listed considered high-risk overlap in categories. Victims are more than male or female, adult, or child, hetero or homosexual. They are more than an individual with or without a disability or mental illness. They are those with and without financial stability. They live in a variety of neighborhoods, cities, and states. It is important that healthcare providers be aware that anyone can be a victim of domestic violence or intimate partner violence—regardless of how minor or severe the abuse is—and assumptions and judgments should be disregarded. Providers should be prepared to assess all patients that come in contact with and be ready to provide assistance and/or resources based on the patient’s needs and wants (44).

Assessing for Domestic Violence

Healthcare organizations have different ways of assessing for domestic violence or intimate partner violence and it is important that providers are aware of their facility’s specific procedures. If no specific screening tool is utilized, healthcare providers may make the decision to implement one of many available (50).

Written questions can be one method of assessment that can be utilized in the waiting room setting and save time on the provider’s end; however, it is important to follow up with the patient regardless of the answer. Many victims will check “no” or be forced to check “no” by the abuser. The healthcare provider should make a verbal statement addressing the “no” and seek reassurance with the answer. A clear statement that could be used is as follows: “I see that you selected “no” to the question regarding domestic violence or intimate partner violence. I want to ensure you do not have any questions about this issue.” If the patient once again answers “no” the provider can reassure that if that were to change, during the visit or in the future, the provider and facility is a safe place to discuss the situation and receive help (50).

The provider should be asking this question in private with the patient as the abuser may be the one who is present with the patient. Finding a way to get the abuser to step out of the room can be challenging. Implementing organizational policies that require providers to have a set time when they discuss healthcare concerns with the patients can be a way to mitigate this, but it is not guaranteed (50).

It is recommended that written assessment forms are kept and signed by the healthcare provider, incorporated into the patient’s permanent medical record, and a provider note added that domestic violence or intimate partner violence was verbally discussed with the patient to ensure that a “yes” is not overlooked (50).

Oral questions are the second method for assessing domestic violence or intimate partner violence. This method does take more time, but sometimes this process can allow patients and providers to ease into the topic.

Providers can start with broad questions such as (50):

• “How are things going at home/work/school?”
• “What is the stress level like?”
• “How are you feeling about your relationships? How is your partner treating you? Are there any problems?”

Patients may wonder why their healthcare provider is asking these questions. They may feel like these are invasive or wonder why it is important to their appointment.

If these concerns are brought up, providers can use that opportunity to shed light on how common domestic violence or intimate partner violence is (50).

• “Since violence is very common in society and can effect health, I ask all of my patients about this.”
• “Many of my patients are experiencing abusive relationships. Some of them may be too scared to bring up the topic themselves, so I have started asking about it to every patient I interact with.”

The other method is to ask direct questions about domestic violence or intimate partner violence.

One set of direct questions is the SAFE Questions adapted from Ashur M. (50):

Stress/Safety

• What stresses do you experience in your relationships?
• Do you feel safe in your relationship?

Afraid/Abused

• 3) People in relationships sometimes fight. What happens when you and your partner disagree?
• Have there been situations in your relationship where you have felt afraid?
• Have you been physically hurt or threatened by your partner?
• Has your partner forced you to engage in sexual activities you didn’t want?

Friends/Family

• Are your friends and family aware of what is going on?

Emergency

• Do you have a safe place to go in an emergency?

Other direct questions can be created based on policy, situation, patient, or age level. Below is a list of questions that can be utilized with young adult and adult patients (50):

• Are you afraid of your partner? Do you feel you are in danger?
• Do you feel safe at home?
• All couples fight, what are fights like at home? Do these fights become physical?
• You have mentioned that your partner has a problem with drinking/drugs/temper/managing stress. When that happens, does your partner ever hurt you?
• Since we last saw each other have you been hit/kicked/punched/etc. or scared?
• Is there anyone in the home that has tried or successfully hit/kicked/etc. or injured you since I last saw you?
• What kind of experiences, if any, have you experienced in your lifetime?
• Do you ever feel controlled or isolated as a result of your partner? This can be in your work life, finances, or relationships.
• Does your partner try to control you through threats of hurting you or your family?
• Has anyone you live with threatened to hurt you or your family?
• Have you ever been slapped, shoved, or pushed by your partner or someone you live with?
• Have you ever been kicked, hurt, or threatened by your partner or someone you live with?
• Have you ever been touched in a way that made you feel uncomfortable?
• Have you ever been made to participate in something sexual despite not wanting to? Regardless of if you said “no” or not.
• Has your partner refused to practice safe sex when you requested it?
• Have you been with your partner and had an episode or episodes of blacking out or not remembering what happened?
• Are you afraid to go home? If so, is there somewhere safe you can go?
• Do you have a safe person you can rely on?
• Have you ever contacted a crisis hotline in the past?
  • If so, do you have a contact person there?
  • If not, why not?
• Do you know the local and national crisis center hotline numbers?
• Do you know the numbers of a few emergency shelters?

