Addiction Nursing in Aotearoa NZ key influences implications

Addiction Nursing in Aotearoa NZ key influences & implications from the Mental Health & Addiction Inquiry Addiction Nursing Symposium, Hamilton 2019 Daryle Deering, RN Ph. D

Cover v Trends u Policy u Interventions u Workforce development and nursng

Policy frameworks u Mental Health Commission’s Blueprint II: Improving mental health and wellbeing for all New Zealanders: How things need to be (2012) u Blueprint II: Improving mental health and wellbeing for all New Zealanders: Making change happen (2012) u Te Tahuhu – Improving Mental Health 2005 -15: The Second Mental Health and Addiction Plan u Te Kokiri: The Mental Health and Addiction Action Plan – 2006 -2015

Sustainable Development Goals u There are gross differences in health and well-being between and within countries. u These differences are the differences and inequalities in social and economic factors. u The lower the socioeconomic position the higher risk of poor health and increased likelihood of premature death

WHO Mental Health Action Plan: 2013 -2020 NZ Rising to the Challenge: Mental health and Addiction Service Plan 2012 -2017 Early detection & care across the life span Increased access - children & youth, older age, adults with high prevalence conditions Enhanced confidence & capability of primary care workforces Greater use of community-based interventions. Accessible community based interventions Multisectorial approach Improved integration across specialist, primary care, other sectors Individual care needs Person & family centred, culturally responsive holistic care Empowerment of people with mental health Social inclusion, peer support, consumer participation in policy, & substance use issues service development delivery & evaluation Promoting good health throughout life Promote health & wellbeing, recovery, reduce harms, address disparities

He Ara Oranga u Recommends specific changes to improve New Zealand’s approach to mental health, with a …focus on equity of access, community confidence in the mental health system and better outcomes, particularly for Māori and other groups with disproportionately poorer outcomes. u Inquiry panel members: Professor Ron Paterson (Chair), Sir Mason Durie, Dr Barbara Disley, Dean Rangihuna, Dr Jemaima Tiatia-Seath, Josiah Tualamali’i

Theme / recommedation Agree to significantly increase access to publicly funded mental health and addiction services for people with mild to moderate and moderate to severe mental health and addiction needs. Commit to increased choice by broadening the types of mental health and addiction services available. Note that this Inquiry fully supports the focus on primary care in the Health and Disability Sector Review, seeing it as a critical foundation for the development of mental health and addiction responses and for more accessible and affordable health services. Identify a lead agency to: provide a stewardship role in relation to the development and sustainability of the NGO sector, including those NGOs and Kaupapa Maori services working in mental health and addiction take a lead role in improving commissioning of health and social services with NGOs. …enhancing cross-government investment in prevention and resilience-building activities. Direct the Ministry of Health to work with people with lived experience, the Health Quality and Safety Commission and DHBs on how the consumer voice and role can be strengthened…

Direct the Ministry of Health to lead the development and communication of consolidated and updated guidance on sharing information and partnering with families and whānau. Support the replacement of criminal sanctions for the possession for personal use of controlled drugs with a full range of treatment and detox services. Establish clear cross-sector leadership and coordination within central government for policy in relation to alcohol and other drugs. Urgently complete the national suicide prevention strategy and implementation plan… Repeal and replace the Mental Health (Compulsory Assessment and Treatment) Act 1992 so that it reflects a human rights-based approach, promotes supported decision-making, aligns with the recovery and wellbeing model of mental health, and provides measures to minimise compulsory or coercive treatment. Establish an independent commission to provide leadership and oversight of mental health and addiction in New Zealand.

Health Policy – continues in transition u Promoting health and wellbeing requires a broad approach – taking social determinants of health into account and involvement of everyone u Relationship between the Crown and Maori - Treaty of Waitangi u Access, responsiveness and outcomes across the lifespan u Supporting people in their communities u Self management and health literacy u Majority supported in primary care, stepped care approach u Integrated care across health boundaries and across sectors e. g. health, social , justice, education sectors u Leadership

Integration – includes bank managers, stock agents, dairy companies as well as diverse workforces including those with lived experience across sectors GPs Salvation Army PACT Supporting Families NASC Federated Farmers Trust Hospital ED Waitaki Mental Health Service Aged care facilities Police Probation City-based specialist services Disability Services Maori Community Services Pacific Community Services

National Drug Policy 2015 -2020 …sets out the Government’s approach to alcohol and other drug issues, with the overarching goal of minimising alcohol and other drug harm, and promoting and protecting health and wellbeing.

Drug law reform – emphasises a health approach vs war on drugs (people) u Removing criminal penalties for the possession, use and social supply of all drugs Misuse of Drugs Act (1975) Amendment Bill; Bill Misuse of Drugs (Medicinal Cannabis) Amendment Act 2018 u Developing a strictly regulated cannabis market – Cannabis referendum 2020 – yes or no vote u Putting more resources into prevention, education and treatment

What’s important u The environment, social and cultural context, social disadvantage u Adverse child events and trauma u The complexity of issues people experience u Increasing numbers of people with long term conditions, disparities in physical health outcomes u ‘Understanding addiction’ and link with practice frameworks u Combating stigma and discrimination u Health care policy direction and legislation and systems of care

The environment Tobacco Alcohol

Trends in drug use IDMS 2006 -16 (Wilkins et al 2017) Drug types and availability wax and wane over time. u 2006 -2016 – increase in methamphetamine availability & declining prices, increase in crystal methamphetamine, decline after bans of synthetic cannabis, but new wave of high potency synthetic cannabinoids 2014 -16, decline in cannabis, declining availability of ecstasy over recent years, reports of increased psychedelics, recovering morphine market.

