New Beginnings
Bringing psychiatric, med/surg and critical care skills into play, chemical dependency nurses help their patients heal inside and out

By Cathryn Domrose
February 13, 2004

A few months after she started attending Alcoholics Anonymous meetings in 1977, Mary Mitch, RN, marched into the chemical dependency unit at St. Mary’s Hospital—now Fairview-University Medical Center—in Minnesota and said, “I want to work here.”

Mitch, who has been a nurse for 39 years and a chemical dependency nurse for 26 years, wanted to learn more about herself and her addiction. “I was having such a struggle with my own drinking,” she said. She was married to an alcoholic. She had drinking in her family. She had three children to raise and wanted to turn her life around.

“I felt [chemical dependency nursing] was an area where I could learn,” she said. “I sought it out mostly because I wanted to discover more about myself.”

As a chemical dependency nurse at Fairview Recovery Services, Mitch still is learning and sharing her experiences when she thinks it will help her patients, especially those who come to the center for the first time. She sees their tears and remorse, and tells them she has walked in their shoes and has struggled with chemical addiction.

“It seems to break the ice,” she said. “When people feel really bad and beaten down, it helps to know that others have been through it, that they’re not the only ones.”

Regardless of whether they have been through recovery, all good chemical dependency nurses are able—in some way—to identify with the patients they treat, those who work in the field say. “You have to have a heart for it,” said Jeanne Moore, RN, director of nursing at Greenbriar Treatment Center in Washington, Pa. “Either you understand it and want to help them or you don’t.”

Nurses who work with chemically dependent patients cannot be judgmental, no matter how many times they have seen someone come through a detox unit or a recovery program. They must combine infinite patience with an ability to set firm boundaries. They must empathize and listen to patients without becoming too involved in the sad stories they hear. They must be skilled at dispensing medications, assessing medical conditions and catching changes in physical conditions, while at the same time listening carefully to what patients are saying and watching what they are doing.

“The nurse’s job is to set up the situation so that the patients can do the work they need to do,” said Steve Gottlieb, MA, RN, a charge nurse at Sierra Tucson hospital in Tucson, Ariz.

Variety of services

Whether they are called rehabilitation centers, recovery centers, chemical dependency units or treatment centers, most places for those who go to deal with some form of chemical addiction offer a variety of services, ranging from a detoxification process to residential treatment to outpatient support programs. They may be freestanding psychiatric hospitals, part of a medical hospital or residential treatment programs, with acute detox facilities, subacute facilities or no detox program at all.

Chemical dependency nurses say they see patients of all ages, social and economic backgrounds and professions. They work with people addicted to alcohol, sedatives, painkillers, opiates and methamphetamines. Many have more than one addiction. Some are dually diagnosed with mental illness.

Most chemical dependency nurses work on the detox units with one or two others in the residential areas to dispense medications, observe patients and monitor medical conditions, such as high blood pressure or diabetes. Nurses also assess new patients, process admissions and do utilization reviews. They often work with a team that may include physicians, therapists, psychiatrists, counselors and dietitians.

Detox work requires a combination of psychiatric, med/surg and critical care nursing skills, said Carol Power, MSN, RN, nursing director at Sierra Tucson. A lengthy and detailed admissions process, increasing amounts of paperwork and faster turnover of beds force nurses to work quickly and think on their feet, while dealing with incoming patients who may be intoxicated or suffering painful withdrawal symptoms.

“There’s a lot to do in a little bit of time,” Moore said. “It gets very hectic. The people aren’t dying here, but it’s more stress than you would think.”

The most dangerous drug to come off of is alcohol, chemical dependency nurses said. Alcohol withdrawal can kill a patient who is not properly monitored and medicated, they said. Detoxing alcoholics may experience hallucinations, shakes, nausea, sweats and chills, as well as sudden changes in blood pressure and other vital signs.

Withdrawal from certain painkillers and sedatives also can have serious medical consequences, including seizures. Detoxing from opiates, such as heroin or morphine, is not deadly but is miserable for the patient—and often the nurse.

“Patients have been very difficult to deal with when they’re coming off opiates,” Mitch said. “They’re miserable. They feel like they’ve got a bad case of the flu.”

During the first few days and sometimes during the recovery process as well, nurses give patients medications to help ease the pain and physical problems caused by withdrawal. The type and amount of medicine depends on the symptoms and the substance patients are withdrawing from.

“The nurse is instrumental in those first two or three days in keeping patients in treatment,” Power said. Nurses try to keep the detox environment calm and unthreatening, she said. The nurse’s message to the patient is, “We’re glad you’re here and we want you to stay.”

Nurturing approach

Mitch recalled how new patients used to be greeted in detox with a barrage of accusations.

Patients were told they were addicts, that they were hurting people, she said. Counselors would get information from families about how much alcohol they drank in a week, how much money they spent on drugs or examples of run-ins with the law and present this information to them in group counseling sessions.

“The counselors were rough,” she said. “They didn’t let people worm out of it or make excuses.”

In recent years, the approach has become much less confrontational and much more nurturing, she said. “It’s more respectful to the patients and it seems better for them.”

At Scripps McDonald Center in La Jolla, Calif., manager Sandra Boller, RN, pushed hard to separate detox from residential rehabilitation. Before, when the center used a medical model, detoxing patients were mixed in with people who were two or three weeks into recovery. The sick detox patients became understandably agitated when someone told them, “You’re just an addict, admit it,” Boller said. “Why all the stress and drama?” It made more sense to wait until they felt well enough to start group counseling sessions.

“I’ve always had a strong belief that you’re more open to something when you feel good,” she said.

