trauma informed off-label use may be discussed. medication ... · intensive psychotherapy for...
TRANSCRIPT
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Trauma Informed
Medication Education 23rd Annual Northeast Regional Psychiatric Nursing Conference
4.4.2019
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Contact Information
Kathryn Kieran, MSN, PMHNP-BC:
[email protected]; 617-855-2468
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Off-label use may be discussed.
Thank you, Patricia
Mangones, NP, Stephanie
Brunet, & Rose Sajjabi.
Support for this work has been
provided by the Anonymous
Women’s Health Fund.
Discuss 3 commonalities between deprescribing and trauma-informed models
Give 3 examples of how trauma can result in over- and under- medicating behaviors
Propose 3 nursing interventions for harmful trauma-related medication behaviors
Learning Outcomes Content Acknowledgement
Trauma Exposure
Preexisting
Occupational
Vicarious
(Boulanger, 2018; Cohen & Collens, 2013)
https://youtu.be/1eziF7t9CcE
Video: Misty
https://maketheconnection.net/ U.S. Department of Veteran’s Affairs
Last summer she self-discontinued her sleep medication, and had poor outcomes.
Misty presents asking to discontinue her sleep medications.
What are some major discussion points?
Case Study
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- Richard Chefetz, 2015, p.131
“Avoiding responding has potential serious negative
consequences in a repetition of past neglect or dismissiveness”
Mind-Body Connections in Trauma
bio psycho social
(Mintz & Belknap, 2011; Karp, 2006)
Placebo and Nocebo
expectation
misattribution
learning
(Hodgkins, et al, 2018; Webster, Weinman, & Rubin, 2016)
Trauma & treatment resistance:
Trust & relationship
Meaning of Medication
“…symptoms serve many functions: to substitute for missing memories, to communicate distress, to
symbolize crucial relationships, to contain internal conflicts, to manage interpersonal issues.”
(Lowenstein & Goodwin, 1999, p.83)
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Medication in Trauma
numb
stigma
body
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Medication in Trauma
ritual
control
avoid
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Medication in Trauma
sleep
anxiety
mood appetite
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Exercise 1: Pick a Problem
Weight gain/ loss Bruising at injection site
Sexual side effects Swallowing liquids
Tremor Changes to libido
Nausea Jittery
Headaches Dreams more vivid
Can’t swallow Cognitive dulling
“Against medication” Shortness of breath
Sensations in mouth “Feel controlled”
Shape of pills Insomnia
Color of pills/liquid Sedation
Under-and-Over-Prescribing
Threading the needle (Davies & Frawley, 1994)
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Irrational Pharmacology
Cognitive challenges
Accentuated power
dynamics
Comorbidity
Self-care deficits
Impacts on Prescribing
(Karlamangla, Tinetti, Guralnik et al., 2007; Kessler, Sonnega, Bromet, Hughes & Nelson, 1995; Resnick, Acierno & Kilpatrick, 1997)
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Exercise 2 (Leonard, Graham, & Bonacum, 2004)
Situation
Background
Assessment
Recommendation/ Request
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Deprescribing Model:
Review medications
Identify targets
Plan a regimen together
Communicate
Frequent review and support
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(Gupta & Cahill, 2016, p.2)
•Universal precautions
•Maximize choices & control
•Collaborate on treatment & recovery
•Safety, respect, & acceptance
•Minimize retraumatization
Trauma-Informed Care:
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(Anai-Otong, 2016)
(Anai-Otong, 2016)
(Gupta & Cahill, 2016, p.2)
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Trauma Informed Medication Education
Review medications
• Universal precautions
Identify target medications
• Collaborate on treatment & recovery
• Maximize choices & control
Plan a regimen
• Communicate
• Frequent review and support
• Safety, respect, & acceptance
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Examples of Communication
expectations
practicalities
treatment interfering
communication
Examples
Review
Ask about specific side-effects
Identify Targets
Assess for stockpiling, agreement with regimen
Offer Reminders or Cues
Printouts, med organizers, set alarms together, post-its
Frequent review
& support
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Examples
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Key Points Medications have meaning
Assess for meaning at every opportunity
Historical trauma beliefs may be guiding current behavior
Mis-taking medications often important ways of coping
Make the medication contract explicit
Discuss a harm-reduction plan
Questions?
