CE: Acute Pain Management for People with Opioid Use Disorder.

: Medication-assisted treatment for opioid use disorder (OUD), which incorporates methadone, buprenorphine, or naltrexone, has been shown to reduce all-cause mortality rates in patients with this disease-and the numbers of patients receiving such treatment is substantial. In 2016, among U.S. patients with OUD, nearly 350,000 were treated with methadone, more than 60,000 were treated with buprenorphine, and more than 10,000 were treated with naltrexone. Managing acute pain in patients receiving this treatment can be a significant nursing challenge. The authors discuss the attributes of the three medications used to treat OUD and, through a composite patient case, review how to manage acute pain effectively in patients receiving this type of treatment.This article is one in a series on palliative care developed in collaboration with the Hospice and Palliative Nurses Association (https://advancingexpertcare.org), which offers education, certification, advocacy, leadership, and research on palliative care.

A systematic nurse-led approach to withdrawal risk screening, prevention and treatment among inpatients with an alcohol use disorder in an ear, nose, throat and jaw surgery department-A formative evaluation.

INTRODUCTION: Among patients with head and neck cancer comorbid alcohol use disorder is frequent which contributes to higher risk of developing perioperative alcohol withdrawal syndrome/delirium or delirium due to medical conditions. Although guidelines emphasize prevention and treatment of alcohol withdrawal in hospitalized patients, a validated systematic approach for management of these patients is still lacking. Our aim was to formatively evaluate our newly developed systematic approach in view of nurses' adherence to screening patients for regular alcohol consumption and managing their withdrawal symptoms using the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised. METHODS: We conducted a formative evaluation to improve the project's design and performance and used a retrospective chart review in a consecutive sample of all adult inpatients with head and neck cancer being assigned for surgery in a university hospital. Our bundle of interventions consisted of nurses' screenings for regular alcohol consumption, withdrawal risk assessment, offering patients a substitution therapy, nurses' assessments of withdrawal symptoms and symptom oriented withdrawal management. Proximate endpoints were analyzed descriptively at each component of the bundle in terms of frequencies and severity of withdrawal symptoms, frequencies of nurses' and doctors' screenings and nurses' assessments performed as required. RESULTS: Between 2013 and 2014, 87 inpatients met inclusion criteria and screenings by doctors/ nurses revealed 49 alcohol consumers, where six screenings were omitted by nurses and six by doctors. Twenty-one consumers were at risk and six of them developed an alcohol withdrawal syndrome. None of the 87 showed an alcohol withdrawal delirium, but five developed a delirium due to medical conditions. Nurses correctly conducted all preventive elements of the intervention bundle in 14 (58%) patients at risk but overall, only performed 50% of the required assessments. CONCLUSIONS: Although nurses safely managed patients' symptoms, nurses' adherence to the interventions was suboptimal and requires stronger leadership.

Adolescents at risk: pain pills to heroin: part II.

Casually exposing adolescents to prescription opioid agents may escalate to daily use. A trend exists for adolescents using prescription opioid agents to substitute heroin because it is significantly cheaper than pills (approximately half of the cost) and is often more readily available. Additionally, it is more potent than most prescription opioid agents and carries increased risks of overdose and death. Although treatment for substance use disorders has traditionally centered on total abstinence, opioid replacement therapy (ORT) is an option that saves lives and prevents overdose deaths. In the United States, ORT is based on two medicines: methadone and buprenorphine. These drugs can be substituted for other opiate agents and have much lower overdose risks. Nursing implications and web-based resources for teaching are presented.

[Motivating discussions, change of attitude and handling with stress - nursing aspects of smoking cessation]. / Motivierende Gespräche, Verhaltensänderung und Stressbewältigung - Pflegerische Aspekte der Entwöhnung.

Smoking cessation is a hard process. Encouragement and assistance are necessary! As a specialist for smoking cessation, you have to provide a good advisory service. That means, you have to solve the expected problems and to give the patient useful tips so he can spend this painful time with success. It is important to motivate the patient again and again, to give him a concept helping to change his habits and be able to cope with this stressful situation.

