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Over the last three decades there has been an increase in the ‘health-damaging’ consumption of recreational, prescribed and illicit psychoactive substances worldwide, across all strata of society, causing a host of social, behavioural, psychological and physical problems. Addiction to alcohol, drugs and tobacco smoking is now regarded as a major public health problem. In most countries, where the consumption of alcohol, tobacco and illicit drugs is increasing quickly, there are limited educational programmes for health care professionals and the health care systems are ill-equipped to handle the sequelae of substance misuse.

According to World Health Organisation (WHO) estimates there are over one billion smokers across the world with nearly one third of smokers are in China. Smoking is rapidly increasing in Third World countries and in Eastern Europe and now causes 4 million deaths a year worldwide. (WHO 1998). For the European Union as a whole, the number of tobacco-related deaths is estimated at well over 500 000 a year (Peto et al. 1992). Alcohol-related diseases and injuries account for 3–4% of the annual global burden of disease and injury. There are around three-quarters of a million alcohol-related deaths each year. Alcohol is a significant factor in hospital admissions, road traffic deaths, industrial accidents, accidental drowning, homicide and suicide (WHO 1998).

The United Nations International Drug Control Programme (UNDCP) estimates that there are at least 250 million misusers of illicit psychoactive substances worldwide. The illicit drug market is equal to about 8–10% of total international trade and it exceeds other global trade such as oil, aviation, motorcars and might be second only to the arms industries. The Commission on Narcotic Drugs (CND 2000) reported that 31 countries in Africa, Asia, the Americas and Europe showed an increase in abuse of heroin. In both Europe and the United States (US), higher levels of misuse have been accompanied by an increase in noninjecting modes of administration. Increasing misuse of amphetamine is also reported in many countries of the European Union. A source of considerable concern is the rising trend in the abuse of methamphetamine in south-east Asia, especially in Thailand. The number of countries reporting the existence of injecting drug users (IDUs) as well as infections with the human immunodeficiency virus (HIV) among IDUs, continues to grow. In countries in central and eastern Europe, Russian Federation and adjacent countries and various Asian countries, there is potential for, an outbreak of epidemic infections of HIV among IDUs. Hepatitis C infections among IDUs and drug-related mortality (mainly involving drug overdose) are also causing concern in some countries.

Role and educational preparation

Health care professionals in both primary health care and residential settings are usually the first point of contact with clients with potential or unrecognized substance misuse problems. The roles of the nurse in relation to substance misuse have been highlighted in a document from the World Health Organization and the International Council of Nurses (1991). These roles have the same commonalities to those subroles health care professionals embrace within the health care system. Despite the magnitude of the problem, and even when drug and alcohol-related problems are identified, health care professionals may be reluctant to respond appropriately. Social prejudice, negative attitudes and stereotyped perceptions of substance misusers are held widely amongst health care professionals and this may lead to minimal care being given to this population (Hanna 1991, Carroll 1996, Rassool 1998, Selleck & Redding 1998). The prevention, early recognition, screening and management of substance use and misuse depend upon education. Studies support that the development of a more positive and nonjudgemental attitude and confidence and skills in identifying and working with substance misuse and related problems, may be partly related to the provision of education and training (Cartwright 1980, Hagemaster et al. 1993, Rassool 1993). However, much professional education and training reinforces the view that dealing with substance misuse is the job of a specialist (Rassool 1993).

In addition to the negative attitudes displayed by nurses towards substance misuse, the literature supports the lack of adequate content of drug and alcohol-related components in undergraduate and postgraduate nursing curricula. Falkowski & Ghodse (1990) reported that, on average, the amount of time devoted to alcohol-related disorders and drug dependence in adult nursing in the United Kingdom (UK) was 4·3 hours, compared to 14·1 hours for mental health nursing. In England, a review on the preparation of nurses for both preregistration and postregistration in substance misuse by the English National Board reaffirms the lack of adequate preparation of nurses, midwives and health visitors, the low priority accorded to substance misuse component and the incongruity of curricular content (ENB 1995). The ENB recommends that substance use and misuse should be included in all preregistration and postregistration nursing, midwifery and health-visiting curricular guidelines. This state of affairs is not solely restricted to the UK but also applicable in Australia and the US. A review of drug and alcohol content of nursing courses within Australia produced similar findings (Pols et al. 1993). Only 7% of the courses included 6 hours or more of drug- and alcohol-related education while an alarming 34% had no content related to drug and alcohol issues. Reviews of nursing curricula in the US provide similar results, indicating the underpresentation of substance misuse content in the nursing curricula (Murphy 1989, Hagemaster et al. 1993, Murphy-Parker & Rassool 2000). Sullivan and Handley (1992) identified that less than 5 hours of substance misuse content is given in both Baccalaureate and Masters’ level nursing programmes in the US. The paucity of substance misuse content in the curricula of undergraduate nursing courses is also common in Brazil and other South American countries.

