Mental health disorder becomes one of some major health problems throughout the world. It normally refers to an individual’s performance of mental functions and ability to adapt to changing circumstances. In most countries, the mental health problem contributes to a substantial proportion towards health problems. Incidence of drug abuse continues to occur even the government had efforts to achieve a drug free Malaysia by the year 2015. There are 300,000 registered addicts in its drug fight from 1998 to 2008 based on the National Drug Agency (ADK) data (Vicknasingam B, ; Mahmud M, 2008). A co-occurring disorder or dual diagnosis is a state where a person have both substance abuse problem and mental health issues such as depression or bipolar disorder. It is not easy dealing with substance abuse and drug addiction but there are various of treatments and steps to achieve the road to recovery. Health-related stigma refer to a socio-cultural process in which social groups are rejected, devalued, and excluded on the basis of a socially discredited health condition (Weiss MG, Ramakrishna J, ; Somma D, 2006). Nurses have an ethical, professional and personal responsibility for their own actions when accomplish their nursing tasks. The nurse supports hope, coping and courage, promoting health and preventing the stigmatize of the illness. Hence, it narrates the right to participate in decision-making, holistic nursing and the right to self-respect. There are significant roles and responsibilities of Mental Health Nurse to eradicate the stigma of substance abuse and variety of interventions toward effectiveness to rehabilitation programme.
In Malaysia, people who involve with drug dependency are likely to experience mental health disorder than general population and if delay in public health response might aggravate the rising of epidemic diseases like HIV and hepatitis. Hence, it has negative consequences to patients, society and their family (Langas, Malt, ; Opjordsmoen, 2011). Substance abuse and mental health problems are increasingly from mild conditions to problems that are so severe which the person is completely incapacitated. Sufficient knowledge about the comorbidity of psychiatric disorder is important to deal with substance-related problems. They can affect anyone at any stage of age. The drug trending in Malaysia is the severe problem of heroin dependence. Heroin remains the preferred choice of drugs for users in Malaysia at 40%, while users of Amphetamine-Type-Stimulants (ATS) account for 14% of the total detected cases in 2008 (Vicknasingam B, ; Mahmud M, 2008).
In northern states of Malaysia, kratom is usually used to treat health problem such as hypertension and diabetes but the scenario had changed when it was misused by certain people. Regular kratom users consume more kratom to rejuvenate energy in order to enable them function as normal (Suwanlert, 1975). In addition, it typically involved teenagers because they can get the substance easily and cheaper compared to others drug like heroin. According to Jansen and Prast (1998), kratom was claimed to have opium-like such as cocaine-like effects, and was used to decline withdrawal symptoms during an opium shortage in Malaysia. Indeed, frequent and prolonged kratom use could eventually lead to addiction in humans (Singh, 2014).
Moreover, there are various factors contribute to substance abuse which are from family factors and also peer influence. According to National Anti-Drug Agency (2009), the major contributory factor of drug abuse was peer influence (57.9%). Family problems and social pressure has prompted adolescents to imitate into their peer group and start trying out drugs. The motive to experiment with drugs is especially strong among immature adolescents who are seeking to belong into a group. These factors might increase the more episodes of drug abuser in Malaysia especially teenagers.
Globally, there are many synthetics drugs invented by unethical personals which contribute greater harm to society especially youngster and adolescence. The latest drug known as “Flakka” and Broward County was the forefront of “Flakka” outbreak in South Florida between 2011 and 2015. “Flakka” has been derived from the Spanish slang “la flaca” which mean of skinny girl, is the street name given to the synthetic cathinone alpha-pyrrolidinophenone (alpha-PVP), a novel psychoactive substance (NPS) that appeared on the recreational drug market as early as 2010 (O’Connor AD, Padilla Jones A, Gerkin RD, & Levine M 2015). The side effects of “Flakka” are agitation, extreme aggression, psychosis and death. Fortunately, this drug has not been reported in Malaysia yet since the widespread only acquired in Western countries.
To overcome a co-occurring disorder, nurses should give the right support, treatment and reclaim patient’s sense of self to get patient fully recovered. There are various challenges for nurses to treat patient with substance abuse. The uprising issue is to keep patient engage with the service after detoxification. Some patients might overcome their withdrawal phase and assumed they had fully recovered from the addiction. The rehabilitation programme takes a certain period of times in order to wean off these substances out of the body slowly under the direction of a medical professional. Nurses are responsible in encouraging the realistic expectation about the prospect of rehabilitation and recovery. Therefore, these actions will influence patients’ view and handle any future relapse that possibly occur. Detoxification was given habitually to elective involvement in outpatient treatment (McNeese-Smith, 2003). A very small percentage patients return for follow-up may affect the rehabilitation programme especially patients with severe dose of substance abuse. Follow-up visits should be scheduled based on the individual needs. Defaulter tracing should be regularly done to ensure compliance with follow-up.
