House Rules -Everyone is normal, until you get to know them

Author: Mark Parkinson BsPharm:  President  AFC-CE

Credit Hours 2 - Approximate time required: 120 min.

Educational Goal

Discuss societal expectations for new residents and how to better utilize House rules for better communication

Educational Objectives

  • Discuss the role of societal expectations in AFC homes
  • How to utilize House Rules better
  • Tell of some socialization tips and tricks for caregivers

 

 

Procedure:

Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer

   The information presented in this activity is not meant contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible

 

 

 

Everyone is normal, until you get to know them.

Ways to Improve House Rules

 

I found this joke on one of those YouTube channels that specialize in funny signs collections.  It made me giggle as I thought about how true that is. The more I thought about it the more I laughed. Then light bulbs started to turn on in my head. This is true for residents of care homes as well. In-home care providers have to struggle with this principle every time they get a new resident. The more I thought about it, the more I realized that this would be a great topic for a CE lesson. How to better communicate with and integrate new clients into your homes. Everyone talks about the medical side of the business, but no one talks about how to socialize with your residents. So I will.

I need to say this right up front. This will not be an all-inclusive lesson that covers everything. This will be more like a tips and tricks type of lesson that will hopefully enhance your current skill set.

So let’s get started.

Social Expectations

To understand what I will be presenting to you we have to talk about some basic underlining concepts about how I think society exists today. Don’t worry, I won’t get all “psycho-social expert” on you because I am not a psychologist. The following is just my view on how people can live next to each other without killing each other every few months, (even though we may want to). You know what I mean, and don’t deny that you haven’t fantasized about taking out “ninja-style” that one neighbor who annoys you so much. The reason we all don’t have a secret stash of assassination equipment is that there is a social expectation that you can do whatever you want in your own home, just as long as it doesn’t affect mine. That expectation puts up a wall that protects us from the annoying actions of all those around us. 

I also believe that humans tend to think that everyone thinks like “me”. We go through life expecting our neighbors to act and think like we do.  We label ourselves “normal” and when they don’t act like us, we label that “abnormal”. Of course, we all know that’s just plain wrong but this fallacy is perpetuated because of the walls we put around ourselves. We can’t see into their homes, so we just assume they think like us and we all get along just fine. That’s why the above joke is so funny. Because it's soooo true. We assume that everyone is “normal” until we have to interact with them then everyone becomes “abnormal” because they naturally don’t think and act like we do. 

Free Portrait Woman photo and picture

We can still function around all these “abnormal” people because the rule of law, proper manners, and social etiquette force us to behave ourselves when we are around each other. Once we get behind the walls of our own home, we forget about all that and can relax into our “normal” selves. So can all those “abnormal” people relax into their abnormal selves, as long as they don’t affect us “normal” people. If we invite any of those abnormal people into our home, we expect them to respect our “normal” behavior. If we go into their home, we temporarily tolerate their abnormal behavior. 

I assume you already know all this stuff, but here comes my main point. What happens when there are no more home walls to retreat behind so we can relax into being “normal”. Like in a foster care home. You are inviting a bunch of abnormal people to live in your home. On the flip side, the new resident finds themselves moving into the home of an abnormal person. If there is more than one resident in the home, the abnormality of the situation is compounded. On top of all that, the State comes into your home, and other health providers are thrust into the situation and they all impose a bunch of rules and expectations that hinder your ability to be “normal” in your own home.  And how do substitute care providers fit into your “normal” home?

Those who agree to take money for caring for others in their home have to accept that “normal” has gone bye-bye. Those foster care providers who expect everyone to just adapt to their “normal” way of living usually have a lot of ongoing difficulty managing their homes and residents. Those providers who succeed are those who actively manage the situation so all the “abnormal” people quickly become “normalized” to their new environment.

Okay, that’s the underlying principles I want everyone to understand. You’d be surprised how often new care providers (foster care home owners and new employee hires alike) don’t get this. They constantly fumble around and complain that the residents aren’t “behaving normally” and are being difficult. I guess since it’s a home environment they think it will just happen all by itself. Well it usually doesn’t, so here are some ways to “make” it happen.

Business Infrastructure

When we first start up our foster care business we think, - “This going to be easy. I’ll just clear out some rooms and people will move in and pay me money to live with my family.” It will be easy to take care of them because everyone already knows how to live in a home environment. All I have to do is what I normally do. No sweat. After all, clients want to live in a warm and cozy home environment instead of a cold sterile nursing home business.”  After a few months, reality kicks in and you think this is not what you signed up for.

And what is that reality? Once you agree to take care of someone you no longer have a home. You have a medical care business, pretending to be a home. So my first tip is- Stop running your home as a home. Run it like a business set up to attract and retain money-paying customers who want to stay in a “home-like” environment but want a medical expert to take care of them. The following are a few tips on how to do that.

 

 

Being Predictable

What turns a home into a business? Rules and procedures. Predictable, repeatable actions that govern everything that goes on in your home. You have to list all the things that you normally do in your home and distill them down to repeatable “To Do” lists. I even suggest that you place a check-off box next to each item and laminate the paper. Then you can use a dry-erase marker and physically check each box as the chore is accomplished. At the end of the day, you erase the checkmarks so you can start over the next day.

What are the benefits of your check-off list?

  • Your home runs more smoothly. Nothing is forgotten or left for another time in the future.
  • Less effort is put into running your home as efficiencies are found and best practices are established.
  • Training and governing employees or substitute caregivers becomes a whole lot easier.
  • The most important item though is that you become predictable. Your clients know what to expect out of you. They know what is going to happen next and more easily adapt their behavior to it. Your normal becomes their normal much quicker when they know what is coming next.
  • Bonus- You will also find that county inspections of your home (business) are accomplished so much easier and faster. Who doesn’t want that?

 

House Rules

You probably know the House Rules just as something the State makes you print out and post in a place where the county inspector will look but nobody else will. It wouldn’t surprise me that some of you are thinking, “We have a list of house rules? Where? What do they say?” In my opinion, House Rules is probably one of the most underutilized communication tools in your business. You read that right. The House Rules is a communication tool that is supposed to help the customer know what is expected of them and what you will do for them. I hope you are having an “I get it now”, light bulb turning on above your head moment, right now. House rules are not a list of restrictions, they are an instruction manual on how to fit into your home. In essence, it tells anyone (resident and employee) how to be “normal” in your home. So, here’s tip number two.

Don’t write the house rule like a prison warden. Write them like a cruise director or advertising agent.

No one likes to be told what they can and cannot do. We all have an inner self who will naturally think, “You’re not the boss of me” and promptly tries to ignore all documents of such nature. Admit it. You probably struggled a lot even writing the dumb thing in the first place. You are also probably avoiding it like something that will make you nauseous just by reading it.

I suggest that you scrap your “can’t do this or that” list and start completely over. Write your new list like an instruction manual on how to easily fit into your cozy home environment. I also suggest that you don’t post it on a board nobody looks at. Print it on nice paper in friendly colors and add some graphics. Put it in a nice frame and place it in each room and dining area.

You want their inner voice to think, “Well that was sure helpful, I’m glad I read that.” Here are some wording suggestions.

  • We want our home to be your home. You will find it helpful if you…place rule here
  • We want your stay with us to be as pleasant as possible. We respectfully ask that you…. Place rule here
  • Use words like refrain instead of can’t or do not.
  • For the safety and comfort of yourself, other residents, and the staff please abstain from ……
  • If you have any concerns, questions, or suggestions, we want to hear from you.
  • Meals (insert any service or activity that you want to emphasize) are served promptly at ….
  • You can expect … list restriction or service to be provided

For example- You can expect that your stay here will be smoke-free. For those wishing to smoke, an area will be provided for you that will not impose on those who have health issues aggravated by cigarette smoke.

  • List any requirements as a service to others not as a restriction.

For example- Your efforts to be respectful of others’ need for privacy will be appreciated. They will also respect your need for privacy in return.

  • Instead of phrases like “home phone use will be restricted only to business hours” use phrases like home phone use are available between the hours of ….
  • Before you write your house rules think “What does the customer need and want to know in order to be comfortable here”

Living Documents

Tip number three. Always be willing to adapt and improve your business practices. It is very unrealistic (and lazy) to expect that your Check Off list and House Rules will never have to be changed from time to time. Write the document on your computer and save the file. It will be easier to make needed changes that way. Review your procedures regularly, on at least a yearly basis. Also, see difficulties that you encounter as opportunities to improve your procedures. Ask yourself, why did that happen and what can I do to prevent it in the future?

 

Competitive Edge

Don’t blow past this and ignore what I just said. You are a business and need to have a competitive advantage over other businesses providing the same medical care. Think of it this way. You want your competitors to have haphazard business practices and house rules that could be used in the state prison system, not you. That way it will be easier to obtain your paying customers away from them.

Employees you’re not off the hook. You have to contribute to the above as well. Because your continued paycheck depends on the business out-competing all others in the area. Besides, a happy well-adjusted client is an easier to take care of client. Who doesn’t want that?

 

Going from Guest to Resident

Let us go back to social expectations again. When you visit someone else’s home, you can fit in by temporarily tolerating all their abnormalities. That’s what polite guests do.  When you move into someone else's home you are no longer a guest. You are a resident which comes with an entirely different set of expectations. You can choose to let the new resident figure things out on their own or you can guide them in the transition. Guess which happens quicker and easier. Duh, right? So what are your business procedures that make it happen? Oh, you don’t have any? No wonder you have experienced some difficulties in the past. Duh, right? So here are some tips to help you establish your transitioning procedures. Many of them are designed to take advantage of the social expectations that are already present in the new resident’s behaviors.

Tip number 4. Get the Paradigm right.

Start with the right state of mind. The fancy word for it is, what is your paradigm?

  • Don’t be a dictatorship. It is my experience that dictators are always followed by rebellions. Remember the “You’re not the boss of me” social expectation.
  • You are not a Bed and Breakfast where every visitor is a guest to be pampered and pandered to. Guests are not expected to change their behaviors.
  • I suggest the middle ground of becoming a Benevolent and wise ruler. You are in charge, but your intent is to benefit all your subjects. You actively guide the new resident in acclimating to your home.

Tip number 5. Bring their Stuff with them

Bring in as much “normal” as you can from the resident’s old home. Allow, even insist on the new resident bringing in:

  • Pictures for the walls
  • Familiar pillows and comforters for the bed.
  • Recliners
  • Photo albums
  • Bedside lamps and clocks or other frequently used electronic gismos

Tip number 6. Polite Expectations

Take advantage of the “you’re a guest in my normal” period of the transition to eliminate disruptive behaviors. Remind them that they chose to move into your home, so it is just polite to respect what’s “normal” behavior in your home. They are already socially trained to think that way so take advantage of it. 