Impact of stigma Many clients receiving methadone treatment feel marginalised and some go to extraordinary lengths to keep their treatment status a secret. (Murphy & Irwin 1992) I couldn’t tell a lot of people when I was on the methadone … it’s crazy really, but I didn’t want to tell anyone …because they’re quite straight these people, you know. Lovely people and I worked for some of them for a couple of years…it’s horrible hiding a secret like that. (Woman, NZ Primary Care Research 2014)

How the issue is framed will influence the approach

Whānau and related concepts such as whanaungatanga are perceived as important components of wellness and the process of healing for Maori. (Huriwai et al 2001) Maori live in diverse cultural worlds. There is no one reality nor is there any longer a single definition, which will encompass the range of Maori lifestyles. (Durie 1998) Working with the family (i. e. biological and adopted, nuclear and extended) of Pacific service users is key to the service users’ successful recovery. (Le Va, Pasifika within Te Pou 2009)

Positive Youth Development

Drug Use Continuum Abstinence Low risk use Hazardous use Problem use Mild dependence Moderate/severe dependence ADDICTION Focussed behavioural change Fundamental lifestyle change

Promoting health & wellbeing – intervene early u Greater emphasis on screening, health promotion and early intervention (brief assessment and interventions) u Motivational approach u Structured frameworks u Reduction or abstinence experiment

Addiction u Fundamentally about compulsive behaviour u Complexity is the norm u ‘Motivated or not’ ‘in denial’ – simplistic and inadequate u Different psychotherapies produce similar treatment – but large scale studies often exclude those with complex issues u More broad based (wellbeing and quality of life) and individualised the treatment – the better the outcome

Why Clinical Case-Management? Approach suited to meet the needs of clients with complex treatment needs and a vehicle for delivery of individualised treatment

Todd, F. C. 2010. Te Ariari o te Oranga: the Assessment and Management of People with Co-existing Mental Health and Substance Use Problems. Ministry of Health, Wellington. • Person centred care, journey of recovery, wellbeing and barriers to wellbeing • Phases of treatment

Recovery and wellbeing is more than “about the drugs” When I think about recovery and wellbeing it’s not just about the drugs, its about the whole picture really, its about sorting all of your issues out… woman receiving OST Requires Profound changes in way relate to self, material world and others Moving from a culture of addiction to a culture of recovery & wellbeing Transition from addict ‘other’ to citizen (Stephen Bamber)

Facilitators to ‘Where you are now’ u Methadone and GP Care u New beginnings, behaviour and lifestyle change u Getting older u Health (including help with general health and mental health issues), finances, housing, education, employment, purpose in life, partners, family and wider support networks, friends, animals u Values and making amends u Giving back - commitment to next generations – (children, grandchildren, others receiving OST) NZ GP Care project (Deering, Schroder et al) 2014

Don’t listen to answer listen to understand And remember…there always two assessments going on

Towards the next wave of MH & Addiction Services and Capability (HWNZ 2011) u Maximise the role of primary care and other front line practitioners/workers …and sharpen up the role of specialist practitioners – both in direct care and greater consultation roles u Enhance capacity and capability in intervening and supporting people who are affected by substance use, behavioural addictions and co-existing issues – everyone including employers, peers, support networks

Nursing workforce implications u Sharpen up the role of specialist nurses – both direct care and greater consultation roles u Maximise the roles of all nurses …work to top of scope and provide an holistic health response u Enhance skills in working with people who are affected by addiction and co-existing problems

Where are we at? u Post-graduate nursing and interdisciplinary specialty education u Increased advanced practice roles, NP, RN prescribing u Standards for Mental Health Nursing & an Addiction specialist nursing framework u Professional bodies u Primary Care Nurse Credentialing u Diversity - leadership, roles and settings

Nurse Practitioners: Louise Leonard, Sarah Barkley, Blair Bishop, Moira Gilmour

Primary Care Nurse Credentialing “I knew there was something wrong, I didn’t want to ask because I didn’t know what to do if they answered yes to a mental health or addiction issue” Te Ao Māramatanga NZ College of Mental Health Nurses. www. nzcmhn. org. nz

What still needs to happen? We need to build on what has been achieved u Politically active, advocacy – professional bodies, political parties u Influence policy u Leadership and advocacy at all levels u Strategic relationships and ‘go to where the people are’ u Increased range of roles in multiple settings u Nursing recruitment and renewal – to meet policy direction u. Nurses wellbeing – systems, self-care, connections, professional bodies, supervision, mentoring, professional development

Advanced Nursing Practice Key issues