Blog 3- Vulnerable Population: Veterans

 Vulnerable Population: Veterans

 

Vulnerable populations are groups that are at high risk for health disparities and health problems (Sussman & Sinclair, 2022). The health disparities and problems are due to socially or economically disadvantages (Sussman & Sinclair, 2022).  I have cared for many veterans in my nursing career, and I have witnessed firsthand the vulnerability and difficulties many of them face. Veterans have higher risks for mental health disorders, substance use, homelessness and suicide (Johnson et al., 2013).

 (We the Veterans, 2024).

 

Homelessness

Veterans have a greater risk of homelessness than the general population.  Twelve to thirty three percent of homeless adults are veterans (Johnson et al., 2013).  Risk factors for homelessness among both veterans and nonveterans include substance abuse, mental abuse, physical abuse, lack of support, lack of affordable housing, and lack of employment (Johnson et al., 2013). For veterans, additional risk factors include post-traumatic stress disorder (PTSD), traumatic brain injury (TBI) and multiple deployments (Johnson et al., 2013). The military culture often correlates seeking help as a sign of weakness (Johnson et al., 2013). 

(Thurston, 2022).

(Pinkston, 2024).

 

Substance Abuse

Substance use disorder (SUD) rates continue to climb in the veteran population (Teeters et al., 2017). Specific environmental stressors are linked to the increase of SUD in military veterans, including deployment, combat exposure, and post-deployment reintegration problems (Teeters et al., 2017). SUDs can also form due to PTSD and depression (Teeters et al., 2017). Histories of trauma, such as child abuse, have been shown to increase the risk of SUD in veterans.  Often these victims join the military to escape their negative home environment (Teeters et al., 2017).

 

Treatment Options

Behavioral and pharmacological treatments are available to help reduce SUDs among veterans.  Psychotherapy interventions include short term cognitive behavioral therapy interventions which focus on thoughts and behaviors associated with increased cravings to substances (Teeters et al., 2017).  Motivational interviewing focuses on engaging veterans to seek treatment (Teeters et al., 2017).

To engage the younger veterans in treatment, Facebook and social media have helped recruit those with SUD to start treatment or seek options (Teeters et al., 2017).  I think using social media will continue to target the younger population.  It will be interesting to see what the continuing development of new technologies will bring to make treatment available and enticing to those who need it.

Medications including methadone, suboxone and naltrexone are approved by the FDA to treat opioid use disorders (Teeters et al., 2017).

(What can be treated through telehealth, n.d.)

41% of veterans live rurally, resulting in lack of access to care.  Increases in telehealth treatment services have advantages including higher attendance, reduced stigma felt by patients, and reduced costs of travel (Teeters et al., 2017).

.

Substance use After Incarceration (Research article)

A study by Barry et al (2023) looked at the risk of SUD related emergency room visits and hospitalizations and overdoses among veterans who reenter the community after incarceration versus veterans who have never been in prison. Data was collected using national VA and Medicare healthcare systems data (Barry et al., 2023).  The research proved that veterans reentering the community after incarceration had double the risk of experiencing SUD related hospital visits.  These results prove how vulnerable the incarcerated veteran population is. 

https://pubmed.ncbi.nlm.nih.gov/36781577/ 

 

 

References

Barry, L. C., Steffens, D. C., Covinsky, K. E., Conwell, Y., Boscardin, J., Li, Y., & Byers, A. L. (2023). High risk of substance use disorder–related outcomes in veterans released from correctional facilities in mid to late life. Journal of General Internal Medicine, 38(5), 1109–1118. https://doi.org/10.1007/s11606-023-08057-y   

Johnson, B. S., Boudiab, L. D., Freundl, M., Anthony, M., Gmerek, G. B., & Carter, J. (2013). Enhancing Veteran-centered care. American Journal of Nursing, 113(7), 24-39. https://doi.org/10.1097/01naj.0000431913.50226.83

Pinkston. (2024, July 19). The State of Veteran Homelessness [2024] - Mission Roll Call. Mission Roll Call. https://missionrollcall.org/veteran-voices/articles/the-state-of-veteran-homelessness-2024/

 Sussman, S., & Sinclair, D. L. (2022). Substance and behavioral addictions, and their consequences among vulnerable populations. International Journal of Environmental Research and Public Health, 19(10), 6163. https://doi.org/10.3390/ijerph19106163