Tip number 7. Playing Host

In the later part of the transition period invite lots of visitors.

Showing off the resident’s new place of domicile is a powerful social reinforcement of “this place is now my place” kind of thinking. Encourage the resident to invite their friends and family over for dinner or throw a housewarming party. When the resident acts as a host for visitors they are socially saying to themselves, come visit me at “my” place. You have to make them feel like they are playing host though or they might just want to use the visit to complain that everyone is being “abnormal” around them.

Holidays are great times to play host to visitors. Take advantage of the social expectations inherent in these events. 

Tip number 8. I’ve got your back, Jack.

It has been my experience that no one yells at someone trying to be helpful. Socially it is counterproductive to hinder someone attempting to be an advocate for you. When residents see that you are actively working for them against someone or something that is being “abnormal”, they will calm down or at least let you get on with what you are doing. Be vocal in your advocating efforts. Let them know that is what you are doing. Do it often enough and the new resident readily becomes a member of your team, easily deferring to you instead of acting on their own. Thus your “normal” has now comes to be their “normal”.

Can you think of other ways to take advantage of already present social expectations? If you can, turn it into a repeatable action and you’re acting like a skilled business professional.

 

U safe Iron Metal Tool Box, Size: 17 Inch at Rs 4500/piece in Mumbai | ID:  15472203412Socialization Toolbox

Just like a professional carpenter has a toolbox full of tools he uses to shape a piece of wood to fit into whatever he is building at the time; caregivers can also do the same to enable new residents to fit into your home. A tool may not be used in every situation but having it before it is needed is a good thing. Here are a few more socialization tools to add to your caregiving toolbox.

Assessing the ability to adapt

Most if not all of your clients will suffer from one or more handicaps that prevent them from behaving as a normal person would. No matter what social expectations we have for them. It could be a physical health, mental health, or developmental health issue. You have to adapt your expectations and practices to accommodate for those handicaps. You’ll have a much easier time if you accept that fact as part of doing In-Home caregiving.

Tool number 1 Assessing for inability to act normal

I suggest that you include in your new move-in process an assessment of the ability to adapt to the new environment. The old saying is “forewarned is forearmed”.  Do they have dementia, mental issues, developmental issues, or similar items?

Tool number 2 Teaching Patience

This is a big issue for new to the business caregivers and new employees. Newbees to the profession are not used to lowering or adjusting their social expectations to accommodate for handicaps that lead to abnormal behaviors. Adult Foster Care business owners have to expect that fact and actively train newbees how to adapt their preconceived notions about client behaviors.  Teach them to extend the time frame aloud to change their behaviors to the new normal.

Tool number 3 Adapt to their reality superficially

Simply put, some of your residents can’t act normally. Lower mental capacity due to poor health prevents them from doing so. It’s okay to let them think you agree with their abnormal behavior while you help them act normal. You are not really lying to them, you as just making accommodations for their inability.  I know that sounds bad and purposely vague. Here are a couple of examples of what I mean.

An elderly dementia patient wanders around looking for the upstairs in a single-story house. Instead of arguing with him about there is no stairs, tell them, “OK I’ll help you find the stairs”. As you walk around the house ask them what they are looking for. If it is an item tell them “Oh I know where that is, no need to go upstairs” then lead them to the item. If it’s a person they are looking for say “Oh, they are not here now they might be a work or something. Let’s watch some TV while we wait for them to return.”

If they repeatably act in an abnormal behavior because of memory loss then say, “Don’t you remember, you told me just yesterday that you were going to (insert normal behavior) You told me to remind you if you forgot.” Make them think it was their idea in the first place, they just forgot.

Tool number 4 Defer to authority

Conflicts over whose “normal” behavior standards are going to be followed (yours or theirs) can sometimes be resolved by deferring to the definition of what is “normal” to someone the resident respects or trusts.  That could be family members, nurses, therapists, or doctors. It could also be from unusual sources of authority such as the Fire Marshal.

For example, It’s ok with us if you smoke but the Fire Marshall has told us that it has to be outside. We’ll lose our business if we go against the Fire Marshall.

This caregiver tool can be tricky to use effectively because you never know who the new resident respects enough to change their behavior for. It requires you to use some skillful questioning before you need to use it.

The principles that make this tool work in my opinion is:

  • Find out who they respect enough that they will follow their recommendations.
  • Interject that authority’s orders into an argument in such a way that the new resident is not arguing with you anymore but with someone who is not there to argue with.
  • You have to show that you also respect that third party's authority.
  • Overuse of the tool makes you look weak. It makes it harder to gain the resident’s respect if you are consistently deferring to someone else.

Tool Number 5 Mirroring

Do you remember the old saying “Birds of a feather flock together”? It refers to how people are more comfortable around like-minded people. We naturally communicate better with people who have the same communication styles that we have. It’s that, our definition of what’s “normal” thing, again. It will be easier to show you than to tell you about this concept. Watch the following video.

 

Funny video right, and oh so true. In the joke, the husband asks a simple direct question and wants a simple direct answer. The wife needs to talk about her experiences and feelings while answering the question.  If you want your resident to be comfortable with you so you can influence them, copy their communication style. If they are a talkative storyteller, let them tell their story then you tell a story back. If they are all about emotions and feelings say I understand how you feel a lot. Then tell them how their words make you feel. If they are short and direct, answer with direct responses.

Mirroring Body Language: The Hidden Code of Connection - BECOME MORE  COMPELLING

Tool Number 6 Reflecting

Reflecting is similar to mirroring, but you use body language on top of what you say. Most experts call this mirroring too, but I changed the name so you can more easily keep them straight in your head. As before, I am going to use a video to show you what I mean.

 

Body language is a subtle but powerful way of influencing another person. Just be careful not to reflect negativity back or you have negated any benefit in communication.

Tool Number 7 Paraphrasing response

Paraphrasing is summing up what you just heard and repeating it back. The purpose is to give the talker the opportunity to tell you if you got it right or wrong. You start your paraphrasing response with, let me get this straight, or I think you mean, or Did I hear you right? You said….

By repeating back what you think they said, it shows them that you are trying to understand what they are saying. It also shows them that you respect what they have to say.

As you get better at paraphrasing you can subtly guide a conversation in two ways.

  1. You paraphrase two responses and let them tell you which is right. “Are you trying to tell me, this or that? Of course, you phrase your desired response favorably and the unwanted response negatively.
  2. You include in your paraphrase an interpretation that is favorable to your way of thinking. If you’re good enough, agreeing with your paraphrase leads them to agree with your side of the story.

 

Conclusion

Well, I just gave you some of my best tips and tricks on how to turn all those abnormal people into normal residents of your home.  They are based on my years of experience and a lot of trial and error. I hope you find them useful. You certainly won’t get this training elsewhere. These are my tips and tricks, make them your tips and tricks by purposely using them and practice, practice, practice.

As always Good Luck in your caregiving efforts.

Mark Parkinson BsPharm

 References:

  1. Social Expectations Influence Behavior. American Psychological Association.Org. April 14,16. https://www.apa.org/pubs/highlights/peeps/issue-67
  2. How to Use "Mirroring" to Build Rapport | The Body Language of Business. Jan 5,10. https://www.youtube.com/watch?v=rqhSWI4-hnA
  3. Vanessa Van Edwards. Mirroring Body Language: 4 Steps To Successfully Mirror Others. Science of People.com. 2023 https://www.scienceofpeople.com/mirroring/

 

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Psychology Primer for In-Home Caregiving

Author: Mark Parkinson BsPharm:  President  AFC-CE

Credit Hours 2 - Approximate time required: 120 min.

Educational Goal

Primer for In-Home Caregivers about psychological conditions

Educational Objectives

  • Present videos about psychological conditions and tell ideas on how to utilize the info in care homes.

 

Procedure:

Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer

   The information presented in this activity is not meant contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible

 

 

 

Psychology Primer for In-Home Caregiving

When you live with your patients you cannot help but be turned into a bit of a psychologist to them. It’s one of the advantages and burdens you have as a caregiver in a home environment.  The advantage is you become closer to the patient than any other medical care provider. The burden is how do you use that intimacy correctly for the best outcomes. As I have said many times, I am just an old country pharmacist, not a trained psychologist. But I have found a psychologist who just might give you some of the understanding that you need to be a better In-home caregiver. I am going to show you a series of YouTube videos presented by Dr. Tracey Marks. In her own words she “makes mental health education videos”. She is psychologist from Atlanta Georgia with more than 20 years of experience. After each video, I will add my thoughts on how you can use the information she presents in a residential care setting.

A warning before we get started. You cannot and should not provide mental health therapy for your clients. Leave that burden to the professionals. You have enough on your plate already just keeping the home and business running smoothly. You can though take advantage of some of the psychology principles to provide a supportive environment for that therapy. At the very least you should have a basic understanding of what’s going on so you can be an effective advocate and caregiver for the client. As you watch each video, I want you to think about how you can use this info to make your In-Home caregiving easy and more effective. You are going to have to adapt the information to fit your own care setting. Whether that is geriatric, development disabled, or mental health home.  Most of the exam questions are designed to tell the powers that be that you actually watched the video so don’t overthink them. Got it, Good, let us Get started.

Exam taking hint*

Print out the exam questions before you start watching the videos or write down the next question as you go.

 

Video 1

 

Coping Skills and Psychological Defenses - An Introduction

 

 

Interesting stuff, right? What I got out of the video was an explanation of why some people are so negative. It is a coping skill. Not a very good one though. If you understand this, it is easier to tolerate outbursts of anger or negative behaviors in others. You could possibly help guide them to more effective coping skills. If the behavior is dangerous though , you should inform a mental health specialist about the issue.

 

Video 2

 

Self-Esteem: How It Changes And 2 Ways to Boost It

 

This video lists several areas where caregivers can help their residents build healthy self-esteem.

  • Recognizing the strengths, a resident has can increase self-esteem.
  • Discouraging criticism of others can reduce self-criticism a promote an increase of self-esteem.
  • Helping the resident with low self-esteem issues accept compliments.

 

Video 3

 

Big Egos vs. Strong Egos: How To Spot A Weak One

 

 

I believe this video helps caregivers evaluate the behaviors of their residents. It also lists 2 ways you can help the resident deal with problems.