Potential adverse effects of discontinuing psychotropic drugs. Part 3: Antipsychotic, dopaminergic, and mood-stabilizing drugs.

Abrupt discontinuation of antipsychotic drugs in patients with schizophrenia is associated with earlier, and often more severe, illness episodes than are seen with gradual discontinuation. Antipsychotic drugs can cause various abnormal motor syndromes, but abruptly stopping them has been associated with the seemingly paradoxical development of similar motor syndromes, such as withdrawal dyskinesias, parkinsonian symptoms, dystonias, and neuroleptic malignant syndrome. Dopamine-releasing and dopamine-agonist drugs are used to treat some of the motor syndromes caused by antipsychotic drugs, but their abrupt discontinuation can also be associated with abnormal syndromes. When antipsychotic drugs, lithium, or certain anticonvulsant drugs are used for treatment of bipolar disorder, rapid versus gradual discontinuation is more likely to lead to greater mood instability and manic relapse. If necessary, these medications should be gradually tapered to minimize all types of adverse discontinuation effects. Patients should be educated about the possible adverse effects of abrupt medication discontinuation.

What do midwives need to understand/know about smoking in pregnancy?

AIM: This paper seeks to help midwives more fully understand smoking in pregnancy, particularly from a midwifery partnership perspective. METHOD: Using the midwifery philosophy of partnership as a framework for reviewing literature on smoking in pregnancy, we explored the literature on nicotine metabolism and addiction in general, and the changes that occur in pregnancy. Quit smoking interventions commonly used were examined to see if knowledge about addiction and the physiological adaptations of pregnancy are incorporated into anti-smoking efforts aimed at pregnant women. RESULTS: Quitting is harder for the pregnant woman because the physiological adaptations of pregnancy increase the clearance of nicotine thus lowering nicotine levels and increasing the desire to smoke. Women who continue to smoke generally have fewer external sources of pleasure and satisfaction in their lives, which, when combined with the physiological and emotional challenges of pregnancy, means that they are less likely to quit smoking and remain abstinent. These factors do not appear to be taken into account for pregnant smokers. The concept of partnership between women and midwives during anti-smoking interactions is lacking. CONCLUSION: Midwives are in a position to support women and their families in all health related issues, including smoking cessation. We recommend that midwives ask permission before making enquires about sensitive issues such as smoking. When discussing smoking with pregnant women, midwives work within the philosophy of midwifery, with the emphasis on building trust and maintaining relationships. Great sensitivity is required and as much as possible the conversation should be a dialogue, not a monologue.

Dexamethasone therapy in patients with brain tumors--a focus on tapering.

Administration of corticosteriods in brain tumor patients requires an understanding of the physiology of the adrenal system and desired patient response. Close attention to other concomitant medications will ensure adequate amounts of all drugs, including dexamethasone. Nurses need to assess patients' tolerance of dexamethasone, discuss these findings with physicians and pharmacists, and educate both patients and family members on doses and tapering schedules tailored to individual patient needs.

Assessing the impact of a nurse-led health education intervention for people with peripheral vascular disease who smoke: the use of physiological markers, nicotine dependence and withdrawal.

This study evaluated the impact of a nurse-led health education programme on the behaviour, nicotine dependence and nicotine withdrawal in patients who smoke and suffer from peripheral vascular disease, based in a large teaching hospital in the north of England. Smoking behaviour was measured by self report, end-expired carbon monoxide and urinary cotinine. Nicotine dependence and withdrawal were measured using a nicotine dependence scale and a nicotine withdrawal scale. The findings demonstrated that the programme did have some impact on behaviour. The study raised issues concerning the measurement of physiological markers for smoking as nursing outcomes. Issues about the measurement of nicotine dependence and withdrawal are highlighted.

Opioid tapering in hematopoietic progenitor cell transplant recipients.

