A MODEL DIDACTIC AND CLINICAL SUBSTANCE ABUSE CURRICULUM DEVELOPED FOR SCHOOLS OF NURSE ANESTHESIA Copyright Sept. 1994 by Gary D. Clark 1 A MODEL DIDACTIC AND CLINICAL SUBSTANCE ABUSE CURRICULUM DEVELOPED FOR SCHOOLS OF NURSE ANESTHESIA Table of Contents INTRODUCTION...................................................................................................................................... 6 Suggestions for the Use Of The Model Curriculum ................................................................................................. 6 1. Provide adequate faculty development ..........................................................................................................6 2. Select an appropriate didactic and clinical strategy ........................................................................................7 3. Evaluate the entire curriculum, the learner, and the outcomes of each ........................................................7 4. Revise the curriculum and the teaching methodology ...................................................................................7 5. Integration of the substance abuse curriculum should not dilute the content or focus ................................8 6. Clinical experiences include patient oriented studies and self-evaluation. ....................................................8 NECESSARY RESOURCES...................................................................................................................... 9 Facilities ................................................................................................................................................................. 9 Didactic Facility .........................................................................................................................................................9 Clinical Facility ...........................................................................................................................................................9 An Approach to the Teaching Process and Methodology ..................................................................................... 10 Framework ..............................................................................................................................................................10 Teaching Process.....................................................................................................................................................10 REFERENCES......................................................................................................................................................... 11 PHILOSOPHY ......................................................................................................................................... 13 Professional Responsibilities of the Nurse Anesthetist ........................................................................................ 14 PROGRAM OBJECTIVES...................................................................................................................... 15 SUBSTANCE ABUSE CURRICULUM TERMINAL OBJECTIVES.................................................. 16 GENERAL ORGANIZATION AND PHILOSOPHY OF THE MODULES ...................................... 17 GENERAL LEARNING OBJECTIVES OF THE LEARNING MODULE 1 ...................................... 18 GENERAL LEARNING OBJECTIVES OF THE LEARNING MODULE 2 ...................................... 19 2 GENERAL LEARNING OBJECTIVES OF THE LEARNING MODULE 3 ...................................... 20 USE OF THE MODULES ....................................................................................................................... 21 MEASURES AND METHODS OF EVALUATION............................................................................. 23 INTRODUCTION TO THE MODULES............................................................................................... 24 MODULE 1 OUTLINE OF DIDACTIC AND CLINICAL COMPONENTS ..................................... 25 MODULE 2 OUTLINE OF DIDACTIC AND CLINICAL COMPONENTS ..................................... 27 MODULE 3 OUTLINE OF DIDACTIC AND CLINICAL COMPONENTS ..................................... 29 SUBSTANCE ABUSE CURRICULUM ................................................................................................. 31 MODULE 1 ........................................................................................................................................................... 31 DIDACTIC UNIT 1 A-D: Introduction to the modules ..............................................................................................31 Substance Abuse Pretest....................................................................................................................................32 DIDACTIC UNIT 2A: Introduction to substance abuse and commonly used terms ................................................33 DIDACTIC UNIT 2B: Defining commonly abused substances and their characteristics ..........................................38 DIDACTIC UNIT 2C: Basic pharmacology - I. Acute and Chronic Abuse ..................................................................42 DIDACTIC UNIT 2D: Defining the Diagnostic and Statistical Manual of Mental Disorders .....................................45 DIDACTIC UNIT 2E: Epidemiology of substance abuse ...........................................................................................48 DIDACTIC UNIT 2F: Etiology of substance abuse....................................................................................................51 Substance Abuse Case Presentation #1 .............................................................................................................55 DIDACTIC UNIT 2G: Introduction to the legal, ethical and moral issues of SA .......................................................56 DIDACTIC UNIT 2H: Basic assessment and diagnostic skills in the SA patient .......................................................60 DIDACTIC UNIT 2I: Multisystem physiology in SA - Level I .....................................................................................64 DIDACTIC UNIT 2J: Attitudes and Self-assessment concerning SA .........................................................................66 CLINICAL UNITS A-G: Introduction to clinical assessment and diagnostics of SA ..................................................71 Formative Evaluation of Module 1 .....................................................................................................................75 MODULE 2 ........................................................................................................................................................... 77 DIDACTIC UNIT A: Multisystem physiology in SA - Level II .....................................................................................77 DIDACTIC UNIT B: Pharmacology - II ......................................................................................................................80 DIDACTIC UNIT C: Prevalence and Patterns of SA ..................................................................................................84 DIDACTIC UNIT D: Tolerance, Toxicity, and Withdrawal from SA ..........................................................................88 DIDACTIC UNIT E: Planning for Intervention, Intervention and Aftercare .............................................................92 DIDACTIC UNIT F: Central Concepts and Research Issues in SA .............................................................................98 DIDACTIC UNIT G: Assessment and Screening of SA patients ..............................................................................101 DIDACTIC UNIT H: Individual, Family, and Group Dynamics related to SA ..........................................................105 DIDACTIC UNIT I: Community resources and treatment options .........................................................................109 CLINICAL UNITS A-I: Increased special skills in clinical planning, recognition, diagnosis, and treatment of SA ..113 3 Formative Evaluation of Module 2 ...................................................................................................................118 MODULE 3 ......................................................................................................................................................... 120 DIDACTIC UNIT A: Multisystem physiology in SA - Level III ..................................................................................120 DIDACTIC UNIT B: Pharmacology - III ...................................................................................................................125 DIDACTIC UNIT C: AIDS and Substance Abuse ......................................................................................................132 DIDACTIC UNIT D: Special At Risk Populations......................................................................................................135 DIDACTIC UNIT E: Interprofessional networking ..................................................................................................139 DIDACTIC UNIT F: Methods of prevention for SA .................................................................................................142 DIDACTIC UNIT G: Impaired Practitioners and Recovery ......................................................................................147 CLINICAL UNITS A-I: Advanced clinical medical sequelae, diagnosis, and treatment of SA..................................153 Formative Evaluation of Module 3 ...................................................................................................................158 Summative Evaluation .....................................................................................................................................160 Substance Abuse Post-test ...............................................................................................................................162 4 ACKNOWLEDGEMENT The author of this manuscript would like to thank and acknowledge several individuals who eagerly contributed their special skills, personal time, and unlimited efforts to aid in the development of this curriculum. I would like to extend my deepest appreciation to the faculty of Nova Southeastern University especially Maria Ligas, Ph.D., Marian Gibney, Ed.D. and Peter Mills, Ed.D. for their expertise and support throughout this project which was invaluable. I would like to thank the AANA for their support of this project, especially John Garde, CRNA, Lorraine Jordan, CRNA and Betty Horton, CRNA who represent the commitment of the AANA to provide an exceptional educational and training process to all student nurse anesthetists. My special appreciation and gratitude are given to Howard Armour, CRNA, Rosalyn Harris-Offut, CRNA and Diana Quinlan, CRNA who are members of the Peer Assistance Advisors Committee in the AANA. Without their dedication, special knowledge, and skills in the area of substance abuse this project would have been impossible. Lastly, to Clarence Baskey, Ed.D., Executive Director of Professional Advancement Programs in Denver, Colorado, Dr. Elizabeth Burns and Janet Ciccone, MA, of Ohio State University, and Joy Will, CRNA, at Washington University, St. Louis who aided in the completion of this project, their recommendations and guidance were of monumental value throughout this process. It is difficult to list all of those who participated in this project in such limited space so, for those that I have not mentioned or recognized I apologize and extend my gratitude. They all freely gave of their talents, their knowledge and their skills toward developing the content of this curriculum. 5 INTRODUCTION The purpose of this manuscript is to provide the American Association of Nurse Anesthetists (AANA) and program administrators of schools of nurse anesthesia a broad model substance abuse (SA) curriculum. This curriculum provides no one best way to develop or disseminate a substance abuse curriculum. However, this manuscript offers guidelines and suggestions for the development and organization of a substance abuse curriculum. Organizations must discover through assessment and evaluation activities which components best aid in the development of a substance abuse curriculum. The contents of this model are based upon extensive research in the area of substance abuse, curriculum, and curriculum development. Disciplines such as nursing, medicine, social work, and many other supporting health care professions have been recruited for the best qualities in substance abuse education. This model can be used in its entirety in order to provide a comprehensive substance abuse curriculum or in segments to fill current deficits. Since there are no available curricula for schools of nurse anesthesia, it is suggested that criteria be established to evaluate one curriculum appropriate for your institution. There are several suggestions that follow which will aid in the use of this curriculum model. Suggestions for the Use Of The Model Curriculum 1. Provide adequate faculty development One of the key elements for effectively providing any curriculum is faculty who are knowledgeable in substance abuse and adult and clinical educational philosophy. Staff development can exist at several levels in substance abuse education, and is more than a variety of workshops. Staff can become teaching faculty or teaching/research faculty. Teaching faculty includes all the clinical and didactic faculty who contribute to the educational foundation of student nurse anesthetists. Teaching/research faculty are those faculty who have highly 6 developed skills and knowledge, and conduct research in the topic of substance abuse. Clinical faculty must not only be well versed in the topic of substance abuse but must also be familiarized with the educational philosophy of the university and subscribe to the educational foundation for teaching student nurse anesthetists about substance abuse. 2. Select an appropriate didactic and clinical strategy In order for students to realize the terminal objectives the modules have been sequenced. Each should be introduced appropriately into the required curriculum. Know the learners in the group, determine their learning preferences and styles, and then choose the appropriate modules, teaching methods, and philosophy for your learners. Arrange for intensive clinical affiliations at local, regional, state and/or national agencies, treatment centers, or health care institutions. The facilitator will require information regarding the time of delivery, resources, and teaching strategies when selecting and utilizing the appropriate curriculum. Recruiting agencies that specialize in substance abuse prevention will expedite the process. 3. Evaluate the entire curriculum, the learner, and the outcomes of each Evaluation is a process which should be implemented throughout the entire process. Eliciting feedback at the end of each session from learners and facilitators will provide valuable information for effective change. Evaluation of the program, especially during the early stages of student learning, should include a) evaluation by the instructor of the student's learning progress, b) evaluation by the student of his/her learning, c) evaluation of the curriculum by the student and faculty, and d) evaluation and critique of the educational process by an external consultant. 4. Revise the curriculum and the teaching methodology The results of the evaluation should be used to change or improve the learning 7 experience. Incorporate suggestions from the learners and the facilitators into the existing methodology. The revision should also include an update of material and teaching methodology to reflect current material. 5. Integration of the substance abuse curriculum should not dilute the content or focus Integration of the substance abuse curriculum allows the educational institution to utilize a variety of resources. However, if integration of the substance abuse curriculum is not specifically focused on the topic of substance abuse the curriculum becomes "watered down" or "diluted" and may become ineffective in producing the desired outcome. The advice from at least one consultant with the expertise in curriculum or educational design should be mandatory in the developmental stages. 6. Clinical experiences include patient oriented studies and self-evaluation. Clinical experiences provide the opportunity for unique learning experiences and a foundation for professional practice. Introducing nurse anesthesia students to patients who abuse substances also offers a wide variety of opportunities. Students can learn about patients who are chemically dependent as well as use the time for reflection and self-evaluation concerning topics and issues in substance abuse. Clinical competencies achieved by the student at each clinical site and during each clinical experience can be assessed using a number of methods including but not limited to; pre and post-testing knowledge, measuring behavioral changes, and project demonstrations. The medical personnel or counselors at the clinical sites, in cooperation with nurse anesthesia faculty, should be responsible for rating the clinical competencies of the student. 8 NECESSARY RESOURCES Facilities Didactic Facility The didactic component of these modules can be implemented in any environment conducive to adult learning. An appropriate learning atmosphere with adequate lighting and temperature and materials such as audiovisual materials, references, chalkboards, flipcharts should be made available. The adult education philosophy as described by Malcolm Knowles (1980) provides greater insight into additional requirements for introducing the substance abuse curriculum. Clinical Facility The clinical component of these modules uses local, regional, state, or national sites. These sites should be active treatment centers or other health care institutions for this clinical educational process. The centers which best serve the purpose of this curriculum should not be limited to patients with alcohol abuse. Instead, centers which provide treatment for different types of chemical dependency should be recruited. The professional medical personnel at these clinical sites should be well credentialed and have some experience with teaching students. If no clinical site is available, site arrangements should be made through a representative of the American Association of Nurse Anesthetists. The clinical experience presents an opportunity for student nurse anesthetists to learn about patients who are chemically dependent. The clinical experience should also provide an opportunity for self-evaluation under the direction of a professional therapist. Self-evaluation and reflection do not constitute treatment during the clinical experience instead, these experiences provide for an opportunity of growth and introspection. 9 An Approach to the Teaching Process and Methodology Framework The program can be free standing, integrated, or the modules can be offered in total or separately as a continuing education process. The minimum program framework should include didactic and clinical instruction each year over the entire span of graduate education for nurse anesthetists. The level of learning should be progressive throughout the program, from beginner to advanced. Facilitators should ascribe to the adult education methodology and philosophy. The didactic and clinical faculty should also possess special knowledge and skills in substance abuse. Teaching Process Students should be given set expectations at the outset of the program and meet with facilitators for formative progress reports. A summation and an opportunity to share experiences with the group should close the learning experience for each individual. The amount of time required for presentation and teaching strategies will vary with each learning experience. Adequate time should be allowed for learning and learning projects. Clinical time should be loosely structured allowing enough time for individual and group meetings, extra projects which may emerge during formative progress sessions, and student contributions to the clinical setting. Faculty should engage the student in ongoing substance abuse research projects, encourage projects for presentation at group meetings or aid and encourage publication relative to substance abuse. 10 REFERENCES Adger, H., DeAngelis, C., & McDonald, E. M. (1986). Model program and curriculum in alcohol and other drug abuse for pediatric medical students, residents, and faculty. (National Institute on Drug Abuse. ADM 281-86-0009). Washington, DC: U.S. Government Printing Office. American Association of Nurse Anesthetists. (1992). CRNA Peer assistance manual. Chicago, IL: American Association of Nurse Anesthetists. American Association of Nurse Anesthetists. (1984). Chemical dependency. Position statement No. 1.7. Chicago: American Association of Nurse Anesthetists. American Nurses' Association. (1990). Suggested state legislation: Nursing disciplinary diversion act. Kansas City, MO: American Nurses' Association. American Nurses' Association. (1984). Addictions and psychological dysfunctions in nursing: The profession's response to the problem. Kansas City, MO: American Nurses' Association. Bard, R., Bell, C.R., Stephen, L., & Webster, L. (1987). The trainer's professional development handbook. San Francisco: Jossey-Bass. Bergquist, W.H. & Phillips, S.R. (1975). Components of an effective faculty development program. Journal for Higher Education. 46,177-209. Brookfield, S.D. (1990). Understanding and facilitating adult learning. San Francisco: JosseyBass. Burns, E.M., Thompson, A., & Ciccone, J.K. (Eds.). (1993). An addictions curriculum for nurses and other helping professionals. (Vols. 1-2). New York: Springer Publishing 11 Co. Elias, J.L. & Merriam, S. (1980). Philosophical foundations of adult education. Malabar, FL: Krieger Publishing Co. Knowles, M.S. (1980). The modern practice of adult education. New York: Cambridge. Knox, A.B. (1989). Adult development and learning. San Francisco: Jossey-Bass. Merriam, S.B. & Caffarella, R.S. (1991). Learning in adulthood. San Francisco: Jossey-Bass. National Nurses Society on Addictions. (1985). Statement on model diversion legislation for chemically impaired nurses. Evanston, IL: National Nurses Society on Addictions. Smith, R.M. (1982). Learning how to learn. Englewood Cliffs, NJ: Cambridge. Tough, E. (1971). The adult learning project: A fresh approach to theory and practice in adult learning. Research and Education Series #1. Toronto: Ontario Institute for Studies in Education. 12 PHILOSOPHY The purpose of this substance abuse curriculum is to address and influence substance abuse education at all levels of faculty, nurse anesthesia graduate schools, and adjunct personnel associated with nurse anesthesia. Substance abuse is a medical disease affecting a large number of individuals in our society. The abuse of alcohol or any other chemical substance knows no limitations. This disease creates physical, emotional, mental, and economic stress on the resources of family, friends, and society. The treatment of this disease requires a number of strategies. The following three strategies prevention, intervention, and treatment of substance abuse each should begin using education as a primary frontline strategy. Educational prevention should then begin with this curriculum. It is anticipated that each student will bring with them values, behaviors, knowledge, and clinical abilities learned through past experience. Many of these students lack the basic knowledge and skills required to deal with substance abuse. It is assumed that these students also willfully participate in learning and strive for understanding to the extent that substance abuse issues can be brought into their personal life and practice. Certified Registered Nurse Anesthetists (CRNAs) encounter substance abuse patients during their daily practice as well as outside their practice of anesthesia. Certified Registered Nurse Anesthetists make community contacts with individuals who are substance abusers or who are considered to be patients "at risk" for substance abuse. The professional organization of nurse anesthesia the American Association of Nurse Anesthetists and their Peer Assistance Committee has developed a number of guidelines in a laudable attempt to address substance abuse within the profession. Based upon information and this author's assessments there are a substantial number of areas which need to be disseminated to faculty, CRNAs, and student nurse anesthetists concerning the topic of substance abuse. Armed with these skills to prevent 13 substance abuse the nurse anesthetist can provide educational experiences to a wide population including peers, patients, other health care providers, and the community. The educational goals are to introduce students at all levels to the issues of chemical dependency enough to have a sustained and lasting effect. Producing positive role models impact upon the educational process in substance abuse. Professional Responsibilities of the Nurse Anesthetist Certified Registered Nurse Anesthetists (CRNAs) are highly trained practitioners who have the unique opportunity and responsibility to educate their patients, peers, and the public in addition to performing their professional duties and delivering anesthesia. According to the AANA Position Statement on Chemical Dependency (1984), CRNAs, as responsible health care providers, are in an important and powerful position to identify, educate, and encourage patients and/or colleagues to seek professional help for substance abuse while recognizing a safe, supportive, and confidential environment. Substance abusers fail to work to their full capacity, burden social health care systems, potentially jeopardize workplace safety, and create unnecessary stress in the home and workplace. Substance abuse education provides a crucial step toward the prevention and research of this disease. In order to achieve the most from this substance abuse curriculum participants must reflect on their personal morals, values, and ethical beliefs; then make a commitment to learning about the disease of substance abuse. Facilitators/teachers must remain sensitive to the adult learner's needs by providing an unobtrusive, entrusting, and nonintimidating learning environment. With appropriate development, implementation and evaluation of a substance abuse program, educators can provide an appropriate instructional curriculum. In addition, learners can adopt the safe, supportive, understanding, and compassionate roles demonstrated by the well informed CRNA. 14 PROGRAM OBJECTIVES 1. Foster awareness, skills, and knowledge of substance abuse in four areas in nurse anesthesia. a. Didactic education. b. Clinical education. c. Administration/Management. d. Scholarship/Research. 