There are many other tools providers can use to assess for aspects of domestic violence or intimate partner violence. One is titled the Danger Assessment and is separated into two parts. The first part is a calendar for victims to document the frequency and severity of the abuse. This can be useful for victims who may be in denial or are trying to minimize the actions of the abuser. The second part of the tool is a set of 20 yes/no questions that are scored to determine the risk for intimate partner homicide (18).

The MOSAIC questions assess how the victim’s situation is similar to other situations that escalated in severity. This method does require a confidential account, but once an account is made and the questions have been answered, a report is created rating the situation on a scale of one to 10. This tool has been utilized by the police employed in determining threats against members of the United States Supreme Court, Congress, and House of Representatives (18).

For children, the Adverse Childhood Experiences quiz allows the individual proving the quiz to score the various types of hallmark signs of abuse, neglect, and rough childhood. The higher the score on the test, the greater the risk was for that child to develop negative outcomes as it pertains to behavior, health, and opportunities later in life (18).

Since stalking is a major topic when it comes to domestic violence the Stalking and Harassment Assessment and Riks Profile is an option for those who are worried they may be a victim of stalking. This test is similar to the MOSAIC in that it requires a confidential account to be made and requires those to answer some questions via an assessment. This assessment takes approximately 15 minutes to complete, and results are generated shortly after, summarizing the situation, and providing the victim with suggestions on how to improve their safety. This assessment is consistent with legal definitions of stalking and was developed with attorneys, law enforcement, victim advocates, prosecutors, and prominent organizations like the Stalking Resource Center (18).

The last tool to be discussed is the Ontario Domestic Assault Risk Assessment. This assessment is done on the abuser, comparing them to other perpetrators. This makes a determination of how likely the abuser is to assault the victim again. There are 13 items on this assessment, and they have a score between zero and one. The result is the total score of all questions, making a maximum number of 13, which is converted into a percentage that estimates the likelihood of abusing the victim again (18).

It is important for healthcare providers to approach this subject after assessing the situation to determine the best way to do so. Trust is very fragile, and it may take several attempts for a victim to feel comfortable enough to speak on the subject. Some may never do so, but asking at every visit or interaction can let the victim know help is available, they are not alone, and they are cared for.

Barriers for Disclosure:

While victims of domestic violence or intimate partner violence can present to any healthcare office or facility, many of them end up in the nearest emergency department. Regardless of where the healthcare provider encounters the victim, they need to be aware of how to assess for domestic violence or intimate partner violence (20).

One major part of the assessment process is the barriers to disclosure. Many barriers exist that healthcare providers have identified, including time constraints. This is something that many healthcare providers can vocalize; limited time leads to rushing through questions and treatments. Lack of training can consist of a lack of knowledge about community services, including 24-hour services; lack of confidence; and concern on how to respond if the patient discloses domestic violence or intimate partner violence. Providers may be worried about offending the patient or have personal discomfort in discussing these topics with individuals (20).

Providers can overcome these barriers through a variety of ways. Time management can assist healthcare providers by adding extra time to each appointment or incorporating the questions while performing other parts of the patient assessment. Lack of knowledge of community resources gives healthcare providers a way to investigate the specific global and community resources to ensure that the patient has a plethora of material they can utilize when they choose to (20).

If worry of offending patients is a barrier to asking patients about domestic violence or intimate partner violence healthcare providers can easily explain that it is best practice, hospital or organizational policy, or the legal obligation of the provider to ask all patients questions regarding domestic violence. Many organizations do have policies that require providers to ask these questions during every visit; note, ensure that your organization’s policies and procedures are properly followed. By explaining that this is a question that everyone is asked, patients may not be offended (20).