At Sierra Tucson, Power also has worked to separate the detox and assessment area from the residential area to reduce the amount of traffic, noise and other disturbances that could easily get on the nerves of on-edge patients. She has set up soft lighting and meditative music. Nurses take newly admitted patients to private areas to take vital signs and information.

At Grapevine Valley Hope in the Dallas/Fort Worth area, patients in detox are encouraged to start group counseling sessions after a day or two if they want to, said Sandi DeLusque, RN. But they are not forced out of bed if they say they feel too sick to get up. “We’ll tell them, ‘You’re right, you don’t feel well. I’ll get you that washcloth.’ ”

As it has in almost every aspect of health care, managed care has forced certain changes on chemical dependency units. When she first began working in the field, Mitch said, patients stayed under medical supervision for up to 60 days. Even then, she wondered if that was enough time for some patients.

“I watched the numbers get cut and cut and cut,” she said. “Now, there’s no inpatient [medical] treatment anymore.” Most hospital-based programs detox patients, then refer them to outpatient treatment centers or move them into a residential program that does not have direct medical supervision.

This residential “social model”—which combines group and family therapy, individual counseling, 12-step programs and medications—has its advantages, Boller said. Patients can learn from each other and support each other and participate in their care. It makes more sense to separate the detox patients who require costly medical supervision from residential rehabilitation patients who mostly don’t, she said.

Greater accountability

Managed care also has forced treatment centers to be more accountable, with measurable goals, said DeLusque, who works in utilization review for Grapevine Valley Hope.

On the other hand, she said, stays are shorter than they used to be, and some patients need more time to work on their problems than insurance companies will pay for.

In the 1970s, when Mitch started, nurses were much more involved in counseling, she said. Now, trained therapists and counselors run most of the group and individual sessions and outpatient rehabilitation. Nurses often focus their patient education on physical aspects of chemical dependency and alternate ways of relieving pain and stress.

They may teach classes on topics such as how drugs and alcohol affect the body, effects of medications and relaxation techniques. Some may offer patients massage, forms of acupuncture, guided-image therapy or other types of pain relief that don’t involve medications.

Although usually not directly involved in therapy, chemical dependency nurses talk to patients constantly. “Sometimes patients will talk more to the nurses than to the counselors,” DeLusque said. Nurses are the ones who see patients pacing the corridors at night or crying and upset after a visit or phone call. Many times, nurses said, they take a few minutes to sit on a patient’s bed and suggest relaxation techniques or share a cup of tea and listen to them.

But chemical dependency patients do not always see the nurse as their advocate. Often, nurses said, they are cast into the role of villains because they won’t give a patient more medication or they enforce rules such as when patients may talk on the phone.

“Pill addicts are especially difficult to deal with because they are so used to manipulating people,” said Teresa Zielinski, RN, an assessment-intake nurse at Scripps McDonald Center. Pill addicts often have gone from doctor to doctor, or bought pills over the Internet, she said. Some are at the nurses station every 10 minutes, asking for medication. “They think they’re going to die. They’re exaggerating their withdrawal symptoms to get another pill.”

The patients can be self-centered, demanding medication when the nurse is talking to a physician or dealing with another patient in crisis.

But these frustrating moments also can be used to help patients deal with their behavior, nurses said. Gottlieb said he may directly share his feelings with the patients, telling them, “When you’re at the med room door every 15 minutes, I feel frustrated.”

Often, he said, they respond by talking about their fears that they can’t go for more than a quarter of an hour without knowing they are going to get a drug. “They’ll start to be able to talk about what’s really going on with them.”

Zielinski often tells patients that they can’t take a pill every time someone upsets them and that they have to learn other ways to cope with their feelings.

“A lot of times they take that as you’re being mean to them, that you don’t like them. I’ve been called every name in the book, but you have to let that go. That’s part of the job.”

Dawn Gessner, RN, a nurse case manager who works with residential patients at Scripps McDonald Center, said patients often come to her later to apologize for things they said during the first part of their stay. “I’m the big bad person when they first come in, but by the time they leave they’re kind of joking, saying, ‘I can’t believe I did that to you.’ ”

Chemical dependency nurses say it hurts to see someone relapse, especially someone who seemed to be doing well for a long time. “You feel bad about it,” DeLusque said, but part of chemical dependency nursing is reassessing, trying to figure out what went wrong and taking a fresh approach.

Zielinski has seen some of her young patients leave treatment, return to drugs and die. “They’re so young and they just can’t believe they can die from this and they do,” she said. “You feel bad, you process it and you move on. That’s a reality with this field.”

Mitch said she gets frustrated with patients who come through detox dozens of times and obviously plan to return to using drugs as soon as they get out. “But how can we judge?” she asked. “That’s the challenge for nursing. That we don’t have judgment and that we put on a fresh approach every time.”

These patients, she added, are a fraction of the ones who come to her unit. Most really want to change their lives and stop taking drugs and alcohol. Watching those patients turn around, say chemical dependency nurses, is what makes their work so wonderful.

“I have more hope in chemical dependency nursing,” said Gessner, who used to work with psychiatric patients, “because you can see changes over a month. You can see people really getting it.”

Moore gets annual calls from a man who was a patient in the treatment center more than 15 years ago. He went through the program and did everything he was supposed to do, she said, and is still clean today. “He calls us on his anniversary,” she said.

One of the greatest rewards of chemical dependency nursing, say nurses, is the feeling of having a direct impact on someone else’s life. It’s not just about dealing with vital signs and dispensing medications and doing paperwork and making patients feel physically comfortable, DeLusque said.

“You’re asking, where is your heart? Where is your soul? You need to find that time to ask those questions because that’s what you need to find out what’s going on.

“It’s the heart and the soul that you’re working on.”

Contact Cathryn Domrose at kaguilar@well.com.