2. Initiate a network of educators and practitioners that are well informed in substance abuse. 3. Disseminate information on substance abuse. 4. Increase the recognition, diagnosis and sequelae of substance abuse. 5. To provide the basic skills required to aid in prevention, intervention, and treatment of the patient in a treatment sequence. 6. Initiate an examination of the Nurse Anesthetist's role in the prevention, intervention, and treatment of substance abuse. 7. To increase the level of clinical and medical knowledge in substance abuse. 8. Facilitate the research component in substance abuse and nurse anesthesia. 15 SUBSTANCE ABUSE CURRICULUM TERMINAL OBJECTIVES 1. Identify familiar behavior patterns in the chemically dependent. 2. Recognize the common medical outcomes of the substance abuser. 3. Discuss the treatment modalities utilized for the chemically dependent. 4. Develop personal insight into values, attitudes, behaviors, and morals concerning substance abuse. 5. Describe the effects of substance abuse on the family unit and special populations that are affected by substance abuse. 6. Describe the moral, cultural, ethical, legal, and social considerations in chemical dependency. 7. Demonstrate the basic skills for diagnosis, intervention, and employment of treatment for the substance abuser. 8. Identify the appropriate collaborative course in the prevention, intervention, and treatment of substance abusers. 9. Describe the role of the nurse anesthetist in the prevention of substance abuse. 10. Engage effectively in research of substance abuse. 11. Demonstrate an active effort to change personal negative attitudes and stereotypes regarding chemical dependency and the substance abuser. 12. Evaluate the effectiveness of efforts in prevention, intervention, and treatment of substance abuse. 13. Formulate steps to respond to chemical abuse patterns. 14. Demonstrate a change in the values, beliefs, perceptions and stereotypical attitudes of the learner. 15. Demonstrate an active role in the education and dissemination of substance abuse information in the community. 16 GENERAL ORGANIZATION AND PHILOSOPHY OF THE MODULES The model course is constructed in three modules with a didactic and clinical component in each. There are three levels of development. First, there is an introduction to the basic and fundamental concepts of substance abuse beginning with module one. Second, the teaching strategy moves toward an intermediate level. The learner should begin to experience more advanced learning experiences at this stage integrating previous didactic and clinical experiences. Third, an advanced level is introduced. At the advanced level learners will be introduced to intermediate and long term treatment, research, and educational methodology for teaching substance abuse. In each module there is an integration of the didactic with the clinical. Each module becomes progressively more difficult. The course is presented in these following modules. 17 GENERAL LEARNING OBJECTIVES OF THE LEARNING MODULE 1 Module 1: Introduction and General Awareness of Substance Abuse. Didactic: Introduction and increased awareness of general concepts, medical consequences and issues in substance abuse. Ethical, moral and legal issues in substance abuse. Clinical: Familiarity with assessment and diagnosis of substance abuse. Self- examination and challenge of personal beliefs, prejudices, and attitudes concerning substance abuse. Exploration of the etiology and the progression of substance abuse. Ideas for a substance abuse research project. Recognizing substance abuse as a disease. 18 GENERAL LEARNING OBJECTIVES OF THE LEARNING MODULE 2 Module 2: Increased Special Skills in the Planning, Recognition, Diagnosis and Treatment of Substance Abuse. Didactic: Increased recognition of related sequelae of substance abuse. Increased appreciation of the biopsychosocial and planning aspects. Clinical: Increased assessment and diagnostic skills. Treatment of family, impaired professionals, and special populations. Planning and basic intervention skills. 19 GENERAL LEARNING OBJECTIVES OF THE LEARNING MODULE 3 Module 3: Professional Responsibilities, Advanced Knowledge, and Demonstrated Skills in Substance Abuse. Didactic: Advanced knowledge of medical sequelae, etiology, and effects of substance abuse. Advanced intervention, planning, assessment, and diagnostic skills. Promotion of scholarship and research topics. Clinical: Advanced prevention, assessment, intervention, post intervention and aftercare skills. Interprofessional collaboration. Demonstrated abilities in substance abuse education. 20 USE OF THE MODULES The philosophy and the objectives of this curriculum provide a basic foundation for the nurse anesthetist. In order for students to learn the topic of substance abuse each module should be delivered in sequence. If integrated, the content of the modules should be included in the curriculum in a sequence that is appropriate for each module and the existing curriculum. These modules are designed to provide independent learning experiences as well as integrated learning experiences. For students to internalize and grow with the information in this curriculum role playing, case presentations, problem-based learning, and experiences play a vital role. The sequence of modules are best offered over the span of the student's graduate study. Module one should be offered in the first year, module two in the second year, and module three in the third year. Each course of study should move the student from a basic course of study toward one that is progressively expanding to a more difficult level. Clinical learning supports the didactic component in each module. Facilitators should develop teaching strategies using an adult education philosophy (Knowles, 1980). Since each teacher employs a number of strategies, these should not be limited. Clinical experiences should be developed at local, regional, or state institutions involved with treating substance abuse patients. These clinical experiences are best served when peers are encountered, interviewed, and observed in the treatment facility. There should be an extensive opportunity for self-exploration during the implementation of these modules. However, this should not be to the exclusion of other patients or learning experiences. The clinical experience should also include patients not yet diagnosed with medical complications resulting from substance abuse and addiction. These experiences should be initiated only at the appropriate level and with proper supervision in the substance abuse education. The Diagnostic and Statistical Manual of Mental Disorders (DSM) from the 21 American Psychiatric Association and the Twelve Steps and Twelve Traditions from Alcoholics World Services are examples of tools that should be integrated into the clinical learning experience. 22 MEASURES AND METHODS OF EVALUATION 1. Clinical competence as assessed by faculty and medical staff at the treatment center. 2. Measure attitudinal change. 3. Assess the value of teaching methods, strategies, and material. 4. Pre and Post-tests to measure didactic knowledge and skills as well as some clinical experiences. 5. Completion of a project (e.g. presentation, poster, publication, or group project) to demonstrate integrated learning and promote scholarship and research. 6. Follow student involvement in post-graduation activities (e.g. community involvement, teaching, and research) 7. Perception of change in attitudes concerning substance abuse in the department or organization. 8. Utilize the Substance Abuse Curriculum Development Questionnaire to measure differences in interest, competence, and importance of substance abuse. 9. Evaluate networking among program administrators, CRNA faculty, student nurse anesthetists. 10. Investigation of learning styles, methods and techniques used by students. 11. Evaluate the perception of substance abuse and the educational process by the faculty. 12. Investigate the number of chemically impaired professionals reported to the National Council of State Boards of Nursing (NCSBN). 13. Utilize student input to evaluate the learning process. 14. Evaluate the community impact of a substance abuse curriculum provided by CRNAs. 15. Initiate continued demographic monitoring of beliefs, attitudes, and knowledge concerning substance abuse. 23 INTRODUCTION TO THE MODULES The assumption is that the adult educational methodology will be used and ascribed to in the implementation of this curriculum. Each of the modules are outlined. Each module is divided into units and the units contain the following information. Module outline and name. Module unit number and approximate time. Overview of the expectation(s) from the module unit. Terminal objective(s) for the unit. Teaching methods, equipment, and supplies for the unit. Unit outline and references. Recommended methods of evaluation. 24 MODULE 1 OUTLINE OF DIDACTIC AND CLINICAL COMPONENTS Module 1: Introduction and General Awareness of Substance Abuse (SA). Didactic Units I. Introduction to the module A. Objectives and goals for the module. B. Syllabus for the module. C. Content and references for the module. D. Group introduction. II. Introduction to substance abuse A. Commonly used terms B. Defining commonly abused substances and characteristics C. Basic Pharmacology - I 1. Acute and Chronic abuse D. Define DSM IV diagnostic criteria E. Epidemiology F. Etiology of SA G. Introduction to legal, ethical, and moral issues in SA H. Basic assessment and diagnostic skills I. Multisystem physiology in SA - I J. Attitudes and self-assessment concerning SA 25 Module 1: Introduction and General Awareness of Substance Abuse (SA). Clinical Units III. Introduction to clinical assessment and diagnostics of SA. A. Self-examination and challenging personal prejudices, beliefs, and attitudes on SA. B. Performing basic clinical assessment and diagnostic procedures. C. Examining the relationship between SA and anesthesia. D. Familiarization with patient and family dynamics. E. Listing the predisposing risks and progressive stages of SA. F. Exploration of the etiology and progression of SA G. Ideas for SA research project (poster, publication, presentation, etc). 26 MODULE 2 OUTLINE OF DIDACTIC AND CLINICAL COMPONENTS Module 2: Increased Special Skills in the Planning, Recognition, Diagnosis, and Treatment of SA. Didactic Units IV. Planning, Recognition, Diagnosis and Treatment of SA sequelae A. Multisystem physiology in SA - II B. Pharmacology - II C. Prevalence and Patterns of SA D. Tolerance, toxicity, and withdrawal from SA E. Planning for intervention, intervention and aftercare F. Central concepts and Research Issues in SA G. Assessment and screening of SA patients H. Individual, family, and group dynamics related to SA I. Identifying community resources and treatment options 27 Module 2: Increased Special Skills in the Planning, Recognition, Diagnosis, and Treatment of SA. Clinical Units V. Clinical Planning, Recognition, Diagnosis and Treatment of SA sequelae A. Barriers to accurate assessment and data collection from patient, family and physical examination B. Interview techniques for extraction of SA information C. Identifying signs and symptoms of SA at all levels D. Appropriate treatment options for all SA stages E. Demonstrate intervention plan, basic intervention and aftercare skills F. Demonstrate basic treatment and/or referral skills G. Examining the importance of the professional role of the nurse anesthetist H. Reflection of personal attitudes and beliefs concerning SA I. Solidify SA research project 28 MODULE 3 OUTLINE OF DIDACTIC AND CLINICAL COMPONENTS Module 3: Professional Responsibilities, Advanced Knowledge, and Demonstrated Skills in Substance Abuse. Didactic Units VI. Advanced clinical medical sequelae, diagnosis, and treatment of SA. A. Multisystem physiology - III 1. Maternal and neonatal 2. Fetal and newborn addiction B. Pharmacology - III C. AIDS and SA D. Special at risk populations E. Interprofessional networking F. Methods of Prevention G. Impaired practitioners and recovery 29 Module 3: Professional Responsibilities, Advanced Knowledge, and Demonstrated Skills in Substance Abuse. Clinical Units VII. Advanced clinical medical sequelae, etiology and effects of SA A. Development of advanced communication and assessment skills B. Advanced intervention skills (in anticipation of resistance from family or patient) C. Development and practice of advanced prevention methods D. Utilization of knowledge for identification, intervention, and aftercare E. Demonstration of interprofessional collaboration F. Demonstrate abilities in SA educational methodology G. Current and logical discussion of SA H. Presentation of SA research project I. Demonstration of attitudinal change concerning SA 30 Substance Abuse Curriculum MODULE 1 DIDACTIC UNIT 1 A-D: Introduction to the modules Total Time: 15-30 min Overview: This unit serves as an introduction for the modules and the educational process in substance abuse. This exercise should be reintroduced at the beginning of each new group and meeting site. Terminal Objective: The student will understand the objectives, goals, and syllabus for the modules. In addition the student will be given references and other pertinent information. The student will have the opportunity to network with others in the group with introductions. Recommended Teaching Methods: Group Process Lecture Discussion Pre-test - Reference sheet 1.0 Materials: Syllabus Pre-test 31 Substance Abuse Pretest Module 1 Didactic Unit 1 Reference Sheet 1.0 Please rate your skill in performing each of the following clinical duties concerning the substance abuse (SA) patient and using the following scale. 1-----2-----3-----4-----5 Low Moderate High Skill Skill Skill Skill Level _______ 1. Composing a problem list of the physiological concerns of the SA patient. _______ 2. Discussing the epidemiology of SA. _______ 3. Identifying the characteristics of commonly abused substances. _______ 4. The pharmacological principles to consider for SA. _______ 5. Defining the DSM IV diagnostic criteria. _______ 6. Discussing the etiology of SA. _______ 7. Recognizing the legal, ethical, and moral issues in SA. _______ 8. Demonstrate basic assessment and diagnostic skills for SA. _______ 9. Recognizing the attitudinal obstacles to good communication with the SA patient and family. _______ 10. Dealing with an impaired colleague. 32 Substance Abuse Curriculum: MODULE 1 DIDACTIC UNIT 2A: Introduction to substance abuse and commonly used terms Total Time: 1 hour Overview: This unit serves as an introduction for the glossary of SA terms and their definitions. The unit will also serve as a introduction to organizations and other resources concerning substance abuse. Terminal Objective: The student will understand the many of the commonly used terms, organizations and resources in SA. In addition the student will be given references for further exploration. Recommended Teaching Methods: Group Process Lecture Discussion Content Outline: VIII. Common terms related to SA A. Addiction B. Dependence C. Use vs. misuse D. Experimentation E. Tolerance F. Additional terms IX. Organizations A. Local B. State C. National D. International X. Resources A. Written materials B. Audiovisual materials C. Professional networking D. Experiential learning 33 References: American Nurses' Association, Drug and Alcohol Nursing Association, and National Nurses Society on Addictions. (1988) The care of clients with addictions: Dimensions of nursing practice. Kansas City, Mo.: American Nurses Association. American Nurses' Association and National Nurses Society on Addictions. (1988). Standards of addictions nursing practice with selected diagnoses and criteria. Kansas City, Mo.: American Nurses' Association. American Psychiatric Association. (1997). Diagnostic and statistical manual (DSM-IV). Washington, DC: APA, American Psychiatric Association. American Psychiatric Association. (1975). A psychiatric glossary. Washington, DC: American Psychiatric Association. Burns, E.M., Thompson, A. & Ciccone, J.K. (Eds.) (1993) An addictions curriculum for nurses and other helping professionals. Vol. 1 & 2. New York: Springer Publishing Co. Flynn, S.P., Davis, A.K., & Fleming, M.F. (1989). Teaching about substance abuse: A resource manual for faculty development. (NIDA & NIAAA No. PH 276). Rockville, MD: U.S. Dept. of Health and Human Services. Kalish, R.A. (1982). Late adulthood: Perspectives on human development. Monterey, CA: Brooks, Cole Publishing Co. Nelson, J.E., Pearson, H.W., Sayers, M. & Glynn, R.J. (1982) Guide to drug abuse and research terminology. Research Issue 26. Rockville, MD: National Institute on Drug Abuse. Rinaldi, R.C., Steindler, E.M. Wilford, B.B., & Goodwin, D. (1988) Clarification and standardization of substance abuse terminology. Journal of the American Medical Association 259(4), 555-557. 34 Resources for Substance Abuse: Alcoholics Anonymous P.O. Box 459 Grand Central Station New York, NY 10163 (212) 686-1100 American Association of Nurse Anesthetists 222 South Prospect Ave. Park Ridge, Ill. 60068 (708) 692 7050 American Council for Drug Education 6193 Executive Boulevard Rockville, MD 20852 (301) 984-5700 American Medical Association Department of Health Education 535 North Dearborn St. Chicago, Ill. 60610 (312) 645-5000 Association of Medical Educators in Substance Abuse (AMERSA) c/o Brown University P.O. Box G Providence, RI 02912 (401) 863-1109 Cork Institute on Black Alcohol and Drug Abuse Morehouse School of Medicine 720 Westview Drive, S.W. Atlanta, GA 30310 Food and Drug Administration Office of Consumer Affairs 5600 Fischer Lane Rockville, MD 20857 (301) 443-6500 Hazelden Educational Materials Pleasant Valley Road 35 Box 176 Center City, MN 55012 (800)328-9000 Johnson Institute 7151 Metro Blvd. Minneapolis, MN 55439 (800) 231-5165 National Clearinghouse for Alcohol and Drug Information Department PP - P.O. Box 2345 Rockville, MD 20852 (301) 469-2600 National Council on Alcoholism 733 Third Ave. New York, NY 10017 (212) 986-4433 National Council on Alcoholism and Drug Dependence, Inc 12 West 21st St. New York, NY 10010 (212) 206-6770 National Highway Traffic Safety Administration 793 Elkridge Landing Road Linthicum, MD 21090 (301) 962-3877 National Library of Medicine Collection Access Section 8600 Rockville Pike Bethesda, MD 20894 National Nurses Society on Addictions 5700 Old Orchard Road, First Floor Skokie, Ill. 60077 (708) 966-5010 Native American Research Information Service (NARIS) The American Indian Institute The University of Oklahoma 555 Constitution Ave. Norman, OK 73037 36 (405) 325-4127 Resources for Substance Abuse (cont.): Office of Minority Health Resource Center (OMHRC) P.O. Box 37337 Washington, DC 20013 (800) 444-6472 Project Cork Institute and Resource Center Dartmouth Medical School Hanover, NH 03756 (603) 646-7540 Rutgers University, Center of Alcohol Studies Smithers Hall, Busch Campus Piscataway, NY 98854 (201) 932-4442 Education and Training Van Nest Hall, Room 301 New Brunswick, NJ 081903 (201) 932-2190 37 Substance Abuse Curriculum: MODULE 1 DIDACTIC UNIT 2B: Defining commonly abused substances and their characteristics Total Time: 1-2 hours Overview: This unit serves as an introductory study of the substances commonly used and their characteristics. The session is intended to familiarize the participant with the major mood altering drugs and provide the framework that will allow comparison of the substances of abuse. Terminal Objective: The student will understand the many of the commonly abused substances, their characteristics, and clinical manifestations. Recommended Teaching Methods: Group Process Lecture Discussion Readings Drug Content Area: from Adger, H., DeAngelis, C., & McDonald, E.M. Course Outline: XI. Common drugs of abuse A. Alcohol B. Marijuana 1. Hashish C. CNS stimulants 1. Amphetamines D. Cocaine 1. Crack E. CNS depressants 1. Barbiturate 2. Non-barbiturate 3. Anti-anxiety agents F. Narcotics/Heroin/other controlled substances 1. opiates a. morphine b. codeine 2. semi-synthetic a. heroin b. hydromorphone 3. synthetic a. methadone 38 b. meperidine c. fentanyl d. sufentanyl G. Hallucinogens 1. LSD 2. Mescaline 3. MDMA H. Phencyclidine (PCP) I. Volatile Inhalants 1. Amyl and isobutyl nitrites J. Nicotine K. Caffeine L. Anabolic steroids M. Over-the-counter drugs XII. Content Area for each drug A. Generic and trade name B. Street names C. General information D. Methods of use E. Clinical manifestations F. Formulation and Paraphernalia G. Treatment for acute abuse 39 References: Adger, H., DeAngelis, C., & McDonald, E.M. (1986). Model program and curriculum in alcohol and other drug abuse for pediatric medical students, residents and faculty. (National Institute on Drug Abuse. ADM 281-86-0009). Washington, DC: U.S. Government Printing Office. Ahmad, G. (1987). Abuse of phencyclidine (PCP): A laboratory experience. Journal of Clinical Toxicology. 25(4), 341-346. Arif, A., & Westermeyer, J. (Eds.) (1988). Manual of drug and alcohol abuse. New York: Plenum Medical Books Co. Boning, J. (1985). Benzodiazepine dependence: Clinical neurobiological aspects. Advances in Biochemical Psychopharmacology. 40, 185-192. Buffum, J. (1982). Pharmacosexology: The effects of drugs on sexual function. Journal of Psychoactive Drugs. 14(1-2), 5-44. Clouet, D.H. (1986). Phencyclidine: An update. (DHHS publication no. ADM 86-1443) Washington, DC: U.S. Government Printing Office. Cushman, P. (1986). Sedative drug interactions of clinical importance. Recent Developments in Alcohol. 4, 61-83. Freund, G. (1984). Biomedical causes of alcohol abuse. Alcohol. 1(2), 129-131. Gawin, F.H., & Ellingwood, E.H. (1988). Cocaine and other stimulants: Action, abuse and treatment. New England Journal of Medicine. 318(18), 1173-1182. Giannini, A.J., Price, W.A., et al. (1986). Contemporary drugs of abuse. American FamilyPhysician .33(3), 207-216. Goldstein, D.B. (Ed.) (1983). The pharmacology of Alcohol. New York: Oxford Press. Goodman, L.S. & Gilman, A. (1975). The pharmacologic basis of therapeutics. New York: Macmillan Publishing Co. National Institute on Drug Abuse. (1990). NIDA Capsules: CAP01-CAP38. Rockville, MD: National Clearinghouse for Alcohol and Drug Information. Peterson, R.G. & Rumack, B.H. (1977). Treating acute acetaminophen poisoning with acetylcysteine. Journal of the American Medical Association. 237, 2406-2407. Spitz, H. & Rosecan, J. (Eds.) (1987). Cocaine abuse: New direction in treatment and research. 40 New York: Brunner/Mazel. Stoelting, R.K. (1987). Pharmacology and physiology in anesthetic practice. Philadelphia: J.B. Lippincott Co. West, R.J. & Russell, M.A. (1985). Dependence on nicotine chewing gum. Journal of the American Medical Association. 256(23), 3214-3215. 