  1. Engage in activities that increase their self-awareness.
  2. Promote self-care activities to improve both mental and physical health.

 

Video 4

 

The 5 Needs That Motivate You And How You Get Stuck

 

There weren’t many actionable items for caregivers in this one. I thought it was very good though at providing basic information about what drives people.

 

Video 5

 

What is Grit and How Do You Get It? Give yourself a break if you don’t have it.

 

 

This video provides ideas on how caregivers can be supportive of their residents’ emotional needs.

 

Video 6

 

Anxiety: 5 primitive Defenses You Use Against It

 

I like the idea of providing a punching bag-like item for residents who are dealing with a lot of built-up emotions.

 

Video 7

 

How Insecure Attachment Affect Your Relationships

 

I thought the first half of this video would be important for Developmentally Disabled homes and the last half for Mental Health Homes.

 

Video 8

 

How To Tell If You're Depressed

 

Depression is a big issue for residents in Adult Foster Care homes.

Everyone feels sad about having to live in your home because they can’t take care of themselves. When does that sadness crossover to become clinical depression that needs treatment? If you understand and recognize clinical depression symptoms better, you can get the help your residents need sooner.

 

Video 9

 

What Does It Mean To Project? A Psychological Defense Mechanism

 

 

I thought it important for you to know what projecting is and how it could be used to explain why residents accuse you of hating them or belittling them because of a mental or physical handicap.

It’s not about what you think of them. It’s about what they think of themselves.

 

Video 10

 

Locus of Control: What Is It & Why It Matters

 

 

I believe this video’s content is best applied to you as a caregiver. Where is your locus of control? How independent are your actions from the negative actions of your residents, other caregivers, and state regulators? What are you going to do to gain control over your own reactions to them?

 

Video 11

 

Seven Positive Psychological Traits That Predict Good Health

 

 

 

I wanted to end on a positive note. I believe that these concepts could also be applied to you to make you a better care provider.

 

Conclusion

Well, that certainly was a different Continuing Education course, wasn’t it? I hope you enjoyed the videos. I would suggest that you rewatch the videos a couple of times. You never know what other gems you might find. Don’t get too caught up in all the psychobabble and definitely don’t psychoanalyze yourself. Remember psychology is just the description of general characteristics of the human mind. It is possible to see all the above troubles in yourselves and your clients. But in reality, they do not seriously affect your or their day-to-day activities.

If you do notice something truly significant, work with a doctor or mental health professional. Finally, remember that in mental health you are not trying for a cure, you are trying to control. You are trying to reduce the negative to the point where the resident can function normally while in your care.

As always, good luck in your caregiving efforts.

Mark Parkinson BsPharm.

 

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What’s the Big Deal with Insulin

Author: Mark Parkinson BsPharm:  President  AFC-CE

Credit Hours 3 - Approximate time required: 180 min.

Educational Goal

Provide instruction about the history and science of insulin and how to manage its administration.

Educational Objectives

  • Tell the history of the discovery and development of insulin
  • Explain the anatomy and physiology of insulin
  • Instruction how to store, administer and manage synthetic human insulin.

 

Procedure:

Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer

   The information presented in this activity is not meant contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible

 

 

 

 What’s the big deal with Insulin

 

A Beginner's Guide to Taking Insulin

You would be hard-pressed to find someone who has not heard of insulin. As an in-home caregiver, you probably know it as the stuff you have to store in the refrigerator and inject with needles. You also probably just had a shiver run down your spine and thought, “I hate needles. Just thinking about them gives me the willies.” So why the refrigerator and the needles? (shiver again) Why can’t they just take a pill like normal sick people? What’s the big deal with insulin and all the blood and poking stuff?

Insulin is simple to understand but very complex in how it is used by the body. Insulin is a hormone produced in the pancreas. It is produced so that our body can utilize important nutrients we have digested. Without it, we die. If its use gets messed up in the body, we can get sick with a variety of illnesses and eventually die miserably. You're probably thinking, “Hey Budy, there’s way too much talk about dying and sickness … and needles (shiver). All this dark talk is making me nervous. Can’t you tone it down a bit? I wanted a CE course that is a bit more on the entertainment side”.

Okay, let’s switch gears and talk about something more pleasant- history. I like stories about history.

 

History of Insulin

Before the 1890s medical scientists didn’t know anything about insulin. They didn’t know how it worked. They didn't know where it came from. They didn't even know that they didn’t know anything. But they did know that certain children would suddenly get very thin and sick. They would get very thirsty, have to go to the bathroom a lot, become very weak, be prone to infections, and get very skinny no matter how much they ate. And the oddest thing of all, their urine had a lot of sugar in it. I wonder how they found the sugar in the urine.

Oh yuck, don’t even think that. They wouldn’t have tasted it would they?

 

 I just looked it up. They noticed that sugar ants were attracted to the urine. They named the disease after its odd sugar symptom, Diabetes Mellitus. In Latin, that means to siphon off sugar.

 

Meanwhile in Berlin, in 1869 a medical student by the name of Langerhans noticed clumps of special cells in the pancreas. Today we call them the “Islets of Langerhans”. Langerhans didn’t know what the cells did but later Edouard Laguesse suggested they might have something to do with digestion. In 1889 Dr Oskar Minkowski wanted to test the idea so he removed the pancreas from a dog to see what would happen. (They had different ideas about animal rights back then.) The dog started to get the same Diabetes Mellitus symptoms as the children, thus confirming Laguesse's suggestion. The medical profession had started to close in on the idea of insulin.

 

Well, scientists knew something in the pancreas was helping but didn’t know what to look for. There were lots of doctors grinding up the pancreas and giving them to patients with no success. You see the pancreas also creates digestive enzymes as well. When you use the whole pancreas, you’re giving the patient way too many digestive enzymes. It caused extreme nausea and didn’t help the diabetes symptoms all that much.  

 

Then World War I happened. (Wars tend to sidetrack everyone’s attention). After the war around 1920 Canadian Fredrick Banting (a trained surgeon) wanted to explore Laguesse’s ideas. He guessed that the islet of Langerhans was the key. He had to separate it from the rest of the pancreas and extract what it was producing. Sounds complicated right? It was, and he needed help in doing so. He went see to Professor John Macleod of Toronto University in hopes that he would help in doing the research. Macleod was skeptical of this surgeon. He didn’t have any training in how to do research. Finally though, he did agree to help and gave him some unused lab space for the summer and an assistant, Charles Best, a student as a helper.  

 

In 1921 Banting and Best were able to extract a chemical soup from a healthy dog’s islets of Langerhans in its pancreas and inject it into a Diabetic dog, and it worked. Within an hour the sugar levels in the urine dropped by 40%. Macleod saw they had something there and he gave them a better lab and more funds and told them to try to repeat the success. Science is getting closer to insulin now.

 

 

Banting and Best started to have success but was having a lot of trouble working with the canine Islet of Langerhans. The dogs kept dying and they were running out of dogs. Over 400 died during the experiments. Seeing they were having some difficulties with the chemistry, Macleod gave the team a biochemist James Collip to help with the chemistry stuff. The team switched to calf’s pancreas, which was easier to obtain, and the pace started to pick up. Collip had the expertise to go from extracting the islets of Langerhans soup to isolating the insulin in it. So now we have the idea man (Banting), the research helper (Best), the money and organization boss (Macleod), and the chemistry guy (Collip). They were able to extract and isolate enough of the stuff that was starting to be called insulin to have a human trial.

On January 11, 1922, Leonard Thompson, a 14-year-old diabetic who lay dying at the Toronto General Hospital, was given the first injection of insulin. And it worked, sort of. The injection he was given came from the extracts Banning and Best had done. That means dog insulin. His symptoms got better (yahoo) but he had a severe allergic reaction (boo). Too much dog in the dog extract. Very close but not quite there yet. They knew they were in the ballpark but needed a purer batch.

So Collip went back to the lab and worked day and night to isolate a purer batch. This time no allergic reaction. Hoorah, a cure for Diabetes Mellitus. No more kids dying horrible deaths. Insulin was now ready to help all those unfortunate kids. Yah….no. There was no way a college lab and one biochemist were going to isolate enough insulin for a bunch of test patients let alone thousands of desperate parents clambering for the new miracle drug. Oh so close, but still a swing and a miss.

 

 

Macleod arranged for Collip to set up shop in the Canadian government-owned Connaught Labs. Finally, enough insulin was purified from cow pancreas….. for just a few test subjects only. Also, Banting, Best Macleod, and Collip started arguing a lot about who was going to get the credit for insulin’s discovery. Collip got fed up and left. Another swing and a miss. No score yet.

Eli Lilly a pharmaceutical company in Indiana heard about the project and volunteered to help. Everyone agreed. Eli Lilly switched to pig pancreases, set up the purification process to produce in bulk, and things were set for mass production. Yah….no (again). You see, Eli Lilly shelled out big bucks to get the ball rolling and wanted the patent on insulin. They wanted to protect their future profits from their investments. Banting and Macleod had a hard time sharing control of the insulin project amongst themselves. They weren’t going to let anyone else butt in. So they didn’t cooperate with the patent thing. They also wanted to keep insulin as cheap as possible so that everyone could afford it.

 

 

 There’s the pitch, the batter swings and …..foul ball. No score yet.

 

 

Finally, the Banting-Mcleod team applied for a patent so no one else could. They gave the patent to the University of Toronto for 1 dollar, so that insulin would stay cheap. Eli Lilly filed for patents on some of their manufacturing processes and insulin was being produced for the masses. There’s the pitch, the batter swings and grazes the ball. It dribbles into the outfield and the runner gets on base. No score yet.

 

“What!?!, you gotta be kidding me”, you say. This is getting ridiculous. The problem that is preventing a homerun score is, that the insulin that is being isolated is either pig or cow insulin, not human insulin. There are slight differences. That means the possibility of allergic reactions and problems with matching human insulin’s effects. But at least we’ve got something that works, right? Yes, solid base hit.

 

Fast forward in time a few decades and several medical and manufacturing advancements. (Too many to mention) Science has figured out how to get E. coli (the bacteria that gives us food poisoning) to produce insulin. It is the closest thing yet to human-made insulin. I mean, come on. That’s so cool! Tricking a deadly bacterium to be an insulin factory for us. We have switched from isolating animal insulin to manufacturing insulin. Science has also been able to map out all the molecules in insulin. Chemically they can dink around with it to produce insulin analogs that have specific effects. (like being long-lasting). They have even made a nasal spray version. So no needles are needed. The chemistry side of me is geeking out about it all. The base runner rounds third base and crosses home base. SCORE!!!. And the crowd goes wild….. sort of (again).

