Getting Past "Just Say No": Reflections on Adolescents and Substance Use

 As the death toll in North America from the opiate overdose crisis continues to rise nurses must re-think the approaches that are being used in the healthcare services that are supposed to be designed to best help youth. There are now decades of evidence that support the ineffectiveness of the 1980s ‘Just Say No’ drug strategies targeted to prevent youth from using drugs. In reflection on my nursing career, mostly in programs and services designed to provide care for people who use substances, I feel heartbroken about the slowness of change in inpatient settings.

 As I near the five-year anniversary of my joining what was heralded as an innovative mental health and substance use program for youth, I also critically question the erosion of that innovation to conform to a rigid system with rigid values about youth who use substances and how to best provide care for them. Three years ago, I walked into the care team station, early for my night shift. I began my night shift routine. I looked at the patient assignment, checked the electronic chart to see if there were any newly admitted patients since my last shift, and then looked at the memo taped to the top of the large desk in the center of the care team station. The communication was informing staff of a new policy and Standard Operating Procedure (SOP) in which all patients returning to the unit following any time off the unit with anyone other than staff would be directed to the exam room, observed while changing into hospital clothes, and have their clothing and shoes searched for any drugs being brought into the unit. 

The first thought that jumped into my mind was, all patients, regardless of circumstances or who they were with? This seemed an over-reactive strategy. Did an incident happen that I missed? I was not the only staff member angry about the new policy. I racked my brain for some serious triggering incident that led to this SOP response. The main thought going through my mind was that we had been open for 3 years without a serious incident and the only things that had changed were leadership. Yes, over the years sometimes substances were used when off the unit. It was understandable, that the two overarching admission criteria were mental health and substance use issues. 

The key intervention that nurses used to mitigate this was building trusting relationships, knowing the patient, asking questions, and knowing what to assess and when. 

 “Did they think about the trauma that this might cause for youth that have been in the prison system or that experienced something similar in abusive relationships?” I bluntly asked one of my co-workers in exasperation. 

 "It makes it unit safer,” they replied. 

“For whom?” I asked, wondering if the decision was made based on consideration of the trauma that many of the youth admitted to the program experienced, or on the optics that hospital executives and leaders wanted to present of patients getting clean and sober as part of the program. 

What happened to the inclusion of harm reduction and trauma-informed practice? Were patients and staff nurses included in the development of this one-size-fits-all approach? The response was that this was standard practice for all inpatient mental health units, but over my 15-year career I had worked in many inpatient mental health services some located in hospitals, some not, some specialized for people who were living with mental health and substance use issues some general, and I had never seen such an invasive procedure. 

 I, along with many staff nurses began to question the motivation for the change. I could not let this go if I wanted to keep working on this unit. But leadership kept changing, and one by one the strong and experienced team left for better opportunities that aligned with their core values. I also left. Months later, I returned. I felt increasing disappointment by new policies like regular police presence and drug-sniffing dogs framed as strategies to increase patient safety. 

I walked to the breakroom. The new manager walked in. I could not be silent. Maybe they would be open to critical feedback. 

“Do you think that sometimes strategies like bringing in drug-sniffing dogs and police might harm more than help?” 

 “I’m not really sure how we could track that,” they replied. “The bottom line is that this is about safety. This isn’t the Downtown Eastside. We can’t let our patients use drugs. This isn’t a harm reduction unit.” 

 I was taken aback. I thought harm reduction was a foundational pillar of the program; that’s why many of us took a chance to work on the unit when it opened. We believed we were taking a trauma-informed, collaborative approach that was different than traditional inpatient mental health units. 

Person-centered, collaborative care should not be a tradeoff under the guise of safety without asking questions about who defines safety and the unintended consequences of risk mitigation without meaningful collaboration of patients and the nurses who are providing the daily care.

Love,

Michelle D.