ELIZABETH, NJ - A few years ago, a 60-year-old Elizabeth man named Nathan was treated for a severe infection in the Emergency Department at Trinitas Regional Medical Center. If not for an innovative program that calls for drug/alcohol screening of all patients at Trinitas, Nathan may have been released and eventually died of a drug overdose. Instead, he was treated for addiction and has been sober for the past two years.
According to hospital officials, drug screening is not a new practice for Trinitas. In 2012, screening at Trinitas became part of an initiative known as the Delivery System Reform Incentive Project (DSRIP). Since then, patients are assessed upon admission using a standardized tool called AUDIT (Alcohol Use Disorders Identification Test). It's just recently that the United States Preventive Services Task Force has recommended that all healthcare providers screen adults for substance use.
Officials said Nathan is one of many patients whose life was saved by screening. Clearly, it's important for healthcare providers to know what their patients may be using in order to provide effective care. But expecting the practitioner to ask adult patients about their history of substance use is not always reasonable.
"Since 2012 we have screened more than 57,000 patients at Trinitas, no doubt saving the lives of countless patients whose substance abuse was identified early," explained Gary S. Horan, FACHE, President and CEO of Trinitas.
They also stated that when appropriate, the Patient Health Questionnaire is administered as a screening for depression. When it is apparent that the patient is using/abusing substances/medications, the nurse engages the patient in an open-ended interview about all patterns of use/abuse. The screenings take only minutes to complete and when administered in a non-threatening, normalized way, patients are very forthcoming.
Based on the assessments, the Clinical Institute Withdrawal Assessment Protocol (CWIA) is followed for those patients who are at risk for detoxifying.
"We immediately identify patients using substances, which then informs the care plan," says James McCreath, Ph.D., Vice President Behavioral Health & Psychiatry at Trinitas. "When the CIWA protocol has been used, the length of inpatient stay for those patients is lower than the baseline. There has been a decreased use of restraints (used for safety when detoxifying patients become agitated and aggressive). There has been a decrease in the number of transfers from medical floors to the Intensive Care Unit. The number of 30-day re-admissions has dropped. There has also been an increase in the number of referrals to substance abuse treatment providers."
Having worked on the Trinitas Substance Abuse Program for almost two years, Gabriela Kennedy, a licensed social worker, and drug and alcohol-credentialed intern, works with people like Nathan on a daily basis and recognizes screening as a life-saving tool.
"I help clients work on their recovery and engagement in the program," she says. "Nathan was screened by Kristine Jackson from DSRIP and she made the referral to attend an assessment at our program. Our program Director Krystyna Vaccarelli, LCSW helps oversee the DSRIP referrals and helps coordinate with John Bosquett, LPC to offer housing for the Real House or a shelter while they start engaging in treatment."
Finally, the devastating depth and scope of the opioid crisis is being recognized. In 2017, more than 70,000 Americans died from a drug overdose. We also now know that addiction to alcohol, legal medications, and illegal substances, can happen to anyone regardless of ethnicity, income, age or educational background. In other words, there is no one profile of an addict.
"Nathan is like any other hard-working individual," says Kennedy. "He has been married and has an extensive work history of managing a large chain of stores for 25 years. It is clear that addiction does not discriminate. It is my belief that Nathan's connection to DSRIP gave him another opportunity at life. Without DSRIP making that first crucial contact, he might not be alive today to share his amazing story."
Unfortunately, Nathan had some health setbacks along the way, which is common during the recovery process, but they did not distract him from his sobriety. From Trinitas, Nathan received a grant for housing at the Real House (formerly Flynn House) that provides sober living for 30 days. "During his time in treatment, he utilized our psychiatric services and medication-assisted treatment options," says Kennedy. "He was prescribed Suboxone to help with his recovery. He also successfully completed the intensive and outpatient level of care."
No longer dependent on drugs, he is able to work full-time and pay his own bills.
Kennedy adds, "Nathan has expressed so much gratitude and love towards Trinitas Substance Abuse Program. He has shown that recovery is possible and that he has created a life worth living."
"We made a significant, culture-changing decision when starting the DSRIP initiative: Every inpatient nurse would be trained to use the AUDIT screening as part of the initial Nursing Assessment," says Horan. "This normalized the screening for alcohol/substance use. The decision to use nurses to do the screenings implicitly recognized the near universality of substance use, while training for universal screening moved staff moved away from any stereotypes about who is an addict based on looks or background."
Healthcare providers typically look to specialists to do substance use screenings. For Trinitas, that would have meant hiring more Addiction Specialists to make contact with every new admission, which could have increased the feeling of stigma, generated patient resistance and led to screenings that remained isolated from the care plan.
Because there is no one type of addict and because so many people from so many backgrounds use/abuse substances/medications there is a critical need to incorporate screenings into the full clinical assessment. To encourage the patient's honest reporting, it is vital that screenings be non-judgmental, normalized and focused on the patient's medical complaint. Screenings can be done - and should be done - by non-addiction staff provided there are also addiction professionals available to support patients who are willing to get help.
When the AUDIT screening is complete, the score is entered into the electronic medical record (EMR). The EMR electronically notifies the Addiction Department of all screenings that show patients at risk. The Addiction Counselor then goes bedside immediately to ascertain what, if anything, the patient wants to do about their use. In some cases, the counselor aims to educate the patient. In other cases, the counselor provides a warm handoff to an addiction provider upon the patient's discharge.
No matter what the situation, McCreath adds, "The United States Preventive Task Force is correct, healthcare providers must incorporate substance use screenings into their full assessments. Patients deserve nothing less."