41 Substance Abuse Curriculum: MODULE 1 DIDACTIC UNIT 2C: Basic pharmacology - I. Acute and Chronic Abuse Total Time: 2-3 hours Overview: This unit serves as an introductory to the pharmacology of the substances commonly abused. The session is intended to familiarize the participant with the pharmacokinetics and pharmacodynamics of major mood altering drugs. Terminal Objective: The student will understand the pharmacologic basis and principles of many of the commonly abused substances, their characteristics, and clinical manifestations. The student will be able to generally relate these principles to anesthesia. Recommended Teaching Methods: Group Process Lecture Discussion Readings Course Outline: XIII. Basic Pharmacology of Commonly Abused Substances A. Overview of the Effects of drugs 1. Signs and symptoms 2. Tolerance 3. Pharmacologic effects B. Alcohol C. Marijuana 1. Hashish D. CNS stimulants 1. Amphetamines E. Cocaine 1. Crack F. CNS depressants 1. Barbiturate 2. Non-barbiturate 3. Anti-anxiety agents G. Narcotics/Heroin/other controlled substances 1. opiates a. morphine b. codeine 2. semi-synthetic a. heroin 42 b. hydromorphone 3. synthetic a. methadone b. meperidine c. fentanyl d. sufentanyl H. Hallucinogens 1. LSD 2. Mescaline 3. MDMA I. Phencyclidine (PCP) J. Volatile Inhalants 1. Amyl and isobutyl nitrites K. Nicotine L. Caffeine M. Anabolic steroids XIV. Origins of drug use, abuse and dependence A. Addiction B. Dependence C. Cross-dependence D. Vulnerability E. Clinical characteristics F. Symptoms G. Tolerance and withdrawal 43 References: Adger, H., DeAngelis, C., & McDonald, E.M. (1986). Model program and curriculum in alcohol and other drug abuse for pediatric medical students, residents and faculty. (National Institute on Drug Abuse. ADM 281-86-0009). Washington, DC: U.S. Government Printing Office. Goodman, L.S. & Gilman, A. (1975). The pharmacologic basis of therapeutics. New York: Macmillan Publishing Co. Grabowski, J. (Ed.). (1984). Cocaine: Pharmacology, effects, and treatment of abuse, NIDA Research Monograph 50. (National Institute on Drug Abuse. ADM 87-1326) Rockville, MD: National Institute on Drug Abuse. Jacobs, M.R. & Fehr, K.O. (1987). Drugs and drug abuse: A reference text. Toronto, Canada: Addiction Research Foundation. Miller, R.D. (Ed.). (1990). Anesthesia. New York: Churchill Livingstone. Rogers, M.C., Tinker, J.H., Covino, B.G. & Longnecker, D.E. (Eds.). (1993). Principles and practice of anesthesiology. St. Louis, MO: Mosby Year Book. Waugaman, W.R., Rigor, B.M., Katz, L.E., Bradshaw, H.W. & Garde, J.F. (1988). Principles and practice of nurse anesthesia. Norwalk, Conn.: Appleton and Lange. 44 Substance Abuse Curriculum: MODULE 1 DIDACTIC UNIT 2D: Defining the Diagnostic and Statistical Manual of Mental Disorders Total Time: 1-2 hours Overview: This unit serves as an introductory to the problem of substance abuse. The session will provide insight into the nature of substance abuse and familiarize the participant with the DSM manual. Terminal Objective: The student will understand the nature and principles of drug use as related to substance abuse. In addition the student will be able to identify patterns and factors which predispose one to substance abuse. Recommended Teaching Methods: Group Process Lecture Discussion Readings Small group role playing Course Outline: XV. Introduction to the nature of substance abuse A. Overview of drug use 1. Healthful 2. Recreational B. Drugs used and potential for abuse 1. Marijuana 2. CNS stimulants 3. Cocaine 4. CNS depressants 5. Narcotics/Heroin/other controlled substances 6. opiates 7. semi-synthetic 8. synthetic 9. Hallucinogens 10. Phencyclidine (PCP) 11. Volatile Inhalants 12. Nicotine 13. Caffeine 14. Anabolic steroids XVI. Defining drug use, abuse and dependence 45 A. Individual perceptions 1. Personal beliefs 2. Personal experimentation 3. Circumstances for drug use 4. Vulnerability for abuse B. Determination of use, misuse, or abuse 1. Personal definition 2. Social definition 3. Medical definition C. Social perceptions of drug use, abuse or dependence 1. Frequent use 2. Social use 3. Responsible use 4. Substance abuse 5. Drug dependence a. Physical dependence b. Psychological dependence c. DSM diagnostic criteria D. Patterns for substance abuse 1. Family history and genetic theory 2. Social learning 3. Dysfunctional family 4. Patterns of communication 5. Family role modeling 46 References: American Association of Nurse Anesthetist. (1992). Peer Assistance Manual. Chicago, IL: American Association of Nurse Anesthetists. American Nurses' Association. (1988). Standards of addictive nursing practice with selected diagnoses and criteria. Kansas City, MO: American Nurses' Association. American Psychiatric Association. (1987). Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: American Psychiatric Association. Anspaugh, D.J., Hamrick, M.H., & Rosato, F.D. (1991). Wellness: Concepts and applications. St. Louis, MO: Mosby Year Book. Arif, A., & Westermeyer, J. (Eds.) (1988). Manual of drug and alcohol abuse. New York: Plenum Medical Books Co. Blechman, E. (1982). Conventional wisdom about familial contribution to substance abuse. American Journal of Drug and Alcohol Abuse. 9(1), 35-54. Frances, R.J. & Miller, S.L. (Eds.) (1991). Clinical textbook of addictive disorders. New York: The Guilford Press. Kinney, J. & Leaton, G. (1991). Loosening the grip: A handbook of alcohol information. St. Louis, MO: Mosby Year Book. Ray, O. & Ksir, C. (1990). Drugs, society, and human behavior. St. Louis, MO: Times Mirror/Mosby College Publishing. U.S. Department of Health and Human Services. (1987). Sixth special report to the U.S. Congress onalcohol and health: From the Secretary of Health and Human Services. (USDHHS Publication No. ADM 87-1519). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. U.S. Department of Health and Human Services. (1990). Seventh special report to the U.S. Congress on alcohol and health: From the Secretary of Health and Human Services. (USDHHS Publication No. ADM 90-1656). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Wegscheider-Cruse, S. (1989). Another chance: Hope and health for the alcoholic family. Palo Alto, CA: Science and Behavior Books. 47 Substance Abuse Curriculum: MODULE 1 DIDACTIC UNIT 2E: Epidemiology of substance abuse Total Time: 1-2 hours Overview: This unit will discuss the incidence, prevalence, morbidity, mortality and demographics differences regarding substance abuse. The session will provide insight into prominent patterns of substance abuse. Terminal Objective: The student will understand the incidence, prevalence, morbidity, mortality, demographics, and prominent patterns of substance abuse. Recommended Teaching Methods: Group Process Lecture Discussion Readings Course Outline: XVII. Epidemiology of substance abuse A. Overview of the incidence and prevalence of SA 1. Overall trend of alcohol consumption 2. Overall trend of other substance use/abuse B. Incidence of substance abuse by age groups 1. Addicted Infants 2. Youth (12-18 years) 3. Young adult (19-25 years) 4. Middle Adult (26-34 years) 5. Older Adult (35+ years) C. Other abused substances 1. Growth of illicit drugs 2. Marijuana use 3. Nicotine 4. Caffeine D. Trends in substance use, misuse and abuse 1. 1970-1980 2. 1980-1990 E. Morbidity and Mortality of substance abuse 1. Factors which define morbidity 2. Causes of mortality 3. Most common physical findings of the abuser 4. Polysubstance abuse 48 References: American Association of Nurse Anesthetist. (1992). Peer Assistance Manual. Chicago, IL: American Association of Nurse Anesthetists. American Nurses' Association. (1988). Standards of addictive nursing practice with selected diagnoses and criteria. Kansas City, MO: American Nurses' Association. Anspaugh, D.J., Hamrick, M.H., & Rosato, F.D. (1991). Wellness: Concepts and applications. St. Louis, MO: Mosby Year Book. Haack, M.R. & Harford, T.C. (1984). Drinking patterns among student nurses. International Journal of Addictions. 19(5), 577-583. Haberman, P.W. (1987). Alcohol use and alcoholism among motor vehicle driver fatalities. International Journal of the Addictions. 22(11), 1119-1128. Kinney, J. & Leaton, G. (1991). Loosening the grip: A handbook of alcohol information. St. Louis, MO: Mosby Year Book. Knox, J.M. (1988). Drinking, driving and drugs. New York: Chelsea House Publications. National Center for Health Statistics. (1981). National health interview survey: Current estimates, United States, 1981. Washington, DC: U.S. Government Printing Office. National Institute on Drug Abuse. (1990). National household survey on drug abuse: Highlights 1988. (NIDA publication no. ADM 90-1681). Rockville, MD: U.S. Department of Health and Human Services. Pinto, R.P., Abrams,D.B., Monti, P.M. & Jacobus, S.I. (1987). Nicotine dependence and likelihood of quitting smoking. Addictive Behaviors. 12(4), 371-374. Ray, O. & Ksir, C. (1990). Drugs, society, and humanbehavior. St. Louis, MO: Times Mirror/Mosby College Publishing. Sanchez,-Craig, M. (1985). Patterns of alcohol use associated with self-identified problem drinking. American Journal of Public Health. 75(2), 178-180. Seigel, R.K. (1982). Cocaine and sexual dysfunction: The course of mama coca. Journal of Psychoactive Drugs. 14(1-2), 17-74. U.S. Department of Health and Human Services. (1987). Sixth special report to the U.S. Congress on alcohol and health: From the Secretary of Health and Human Services. (USDHHS Publication No. ADM 87-1519). Rockville, MD: National Institute on Alcohol Abuse and 49 Alcoholism. U.S. Department of Health and Human Services. (1990). Seventh special report to the U.S. Congress on alcohol and health: From the Secretary of Health and Human Services. (USDHHS Publication No. ADM 90-1656). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Wechsler, H. & Rohman, M.E. (1981). Patterns of drug use among New England college students. American Journal of Drug and Alcohol Abuse. 8(1), 27-37. Williams, G.D., Gant, B.F., Stinson, F.S., Zobeck, T.S., Aitken, S. S. & Noble, J. (1988). Trends in alcohol-related morbidity and mortality. Public Health Reports. 103(61), 592-597. Wilsnack, S.C. (1987). Drinking and drinking problems in women: A U.S. longitudinal survey and some implications for prevention. In: T. Loberg, W.R. Miller, P.E. Nathan, & G.A. Marlatt. Addictive Behavior: Prevention and Early Intervention. Amsterdam, Netherlands: Swets and Seitlinger. 50 Substance Abuse Curriculum: MODULE 1 DIDACTIC UNIT 2F: Etiology of substance abuse Total Time: 2-3 hours Overview: This unit will discuss the predisposing risk factors for the substance abuser as well as some of the mechanisms for reducing these at risk populations. The session will delve into environmental influences, genetic influences, and the dysfunctional family as possible relationships to prominent patterns of substance abuse. Terminal Objective: The student will understand the various valid theories predisposing patients to substance abuse. Recommended Teaching Methods: Group Process Lecture Discussion Readings Case Presentation # 1 Reference Sheet 1.1 Course Outline: XVIII. Etiology of substance abuse A. Factors which may contribute to SA behavior 1. Individual/Personal a. genetic b. family pressures c. living patterns d. personal reflection 2. Environmental a. demographics of use and availability b. cultural patterns c. socioeconomic patterns d. profession/occupation 3. At risk behavior a. dysfunctional families b. stress c. personality d. healthy coping strategies B. Methods for reducing the incidence of SA for the at risk patient 1. exercise 2. nutrition 3. smoking cessation 51 4. reducing drug and alcohol intake 5. reducing the incidence of AIDS 6. stress reduction a. biofeedback b. hypnosis c. reflexology d. support groups e. directions in problem-solving 7. community support 8. self-help C. Health education in SA 1. Needs assessment 2. Goal formulation 3. Plan for implementation 4. Adult education philosophy 5. Implementation 6. Evaluation D. Personal reflection and self-evaluation 1. Case presentation # 1 2. ethical issues concerning SA 3. stereotypical assessment of SA 52 References: American Association of Nurse Anesthetist. (1992). Peer Assistance Manual. Chicago, IL: American Association of Nurse Anesthetists. American Nurses' Association. (1988). Standards of addictive nursing practice with selected diagnoses and criteria. Kansas City, MO: American Nurses' Association. Clarke, M. (1984). Stress and coping: Constructs for nursing. Journal of Advanced Nursing. 9, 313. Clarke, C. (1986). Wellness: Concepts, theory, research and practice. New York: Springer Publishing. Eckhardt, M.J., Harford, T.C. et. al. (1981, April). Health hazards associated with alcohol consumption. Journal of the American Medical Association. 246(6), 648-666. Gallagher, W. (1986, August). The looming menace of designer drugs. Discover. pp 24-35. Goodstadt, M.S. (1986). School-based drug education in North America: What is wrong? What can be done? Journal of School Health. 56(7), 278-281. Haack, M.R. & Harford, T.C. (1984). Drinking patterns among student nurses. International Journal of Addictions. 19(5), 577-583. Haberman, P.W. (1987). Alcohol use and alcoholism among motor vehicle driver fatalities. International Journal of the Addictions. 22(11), 1119-1128. Hilton, M.E. (1987). Regional diversity of U.S. drinking patterns. Berkeley, CA: Institute of Epidemiology and Behavioral Science. Hutchinson, S. (1988). Self-care and job stress. Image. 19, 192-196. Knox, J.M. (1988). Drinking, driving and drugs. New York: Chelsea House Publications. Lexy, S. (1983). Managing the drugs in your life: A personal guide to the responsible use of drugs, alcohol, medicine. New York: McGraw-Hill. References: McDonough, J.P. (1990). Personality, addiction, and anesthesia. Journal of the American Association of Nurse Anesthetists. 58(3), 193-200. National Institute on Drug Abuse. (1990). National household survey on drug abuse: Highlights 1988. (NIDA publication no. ADM 90-1681). Rockville, MD: U.S. Department of Health and 53 Human Services. Pinto, R.P., Abrams,D.B., Monti, P.M. & Jacobus, S.I. (1987). Nicotine dependence and likelihood of quitting smoking. Addictive Behaviors. 12(4), 371-374. Ray, O. & Ksir, C. (1990). Drugs, society, and human behavior. St. Louis, MO: Times Mirror/Mosby College Publishing. Sanchez,-Craig, M. (1985). Patterns of alcohol use associated with self-identified problem drinking. American Journal of Public Health. 75(2), 178-180. Scott, C. & Hawk, J. (1986). Heal thyself: The health of health care professionals. New York: Brunner/Mazel. Seigel, R.K. (1982). Cocaine and sexual dysfunction: The course of mama coca. Journal of Psychoactive Drugs. 14(1-2), 17-74. Summerfield, L.M. (1991). Drug and alcohol prevention education. ERIC Digest (Office of Educational Research and Improvement. RI 88062015). Washington, DC: Department of Education U.S. Department of Health and Human Services. (1990). Seventh special report to the U.S. Congress on alcohol and health: From the Secretary of Health and Human Services. (USDHHS Publication No. ADM 90-1656). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Wechsler, H. & Rohman, M.E. (1981). Patterns of drug use among New England college students. American Journal of Drug and Alcohol Abuse. 8(1), 27-37. Williams, G.D., Gant, B.F., Stinson, F.S., Zobeck, T.S., Aitken, S. S. & Noble, J. (1988). Trends in alcohol-related morbidity and mortality. Public Health Reports. 103(61), 592-597. Wilsnack, S.C. (1987). Drinking and drinking problems in women: A U.S. longitudinal survey and some implications for prevention. In: T. Loberg, W.R. Miller, P.E. Nathan, & G.A. Marlatt. Addictive Behavior: Prevention and Early Intervention. Amsterdam, Netherlands: Swets and Seitlinger. 54 Substance Abuse Case Presentation #1 Module 1 Didactic Unit 2F Reference Sheet 1.1 Jay Johnson, is a 23 year old graduate of a leading school of nurse anesthesia and presents with complaints of stress and requests something to help him relax. He is an anesthesia practitioner working full-time and studying for an advanced degree in the evenings. He has little time for socialization and is currently divorced and has one child. His parents are divorced and his father has had a chronic drinking problem. Jay has also recently been named in litigation. He has two brothers, one which has had frequent history of DWI and a second which used illicit drugs while in the service. Jay does not drink or use street drugs. He clearly states his position as an anti-drinker and antidrugs. He attends Al-Anon meetings every couple of months. Risk Factors to consider for this Young Adult: 1. 2. 3. 4. 5. 6. 7. 8. 9. Exposure to drug users in social and work environments Marital and work stability Unemployment Divorce Psychological or psychiatric difficulties or distress Low self-esteem Depression Peer support Substance abuse by parents 55 Substance Abuse Curriculum: MODULE 1 DIDACTIC UNIT 2G: Introduction to the legal, ethical and moral issues of SA Total Time: 2-3 hours Overview: This unit will discuss the legal, ethical and moral issues of SA. This will include discussion of the impaired professional. Terminal Objective: The student will understand the various ethical, legal, and moral issues related to substance abuse. Recommended Teaching Methods: Group Process Lecture Discussion Readings Role Playing Field trips to agencies for observation and/or limited interaction Course Outline: XIX. Legal issues related to SA A. Roles of State Boards of Nursing B. Disciplinary actions C. Diversion of controlled substances D. Professional/administrative responsibilities E. Knowledge of Drug enforcement agencies F. Screening for recovering abuser G. Criminal and civil liabilities H. Patient confidentiality XX. Ethical issues related to SA A. AANA code of ethics B. AANA Peer Assistance statement C. Professional codes D. Ethical considerations for reporting E. Ethical considerations for intervention F. Impaired professionals G. Other issues related to SA XXI. Moral issues related to SA A. Impaired professionals 1. Prevalence of SA 2. Attitude of professionals 3. Availability of substances for abuse 56 4. Behaviors of impaired professionals, employers, co-workers, and family which encourage SA. 5. Recovery of impaired professionals 6. Returning impaired professionals to work XXII. Peer Assistance A. SA Education B. Intervention for SA of colleague C. Intervention organizations and treatment D. Aftercare and employment 1. Department policies and procedures 2. Motivation of abusers to seek treatment 3. Support groups 4. Peer assistance E. Changing attitudes toward impaired professionals 57 References: American Association of Nurse Anesthetist. (1992). Peer Assistance Manual. Chicago, IL: American Association of Nurse Anesthetists. American Nurses' Association. (1988). Standards of addictive nursing practice with selected diagnoses and criteria. Kansas City, MO: American Nurses' Association. Bissell, L. & Haberman, P. (1984). Alcoholism in the professionals. New York: Oxford University Press. Bissell, L. & Royce, J. (1987). Ethics for addiction professionals. Center City, MN: Hazelden Foundation Cannon, B.L. & Brown, J.S. (1988). Nurses' attitudes toward impaired colleagues. Image, Summary 20, 9-101. Caracci, K.O. (1992). The relationship between alcohol use and knowledge among nurses. Journal of Alcohol and Drug Education. 37(3), 66-73. Clarke, M. (1984). Stress and coping: Constructs for nursing. Journal of Advanced Nursing. 9, 313. Connell, C.C. & Murphy, J.F. (1987, Aug.). New dimensions of regulating the practice of professional nursing. Nursing Management, 18(8), 62-64 Dogoloff, L. & Angarola, R. (1985). Urine testing in the workplace. New York: American Council for Drug Education. Foster, S.D. & Jordan, L.M. (Eds.). (1994). Professional aspects of nurse anesthesia practice. Philadelphia: F.A. Davis Co. Gallagher, W. (1986, August). The looming menace of designer drugs. Discover. pp 24-35. Gerber, L.A. (1983). Married to their careers: Career and family dilemmas in doctor's lives. New York: Tavistock Publications. Haack, M.R. & Harford, T.C. (1984). Drinking patterns among student nurses. International Journal of Addictions. 19(5), 577-583. Hutchinson, S. (1988). Self-care and job stress. Image. 19, 192-196. Hutchinson, S.A. (1987, Nov./Dec.). Toward self-integration: The recovery process of chemically dependent nurses. Nursing Research. 36(6), 339-343. 58 Kilty, K. (1975). Attitudes toward alcohol and alcoholism among professionals and nonprofessionals. Journal of Studies on Alcohol. 35(3), 327-347. Leiker, T. (1989). The role of the addictions nurse specialist in a general hospital setting. Nursing Clinics of North America. 24(1), 137-149. Lexy, S. (1983). Managing the drugs in your life: A personal guide to the responsible use of drugs, alcohol, medicine. New York: McGraw-Hill. McDonough, J.P. (1990). Personality, addiction, and anesthesia. Journal of the American Association of Nurse Anesthetists. 58(3), 193-200. Moore, G. & Hogan, R.L. (1987). Substance abuse and the nurse: A legal and ethical dilemma. Journal of Professionals Nursing. 3(1), 5. Naegle, M. (1985, Apr./May). Impaired nursing practice: Ethical and legal issues. Imprint. 32(2), 48-56. National Institute on Drug Abuse. (1990). National household survey on drug abuse: Highlights 1988. (NIDA publication no. ADM 90-1681). Rockville, MD: U.S. Department of Health and Human Services. Ray, O. & Ksir, C. (1990). Drugs, society, and human behavior. St. Louis, MO: Times Mirror/Mosby College Publishing. Sanchez,-Craig, M. (1985). Patterns of alcohol use associated with self-identified problem drinking. American Journal of Public Health. 75(2), 178-180. Scott, C. & Hawk, J. (1986). Heal thyself: The health of health care professionals. New York: Brunner/Mazel. Swenson, I., Havens, B. & Chamagne, M. (1989). State boards and impaired nurses. Nursing Outlook. 37(2), 94-96. Twerski, A.J. (1982). It happens to doctors, too. Center City, MN: Hazelden Co. Wechsler, H. & Rohman, M.E. (1981). Patterns of drug use among New England college students. American Journal of Drug and Alcohol Abuse. 8(1), 27-37. 59 Substance Abuse Curriculum: MODULE 1 DIDACTIC UNIT 2H: Basic assessment and diagnostic skills in the SA patient Total Time: 2-3 hours Overview: This unit will discuss the skills related to clinical assessment and diagnosis of the SA patient. Terminal Objective: The student will understand the various basic techniques required to obtain a history and physical from substance abuse patients. These basic interviewing skills will enable the student to obtain the groundwork for planning, treatment or referral of the SA patient. Recommended Teaching Methods: Group Process Lecture Discussion Readings Role Playing Field trips to agencies for observation and/or limited interactions Case examples Course Outline: XXIII. Defining addiction A. Dependence 1. Psychological 2. Physiological feelings B. Addiction 1. Manifestations a. Physiological changes b. Tolerance c. Cross tolerance d. Multiple or dual diagnosis 2. Behavioral effects a. Gambling b. Sexual disorders c. Physical problems d. Emotional e. Professional f. Social g. Family C. The disease concept of addiction 1. Impairment 60 a. Early b. Middle c. Late 2. Denial of addiction a. Family support for denial b. Social support for denial c. Professional support for denial D. Diagnosis of addiction 1. Acute medical sequela a. Physical findings 2. Chronic medical sequela a. Physical findings 3. Engaging patient a. Patient who accepts disease b. Patient who denies disease 4. Establishing a supportive relationship a. Using interviewing skills b. Showing respect and empathy for patients 5. Understanding the impact of SA 6. Things to avoid during an interview a. Comparisons b. Value-laden terms c. Scare tactics d. Arguments e. Hostility f. Enabling 61 References: Arif, A., & Westermeyer, J. (Eds.) (1988). Manual of drug and alcohol abuse. New York: Plenum Medical Books Co. Block, M.R. & Coulehan, J.L. (1987, Jan.). Teaching the difficult interview in a required course on medical interviewing. Journal of Medical Education. 62(1), 35-40. Bluhm, J. (1987). When you face the chemically dependent patient: A practical guide for nurses. St. Louis, MO: Ishiyaku EuroAmerica, Inc. Cananough, R.M. (1986). Obtaining a personal and confidential history from adolescents. An opportunity for prevention. Journal of Adolescent Health Care. 7(2), 118-122. Chappel, J.N., Veach, T.L., Krug, R.S. (1985). The substance abuse attitude survey: An instrument for measuring attitudes. Journal of Studies on Alcohol. 46, 48-52. Donovan, D. & Marlatt, G. (1988). Assessment of addictive behaviors. New York: The Guilford Press. Ewing, J.A. (1984). Detecting alcoholism: The CAGE questionnaire. Journal of the American Medical Association. 252, 1905-1907. Frances, R. & Miller, S. (Ed.). (1991). Clinical textbook of addictive disorders. New York: The Guilford Press. Jack, L. (Ed.). (1990). The core curriculum of addictions nursing. Skokie, IL: Midwest Education Association, Inc. Lipkin, M., Quill, T.E. & Napodano, R. (1984). The medical interview: A core curriculum for residencies in internal medicine. Annals of Internal Medicine. 100, 277. McLellan, A., Luborsky, L. Woody, G., & O'Brien, C. (1980). An improved diagnostic instrument for substance abuse patients: The addiction severity index. Journal of Nervous and Mental Disorders. 168, 26-33. Mumford, E., Anderson, R. Cuerden, T. & Scully, J. (1984). Performance-based evaluation of medical student' interviewing skills. Journal of Medical Education. 59, 133. Pokovny, A.D., Miler, B.A., & Kaplan, H.B. (1972). The brief MAST: A shortened version of the Michigan alcohol screening test. American Journal of Psychology. 129, 342-345. Selzer, M.L., Vinokur, A., & van Rooijen, L. (1975). A self-administered short Michigan alcoholism screening test (SMAST). Journal of Studies on Alcohol. 36, 117-126. 62 Skinner, H.A., Holt, S., Schuller, R., Roy, J., & Israel, Y. (1984). Identification of alcohol abuse using laboratory tests and a history of trauma. Annals of Internal Medicine. 