From nursing point of view, patient who involve with substance abuse will present some unwelcome challenges due to dependency behaviour which can be a disruptive influence in the ward. Nurses in ward need to be alert to any substances brought by visitors who sometime claims to be patients’ relatives but actually become drug pushers. Close supervision and careful control of such visitors are important to prevent the patient from getting the substances. Nurses can deny them from access to vulnerable patients. Patient’s behaviour and family member refuse to cooperate with nurses regarding the treatment will induce another challenge. Communication and other barriers inhibit the progression of care to the patients.
In addition, the withdrawal symptoms faced by patient with drug addiction effectuate the nurses to be more caution to ensure the symptoms are treated well and do no harm to the patient. Mental health nurses are aware regarding the condition of patient with substance abuse and knowledgeable in treating the physical withdrawal phase such as nausea and chest pain. They suffer overwhelming physical symptoms due to the body’s response to working without a substance it’s depended on. Nurses must be prepared for these physical effects and provide treatments to ease the symptoms and any tendency of aggressive behaviour. The physical effects are sometimes so severe that patients return to drugs to ease the discomfort.
The relapse episodes and rehabilitation cost become another challenges in treating the drug addiction. Rehabilitation and treatment programs will be received by drug abusers for two years as mandated by the law. According to Malaysian Psychiatric Association (2008), government has spent RM3000 per month for each person and a staggering RM300 million yearly for rehabilitation programs. Drug relapse is a complex, volatile, and vibrant process. The phase of relapse can be defined as intake, usage, misuse of psychoactive substance after one had received drug addiction treatment and rehabilitation, in physically and psychologically. There was evidence of 90% relapsed cases among heroin addicts within six months after been discharged from rehabilitation centres (Mohamad Hussain & Mustafa, 2001). Although some of the programs in rehabilitation centre had been successful but the relapse was still occurred.
Mental health nurses are backbone in eradicating the stigma of drug addictions. Progressively, professional organizations and governments are mobilizing resources towards managing and preventing health-related stigma. Nurses have a vital role in the prevention, detection and treatment of mental health and substance abuse problems. Nursing care must be given unconditionally and without any type of discrimination. Nurses encounter with the high risk people of all ages who are in danger of developing mental health and substance abuse problems. This affects not only the individual but also the family, society and workplace in general.
To eradicate the stigma of the illness, nurses should critically identify the factors contribute the persons into substance abuse therefore, nurses have to join the collaboration with other professional and agencies. The range of drug addiction group was not only involving the low income, but also including the more luxurious and over gender, age and adolescents (Ibrahim, & Kumar, 2009). Active participation in creating the awareness and prevention among society become the primary care and frontline to inhibit the progression of phenomenon in the society. Positive motivation and exposure regarding the care and management of drug abuser might assist in eradicating the negative stigma so that the public will change their perception towards drug abuser.
Awareness programs regarding the harmful consequences of trying out drugs and getting addicted could be set up for the public. Everyone should be attentive of the possible impacts of drug addiction so that they would stop before their curiosity cause them into trying out something that ruin their life. Hence, efforts could be done to diminish the negative effects of peer influence. Specifically, community nurses entitle to give health education to the school teenagers in order for students to learn the negative consequences of drugs. This is important to prevent them from become influenced by peers who impose negative impacts. Education institutions should remain conducting drug education programs continuously with participation by parents towards their child’s life, and a healthy environment as well as collaborating together with teachers to identify any warning signs if they arise (Pentz MA, 1996).
Mental Health Nurses also involve and committed with psychosocial treatments for drug abusers. Structured psychosocial interventions include inpatient care, relapsed prevention model, controlled use of substance, contingency management and community reinforcement approach. Nurses have a special responsibility when encountering vulnerable groups. They also involve with Community Reinforcement Approach (CRA) where patients will be taught to handle and recognise triggers to substance such as situation or internal states. They also responsible in educate the patient how to earn money with some activities like gardening and baking. Some leisure activities such as join a group therapy and sports might convert the craving of addiction among patients.
Nurses also have to maintain professional attitude and self-composure during nurture care to patients. Personality appearance and rapport with patients are main components of effective communication. Nurses responsible as co- facilitator during counselling session especially when it jumps into some sensitive issues. Patients felt open to share their problems and seek for any query when needed. Nurses act as the person who they can rely on. Motivational interviewing is a collective conversation style for establish a person’s own motivation and desire to change (Miller and Rollnick, 2013). Hence, nurses could establish any problems or triggers face by patient and family members towards rehabilitation program.
Nursing is inextricably connected with human rights, comprising the right to dignity and the right to be treated with respect. Substance abuse nurses often play a teaching role in addition to provide physical and psychosocial care. Psychosocial care includes the rehabilitation programs and also counselling session. As the patient’s educator, they teach patients about the dangers of drug abuse which includes the psychological and physical effects such as relationship impairment with the social community and family members and also the impact on meeting basic needs likes holding down a job. They also educate patients regarding treatment options, including those they can use on either an inpatient or outpatient basis. Nurses might educate a patient’s family members about what to expect from the rehab process and how they can support their loved one’s attempt to conquer drug addiction.