PURPOSE/OBJECTIVES: To describe current opioid-tapering practice, patient pain levels and withdrawal symptoms, and nurse documentation during opioid tapers. DESIGN: Descriptive, exploratory, prospective, quantitative, and qualitative. SETTING: A 32-bed blood and marrow transplant unit in a large, tertiary U.S. care center. SAMPLE: 45 blood and marrow transplant recipients between the ages of 7-64. Types of transplant were autologous, allogeneic, and unrelated donor marrow; peripheral blood stem cell; and umbilical cord blood. METHODS: In daily interviews, patients reported pain levels and withdrawal symptoms during opioid tapers. Demographic, medication, and nurse documentation data were obtained from patient hospital records. MAIN RESEARCH VARIABLES: Taper length, daily opioid dosage, pain, withdrawal symptoms, and nurse documentation. FINDINGS: Length of taper ranged from 1-17 days (X = 6.53, SD = 4.26). Analysis of variance indicated no difference by disease or transplant type in length of taper, cumulative opioids given pretaper or during taper, or number of self-reports of withdrawal symptoms. Daily changes in nurse-administered opioid dosage during tapers ranged from a decrease of 67% to an increase of 14%. Children received significantly more opioids/kg during taper than adults. Means of adults' and children's self-reports of pain were low. The means of patient-reported withdrawal symptoms were highest on taper days two through six. Nurse documentation was sparse. CONCLUSIONS: Daily taper rates vary widely, pain is well managed, and most patients experience several withdrawal symptoms. IMPLICATIONS FOR NURSING PRACTICE: Use of an opioid-taper guideline may promote consistency of tapering while not increasing levels of pain or withdrawal symptoms.

Tratamento ambulatorial da síndrome de abstinência do álcool / Outpatient treatment of the alcohol abstinence syndrome

O objetivo deste trabalho é demonstrar a viabilidade do tratamento ambulatorial da abstinência alcoólica (TAAA) realizado por enfermeira especialista. Neste sentido, 114 pacientes abstinentes, em grau leve ou moderado, foram avaliados através de história clínica, exame físico de enfermagem e escala CIWAA (Clinical Institute Withdrawal Assesment for Alcohol). O programa de desintoxicaçäo promoveu avaliaçöes diárias por um período de sete dias, recebendo assim orientaçöes relativas a abstinência alcoólica, cuidados gerais e, quando necessário, foi utilizada terapêutica medicamentosa (BZD), como auxiliar no abrandamento dos sinais e/ou sintomas de abstinência. A maioria dos pacientes era do sexo masculino, com idade média em torno de 39 anos, 75 por cento dos pacientes atendidos apresentavam abstinência leve. A insônia, a agitaçäo psicomotora e o tremor de extremidades foram os sinais e sintomas que prevaleceram no decorrer do tratamento. Apenas 20,2 por cento dos pacientes foram encaminhados a avaliaçäo específica com clínico, por apresentarem alguma queixa ou alteraçäo clínica significativa. Sendo assim, a hipertensäo arterial (30,4 por cento) e a síndrome dispéptica (26,1 por cento) mostraram-se presentes durante a investigaçäo clínica. Ao término do período de desintoxicaçäo proposto, a taxa de aderência permaneceu em torno de 73 por cento. Visando um melhor acompanhamento, os pacientes foram encaminhados a terapia individual ou em grupo, conforme a necessidade de cada um. O tratamento ambulatorial realizado por enfermeira, muito mais que oferecer uma forma alternativa de abordagem terapêutica, amplia o campo de atuaçäo do especialista em saúde mental, oferecendo a baixo custo social e assistencial, uma proposta de tratamento individualizado, objetivo, seguro e eficaz da síndrome de abstinência alcoólica.

Análise dos pacientes portadores de Síndrome de Abstinência Alcóolica submetidos a dexintoxicaçäo ambulatorial por enfermeiras / Nurse evaluation of alcohol withdrawal symptoms among patients undergoing outpatient detoxification

A intençäo deste estudo é validar a prevalência dos principais sintomas dos pacientes abstinentes submetidos à desintoxicaçäo alcóolica ambulatorial realizada por enfermeiras. Foi estuda a prevalência dos sinais e sintomas em 114 pacientes, de ambos os sexos, oriundos em sua maioria do Pronto Socorro de Psiquiatria dessa instituiçäo, portadores de Síndrome de Abstinência Alcóolica (SAA), após cessarem a ingestäo alcóolica, estando os mesmos em várias fases de evoluçäo...