Considerations for Vulnerable Populations

Population

Special Considerations

Concurrent Disorders

• Concurrent disorder refers to individuals experiencing at least one diagnosable mental disorder along with at least one substance use disorder (Health Canada, 2002).
• Individuals with concurrent disorders can experience: a worsening of psychiatric symptoms, increased risk of suicidal and self-harming behaviours, decreased physical health, amongst others (Donald, Dower, & Kavanagh, 2005; Hunt et al., 2013).

• Nurses should use multi-faceted care plans that include both psychosocial and pharmacological approaches (Kelly et al., 2012). Psychosocial interventions found to be most effective include:

• motivational interviewing and brief intervention
• cognitive behavioural therapy
• Twelve-Step Facilitation
• Case management including Assertive Community Treatment
• Contingency management

• Further information on psychosocial interventions can be found in Appendix K.

First Nations, Inuit, and Métis

• When working with individuals from First Nations, Inuit, and/or Métis communities, it is vital to approach health and wellness in ways that are:

1. Holistic and strengths-based
2. Integrate cultural practices
3. Promote a balance of mental, physical, emotional, and spiritual well-being, taking into consideration culture as the central component.

For more information, please referrer to Appendix K or http://rnao.ca/substanceuse, for a synopsis of substance use issues in First Nation communities created by the National Native Addictions Partnership Foundation.

Homeless, Under-housed, and Transient Populations

• Nurses should view every encounter with a homeless client as an opportunity to assess for substance use.
• Effective interventions to engage, retain and reduce substance use in this population include:

1. Case management
2. Therapeutic communities
3. Alternative housing programs (i.e.  “housing first” approaches)

Immigrant and Newcomers to Canada

• Issues such as language barriers, cost, limited accessibility, trust and other cultural barriers can impede the care of immigrants and newcomers with a substance use disorder
• When working with a newcomer population, nurses should:

1. Discuss the client’s cultural beliefs and needs with the client in a respectful way and that they are included in the care plan.
2. Assess the following:

• Role in the family, based on their culture
• Religious/spiritual beliefs and religious influence;
• Language of origin and the need for an interpreter
• Style of communication, which can be culturally driven
• Beliefs about health and healing (e.g., traditional cultural beliefs, folk medicine, prayers, healers, alternative therapies, etc.).

Incarcerated Women

• When working with incarcerated women with a history of substance use, nurses should:

1.  Provide individualized care in an environment separate from the general prison population
2. Develop  trust-based relationships between health-care providers and incarcerated women to increase engagement in therapy
3. Use integrated approaches that incorporate empowerment models such as:

• Mentoring through successful peer role models
• Use of MI techniques and approaches
• Create linkages between prison and community-based treatment

Lesbian, Gay, Bisexual, Transgendered, Two-Spirited, Intersex, Queer, Questioning, or Asexual (LGBTTIQQA)

• LGBTTIQQA population are at increased risk for a substance use disorder due to factors related to wide-spread marginalization and discrimination, ranging from insensitivity to violence
• The use of support groups, assistance from support agencies, the provision of accurate health information, and the promotion of positive community linkages are important considerations when working with individuals from the LGBTTIQQA population.

Older Adults

• Alcohol, prescription medications, and over-the-counter medications are the most commonly misused substances among older adults
• Nurses should use appropriate screening tools, such as the SMAST-G or MME when assessing for substance use disorders.
• When initiating care with older adults, nurses must recognize that detoxification may require a longer timeframe due to potential physical and psychiatric co-morbidities, and age related physiological changes
• Pharmacological interventions in older adults also require closer monitoring, due to physiological and psychological changes
• Effective case management is essential when working with older adults, as their social networks may be limited as a result of their substance use, physical limitations, and/ or loss of family members and friends

Pregnant and Postpartum Women

• Intervention to reduce substance use in pre and postnatal  women is vital due to the multiple complications that can result for both the mother and the developing fetus and baby
• Nurses should intervene with women during the preconception, pregnancy, and postpartum periods to reduce substance use.
• Nurses should:

1.  Screen all clients using appropriate screening tools
2. Provide brief interventions for support (see Appendix H and Appendix J)
3. Offer follow-up support to clients who engage in substance use during pregnancy and in the postpartum period  (i.e. home visiting programs are shown to be beneficial)

(Burns et al., 2010).

Sex Trade Workers

• When working with this population, nurses should:

1. Establish and maintain trust
2. Screen for sexually transmitted diseases, and periodic skin testing for tuberculosis
3. Provide education on safe substance use administration, safe sex practices, and methods to decrease the risk of contraction of blood-borne pathogens.
4. Support access to basic requirements that determine health, including housing and health services