History and Evolution of Substance Abuse Treatment in the USA

1. 1st International Alcohol, Tobacco and Other Drugs Nursing & Midwifery ConferenceFlinders UniversityAdelaide, AustraliaApril 16, 2003ISSUES IN NURSING EDUCATION Dana Murphy-Parker, RN, MS, CNS Professor of Nursing Arizona Western College Yuma, Arizona

2. Getting from There to Here • Chair of International Committee, National Nurses Society on Addictions: looking for UK connections professionally • Association of Nurses in Substance Abuse, Annual Conference, April, 1998 • Clinical placement in January, 1999 for graduate work exchange, University of Colorado,Denver. • Experiental philosophical differences in the way drug and alcohol problems and treatment approaches were viewed.

3. Questions? • How has the treatment of substance misuse/addictions evolved in the USA? • Why is drug and alcohol problems not viewed as a healthcare issue • How has the “Abstinence Philosophy”, the “War on Drugs”, the “Just Say No”, program, “Zero Tolerance” & “Mandatory Minimum Sentencing” impacted on treatment programs in the United States? • What can the US learn from Britain (and now Australia) in regard to treatment of persons with substance misuse?

4. Today’s Objectives • Give a brief history of substance abuse philosophies and concepts in the USA. • Discuss the development of nurses’ involvement in raising awareness of the need for substance abuse education within the nursing profession in the USA. • Discuss a research study which examined the relationship of addiction education and attitudes/beliefs of nursing students towards persons with alcohol problems • Acknowledgment: • Ruby Martinez, PhD, RN, CS University of Colorado Health Sciences Center Alpha Kappa Chapter-at Large, Sigma Theta Tau, International

5. Historical Events Affecting Substance Misuse in the USA • 1870 - American Association for the Cure of Inebriates (AACI). • 1876 - Quarterly Journal of Inebriety • 1884 – Sister society formed in England and co-conference between US and England in 1887. • 1888 - AACI changed name to American Association for the Study & Cure of Inebriety. • 1891 - Over 2,000 physicians , numerous libraries and asylums subscribed to the associations’ journal. • 1914 - Harrison Anti-Narcotic Act

6. Historical Events Affecting Substance Misuse in the USA, (2). • 1914 - Harrison Anti-Narcotic Act “A physician could prescribe narcotics in the course of his professional practice only” • ***** It was simply “feeding a bad habit, not only immoral, but now illegal (Gray, 1998, p. 45).” 1920 - American Association for the Study & Cure of Inebriety becomes non-existent. 1920 – The Volstead Act: Prohibition of alcohol in the USA

7. The most important consequence of the Harrison Anti-Narcotic Act was attaching criminal consequences to drug addiction. The emphasis was placed on interdiction and prohibition, rather than on assistance and treatment (Sullivan, 1995). The interpretation and enforcement of this law cast a long and chilling shadow over the development of progressive treatment programs for substance misuse in the USA. The Harrison Anti-Narcotic Act was initiated with an appropriation of $150,000 for enforcement of its provisions. Over eighty years later, we are spending that much every three minutes with the "War on Drugs"!

8. 1935 Alcoholics Anonymous • Founded by Bill Wilson and Dr. Bob • Both the medical and psychiatric communities rejected it

9. 1940- Yale Center for Alcoholic Studies • First academic program to seriously study alcoholism

10. 1950s • American Medical Association Declared “Alcoholism” a disease in 1954 • By the end of this decade, there were 200 small independent treatment programs in the USA

11. Confrontation Model • Ruth Fox, MD - Founder of the American Society o f Addiction Medicine (ASAM) in 1955. • She summarized her clinical experience and views in psychodynamic terms. - • “Most patients refuse to face their alcoholism for many years, using the defense mechanisms of denial, rationalization, regression & projection..the

12. Confrontation Model (con’t) • The person builds up an elaborate defense system in which he DENIES that he is an alcoholic (drug addict)…rationalizes that he drinks for all of his problems in life and projects the blame for the trouble he is in on others (1967) • Assumption of these inherent defenses were accepted  Confrontation Model…tactic of attacking defenses to break denial.