101, 847-851. Stillman, P.L., Burpeace-DiGregorio, M.Y., Nicholson, G.I., Sabers, D.L., & Stillman, A.E. (1983). Six years of experience using patient instructors to teach interviewing. Journal of Medical Education. 58, 941. Tarter, R. & Hegedus, A. (1991). The drug use screening inventory. Alcohol Health and Research World. 15(1), 65-75. Werner, A. & Schneider, J.M. (1974). Teaching medical students interactional skills: A research based course in the doctor-patient relationship. New England Journal of Medicine. 290, 1232. 63 Substance Abuse Curriculum: MODULE 1 DIDACTIC UNIT 2I: Multisystem physiology in SA - Level I Total Time: 2 hours Overview: This unit will discuss the physiology related to the early stages of substance abuse. The systems will be introduced in an extensive manner as a supplement to the assessment and diagnostic skills segment. Terminal Objective: The student will understand the physiologic basis of the early stages of substance abuse. This enhanced knowledge will provide a foundation for supporting the assessment and diagnostic skills of the student. Recommended Teaching Methods: Group Process Lecture Discussion Readings Pathology Case examples Course Outline: XXIV. A. Cardiovascular 1. Cardiac response to selected drugs 2. Hematologic changes 3. Vascular changes B. Digestive system 1. Esophagus 2. Stomach 3. Small bowel 4. Large bowel C. Endocrine 1. Pancreas 2. Liver 3. Spleen 4. Immunologic D. Pulmonary E. Neuromuscular References: Arif, A., & Westermeyer, J. (Eds.) (1988). Manual of drug and alcohol abuse. New York: 64 Plenum Medical Books Co. Anspaugh, D.J., Hamrick, M.H. & Rosato, F.D. (1991). Wellness: Concepts and applications. St. Louis, MO: Mosby-Year Book. Burton, A.C. (1972). A physiology and biophysics of the circulation. Chicago: Year Book Medical Pub. Clark, W.G. et al. (1988). Goth's medical pharmacology. St. Louis, MO: C.V. Mosby Co. Cohen, S. & Callahan, J. (Eds.). (1986). A specific approach to the treatment of alcohol abusing patients. New York: Hayworth Press. Frances, R.J. & Miller, S.L. (Eds.). (1991). Clinical textbook of addictive disorders. New York: Guilford Press. Ganong, W.F. (1989). Review of medical physiology. Los Altos: Lange Medical Publications. Goodman, L.S. & Gilman, A. (1975). The pharmacologic basis of therapeutics. New York: Macmillan Publishing Co. Goudsouzian, N.G. Karamanian, A. (1984). Physiology for the anesthesiologist. New York: Appleton-Century-Crofts. GuytoPhiladelphia: W.B. Saunders Co. Kinney, J. & Leaton, G. (1991). Loosening the grip: A handbook of alcohol information. St. Louis, MO: Mosby-Year Book. Michenfelder, J.D et al. (1969). Neuroanesthesia. Anesthesiology. 30, 65. National Institute on Drug Abuse. (1990). NIDA Capsules: CAP01-CAP38. Rockville, MD: National Clearinghouse for Alcohol and Drug Information. Project Cork Institute of Dartmouth Medical School. (1981). Alcohol use and its medical consequences: A comprehensive slide teaching program for biomedical education. Timonium, MD: Milner-Fenwick. Rogers, M.C., Tinker, J.H., Covino, B.G., & Longnecker, D.E. (Eds.). (1993). Principles and practice of anesthesiology. St. Louis, MO: Mosby Year Book. Stoelting, R.K. (1987). Pharmacology and physiology in anesthetic practice. Philadelphia: J.B. Lippincott Co. 65 Substance Abuse Curriculum: MODULE 1 DIDACTIC UNIT 2J: Attitudes and Self-assessment concerning SA Total Time: 1 hour Overview: Students should be sensitive to the influence CRNAs attitudes have on recognition, patient relationships, and diagnosis of SA. They should recognize SA as a disease process and their professional role in providing prevention. Terminal Objective: The student will understand their professional responsibility concerning SA. They will provide a nonjudgmental and nonmoralistic approach to SA. Establish appropriate optimism about their prognosis. Can accept substance abusers as appropriate to provide medical attention. Recommended Teaching Methods: Group Process Lecture Discussion Readings Case examples Course Outline: XXV. Contemporary Issues of drug use A. History of substance use, misuse, and abuse. B. Legal addictive substances 1. Alcohol 2. Caffeine 3. Nicotine C. Societal patterns of drug use D. Drug use among special populations E. Aging and substance use F. Life use patterns XXVI. Reasons for Using drugs A. Peer pressure B. "Euphoric Seeking" or "Pain Relief" C. Choices concerning use XXVII. Attitudes concerning the topic of SA A. Biased and non-biased attitudes B. The disease model of SA C. Influence of attitudes on patient relationships D. Influence of attitudes on patient care E. Attitude development 66 1. Personal 2. Family 3. Society 4. Cultural F. Stereotypes XXVIII. Impaired professionals A. Patterns for CRNAs B. Factors which determine impairment C. Legal implications D. Willingness to learn about substance abuse XXIX. Employing methods for inducing positive attitudes and recognizing negative attitudes. A. Evaluation of personal attitudes, values, morals and beliefs B. Learning about the SA disease model C. Recognize and practice prevention D. Understand that your professional role places you in a powerful position for producing change 67 References: American Association of Nurse Anesthetist. (1992). Peer Assistance Manual. Chicago, IL: American Association of Nurse Anesthetists. American Nurses' Association. (1988). Standards of addictive nursing practice with selected diagnoses and criteria. Kansas City, MO: American Nurses' Association. American Psychiatric Association. (1997). Diagnostic and statistical manual (DSM-IV). Washington, DC: APA, American Psychiatric Association. American Psychiatric Association. (1975). A psychiatric glossary. Washington, DC: American Psychiatric Association. Barber, J.G. & Grichting, W.L. (1987). Assessment of drug attitudes among university students using the short form of drug attitudes scale. International Journal of Addictions. 22(10), 10331039. Baum, C.D., Kennedy, M. & Jones, J. (1984). Drug use in the United States. Journal of the American Medical Association. 251(10), 1293-1297. Bluhm, J. (1987). When you face the chemically dependent patient: A practical guide for nurses. St. Louis, MO: Ishiyaku EuroAmerica, Inc. Bureau of National Affairs. (1986). Alcohol and drugs in the workplace: Costs, controls, and controversies. Washington, DC: Bureau of National Affairs. Cafiso, J., Goodstadt, M.S., Garington, W.K., et al. (1982). Television portrayal of alcohol and other beverages. Journal on Studies on Alcohol. 43, 964-989. Califano, J.A. (1979, Feb. 19). How alcohol damages America. Life and health. Chappel, J., Veach, T.L. & Krug, R. (1985). The substance abuse attitude survey: An instrument for measuring attitudes. Journal of Studies on Alcohol. 46(1), 48-52. Cohen, S. (1982). Cannabis and sex: Multifaceted paradoxes. Journal of Psychoactive Drugs. 14(2), 55-58. Cook, J. & Fontaine, K. (1991). Essentials of mental health nursing. Menlo Park, CA: AddisonWesley. Cornish, R.D. & Miller, M.V. (1976). Attitudes of registered nurses toward the alcoholic. Journal of Psychiatric Nursing and Mental Health Services. 14(2), 19-22 68 Foster, S.D. & Jordan, L.M. (Eds.). (1994). Professional aspects of nurse anesthesia practice. Philadelphia: F.A. Davis Co. Hanna, E. (1978). Attitudes toward problem drinkers. Journal of Studies on Alcohol. 1, 98-109. Hatterer, L. (1979). The pleasure addicts: The addictive process, food, sex, drugs, alcohol, work and more. South Brunswick, NJ: Barnes, Co. Hingson, R.W. (1983). Impact on legislation raising the legal drinking age in Massachusetts from 18-20. American Journal of Public Health. 73, 163-170. Lyttle, T. (1988). Drug based religions and contemporary drug taking. Journal of Drug Issues. 18(2), 271-284. Jack, L. (Ed.). (1990). The core curriculum of addictions nursing. Skokie, IL: Midwest Education Association, Inc. Jellinek, E.M. (1952). Phases of alcohol addiction. Quarterly Journal for the Study of Alcoholism. 13, 673-684. Jones, C. & Battjes, R. (Eds.). (1985). Etiology of drug abuse: Implications for prevention. (DHHS Publication No. ADM 87-1335). Washington, DC: U.S. Government Printing Office. Kamerow, D.B., Pincus, H.A. & Macdonald, D.I. (1986). Alcohol abuse, other drug abuse, and mental disorders in medical practice. Prevalence, costs, recognition, and treatment. Journal of the American Medical Association. 255(15), 2054-2057. Keltner, N., Schwecke, L., & Bostrom, C. (1991). Psychiatric nursing: A psychotherapeutic management approach. St. Louis, MO: Mosby-Year Book. McAndrew, M. (1990). People who depend upon substances other than alcohol. In: E. Varicarolis. Foundations of psychiatric mental health nursing. Philadelphia: W.B. Saunders Co. pp. 632-676. Nurco, D.N., Shaffer, J.W., Hanlon, T.E., Kinlock, T.W. Duszynski, K.R. & Stephenson, P. (1987). attitudes toward narcotic addiction. The Journal of Nervous and Mental Disease. 175(11), 653-660. Peele, S. (1982). Love, sex, drugs and other magical solutions to life. Journal of Psychoactive Drugs. 14(1-2), 125-131. Richman, J. (1988). Sociological perspectives on illegal drug use: Definitional, reactional and etiologic insights. Behavioral Sciences of the Law. 3(3), 249-258. 69 Sadler, D. (1984, June/July). Physicians' attitudes on alcohol abuse are changing. American Medical News. Stabenau, J. (1990). Addictive independent factors that predict risk for alcoholism. Journal of Studies on Alcohol. 51(2), 164-174. Stephens, R. (1985). The sociocultural view of heroin use: Toward a role-theoretical model. Journal of Drug Issues. 15(4), 433-446. Swanson, A. & Hurley, P. (1983). Family systems: Values and value conflicts. Journal of Psychosocial Nursing and Mental Health Services. 21(7), 25-30. Szasz, T. (1974). Ceremonial Chemistry. New York: Doubleday. Turner, T.B. Bennett, V.L. & Hernandez, H. (1981). Beneficial side of moderate alcohol use. Johns Hopkins Medical Journal. 148(2), 53-63. Vaillant, G. (1970). The natural history of narcotic drug addiction. Seminars in Psychiatry. 2, 486-498. Voss, H. & Clayton, R. (1987). Stages in involvement with drugs. Pediatrician. 14, 25-31. Wechlser, H. McFadden, M., & Bohman, M. (1980). Drinking and drug use among college students in New England. Journal of the American College Health Association. 18, 275-279. Werch, C.E. & Gorman, D.R. (1987). Relationship between self-control consumption patterns and problems of college students. Journal of Studies on Alcohol. 49(1), 30-36. 70 Substance Abuse Curriculum: MODULE 1 CLINICAL UNITS A-G: Introduction to clinical assessment and diagnostics of SA Total Time: 15 hours Overview: The clinical units will provide the student with the experience to apply scientific knowledge in caring for the SA patient. There will also be an extensive opportunity for analyzing and challenging personal attitudes concerning SA. Additionally, there will be an opportunity to engage in multidisciplinary collaboration for SA. Terminal Objective: a) The student will be able to conduct a basic screening, history, and physical for the SA patient. b) Discuss the diagnosis of SA. c) Recommend support groups for a basic prevention and intervention process. d) Examine personal values, beliefs, and attitudes concerning SA. e) Begin the development of a SA research project. Recommended Teaching Methods: Group Process Lecture Discussion Readings Videos Role Playing Case presentations Instructional Activity Sequence: First hour is dedicated to conference time conducted by a clinical faculty member. Second hour includes an introduction to the methods for history and physical using a variety of instruments (e.g. CAGE). Third hour is for taking the Short MAST or other SA self-examination and for demonstrating techniques used for obtaining a history and physical (consider role playing with variety of patients). Fourth hour through the ninth hour provides contact with patients in the clinical setting for structured learning experiences. Tenth hour provides an opportunity for students to discuss and research ideas for the SA research project. Eleventh hour through the fifteenth hour provides the student an opportunity to share time with a clinical counselor. Course Outline: XXX. Introduction to clinical assessment and diagnostics of SA A. Self-examination and challenging personal prejudices, beliefs, and attitudes on SA B. Performing basic clinical assessment and diagnostic procedures 71 C. Learning the relationship between SA and anesthesia D. Familiarization with patient and family dynamics 1. Observation and participation in prevention and treatment programs 2. Learn the role of support groups in treating substance abuse E. Listing the predisposing risks and progressive stages of SA 1. Physical responses 2. Psychosocial responses 3. Physiological responses 4. Cognitive changes F. Exploration of the etiology and progression of SA G. Ideas for SA research project 72 References: Arif, A., & Westermeyer, J. (Eds.) (1988). Manual of drug and alcohol abuse. New York: Plenum Medical Books Co. Block, M.R. & Coulehan, J.L. (1987, Jan.). Teaching the difficult interview in a required course on medical interviewing. Journal of Medical Education. 62(1), 35-40. Bluhm, J. (1987). When you face the chemically dependent patient: A practical guide for nurses. St. Louis, MO: Ishiyaku EuroAmerica, Inc. Cavanaugh, R.M. (1986, Mar.). Obtaining a personal and confidential history from adolescents. An opportunity for prevention. Journal of Adolescent Health Care. 7(2), 118-122. Clark, W.D. (1985, Nov.). The medical interview: Focus on alcohol problems. Hospital Practice. pp. 59-68. Clark, W.D. (1981). Alcoholism: Blocks to diagnosis and treatment. American Journal of Medicine. 71, 275-286. Cox, A. (1981). Training guidelines and workbook for the behavioral management of intoxicated and disruptive clients. Toronto, Canada: Addiction Research Foundation. Craig, R.J. (1988). Diagnostic interviewing with drug-abusers. Professional Psychological Research Practice. 19(1), 14-20. Ewing, J.A. (1984). Detecting alcoholism: The CAGE Questionnaire. Journal of the American Medical Association. 252, 1905-1907. Holt, S. Skinner, H.A. & Israel, Y. Early identification of alcohol abuse: Clinical and laboratory indications. Canadian Medical Association Journal. 124, 1279-1299. Johnston, L.D., O'Malley, P.M. & Bachman, J.G. (1987). National trends in drug use and related factors among American high school students and young adults, 1975-1986. (DHHS Publication No. ADM 87-1535). Washington, DC: U.S. Government Printing Office. Keltner, N., Schwecke, L., & Bostrom, C. (1991). Psychiatric Nursing: A psychotherapeutic management approach. St. Louis, MO: Mosby-Year Book. Lipkin, M., Quill, T.E. & Napodano, R. (1984). The medical interview: A core curriculum for residencies in internal medicine. Annals of Internal Medicine. 100, 277. Milhorn, H.T. (1988). The diagnosis of alcoholism. American Family Physician. 37, 175-183. 73 Mumford, E., Anderson, R. Cuerden, T. & Scully, J. (1984). Performance-based evaluation of medical student' interviewing skills. Journal of Medical Education. 59, 133. National Council on Alcoholism. (1972). Criteria for the diagnosis of alcoholism. Annals of Internal Medicine. 77, 249-258. Skinner, H.A., Holt, S., Schuller, R., Roy, J., & Israel, Y. (1984). Identification of alcohol abuse using laboratory tests and a history of trauma. Annals of Internal Medicine. 101, 847-851. Stillman, P.L., Burpeace-DiGregorio, M.Y., Nicholson, G.I., Sabers, D.L., & Stillman, A.E. (1983). Six years of experience using patient instructors to teach interviewing. Journal of Medical Education. 58, 941. Tarter, R. & Hegedus, A. (1991). The drug use screening inventory. Alcohol Health and Research World. 15(1), 65-75. Tiebout, H.M. (1953). Problems of addiction and habituation. New York: Grune and Stratton. Werner, A. & Schneider, J.M. (1974). Teaching medical students interactional skills: A research based course in the doctor-patient relationship. New England Journal of Medicine. 290, 1232. 74 Formative Evaluation of Module 1 Substance Abuse Curriculum Reference Sheet 1.3 Using the following scale please rate your accomplishments of the objectives in Module 1 including the didactic and clinical components of the substance abuse curriculum. 1-------2-------3-------4-------5 Low Moderate High Accomplishment Level of Accomplishment ____Understanding the objectives, goals and syllabus for the modules. ____Recognizing commonly used terms, organizations, and resources in the field of substance abuse. ____Recognizing the commonly abused substances, their characteristics and clinical manifestations. ____Understanding the pharmacologic basis and principles of many commonly abused substances. ____Identifying patterns and factors which predispose one to substance abuse. ____Relating the incidence, prevalence, morbidity, demographics and prominent patterns of substance abuse. ____Recognizing valid theories predisposing patients to substance abuse. ____Discussing the ethical, legal, and moral issues related to substance abuse. ____Applying basic techniques for obtaining a history and physical and interviewing a substance abuse patient. ____Implementing a plan for treatment and referral of the substance abuse patient. ____Discussing the physiology of the early stages of substance abuse. ____Understanding professional responsibilities concerning substance abuse. 75 ____Enhanced clinical skills in diagnosing substance abuse. ____Examining personal beliefs, values and attitudes concerning substance abuse. Additional Comments: 76 Substance Abuse Curriculum MODULE 2 DIDACTIC UNIT A: Multisystem physiology in SA - Level II Total Time: 2 hours Overview: This unit will discuss the physiology related to the stages of substance abuse. The systems will serve as a supplement to the assessment and diagnostic skills segment. Terminal Objective: The student will understand the physiologic basis of the stages of substance abuse. This enhanced knowledge will provide a foundation for supporting the assessment and diagnostic skills of the student. Recommended Teaching Methods: Group Process Lecture Discussion Readings Case examples Course Outline: XXXI. Skeletal A. History of fractures B. Malnutrition C. Osteoporosis D. Joint pain or deformity XXXII. Skin A. Abscesses B. Bruises C. Needle marks D. Scars E. Jaundice XXXIII. Lymphatic System A. Adenopathy XXXIV. Genitourinary A. Venereal diseases B. Renal failure C. Sexual dysfunction 77 References: Arif, A., & Westermeyer, J. (Eds.) (1988). Manual of drug and alcohol abuse. New York: Plenum Medical Books Co. Anspaugh, D.J., Hamrick, M.H. & Rosato, F.D. (1991). Wellness: Concepts and applications. St. Louis, MO: Mosby-Year Book. Burton, A.C. (1972). A physiology and biophysics of the circulation. Chicago: Year Book Medical Pub. Clark, W.G. et al. (1988). Goth's medical pharmacology. St. Louis, MO: C.V. Mosby Co. Cohen, S. & Callahan, J. (Eds.). (1986). A specific approach to the treatment of alcohol abusing patients. New York: Hayworth Press. Frances, R.J. & Miller, S.L. (Eds.). (1991). Clinical textbook of addictive disorders. New York: Guilford Press. Ganong, W.F. (1989). Review of medical physiology. Los Altos: Lange Medical Publications. Goodman, L.S. & Gilman, A. (1975). The pharmacologic basis of therapeutics. New York: Macmillan Publishing Co. Goudsouzian, N.G. Karamanian, A. (1984). Physiology for the anesthesiologist. New York: Appleton-Century-Crofts. Guyton, A.C. (1986). Textbook of medical physiology. Philadelphia: W.B. Saunders Co. Kinney, J. & Leaton, G. (1991). Loosening the grip: A handbook of alcohol information. St. Louis, MO: Mosby-Year Book. Michenfelder, J.D et al. (1969). Neuroanesthesia. Anesthesiology. 30, 65. National Institute on Drug Abuse. (1990). NIDA Capsules: CAP01-CAP38. Rockville, MD: National Clearinghouse for Alcohol and Drug Information. Project Cork Institute of Dartmouth Medical School. (1981). Alcohol use and its medical consequences: A comprehensive slide teaching program for biomedical education. Timonium, MD: Milner-Fenwick. Rogers, M.C., Tinker, J.H., Covino, B.G., & Longnecker, D.E. (Eds.). (1993). Principles and practice of anesthesiology. St. Louis, MO: Mosby Year Book. 78 Stoelting, R.K. (1987). Pharmacology and physiology in anesthetic practice. Philadelphia: J.B. Lippincott Co. Waugaman, W.R., Rigor, B.M., Katz, L.E., Bradshaw, H.W. & Garde, J.F. (1988). Principles and practice of nurse anesthesia. Norwalk, Conn.: Appleton and Lange. 79 Substance Abuse Curriculum: MODULE 2 DIDACTIC UNIT B: Pharmacology - II Total Time: 2-3 hours Overview: This unit serves as a further introduction to the pharmacology of the substances commonly abused. The session is intended to familiarize the participant with the pharmacokinetics and pharmacodynamics of major mood altering drugs. Terminal Objective: The student will understand the pharmacologic basis and principles of many of the commonly abused substances, their characteristics, and clinical manifestations. The student will be able to generally relate these principles to anesthesia. Recommended Teaching Methods: Group Process Lecture Discussion Readings Course Outline: XXXV. Pharmacology of Commonly Abused Substances A. Pharmacokinetics and Pharmacodynamics of substances 1. Alcohol 2. Marijuana 3. CNS stimulants 4. Cocaine 5. CNS depressants 6. Narcotics/Heroin/other controlled substances 7. Opiates 8. Semi-synthetic 9. Synthetic 10. Hallucinogens 11. Phencyclidine (PCP) 12. Volatile Inhalants 13. Nicotine 14. Caffeine 15. Anabolic steroids XXXVI. Metabolism, clearance, and elimination of substances A. Metabolism 1. Hepatic 2. Renal 3. Biliary 80 4. Metabolic degradation B. Pharmacologic management of withdrawal 1. Intermittent or recurrent withdrawal 2. Complicated withdrawal 3. Unrecognized withdrawal 4. Preanesthetic transition from abuse to withdrawal XXXVII. Variances in individual responses to Pharmacodynamics A. Bioavailability B. Renal function C. Hepatic function D. Age E. Enzyme activity XXXVIII. Variances in individual response to Pharmacokinetics A. Receptor responsiveness B. Drug concentration C. Genetics 81 References: Adger, H., DeAngelis, C., & McDonald, E.M. (1986). Model program and curriculum in alcohol and other drug abuse for pediatric medical students, residents and faculty. (National Institute on Drug Abuse. ADM 281-86-0009). Washington, DC: U.S. Government Printing Office. Ahmad, G. (1987). Abuse of Phencyclidine (PCP): A laboratory experience. Journal of Clinical Toxicology. 25(4), 341-346. American Society of Anesthesiologists Ad Hoc Committee on the Effect of Trace Anesthetics on the Health of Operating Room Personnel. (1974). Occupational diseases among operating room personnel: A national study. Anesthesiology. 41, 321. Barash, P.G., Cullen, B.F. & Stoelting, R.K. (Eds.). (1989). Clinical anesthesia. Philadelphia: J.B. Lippencott Co. Berkowitz, B.A. (1976, Jan.). Relationship of pharmacokinetics to pharmacological activity: Morphine, methadone, naloxone. Clinical Pharmacokinetics. pp. 219-230. Boning, J. (1985). Benzodiazepine dependence: Clinical neurobiological aspects. Advances in Biochemical Psychopharmacology. 40, 185-192. Busto, V. (1986). Patterns of benzodiazepine abuse and dependence. British Journal of Addictions. 81(1), 87-94. Corbett, T.H. (1973). Retention of anesthetic agents following occupational exposure. Anesthesia and Analgesia. 52, 614. Cushman, P. (1986). Sedative drug interactions of clinical importance. Recent Developments in Alcohol. 4, 61-83. Freund, G. (1984). Biomedical causes of alcohol abuse. Alcohol. 1(2), 129-131. Gawin, F.H. & Ellingwod, E.H. (1988). Cocaine and other stimulants: Action, abuse and treatment. New England Journal of Medicine. 318(18), 1173-1182. Goldstein, D.B. (Ed.) (1983). The pharmacology of alcohol. New York: Oxford Press. Goodman, L.S. & Gilman, A. (1975). The pharmacologic basis of therapeutics. New York: Macmillan Publishing Co. Grabowski, J. (Ed.). (1984). Cocaine: Pharmacology, effects, and treatment of abuse, NIDA Research Monograph 50. (National Institute on Drug Abuse. ADM 87-1326) Rockville, MD: National Institute on Drug Abuse. 82 Jacobs, M.R. & Fehr, K.O. (1987). Drugs and drug abuse: A reference text. Toronto, Canada: Addiction Research Foundation. Land, W.E.M. & Zakhari, S. (1990). Alcohol and cardiovascular disease. Alcohol Health and Research World. 14(4), 304-312. Malseed, R. (1985). Pharmacology: Drug therapy and nursing considerations. Philadelphia: J.B. Lippincott. Miller, R.D. (Ed.). (1990). Anesthesia. New York: Churchill Livingstone. Peterson, R.G. & Rumack, B.H. (1977). Treating acute acetaminophen poisoning with acetylcysteine. Journal of the American Medical Association. 237, 2406-2407. Physicians' Desk Reference. (1993). Oradell, NJ: Medical Economics Co. Physician' Desk Reference For Nonprescription Drugs. (1993). Oradell, NJ: Medical Economics Co. Pickens, R.W., Svikis, D.S. (Eds.). (1988). Biological vulnerability to drug abuse, NIDA Research Monograph 89. Rockville, MD: National Institute on Drug Abuse. Rogers, M.C., Tinker, J.H., Covino, B.G. & Longnecker, D.E. (Eds.). (1993). Principles and practice of anesthesiology. St. Louis, MO: Mosby Year Book. Spiker, D.G., et al. (1975). Tricyclic antidepressant overdose: Clinical presentation and plasma levels. Clinical Pharmacologic Therapy. 18(5), 539-546. Sullivan, J.B. et al. (1979). Management of tricyclic antidepressant toxicity. Topics in Emergency Medicine. 