Discomfort may lead healthcare providers to avoid the question completely or rush over it in hopes of not having to deal with it. Unfortunately, sensitive topics can lead to discomfort during discussion, but it is important to remember that someone’s life might be in danger, and asking that single question can save a life (20).

Some patients do not leave their abuser despite the resources healthcare providers give them as covered earlier in this course. Regardless of how many times a patient presents to a hospital or doctor’s office, the healthcare provider is responsible for asking, offering resources and support, and providing treatment to the patient. In time the patient may be able to leave the abuser, and trust in a healthcare provider can be pivotal in that moment (20).

The History Assessment

Commonly known as a “history and physical,” this is the part of the assessment that delves into the patient’s full medical history and where a physical assessment from head to toe is conducted. Depending on the location of the exam—a doctor’s office versus an emergency department—the collection of this data may vary. A primary care provider’s examination greatly contrasts with an exam performed in the emergency department. Regardless, attention to detail can reveal concerning or conflicting information (41).

A patient’s medical history consists of any and all medical conditions the patient has been diagnosed with, past and present. Treatment for these diagnoses is collected with additional information gathered to determine if there are any side effects or adverse reactions to any treatments. Determining if the patient smokes, drinks, takes any illicit drugs, or uses other tobacco products is the goal of obtaining a social history from the patient. The social history assessment also includes asking about spirituality, sexual activity/habits, occupation, relationship status, and hobbies (41).

Family history is often collected with the medical history to assess the patient for genetic predisposition to certain medical conditions. The surgical history is a record of all elective and emergent surgeries done in the patient’s lifetime. This can include any anesthesia reactions or complications that happened as a result of the surgery. The provider also assesses for allergies and any medications the patients take, both prescribed and over-the-counter (41).

Pediatric considers consist of immunization status and developmental milestones. Parents of infants should be asked about pregnancy challenges or diagnoses such as pre-eclampsia, delivery, prematurity, and postpartum complications. For those of childbearing age, or if menstruation is suspected, asking young adult and adult females about their last menstrual period and the possibility of pregnancy is important (41).

When assessing a victim of domestic violence, collecting a history and physical can produce some challenges. The abuser may present with the patient, dominating the conversation or answering the questions for the patient. They may act like a dotting partner or parent or family member, doing everything they can to be the “perfect” support person for the patient. They may point blame at the patient in a causal manner. “She’s just clumsy” or “he’s such an adventurous toddler; he climbs on everything.” Those phrases may prove to be useful when comparing it to the information gathered from the physical assessment (41).

The Physical Assessment

Depending on what a patient’s chief complaint is upon presentation to the provider’s office or hospital, some type of physical examination is done. This consists of inspecting, palpating, percussing, and auscultating areas of the body. Some exams are more thorough than others depending on location. An emergency room provider is not going to perform an in-depth head-to-toe assessment on every patient. Instead, they assess the area of complaint and determine a diagnosis or other tests that need to be done. Family providers are more invested in the patient as a whole as they manage the patient’s chronic medical conditions as well as collaborate with specialists to ensure the patient is receiving the best treatments (61).

Below is a table of each body system and how a perfect patient—no medical conditions or diagnoses—would appear versus any signs and symptoms that could indicate a patient is a victim of domestic violence. It is vital to remember that many medical conditions can look like domestic violence: those with clotting disorders are more prone to bruising, so multiple bruises in various stages of healing could be attributed to the medical condition. This is why it is important for healthcare providers to collect a comprehensive medical history as well as a detailed description of why they are seeking help. Some injuries are caused in particular ways that do not match the story being told (61).

The list provided is by no means complete. Healthcare providers may see patients who are coming in for a routine physician appointment, or those patients may be the victims of severe trauma and are fighting for their lives. The case study below depicts one such instance.

Case Study:

A 27-year-old woman is brought to the emergency department via emergency medical services as “car versus pedestrian”. The initial report stated she ran over several times an SUV-sized vehicle. Upon receiving the patient at the hospital, the trauma team was activated for severe crush injuries and internal hemorrhage. Lifesaving interventions were started in the emergency department and continued in the operating room.

What the emergency department staff was unaware of was the driver of the vehicle was the woman’s husband. The couple was outside of their house arguing when the husband stepped into the vehicle and proceeded to run his wife over with the car. Their two children aged seven and two were in the vehicle.

Investigation into the patient’s medical history, phone records, and testimony from friends and family revealed that the woman had been worried about something like this happening. She had confided in a friend that her husband had been making threats to her their entire relationship, but recently they “seemed different.” While her friend was concerned, she did nothing to assist, instead, telling the victim it would all pass.

