The Opioid Epidemic and Rural Provider Burnout

“If it gets much worse, we will need full-time security”
— Lori, RN

·A while back, I blogged about my theory that healthcare provider burnout is related to patients’ untreated mental health issues. Since healthcare providers are ‘orchids’ (my term for sensitive, feeling people), we tend to absorb the suffering around us. Dynamic forces in the healthcare industry, coupled with an increase in patient suffering, have conspired to create a parallel process in which healthcare providers now experience many of the same mental health issues as our patients.

Back in November, I was in rural Ohio training nurses on how to use STI with chronic care patients. About thirty minutes into the first training session, I asked the nurses about their most challenging patients.

What happened next completely shocked me.

It started when a 30-something female nurse stood up and announced that she was tired of being yelled at by patients looking for pain pills. Before she could finish her thought, other nurses chimed in, talking over one another about the daily struggle of being the “pain-med-cop,” as one nurse called it. They went on to discuss the following situations, emphasizing that these are daily occurrences:  

  •  Patients stalk providers on the phone and leave profanity-laced messages about prescription refills.
  • Patients show up without appointments, yelling and screaming for their pain medications in the waiting room, inciting other patients.
  • Near riots form in waiting rooms, as patient anger spreads.
  • ·Patients tell elaborate, complicated stories of lost pain medications.
  • Drug seeking patients journey between the doctor’s office and the police station.
  • Police reports alleging stolen medications and uncorroborated crimes are commonplace.
  • Teenagers attend “skittle parties,” wherein high school age children bring their parents’ medications to parties and mix them in a bowl. Partygoers then take these pills to “see what happens.”
  • Geriatric patients joke with providers about needing more “Xannies” (Xanax pills) and “Blueies” (Oxycontin pills).

As participants told story after story, a nurse in the front row began convulsing with sobs. I stopped the class and asked her what was wrong. She said she wasn’t sure if she could continue working as a nurse. She has been a nurse for 14 years, but said it was too upsetting for her to see “good teenagers becoming drug addicts.”

Prior to this moment I had been surprised, but kept calm and logical. As this nurse sobbed with desperation about the situation, I began to feel panicked. 

You have no idea what we go through every day
— Macie, LVN

Why did I feel panicked?

  • Because this nurse’s desperation felt real.
  • Because in the twenty minutes leading up to the crying nurse, not one participant had expressed compassion for the patients struggling with substance abuse.
  • Because I have worked with these nurses and know them to be compassionate professionals.
  • Because when it was suggested that the patients’ behaviors might not be rooted in disrespect, but rather based on a desperation that comes with withdrawal and addiction, I was roundly corrected by the group: “You don’t know what we go through every day.”
  • Because it is an uphill battle when people are not open to alternate perspectives, but cling to possible thought distortions.
  • Because this type of anger is destructive to these nurses and the healthcare organization, and it is contagious to their patients.
  • Because these nurses reported having problems at home as a result of stress at work.
  • Because if these compassionate professionals were unwilling or unable to help patients struggling with substance abuse, who would help these patients?
  • Because I wasn’t sure how these nurses could do STI when they were clearly struggling themselves.

I quickly changed course and decided to teach the nurses how to use STI on themselves to increase their existing coping skills. The training felt different from others. It felt like there was a pressure on me to save these nurses for their sake, and for the sake of their patients.

My panic turned to profound sadness when one of the nurses shared the following story:

One of our male patients called about a month ago, sobbing. He begged me to help him. He said he knew he was addicted to his Vicodin, but couldn’t stop. He said he was on the verge of using heroin and asked if we could help him.

The nurse tried to get this patient into rehab but the process took weeks. By the time insurance approved the rehab stay, the patient couldn’t be found. His family said he was on the street. 

I asked the nurse how this situation affected her. She said she was okay, that this kind of thing happened all the time.  (My interpretation: This nurse had already shut down, which is a sure sign of provider burnout.)

After the training ended, I scoured the web for resources. What would a patient do if he or she wanted help with an addiction? There were no drug rehab facilities within 50 miles of the hospital and only four Narcotics Anonymous meetings each week in a town fifteen minutes away.  

