Week 9

Question 1

Role of CHN

Answer 1

Prevention and minimization of harm associated with problematic substance use
CHN’s must: Develop and engage in health-promoting practice
Must understand dynamics, social and health effects, and root causes of substance use
Advocate for nursing practice that creates and embraces social justice
Practice intentionally aiming at achieving social justice goals and outcomes that improve health experiences and conditions of individuals, their communities, and society
People from all walks of life can experience problematic substance use!
Never assume people who experience multiple disadvantages will inherently use substances

Question 2

What is Praxis

Answer 2

By definition: it is the process of using a theory or something you’ve learned in a practical way
Think of it as as “putting your money where your mouth is”
It is the process by which a theory/lesson/concept/ skill is enacted/performed/realized
It is deliberate and is used to create a more just world In nursing, we use praxis to apply knowledge in nursing situations to advance goals in society and in the world, and to eliminate any injustice and discrimination in care

Question 3

What u say matters

Answer 3

Language is a powerful tool How we discuss and understand substances in regards to use, what is problematic, and addiction is evidence of this
Please refrain from using the term “substance abuse” due to negative judgments, instead use language from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) which uses “substance use disorder”

Question 4

Substance Use Disorder

Answer 4

Defined as mild, moderate, or severe
Determined by the number of diagnostic criteria met by the individual
Occurs when the recurrent use of alcohol or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at home, work, or school.

Question 5

Addiction

Answer 5

Terms like substance use, substance abuse, substance use disorder, addiction, and dependence are sometimes used interchangeably
The term addiction carries the greatest stigma of all
It is often equated with physical dependence, but it also is used to define non-substance related behavioural addictions

Question 6

Dependence

Answer 6

Progressive in nature, and affects the physiological, cognitive, behavioural, and psychological dimensions of a person’s health.
It is manifested by continuous use despite the presence of problems
Results in tolerance, withdrawal, and compulsive substance taking behaviour

Question 7

Problematic Substance Use

Answer 7

Complex issue that spans the life cycle
Can have severe and permanent consequences for individuals, families, and communities
Leads to adverse physical, psychological, legal, social, or interpersonal

Question 8

Physical Dependence

Answer 8

Occurs when an individual’s body reacts to the absence of a drug with withdrawal symptoms

Question 9

Psychological Dependence

Answer 9

Occurs when drug use becomes central to a person’s thoughts and emotions

Question 10

Violence, Trauma, Mental Health and Substance Use

Answer 10

An estimated 50% of women and 33% of men (Canadian of course) have experienced at least one incidence of sexual or physical violence over their lifetime
Intimate partner violence, child abuse, and sexual assault have all been associated with negative health effects including problematic substance use and mental health challenges
These effects must be understood in the context of a cumulative lifetime rather than one event
Reflect back on your learning -> research tells use that there is a strong relationship between adverse childhood experiences (ACE’s) and problematic substance use, persistent pain, and behavioural problems
Women who experienced violence have significantly higher rates of substance use and mental health concerns compared to women who have not

Question 11

Chronic Pain

Answer 11

Chronic pain is complex, contextual, and subjective
Every patient will respond to treatment differently, as pain is produced and processed within the brain
Trauma and violence actually have a marked impact on structures and processes of the brain that mediate pain responses
Someone’s housing status is not a reason to not address chronic pain management
Opioids should not be used as first line treatment for chronic pain, and neither should they be a last attempt

Question 12

Problematic Substance Use

Answer 12

The overall cost of substance use, including alcohol, tobacco, and illicit drugs to Canadians, is an estimated $46 billion with tobacco, and alcohol accounting for almost 63% of the total

Question 13

Social-Ecological Framework and Opioid Crisis***

Answer 13

Individual: age, race, gender, socio-demographic factors, stress and trauma exposure, physical and mental health, pain, withdrawal symptoms, self-stigma, self-determination, biological and genetic susceptibility
Relationships (or interpersonal): influence of family, friends, coworkers, opioid access via family, friends, coworkers, family history of substance use
Community: quality care, treatment availability + access, drug disposal facilities, community norms, workplace + school, geographic variations, access to legal and illegal opioids, overprescription, types of rx opioids,
Society: law enforcement & policing, educational campaigns, insurance coverage, government regulation & policies, economic conditions & employment rate, opioid supply and price, legal & illegal advertising, discrimination & prejudice, social stigma, media & social networks