1(3), 65-71. Teped, H. (1985). Biochemical basis of alcoholism: Statements and hypotheses of present research. Alcohol. 2(6), 711-788. Wesson, D. & Smith, D. (1977). Barbiturates: Their uses, misuse and abuse. New York: American Science Press. West, R.J. & Russell, M.A. (1985). Dependence on nicotine chewing gum. Journal of the American Medical Association. 256(23), 3214-3215. 83 Substance Abuse Curriculum: MODULE 2 DIDACTIC UNIT C: Prevalence and Patterns of SA Total Time: 1 hour Overview: This unit will discuss the prevalence trends of SA in a variety of age groups. The patterns of use of SA for different age groups will also be discussed. Terminal Objective: The student will understand the prevalence trends and patterns of use of SA through the lifespan. Recommended Teaching Methods: Group Process Lecture Discussion Readings Course Outline: XXXIX. Prevalence and patterns of trends in SA A. Prevalence and patterns of alcohol effects/consumption among 1. Neonates 2. Infancy 3. Childhood 4. Adolescent 5. Young Adult 6. Middle Adulthood 7. Elderly B. Prevalence and patterns of misused and abused prescription and over-the-counter drugs among 1. Neonates 2. Infancy 3. Childhood 4. Adolescent 5. Young Adult 6. Middle Adulthood 7. Elderly C. Trends of commonly misused and abused drugs by 1. Children 2. Adolescents 3. Adults 4. Elderly 5. Tobacco use 84 6. Caffeine D. Factors which influence use, misuse, and abuse 1. Drug Availability 2. Gender 3. Race 4. Socio-economic 5. Demographics 6. Cultural 7. Religious 8. Adolescent attitudes 9. Family patterns 10. Social patterns 11. Psychological 85 References: American Association of Nurse Anesthetist. (1992). Peer Assistance Manual. Chicago, IL: American Association of Nurse Anesthetists. Anderson, E.E. & Quost, W. (1983). Young children in alcoholic families: A mental health needs assessment and intervention/prevention strategy. Journal of Primary Prevention. 3, 174187. Blechman, E. (1982). Conventional wisdom about familial contributions to substance abuse. American Journal of Drug and Alcohol Abuse. 9(1), 35-54. Burden, D. & Gottlieb, N. (Eds.). (1987). The woman client. London: Tavistock. Elkin, M. (1984). Families under the influence. New York: W.W. Norton. Friensen, V.I. (1983). The family in the etiology and treatment of drug abuse: Toward a balanced perspective. Advances in Alcohol and Substance Abuse. 2(4), 77-86. Fossum, M. & Mason, M. (1986). Facing shame: Families in recovery. New York: W.W. Norton. Giannetti, V. Medication utilization problems among the elderly. Health Social Work. 8(4), 262270. Glynn, T.J. (1984). Adolescent drug use and family environment: A review. Journal of Drug Issues. 14, 271-298. Hofling, C.K. & Lewis, J. (1980). The family: Evaluational treatment. New York: Brunner/Mazel. Kaufman, E. (Ed.). (1983). Power to change: Family case studies in the treatment of alcoholism. New York: Gardner. Morbidity and Mortality Weekly Review. (1987). Human immunodeficiency virus infection in the United States: A review of current knowledge. MMRW Supplement. 36(S-6). National Council on Alcoholism. (1972). Criteria for the diagnosis of alcoholism. Annals of Internal Medicine. 77, 249-258. National Institute on Drug Abuse. (1990). National household survey on drug abuse: Highlights 1988. (NIDA publication no. ADM 90-1681). Rockville, MD: U.S. Department of Health and Human Services. 86 National Institute on Drug Abuse. (1987). Data from the drug abuse warning network (DAWN), semiannual report, trend data, through January to June 1987, Statistical Series G, Number 20. Rockville, MD: National Institute of Drug Abuse. Orford, J. & Harwin, J. (1982). Alcohol and the family. New York: Martin's. Regan, D.C., Erlich, S. & Finnegan, L. (1987). Infants of drug addicts: At risk for child abuse, neglect, and placement in foster care. Neurotoxicology and Teratology. 9(4), 315-319. Stanton, M.D. (1986). Family therapy of drug abuse and addiction. New York: Guilford. Steinglass, P., Bennett, L., Wolin, S., & Reiss, D. (1987). The alcoholic family. New York: Basic Books. Tabakoff, B., Sutker, P. & Randall, C. (1983). Medical and social aspects of alcohol abuse. New York: Plenum Press. U.S. Department of Health and Human Services. (1990). Seventh special report to the U.S. Congress on alcohol and health: From the Secretary of Health and Human Services. (USDHHS Publication No. ADM 90-1656). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Werner, E.E. (1985). Resilient offspring of alcoholics: A longitudinal study from birth to age 18. Journal of Studies on Alcohol. 47(1), 34-40. Wilsnack, S.C. (1987). Drinking and drinking problems in women: A U.S. longitudinal survey and some implications for prevention. In: T. Loberg, W.R. Miller, P.E. Nathan, & G.A. Marlatt. Addictive Behavior: Prevention and Early Intervention. Amsterdam, Netherlands: Swets and Seitlinger. 87 Substance Abuse Curriculum: MODULE 2 DIDACTIC UNIT D: Tolerance, Toxicity, and Withdrawal from SA Total Time: 1 hour Overview: Students will explore in depth the physiological process of tolerance and toxicity of addictive substances, as well as the withdrawal from substances. This unit will aid in further identification of key concepts, physiological responses and treatment in SA. Terminal Objective: The student will understand the concepts of tolerance, cross-tolerance, drug toxicity and withdrawal and as it relates to SA and anesthesia. Recommended Teaching Methods: Group Process Lecture Discussion Readings Course Outline: XL. Tolerance A. Stages of the addiction process leading to tolerance 1. Initial contact with substance a. Reasons (1) Peer Pressure (2) Medication use toward misuse (3) Thrill seeking (4) Self-Medication b. Consider abstinence 2. Experimentation a. Increasing the length and intensity of effects b. Mood altering 3. Excessive use a. Can withdraw or continue misuse b. Risks social, psychological and physical damage to continue substance use 4. Addiction a. Physical and psychological dependence b. Outside help required to reverse process 5. Increased tolerance a. Requires increasing amounts b. Effect of substance becomes diminished with same amounts c. Cross-tolerance 88 (1) Poly substances use 6. Recovery a. Detoxification b. Behavior modification to change lifestyle c. Long term support groups B. Toxicity 1. Assessment 2. Acute management a. Intoxication b. Toxic reactions to drugs c. Drug interactions 3. Long-term management a. Recognition of chronic pathology b. Detoxification c. Treatment for chronic physical pathology C. Withdrawal 1. Medical assessment 2. Differential Diagnosis 3. Physiology of withdrawal 4. Half-life and duration of substances 5. Indications for withdrawal 6. Common course of withdrawal for substances 7. Differences in withdrawal patterns 8. Complications of withdrawal 89 References: Adger, H., DeAngelis, C., & McDonald, E.M. (1986). Model program and curriculum in alcohol and other drug abuse for pediatric medical students, residents and faculty. (National Institute on Drug Abuse. ADM 281-86-0009). Washington, DC: U.S. Government Printing Office. Ahmad, G. (1987). Abuse of Phencyclidine (PCP): A laboratory experience. Journal of Clinical Toxicology. 25(4), 341-346. American Psychiatric Association. (1997). Diagnostic and statistical manual (DSM-IV). Washington, DC: APA, American Psychiatric Association. American Society of Anesthesiologists Ad Hoc Committee on the Effect of Trace Anesthetics on the Health of Operating Room Personnel. (1974). Occupational diseases among operating room personnel: A national study. Anesthesiology. 41, 321. Barash, P.G., Cullen, B.F. & Stoelting, R.K. (Eds.). (1989). Clinical anesthesia. Philadelphia: J.B. Lippencott Co. Berkowitz, B.A. (1976, Jan.). Relationship of pharmacokinetics to pharmacological activity: Morphine, methadone, naloxone. Clinical Pharmacokinetics. pp. 219-230. Boning, J. (1985). Benzodiazepine dependence: Clinical neurobiological aspects. Advances in Biochemical Psychopharmacology. 40, 185-192. Busto, V. (1986). Patterns of benzodiazepine abuse and dependence. British Journal of Addictions. 81(1), 87-94. Corbett, T.H. (1973). Retention of anesthetic agents following occupational exposure. Anesthesia and Analgesia. 52, 614. Cushman, P. (1986). Sedative drug interactions of clinical importance. Recent Developments in Alcohol. 4, 61-83. Dole, V. (1988, Nov.). Implications for methadone maintenance for theories of narcotic addiction. Journal of the American Medical Association. 260, 20. Freund, G. (1984). Biomedical causes of alcohol abuse. Alcohol. 1(2), 129-131. Gawin, F.H. & Ellingwod, E.H. (1988). Cocaine and other stimulants: Action, abuse and treatment. New England Journal of Medicine. 318(18), 1173-1182. Goldstein, D.B. (Ed.) (1983). The pharmacology of alcohol. New York: Oxford Press. 90 Goodman, L.S. & Gilman, A. (1975). The pharmacologic basis of therapeutics. New York: Macmillan Publishing Co. Rogers, M.C., Tinker, J.H., Covino, B.G., & Longnecker, D.E. (Eds.). (1993). Principles and practice of anesthesiology. St. Louis, MO: Mosby Year Book. Stoelting, R.K. (1987). Pharmacology and physiology in anesthetic practice. Philadelphia: J.B. Lippincott Co. 91 Substance Abuse Curriculum: MODULE 2 DIDACTIC UNIT E: Planning for Intervention, Intervention and Aftercare Total Time: 6 hours Overview: Students should be able to effectively plan the intervention process, apply the intervention process, and recommend treatment modalities in recovery. Students should be able to encourage patient and family to initiate and accept treatment by using supportive and unbiased confrontation. Family and patient education and good communication skills will aid the process. Terminal Objective: The student will understand the intervention planning process, how to intervene and the recovery process. Recommended Teaching Methods: Group Process Lecture Discussion Readings Course Outline: XLI. Planning for Intervention A. Prevention 1. Education a. Continuing professional education b. Community education c. Health education and wellness clinics d. Drug free social activities 2. Policy a. Social policy (1) Encourage development of functional family units (2) Education at all levels (3) Education for "high risk" groups (4) Drug free community environments b. Workplace policy (1) support abstinence (2) support education (3) institute employee assistance programs (EAP) c. Family unit policy (1) Clear (a) rules (b) roles (c) rhetoric (communication) 92 (2) Balanced and cooperative efforts to maintain (a) communication (b) power (c) relationships 3. Family interview a.Recognizing dysfunctional family units (1) Arguments (2) Cyclical manipulation (3) Enablers and Caretakers (4) Economic strain (5) Poor interaction (6) Rebellious and alienated (7) History of substance abuse (8) Inadequate parental direction (9) Antisocial behavior b. Impact of substance abuse on (1) Family (2) Colleagues (3) Community (4) Society B. Intervention 1. Goals for intervention 2. Strategies for intervention a. Primary prevention (1) Education with factual information (2) Nonusers (3) Low risk groups (4) Encouraging strong coping attitudes/positive reinforcement b. Intervention with high risk patients (1) Express concern for health (2) Correlate problems with SA (3) Clarify misinterpretations (4) Provide factual information (5) Review all the risks with continued abuse (6) Provide motivation/support for changes (7) Arrange social support (8) Continue relationship for monitoring (9) Negotiate plan for changes in behavior c. Secondary prevention with recovering patient (routine screening reveals abuse) (1) Concern for health (2) Clarify questions (3) Provide factual information 93 (4) Review risks (5) Quantify physical and psychological harm (6) Treatment of medical sequelae (7) Examine social support (8) Counseling for addiction d. Tertiary prevention for relapse (1) Close monitoring (2) Continued education (3) Positive reinforcement of acceptable behavior (4) Continued counseling for recovery e. Promotion of personal health and prevention (1) Promoting health education (2) Social supports which limits SA (3) Community sponsored prevention (4) Provide factual information (5) Reinforce existing plan f. Identification of resources available (1) Therapy (2) Education (3) Evaluation (4) Medical (5) Laboratory testing (6) Interdisciplinary team (7) Professional responsibility of the CRNA (8) Referral resources g. Identification of treatment settings available (1) Support groups (2) Outpatient facilities (3) Inpatient facilities (4) Therapeutic community h. High Risk individuals (1) Quantify risk factors (2) Education and counseling available for family (3) Follow reactions in family (depression, hostility) (4) Immediate referral for therapy (5) Long-term follow-up/monitoring i. Engaging (1) Identify substance(s) being abused (2) Preparation of all participants for effective intervention (3) Collection of data to confront severity of SA disease (4) Team collaboration in diagnosis and planning (5) Implement plan and initiate support for medical consequences (withdrawal, overdose) 94 (6) Initiate treatment (7) Educate individual, colleagues, family, support group (8) Refer patient for long term recovery C. Aftercare/Recovery 1. Motivation of Recovery 2. Referral to support groups 3. Continued education 4. Frequent laboratory testing 5. Promotion of Wellness 6. Positive reinforcement 95 References: American Psychiatric Association. (1997). Diagnostic and statistical manual (DSM-IV). Washington, DC: APA, American Psychiatric Association. Bartlett, E. (1981). The contribution of school health education to community health promotion: What can we reasonably expect? American Journal of Public Health. 71(12), 1384-1391. Beattie, M. (1989). Beyond codependency and getting better all the time. San Francisco: Harper/Hazelden. Bell, C. & Battjes, R. (1985). Prevention research: Deterring drug abuse among children and adolescents. (NIDA Research Monograph No. 63). (DHHS Publication No. ADM 87-1334). Rockville, MD: Department of Health and Human Services, Public Health Service. Bomar, P. (Ed.). (1989). Nurses and family health promotion: Concepts, assessment and interventions. Baltimore: Williams and Wilkins. Dryfoos, J. (1990). Adolescents at risk: Prevalence and prevention. New York: Oxford University Press. Elkin, M. (1984). Families under the influence. New York: W.W. Norton. Fawzy, F.I., Combs, R.H. et.al. (1983). Generational continuity in the use of substances: the impact of parental substance abuse on adolescent use. Addictive Behavior. 8(2), 109-114. Frances, R. & Miller, S. (Eds.). (1991). Clinical textbook of addictive disorders. New York: The Guilford Press. Fossum, M. & Mason, M. (1986). Facing shame: Families in recovery. New York: W.W. Norton. Gawin, F.H. & Ellingwod, E.H. (1988). Cocaine and other stimulants: Action, abuse and treatment. New England Journal of Medicine. 318(18), 1173-1182. Goldstein, D.B. (Ed.) (1983). The pharmacology of alcohol. New York: Oxford Press. Goodman, L.S. & Gilman, A. (1975). The pharmacologic basis of therapeutics. New York: Macmillan Publishing Co. Goplerud, E. (1991). Preventing adolescent drug use: From theory to practice. (DHHS Publication No. ADM 91-1725). Rockville, MD: U.S. Department of Health and Human Services 96 Jones, C. & Battjes, R. (1985). Etiology of drug abuse: Implications for prevention. NIDA Research Monograph 56. (DHHS Publication No. ADM 87-1335). Rockville, MD: Department of Health and Human Services. Kunpfer, K. & Turner, C. (1991). The social ecology model of adolescent substance abuse: Implications for prevention. The International Journal of the Addictions. 25(4A), 435-463. Moskowitz, J. (1989). The primary prevention of alcohol problems: A critical review of the research literature. Journal of Studies of Alcohol. 50(1), 54-88. Nowinski, J. (1990). Substance abuse in adolescents and young adults: A guide to treatment. New York: W.W. Norton and Co. Office for Substance Abuse Prevention. (1991). Parent training is prevention: Preventing alcohol and other drug problems among youth in the family. (DHHS Publication No. ADM 91-1715). Rockville, MD: U.S. Department of Health and Human Services. Pender, N. (1987). Health promotion in nursing practice. Norwalk, Conn.: Appleton and Lange. Rankin, S. & Duffy, K. (1983). Patient education: Issues, principles, and guidelines. Philadelphia: J.B. Lippincott Co. Stuart, G. & Sundeen, S. (1991). Principles and Practice of Psychiatric Nursing. St. Louis, MO: Mosby Year Book. Sullivan, E., Bissell, L., & Williams, E. (1988). Chemical dependency in nursing: The deadly diversion. Menlo Park, CA: Addison-Wesley Publishing. Tanner, E. (1991). Assessment of a health-promotive lifestyle. Nursing Clinics of North America. 26(4), 845-854 U.S. Department of Health and Human Services, Public Health Service. (1990). Healthy people 2000: National health promotion and disease prevention objectives. (DHHS Publication No. PHS 91-50213). Washington, D.C.: Superintendent of Documents, U.S. Government Printing Office. Varcarolis, E. (1990). Foundations of psychiatric mental health nursing. Philadelphia: W.B. Saunders. Verebey, K., Martin, D.M. & Gold, M.S. (1987). Interpretation of drug abuse testing: Strengths and limitations of current methodology. Psychiatric Medicine. 3, 287. 97 Substance Abuse Curriculum: MODULE 2 DIDACTIC UNIT F: Central Concepts and Research Issues in SA Total Time: 2 hours Overview: Students should be introduced to current problems and issues related to SA. This should allow for active discussion of issues and aid in the development of a research project. Terminal Objective: The student will be able to identify current issues and problems related to SA. The discussion of these issues should lead the student to explore ideas toward the development of a research project. Recommended Teaching Methods: Group Process Lecture Discussion Readings Course Outline: XLII. Policy issues A. Social policy 1. Development of substance abuse legislation a. Local b. Regional c. National d. International 2. SA Education effectiveness at all levels 3. General Testing for SA 4. AIDS and SA B. Workplace policy 1. Who is responsible? 2. How should SA be handled in the workplace? C. Family unit policy 1. Balanced and cooperative efforts for a. communication a. power b. relationships 2. Educate family members? D. Dysfunctional family units 1. Treatment of dysfunctional units and components? XLIII. Impact of substance abuse on A. Family 98 B. Colleagues C. Community D. Society E. Adequate utilization of resources? XLIV. Evaluation of SA policy A. Methodology 99 References: Ackerman, R.J. (1987). Children of alcoholics: A bibliography and resource guide, Third Edition.Holmes Beach, FL: Learning Publications, Inc. American Association of Nurse Anesthetist. (1992). Peer Assistance Manual. Chicago, IL: American Association of Nurse Anesthetists. American Nurses' Association. (1988). Standards of addiction nursing practice with selected diagnoses and criteria. Kansas City, MO: American Nurses' Association. Foster, S.D. & Jordan, L.M. (Eds.). (1994). Professional aspects of nurse anesthesia practice. Philadelphia: F.A. Davis Co. Googins, B. (1989). Two parallel plans of attack: Drug testing at the workplace. Employee Assistance.1(8), 1 & 45. Kurtz, N.R., Goggins, B. & Howard, H. (1984). Occupational alcoholism: An annotated bibliography. Toronto, Canada: Addiction Research Foundation. Office of Substance Abuse Prevention. (1990). A practical guide for high-risk youth prevention programming. Rockville, MD: Office of Substance Abuse Prevention. Olson, S. & Gerstein, D.R. (1985). Alcohol in America: Taking action to prevent abuse. Washington, DC: National Academy Press. Schuster, C.R. (1987). The United States' drug scene: An overview. Clinical Chemistry. 33(11B), 7B-12B. Simpson, D.D., George, W.J., & Lehman, W.E.K. (1988). Addiction careers: Summary of students based on the DARP (Drug Abuse Reporting Program) 12 Year Follow-up. Rockville, MD: National Institute on Drug Abuse. Vaillant, G.E. (1983). The natural history of alcoholism. Cambridge, MA: Harvard University Press. 100 Substance Abuse Curriculum: MODULE 2 DIDACTIC UNIT G: Assessment and Screening of SA patients Total Time: 2 hours Overview: This unit will aid in the development of skills in assessing and screening patient patterns of behavior for substance abuse Terminal Objective: The student will understand the clinical diagnostic criteria and screening methods in SA patients. Recommended Teaching Methods: Group Process Lecture Discussion Readings Demonstration Course Outline: XLV. Diagnostic Criteria and assessment of problems in the lifespan. A. Signs and symptoms of SA 1. General appearance a. Tremor b. irritability c. excitability d. Jaundice e. poor appearance 2. Mouth a. Periodontal disease b. coated tongue 3. Face and Hands a. Rosacea, seborrheic dermatitis b. Parotid swelling c. spider nevi d. finger clubbing e. Dupuytren's contracture f. Multiple surgical scars 4. Miscellaneous a. Trauma b. Random blood alcohol > 65 mmol/l c. Random urine testing d. Specific laboratory testing 101 (1) serum y-glutamyl transpeptidase level is raised 70-80% in alcoholic patients (a) one of the best early indicators (2) mean corpuscular volume is raised 75-90% in alcoholic (3) Serum high density lipoprotein cholesterol level is raised 5080% in alcoholic (4) Serum glutamate dehydrogenase level demonstrates lever disease in alcoholic (5) Serum transferrin level is elevated in 80% of alcoholic patients (6) Ratio of z-amino-n-butyric acid to leucine is dependent on patient and nutrition but raised in alcoholic. B. Screening procedures for SA are appropriate during 1. History and physical a. H & P should begin with nonthreatening habits like tobacco use, exercise, alcohol use, then illegal drug use. b. direct communication and observation to determine drug use c. CAGE Questions/MAST/SMAST d. Recognizing Acute illnesses induced by SA e. Recognizing Chronic illness associated with SA 2. Hospital admissions 3. Trauma 4. When symptoms suggest SA 5. Family problems a. Identify family members that may help or abuse 6. Anytime C. Determine patterns of use and establishing diagnosis 1. social use a. Loss of control of drug use 2. physiological need a. tolerance b. withdrawal symptoms c. blackouts d. family history of SA 3. multiple drug use 4. SA a. adverse effects on patient, family, community b. patient's feelings about SA D. Required Communication skills 1. Coping with patient behaviors which influence obtaining an accurate history 2. Encouraging self-disclosure 3. Establishing a relationship 4. Teaching patient and family about SA 102 References: American Nurses' Association. (1988). Standards of addiction nursing practice with selected diagnosis and criteria. Kansas City, MO: ANA Baird, M.A. (1980). Chemical dependency: A protocol for involving the family. Family Systems Medicine. 3, 216-220. Barash, P.G., Cullen, B.F. & Stoelting, R.K. (Eds.). (1989). Clinical anesthesia. Philadelphia: J.B. Lippencott Co. Barnes, H.N., Aronson, M.D. & Delbanco, T.L. (Eds.). (1987). Alcoholism: A guide for the primary care physician. New York: Springer-Verlog Bates, B. (1983). A guide to physical examination. Philadelphia: Lippincott. Brodsley, L. (1982). Avoiding a crisis: The assessment. American Journal of Nursing. 82(12), 1865-1871. Brown, S.A., Christiansen, B.A. & Goldman, M.S. (1987). Alcohol expectancy questionnaire: An instrument for assessment and adult alcohol expectancies. Journal Studies on Alcohol. 48(5), 483-491. Clark, W.D. (1985, Nov.). The medical interview: Focus on alcohol problems. Hospital Practice. pp. 59-68. Clark, W.D. (1981). Alcoholism: Blocks to diagnosis and treatment. American Journal of Medicine. 71, 275-286. Cohen, S. & Gallant, D.M. (1981). Diagnosis of drug and alcohol abuse. Medical Monograph Series. 1(6). Ewing, J.A. (1984). Detecting alcoholism: the CAGE questionnaire. Journal of the American Medical Association. 252, 1905-1907. Gallant, D. (1987). Alcoholism: A guide to diagnosis, intervention, and treatment. New York: W.W. Norton and Co. Holt, S., Skinnor, H.A. & Israel, Y. (1981). Early identification of alcohol abuse: 2. Clinical and Laboratory indicators. Canadian Medical Association Journal. 124, 1279-1299. Milhorn, H.T. (1988). The diagnosis of alcoholism. American Family Practice. 37, 175-183. National Council on Alcoholism. (1972). Criteria for the diagnosis of alcoholism. Annals of 103 Internal Medicine. 77, 249-258. Podrosky, D.L. & Sexton, D.L. (1988, Spr.). Nurses' reaction to difficult patients. Image. 26, 1620. Rogers, M.C., Tinker, J.H., Covino, B.G., & Longnecker, D.E. (Eds.). (1993). Principles and practice of anesthesiology. St. Louis, MO: Mosby Year Book. Schuckit, M. (1979). Drug and Alcohol Abuse: A clinical guide to diagnosis and treatment. New York: Plenum Press. Stoelting, R.K. (1987). Pharmacology and physiology in anesthetic practice. Philadelphia: J.B. Lippincott Co. Tennant, F.S., Day, C.M. & Ungerleider, J.T. (1977). Screening for drug and alcohol abuse in general medical population. Journal of the American Medical Association. 242, 533-535. 