13. Nursing and Professional Organizations: Specialty of Substance AbuseEfforts within the Profession • National Nurses Society on Addictions (1975) • Drug and Alcohol Nurses Association • Consortium of Association of Nurses in • Substance Abuse • All 3 have merged into The International Nurses Society on Addictions – 1996 – 1998; name change in 2000. • National Consortium of Chemical Dependency Nurses (NCCDN)

14. Need for Educational Content on Substance Abuse Disorders • 1984 – America Nurses Association, Drug and Alcohol Nurses Association & National Nurses Society on Addictions “Addictions and Psychological Dysfunctions: The Profession’s Response to the Problem

15. A Response from the Nursing Profession • 1992: American Association of Colleges of Nurses (AACN) formed Substance Abuse Task Force to develop policy statement to address problems of substance use in the nursing community. • 1993: AACN developed a position statement of the need for addictions content to be included in all nursing education.

16. FEDERAL INITIATIVES: FACULTY DEVELOPMENT (1991) :NIAAA, NIDA & OFFICE FOR SUBSTANCE ABUSE PREVENTION (NOW CENTER FOR SUBSTANCE ABUSE PREVENTION) • PROJECT SAEN: • Dr. Madeline Naegle of New York University. NLN (1991) • AN ADDICTIONS CURRICULUM & Other Helping Professions: • Dr. Elizabeth M. Burns, Ohio State University SON. (1993) • PROJECT NEADA (1990): • Dr. Olga M. Church, University of Connecticut SON.

17. PUBLICATIONS (USA) Supporting a Lack of Addictions Education in Nursing School Curricula • Survey found 82%-98% of baccalaureate, master’s & nurse practitioner programs offered the subject of alcohol & drug abuse on an average of 3-5 hours during the entire training program. (Carter. 1983) • Sullivan & Handley (1993) consistently found that there were less than 5 hours of substance abuse content given in both baccalaureate & master’s level nursing. • Hoffman and Heinemann (1987) found that undergraduate curricula offered an average of 1 – 5 hours of substance abuse instruction over a course of 2 – 4 years in diploma, associate and BSN program

18. In The USA:Educational Preparation For Addictions Nursing Practice Has Lagged Behind Education For Other Nursing Specialties. • Murphy, Shirley (1989). Journal of Nursing Education). “The Urgency of Substance Abuse Education in Schools of Nursing”. “Nurses….report their educational experiences offer little to prepare them to develop substance abuse prevention & intervention program” • Naegle, Madeline A. (1989) (Alcohol Health & Research “World) “Targets for Change in Alcohol & Drug Education for Nursing Roles”. “(Nursing) education has not kept pace with these (abuse of alcohol & drugs) issues, and most nurses daily confront deficits in their understanding of alcohol & drug abuse..

19. Educational Preparation For Addictions Nursing Practice Has Lagged Behind Education For Other Nursing Specialties(2) • Rassool, G.H. & Oyefeso, N. (1993). The Need for Substance Misuse Education in Health Studies Curriculum: A Case for Nursing Education. Nurse Education Today, 13, 107-110. Both at St. George’s Hospital in London • A systemic review of nursing curricula conducted in 1997 (Howard, Walker & Walker) concluded that: • little attention was devoted to either theoretical or clinical education in the substance area and that the proportion of alcohol and drug education received by student nurses was substantially lower than that of medical students and other healthcare professionals.

20. Why NOT????What are the reasons that we are not educating nursing students and nurses in this area?

21. Nurses Attitudes Towards Persons With Addictions • Literature Review on Attitudes • Naegle (1989) states a negative attitude and pessimism persists within the nursing community that doubts alcoholics can have successful treatment outcomes • Studies (Starkey, 1980; Smith, 1992) show nurses to be moralistic, pessimistic, authoritarian & perceive this population to be weak rather than ill.

22. Client Response as a Determinant of Attitude • Research demonstrates that the quality of care provided is correlated to attitudes of providers (Hanna, 1991). • Eleanor J. Sullivan (1995) states that nurses attitudes towards persons with addiction problems correlate with their amount of knowledge about addictions • G. Hussein Rassool (1998) suggests the development of a non-judgmental and positive attitude towards alcoholics and other substance abusers may be partly related to training and education

23. The Relationship Between Attitudes and Knowledge A lack of knowledge about alcohol & drug abuse issues is a primary reason for nurses’ negative attitudes towards working with persons with addictions (Happell & Taylor, 1999)

24. International Council of Nurses (ICN); 1st TINN MeetingLondon, 1999 • THE NUMBER 1 theme which emerged: “Education on substance misuse and addictions in nursing is missing or insufficient in nursing school curricula and a resolution for improvement must go the ICN, WHO & UN”.