Generally, health-promotion and prevention has received attention in Malaysia nowadays. Professional and political agreement identified that it is better to prevent than to cure. Collaboration between government with other professionals and agencies is a crucial component in providing addiction psychiatric services such as National Anti-Drug Agency (NADA). This effort will enhance the opportunities for early intervention by promoting awareness among the general public and other professionals on drug issues. Networking upsurges the value of service to patients and allow them to receive the appropriate support and care outside of clinical settings. However, the health-promoting aspect must not dominate the fact that people do nevertheless become ill and need nursing care.
Rehabilitation programmes may necessitate a long length of time depend on how a person responding with the effectiveness of the treatment. Nurses are one of the health practitioners who are helping patients undergo drug rehabilitation. By assisting them in amending to life without drugs, monitoring their progress, and teach them how to maintain their sobriety after leaving rehabilitation programmes will contribute for the effectiveness to overcome the relapse. A good rapport with patient influence the positive feedback which the patient will use nurses as a resource or support during times of difficulty. It may be assumed that the loneliness and/or less family relationships in drug dependents lead to social isolation that potentially could provide a lack of the social support needed (Golden, 2009; Tomaka, Thompson, ; Palacios, 2006).
Methadone Maintenance Treatment (MMT) has been invented in Malaysia since 2005 in order to treat the opioid dependence patients. MMT was a part of the National Harm Reduction Program. It initially started with antagonist medication (naltrexone) and changed to agonists medication (buprenorphine and methadone). The aim of MMT is for treat addiction and reduce the prevalence of epidemic diseases such as HIV and hepatitis C. In the international drug field, it shows growing evidence that opioid agonist maintenance treatment is effective and is being widely used (Institute of medicine, 2006). Through this program, the patient able to adapt their new life without dependence on drugs. MMT was helpful in improving the quality of life of outpatients in MMT clinic in Xi’an, China, during the first three months of treatment (L. Xiao, Z. Y. Wu, W. Luo, & X. L. Wei, 2010).
The other strategies are increase in knowledge-based quality which important tool for quality assurance of delivered cares. It is a challenge for the healthcare services to meet the patient’s need with the necessary competency. Because addiction is both a physical and psychological health issue, substance abuse nurses need training and experience in general medical care and mental health. They must understand the psychological issues that cause to addiction so they can help patients overcome these problems and reduce the risk of relapse. Post basic or advanced diploma in Mental Health Nursing has been provided by Ministry of Health Malaysia which conducted by training institute to establish and maintain the higher standard of nursing knowledge. The Malaysian Ministry of Health has upgraded majority of post basic courses in Nursing to Advanced Diploma in 2012 (Ministry of Health Malaysia, 2012).
Research and reflective is an essential component of evidence base practice whereby conveying knowledge to practice and vice-versa. Monitoring and evaluation of the program to ensure a sustainable success like the respondents’ feedback is useful to evaluate and improve the effectiveness of rehabilitation program. Quality improvement such as Key Performance Indicators (KPI) helps nurses to continuously strive to provide better care of patients. The relevant amendment is necessary towards a better success rate among substance abuser in Malaysia. For example, the psychiatrist of the respective centre will provide additional training for nursing staff such as monitor patient by using withdrawal or severity scale. The length of inpatient management should be personalized to the specific needs of each patient. The World Health Organization Quality of Life (WHOQOL) project was introduced in 1991 and aimed to develop an international cross-culturally comparable quality of life assessment instrument. It evaluates the individual’s perceptions in the context of their personal goals, culture and value systems in worldwide.
Effective work force management and training is essential to overcome the limited resource and manpower in providing new services. It can be done both formally and informally through courses, supervision, workshops, bedside teaching, ward rounds and continuing nursing education. They must expertise what psychological issues arise when patients attempt to conquer their addictions so they can help patients create strategies for coping with the impact of starting a new life. For example, patients sometimes suffer from anxiety, depression and even thoughts of suicide when going through withdrawal phase. It is necessary to improve the working conditions for nurses who wish to conduct research in mental health and substance abuse either in the specialised or the community health services. This is necessary for nurses to perform knowledge-based practice, documentation, developing and applying new knowledge and practice to a greater extent.
Professionalisms should be maintained at all time and every patient entitles confidentiality and privacy. Eradicating the stigma of the illness and ensure the effectiveness of rehabilitation programs are not relying on nurses only but it involves everyone especially related to individual behaviours. Governments and professional organizations are mobilizing resources towards preventing and managing health-related stigma. The ongoing process require support from family members and patients’ effort to achieve the main goal. Nurses always provide care for people with serious mental problems and to substance abusers. It is important that the roles of nurses are not considered in isolation, but as a key part of a multidisciplinary team, responding to locally identified need. Nurses can bring essential skills to multi-disciplinary teams and have the competences to implement in cost-effectively. In future, research could further expand on this area to gain more comprehensive understanding of non-user perceptions across the population of Malaysia. There are often signs of these problems in childhood and adolescence which early intervention is therefore very important. Greater knowledge about groups at risk will provide the basis for new insights and interventions. The increasingly ageing population will increase the need for strengthened and accessible mental health services until the end of the life span.