Author’s Note: Domestic Violence of the Child and Burns

Burns in children experiencing domestic violence are not uncommon. Many abusers try to use the excuse that the child “put their hand into the hot pot of water” which led to the burn. Instinctively, when their hand is forced into hot water the child is going to clench their fist, essentially “sparing” the palm from being burned. This would not happen if the child were to willingly put their hand in the hot water. This sparing happens on other parts of the body when immersed in hot water. When the body is in a tub, they will curl their legs up to their chest, saving the abdomen and creases of the limbs from severe burns or being burned at all. The soles of the feet might be saved due to them being pressed against the bottom of the tub (56).

Glove pattern burns or “waterlines” are indicators that the child was held in the water and has a clear line of demarcation. If someone were to fall in, the burn marks would be in a splash-like pattern with no uniform end line. While these types of injuries are most common in children, they can happen in adults (56).

Effects of Domestic Violence

Victims report many short and long-term effects that result from domestic violence or intimate partner violence. It may take a long time for these effects to go away, or victims may live with them for the rest of their lives. For healthcare providers, it is important that encouragement is present in conversations and providing reminders that recovery is possible and looks different for everyone. If a victim’s definition of recovery is that they can sleep three hours a night, then that is recovery for that particular individual. If a victim wants to be able to rebuild relationships they lost when living with the abuser, then that is recovery for that individual (23).

Below is a small list of short and long-term effects that individuals can experience during and after abuse.

Case Study:

Jeremy arrives at his physician’s office looking to make an appointment. He appears to be in distress and panicking. “This is the only time she’s not home. I don’t know when I’ll be able to get away again,” he tells the receptionist when asked to schedule an appointment at a later date. Fortunately, there was an opening, so Jeremy was brought back to an exam room where he confessed to the provider that he is having a hard time sleeping and seeing that “she is still around.”

When asked about who “she” is, Jeremy immediately stops talking. Unsure of what to do, the staff leaves Jeremy alone and calls for a law enforcement officer and mental health counselor to come assess Jeremy who ends up being transported to the nearest emergency department.

In the emergency department, Jeremy tells the physician that he just wants to be left alone so “she” can’t find him. One of the other staff members recognizes Jeremy and tells the provider that Jeremy was in an abusive relationship a year ago. Jeremy had some “rough patches” with drinking and self-isolation. but he had been doing better. Since the staff member has a good rapport with Jeremy, he goes in to talk with him.

Jeremy admits that he’s been having dreams of “her”, his ex-wife Sharon. He reports he sometimes sees her in different places in the house, just out of reach but always watching. “Sharon’s always there, but today she wasn’t. So, I left.” He states that he cannot tell if it is really her or not since she would sneak up on him without noticing. The staff member notices self-inflicted scratch marks on Jeremy’s arms and his anxious pacing.

Statistics and Prevalence of Domestic Violence

General:

Looking at the overall data for domestic violence or intimate partner violence, there is a large prevalence and many factors that can contribute to or exacerbate the problem.

On average, there are 20 individuals living in the United States who are physically abused by an intimate partner every minute. That is approximately 28,800 people in a 24-hour period. Annually, the estimated total is over 10 million men and women. According to data, approximately 20,000 phone calls are made to nationwide domestic violence hotlines daily. This does not account for chat services offered online or via text message. Comparing that information to the estimated number of individuals experiencing physical abuse within a 24-hour period, it appears as though many may be seeking help or assistance. However, it is important to keep in mind that abuse can be more than just physical as mentioned. Data does not provide how many individuals are sexually, psychologically/emotionally, or technologically abused every minute (33).

Intimate partner violence affects more than 12 million people annually in the United States; daily that is approximately 32,876,712 individuals. Between 1994 to 2010 four in five victims of intimate partner violence were women. Seventy-seven percent of women from ages 18 to 24 who were victims of intimate partner abuse had been abused by the same partner previously; from ages 25 to 34 the percentage was 76%, and those aged 35 to 49 had a rate of 81% (33).

Rape accounts for a large part of intimate partner violence as one in 10 women have been victims of rape by their intimate partner. Fifty-one percent of women report rape is carried out by their intimate partner, while 40.8% report the rape was carried out by an acquaintance. Experiencing sexual coercion is estimated to encompass around 13% of women and 6% of men; victims are non-physically forced to participate in sexual acts they do not want to do (33).