104 Substance Abuse Curriculum: MODULE 2 DIDACTIC UNIT H: Individual, Family, and Group Dynamics related to SA Total Time: 2 hours Overview: This unit will aid in the understanding of the impact of SA on the individual, family, and group processes. Identification of problems which lead to SA and poor communication methods will be reviewed. Terminal Objective: The student will understand factors which place individuals at risk for SA. They will be able to describe the correlation between dysfunctional family communication and SA. They will be able to identify critical and common patterns of group communication and education. Recommended Teaching Methods: Group Process Lecture Discussion Readings Demonstration Course Outline: XLVI. Individual communication patterns A. Impact of SA on Individual communications B. Maladaptive patterns C. Marital relationships 1. Domestic violence 2. Child abuse D. Enablers E. Roles of children F. Rituals XLVII. Family communication patterns A. Impact of SA on family communication B. Health Problems C. SA and children D. Theories of family or genetic risk E. Role modeling XLVIII.Group communications patterns A. Support Groups intervention and communication B. Children with HIV C. Emotional support for families of SA patients D. Roles and coping strategies for groups 105 E. Educational intervention F. Prenatal teaching G. Economic ramifications 106 References: Ackerman, R.J. (1987). Children of alcoholics: A bibliography and resource guide, Third Edition. Holmes Beach, FL: Learning Publications, Inc. American Nurses' Association. (1988). Standards of addiction nursing practice with selected diagnosis and criteria. Kansas City, MO: ANA Anderson, E.E. & Quost, W. (1983). Young children in alcoholic families: A mental health needs assessment and intervention/prevention strategy. Journal of Primary Prevention. 3, 174-187. Baird, M.A. (1980). Chemical dependency: A protocol for involving the family. Family Systems Medicine. 3, 216-220. Barnes, H.N., Aronson, M.D. & Delbanco, T.L. (Eds.). (1987). Alcoholism: A guide for the primary care physician. New York: Springer-Verlog Bartlett, E. (1981). The contribution of school health education to community health promotion: What can we reasonably expect? American Journal of Public Health. 71(12), 1384-1391. Blechman, E. (1982). Conventional wisdom about familial contributions to substance abuse. American Journal of Drug and Alcohol Abuse. 9(1), 35-54. Brown, S.A., Christiansen, B.A. & Goldman, M.S. (1987). Alcohol expectancy questionnaire: An instrument for assessment and adult alcohol expectancies. Journal Studies on Alcohol. 48(5), 483-491. Elkin, M. (1984). Families under the influence. New York: W.W. Norton. Ewing, J.A. (1984). Detecting alcoholism: the CAGE questionnaire. Journal of the American Medical Association. 252, 1905-1907. Fisk, N.B. (1986). Alcoholism: Ineffective family coping. American Journal of Nursing. 896(5). 586-587. Fossum, M. & Mason, M. (1986). Facing shame: Families in recovery. New York: W.W. Norton. Gallant, D. (1987). Alcoholism: A guide to diagnosis, intervention, and treatment. New York: W.W. Norton and Co. Holt, S., Skinnor, H.A. & Israel, Y. (1981). Early identification of alcohol abuse: 2. Clinical and Laboratory indicators. Canadian Medical Association Journal. 124, 1279-1299. Kaufman, E. (Ed.). (1983). Power to change: Family case studies in the treatment of alcoholism. 107 New York: Gardner. Milhorn, H.T. (1988). The diagnosis of alcoholism. American Family Practice. 37, 175-183. National Council on Alcholism. (1972). Criteria for the diagnosis of alcoholism. Annals of Internal Medicine. 77, 249-258. Orford, J. & Harwin, J. (1982). Alcohol and the family. New York: Martin's. Podrosky, D.L. & Sexton, D.L. (1988, Spr.). Nurses' reaction to difficult patients. Image. 26, 1620. Rogers, M.C., Tinker, J.H., Covino, B.G., & Longnecker, D.E. (Eds.). (1993). Principles and practice of anesthesiology. St. Louis, MO: Mosby Year Book. Schuckit, M. (1979). Drug and Alcohol Abuse: A clinical guide to diagnosis and treatment. New York: Plenum Press. Stoelting, R.K. (1987). Pharmacology and physiology in anesthetic practice. Philadelphia: J.B. Lippincott Co. Tabakoff, B., Sutker, P. & Randall, C. (1983). Medical and social aspects of alcohol abuse. New York: Plenum Press. Tennant, F.S., Day, C.M. & Ungerleider, J.T. (1977). Screening for drug and alcohol abuse in general medical population. Journal of the American Medical Association. 242, 533-535. 108 Substance Abuse Curriculum: MODULE 2 DIDACTIC UNIT I: Community resources and treatment options Total Time: 1 hours Overview: This unit will discuss the planning, diagnosis and treatment sequence for SA patients. Terminal Objective: The student will be able to recognize, diagnose, as well as plan intervention, treatment, and aftercare. They will be able to discuss diagnosis of substance abuse in their patients. Students will be able to formulate and utilized treatment modalities in the treatment of SA. Recommended Teaching Methods: Group Process Lecture Discussion Readings Role Playing Course Outline: XLIX. Review DSM IV and ICD diagnostic criteria L. Planning A. Subjective B. Objective C. Use of consultants D. Prevention 1. Education 2. Avoidance 3. Recognition of high-risk populations E. Acute management 1. Intoxication 2. Withdrawal 3. Overdose 4. Toxic reactions F. Long-term planning 1. Relationships 2. Types of treatments 3. Pharmacotherapy 4. Collaboration LI. Treatment A. Consequences of routes of administration B. Chronic pathology 109 C. Trauma D. Effects of SA on Mother and Fetus E. Influence on family, work and social environment F. Psychotic response G. Anxiety reaction H. Organic Brain syndrome LII. Community resources available A. Prevention and education B. Treatment and assistance C. Recovery and restoration to productive role in society 110 References: Alexander, B.K. & Hadaway, P. (1982). Opiate addiction: The case for adaptive orientation. Psychological Bulletin. American Nurses' Association. (1988). Standards of addiction nursing practice with selected diagnoses and criteria. Kansas City, MO: American Nurses' Association. American Psychiatric Association. (1997). Diagnostic and statistical manual (DSM-IV). Washington, DC: APA, American Psychiatric Association. Barbarin, O. (1979). Recidivism in drug addiction: A behavioral analysis. Addictive Behaviors. 4(2), 121-132. Bennett, G., Vourakis, C., & Woolf, D. (1983). Substance abuse: Pharmacological, developmental and clinical perspectives. New York: John Wiley. Blume, S.B. (1987). Confidentiality of patient records in alcoholism and drug treatment programs. New York: American Medical Society on Alcoholism and Other Drug Dependencies, Inc. and National Council on Alcoholism, Inc. Bready, L.L. & Smith, R.B. (1987). Decision making in anesthesiology. Toronto, Canada: B.C. Decker, Inc. Brill, L. (1977). The treatment of drug abuse: Evolution of a perspective. American Journal of Psychiatry. 134(2), 157-160. Cadoret, R.J. (1986). An adoption study of genetic and environmental factors in drug abuse. Archives of General Psychiatry. 43(12), 1131-1136. Childress, A.R., McLellan A.T. & O'Brian, C. (1985). Behavioral therapies for substance abuse. International Journal of American Psychiatric Association: Addictions. 20(6 & 7), 947-969. Cooper, J.R., Altman, F., Brown, B.S., Czechowicz, D. (Eds.). (1986). Research on the treatment of narcotic addiction: State of the art. Rockville, MD: National Institute on Drug Abuse. DeLem, G. (1987). Alcohol use among drug abusers: Treatment outcomes in a therapeutic community. Alcoholism: Clinical and Experimental Research. 11(5), 430-436. Dole, V. (1988, Nov.). Implications for methadone maintenance for theories of narcotic addiction. Journal of the American Medical Association. 260,20. Donovan, J.M. (1986). An etiologic model of alcoholism. American Journal of Psychiatry. 143(1), 1-11. 111 Douglas, D.B. (1986). Alcoholism as an addiction: The disease concept reconsidered. Journal of Substance Abuse Treatment. 3(2). Jacobs, P., Laurie, A. & Cuzzi, L. (1983). Coordination of services to methadone mothers and their addicted newborns. Health Social Work. 8(4), 290-298. Raffoul, P.R. (1986). Drug misuse among older people: Focus for interdisciplinary efforts. Health Social Work. 11(3), 197-203. 112 Substance Abuse Curriculum: MODULE 2 CLINICAL UNITS A-I: Increased special skills in clinical planning, recognition, diagnosis, and treatment of SA Total Time: 15 hours Overview: The clinical units will provide the student with the experience to apply scientific knowledge in caring for the SA patient. There will be an extensive opportunity for analyzing and challenging personal attitudes concerning SA. Additionally, there will be an opportunity to engage in multidisciplinary collaboration for SA. One important component of this module is to delve extensively into the interview, diagnosis, treatment and recovery process of the substance abuse patient. Terminal Objective: a) The student should be able to conduct an interview, history, and physical extracting important information from the SA patient. b) Discuss the interview, diagnosis, and treatment options for SA patients. c) Recommend supportive therapy and groups for the prevention, intervention, and recovery process. d) Examine personal values, beliefs, and attitudes concerning SA. e) Identify and begin solidification of a SA research project. Recommended Teaching Methods: Group Process Lecture Discussion Readings Videos Role Playing Case presentations Instructional Activity Sequence: First hour is dedicated to conference time conducted by a clinical faculty member examining the barriers to accurate assessment and collection of data from patients, family and during the physical examination. Second and third hours include a review and demonstration (one-on-one) of the methods for an extensive interview, history and physical using a variety of criteria (DSM IV) and instruments. Fourth hour is for SA self-examination with a clinical counselor. Fifth hour provides the opportunity for recognition of signs and symptoms of SA and discussion of the appropriate treatment plan. Sixth hour allows demonstration of a plan for intervention, basic intervention, and the aftercare process. Seventh hour students should be expected to demonstrate basic treatment and referral skills for the SA patient. 113 Eighth through thirteenth hour provides the student an opportunity to share time with a clinical counselor in the clinical setting examining appropriate cases. Fourteenth hour is a debriefing and discussion of preceding activities and a review of techniques, methods, philosophy, and clinical experiences. Fifteenth hour allows research and solidification of SA research project. Course Outline: LIII. Clinical assessment and diagnostics of SA A. Self-examination and challenging personal prejudices, beliefs, and attitudes on SA B. Performing clinical assessment and diagnostic procedures C. In depth exploration of the relationship between SA and anesthesia D. Familiarization with barriers to patient, family dynamics and physical examination 1. Participation in prevention and treatment programs 2. Discuss and utilize support groups in treating substance abuse E. Utilizing the planning, recognition, diagnostic, and treatment skills in SA 1. Early recognition of SA 2. Diagnosing SA 3. Planning treatment for SA 4. Treatment of SA F. Recognition and management of withdrawal syndromes G. Clinical presentations of appropriate cases for review H. Solidification of research project in SA 114 References: Arif, A., & Westermeyer, J. (Eds.) (1988). Manual of drug and alcohol abuse. New York: Plenum Medical Books Co. Baird, M.A. (1985). Chemical dependency: A protocol for involving the family. Family Systems Medicine. 3, 216-220. Block, M.R. & Coulehan, J.L. (1987, Jan.). Teaching the difficult interview in a required course on medical interviewing. Journal of Medical Education. 62(1), 35-40. Bluhm, J. (1987). When you face the chemically dependent patient: A practical guide for nurses. St. Louis, MO: Ishiyaku EuroAmerica, Inc. Cavanaugh, R.M. (1986, Mar.). Obtaining a personal and confidential history from adolescents. An opportunity for prevention. Journal of Adolescent Health Care. 7(2), 118-122. Chappel, J.H., Veach, T.L. & Krug, R. (1985). The substance abuse attitude survey: An instrument for measuring attitudes. Journal Studies of Alcohol. 46(1), 48-52. Clark, W.D. (1985, Nov.). The medical interview: Focus on alcohol problems. Hospital Practice. pp. 59-68. Clark, W.D. (1981). Alcoholism: Blocks to diagnosis and treatment. American Journal of Medicine. 71, 275-286. Cox, A. (1981). Training guidelines and workbook for the behavioral management of intoxicated and disruptive clients. Toronto, Canada: Addiction Research Foundation. Craig, R.J. (1988). Diagnostic interviewing with drug-abusers. Professional Psychological Research Practice. 19(1), 14-20. Cyr, M.G. & Wartman, S.A. (1988). The effectiveness of routine screening questions in the detection of alcoholism. Journal of the American Medical Association. 259, 51-54. Deveny, P. & Saunders, S. (1986). Physicians' handbook for medical management of alcohol and drug related problems. Toronto, Canada: Addiction Research Foundation. Ewing, J.A. (1984). Detecting alcoholism: The CAGE Questionnaire. Journal of the American Medical Association. 252, 1905-1907. Gitlow, S.E. & Peyser, H.S. (1980). Alcoholism: A practical treatment guide. New York: Grune and Stratton. 115 Holt, S. Skinner, H.A. & Israel, Y. Early identification of alcohol abuse: Clinical and laboratory indications. Canadian Medical Association Journal. 124, 1279-1299. Johnson Institute. (1987). How to use intervention in your professional practice. Minneapolis: Johnson Institute. Johnson Institute. (1979). Chemical dependency and recovery are a family affair. Minneapolis: Johnson Institute. Johnston, L.D., O'Malley, P.M. & Bachman, J.G. (1987). National trends in drug use and related factors among American high school students and young adults, 1975-1986. (DHHS Publication No. ADM 87-1535). Washington, DC: U.S. Government Printing Office. Keltner, N., Schwecke, L., & Bostrom, C. (1991). Psychiatric Nursing: A psychotherapeutic management approach. St. Louis, MO: Mosby-Year Book. Lipkin, M., Quill, T.E. & Napodano, R. (1984). The medical interview: A core curriculum for residencies in internal medicine. Annals of Internal Medicine. 100, 277. Manno, J.E. (1986). Interpretation of urinalysis results. Urine Testing for Drugs of Abuse. Research Monograph Series, No. 73. Rockville, MD: National Institute on Drug Abuse. Milhorn, H.T. (1988). The diagnosis of alcoholism. American Family Physician. 37, 175-183. Miller, M.R. & Hester, R.K. (1986). Inpatient alcoholism treatment: Who benefits? American Psychologist. pp. 794-805. Mumford, E., Anderson, R. Cuerden, T. & Scully, J. (1984). Performance-based evaluation of medical student' interviewing skills. Journal of Medical Education. 59, 133. National Council on Alcoholism. (1972). Criteria for the diagnosis of alcoholism. Annals of Internal Medicine. 77, 249-258. Skinner, H.A., Holt, S., Schuller, R., Roy, J., & Israel, Y. (1984). Identification of alcohol abuse using laboratory tests and a history of trauma. Annals of Internal Medicine. 101, 847-851. Stillman, P.L., Burpeace-DiGregorio, M.Y., Nicholson, G.I., Sabers, D.L., & Stillman, A.E. (1983). Six years of experience using patient instructors to teach interviewing. Journal of Medical Education. 58, 941. Tarter, R. & Hegedus, A. (1991). The drug use screening inventory. Alcohol Health and Research World. 15(1), 65-75. 116 Taylor, R.B. (1982). Health promotion: A guide to clinical practice. Norwalk: Appleton-CenturyCrofts. Tiebout, H.M. (1953). Problems of addiction and habituation. New York: Grune and Stratton. Washton, A.M. & Gold, M.S. (Eds.) (1987). Cocaine. New York: Guilford Press. Weinberg, J.R. (1974). Interview techniques for diagnosing alcoholism. American Family Physician. 9, 107-115. Werner, A. & Schneider, J.M. (1974). Teaching medical students interactional skills: A research based course in the doctor-patient relationship. New England Journal of Medicine. 290, 1232. 117 Formative Evaluation of Module 2 Substance Abuse Curriculum Reference Sheet 1.4 Using the following scale please rate your accomplishments of the objectives in Module 2 including the didactic and clinical components of the substance abuse curriculum. 1-------2-------3-------4-------5 Low Moderate High Accomplishment Level of Accomplishment ____Discussing the physiologic basis of the stages of substance abuse. ____Understanding and discussing the pharmacologic basis and principles of many of the commonly abused substances, their characteristics and clinical manifestations as related to anesthesia. ____Recognizing the prevalence, trends and patterns of substance abuse through the lifespan. ____Understanding the concepts of tolerance, cross-tolerance, drug toxicity, and withdrawal as it relates to substance abuse and anesthesia. ____Planning for intervention, how to intervene and the recovery process. ____Discussing issues and problems related to substance abuse. ____Developing a research project for the topic of substance abuse. ____Developing clinical diagnostic criteria and screening methods for the substance abuse patient. ____Describing the correlation between dysfunctional family communication and substance abuse. ____Recognizing at risk populations. 118 Reference Sheet 1.4 (cont.) ____Identifying common patterns of group communication and education. ____Diagnosing, planning for intervention, treatment, and aftercare of the substance abuse patient. ____Formulating and utilizing treatment modalities in the treatment of substance abuse. ____Conducting an extensive interview, history and physical, extracting important information from the substance abuse patient. ____Collaborating with multiple disciplines concerning substance abuse. ____Recommending supportive therapy and groups. ____Examine personal values, beliefs, and attitudes concerning substance abuse. ____Solidification of research project for the topic of substance abuse. Additional Comments: 119 Substance Abuse Curriculum MODULE 3 DIDACTIC UNIT A: Multisystem physiology in SA - Level III Total Time: 2 hours Overview: This unit will discuss the detailed physiology related to the central nervous system, maternal and the neonatal patient, fetal and newborn addiction, and SA in children addiction. The unit will serve to assist the student in the assessment and diagnostic skills of SA. Terminal Objective: The student will understand the physiologic basis of maternal and fetal addiction, neonatal and newborn addiction, and SA in children. Enhanced knowledge will provide a foundation for supporting the assessment and diagnostic skills of the student. Recommended Teaching Methods: Group Process Lecture Discussion Readings Case examples Course Outline: LIV. Central nervous system A. Neuroanatomy and physiology B. Neural cell C. Neural synapse and transmitters D. Brain 1. Physiology 2. Function a. cognitive b. psychomotor c. affective 3. Gerontologic changes 4. Substance abuse a. specific agents of abuse (1) sites of action b. mechanism of action c. effects 5. SA related Behavior 6. Nutrition E. Psychiatric disorders 120 LV. Maternal and neonatal A. Substance use, misuse, and abuse 1. During pregnancy 2. Post partum 3. Nursing mothers B. Fetal physiological effects of SA C. Neonate drug effects 1. Alcohol syndrome 2. Maternal SA 3. Withdrawal 4. Drugs and fetal development LVI. Children and SA A. Growth and development related to SA B. Substances commonly abused by children 1. Inhalants 2. Tobacco 3. Alcohol 4. Marijuana 5. Cocaine 6. Caffeine 121 References: Abel, E.L. (1984). Pharmacology of alcohol relating to pregnancy and lactation. New York: Plenum Press. Acker, D., Sachs, M.D., Tracy, K.J. & Wise, W.E. (1983). Abruptio placenta associated with cocaine use. American Journal of Obstetrics and Gynecology. 146(2), 120-221. Arif, A., & Westermeyer, J. (Eds.) (1988). Manual of drug and alcohol abuse. New York: Plenum Medical Books Co. Anspaugh, D.J., Hamrick, M.H. & Rosato, F.D. (1991). Wellness: Concepts and applications. St. Louis, MO: Mosby-Year Book. Barten, J. & Talbott, S. (Eds.). (1989). Primary prevention in psychiatry: The state of the art. Washington, D.C.: American Psychiatric Press. Beauvais, F. & Oetting, E.R. (1988). Inhalant abuse by young children. research Monograph, No. 85. (DHHS Publication No. ADM 88-1577). Washington, D.C.: National Institute for Drug Abuse. Bonagura, J.A., Rhonehouse, M. & Bonagura, E.W. (1988). Effectiveness of four school health education projects upon substance use, self-esteem, and adolescent stress. Health Education Quarterly. 15(1), 81-92. Burns, E.M., Thompson, A. & Ciccone, J.K. (Eds.). (1993). An addictions curriculum for nurses and other helping professionals. (Vol. 1 & 2). New York: Springer Publishing Co. Burton, A.C. (1972). A physiology and biophysics of the circulation. Chicago: Year Book Medical Pub. Chasnoff, I.J., Burens, W.J., Schroll, S.H. & Burns, K.A. (1985). Cocaine use in pregnancy. The New England Journal of Medicine. 313(11), 666-669. Chasnoff, I.J., Schroll, S.H., Burns, W.J., & Burns, D. (1984). Maternal non-narcotic substance abuse during pregnancy: Effects on infant development. Neurobehavioral Toxicology and Teratology. 6(4), 277-280. Clark, W.G. et al. (1988). Goth's medical pharmacology. St. Louis, MO: C.V. Mosby Co. Clarren, S.K. (1982). The diagnosis and treatment of fetal alcohol syndrome. Comprehensive Therapy. 8, 41. Cohen, S. & Callahan, J. (Eds.). (1986). A specific approach to the treatment of alcohol abusing 122 patients. New York: Hayworth Press. Coles, C.D., Smith, I.E., Lancaster, J.S. & Flaek, A. (1987). Persistence over the first month of neurobehavioral differences in infants exposed to alcohol prenatally. Infant Behavior and Development. 10(1), 23-37. Fox, N.L., Sexton, M.J. & Hebel, R.J. (1987). Alcohol consumption among pregnant smokers: Effects of smoking cessation intervention program. American Journal of Public Health. 77(2), 211-213. Fried, P.A., Buchingham, M. & Von Kuloniz, P. (1983). Marijuana use during pregnancy and perinatal risk factors. American Journal of Obstetrics and Gynecology. 146(8), 992-994. Frances, R.J. & Miller, S.L. (Eds.). (1991). Clinical textbook of addictive disorders. New York: Guilford Press. Ganong, W.F. (1989). Review of medical physiology. Los Altos: Lange Medical Publications. Goodman, L.S. & Gilman, A. (1975). The pharmacologic_basis of therapeutics. New York: Macmillan Publishing Co. Golden, N.L., Kuhnert, B.R., Sokol, R.J., Martier, S. & Bagby, M.S. (1984). Phencyclidine use during pregnancy. American Journal of Obstetrics and Gynecology. 148(3), 254-259. Goldstein, D.B. (Ed.). (1983). Pharmacology of Alcohol. New York: Oxford University Press. Goudsouzian, N.G. Karamanian, A. (1984). Physiology for the anesthesiologist. New York: Appleton-Century-Crofts. Guyton, A.C. (1986). Textbook of medical physiology. Philadelphia: W.B. Saunders Co. Horowitz, J. (1988). Anesthetic implications of substance abuse in the parturient. Journal of the American Association of Nurse Anesthetists. 56, 510. James, J.E. & Paul, I. (1985). Caffeine and human reproduction. Reviews on Environmental Health. 5(2), 151-167. Lee, M.I., Stayker, J.C. & Sokol, R.J. (1985). Perinatal care for narcotic-dependent gravidas. Perinatology-Neonatology. 9(6), 135-140. Kinney, J. & Leaton, G. (1991). Loosening the grip: A handbook of alcohol information. St. Louis, MO: Mosby-Year Book. 123 Michenfelder, J.D et al. (1969). Neuroanesthesia. Anesthesiology. 30, 65. Miller, R.D. (1990). Anesthesia. New York: Churchill Livingstone. National Institute on Drug Abuse. (1990). NIDA Capsules: CAP01-CAP38. Rockville, MD: National Clearinghouse for Alcohol and Drug Information. Project Cork Institute of Dartmouth Medical School. (1981). Alcohol use and its medical consequences: A comprehensive slide teaching program for biomedical education. Timonium, MD: Milner-Fenwick. Rementeria, J.L. (1977). Drug abuse in pregnancy and neonatal effects. St. Louis, MO: C.V. Mosby. Rogers, M.C., Tinker, J.H., Covino, B.G., & Longnecker, D.E. (Eds.). (1993). Principles and practice of anesthesiology. St. Louis, MO: Mosby Year Book. Rosett, H.L. & Weiner, L. (1984). Alcohol and the fetus: A clinical perspective. New York: Oxford University Press. Stoelting, R.K. (1987). Pharmacology and physiology in anesthetic practice. Philadelphia: J.B. Lippincott Co. Waugaman, W.R., Rigor, B.M., Katz, L.E., Bradshaw, H.W. & Garde, J.F. (1988). Principles and practice of nurse anesthesia. Norwalk, Conn.: Appleton and Lange. 