Question 14

Tobacco Use

Answer 14

In 2020, approx 3.2 million Canadians (10% of the population) smoked tobacco
This includes a higher percentage of men (12% or 1.9 million) versus women (9% or 1.4 million) 8% of Canadians smoke daily (2.5 million) and 2% (741 000) smoked occasionally.
Youth smoking (ages 15-19 years) decreased to 3% (63 000) from 5% in 2019 Only 2% of the population reported smoking cigars, 1% reported water-pipe smoking, and 1% reported using chewing tobacco
17% (5.2 million) of Canadians aged 15 years + had ever vaped, majority having used a vaping liquid containing nicotine 45% reported using a fruit flavour, 17% a mint or menthol, and 10% a tobacco flavour
Most people purchased their vape from a vape shop, convenience or gas store, supermarket/grocery store, and online sales

Question 15

Smoking Health Effects

Answer 15

Smoking leads to disease and disability and harms nearly every organ of the body
Cancer (Mouth and throat, esophagus, lungs, bronchus, trachea, larynx, liver, stomach, pancreas, colon and rectum, kidney and pelvis, bladder, cervix, and acute myeloid leukaemia)
Heart disease (Coronary artery disease, raise triglycerides, damages blood vessels and cause thickening/narrowing of vessel walls, increases stroke risk) COPD
Fertility (affects men’s sperm)
Bone health Cataracts (increases risk)
Type 2 Diabetes Mellitus (increases risk and can make it harder to control)

Question 16

Alcohol Use

Answer 16

In 2020: 64% (20 million) Canadians aged 15 + reported using alcohol in the last 30 days Heavy alcohol use (4+ drinks/occasion): 47% (14.8 million) Canadians reported heavy use in the last 12 months
Heavy alcohol use was higher among men (52% or 8.0 million) compared to women (43% or 6.8 million)

Question 17

Health Effects of Alcohol

Answer 17

Short Term Health Risks:
Injuries (MVC, falls, drownings, burns)
Violence (homicide, suicide, sexual assault, intimate partner violence)
Alcohol poisoning Risk sexual behaviours (unprotected sex, or sex with multiple partners which could result in unintended pregnancy or sexually transmitted diseases)
Miscarriage and stillbirth, or fetal alcohol spectrum disorders among pregnant women

Long-Term Health Risks
High blood pressure, heart disease, stroke
Liver disease, digestive problems, pancreatitis
Cancer of the breast, mouth, throat, esophagus, larynx, liver, colon, and rectum
Weakened immune system Learning and memory problems
Mental health problems including depression + anxiety
Social problems including family and job related problems
Alcohol use disorders or alcohol dependence

Question 18

Low Risk Drinking Guidelines

Answer 18

Reduce your long-term health risks by drinking no more than: 10 drinks/week for women, with no more than 2 drinks a day “most days” 15 drinks/week for men, with no more than 3 drinks a day “most days”
Plan non-drinking days every week to avoid developing a habit
Special Occasions
Reduce your risk of injury/harm by drinking no more than 3 drinks (women) and 4 drinks (men) on any single occasion

Question 19

Cannabis Use

Answer 19

In 2020: 40% (12.6 million) Canadians aged 15+ reported ever smoking cannabis
Smoking in the last 30 days was reported by 10% (3.2 million) Canadians aged 15+ 11% (3.5 million)
Canadians aged 15+ reported vaping cannabis, and use within the last 30 days was reported by 4% (1.1 million) Canadians age 15+

Question 20

Health Effects of Cannabis

Answer 20

Short Term Health Effects
Decreased blood pressure, which can increase risk of falls and syncope Increased heart rate (concerning for some cardiac conditions)
Psychotic episodes (paranoia, delusions, hallucinations)
Confusion Impaired ability to remember, concentrate, pay attention (Government of Canada, 2021)

Long Term Health Effects
Increased risk of dependency
Lung health (bronchitis, lung infections, chronic cough, increase mucous production)
Effects on the brain (memory, concentration, decision making)
Increased risk of developing mental illnesses like psychosis or schizophrenia, in addition to an increased risk of suicide, depression, and anxiety disorders

Question 21

Cannabis Hyperemesis Syndrome

Answer 21

resulting in reoccurring nausea, vomiting, dehydration and abdominal pain

Question 22

Opioid Reliance**

Answer 22

Has increased over time, as has opioid-related morbidity and deaths In 2018, 12.7% of Canadians reported having used opioid pain relief medications within the last year
Among these 9.6% had engaged in problematic use that could cause harm to their health