“Not again…. Now what’s wrong” you say. You see, it’s the cost. All that science stuff is really expensive and difficult. You try tricking bacteria to make something. It ain’t a cheap process buddy.

So the price of insulin products has soared in the last few years. Thank goodness for insurance, right? If they cooperate that is. When they don’t cooperate and deny the drug payments they’re about as bad as….. insulin needles (shiver).

 So that’s a brief history of insulin. Easy to understand, but really complex and difficult in the details. How’s that for an entertaining CE? History stories, baseball analogies, and science all in one. Are we good now? Let’s keep on going. We’re moving on now to the anatomy and physiology of insulin in the human body. What, you thought we were done? Not by a long shot, baby. Insulin is too complicated a subject to fit into a short CE lesson.

 

Anatomy and Physiology of Insulin

The reason we produce insulin from the pancreas is to help us process glucose and some of the fatty stuff that results from the digestion of the foods we eat. Simple enough to understand but there are a lot of details that you need to know to truly understand what is going on. That greater understanding will help you react more appropriately when needed in your caregiving. Let’s get into the details of what insulin is, where it comes from, where it goes, and how it is used in the body. (sorry- no more history or baseball stories) Now wait a minute, I know you are probably thinking, “Ug this is going to read like a boring encyclopedia.”  Give me a chance, you might be surprised by some of the scientific details about insulin.

What is Insulin

You’re probably used to thinking of insulin as a drug, but it’s actually classified as a hormone. What exactly is a hormone? By definition, a hormone is a substance that is produced in an organ that is transported around the body. It stimulates a chemical action that increases a bodily function. Another important detail is chemically, insulin is classified as a protein.  “What do you mean, like meat?” you are thinking.  Well, a protein is actually a sequence of amino acids that are strung together to form a larger molecule. Picture it as a long chain that is twisted up and it forms a certain shape. You see I told yah, surprising little details that will be important later on.

Where does Insulin come from

You already know that insulin is produced in the Islets of Langerhans in the Pancreas. The details that you don’t know yet are that there are several different kinds of cells in the islets of Langerhans. The important ones in insulin production are called the alpha and beta cells. The alpha cells produce glucagon, and the beta cells produce insulin. (More little details that will be important later on.) The islets of Langerhans only comprise about 1% of the pancreas. The rest of the pancreas is comprised of the acini tissue that produces enzymes and bicarbonates used in digestion. The important thing to remember is that there is only a small, limited supply of insulin-producing beta cells in the pancreas.

As you can imagine, insulin production is quite complex and involves several steps. The process ends with the insulin and other molecules being stored up in little bubbles called vesicles. When glucose concentrations are high, the vesicles are stimulated thru several more steps. It involves potassium and calcium that help fuse the vesicles to the beta cell's membrane wall and they “pop”, releasing the insulin into the bloodstream.

Where Does Insulin Go

A lot of blood goes thru the pancreas. The important direction of flow concerning insulin is that it comes from the small intestine loaded with nutrients like glucose and amino acids. Then the pancreas adds insulin to the mix and then the blood flows to the liver. In the liver, insulin has 4 times the effect as compared to other parts of the body. After the liver, the nutrient and insulin-rich blood flows to the rest of the body. It even crosses the blood-brain barrier into the central nervous system which includes the brain. Wherever nutrients are required, insulin goes along to help get the important stuff inside the cells where it is needed.

What Does Insulin Do

Think of insulin as a key that unlocks cellular doors. Around each cell, there is a membrane that keeps the important bits and chemicals from mixing with the chemical soup that surrounds it. If you want molecules to pass through the cellular membrane, you have to open channels that are designed to let that certain thing inside. Once that is done the channel closes so important stuff doesn’t leak out and unwanted stuff doesn’t leak in. One of the more important chemicals that we want in our cells is glucose, the primary fuel that powers the cell's workings. Insulin is the hormone that opens the glucose channels in the cellular wall. There are other chemicals that rely upon insulin to get into cells. For example, amino acids that the muscles use to build proteins are also insulin-dependent.

A few words about glucose. Glucose is a very reactive molecule. It easily combines with other molecules and tissues, and it messes things up. (Remember that fact when we talk about Diabetes). You don’t want a lot of excess glucose floating around but it’s too important to just flush it away in the urine with the rest of the body's waste products. Our bodies have two ways to convert the excess glucose into safer, easily stored molecules.  The liver turns glucose into glycogen and the adipose cells convert glucose into triglyceride. You might know the triglyceride-packed adipose cells as your fat stores. When the body needs glucose and there’s not enough in the blood, the body breaks apart the storage molecules back into glucose.  

How Does Insulin Work

Insulin not only is the key that unlocks cellular doors, but it is also a key that when inserted, starts certain cellular processes working. Things like producing cellular energy, making muscle material, and of course fat production. I will spare you all the complex details, but for those science nerds out there, the list of primary cellular processes is:

  • Glucose uptake
  • Lipogenesis
  • Amino Acid uptake
  • Glycolysis
  • Glycogenesis
  • Protein synthesis

The way that insulin does all these processes is complex but easily understood. There are certain structures within the cell wall that are called receptors. The insulin receptor has a part that extends outside the cell and a part that hangs inside the cell. The outside part has a pocket shaped so only insulin fits in it. When insulin floats near enough, it fits into the pocket. The receptor changes so that certain molecules fall off the end and float around on the inside of the cell. Those molecules in turn connect to the inner workings of the cell and the right cellular machinery starts up.

Turning the process off

Any insulin-dependent activity that can be started up, needs to be able to be turned off as well. If you don’t, all the glucose will be used up. The “turn-off switch” is located back in the islets of Langerhans again. This time were dealing with the Alpha cells and a hormone called glucagon.

Glucagon does the opposite of insulin. It tells the liver to convert glycogen to glucose and the adipose cells to release and break up triglycerides into glycerol and fatty acids. Glycerol and the fatty acids can then be converted into glucose. In addition, glucagon can also tell muscles to break apart some of their proteins into amino acids. The amino acids can be turned into glucose as well. Finally, glucagon tells the beta cells in the pancreas to slow down the making of insulin. All of these processes make it easier to build up the concentration of glucose in the blood even if there is no food being consumed. When the concentration of glucose is high enough insulin production starts up again and glucagon production is inhibited.

The glucagon vs insulin is a balancing act based on a negative feedback loop. It happens automatically as part of the dynamic system we call homeostasis. It enables cellular machinery to adapt to the changing needs of the body. For example, you don’t need a lot of glucose fuel in the brain if it’s sleeping.

 

 

If this is getting to sound a bit too complicated, of course it is. Everything about insulin is always complex.

Don’t get too caught up in the details though because of course insulin is simple too. Keep your focus on the big picture. Glucose up, insulin up. Insulin goes into cells, and glucose and amino acids go into cells.  Glucose in blood goes down and glucagon starts up, then insulin production is slowed down until the glucose levels are right again.

 

 

 

 

Diabetes and Insulin

You can’t talk about insulin without bringing up Diabetes. There are two versions of the disease. Type I is where the beta cells have all died off. Injecting insulin is the only option for treatment. In Type II the body is becoming insulin resistant. Insulin is being produced but the process is messed up somewhere. In the beginning of Type II the doctor can give some pills that help increase insulin effectiveness. You can also control glucose levels thru diet and exercise. If therapy fails, then insulin injections will probably be needed.

I think that you have had just about enough of me being a science nerd and sounding like an encyclopedia. I am going to mix things up a bit and show you a video about diabetes instead. It’s great to be shown what’s going on instead of reading about what’s going on. Warning there will be at least one test question on the video material.

 

 

Okay, we’ve had some history, baseball, encyclopedia stuff, and a video about diabetes. Let’s see, what’s left to cover… hummm. Oh yah, Drugs and Caregiving.

Caregiving and Insulin Drugs

The goal of insulin drug therapy is to regulate the body so there is a normal flow of blood glucose. The cells need to have enough fuel no matter what happens. But as you now know, blood glucose changes a lot throughout the day. It rises with each meal, it lowers after exercise, and it increases if there is a sickness. It’s enough to make your head spin. What does that all mean for the patient and their caregiver? It means there will be no easy “one size fits all” drug regime. No “one and done on the run”. You may even have two different types of insulins to inject at different times of the day. It is going to take a lot of monitoring and adjusting as you go.

Insulin therapy may be complex, but it is also easy to understand. The basics are you find out where the blood glucose concentration is at by doing a finger stick. Then you adjust the regime according to the doctors’ instructions and you’re done.

 

If the blood glucose doesn’t come under control, you notify the doctor and let them worry about changing the regime. There is even a surgically inserted insulin pump that does the monitoring adjusting and injecting automatically. For more information about diabetes management see my other CE lessons or contact the patient’s Diabetes care team.

Blood, injections, needles, Yikes! Why can’t there be some simple pills to take? Let’s talk about why there are no insulin pills. Remember, insulin is basically a complex protein. We can crystalize that protein and put it in a pill. We can even concentrate it down and store it in a capsule. That’s not the issue. The problem occurs when the insulin protein goes through the digestive tract. The body just digests it before it can reach the blood. Man-made insulin has to be delivered directly into the bloodstream for it to have any effect. For you needle haters, that’s a real bummer.

Alternatives to injectables

Recently several inhaled versions of insulin have been approved by the FDA. Yes! No needles. Unfortunately, they cost more than injectable insulins (a lot more). Insurances are not very cooperative about paying the extra cost. They see inhaled versions as more of a convenience than a therapeutic necessity. A swing and a miss. (more baseball jargon)

If you are thinking that the insulin pump thing sounds like an easy alternative to needles, you would be wrong. They also cost a lot more and require a lot of maintenance and expertise. There is also the constant danger of infections that reach the bloodstream fast. 

 

 

 

A hit, but a foul ball-  if the batter is an In-home caregiver.

 

 

 

Synthetic Insulins

Now we have come back full circle and are ready to talk about the stuff you have stored in your refrigerator. Harvested and purified, bovine (cow) and porcine (pig) insulin is not used much anymore. I haven’t seen a bottle of it in decades. The stuff you’re used to seeing is manufactured. (remember the tricked bacteria thing). It is officially known as synthetic human insulin. It comes in several different types, all based on how fast you want the injected insulin to work. To understand what that means to your clients, it’s best if you know three different terms. They describe the timing of when the patient’s insulin prescription works.