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References
Antai-Otong, D. (2016). Caring for trauma survivors. The Nursing Clinics of North America, 51(2), 323–333.
Boulanger, G. (2018). When is vicarious trauma a necessary therapeutic tool? Psychoanalytic Psychiatry, 35(1),
60-69.
Chefetz, R. (2015). Intensive psychotherapy for persistent dissociative processes: The fear of feeling real. NYC, NY: W.W.
Norton & Co.
Cohen, K., & Collens, P. (2013). The impact of trauma work on trauma workers: A metasynthesis on
vicarious trauma and vicarious posttraumatic growth. Psychological Trauma: Theory, Research, Practice and Policy,
5(6), 570-580.
Elwyn, G., Dominick Frosch, D., Thomson, R., Joseph-Williams, N., Lloyd, A., Kinnersley, P., Cording, E.,
Tomson, D., Dodd, C., Rollnick, S., Adrian Edwards, A., & Michael Barry, M. (2012). Shared decision
making: A model for clinical practice. Journal of General Internal Medicine, 27(10):1361–7.
Gupta, S., & Cahill, J. D. (2016). A prescription for “deprescribing” in psychiatry. Psychiatric Services , 67(8),
904–907.
Davies, J.M., & Frawley, M.G. (1994). Treating the adult survivor of childhood sexual abuse: A psychoanalytic
perspective. NYC, NY: Basic Books.
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References
Groopman, J. (2007, October). What’s the trouble? How doctors think. The New Yorker. Retrieved from
https://www.newyorker.com/magazine/2007/01/29/whats-the-trouble on November 2, 2018.
Hodgkins, G.E., Blommel, J.G., Dunlop, B.W., Iosifescu, D., Mathew, S.J., Neylan, T.C., Mayberg, H.S., &
Harvey, P.D. (2018). Placebo effects across self-report, clinician rating, and objective performance tasks
among women with Post-Traumatic Stress Disorder: Investigation of placebo response in a
pharmacological treatment study of Post-Traumatic Stress Disorder. Journal of Clinical Psychopharmacology,
38, 200-206.
Karlamangla, A., Tinetti, M., Guralnik, J., Studenski, S., Wetle, T., & Reuben, D. (2007). Comorbidity in
older adults: nosology of impairment, diseases, and conditions. The Journals of Gerontology. Series A, Biological
Sciences and Medical Sciences, 62(3), 296–300.
Karp, D. (2006). Is it me or my meds? Cambridge, MA: Harvard University Press.
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder
in the National Comorbidity Survey. Archives of General Psychiatry, 52(12), 1048–1060.
Leonard, M., Graham, S., & Bonacum, D. (2004). The human factor: the critical importance of effective
teamwork and communication in providing safe care. Quality and Safety in Health Care, (13)suppl 1, i85-i90.
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References
Mintz, D. & Belnap, B.A. (2011). What is psychodynamic psychopharmacology? An approach to
pharmacological treatment resistance in Eric M. Plakun, (Ed.), Treatment resistance and patient authority:
The Austen Riggs reader (pp. 42-65). NYC, NY: W.W. Norton & Co.
Resnick, H..S., Acierno, R., & Kilpatrick, D.G. (1997). Health impact of interpersonal violence 2: Medical
and mental health outcomes. Behavioral Medicine , 23(2), 65–78.
U.S. Department of Veteran’s Affairs. (n.d.) Misty found healing for MST in a women's group. Retrieved
from https://maketheconnection.net/stories/642 on August 10, 2018.
Webster, R.K., Weinman, J. & Rubin, G.J. (2016). A Systematic review of factors that contribute to nocebo
effects. Health Psychology, 35(12), 1334-1355.