25. “Examining the Relationship of Addictions Education in Nursing School Curricula to Attitudes/Beliefs of Nursing Students Towards Alcoholics” • Is the lack of teaching of addictions in nursing schools across the country related to a negative attitude on the part of the nurse when working with a person experiencing a problem with alcohol? • Would deliberate addictions education given to nursing students make a difference in their attitudes towards a person with an alcohol problem? • Would exposing nursing students to a person who has successful recovered/overcome alcoholism further make a difference in the nursing students attitudes?

26. HypothesisBasic Premise: Students knowledge about addiction would increase by offering a lecture on substance abuse 1. Beliefs of nursing students toward people with alcohol problems will be more favorable after a program of classroom instruction about alcohol problems. • 2. A group of nursing students given both classroom instruction and exposure to a person recovering from alcoholic disease will express more favorable attitudes towards persons with the disease after teaching and discussion. • 3. A group of nursing students given both classroom instruction and exposure to a person recovering from problems with alcohol will express more favorable attitudes towards persons with the disease than students exposed to classroom teaching only.

27. “Examining the Relationship of Addictions Education in Nursing School Curricula to Attitudes of Nursing Students Towards Alcoholics”: • A Quasi-Experimental Repeated Measure Design • Group 1 • Pretest>>>>Treatment>>>>Posttest>> 3 month • Group 2 Pretest>>Treatment & Recovered Guest Speaker>>>>Posttest >>>3 month F/U test

28. Knowledge of Alcoholism was measured by a questionnaire devised by authors using the CARN (Certified Addictions Registered Nurse) Review Resource Manual. (permission granted by Lynette Jack, PhD, RN, CARN • Examples of questions: 1. The nurses bases her assessment of the alcoholic client on the knowledge that pharmacologically, alcohol is a • Stimulant • Hallucinogen • Depressant • Phenothiazine (correct answer, C) 2. Nursing assessment of the alcoholic during detoxification would include data related to: • Ability to tolerate job-release stress • Ability to express emotion • Response to major tranquilizers given • Seizure potential (correct answer, D)

29. Results of Knowledge Tests • There were no significant knowledge differences between the 2 Groups for the pre-test. • Both Groups had an increase in knowledge level from the pre-test to the post-test. • Group 2 who had the discussion with the recovering person, demonstrated significantly higher knowledge scores from Group 1 from the pre-test to the post-test.

30. Marcus Alcoholism Questionnaire (1963)9 Factors On Which The Instrument Attitudes About Alcoholism • Emotional difficulties as causes of alcoholism • Loss of control • Prognosis for recovery • The alcoholic as a steady drinker • Alcoholism as a character defect • Social status as a cause of alcoholism • Alcoholism as an illness • Harmless voluntary indulgence • Alcohol is a highly addictive substance

31. No further significant differences between the Group 1 and Group 2 • Factor 1: Emotional difficulties as causes of alcoholism A high score indicates that emotional difficulties contribute to alcoholism (True). Findings Group 1 & Group 2 both had increased means from pre-test to post-test indicating that students increased their understanding/belief that a person who has a history of emotional/psychological problems contributes to a greater risk for alcoholism

32. Significant Findings: from Pre-tests to Post-tests • Factor 2: Loss of control A high score indicates the belief that the alcoholic is unable to control his drinking behavior (True) Findings Group 1 & Group 2 showed a significant difference from pre-test to post-test. This meant that students were more likely to believe and understand that a person who has problems with alcohol are unable to control the amount they drink. Group 2 subscales improved over Group 1 indicating Group 2 had greater recognition of loss of control

33. Significant Findings:from Pre-tests to Post-tests (2) • Factor 3: • Prognosis for recovery: • A high score indicates the belief that one can not and does not recover from alcoholism. (False) Findings: Group 1 & Group 2 showed improved scores from pre-test to post-test which supported that the nursing students did increase their beliefs that a person could recover from alcoholism.