  • Onset -is the length of time before the insulin hits the bloodstream and begins to lower blood glucose.

 

  • Peak- is the time when insulin is at its maximum effectiveness at lowering blood glucose levels.

 

  • Duration -is the length of time the insulin continues to work at lowering blood glucose levels.

 

Here’s a table of the different types of synthetic insulins and how fast they work and for how long.

Basal and Pulse levels

So why all the complex variety? Because it’s insulin, of course, complex is its middle name. It’s also easy to understand if you know two factors of endogenous insulin production (natural insulin production in the body). Basel levels and pulse doses.

  • Basal levels - As long as the cells of the body are alive there will be a need to send fuel to them. Even when you are asleep there are lots of cells working. To meet the constant need, the pancreas constantly has to produce insulin. That’s the base level of insulin concentration.
  • Pulse doses- If cellular activity increases or food is eaten, blood glucose levels fluctuate. The pancreas is stimulated to send out extra insulin to take care of the fluctuations in blood glucose.

Diabetic insulin therapy regimens try to copy these varying endogenous levels by using different types of synthetic human insulins. Long-acting versions copy the basal level, while fast-acting is meant to copy the pulse doses. There are even prescriptions that have a mix of both short and long-acting insulins.

Therapy management

Do your job right

As an In-Home caregiver, your job is to monitor how drug therapies are working. That means keeping track of the good effects that are supposed to happen and the bad effects that might happen.  You’re monitoring the drugs so that you can tell if you’re doing a good enough job of taking care of your paying customers. You’re also monitoring the drugs to tell the prescriber if his chosen therapy is doing what he expected it to do. If you are not actively pursuing this aspect of In-Home caregiving, I highly recommend that you change your business priorities. Those who just act like a glorified babysitter are being lazy. Lazy caregivers are ironically making their jobs harder because sick patients take more caregiving effort. Also, they lose paying customers faster than they ought to. If you want an easier more stable source of income, then monitor the drugs for effect and tell the doctor when things don’t go as anticipated, and do it quickly.

Goals of Therapy for Insulin

You can tell if the insulin therapy is doing what it’s supposed to do by paying attention to two measurements. Blood glucose concentrations and Hemoglobin A1C

Blood glucose concentration measurements are acquired from a blood sample. A drop of blood is placed on a test strip inserted into a blood glucose meter. The blood sample usually comes from poking the finger with a lancet device. The procedure is commonly called getting sugar levels from a finger stick, or just a finger stick.

Readings can vary depending on the time of day, the place where the blood is taken, the health of the patient, etc.…  If it sounds complicated, of course it is, insulin is involved. It will be important to get some training from the doctor or diabetes educator.

In general, the Centers for Disease Control (CDC) states,

“A blood sugar target is the range you try to reach as much as possible. These are typical targets: Before a meal: 80 to 130 mg/dL.

Two hours after the start of a meal: Less than 180 mg/dL.”

Because of the variability of the finger sticks, doctors also take a Hemoglobin A1C test, A1C for short. I won’t go into the details because of course it’s complicated. According to the American Diabetes Association (ADA),

“The goal for most adults with diabetes is an A1C that is less than 7%.”

A good insulin prescriber will tell you what the treatment goals they are shooting for. If they don’t tell you, ask for them. (It will also make you look professional too). From then on, therapy management is simply comparing your individual reading to the goals set by the prescriber. I recommend that you keep a record of your finger sticks and send them with the patient whenever they see the doctor. Don’t worry so much about individual readings. There are always going to be “one-off” spikes in the readings.  You’re looking for patterns over time. (Too low and too high) If you see any patterns developing, call the doctor.

Side Effects

Synthetic human insulin is pretty well tolerated with few side effects. There is always the possibility of an allergic reaction or infections developing. Look for lumps, pits, swelling, redness, or itching at the injection site. Rotating the injection site and finger stick location will help prevent tissue scarring from developing.  There is also the real chance of the insulin working too good and crashing blood sugar levels (hypoglycemia). Always have a sugary snack handy just in case. Look for:

  • Fast heartbeat.
  • Nervousness or anxiety.
  • Irritability or confusion.
  • Hunger

Finally, weight gain is always possible. You’ll have to take the residents’ weight from time to time and place the information in their records.

Storage and Dispensing Insulin

Why the refrigerator?

Insulin is a rather fragile molecule. It degrades fairly easily. If you shake the vial the molecules can break. If it gets too cold or freezes it can break. If it gets too hot, it breaks. Even at room temperature, it starts to degrade after 28 days. So, you have to store unused vials in the frig to keep the insulin fresh. Here is what that means to you as an In-home caregiver.

You have to store the insulin in a secured box in the fridge, just like the rest of the drugs you’re in charge of. The temperature of the area of the fridge you keep the storage box in has to be between 36°F to 46°F. A thermometer will have to be kept somewhere near the box. There are easy-to-read frig thermometers you can buy. No freezing of the insulin in the cold spots at the back of the frig, where the air circulation is bad.

The one vial that you’re giving the shots from has to be watched as well. You can’t store it in the sun or near a heater. Keeping it in a car is a no-no too unless it’s kept in a special insulated insulin storage device. They keep the insulin from getting too hot. You can buy those too, for when your insulin using resident goes on day trips or longer. You can’t keep the insulin in a coat pocket. It shakes too much. You can’t keep it in a shirt pocket. It gets too hot. They do make fanny packs specially built to carry insulin on the patient or caregiver.

If the resident has permission to self-inject, you have to have that in writing from the doctor. Keep the permission slip in your records and make copies when necessary. You also have to ensure that when the insulin is out of your control (like on trips, job sites, or in the resident’s room) the insulin is being stored properly or don’t give out the insulin at all.

Why, you ask? Two reasons;

  • Broken insulin molecules are not insulin. They won’t fit into the insulin receptors and trigger the proper reaction. And those broken bits of “not insulin” floating around, who knows what they are going to do. Probably nothing, but I am not going to be the one responsible for finding out if that’s true or not.
  • “Not insulin” molecules reduce the real insulin’s concentration so you’re not giving enough insulin at the time of injection.

You can tell if the insulin has gone bad by comparing it to a fresh vial. If the fresh insulin is clear, watch for floaties or color changes. Longer-acting insulin has ingredients added to make the insulin last longer. That makes the long-lasting insulin look cloudy and the particulates can settle out. Before using the long-acting insulins, you will have to gently roll the vial 10 times. Resist the temptation to shake the container. You can tell if these types of insulins have gone bad by color changes and the vial looks like frost is collecting on the inside of the containers. Each container of insulin has an expiration date printed on it. Throw away any expired or suspicious-looking insulins. Don’t take chances with the “not insulin” stuff.

 

Delivery Devices

We’re not talking delivery by FedEx here. We are talking about vials of insulin, delivered via needles. (Shiver, Shiver). Oh stop that! It’s not that bad. Today’s insulin syringes are so fine (thin) that getting poked by one hurts less than pinching yourself. In fact, they are so thin that there is a danger of snapping off the needle in the skin if handled too ruffly. Then you have to go get it like you would a sliver of wood, with a magnifying glass and tweezers.

 

 

Insulin prescriptions come in multi-use vials. Each vial has a rubber stopper where you insert the needle. Then you hold the vial straight up and draw out the proper dose. Keep the tip of the needle out of the air space to prevent drawing up bubbles.

Drug Manufacturers also make multidose insulin devices that look like a pen. Except there is insulin instead of ink and you have to screw on the needle. (Good, you didn’t shiver that time). The pens are more expensive, but they are easier because you don’t have to draw up insulin from a vial. They are especially handy for those residents who take insulin when you’re not around to supervise them. If you can’t quite visualize all of this, don’t worry. I’m going to post videos of what this all looks like at the end of the lesson.

 

The final thing you have to worry about as an In-home caregiver is what to do with the needles and the lancet blades after you are done with them. Legally you have to place them in a red sharps container or a thick-walled plastic jug, like an empty laundry soap container. You then have to properly dispose of the sharps container with the garbage service. Just to warn you it’s going to cost more. Call the garbage company for details. You can make the sharps containers last longer and reduce disposal costs by putting just the screw-on needles, the lancet blades and the needle portion of the syringe into the sharp’s container. The rest of the syringe can be thrown out with the regular garbage.

 

Conclusion

Well that’s that then. You’re all ready to go aren’t yah? Not so many worries now and no shivering, right? Good good, I know you can do it. After all, you are a professional and now know quite a bit about insulin and how to deal with dispensing it. Also, take comfort that you are an important part of a diabetes care team. If you are still unsure of the details, lean on the other members of the team for support. Ok, are we good now? That’s excellent. Here are the links to the videos I promised.  There will be test questions.

Insulin Administration Videos

For this video you have to visit  AARP website. Click on the image or link - Once you are done click on the back arrow in the top light hand coner of you computer

Managing Medications: Administering Insulin Injections

https://videos.aarp.org/detail/video/6113757614001/managing-medications:-administering-insulin-injections

 

For the following videos just click on the arrow in the picture. 

 

How to Inject Insulin with a Pen and Pen Needle

 

How to Inject Insulin with a Syringe

 

As always Good Luck in your caregiving efforts.

Mark Parkinson BsPharm

 

References:

  1. Clevland Clinic.org. Oct/23. https://my.clevelandclinic.org/health/articles/22601-insulin
  2. Wikipedia the Free Encyclopedia https://en.wikipedia.org/wiki/Insulin
  3. The Discovery of Insulin, The Miracle- Part 1. Extra History. Nov 18, 21

https://www.youtube.com/watch?v=Qs_QCJv3HrA&t=523s

  1. Banting's Miracle Drug. World Collaborative. May 8, 18

https://www.youtube.com/watch?v=kVG7xlY7xVg

  1. How insulin works. Novo Nordisk insulin-containing products. Aug 2, 18

https://www.youtube.com/watch?v=HJGjNTJgf48

  1. Endocrinology Pancreas: Insulin Function. Ninja Nerd. Medical Lecturers. May 11, 17. https://www.youtube.com/watch?v=w4jHtPUNg6E&t=7s
  2. Philip Newsholme, Vinicius Cruzat, Frank Arfuso, Kevin Keane. Nutrient regulation of insulin secretion and action. Journal of Endocrinology. Volume 221: Issue 3. Jun/14. https://joe.bioscientifica.com/view/journals/joe/221/3/R105.xml
  3. Diabetes Mellitus | Type I and Type II Diabetes Mellitus. Ninja Nerd. Medical Lectures. Apr 22, 20. https://www.youtube.com/watch?v=-axOMKLkLLQ
  4. Endocrinology | Pancreas: Glucagon Function. Ninja Nerd. Medical Lectures. May 11, 17. https://www.youtube.com/watch?v=b2Kcp5hJBXE
  5. Amy Hess-Fischl, E.Lisa Jaffe. What Is Insulin? com. Feb 15, 22. https://www.healthcentral.com/condition/type-1-diabetes/what-insulin
  6. Insulin, Medicines, & Other Diabetes Treatments. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Oct/22https://www.niddk.nih.gov/health-information/diabetes/overview/insulin-medicines-treatments

 

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Addiction and Pseudo-Addiction

An Advanced CE  

Author: Mark Parkinson BsPharm:  President  AFC-CE

Credit Hours 3 - Approximate time required: 180 min.