Question 23

Opioid Crisis**

Answer 23

Is a result of multiple factors: Misunderstanding of the additive risk of prescription opioids
Psychological, social, and biological risk factors (genetics, mental health, early life experiences, trauma, poverty, lack of secure housing, and other social determinants)
Stigma towards substance use disorders
Frequent opioid prescribing and high amounts being prescribed for pain relief
Lack of awareness or access to alternative treatments for pain
Use of prescription opioids to whom they are not prescribed
Lack of access to prescription opioids leading to illicit opioid use Illegal drugs that are laced with fentanyl and its analogues
A lack of comprehensive care to respond to physical and mental health needs of an individual

Question 24

Opioid Overdose

Answer 24

There were a total of 30, 843 apparent opioid toxicity deaths between January 2016 and March 2022
In 2022, there have been approximately 21 deaths/day 94% of opioid overdose deaths happen by accident
Young Canadians aged 15-24 are the fastest-growing population requiring hospital care from opioid overdoses
Males accounted for the majority of accidental apparent opioid deaths (76%) so far in 2022
The majority of accidental apparent opioid toxicity deaths were among ages 20-59
Majority of deaths occurred in British Columbia, Alberta, and Ontario (90% of ask deaths in these areas alone)
Elevated rates were also seen in the Yukon

Canada’s street drugs have become tainted with other powerful opioids like Fentanyl Fake pills are produced with unknown amounts of fentanyl
Some drugs contain fentanyl accidentally when made on the same surfaces
You can’t see, taste, or smell fentanyl
Fentanyl is approximately 100 times stronger than morphine
Just under half (44%) of accidental apparent opioid related deaths in 2022 also involved a stimulant - reflecting a poly substance nature of the crisis In a report released by the DEA, 42% of pills tested for fentanyl contained at least 2mg of fentanyl
They also reported that drug trafficking organizations typically distribute fentanyl by the kilogram, and one kilogram of fentanyl is enough to kill approximately 500 000 people
Because of the potency, dealers only need to traffic smaller quantities to maintain the drug effects consumers expect.
They can also add bulking agents like flour or baking soda to increase supply without adding costs It is much more profitable to cut a kg of fentanyl compared to a kg of heroin

Question 25

Opioid Overdose

Answer 25

In Ontario, a 2021 report found that one third of those who died from opioid toxicity were employed at the time of death/ worked in the construction industry The pattern has also been reported in BC where one fifth of deaths occurred among those in the construction industry 98.4% of construction workers who died of an opioid toxicity were male In only 17.5% of cases there was an individual present who could have intervened (80% of incidents occurred in a private residence, not the job site) In deaths with someone present, Naloxone was only administered 50% of the time Possible reasons: Physical demands of the job increase risk of injury and presence of chronic pain which may contribute to opioid use Mental health challenges associated with long hours, precarious, competitive, and repetitive tasks may also contribute Due to the nature of some construction work, it may be more accessible for those to gain employment who already use substances compared to other sectors In addition, there is a high proportion of men in younger age groups - which could explain the clustering of related deaths

Question 26

Harm Reduction

Answer 26

Represents a continuum of services that embody a philosophical, pragmatic, and compassionate approach to providing care while minimizing the negative harms associated with substance use Understands that not all people have the same ability to change, the same level of substance use, or even experience the same harms Abstinence is rather a focus on the reduction of use with the ultimate aim of no use We may view harm reduction and abstinence in regards to substance use as a continuum with one on each end. Example: in terms of alcohol intake, harm reduction would focus on safe alcohol consumption regardless of the level of consumption versus abstinence where the focus would be on complete cessation (Alcoholics Anonymous promotes an abstinence based model)

Question 27

Housing First

Answer 27

A mental health strategy that focuses on housing people regardless of current patterns of substance use Provides clients with assistance in finding and obtaining safe, secure, and permanent housing as quickly as possible Individuals and families are not required to demonstrate that they are “ready” for housing Housing is not conditional on sobriety or abstinence Is an evidence-based practice intended to serve chronically homeless individuals with co-occurring mental illness and substance use disorders There are typically 5 core principles of Housing First approaches Immediate access to housing with no readiness requirements Consumer choice and self-determination (client choice in location, type) Recovery orientation (access to a range of supports) Individualized and client-driven supports Social and community integration

Question 28

Supervised Consumption Sites

Answer 28

They provide a safe, clean space for people to bring their own drugs to use in the presence of trained staff Prevent accidental overdose Reduce the spread of infectious diseases such as HIV In Ontario, supervised consumption sites are called “Consumptions and Treatment Services” (CTS) Closest site to North Bay is in Sudbury