124 Substance Abuse Curriculum: MODULE 3 DIDACTIC UNIT B: Pharmacology - III Total Time: 2-3 hours Overview: This unit serves as a final consolidation of pharmacological principles and the pharmacology of the substances commonly abused. The session is intended to familiarize the participant with the substance abuse as it relates to anesthesia. Terminal Objective: The student will understand the pharmacologic basis and principles of abused substances, their characteristics, and clinical manifestations as they relate to the administration of anesthesia. They will be able to describe the anticipated interaction of abused drugs with anesthetics as well as the effects from polysubstance substance use/abuse. Recommended Teaching Methods: Group Process Lecture Discussion Readings Clinical patient case Course Outline: LVII. Pre Anesthetic considerations for SA A. Laboratory tests 1. Toxicology assays 2. Liver function tests 3. CBC 4. Electrolyte 5. Hepatitis 6. HIV 7. Systemic infections a.Cultures b.Tuberculosis c.Syphilis d.Sepsis 8.Neuroreceptors and transmitters a.Kappa/Mu/others b.Alpha2-receptor agonists B. Drug dependence and premedication 1. Alcohol dependence 2. Opioid dependence 3. Nicotine dependence 125 4. Other drug dependencies 5. Recovering addict 6. Use of Disulfiram (Antabuse) and Naltrexone 7. Use of AZT C.Pharmacokinetic and Pharmacodynamic considerations of abused substances and anesthesia 1. Alcohol 2. Marijuana 3. CNS stimulants 4. Cocaine 5. CNS depressants 6. Narcotics/Heroin/other controlled substances 7. Opiates 8. Semi-synthetic 9. Synthetic 10. Hallucinogens 11. Phencyclidine (PCP) 12. Volatile Inhalants 13. Nicotine 14. Caffeine 15. Anabolic steroids LVIII. Metabolism, clearance, and elimination of substances with regards to anesthesia A. Metabolism 1. Hepatic 2. Renal 3. Biliary 4. Metabolic degradation 5. GABA receptors B. Pharmacologic management of withdrawal 1. Intermittent or recurrent withdrawal 2. Complicated withdrawal 3. Unrecognized withdrawal 4. Preanesthetic transition from abuse to withdrawal 5. Unrecognized medical events interpreted as withdrawal LIX. Anesthetic technique (Drugs used for anesthesia) A. Pharmacologic considerations for anesthetic selection B. Nonpharmacologic intervention (TENS) C. Limitations of the anesthetic technique D. Anesthetic requirements for SA patients LX. Post anesthetic considerations A. Post operative pain control 1. Use of naloxone 2. Methadone use 126 3. Patient controlled analgesia (PCA) units 4. Nonsteroidal antiinflammatory drugs (e.g. Ketorolac) 5. Agonists/Antagonists a. Dezocine b. Butorphanol c. Nalbuphine d. Pentazocine 6. Pharmacologic cross-tolerance B. Recovery and Relapse with pharmacologic intervention 1. Neurochemical mechanisms 2. Psychological mechanisms a.Fear of pain b.Pleasure seeking c.Stress C. Medical care in recovery 1. Treatment strategies a. American Society of Addiction Medicine (ASAM) for medical care in recovery 2. Treatment of Chronic Pain a.Discharge medication b.In active SA patient c.In Recovering SA patient 127 References: Adger, H., DeAngelis, C., & McDonald, E.M. (1986). Model program and curriculum in alcohol and other drug abuse for pediatric medical students, residents and faculty. (National Institute on Drug Abuse. ADM 281-86-0009). Washington, DC: U.S. Government Printing Office. Adler, G.R., Potts, F.E., Kirby, R.R. et al. (1985). Narcotics control in anesthesia training. Journal of the American Medical Association. 253, 3133. Ahmad, G. (1987). Abuse of Phencyclidine (PCP): A laboratory experience. Journal of Clinical Toxicology. 25(4), 341-346. American Society of Anesthesiologists Ad Hoc Committee on the Effect of Trace Anesthetics on the Health of Operating Room Personnel. (1974). Occupational diseases among operating room personnel: A national study. Anesthesiology. 41, 321. Angell, M. (1982). The quality of mercy. New England Journal of Medicine. 306, 98. Antelman, S.M. (1981) Amitriptyline provides long-lasting immunization against sudden cardiac death from cocaine. European Journal of Pharmacology. 69, 119. Barash, P.G., Cullen, B.F. & Stoelting, R.K. (Eds.). (1989). Clinical anesthesia. Philadelphia: J.B. Lippencott Co. Berkowitz, B.A. (1976, Jan.). Relationship of pharmacokinetics to pharmacological activity: Morphine, methadone, naloxone. Clinical Pharmacokinetics. pp. 219-230. Boning, J. (1985). Benzodiazepine dependence: Clinical neurobiological aspects. Advances in Biochemical Psychopharmacology. 40, 185-192. Bruce, D.L. (1983). Alcoholism and anesthesia. Anesthesia and Analgesia. 62, 84. Buckley, M.M.T., Brogden, R.N. (1990). Ketorolac: A review. Drugs. 39, 86. Busto, V. (1986). Patterns of benzodiazepine abuse and dependence. British Journal of Addictions. 81(1), 87-94. Corbett, T.H. (1973). Retention of anesthetic agents following occupational exposure. Anesthesia and Analgesia. 52, 614. Cushman, P. (1986). Sedative drug interactions of clinical importance. Recent Developments in Alcohol. 4, 61-83. DeLander, G.E., Porthoghese, P.S. & Takemori, A.E. (1984). Role of spinal mu opioid receptors 128 in the development of morphine tolerance and dependence. Journal of Pharmacologic Experimental Therapy. 231(1), 91. Elliot, H.W. (1975). Effects of street drugs on anesthesia. International Journal of Clinical Pharmacology. 12, 134. Fabiani, C.A. (1991). From coca chewing to cocaine smoking. Resident Staff Physician. 37, 101. Farley, W.J. & Talbott, G.D. (Eds.). (1983). Anesthesiology and addiction. Anesthesia and Analgesia. 62, 465. Filshie, J. (1988). The non-drug treatment of neuralgic and neuropathic pain of malignancy. Cancer Survey. 7(1), 161. Freund, G. (1984). Biomedical causes of alcohol abuse. Alcohol. 1(2), 129-131. Frost, E.A. (Ed.). (1988). Pre-anesthetic assessment. Boston: Birkhauser. Gawin, F.H. & Ellingwod, E.H. (1988). Cocaine and other stimulants: Action, abuse and treatment. New England Journal of Medicine. 318(18), 1173-1182. Gerard, D.L., Saenger, G. & Wile, R. (1962). The abstinent alcoholic. Archives of General Psychiatry. 6, 83. Gold, M., Pottash, A., Sweeney, D. et al. (1980). Opiate withdrawal using clonidine. A safe, effective, and rapid non-opiate treatment. Journal of the American Medical Association. 243(4), 343. Goldstein, D.B. (Ed.) (1983). The pharmacology of alcohol. New York: Oxford Press. Goodman, L.S. & Gilman, A. (1975). The pharmacologic basis of therapeutics. New York: Macmillan Publishing Co. Grabowski, J. (Ed.). (1984). Cocaine: Pharmacology, effects, and treatment of abuse, NIDA Research Monograph 50. (National Institute on Drug Abuse. ADM 87-1326) Rockville, MD: National Institute on Drug Abuse. Guiffrida, J.G., Bizzarri, D.V., Saure, A.C. et al. (1970). Anesthetic management of drug abusers. Anesthesia and Analgesia. 49(2), 272. Jacobs, M.R. & Fehr, K.O. (1987). Drugs and drug abuse: A reference text. Toronto, Canada: Addiction Research Foundation. 129 Land, W.E.M. & Zakhari, S. (1990). Alcohol and cardiovascular disease. Alcohol Health and Research World. 14(4), 304-312. Malseed, R. (1985). Pharmacology: Drug therapy and nursing considerations. Philadelphia: J.B. Lippincott. McQuay, H. (1988). Pharmacologic treatment of neuralgic and neuropathic pain. Cancer Survey. 7(1), 141. Millan, M. (1986). Multiple opioid systems and pain. Pain. 27, 303. Miller, R.D. (Ed.). (1990). Anesthesia. New York: Churchill Livingstone. O'Brian, J., Benfield, P. (1989). Dezocine: A preliminary review of its pharmacodynamic and pharmacokinetic properties and therapeutic efficacy. Drugs. 38(2), 226. Orkin, L.R. & Chen, C.H. (1977). Addiction, alcoholism and anesthesia. Southern Medical Journal. 70, 1172. Osborne, N.N. (1977). Naloxone alters pain perception and somatosensory evoked potentials in normal subjects. Nature. 270, 620. Peterson, R.G. & Rumack, B.H. (1977). Treating acute acetaminophen poisoning with acetylcysteine. Journal of the American Medical Association. 237, 2406-2407. Physicians' Desk Reference. (1993). Oradell, NJ: Medical Economics Co. Physician' Desk Reference For Nonprescription Drugs. (1993). Oradell, NJ: Medical Economics Co. Pickens, R.W., Svikis, D.S. (Eds.). (1988). Biological vulnerability to drug abuse, NIDA Research Monograph 89. Rockville, MD: National Institute on Drug Abuse. Rogers, M.C., Tinker, J.H., Covino, B.G. & Longnecker, D.E. (Eds.). (1993). Principles and practice of anesthesiology. St. Louis, MO: Mosby Year Book. Scott, L.E., Clum, G.A., & Peoples, J.B. (1983). Preoperative predictors of postoperative pain. Pain. 15, 283. Spiker, D.G., et al. (1975). Tricyclic antidepressant overdose: Clinical presentation and plasma levels. Clinical Pharmacologic Therapy. 18(5), 539-546. Stuart, G. & Sundeen, S. (Eds.). (1986). Principles and practice of psychiatric nursing. St. Louis, 130 MO: C.V. Mosby. Sullivan, J.B. et al. (1979). Management of tricyclic antidepressant toxicity. Topics in Emergency Medicine. 1(3), 65-71. Teped, H. (1985). Biochemical basis of alcoholism: Statements and hypotheses of present research. Alcohol. 2(6), 711-788. Wesson, D. & Smith, D. (1977). Barbiturates: Their uses, misuse and abuse. New York: American Science Press. West, R.J. & Russell, M.A. (1985). Dependence on nicotine chewing gum. Journal of the American Medical Association. 256(23), 3214-3215. 131 Substance Abuse Curriculum: MODULE 3 DIDACTIC UNIT C: AIDS and Substance Abuse Total Time: 1 hour Overview: This unit will discuss the physiologic basis, prevention, precautions and considerations for the HIV positive patient. Terminal Objective: The student will recognize the primary elements in the process of immunosuppression and the cascade of events leading to the deactivation of the immune response. They will be able to identify factors which predispose the substance abuser to AIDS. Students will be able to formulate and utilize preventative treatment modalities for AIDS. Recommended Teaching Methods: Group Process Lecture Discussion Readings Role Playing Course Outline: LXI. Immune response A. Cellular Invasion B. AIDS virus C. Symptoms of AIDS D. At risk populations 1. Cultures 2. Socioeconomic groups E. Spread of AIDS virus 1. Sexual 2. Contaminated needles 3. Suppressed immune system 4. Breast feeding 5. Mother to fetus F. Ethical considerations G. Economic impact LXII. Education 1. Prevention 2. Avoidance 3. Recognition of high-risk populations 4. AIDS resource centers 132 References: AIDS called 'Most threatening' illness in history. (1987, May). U.S. Medicine. Alexander, B.K. & Hadaway, P. (1982). Opiate addiction: The case for adaptive orientation. Psychological Bulletin. American Medical Association. (1987). Prevention and control of AIDS: An interim report. Chicago, IL: Report of the Board of Trustees, AMA American Medical Association. (1972). Human sexuality. Chicago, IL.: AMA Committee on Sexuality. American Nurses' Association. (1988). Standards of addiction nursing practice with selected diagnoses and criteria. Kansas City, MO: American Nurses' Association. American Psychiatric Association. (1997). Diagnostic and statistical manual (DSM-IV). Washington, DC: APA, American Psychiatric Association. Associated Press. (1987, June 15). AIDS treatment costs by mid-1991. Houston Chronicle. estimated at more than $37 Billion Awe, R.J. et al. (1987). AIDS: A guide for survival. Houston, TX: Harris County Medical Society and The Houston Academy of Medicine. Barbarin, O. (1979). Recidivism in drug addiction: A behavioral analysis. Addictive Behaviors. 4(2), 121-132. Bennett, G., Vourakis, C., & Woolf, D. (1983). Substance abuse: Pharmacological, developmental and clinical perspectives. New York: John Wiley. Blume, S.B. (1987). Confidentiality of patient records in alcoholism and drug treatment programs. New York: American Medical Society on Alcoholism and Other Drug Dependencies, Inc. and National Council on Alcoholism, Inc. Broder, S. (1987). Identification of therapies against the retroviruses. Annals of Internal Medicine. pp.569-574. Clark, M. & Gonzalez, D.L. (1987, July). The mosquito AIDS scare. Newsweek. Conant, M.S. (1987, June). Confronting AIDS in primary care. Patient Care. DeVita, V.T. (1987). Developmental therapeutics and the acquired immunodeficiency syndrome. Annals of Internal Medicine. 106, 56-71. 133 Drew, L. (1987, June). The problem with testing. Newsweek. Fischl, M.A. (1987). Evaluation of heterosexual partners, children and household contacts of adults with AIDS. Journal of the American Medical Association. 257(5). Gordon, S. & Gordon, J. (1983). Raising your child conservatively in a sexually permissive world. New York: Simon and Schuster. Groopman, J.E. (1987, June). Taking care of AIDS patients. The Internist. If your test for antibody to the AIDS virus is positive... (1986, Oct.). American Red Cross. Jabs, C. (1987, Jan.). Safe sex. Self. Kaus, M. (1987, July 13). The small health problem' of AIDS. Newsweek. O'Brien, K.J. (1987, Apr.). Will the nation's health insurers survive the AIDS epidemic. The Internist. Smilgis, M. (1987, Feb. 16). The big chill: Fear of AIDS. Time. Stengel, R. (1985, Dec. 9). Children having children. Time. 134 Substance Abuse Curriculum: MODULE 3 DIDACTIC UNIT D: Special At Risk Populations Total Time: 2 hours Overview: This unit will discuss the populations who are at risk for substance abuse. The unit will aid in the implementation of educational and preventative programs for a Drug free environment. Terminal Objective: The student will formulate and implement an educational and preventative programs for their community. They will be able to identify factors which predispose the individual to substance abuse. Recommended Teaching Methods: Group Process Lecture Discussion Readings Role Playing Course Outline: LXIII. Educating Role of the CRNA in the community and for "At Risk" Populations A. Defining basic terms for the community B. Discussing drugs and drug effects commonly used C. Relating reasons for SA D. Describing ethnic and age differences in SA E. Reviewing physical illnesses related to SA F. Reviewing psychological illnesses related to SA G. Listing support groups and community organizations that aid in the prevention of SA and the substance abuser H. Commenting on the ethical, moral, and legal considerations regarding SA I. Denoting the economic impact of SA J. Encouraging the use of counseling and treatment to reduce incidence LXIV. Education about critical patterns of SA A. Behaviors B. Family and social influences C. Growth and development patterns D. Child health 1. Well baby clinics 2. School SA program References: American Medical Association. (1987). Prevention and control of AIDS: An interim report. 135 Chicago, IL: Report of the Board of Trustees, AMA American Medical Association. (1972). Human sexuality. Chicago, IL.: AMA Committee on Sexuality. American Nurses' Association. (1988). Standards of addiction nursing practice with selected diagnoses and criteria. Kansas City, MO: American Nurses' Association. American Psychiatric Association. (1997). Diagnostic and statistical manual (DSM-IV). Washington, DC: APA, American Psychiatric Association. Arkin, E.B. & Funkhouser, J.E. (Eds.). (1990). Communicating about alcohol and other drugs: Strategies for reaching populations at risk. Rockville, MD: U.S. Department of Health and Human Services, Office for Substance Abuse Prevention. Arneson, S.W., Triplett, J.L. Schweer, K.D. & Snider, B.C. (1983). Children of alcoholic parents: Identification and intervention. Children's Health Care. 11, 107-112. Associated Press. (1987, June 15). AIDS treatment costs estimated at more than $37 Billion by mid-1991. Houston Chronicle. Awe, R.J. et al. (1987). AIDS: A guide for survival. Houston, TX: Harris County Medical Society and The Houston Academy of Medicine. Baily, G.W. (1989). Current perspectives on substance abuse in youth. Journal of the American Academy of Child and Adolescence Psychiatry. 28, 151-162. Barbarin, O. (1979). Recidivism in drug addiction: A behavioral analysis. Addictive Behaviors. 4(2), 121-132. Barten, J. & Talbott, S. (Eds.). (1989). Primary prevention in psychiatry: The state of the art. Washington,D.C.: American Psychiatric Press. Beck, K.H. (1990). Monitoring parent concerns about teenage drinking and driving: A random digit dial telephone survey. American Journal of Drug and Alcohol Abuse. 16, 109-124. References: Bennett, G., Vourakis, C., & Woolf, D. (1983). Substance abuse: Pharmacological, developmental and clinical perspectives. New York: John Wiley. Beauvais, F. & Oetting, E.R. (1988). Inhalant abuse by young children. Research Monograph No. 85. (DHHS Publication No. ADM 88-1577). Washington, D.C.: National Institute on Drug Abuse. 136 Black, C. (1982). It will never happen to me. Denver: MAL Books. Blume, S.B. (1987). Confidentiality of patient records in alcoholism and drug treatment programs. New York: American Medical Society on Alcoholism and Other Drug Dependencies, Inc. and National Council on Alcoholism, Inc. Bonagura, J.A., Rhonehouse, M. & Bonagura, E.W. (1988). Effectiveness of four school health education projects upon substance use, self-esteem, and adolescent stress. Health Education Quarterly. 15(1), 81-92. Broder, S. (1987). Identification of therapies against the retroviruses. Annals of Internal Medicine. pp.569-574. Brown, S.A., Christiansen, B.A. & Coldman, M.S. (1987). The alcohol expectancy questionnaire: An instrument for the assessment of adolescent and adult alcohol expectancies. Journal of Studies on Alcohol. 48, 483-491. Caudill, B. (1989). Project impact: A national study of high school substance abuse intervention training. Journal of Alcohol and Drug Education. 35, 61-74. Clark, M. & Gonzalez, D.L. (1987, July). The mosquito AIDS scare. Newsweek. Crumley, F.E. (1990). substance abuse and adolescent suicidal behavior. Journal of the American Medical Association. 263, 3051-3056. DeVita, V.T. (1987). Developmental therapeutics and the acquired immunodeficiency syndrome. Annals of Internal Medicine. 106, 56-71. Drew, L. (1987, June). The problem with testing. Newsweek. Fischl, M.A. (1987). Evaluation of heterosexual partners, children and household contacts of adults with AIDS. Journal of the American Medical Association. 257(5). Globetti, G. (1988, Winter). alcohol education and minority youth. Journal of Drug Issues. pp. 115-129. Gordon, S. & Gordon, J. (1983). Raising your child conservatively in a sexually permissive world. New York: Simon and Schuster. Greenspan, S.I. (1985). Research strategies to identify developmental vulnerabilities for drug abuse. Research Monograph No. 56. Washington, D.C.: National Institute for Drug Abuse. pp 136-154. 137 Grenier, C. (1985). Treatment effectiveness in an adolescent chemical dependency treatment program: A quasiexperimental design. International Journal of the Addictions. 20, 381-391. Jabs, C. (1987, Jan.). Safe sex. Self. Lewis, C.E. & Lewis, M. (1984). Peer pressure and risk-taking behaviors in children. American Journal of Public Health. 74, 580-584. McDonald, D.I. (1989). Drugs, drinking, and adolescents. Chicago: Year Book Medical Publishers. Natapoff, J. & Weiczorek, R.R. (Eds.). (1990). Maternal child health policy: A nursing perspective. New York: Springer. National Institute on Drug Abuse. (1991). National household survey on drug abuse: Main findings 1990. (DHHS Publication No. ADM 91-1788). Rockville, MD: U.S. Department of Health and Human Services. Pentz, M.A., Dwyer, J.H., Mackinnon, D.P., et al. (1989). A multicommunity trial for primary prevention of adolescent drug abuse. Journal of the American Medical Association. 261, 32593266. Riley, K. & Klockars, A.J. (1984). A critical reexamination of the adolescent alcohol involvement scale. Journal of Studies on Alcohol. 45, 184-187. Stengel, R. (1985, Dec. 9). Children having children. Time. U.S. Department of Education. (1988). Drug prevention curricula: A guide to selection and implementation. Washington, D.C.: Office of Educational Research and Improvement. Wegscheider, S. (1981). Another chance. Palo Alto, CA: Science and Behavior Books. 138 Substance Abuse Curriculum: MODULE 3 DIDACTIC UNIT E: Interprofessional networking Total Time: 1 hour Overview: This unit will introduce the student to professionals who practice outside their clinical settings. They will participate in discussions that plan education and treatment for communities, professional groups and SA patients. Terminal Objective: The student will be able to participate with professionals outside the immediate clinical setting and provide education for communities and professional groups. They will be able to discuss available resources regarding substance abuse. Students will be able to formulate a collaborative network of professionals in the area of substance abuse. Recommended Teaching Methods: Group Process Lecture Discussion Readings Site visits Course Outline: LXV. Individual experiences for collaboration in SA A. Recognizing, isolating, and identifying professionals in the clinical setting. 1. Professional teachers in the clinical setting. 2. Professionals in collaboration with the clinical faculty. 3. Personnel who provide support services to the clinical setting. 4. Use of consultants for collaborative purposes B. Leadership roles in the field of SA as a professional 1. Commitment to a profession LXVI. Group experiences for collaboration in SA A.Recognizing, isolating, and identifying professionals in community groups 1. Networking and socialization within the community 2. Developing an identity as a successful leader in groups 3. Methods for conducting meetings and collaborative networking within the community 4. Use of community groups for collaboration LXVII. Community resources available for networking A. Education B. Prevention C. Treatment and assistance D. Recovery and restoration to productive role in society 139 References: Alexander, B.K. & Hadaway, P. (1982). Opiate addiction: The case for adaptive orientation. Psychological Bulletin. American Nurses' Association. (1988). Standards of addiction nursing practice with selected diagnoses and criteria. Kansas City, MO: American Nurses' Association. American Psychiatric Association. (1997). Diagnostic and statistical manual (DSM-IV). Washington, DC: APA, American Psychiatric Association. Barbarin, O. (1979). Recidivism in drug addiction: A behavioral analysis. Addictive Behaviors. 4(2), 121-132. Bard, R., Bell, C.R., Stephen, L. & Webster, L. (1987). The trainer's professional development handbook. San Francisco: Jossey-Bass. Batten, Joe D. Tough-minded Leadership. New York: AMACOM, 1989. Bennett, G., Vourakis, C., & Woolf, D. (1983). Substance abuse: Pharmacological, developmental and clinical perspectives. New York: John Wiley. Blume, S.B. (1987). Confidentiality of patient records in alcoholism and drug treatment programs. New York: American Medical Society on Alcoholism and Other Drug Dependencies, Inc. and National Council on Alcoholism, Inc. Bready, L.L. & Smith, R.B. (1987). Decision making in anesthesiology. Toronto, Canada: B.C. Decker, Inc. Brill, L. (1977). The treatment of drug abuse: Evolution of a perspective. American Journal of Psychiatry. 134(2), 157-160. Cadoret, R.J. (1986). An adoption study of genetic and environmental factors in drug abuse. Archives of General Psychiatry. 43(12), 1131-1136. DeLem, G. (1987). Alcohol use among drug abusers: Treatment outcomes in a therapeutic community. Alcoholism: Clinical and Experimental Research. 11(5), 430-436. DePree, Max. Leadership is an Art. New York: Dell Publishing, 1989. Dole, V. (1988, Nov.). Implications for methadone maintenance for theories of narcotic addiction. Journal of the American Medical Association. 260, 20. Gardner, John. On Leadership. New York: The Free Press, 1990. 140 Jacobs, P., Laurie, A. & Cuzzi, L. (1983). Coordination of services to methadone mothers and their addicted newborns. Health Social Work. 8(4), 290-298. Kotter, John P. A Force for Change: How Leadership Differs from Management. New York: The Free Press, 1990. Kran, K.E. (1984). Mentoring at work: Developmental relationships in organizational life. Glenview, IL: Scott, Foresman. Levinson, D.J. (1978). The seasons of a man's life. New York: Knopf. Lipnack, J. & Stamps, J. (1982). Networking: People connecting with people, linking ideas and resources. New York: Doubleday. Raffoul, P.R. (1986). Drug misuse among older people: Focus for interdisciplinary efforts. Health Social Work. 11(3), 197-203. Smith, L & Wagner, P. (1980). The networking game. Denver: Network Resources. 141 Substance Abuse Curriculum: MODULE 3 DIDACTIC UNIT F: Methods of prevention for SA Total Time: 2 hours Overview: Students should be able to effectively identify and plan the prevention process, apply the prevention process, and recommend modalities in prevention. Students should be able to encourage patient, families, groups, and communities to initiate prevention by using sound and supportive educational methods. Terminal Objective: The student will understand the preventative process, how to implement preventative methodologies, and evaluate the outcomes of those techniques. Recommended Teaching Methods: Group Process Lecture Discussion Readings Course Outline: LXVIII. Planning for Prevention A. Prevention 1. Education a. Continuing professional education b. Participating in community education c. Health education and wellness clinics d. Drug free social activities 2. Promoting health a. Developing goals for improved community health b. Education concerning the safe use of drugs and alcohol c. Teaching safe sex d. Describing good nutritional habits e. Encouraging exercise f. Aiding in smoking cessation exercises g. Teaching relaxation techniques (1) Hypnosis (2) Biofeedback (3) Reflexology (4) Touch Therapy (5) Acupuncture (6) Time management h. Teaching conflict resolution 142 (1) Problem-solving methods (2) Support groups i. Supporting the use of community support groups and resources 3. Community educational participation a. Supporting community action b. Participating in community support groups and agencies c. Improving social perception and laws related to SA d. Creating a network of professionals e. Support drug free environments f. Aid institutions in developing a rational substance free environment 143 References: Bartlett, E. (1981). The contribution of school health education to community health promotion: What can we reasonably expect? American Journal of Public Health. 