Teeters, J., Lancaster, C., Brown, D., & Back, S. (2017). Substance use disorders in military veterans:Prevalence and treatment challenges. Substance Abuse and Rehabilitation, Volume 8(1), 69–77. https://doi.org/10.2147/sar.s116720

Thurston, A. (2022, November 9). Why Veterans Remain at Greater Risk of Homelessness. Boston University; The Brink. https://www.bu.edu/articles/2022/why-veterans-remain-at-greater-risk-of- homelessness/

We the Veterans. (2024). We the Veterans. We the Veterans . https://www.wetheveterans.us/ 

What can be treated through telehealth? | Telehealth.HHS.gov.         (n.d.). Telehealth.hhs.gov. https://telehealth.hhs.gov/patients/what-can-be-treated-through-telehealth

 

Blog 2- The Stigma Around Addiction

 What is stigma?

    Stigma is the negative beliefs, attitudes, or perceptions that can lead to discrimination and separate one group or person from the rest of society (Judd et al., 2021).  Unfortunately, opioid use addiction is the most stigmatized health condition in the world (Cheetham et al., 2022).  Society often views opioid addiction as a personal choice rather than a disease (Cheetham et al., 2022).  The public views those with opioid use addiction as dangerous, manipulative, and undeserving of health care benefits, housing, and resources for food (Cheetham et al., 2022).

 (Substance Use Services Blog Series, 2020).

Why Does Stigma Exist?

Stigma exists because of the lack of knowledge the public has on the disease of addiction (Cheetham et al., 2022).  The public often hears the negative aspects of addiction through the media, such as the news (Cheetham et al., 2022).  The news is known for portraying the negative side of stories for a more dramatic reaction from the public.  How often do we hear the positive aspects of improvement in opioid treatment facilities on the news? Never. Usually the news talks about the number of overdoses and deaths that follow addiction. 

          Stigma can also exist because of the policies and regulations around treatment (Cheetham et al., 2022).  Methadone and suboxone clinics have strict rules for treatment, including drug testing, amounts of doses that can be filled at once, where the medication can be picked up, and who is allowed to prescribe the medication (Cheetham et al., 2022). The public forms a negative stigma around treatment because of all the rules that exist.   

What Are The Effects of Stigma?

    Stigma makes it difficult for those with opioid addiction to find quality health care.  Many providers refuse to care for patients who suffer from addiction because of the monitoring, regulations, and rules around treatment plans (Cheetham et al., 2022). Providers have a fear that their reputations will be ruined (Cheetham et al., 2022). Providers also feel that these patients are difficult to manage because they have a difficult time achieving pain control and are often looked at as "drug seeking" (Cheetham, et al., 2022).  I am ashamed to admit this, but I hear the "drug-seeking" comment at least once a shift from providers and healthcare workers caring for those with opioid use addiction.  I can understand the frustration providers feel when their patients state their pain is a 10/10 while they are relaxing on their phones, texting, and smiling.  Believe me, I get it.  It is not our job to treat these patients with any lack of respect, judgment, or slang language including "drug-seeker".  It is never acceptable. 

Confronting the Stigma of Opioid Addiction in Nassau County FL. (n.d.)

  Stigma can also cause a patient to lose social support and go into isolation (Christie, 2021).  The shame from the stigma of opioid use addiction can lead to weaker relationships among friends and families (Christie, 2021). This isolation also leads to a lower desire to seek treatment opportunities which ultimately can lead to overdoses and mortality (Christie, 2021).   

How Can We Avoid Stigma?

    To avoid stigma, it is important to educate the public on addiction (Cheetham et al., 2022).  The public needs to see that addiction is a disease and not a choice and that it can be treated successfully (Cheetham et al., 2022).  The public needs to see videos such as Andrew Allen's interview from Husson University ( linked below). 

 

https://husson.instructure.com/courses/2029948/files/164206902?module_item_id=39648104

In this interview, Andrew does an amazing job explaining how his addiction started, how it impacted his life, and how he never lost hope in finding treatment.  Stories like Andrew's will speak to the public in a positive light.

    Stigma can also be avoided by using destigmatizing language when discussing cases of patients with opioid use disorder (Cheetham et al., 2022). The words we choose to use are influential on the attitudes and beliefs of those around us (Cheetham et al., 2022).  For example, using the term "druggie" should be replaced with "a person who suffers from opioid use addiction" (Cheetham, et al., 2022). The healthcare community as a whole needs to educate all staff about destigmatizing language in hopes of decreasing the stigma around addiction.