Question 29

Needle Exchange Sites

Answer 29

Reduce transmission of HIV, Hep B, Hep C, and other blood borne pathogens Reduce usage drug use and sexual behaviours associated with the transmission of blood borne pathogens Reduce the number of needles discarded in the community NEP is often the only contact some people have with health or social service providers

Question 30

Safer Supply Programs**

Answer 30

Provide prescribed medications as a safer alternative to toxic illegal drug to people who are at high risk for overdose These programs help prevent overdoses, save lives, and connect people who use drugs with other health and social services Medications prescribed may include opioids, stimulants or benzodiazepines In 2020 a pilot program of 10 safer supply sites occurred in three provinces. Participants reported improve health, wellbeing and quality of life, in addition to decrease stress, more energy and feeling more active, as well as being able to address other health issues

Question 31

Safe Injection ***

Answer 31

Nurses can provide education regarding the basics of safe injections IV injections How to safely choose a site Veins vs. Arteries Exercises for improving vein visibility Cleaning your site Inserting your needle Missed shots + aftercare

Question 32

Injecting Cocaine

Answer 32

Injecting Cocaine: has a numbing effect on the vein + causes constriction so be extra careful you’re in the right spot before injecting IV cocaine only lasts for a short period of time, so if you are injecting multiple times it can be traumatic for the tissues

Question 33

Injecting Crack

Answer 33

Injecting Crack: it comes in a solid form, for it has to be dissolved first. The safest way to do this is with powdered citric or ascorbic acid - avoid lemon juice or vinegar as they can lead to infection To dissolve: put the crack in the citric/ascorbic acid in the cooker, add water and mash +mix well. Only use what you need because it’s hard on the veins

Question 34

Naloxone Programs

Answer 34

Naloxone (Narcan) is a drug that can temporarily reverse an opioid overdose Only works if the person has opioids in their system Intranasal and intramuscular kits are available to the public for free over the counter Available through 3 programs: Ontario Naloxone Program (ONP): Needle syringe/exchange program, Hep C programs, and participating community agencies Ontario Naloxone Program for Pharmacies (ONPP): Participating pharmacies distribute kits Ministry of Community Safety and Correctional Services - Take Home Naloxone Program: Individuals in provincial correctional facilities who are at risk of an opioid overdose and would like a kit are trained and given kits when released from custody

Question 35

CHN's and Harm Reduction

Answer 35

Need to be prepared for controversy and debates that harm reduction may elicit Strong community stakeholder endorsement is essential, and there may be public resistance to the “appropriateness” of harm reduction programs Be aware that this can polarize the conversation, but also open up the conversation for a shift in knowledge, attitudes, and values!

Question 36

Primordial Prevention

Answer 36

Nurses supporting public policy making that reduces structural inequities Example: poverty is structural in that its related to economic policies, employment policies, discriminatory histories and systems, access to social services, and related factors Reducing poverty could including implementing guaranteed annual income, employment supports geared to refugees, or an increase in child benefits

Question 37

Primary Prevention

Answer 37

Involves preventing problematic substance use before it occurs with more focus on the individual or community rather than broader system Includes activities geared towards preventing regular substance use from becoming problematic ie: the initiative that created Canada’s Low-Risk Alcohol Drinking Guidelines Intervene with families around issues that lead to trauma, which might involve programs that support men who have been violent in changing their violent behaviours, parenting programs that provide alternative discipline options to corporal punishment, anti-racism problems in schools, or education for health and social service providers in how to be 2SLGBTQIA + allies

Question 38

Secondary Prevention

Answer 38

Involve early identification of what substance use becomes problematic and rapid support to assist the individual in addressing root causes to reduce or end substance use Example: screening, tools, or conversations that allow for the detection of signs and symptoms of problematic use ie the 11 criteria of substance use disorders Can occur on an inpatient or outpatient basis, be supported privately or publicly and involve a wide variety of tools May involve individual or group counselling with a focus on moving the individual from problematic use to recovery

Question 39

Tertiary Prevention

Answer 39

Reducing harms of problematic use both for individuals and their families + communities Treatment can be included as a form of tertiary prevention as well as secondary Other examples: clean needles, pop-up supervised consumption sites, managed alcohol programs, naloxone distribution programs Might include services for families such as Al-Anon, child welfare system (is intended to be used as this, but we understand this isn’t necessarily reflective of the current system and the systemic racism by the overrepresentation of First Nation, Metis, and Inuit children in the system)

Question 40

Quarternary Prevention

Answer 40

Addressing stigma around substances within the healthcare system among professionals, and ensuring CHN’s are following the lead of individuals, families and communities in determining if substance use is problematic.