Educational Goal

Tell of a case study of pseudo-addiction and teach how to deal with addiction side effects of opiate drugs.  

Educational Objectives

  • Present a review of possible case of pseudo-addiction
  • Tell of how opiates work by mimicking endorphins
  • Tell of the consequences of long term opiate use
  • Discuss about the principle of pseudo-addiction
  • Present the In-Home caregiving model of care

 

Procedure:

Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.

Disclaimer

   The information presented in this activity is not meant contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible

 

 

 

Addiction and Pseudo-addiction.

An Advanced CE. 

 

Note to reader. I initially started writing this course as a simple easy to read 1 hour course. The more I researched, the more the topic expanded and the more complex it became. I gave up on simple and turned the course into a more advanced and complex 3-hour CE. Hang in there with me. Even though some will struggle with a few of the advanced details, I promise the extra effort will be worth it. In the second half of the lesson, I have managed to insert a lot of the tricks I learned over the years on how to influence a doctor. If you are still put off, well, I have plenty of easier CEs to choose from. Mark P

I recently moved my 87-year-old Mother-in-law into my home.  As a result, I find myself in the In-home care biz again. I’m back in the care trenches, battling my way through solving medical problems and trying to get the medical community to cooperate. You know what I have found out. Some doctors are still clueless about how to treat patients with In-home caregivers.  I find myself having to pull the, I’m a trained pharmacist card before I can get them to realize that there is a care professional living with and skillfully managing their patient for them. That should change the way they treat my mom, but sometimes it doesn’t. For example, they should loosen up the number of prescriptions that are written for pain. But I find that I am having to fight far too much to get what I think she needs to live a comfortable life.

Here are the details. My mom has a bad arthritis problem. That means she is a chronic pain patient. She wants to have a constant supply of Vicodin, a narcotic drug used to manage pain. The doctor is worried about opiate addiction and keeps trying to push Ibuprofen on her to manage the pain. Unfortunately, my mom also has stage 4 kidney failure issues. The more ibuprofen she takes the faster her kidneys will fail completely. So what am I supposed to do? My mother-in-law is complaining of unresolved pain issues and the doctor is saying that is just a narcotic addiction talking. So now my mom is taking more ibuprofen than is good for her just to get by.

Drug terminology-  opiate and narcotic drugs work the same way in the body. So from now on when I say opiates I am also talking about narcotic drugs.

Who’s right and who’s wrong?  As a pharmacist and an experienced In-home caregiver, I can say they are both right and they are both wrong. Let’s explore the questions together and later I’ll tell you the steps I am taking to resolve the issue. That is where I stuck all my professional caregiver secrets.

 

In my opinion, this is a case of pseudo-addiction versus actual addiction versus opiate dependence. These are terms that you as a caregiver need to understand and be able to use appropriately in your care practice. It’s kind of weird, isn’t it? You as a professional caregiver have a care practice. Just like any other health professional. The thought certainly changes the way you look at your day-to-day activities, doesn’t it? You have to understand what’s going on. That understanding will give you the power to try to influence the outcomes when you think your resident is not being taken care of adequately.  It will also enable you to safeguard your resident from the unwanted side effects of any therapy. That is what you are supposed to do as the patient’s advocate.

So, let’s broaden your understanding of the important terms. Fair warning, we’re going on a deep dive into the workings of the brain and nervous system. Hang in there with me. When I’m done, a lot of things will be so much clearer to you.

What Normally Occurs

Did you know that our bodies make their own opiate-like chemicals. You might have heard of the term endorphins. According to the website, Cleveland Clinic:

 

“Endorphins are chemicals (hormones) your body releases when it feels pain or stress. They’re released during pleasurable activities such as exercise, massage, eating and sex too. Endorphins help relieve pain, reduce stress and improve your sense of well-being.

Endorphins are created in your pituitary gland and hypothalamus, both located in the brain. Endorphins are a type of neurotransmitter, or messenger in your body. They attach to your brain’s reward centers (opioid receptors) and carry signals across your nervous system.”

 

When our brain senses a stressor, either emotional or pain, it sends a signal to the pituitary gland to release what some people call the “Happy Hormone”. The endorphins travel around the body seeking to place themselves into specialized receptors that stick outside of cells. These receptors are called mu receptors. When the endorphins are placed in the mu receptors, cellular processes are started that help us cope with the stressor. When the stressor is gone the pituitary gland stops making endorphins and we get back to feeling normal again.

Endorphins are also part of our reward system. They help us experience pleasure in doing the things our bodies need to do. When we do things like eat, have sex, exercise, or win a competition, endorphins are released. We experience pleasure in doing those activities. The pleasure encourages us to continue doing those beneficial activities in the future.

This is all part of our homeostatic mechanisms designed to bring us back to normal and keep us there, despite the changes that occur around us or injuries that we sustain. Our bodies put a lot of effort into keeping the endorphins flowing at the proper rate so that we can function normally. No matter what bad things happen or what needs we have.  

Taking advantage of the system

Medical science has found that a class of chemicals called opiates also fits into the mu receptors. In fact, they fit so well that we also call the mu receptors, opiate receptors. This has enabled opioid substances to be used in pain management. Their use as painkillers dates back to antiquity.

The website MayoClinic.org summarizes the therapeutic effects of opioids as follows

“Opioids trigger the release of endorphins, your brain's feel-good neurotransmitters. Endorphins muffle your perception of pain and boost feelings of pleasure, creating a temporary but powerful sense of well-being”

 

Whenever there is a pain management need, doctors can give an opiate drug (also known as narcotics). The medication artificially increases the natural pain-relieving systems of our bodies. In addition, it makes the patient feel good about it. It may seem like the perfect drug solution to pain. In the short term, opiates are very effective. But in the long term, things start to go astray.  

An Unwanted Drug Side Effect

Those who are debilitated by pain greatly appreciate the opiates’ ability to quickly and reliably relieve their suffering. Those who have chronic pain issues learn to rely on opiate use to function on a day-to-day basis. Unfortunately with long-term manipulation of the endorphin system, other effects start to appear. More and more drug is needed to maintain effective pain relief. Higher doses are also related to developing a craving for the euphoria the drug can give. These cravings lead the patient to misuse the drug to feel good. The euphoria becomes more important than the pain relief. Soon addictive behaviors start to negatively affect the patient’s life.  The patient wants to keep taking the drugs even if their use is causing greater harm.

I think it is important for you as a caregiver to understand why and how these negative effects can occur. With that greater understanding, you will be better able to manage the situation more effectively.

 

False perception of healing

Even though opioids are very good at pain relief they do almost nothing to heal the underlying cause of the pain. Unfortunately, the patient does not know this. They start to falsely associate feeling good with their injuries being healed. Of course that never happens, no matter how good they feel. This incorrect expectation leads to dependence on the euphoria over pain relief to lead a normal life.

Sedation

There are cells with mu receptors that when activated have a sedating effect. In normal function these cells are telling the body to slow down, you’re injuring yourself. They are also telling the body to rest so it can heal faster. When you artificially increase the activation of the opiate receptors you can over sedate the patient and make them drowsy or dizzy. That is why each bottle of narcotics and opiates has a drowsiness/ do not operate heavy machinery warning on the label.

If these two were the only side effects you would have to worry about, that would be okay because you could handle those. But there are other unwanted drug effects that come with long-term use of the drugs that are much more problematic.

Tolerance

When we experience stressors long term, our body is able to adapt by decreasing the amount of mu receptors on cell surfaces. We become less able to feel the negative effects of the stressor. It allows us to tolerate the stressor more efficiently over time. In addition, the body naturally adapts to the extra sedation present by increasing the amount of chemicals that promote alertness. This is part of our natural “toughing up” process. When the stress levels are reduced the number of receptors goes back to normal levels and alertness chemical production is reduced. The body doesn’t need them anymore so they go away and be themselves.

When you artificially increase the activation of the opiate receptors the body is naturally stimulated to change the number of receptors that are present.  Over time, that decreases the body’s reaction to the drug dose. You have to start taking more of the drug to get the same reaction. It is an unavoidable reaction to long-term opiate drug use.

Dependence and Withdrawal Symptoms

Long-term opiate users become dependent on the drug to feel normal. Even if there are no pain symptoms to control. The reason for dependence takes some explanation to understand. Long-term users reach an artificial equilibrium of endorphin/opiate receptor levels. If the drug is discontinued the support for that level is now gone and withdrawal symptoms occur. Ironically the absence of drugs has now become the stressor to the system. When there is a sudden discontinuation of long-term opiate drug use there is a sudden reduction of its sedation effect. Yet there is the same amount of alertness chemicals present in the nerve cells. The results are an overstimulation of the nervous system. The unpleasant symptoms experienced by the drug user include jitteriness, anxiety, sleeplessness, muscle cramps, muscle aches, flu-like symptoms, pupil dilation, nausea, vomiting, and diarrhea. Frequently when withdrawal symptoms occur, the sufferer does not know the underlying causes of the symptoms. This creates fear and they falsely think that real damage is occurring. Often, they say they feel like they are dying. Unfortunately though, real deaths have been reported in some severe cases of withdrawal.

Addiction

Defining addiction is very difficult because the term means different things to different people. Because of the negative reputation it has we tend to define it differently depending on how well we know the person who is addicted. In general, we tend to go easier on ourselves and our loved ones and harsher on complete strangers. Also, the line between the definition of addiction and dependence blur. Many people consider them as the same thing. Thinking in these terms is wrong and leads patients to be misdiagnosed and or avoid preventative therapies and effective treatments.

The American Society of Addiction Medicine defines addictions as,

“Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.”

 

In layman's terms, people who are addicted have a near-irresistible urge to take drugs, knowing full well that they are causing harm to themselves and the people around them.  

