Substance Use Disorders: A Curriculum Response

Marian L. Farrell, PhD, PMH-NP, BC, PMH-CNS, BC, CRNP


Online J Issues Nurs. 2020;25(1) 

In This Article

Scope of the Problem

The number of individuals affected by SUD, specifically alcohol and opioids is staggering, often resulting in increases in visits to the emergency department, inpatient stays, and death. Among individuals aged 12 and older, 14.5 million people identified themselves as experiencing an alcohol use disorder in 2017 (SAMHSA, 2018). In that same year, approximately 30.5 million people aged 12 or older used an illicit drug during the past 30 days; an estimated 11.1 million people misused opioids; 11.1 million individuals misused pain relievers; and heroin was used 886,000 individuals (SAMHSA, 2018).

In the US, the Centers for Disease Control and Prevention (CDC) estimates that an average of six people die as a result of alcohol poisoning each day (CDC, 2015). According to the National Institute on Drug Abuse (2019), more than 70,200 Americans died from drug overdoses in 2017. The statistic includes both illicit drugs and prescription opioids. The number of individuals who die as a result of drug and illicit drug use is alarming. Current statistics related to substance use disorders demonstrate not only an increasing number of affected individuals, including their family, friends, co-workers, and communities, but also the burden on healthcare providers and facilities to meet the increasing number of individuals requiring treatment in emergency, in-patient, and outpatient facilities. This is truly a healthcare crisis and one to which leaders in the nursing profession must respond through a partnership involving education, practice, research, and policy. This article will focus on the role of education in the partnership.

The lack of sufficient time and content in nursing education curricula to adequately cover the complexity of SUD has been documented in the literature for over 50 years. Johnson (1965) identified a lack of adequate preparation and experiences as a barrier, thus preventing nurses from providing an appropriate level of care to individuals experiencing alcohol use disorders (AUDs). Hoffman & Heinemann (1987) reported an average amount of time teaching alcohol and drug content as one to five hours in all three types of programs (i.e., diploma associate, and baccalaureate) surveyed. Murphy (1989) identified a 20-year pattern of nurses who failed to attain a sufficient level of preparedness to identify and adequately treat patients with SUD during their initial education. Murphy further described the need for additional curriculum development, theory development, research, and preparation of faculty. Naegle (1994) identified gaps in nursing education regarding substance abuse and linked the role of nurses treating patients with substance use disorders with two primary objectives: to "identify alcohol related problems in patients and to refer them to treatment specialists" (p. 155). Howard, Walker, Walker, & Suchinsky (1997) reviewed multiple surveys regarding inclusion of drug and alcohol content in nursing education curricula, reporting limitations in content and time allotted for didactic and clinical experiences.

Savage, Dyehouse, & Marcus (2014) reported a cross-sectional, electronic survey of schools of nursing to determine the mean number of alcohol-related content hours; content offered; and inclusion of strategies to reduce at-risk drinking, such as screenings and brief interventions. Sixty-nine schools responded to the survey, however, three schools did not offer a bachelor's degree in nursing. Only 39 of the eligible 66 schools provided the total hours related to alcohol-related content, resulting in a mean of 11.3 hours (SD = 8.3 hours) of alcohol-related content. Psychiatric/mental health courses included the highest amount of specific content (mean = 4.9 hours, SD = 5.03). However, 29.3% of respondents reported less than three hours of alcohol-related content in the psychiatric/mental health course (Savage et al, 2014).

Adult health/medical surgical nursing courses reported a mean of 2.6 hours (SD = 3). The least amount of alcohol-related content hours was found in women and children's health courses (mean = 1.8 hours, SD = not reported) and community/public health courses (mean = 1.6 hours, SD = not reported ). A mean of 6 hours was reported for the total alcohol-related content hours computed for all courses other than the psychiatric course (Savage et al., 2014). Less than 10% of the schools required competency in screening and brief intervention. Savage et al. (2014) suggested incorporating content aimed at prevention and early intervention for risk of use. In addition, there needs to be a lifespan approach in baccalaureate program curricula addressing the needs of individuals experiencing alcohol use disorders. Other recommendations for a lifespan approach across a baccalaureate program curriculum included genetics; neurobiology of alcohol addiction; prevention of AUDs; screening and brief intervention for at-risk alcohol use and AUDs; withdrawal management; treatment for AUDs; alcohol-related health consequences; and potential legal and ethical issues (Savage et al., 2014).

The National Council of State Boards of Nursing (NCSBN) surveyed 6000 candidates who successfully completed the NCLEX-RN examination during the time period of April 15, 2016 through March 15, 2017. Survey participants (55.0%) described the client population as acutely ill (55.0%) and noted 27.2% of the client population had behavioral/emotional conditions (NCSBN, 2018).

The shortage of content hours related to alcohol and other substance use disorders in baccalaureate curricula has consequences. Newly licensed registered nurses may lack sufficient knowledge regarding the care of individuals who experience alcohol use disorders. The shortage of existing and newly licensed registered nurses and advanced practice nurses with expertise in treating individuals with alcohol use disorders threatens the level of care required by this population. Nurse educators often lack sufficient expertise in alcohol use disorders thus diminishing the potential for strengthening curricula.

To initiate curricular change, a perceived need to change is essential. It is well established that current approaches to curriculum design in baccalaureate nursing education programs often lack sufficient experiences and depth of knowledge regarding substance use disorders. Kane (2012, 2015) described essential competencies for registered nurses related to psychiatric and substance use disorders. She leads a core group of nurse educators and practitioners who continue to advocate for the development of a set of competencies for nurses who provide care for individuals experiencing substance use disorders.

An expert panel (the Psychiatric Mental Health Substance Abuse Essential Competencies Taskforce of the American Academy of Nursing Psychiatric Mental Health Substance Abuse) developed the Essential Psychiatric and Mental Health and Substance Use Competences (2012). The guidelines include the following core nursing content areas: growth and development; neurobiological basis of care practice; pharmacotherapeutics and basic principles of pharmacology; communication theory and interpersonal relational skills; clinical decision making; patient care roles; healthcare settings; cultural ethnic and spiritual concepts; health promotion and illness prevention; concepts of chronic illness; ethical and legal principles; vulnerable populations; and nursing research. Challenges of changing nursing curricula include time allotted for the content and the environment in which it is delivered.