Workplace:

Being a victim of domestic violence can create problems in areas outside of the relationship. School or work can be drastically affected. One survey shows that 64% of those who self-identified as victims of domestic violence or intimate partner violence report that their work was affected as a result of the violence. This ranged from being distracted at 57% while fear of being discovered at work was 45%. Two out of every five victims reported they were worried an unexpected visit from their intimate partner would occur or the partner would unexpectedly call work (36).

The fear of an abuser unexpectedly showing up to a place of work is real for victims. Some may use work as a way to plan their escape from the abusive situation. Going to work might be an act to make the abuser think all is well in the relationship while the victim is fleeing. As discussed, many victims do not share their abuse with others. Coworkers may not know what is going on and let the abuser know the victim is not at work or let them enter the building, unaware that they are putting the victim or others at risk. It is important to note that 20% of homicides related to domestic violence or intimate partner violence do not result in the death of the victim. Instead, those who are killed consist of law enforcement officers or other first responders, individuals who try to intervene during an abusive episode, or bystanders caught in the middle of the situation (36).

Interestingly, 63% of cooperate executives report domestic violence is a major societal problem and 55% report it impacts productivity in their companies. The percentage of executives saying that domestic violence impacted the bottom line was 43%, a substantial number. However, when compared to the employees of these companies 43% is insignificant as 91% of employees said violence impacted the bottom line. Seventy-one percent of those same executives did not believe domestic violence or intimate partner violence was a major concern in their company. Despite this statement, domestic violence contributes to approximately 8 million lost days of paid work annually, this is the equivalent of over 32,000 full-time jobs. Data continues to support the need for awareness on all levels of the corporate ladder to better help victims (36).

Weapons:

Reports put emphasis on how weapons can affect the situation. Nineteen percent of domestic violence or intimate partner violence cases involve a weapon. An estimated 13.6% of women living in the United States report they have been threatened by their intimate partner with the use of a firearm. Out of that 13.6%, 43% of women report being physically injured. In a seven-year period between 2010 and 2017 intimate partner homicides using firearms increased by 26% while homicides using other weapons decreased. Having access to a firearm increases the risk of homicide is increased by 500% and increases the chance of femicide—homicide of a woman by a man based on their gender—by 1,000% (36).

Other data on firearms and homicide in domestic violence or intimate partner violence situations show that incidences involving firearms result in death twelve times more than other weapons or use of bodily force. Twenty percent of women who obtain an emergency protective or restraining order are murdered within the first two days of obtaining that order; about 33% of them are murdered within the first month. Stalking plays a large factor in domestic violence as well; 58% of the women who survived a murder attempt and 76% of those who were murdered were initially victims of stalking (36).

Some may suggest the victim purchasing a firearm for safety, and this can be met with mixed reviews. If the victim lives with the abuser, this may not be a reasonable option due to the risk of the abuser locating the firearm and using it. Data shows that victims owning a firearm is not a protective factor against domestic abusers and there is a 50% increase of intimate partner homicide while doubling the chances of a firearm homicide (36).

Some states have created legislation and laws to prevent abusers from owning or possessing firearms. In those states, the rate of intimate partner homicide is 13% lower than in states that do not have these types of laws or legislation in place. States that require abusers to relinquish firearms and prohibit them from purchasing additional firearms have a 12% decrease in homicide. Federal law does exist to control abusers from owning or purchasing firearms based on certain criteria; however, no process is without fault or room for abusers to evade the system, and providers should be aware of such by always assessing for a victim’s safety and the presence of any weapons within the home or where the abuser could easily access them. This could be through friends, family, neighbors, legal purchase, or illegal obtainment (36).

Kentucky Specific Data:

According to research, 45.3% of women and 35.5% of men that reside in Kentucky report having been a victim of domestic violence or intimate partner violence and/or rape in their lifetime. Out of all 50 states, Kentucky is ranked 11^th for the highest rate of femicide in the country with 1.77 per 100,000 females; Alaska had the highest rating with 396 per 100,000 females. Comparing this data with the lowest states Maine, Nebraska, and New York tied for 44^th with a 0.73 per 100,000 femicide rate. It is fair to note that Alabama and Florida did not have data collected and/or submitted for this particular study which may have impacted the results of ranking (32).