The details of how opiate addiction occurs are not well understood. Why one person becomes addicted and others on the same dose don’t, is a matter of ongoing research.

Major factors in becoming addicted.

  • Continued opiate use creates artificially high opiate receptor activation. The body adjusts itself to this new normal. Basically, you’re rewiring the brain. Some of these adjustments reduce the brain’s ability to think about the consequences of their actions. They are physically losing their ability to think straight.
  • Some people are genetically more susceptible to these changes in the brain’s rewiring than others. Or they are halfway there already because of damage caused by other illnesses or have birth defects in the brain.
  • The addicted surround themselves in an environment that reduces the negative consequences of their actions or allows the patient to delude themselves about what is actually happening. Thus, making it easier to become addicted.

So going back to my mom's case. Knowing all of the mechanisms that can lead to misuse and abuse, do you think the doctor’s opiate addiction fears were justified?

In my opinion, the answer is yes and no.

Yes, I agree that there is a real possibility of addiction.

No, the doctor did not even take the time to determine if my Mom has learned to equate the euphoria as being effective pain management instead of the absence of pain. There were no questions about any addictive behaviors at all. In my opinion, the doctor thought that asking for more prescriptions was by itself a sign of an addiction developing. Having been denied effective and safe pain therapy my Mom is now getting really grouchy and demanding. Ironically she is starting to behave like she is addicted. My mom’s case is a classic example of Pseudo-addiction.

 

Pseudo-addiction

According to the website Medical News Today

“Pseudoaddiction is a term that describes when someone with untreated or improperly managed pain displays substance misuse in a way that mimics addiction.”

 

It is a case of misuse of the prescription because of mistreatment of the patient, not because of addiction. It results from a series of events that are wrought with communication errors and divergent expectations.

  1. A chronic pain sufferer goes to the doctor expecting effective pain relief therapy.
  2. The doctor prescribes a drug regime that they feel is adequate to manage the pain.
  3. The patient follows the therapy but still experiences significant pain. As a result, the patient either
    • Loses faith in the doctors’ instructions and takes more of the opiate than was prescribed. Thus, they run out of the opiate drug too soon and go back to the doctor for more too soon.
    • The patient follows the prescription but is in pain for the entire course of therapy. They go back to the doctor and try to talk the doctor into giving them a greater amount of opiate drugs.
  4. The doctor gets mad at the patient for not following their instructions or does not believe the patient’s reports of inadequate pain control. As a result, the doctor either
    • Makes the patient wait for a new prescription for opiate drugs
    • Gives the patient a new opiate prescription but does not increase the dose.
  5. The patient loses faith in the doctor’s ability to treat their pain and takes matters into their own hands and either
    • Seeks for another doctor, based predominately on their willingness to give larger prescriptions of opiate drugs. (Doctor shopping)
    • Keeps their original doctor but fulfills their unmet needs by going to multiple prescribers at one time. For example, dentists, ER doctors etc.… (Opiate shopping)
    • Obtains additional opiate drugs by questionable means. Either stealing other patients’ opiates or buying them illegally from a drug dealer. (Diversion)
    • Follows the original therapy but becomes fixated on their pain symptoms and drug use. They severely alter their lifestyle and social interactions in an attempt to avoid the onset of pain. (Pain over reporting and or over-adapting their life around their drug use)

From the uninformed Doctor’s perspective, the above are signs of drug abuse. In reality, inadequately treated patients are not abusing opiate drugs but misusing pain therapy in order to control their unresolved pain issues. In the case of pseudo-addiction, abuse, and misuse are not the same thing.   

So going back to the original case again, knowing the possible sequence of events that has occurred, do you think my Mom is justified in her mistrust of the Doctor’s ability to adequately treat her pain?

In my opinion, the answer is yes and no.

Yes, I agree that my Mom is being undertreated.

Yes, I know my Mom is understandably overly motivated to go beyond the Doctor’s original opiate drug therapy instructions.

No, I do not think that my Mom is communicating with the Doctor enough to make them understand the circumstances correctly.

No, I think that my Mom incorrectly thinks that the absence of pain means that she is getting healed. So as a result, she concentrates only on opiate therapy. She is stuck in her thinking that it is the best way to get to make the pain problem go away.

 It is easy to see that if things don’t change, my Mom is heading for trouble. She is already severely curtailing her interaction with life to avoid the possibility of creating extra pain. She is also taking more ibuprofen than what is good for her kidneys. If you are thinking that you could step in and help- you’re on the right track. In-home caregivers are particularly situated to help work out the problems associated with pseudo-addiction. But before we get into that, there are a few more facts that you need to know.

Onset of Dependence and Addiction

It is almost impossible to tell when dependence and addiction are starting to occur. As you have noticed the signs of Addiction are almost the same for pseudo-addiction. Even pain management experts have difficulties in seeing the telltale signs in the beginning. So how are you the caregiver supposed to know when your resident is heading down the addiction path?

To help you with a broader understanding of the issue I have found an article from the website NIH National Library of Medicine entitled Opiate Use Disorder. The article describes a mental disorder found in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5). It states,

 “Opioid use disorder is the chronic use of opioids that causes clinically significant distress or impairment.”  

Sounds like a good enough description of addiction to me. The article continues.

“The opioid-use disorder is defined as opioid use and the repeated occurrence within 12 months of two or more of eleven problems. The problems include opioid withdrawal with stopping opioid use, giving up essential life events for opioid use, and excessive time using opioids. The individual also has significant impairment or distress as a result of opioid use. Six or more items on the diagnostic criteria indicate a severe condition.

The signs and symptoms of opioid use disorder include drug-seeking behavior, legal or social ramifications due to opioid use, and multiple opioid prescriptions from different clinicians. Furthermore, various medical complications from the use of opioids, opioid cravings, increased opioid usage over time, and symptoms of opioid withdrawal with stopping opioids.

A list of the eleven problems is given below:

  • Continued use despite worsening physical or psychological health
  • Continued use leading to social and interpersonal consequences
  • Decreased social or recreational activities
  • Difficulty fulfilling professional duties at school or work
  • Excessive time to obtain opioids, or recover from taking them
  • More taken than intended
  • The individual has cravings
  • The individual is unable to decrease the amount used
  • Tolerance
  • Using despite it being physically dangerous settings
  • Withdrawal

A full social history and mental health history should be a part of the history for a patient meeting the criteria of an opioid use disorder. Furthermore, the patient's previous injury history should be recorded.

Opioid withdrawal symptoms include abdominal cramps, craving, agitation, diarrhea, pupil dilation, anxiety, elevated blood pressure, sneezing, sweating, elevated heart rate, tearing, shakiness, muscle pain, rhinorrhea, goosebumps, and insomnia.

Opioid intoxication symptoms include confusion, miosis, hypersomnia, nausea, euphoria, constipation, and decreased pain perception.

For suspected opioid overdose, on a physical exam, there are pinpoint pupils. The patient can be hypothermic or bradycardic, with limited responsiveness or unconsciousness.”

This is how mental health specialists describe and diagnose opiate addiction. I hope you found the above quotes useful in clarifying the confusing issues related to opiate addiction and pseudo-addiction issues.  I certainly did.

Resolution of Addiction

The homeostatic mechanisms of endorphins and opiate receptors are quite dynamic. Physical withdrawal and dependence issues usually resolve themselves in a couple of weeks, depending upon the severity of the case.

 

 

 

Emotional and behavioral problems are resolved much more slowly. Old habits need to be broken. Attitudes and expectations have to be brought closer to reality. New coping abilities to stressors have to replace drug-based coping strategies. Drug use supporting environments have to change and drug craving triggers have to be identified and avoided. If these issues are not handled appropriately then addiction relapses are almost unavoidable.

 

 

That is a long list of issues. Too long and difficult for an In-home caregiver to handle by themselves. Smart adult foster care providers will assemble a team of other health professionals to help tackle difficult cases.  

 

Other side effects of opiate issues

Addiction is not the only opiate side effect that you as a caregiver will have to manage. Other possible problems include-

  • Nausea and vomiting are always a possibility when taking a drug. Food does not affect opiates so in the case of nausea, soda crackers are an easy first step to try.
  • Some people are allergic to opiates so watch for rash and itching.
  • Dry mouth and constipation are the result of the opiates slowing down nerve transmissions. Drinking extra water is an easy first step. Stimulation of function may also be needed. Sucking on a tart candy will help the dry mouth. A stimulant laxative may be needed to relieve constipation.
  • Respiratory depression is a major cause of death in overdosing. Monitor closely breathing function in those with compromised lung function.

 

In-home Caregivers and Pain Management

For those who have stuck it out so far congratulations. You now know enough to start talking with doctors and nurses competently about opiate use problems. But how do you have those conversations without being thought of as an uneducated fool?

There are several weaknesses in the Adult Foster Care industry.

  1. There is no diploma hanging on your wall certifying you know what you are talking about.
  2. Far too many see you as a glorified babysitter who is not supposed to think for themselves about medical matters.
  3. There is no place where you can learn all the good In-home caregiving tricks. Everything is mostly “teach yourself as you go”.
  4. We tend to be very isolated from other in-home caregivers. Why would you tell your competition all your best caregiving secrets?

 

This is where I come in. I am not your competition. I am going to give you all my best In-home caregiving secrets. They will help you get around not having a degree and being viewed as being on the lowest rung of the medical profession ladder. See, I told you that I would make it worth your while to struggle through all this advanced material.

Let me start by talking about what I call the In-home Caregiving model. In-home caregiving is different from caregiving in a nursing home or hospital. You have an advantage that those facilities don’t have. Let me explain.

The Adult Foster Providers Care Model

Adult Foster Care providers are the only medical profession that invite their patients into their homes so that they can take care of them. That living arrangement allows you to act as the agent of the doctor and act as the advocate of the patient. Both servant and supervisor of the desires of both patient and doctor. To take advantage of that aspect I present to you the following seven-step caregiving plan.

The In-home Caregiving Model

  1. Help the patient convey the details of their health problem to the doctor
  2. Confirm that the patient understands the details of the therapy the doctor chooses to implement. What the therapy does, what are the goals of the treatment, and what the doctor wants the patient to do.
  3. Ensure that the doctors’ prescribed therapy is being followed correctly.
  4. Report back to the doctor about the therapy's effectiveness and what problems have occurred.
  5. Confirm that the doctor understands the feedback being told to them.
  6. Question the doctor about all therapy choices and possible alternative therapies.
  7. Safeguard the patient by ensuring that the resident’s needs are ultimately being met.