References

Cheetham, A., Picco, L., Barnett, A., Lubman, D. I., & Nielsen, S. (2022). The impact of stigma on people with opioid use disorder, opioid treatment, and policy. Substance Abuse and Rehabilitation, 13(13), 1–12. https://doi.org/10.2147/SAR.S304566

Christie, N. (2021). The role of social isolation in opioid addiction. Social Cognitive and Affective Neuroscience, 16(7), 645–656. https://doi.org/10.1093/scan/nsab029

Confronting the Stigma of Opioid Addiction in Nassau County FL. (n.d.). https://www.nassaufldrugprevention.org/what-is-stigma

Judd, H., Meier, C. L., Yaugher, A. C., Campbell, E., & Atismé-Bevins, K. (2021). Opioid use disorder stigma reduction through story telling narrative and sharing: A qualitative review and lessons learned. International Journal of Mental Health and Addiction, 21(1). https://doi.org/10.1007/s11469-021-00606-y

Substance Use Services Blog Series: Different Kinds of Stigma, Shame, and Self-Compassion. (2020, June 18). Deltassist Family and Community Services Society. https://deltassist.com/substance-use-services-blog-series-different-kinds-of-stigma-shame-and-self-compassion

Blog 2- Opioid Use Treatment

 

Pharmacological

The most widely prescribed pharmacological opioid treatment medication is methadone and buprenorphine, or Suboxone (Patel et al., 2021).  Methadone can help neuropathic pain and opioid intolerance and mimics the effects of both morphine and heroin (Patel et al., 2021).  Suboxone also can be used to treat pain but has a less withdrawal effects than methadone (Patel et al., 2021).  Methadone and suboxone both involve regulations for prescribing, including only being dispensed through certified treatment programs (Patel et al., 2021).

(What Is Methadone And How Does It Really Work? , n.d.).

Barriers to pharmacological treatment

                When first starting methadone, it must be taken every 8 to 12 hours (Patel et al., 2021).  This is difficult for patients because it can only be dispensed at a certified treatment center.  These treatment centers may not always be at a close distance to patients.  Especially if patients can’t drive, transportation to the treatment centers may be very difficult and stressful (Patel et al., 2021). Lifting regulations around dispensary rules will allow patients to fill these medications like the rest of their medications and allow them to take their medications at home (Patel et al., 2021).

                Only 6% of physicians have received the authorization waiver to prescribe suboxone, which leaves many counties in the United States without a physician who can prescribe suboxone for treatment.  This number is concerning, especially regarding the lack of care those with opioid use addiction receive.  Many physicians admit to lacking knowledge, education, and experience in prescribing suboxone and have little interest in participating in the training to be certified in prescribing suboxone (Patel et al., 2021).  Education around addiction, treatment, and prescribing suboxone and methadone needs to be done at a graduate level.  Mandated training and certification can help increase access to physicians able to prescribe these medications (Patel et al., 2021).

Contingency Management

Contingency management is proven to be one of the most effective treatments for opioid addiction, but it is rarely used in healthcare (Patel et al., 2021).  It uses positive reinforcement to reward those who submit negative drug tests (Patel et al., 2021). Rewards such as vouchers for money, food, and gift cards are given to those who continuously provide negative drug screens (Patel et al., 2021).  This seems like a great system to provide positive reinforcement to those struggling with opioid abuse, but I honestly have never heard of this!  I have taken care of hundreds of patients who have a substance use disorder and have never heard them mention contingency management before.   

(Stock, 2024).

     Barriers to contingency management of course include funding (Patel et al., 2021). Who would fund all of these prizes?   An idea for funding could be through donations of treatment centers and rehabilitation centers.

References

Patel, K., Bunachita, S., Agarwal, A. A., Lyon, A., & Patel, U. K. (2021). Opioid use disorder: Treatments and barriers. Cureus, 13(2). https://doi.org/10.7759/cureus.13173

Stock, P. (2024). Prizes Stock Illustrations – 7,636 Prizes Stock Illustrations, Vectors & Clipart - Dreamstime. Dreamstime. https://www.dreamstime.com/illustration/prizes.html

What Is Methadone And How Does It Really Work? (n.d.). Methadone.org. https://www.methadone.org/

Blog one: The Social Determinants of Health

What are the social determinants of health?