Despite the recommendations, positional statements and educational initiatives in the US and UK (NNSA 1981; ENB 1995, 1996), there is little evidence to suggest that the integration of substance misuse component in the undergraduate and postgraduate curriculum has been implemented in educational institutions (Happell & Taylor 1999, Rassool 1999, Murphy-Parker & Rassool 2000). However, it is acknowledged that in both the US and the UK the integration of substance use and misuse components in the undergraduate and postgraduate curriculum are still restricted to a few centres of excellence.

Responding to the challenges

There are challenges and barriers that continue to impede the delivery of care to substance misusers and the teaching of substance use and misuse as an integrated part of nursing curricula. The denial of health care workers and the general public alike of the existence of substance misuse continues to present an obstacle to the provision of early recognition, health education and effective care. Furthermore, there is dissonance between their personal belief-therapeutic pessimism, i.e. there is nothing that can be done or should be done, and their professional roles (de-skilled, lacking in confidence, etc.). There is also the question of the low priority accorded to this speciality and poor strategic planning to create an organizational learning culture in responding to substance misuse problems. To enable nurses and other health care professionals to respond to substance misusers, demands a cultural shift in many of the paradigms that have traditionally guided the work of generic health care professionals. More emphases are being directed towards public health, prevention and harm-reduction and these new challenges will have an impact on the role and function of the health care professionals in order to meet the changing health needs of the general population. The need for research in identifying the factors that lead to the inability of nurses and health workers to recognize and respond to substance misusers is of paramount importance.

Another challenge is to overcome the marginalization of the importance of a substance misuse component in nurse education curricula and clinical practice, at undergraduate and postgraduate levels. Guidelines provided by national bodies are a good starting point in the application of the principles of good practice and education and the required standards. The consequences of lack of adequate education and training at undergraduate level are a self-perpetuating cycle. Where a low priority is accorded to both policy and educational development in this area, there is no opportunity for health care professionals to develop role adequacy. This results in reinforcing the negative attitudes and the reluctance of health care professionals to respond effectively to substance misusers (Rassool 1993). In addition, the delivery of teaching about substance use and misuse has been hampered by the lack of specialist tutors in the field of addiction and the overcrowded curricula. For those who specialize in addiction nursing, there is limited opportunity for them to undertake the basic and advanced educational programme in addiction nursing to increase the pool of expertise in this speciality. Resources should be allocated by professional bodies to overcome the deficit in the preparation of those who are required to implement the policy recommendation and the delivery of teaching.

Finally, a neglected area is the health education of the nurse in relation to their personal use and misuse of tobacco, alcohol and other psychoactive substances. These important aspects should be given due prominence in both the curriculum and teaching guidelines. Both the provisions of counselling and treatment services for professionals with problems with drug or alcohol should be part of the occupational health or peer assistance programme.


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On a global level, there should be collaboration between professional associations, educational institutions, academics, clinicians and researchers for the purpose of establishing mutual co-operation in the conduction of activities and projects related to teaching, research, community services and exchange of faculty and students. The WHO, International Council of Nurses (ICN) and the national professional associations should provide the leadership to steer the development of rationale, scope, functions and preparation for clinical practice, coupled with the development of a theoretical framework and research-based practice in substance misuse and addiction nursing.

So far, it seems that the statutory bodies and professional organizations have made little impact on the process of change. For too long, as a professional discipline, we all have accepted an extremely narrow perspective of the importance of substance use and misuse education and above all, we have been unable to influence those who are responsible for shaping educational, health and social policies for real change to occur. It is argued that we need to capitalize on the current political climate and go beyond self-interest to focus on an effective strategy for enhancing substance misuse education in the professional arena. Complacency or commitment?


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