In this model of care the In-home care provider ensures that proper communication is occurring between patient and doctor, monitors the therapy for effect, and follows up on any concerns that may arise. Each step is important and is flexible enough to be able to apply it to any situation.

In regard to pain management, this is what I would do if I were following the above seven steps of action.

 

Step 1. Ask the resident the questions that you think the doctor will ask before the appointment. That would include

  1. Where is the pain located?
  2. What causes the pain to happen?
  3. How severe the pain is. (Use the pain scale of 1 to 10, ten being the worse)
  4. How frequently does the pain occur?
  5. How long does the pain last?

 

The resident is now better prepared to communicate their needs to the doctor, and you are also better prepared to fill in any details that may be forgotten by the resident.

Step 2. After the doctor chooses a therapy, ask the doctor

  • What is the therapy supposed to do, and how does it work?
  • What are the goals of the treatment?
  • Are there any specific instructions that need to be followed?

By hearing the answers to these questions, the patient gains a more realistic expectation of therapy. Also, the doctor sees that there is a care professional who is ready to monitor the therapy for effectiveness. If this line of questioning annoys the doctor, it informs you that there may be potential problems in the future that you may have to deal with. Most likely though, it will surprise and please the doctor when they understand what you are trying to do.

Step 3. Before you leave, tell the doctor that you will be charting the administration of any drugs in a MARS and that you will give them a copy if they desire it. More importantly, tell them that you will also be using a PRN log to keep track of the therapy’s outcomes. The more information a doctor has the better decisions they make.

Step 4. a) Ask the doctor what reporting they need to have and when they would like to have it. This is going to surprise the doctor. Nobody but a care professional asks those questions. It establishes a whole new level of doctor-patient communication expectations.

  1. b) When you pick up the prescription, note the possible side effects that are mentioned in the accompanying patient education papers. It will provide you with a list of things to monitor for.
  2. c) Report back to the doctor if the goals of therapy are being met. Also, report problems or concerns that you or the patient have. I suggest that you do this even if the doctor says that you don’t need to. It adds a layer of doctor involvement and accountability. It discourages the old “prescribe and forget” kind of therapy that could happen in a busy doctor’s office. It also provides critical documentation that you will need if you have to do battle with the doctor over issues that may arise in the future. Like if the pain is not being relieved or side effects are hurting the patient. If you do not report back, the doctor will assume that everything is going well in the therapy.

Step 5. If the doctor does not respond to your concerns in a favorable way, you will have to be prepared to do battle to get what your residents need. I think the safest way for you to challenge the doctor is by asking questions. The questions should encourage the doctor to explain any concerns that they have. Their responses will also help you determine if the doctor truly understands what is going on.

 

Here is an example of the type of conversation that I am talking about.

 

Caregiver, “I noticed that you did not renew the Vicodin prescription for my resident. What concerns do you have that are preventing you from giving more refills?”

Doctor, “I don’t think there is a need for the narcotic anymore.”

Caregiver, “Did you see the PRN report I sent to your office? It reports that the frequency of administration is not diminishing. Does that indicate that there is still a need for the prescription?”

Doctor, “That also might suggest that dependence is developing. I don’t want the patient to get addicted.”

Caregiver, “I understand your fears, but my resident is still suffering in pain. What information do you need that I can monitor for you that would reduce your concerns?

Step 6. If I have gotten this far in the action steps and am still having difficulties, I know it’s time to start thinking outside the box. As a caregiver, I know that I can’t make changes to therapy. But as the patient's advocate, I know that I have the right to ask the doctor about other treatment options or adjust the current therapy.  This step gets tricky. How do you influence the doctor when they think that they’re smart and you’re not? Again, I start by asking questions. I have found that the more informed the questions are, the harder it is for the doctor to ignore my subtle attempts to influence their choice of therapies.  

Here are some examples.

I was told by the pharmacist that all Nsaids, specifically Ibuprofen, damage the kidneys. Do you think that the possibility of narcotic addiction outweighs the kidney damage that is happening?

I have noticed that addiction means different things to different people. How do you define addiction? (doctor’s answer) Hum, I am having difficulty seeing those aspects in my resident’s behavior. How would you suggest I monitor the patient for those addiction symptoms? (doctor’s answer) When should I report back to you my observations?

To do this step right, you have to know what you are talking about, or you come off as a fool. I have the advantage of being a pharmacist. You will have to do some research and possibly quote some articles that you have read.  For example;

I was reading from the Royal College of Anesthetists website that “Patients using intermittent opioid dosing regimens might not become tolerant to side effects.” Could we use intermittent opiate dosing for my resident’s chronic pain problems to help avoid dependence and still take advantage of the medication’s powerful effects?

 

Step 7. The patients’ needs need to be met. The hard choices

As a licensed caregiver, you have to follow the doctor’s instructions no matter what. But the patient has the right to do whatever they want. Their needs and desires trump the desires and instructions of the doctor. Even though you have tried very hard to make everything work out, sometimes that just don’t. To meet the needs of your resident you (the advocate) will have to fire the doctor and get a new one. You will need to have a long talk with the resident, their family, and or the person who has power of attorney over the resident to do so.

This is not done lightly. Reputations are on the line. You will find that doctors talk to each other, and gossip is spread between doctor’s offices. There is a danger that you or the patient gets labeled as being uncooperative and the same difficulties follow you to the new doctor. To avoid this problem, you have to use a lot of tact with the old doctor, (you might have to work with them again after all). In communicating with the new doctor just state in a matter-of-fact way what you think the resident’s needs are. Don’t accuse the old doctor of anything and discourage the patient from complaining about the old doctor with the new one. Even though it is human nature to justify an old doctor being fired by pointing out their faults, there really is no need to. A patient can switch doctors anytime they want and for any reason they want. They don’t have to justify their actions to anyone and it’s better if they don’t.

On the other hand, if the new doctor comes to the same conclusions as the last one, you and the resident might have to re-evaluate your positions on the topic.  Sometimes practicality wins out over idealism.

In regard to chronic pain issues, there might be a third option available for you to pursue. There are clinicians who specialize in pain management.  To not insult the old doctor, I recommend that you act as a concerned third party and avoid direct confrontation. State that the patient is having a lot of difficulties with the situation (purposely be vague about the details). Bring up the idea that you think the patient will be more cooperative with a doctor who specializes in pain management. Ask the doctor for a referral for insurance purposes. You will note that by using these tactics you have skillfully diverted all blame away from the doctor. In the long run, things will be better for you and your residents if you do.

 

What I am going to do for my Mom

Back to my Mother-in-law’s case. She has decided that she wants a new doctor. She has given me a shopping list of attributes she wants her new doctor to have. I am finding it difficult to find her the perfect doctor she wants. She may have to settle for a little less perfection.

Surprisingly, in going through step 5 of the action plan the old doctor was the one who suggested the pain specialist option. I think the doctor secretly doesn’t want to deal with the hassles of addiction versus pseudo-addiction problems. Regardless of that, my mom still wants her perfect doctor. We’ll see if I can make it happen for her.  

There may be a few of you who notice that I am not fully practicing what I preach with my Mother-in-law. I am having extra difficulties because my mother suffers from Son-in-law syndrome. She automatically thinks I am stupid because I am the son-in-law and she is much smarter than me despite my degree and decades of experience. Go figure. Wish me luck in my struggles with the old coot.

 

Conclusion

Because opiate and narcotic drugs activate the body's own pain-relieving systems so effectively, they are often the preferred medication in treating short-term pain. Unfortunately, there are dependence, withdrawal, and addiction risks if the opiates are used chronically. The patients may erroneously come to believe that feeling good is the same as pain relief. They may seek opiates for the euphoria effect even if it harms them. If the patient crosses over from pain relief to the need to feel euphoria, they are on the pathway to addiction. They need to be protected against this unwanted side effect.

These concerns lead doctors to deny their patients long-term opiate therapy. If this action leads patients to suffer because of inadequate pain relief, they may misuse opiate therapy in ways that mimic addiction symptoms.

Adult Foster Care providers are in an excellent position to resolve such pseudo-addiction issues by being both servant and supervisor to both doctors’ and residents’ needs. The In-Home care model is an effective way to work through these problems and greatly reduce the possibility of pseudo-addiction occurring. I hope that giving you so many details on how I would handle the situation helps you formulate your own plan of action.

 

As always, Good Luck in your caregiving efforts.

Mark Parkinson BsPharm

References:

  1. Marion Greene, R. Andrew Chambers. Pseudoaddiction: Fact or Fiction? An Investigation of the Medical Literature. National Library of Medicine NIH. PMCID: PMC4628053. Oct. ,15 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4628053/
  2. Jennifer Huizen. What to know about pseudoaddiction. Medical News Today.com. Mar 3,23 https://www.medicalnewstoday.com/articles/pseudoaddiction
  3. Opioid addiction. gov National Library Of Medicine NIH. 2023. https://medlineplus.gov/genetics/condition/opioid-addiction/
  4. How opioid use disorder occurs. org. Nov 29,23 https://www.mayoclinic.org/diseases-conditions/prescription-drug-abuse/in-depth/how-opioid-addiction-occurs/art-20360372#:~:text=Opioids%20are%20highly%20addictive%2C%20in,powerful%20sense%20of%20well%2Dbeing.
  1. Thomas R. Kosten, Tony P. George. The Neurobiology of Opioid Dependence: Implications for Treatment. Sci Pract Perspect. 2002 Jul; 1(1): 13–20. National Library of Medicine NIH. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851054/
  2. Ream Al-Hasani, Michael R. Bruchas. Molecular Mechanisms of Opioid Receptor-dependent Signaling and Behavior. Anesthesiology December 2011, Vol. 115, 1363–1381.https://pubs.asahq.org/anesthesiology/article/115/6/1363/13046/Molecular-Mechanisms-of-Opioid-Receptor-dependent
  3. Shane Darke, Sarah Larney, Michael Farrell. Yes, people can die from opiate withdrawal. Addiction, Society for the Study of Addiction SSA. Aug 11,16. https://onlinelibrary.wiley.com/doi/full/10.1111/add.13512
  4. What is the definition of addiction?. American Society of Addiction Medicine.org. Sept.15,19. https://www.asam.org/quality-care/definition-of-addiction
  5. Side effects of opioids. Faculty of Pain Medicine of the Royal College of Anesthetists 2023. https://fpm.ac.uk/opioids-aware-clinical-use-opioids/side-effects-opioids

 

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