The healthcare community needs to start recognizing the connection between all of these problems. We can’t talk about healthcare outcomes and provider burnout without talking about the social and economic issues that plague our patients. Untreated mental health issues, economic problems, globalization, the opioid epidemic, et cetera, need to be made part of the conversation.

The recent election results have made it abundantly clear that small town America feels marginalized and ignored by the rest of the country. It’s time to roll up our sleeves and collectively work on creative solutions to solve the seemingly intractable problems that plague many of our patients, especially those patients and providers living in small towns.

ADAMH Board statistic

ADAMH Board statistic

Having witnessed the devastation firsthand, the Stellicare team is committed to ending the suffering caused by the opioid epidemic. To that end, we will help the Ohio ADAMHS Opiate Task Force create solutions for patients and providers. 

Untreated Patient Depression and Provider Burnout

Hailey Osmond in The Sixth Sense

Hailey Osmond in The Sixth Sense

“I see dead people everywhere.”

Sometimes I feel like Hailey Osmond’s character in the Sixth Sense, living in some alternate reality. Hundreds of studies illustrate the connection between untreated mental health issues and poor clinical outcomes, but there is no discussion of how patients’ untreated depression and mental health problems affect healthcare providers.

“I see suffering everywhere.”

Patients suffer silently which negative impacts everything including the very people tasked with caring for them.

As a psychotherapist by training and Orchid (my term for sensitive, feeling people) by birth, I pick up on other people’s emotions. Emotions are contagious on a cellular level and experienced in the body. If someone is sad and within arm’s reach, I’ll start feeling constriction in my throat and heaviness in my chest. My patients are always shocked when I ask them in real time if they have a lump in their throat or heaviness in their chest. They don’t realize their sadness is contagious to everyone around them. (Good therapists understand this phenomenon and use it to help their patients identify, label and manage their emotions.)

Most people aren’t consciously aware of this contagion, but they know it unconsciously which is why most of us dodge depressed people. Who wants to feel hopeless?

When I worked as a medical social worker—before creating STI–I actively avoided my depressed patients. What could I possibly do to help these patients? Almost all of them refused to go to outpatient psychiatry. Most would not take anti-depressants. When we talked, there was an endless litany of seemingly unsolvable problems. I left these conversations feeling defeated, angry, sad and guilty.

• Defeated: there didn’t appear to be a solution.
• Angry: it felt like I had wasted my time.
• Sad: I felt incompetent. (“A good social worker would know how to help this patient.”)
• Guilty: I “shouldn’t” feel angry and shouldn’t dodge my patients.

It was a daily cycle of unproductive conversations, bad feelings, and self-flagellation. When things in my personal life were going well, this wouldn’t impact me as much, but when things weren’t going well, the experience was more intense. I’d call in sick. I’d feel angry for no known reason.

…which is why most of us dodge depressed people.

I used to think it was just me, but after talking to thousands of healthcare professionals around the country, I discovered other clinicians had similar experiences.

Different professions experience it differently: Doctors might experience their patient’s fatigue and lack of motivation to change behaviors. Nurses might feel their patient’s anxiety waiting for test results. Dietitians and pharmacists possibly experience their patients’ frustration with complicated medication regimes.

My theory is that patients are silently struggling with mental health challenges, often unaware of what is happening. Health care professionals feel our patients’ unprocessed emotions, internalize them and wonder why we feel burnt out.

It wasn’t always like this.

Back in the good old days–before electronic health records and onerous regulations–there was time to sit face-to-face with patients and talk. A few minutes of real attention is healing. Even if we couldn’t fix their problems, patients sensed we cared for them which in and of itself was healing. As a result, they felt better, and we felt like healers.

Now we’re so anxious about getting everything done that sitting with patients for two minutes seems like a luxury we can’t afford. We intuitively sense and internalize our patients’ emotional distress and depression, but don’t have the time or resources to understand it much less connect with our colleagues to process it or do self-care behaviors. Over time, we start shutting down.

As a result, we experience the same symptoms of emotional distress as our patients. It’s a parallel process. Doctors are committing suicide at a record rate. Forty percent of hospital nurses report feeling burnt out. Social workers leave the profession.

It’s critical that we address our patients’ untreated depression and mental health struggles for the sake of both patients and healthcare providers. We can’t roll the clock back on electronic records and regulations, but health care organizations can implement innovative collaborative care solutions for the sake of their patients and health care providers.