71(12), 1384-1391. Beattie, M. (1989). Beyond codependency and getting better all the time. San Francisco: Harper/Hazelden. Bell, C. & Battjes, R. (1985). Prevention research: Deterring drug abuse among children and adolescents. (NIDA Research Monograph No. 63). (DHHS Publication No. ADM 87-1334). Rockville, MD: Department of Health and Human Services, Public Health Service. Bomar, P. (Ed.). (1989). Nurses and family health promotion: Concepts, assessment and interventions. Baltimore: Williams and Wilkins. Clarke, M. (1984). Stress and coping: Constructs for nursing. Journal of Advanced Nursing. 9, 313. Clarke, C. (1986). Wellness: Concepts, theory, research and practice. New York: Springer Publishing. Dryfoos, J. (1990). Adolescents at risk: Prevalence and prevention. New York: Oxford University Press. Elkin, M. (1984). Families under the influence. New York: W.W. Norton. Fawzy, F.I., Combs, R.H. et.al. (1983). Generational continuity in the use of substances: the impact of parental substance abuse on adolescent use. Addictive Behavior. 8(2), 109-114. Fossum, M. & Mason, M. (1986). Facing shame: Families in recovery. New York: W.W. Norton. Goldstein, D.B. (Ed.) (1983). The pharmacology of alcohol. New York: Oxford Press. Goplerud, E. (1991). Preventing adolescent drug use: From theory to practice. (DHHS Publication No. ADM 91-1725). Rockville, MD: U.S. Department of health and Human Services Haberman, P.W. (1987). Alcohol use and alcoholism among motor vehicle driver fatalities. International Journal of the Addictions. 22(11), 1119-1128. Hutchinson, S. (1988). Self-care and job stress. Image. 19, 192-196. Jones, C. & Battjes, R. (1985). Etiology of drug abuse: Implications for prevention. NIDA 144 Research Monograph 56. (DHHS Publication No. ADM 87-1335). Rockville, MD: Department of Health and Human Services. Knopping, P., & Maultsby, M. (1977). Rational self-counseling: Primary prevention for alcohol abuse. Alcohol Health and Research World. 2(1), 31-35. Knox, J.M. (1988). Drinking, driving and drugs. New York: Chelsea House Publishers. Kunpfer, K. & Turner, C. (1991). The social ecology model of adolescent substance abuse: Implications for prevention. The International Journal of the Addictions. 25(4A), 435-463. Lexy, S. (1983). Managing the drugs in your life: A personal guide to the responsible use of drugs, alcohol, and medicine. New York: McGraw-Hill. Moskowitz, J. (1989). The primary prevention of alcohol problems: A critical review of the research literature. Journal of Studies of Alcohol. 50(1), 54-88. Nowinski, J. (1990). Substance abuse in adolescents and young adults: A guide to treatment. New York: W.W. Norton and Co. Nurse, A.R. (1982). The role of alcohol in relationship to intimacy. Journal of Psychoactive Drugs. 14(1-2), 159-162. Office for Substance Abuse Prevention. (1991). Parent training is prevention: Preventing alcohol and other drug problems among youth in the family. (DHHS Publication No. ADM 91-1715). Rockville, MD: U.S. Department of Health and Human Services. Pender, N. (1987). Health promotion in nursing practice. Norwalk, Conn.: Appleton and Lange. Pinto, R.P., Abrams, D.B., Monti, P.M., & Jacobus, S.I. (1987). Nicotine dependence and likelihood of quitting smoking. Addictive Behaviors. 12(4), 371-374. Rankin, S. & Duffy, K. (1983). Patient education: Issues, principles, and guidelines. Philadelphia: J.B. Lippincott Co. Rindor, I. (1978). The effects of marijuana: A social-psychological interpretation. Psychiatry. 41, 202-206. Sanchez-Craig, M. (1985). Patterns of alcohol use associated with self-identified problem drinking. American Journal of Public Health. 75(2), 178-180. Scott, C., & Hawk, J. (1986). Heal thyself: The health of health care professionals. New York: Brunner/Mazel. 145 Tanner, E. (1991). Assessment of a health-promotive lifestyle. Nursing Clinics of North America. 26(4), 845-854 U.S. Department of Health and Human Services, Public Health Service. (1990). Healthy people 2000: National health promotion and disease prevention objectives. (DHHS Publication No. PHS 91-50213). Washington, D.C.: Superintendent of Documents, U.S. Government Printing Office. 146 Substance Abuse Curriculum: MODULE 3 DIDACTIC UNIT G: Impaired Practitioners and Recovery Total Time: 3-4 hours Overview: This unit will discuss the health care practitioner population who are impaired. The unit will aid in placing into perspective the historical components, implications, and the recovery process of impaired professionals. The unit will also address the symptoms, planned intervention, intervention, and recovery process. Terminal Objective: The student will be able to describe the symptoms and patterns of use for an impaired professional. They will be able to describe the legal, moral and ethical implications of an impaired professional as related to the individual, the community, and society. The student will be able to formulate and implement a plan for intervention and recovery of impaired practitioners. Recommended Teaching Methods: Group Process Lecture Discussion Readings Role Playing Course Outline: LXIX. Historical components of substance abuse by health practitioners A. Substance abuse and the Ancients B. European medical professionals and drug experimentation C. Early American use and abuse of drugs D. Literature reviewing SA among CRNAs LXX. Prevalence of SA among professionals A. Predisposition to SA by professional practitioners B. Talbott's "Conspiracy of Silence" C. Critical patterns of SA 1. Disciplinary actions 2. Voluntary treatment 3. Intervention and Recovery D. Impaired professionals and punitive outcomes LXXI. Substance abuse the "Disease" A. Symptoms of addicted professionals 1. Behaviors 2. Physical signs 3. Economic problems 147 B. Occupational hazards concerning SA 1. Availability of drugs 2. Stress 3. Limited socialization LXXII. Administration and SA A. Responsibilities of Management B. Policies and procedures for SA C. Behavior 1. Recording patterns 2. Administrators response 3. Colleagues response 4. Family response D. Intervention for the impaired professional E. Recovery and aftercare of the impaired professional F. Employee Assistance Programs (EAP) G. Referral for colleagues H. Contracts for colleagues returning to work LXXIII. Ethical, moral and value conflicts of the impaired professional A. AANA and ANA Professional codes for SA B. Ethical dilemmas for reporting colleagues C. Ethical concerns for patient safety LXXIV. Peer Assistance and Recovering professionals A. Role and responsibility B. Continuing education in SA C. Support groups for 1. Impaired professional 2. Colleagues 3. Family D. Networking 148 References: American Association of Nurse Anesthetist. (1992). Peer Assistance Manual. Chicago, IL: American Association of Nurse Anesthetists. American Nurses' Association. (1988). Standards of addiction nursing practice with selected diagnoses and criteria. Kansas City, MO: American Nurses' Association. American Nurses' Association. (1984). Addictions and psychological dysfunctions in nursing. Kansas City, MO: American Nurses' Association. American Psychiatric Association. (1997). Diagnostic and statistical manual (DSM-IV). Washington, DC: APA, American Psychiatric Association. Anthony, W. A. (1972). Societal rehabilitation: Changing society's attitudes toward the physical and mentally disabled. Rehabilitation Psychology. 19, 117-126. Assareh, S. (1987). Substance abuse testing in the workplace: A review. American Association of Occupational Health Nursing Journal. 35(5), 204-209, 246-248. Barten, J. & Talbott, S. (Eds.). (1989). Primary prevention in psychiatry: The state of the art. Washington,D.C.: American Psychiatric Press. Bennett, G., Vourakis, C., & Woolf, D. (1983). Substance abuse: Pharmacological, developmental and clinical perspectives. New York: John Wiley. Bissell, L. & Jones, R.W. (1976). The alcoholic physician: A survey. American Journal of Psychiatry. 133, 1142-1146. Bissell, L. & Jones, R.W. (1981). The alcoholic nurse. Nursing Outlook. 29(2), 96-101. Bissell, L. & Haberman, P. (1984). Alcoholism in the professionals. New York: Oxford University Press. Bissell, L. & Royce, J. (1987). Ethics for addiction professionals. Center City, MN: Hazelden Foundation. Black, C. (1982). It will never happen to me. Denver: MAL Books. Blume, S.B. (1987). Confidentiality of patient records in alcoholism and drug treatment programs. New York: American Medical Society on Alcoholism and Other Drug Dependencies, Inc. and National Council on Alcoholism, Inc. Bok, S. (1987). Whistleblowing and professional responsibilities. New York University 149 Education Quarterly. 11(4), 2-10. Burkhalter, P. (1975). Alcoholism, drug abuse and addiction: A study of nursing education. Journal of Nursing Education. 14, 30-35. Cannon, B.L. & Brown, J. S. (1988). Nurses' attitudes toward impaired colleagues. Image. Summary 20, 9-101 Carter, A.J. (1983). Nurses: Alcohol and drug abuse training in nursing schools. Alcohol Health and Research World. 8, 24-29. Clark, M. (1988). Preventing drug dependency: Part I, recognizing risk factors. Journal of Nursing Administration. 191(1), 21-26. Clark, M.D. (1988). The recovering nurse: The employment interview. Nursing Management. 19, 33-37. Clement, S. (1986). The identification of alcohol-related problems by general practitioners. British Journal of Addiction. 81, 257-264. Cross, L. (1985). Chemical dependency in our ranks. Nursing Management. 16, 15-16. Dogoloff, L. & Angarola, R. (1985). Urine testing in the workplace. New York: American Council for Drug Education. Drew, L. (1987, June). The problem with testing. Newsweek. Estes, N.J. & Heinemann, M.E. (Eds.). (1986). Alcoholism: Development, consequences, and interventions. St. Louis, MO: C.V. Mosby. Greenspan, S.I. (1985). Research strategies to identify developmental vulnerabilities for drug abuse. Research Monograph No. 56. Washington, D.C.: National Institute for Drug Abuse. pp 136-154. Gurel, M. (1976). An alcoholism training program: Its effect on trainees and faculty. Nursing Research. 25, 127-132. Haack, M. & Hughes, T. (1987). Addiction in the nursing profession: Approaches to intervention and recovery. New York: Springer Publishing. Helwick, S. A. (1985). Substance abuse education in medical school: Past, present, and future. Journal of Medical Education. 60(9), 707-711. 150 Hoffman, A.L. & Estes, N.J. (1986). A tool for measuring body and behavioral experiences. Alcohol Health and Research World. 11(1), 26-29. Holder, J.P. (1986). The effects of clinical education setting on student anxiety levels. Journal of the American Association of Nurse Anesthetists. 54, 537. Holmes, P.R. (1975). The many faces of alcoholism. Supervisor Nurse. 6(9), 16-19. Kilty, K. (1975). Attitudes toward alcohol and alcoholism among professionals and non professionals. Journal of Studies on Alcohol. 36(3), 327-347. Lewis, C.E. & Lewis, M. (1984). Peer pressure and risk-taking behaviors in children. American Journal of Public Health. 74, 580-584. Long, P. Gelfand, G., & McGill, D. (1991). Inclusion of alcoholism and drug abuse content in curricula of varied health care professions. Journal of the New York State Nurses Association. 22(1), 9-12. McAuliffe, W.E. (1984). Nontherapeutic opiate addiction in health professionals: A new form of impairment. American Journal of Drug and Alcohol Abuse. 10, 1-22. McDonough, J.P. (1990). Personality, addiction and anesthesia. Journal of the American Association of Nurse Anesthetists. 58(3), 193-200. Murphy, S.A. (1991). An empirically based substance abuse course for graduate students in nursing. Journal of Nursing Education. 30(6), 274-277. Naegle, M. (1985). Creative management of impaired nursing practice. Nursing Administration Quarterly. 9(3), 16-26. National Institute on Drug Abuse. (1991). National household survey on drug abuse: Main findings 1990. (DHHS Publication No. ADM 91-1788). Rockville, MD: U.S. Department of Health and Human Services. Norris, J., Pierson, F. & Waugaman, W. (1988). Critical factors associated with substance abuse and chemical dependency in nurse anesthetists. Journal of Alcohol and Drug Education. Winter, 6-11. Smith, D.E. & Seymour, R. (1985). A clinical approach to the impaired health professional. International Journal of Addictions. 39, 1327-1332. Siegal, H. & Rudisill, J.R. (1983). Teaching medical students about substance abuse in a weekend intervention program. Journal of Medical Education. 58(4), 322-327. 151 Spencer, F.L. (1988). Attitudes of registered nurses toward their peers who are perceived as substance abusers: Abstract. Association of Black Nursing Faculty in Higher Education Newsletter. 1(4). Sullivan, E.J., Bissell, L. & Williams, E. (1987). Chemical dependency in nursing: The deadly diversion. Redwood City, CA: Addison-Wesley Publishing. Swenson, I. Havens, B. & Champagne, M. (1987). Interpretations of state board criteria and disciplinary procedures regarding impaired nurses. Nursing Outlook. 35, 108-110. U.S. Department of Education. (1988). Drug prevention curricula: A guide to selection and implementation. Washington, D.C.: Office of Educational Research and Improvement. Ward, C.E. (1983). Drug use in anesthesia training programs. Journal of the American Medical Association. 250, 922-926. Wegscheider, S. (1981). Another chance. Palo Alto, CA: Science and Behavior Books. 152 Substance Abuse Curriculum: MODULE 3 CLINICAL UNITS A-I: Advanced clinical medical sequelae, diagnosis, and treatment of SA Total Time: 15 hours Overview: The clinical units will provide the student with advanced experience to apply scientific knowledge in caring for the SA patient. There will be an extensive opportunity for employing knowledge and skills concerning the SA patient. Additionally, there will be an opportunity to engage in multidisciplinary collaboration and networking of community organizations for the treatment of SA. One important component of this module is to delve extensively into the diagnosis, intervention, treatment and recovery process of the substance abuse patient. Terminal Objective: a) The student should be able to conduct an interview, history, and physical, screening questions and follow-up history, evaluation of laboratory data to establish a diagnosis of SA. b) Conduct a family interview to establish and discuss the diagnosis and work with denial of SA. c) Initiate a referral for further assessment and treatment to a local community resource. d) Participate in a formal intervention session under the supervision of a trained SA professional. e) Present and disseminate the SA research project. Recommended Teaching Methods: Group Process Lecture Discussion Readings Videos Role Playing and videotaped sessions Case presentations Instructional Activity Sequence: First hour is dedicated to conference time conducted by a clinical faculty member examining the process of relating the diagnosis, intervention and working with denial. Second and third hours include a participation in the methods for an extensive interview, history and physical using a variety of criteria, mnemonics, laboratory tests, and other instruments. Fourth through the seventh hours are for participating in advanced or upper level group sessions under the direction of a clinical faculty counselor. Eighth through tenth hours provides the opportunity to present a diagnosis of SA, intervene, and work with denial. Eleventh through twelfth hours allow demonstration of a plan for intervention, basic intervention, referral skills and the aftercare process. 153 Thirteenth and Fourteenth hours allow students to disseminate results from research projects. Fifteenth hour students should be debriefed for the previous activities allowing for expression of feelings and supporting reflection into areas needing improvement. Course Outline: LXXV. Clinical assessment and diagnostics of SA A. Performing clinical assessment and diagnostic procedures B. Advanced exploration of the interpretation of data concerning SA C. Participating in family intervention 1. Planning the process 2. Intervention 3. Working with denial 4. Recovery and aftercare contracts D. Utilizing diagnostic, and treatment skills in SA 1. Detailed history and physical for SA 2. Diagnosing SA 3. Detailed history from family 4. Planning Treatment for SA 5. Referral of SA patient 6. Follow-up history E. Presentations of appropriate cases for review F. Presentation of SA research project G. Debriefing concerning experiences in SA education 154 References: Arif, A., & Westermeyer, J. (Eds.) (1988). Manual of drug and alcohol abuse. New York: Plenum Medical Books Co. Baird, M.A. (1985). Chemical dependency: A protocol for involving the family. Family Systems Medicine. 3, 216-220. Block, M.R. & Coulehan, J.L. (1987, Jan.). Teaching the difficult interview in a required course on medical interviewing. Journal of Medical Education. 62(1), 35-40. Bluhm, J. (1987). 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(1988). Diagnostic interviewing with drug-abusers. Professional Psychological Research Practice. 19(1), 14-20. Cyr, M.G. & Wartman, S.A. (1988). The effectiveness of routine screening questions in the detection of alcoholism. Journal of the American Medical Association. 259, 51-54. Deveny, P. & Saunders, S. (1986). Physicians' handbook for medical management of alcohol and drug related problems. Toronto, Canada: Addiction Research Foundation. Ewing, J.A. (1984). Detecting alcoholism: The CAGE Questionnaire. Journal of the American Medical Association. 252, 1905-1907. 155 Gitlow, S.E. & Peyser, H.S. (1980). Alcoholism: A practical treatment guide. New York: Grune and Stratton. Holt, S. Skinner, H.A. & Israel, Y. Early identification of alcohol abuse: Clinical and laboratory indications. Canadian Medical Association Journal. 124, 1279-1299. Johnson Institute. (1987). How to use intervention in your professional practice. Minneapolis: Johnson Institute. Johnson Institute. (1979). Chemical dependency and recovery are a family affair. Minneapolis: Johnson Institute. Johnston, L.D., O'Malley, P.M. & Bachman, J.G.(1987). National trends in drug use and related factors among American high school students and young adults, 1975-1986. (DHHS Publication No. ADM 87-1535). Washington, DC: U.S. Government Printing Office. Keltner, N., Schwecke, L., & Bostrom, C. (1991). Psychiatric Nursing: A psychotherapeutic management approach. St. Louis, MO: Mosby-Year Book. Lipkin, M., Quill, T.E. & Napodano, R. (1984). The medical interview: A core curriculum for residencies in internal medicine. Annals of Internal Medicine. 100, 277. Manno, J.E. (1986). Interpretation of urinalysis results. Urine Testing for Drugs of Abuse. Research Monograph Series, No. 73. Rockville, MD: National Institute on Drug Abuse. Milhorn, H.T. (1988). The diagnosis of alcoholism. American Family Physician. 37, 175-183. Miller, M.R. & Hester, R.K. (1986). Inpatient alcoholism treatment: Who benefits? American Psychologist. pp. 794-805. Mumford, E., Anderson, R. Cuerden, T. & Scully, J. (1984). Performance-based evaluation of medical student' interviewing skills. Journal of Medical Education. 59, 133. National Council on Alcoholism. (1972). Criteria for the diagnosis of alcoholism. Annals of Internal Medicine. 77, 249-258. Skinner, H.A., Holt, S., Schuller, R., Roy, J., & Israel, Y. (1984). Identification of alcohol abuse using laboratory tests and a history of trauma. Annals of Internal Medicine. 101, 847-851. Stillman, P.L., Burpeace-DiGregorio, M.Y., Nicholson, G.I., Sabers, D.L., & Stillman, A.E. (1983). Six years of experience using patient instructors to teach interviewing. Journal of Medical Education. 58, 941. 156 Tarter, R. & Hegedus, A. (1991). The drug use screening inventory. Alcohol Health and Research World. 15(1), 65-75. Taylor, R.B. (1982). Health promotion: A guide to clinical practice. Norwalk: Appleton-CenturyCrofts. Tiebout, H.M. (1953). Problems of addiction and habituation. New York: Grune and Stratton. Washton, A.M. & Gold, M.S. (Eds.) (1987). Cocaine. New York: Guilford Press. Weinberg, J.R. (1974). Interview techniques for diagnosing alcoholism. American Family Physician. 9, 107-115. Werner, A. & Schneider, J.M. (1974). Teaching medical students interactional skills: A research based course in the doctor-patient relationship. New England Journal of Medicine. 290, 329. 157 Formative Evaluation of Module 3 Substance Abuse Curriculum Reference Sheet 1.5 Using the following scale please rate your accomplishments of the objectives in Module 3 including the didactic and clinical components of the substance abuse curriculum. 1-------2-------3-------4-------5 Low Moderate High Accomplishment Level of Accomplishment ____Understanding the physiologic basis of maternal and child, fetal, neonatal and newborn addiction. ____Discuss the pharmacologic basis and principles of abused substances, their clinical manifestations as they relate to anesthesia. ____Anticipating interactions of abused drugs and polysubstance abuse with anesthetics. ____Recognizing the primary elements in the process of immunosuppression and deactivation of the immune response. ____Identifying factors which predispose substance abusers to AIDS. ____Formulating preventative treatment modalities for AIDS. ____Developing and presenting educational and prevention programs for communities concerning substance abuse. ____Networking with professionals outside the immediate clinical setting, discussing resources available and formulating a collaborative network of professionals in the area of substance abuse. ____Implement preventative methodologies and evaluate the outcomes. 158 Reference Sheet 1.5 (cont.) ____Diagnosing the symptoms and patterns of use in the impaired professional. ____Describing the legal, moral, and ethical implications of the impaired professional and how they relate to the individual, the community, and society. ____Implementing a plan for intervention, treatment and recovery of the impaired professional. ____Conducting an interview, history, physical, interpretation of laboratory data, screening questions, and follow-up history ____Conducting a family interview discussing diagnosis and working with denial. ____Initiate referral for future assessment and treatment to local community resources. ____Participation in formal intervention sessions with trained substance abuse professionals. ____Presenting and disseminating the substance abuse research project. Additional Comments: 159 Summative Evaluation Substance Abuse Curriculum Reference Sheet 1.6 Using the scale please rate your level of accomplishment for the learning objectives for the entire substance abuse curriculum. 1--------2--------3--------4--------5 Low Moderate High Accomplishment Level of Accomplishment ____Identifying familiar behavior patterns in the chemically dependent. ____Recognizing the common medical outcomes of the substance abuser. ____Discussing the treatment modalities utilized for the chemically dependent. ____Developing personal insight into values, attitudes, behaviors, and morals concerning substance abuse. ____Describing the effects of substance abuse on the family unit and special populations that are affected by substance abuse. ____Describing the moral, cultural, ethical, legal, and social considerations in chemical dependency. ____Demonstrating the basic skills for diagnosis, intervention, and employment of treatment for the substance abuser. ____Identifying the appropriate collaborative course in the prevention, intervention, and treatment of substance abusers. ____Describing the role of the nurse anesthetist in the prevention of substance abuse. ____Engaging effectively in research of substance abuse. 160 Reference Sheet 1.6 (cont.) ____Demonstrating an active effort to change personal negative attitudes and stereotypes regarding chemical dependency and the substance abuser. ____Evaluating the effectiveness of efforts in prevention, intervention, and treatment of substance abuse. ____Formulating steps to respond to chemical abuse patterns. ____Demonstrating a change in the values, beliefs, perceptions and stereotypical attitudes of the learner. ____Demonstrating an active role in the education and dissemination of substance abuse information in the community. Additional Comments: 161 Substance Abuse Post-test Module 3 Reference Sheet 1.7 Please rate your skill in performing each of the following clinical duties concerning the substance abuse (SA) patient and using the following scale. 1-----2-----3-----4-----5 Low Moderate High Skill Skill Skill Skill Level _______ 1. Composing a problem list of the physiological concerns of the SA patient. _______ 2. Discussing the epidemiology of SA. _______ 3. Identifying the characteristics of commonly abused substances. _______ 4. The pharmacological principles to consider for SA. _______ 5. Defining the DSM IV diagnostic criteria and performing intervention. _______ 6. Discussing the etiology of SA. _______ 7. Recognizing the legal, ethical, and moral issues in SA. _______ 8. Demonstrate basic assessment and diagnostic skills for SA. _______ 9. patient and family. Recognizing the attitudinal obstacles to good communication with the SA _______ Dealing with an impaired colleague. 10. 162