34. Significant findings: Between Group 1 & Group 2 • Factor 4: The Alcoholic as a Steady Drinker. A high score indicates that a person who periodically drinks (“binge drinking”) excessive amounts of alcohol can have problems with alcohol (True) • Findings : Group 2 had a significantly higher mean than Group 1

35. Significant findings Between Group 1 & Group 2, (2) • Factor 5: Alcoholism and Character Defect: A high score indicates the belief that the alcoholic is a weak-willed person (False) Findings: Group 2 had a significantly lower mean than Group 1. ***** In addition, both Group 1 and Group 2 had significantly lower means from the pre-test to the post-test

36. Significant findings: Between Group 1 & Group 2, (3) • Factor 6: Social status of a person with alcoholism: A high score indicates the belief that alcoholics come from the lower socioeconomic strata of society (False) Findings: The pre-test to post-test means increased slightly for both groups, indicating a poor understanding regarding social status of person with alcohol problems

37. Between Group Differences (Not Significant) • Factor 7: Alcoholism as a disease. A high score indicates the belief that alcoholism is not an illness (False) Findings Group 1’s mean increased from pre-test to post-test indicating that Group 1 was more likely to think that alcoholism is not a disease Group 2’s mean slightly decreased from pre-test to post-test indicating that Group 2 students were more likely to believe that alcoholism is a healthcare disorder.

38. Factor 8:Voluntary heavy indulgence of alcohol is harmless • A high score indicates the belief that the alcoholic is a harmless heavy drinker whose drinking is motivated only by his fondness for alcohol (False) Findings Group 1 & Group 2 had lower means from pre-test to post-test indicating that both groups of students believed that heavy drinking was harmful and that a person who drinks heavily has a problem with alcohol rather than simply liking to drink

39. Significant Findings:from Pre-tests to Post-tests (4) • Factor 9: Alcohol is a highly addicting substance A high score indicates the belief that alcohol is a highly addicting substance (True) Findings Group 1’s mean scores showed that these students were less likely to believe that alcohol was a highly addicting substance Group 2 did have a higher mean from Group 1 however there was no change in their mean from pre-test to post-test.

40. “Examining the Relationship of Addictions Education in Nursing School Curricula to Attitudes of Nursing Students Towards Alcoholics” 1. Have you had any personal experience with anyone having an alcohol problem that you feel effects your attitude towards alcoholics?” (include yourself(asked on pre-test only) Yes ____ No ____. If your answer is YES, please briefly explain 2. "Do you believe that a person who has an addiction to alcohol can recover?" Yes _______ No ______. Please briefly explain your answer.**(asked on pre & Post test) __  3. "If the School of Nursing were to offer a course in The Role of theNurse in Addiction Issues, would you be interested in taking this course?" _______Yes ______NO **(asked on post test)

41. “Examining the Relationship of Addictions Education in Nursing School Curricula to Attitudes of Nursing Students Towards Alcoholics” • The qualitative questions revealed the high prevalence of alcohol abuse within American families • Recovery is possible if the person wants to and is willing to accept help • Most interesting was that whether a participant indicated a “yes” or “no” on their thoughts about the possibility of recovery, their written explanations about recovery were similal • indicates that the concept of recovery is not clear, What does recovery mean?? • How do we measure SUCCESS?

42. “Examining the Relationship of Addictions Education in Nursing School Curricula to Attitudes of Nursing Students Towards Alcoholics” • Main Themes • The person must be willing to stop drinking • Once the drinking stops they will forever struggle with how alcohol fits into their life • Alcoholism is a chronic condition that involves relapse • Some participates viewed recovery as inconsistent with the chronic nature of alcoholism. Even with abstinence, the person is still not “recovered” because the underlying condition of alcoholism is still present for that person.

43. “To Treat the hemorrhage or the pancreatitis and not the alcoholisms is poor health care, akin to treating anemia without treating the colon cancer that causes it (Sullivan, 1995)”

44. “Changing the Conversation” in the USAA National Treatment Initiative(CSAT/SAMHSA) • “We envision a society where people who are addicted to alcohol or other drugs, people in recovery from addiction, and people at-risk for addiction are valued and treated with dignity; and where stigma, accompanying attitudes, discrimination and other barriers to recovery are eliminated. We envision a society where addiction is recognized as a public health issue, a treatable disease for which individuals should seek and receive treatment; and where treatment is recognized as a specialized field of expertise” ”