Social determinants of health are the non-medical factors that influence health outcomes and health inequities (Glenn et al., 2024).  These factors include access to health care, education, environment, social support, and economic stability (Glenn et al., 2024).  Not only do social determinants of health exist at an individual level, but also on a community level.

Why are they important?

 I never learned about the social determinants of health in my undergraduate schooling.  The focus of education was geared more towards treating a patient’s medical condition and diagnosis as opposed to their non-medical factors.  I became more aware of the social determinants of health as I practiced as a registered nurse. Caring for my patients on the front line showed me how the variety of different environments, education levels, and social supports affect the health of my patients.  I started to see patterns such as uncontrolled diabetes or hypertension in my homeless diabetic patients or increased exacerbations in my chronic obstructive pulmonary disease (COPD) patients who either smoke or are exposed to secondhand smoke.  It was clear that their environments were directly affecting their health.  If healthcare professionals do not try to resolve the factors involved with social determinants of health, they will continue to treat the negative effects of these factors repeatedly.  This increases healthcare costs, leads to crowded emergency departments, and increases healthcare provider burnout (Glenn et al., 2024).

Responsibility of healthcare professionals?

I believe that healthcare professionals must screen for any issues with their patient’s social determinants of health because of their strong effect on patient health outcomes.  However, I will admit that the job is easier said than done.  Many offices are utilizing screening tools to assess limitations in social determinants of health and recording data so that it can be used to assess the needs of the community (Glenn et al., 2024).  I do believe other disciplines such as social work or case managers can assist the provider in discussing resources and community assistance programs once a provider identifies a need, but I do not agree that this job solely belongs to outside disciplines.

A study by Glenn et al. (2024) shows that providers believe the social determinants of health affect their patients but feel as though their healthcare organizations limit their ability to appropriately address their needs. Many barriers exist in the screening of the determinants of health including time (Glenn et al., 2024). Providers feel as though they don’t have adequate time in their scheduled appointments to discuss a patient’s non-clinical needs (Glenn et al., 2024).  Time seems nonexistent in healthcare right now.  Not only are patients waiting extensive amounts of time to receive an appointment time, but once they arrive, they often are rushed in and out because of the provider’s heavy schedules.  I currently work in an inpatient hospital setting.  I often see providers poke their heads in and out of a patient room in less than one minute for their “visit” of the day.  How can a patient even have the time to bring up an issue like food insecurity or lack of funds to pick up their prescription when the provider sees them for sixty seconds?

Providers must inform their organizations of the barriers they may face to adequately screen and identify needs in a patient’s social determinants of health.  Healthcare professionals need to be educated in their schooling about the importance of identifying patient’s needs and how the determinants of health affect health outcomes. Healthcare providers need to collaborate with community-based organizations and advocate for health policy and system changes to dig into the causes of needs in social determinants of health.

Barriers to acceptance

How many healthcare professionals reading this blog have spent most of their shift addressing a need a patient may have for them to decline the help?  I remember working closely with discharge planners to find a transitional bed for a homeless patient.  They declined the help and left the hospital the same way they arrived…homeless.  It is hard to accept.  I wanted to yell “FINE, see you back here in a few days!” But of course, I couldn’t.

A study done by Pfeiffer et al. (2022) proves that patients decline assistance because of the stigma that their community associates with accepting help.  Many patients feel embarrassed to admit they need help and feel as though they are failing their families (Pfeiffer et al., 2022). Providers need to understand that patients may feel ashamed to accept help.  It may even take a handful of appointments and discussions before a patient accepts assistance.  Establishing a trusting relationship with a patient takes time.  Healthcare professionals must remain non-judgmental to help promote honesty and compliance with their patients.  I know this is also easier said than done!

                                                              References

Glenn, J., Kleinhenz, G., Jenna M., Smith, R., Victor B.A., Donoso, P. G., Stone, S., Hanson, C. L., Redelfs, A. H., & M. Lelinneth. (2024). Do healthcare providers consider the social determinants of health? Results from a nationwide cross-sectional study in the United States. BMC Health Services Research, 24(1). https://doi.org/10.1186/s12913-024-10656-2

Pfeiffer, E. J., De Paula, C. L., Flores, W. O., & Lavallee, A. J. (2022). Barriers to patients’ acceptance of social care interventions in clinic settings. American Journal of Preventive Medicine, 63(3), S116–S121. https://doi.org/10.1016/j.amepre.2022.03.035