Jessica Dunne

Jessica Dunne 

RE: Discussion – Week 5


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NURS 6050C: Policy and Advocacy for Improving Population Health


     In many parts of the country, alcohol misuse is socially and culturally acceptable. However, it does not make any safer, or any less severe than any other substance use disorder. According to McCarty et al. (2018), 6.1% of the population meets the clinical criteria of alcohol use disorder (AUD) and need treatment to stop drinking (McCarty et al., 2018). The American Addiction Centers (2018) point out that long-term alcohol use leads to other chronic diseases and socio-economic issues. The United States spends more than $600 billion annually to combat substance abuse (America Addiction Centers, 2018). Knickman and Kovner (2015) maintain that socio-demographic factors play a significant role in alcohol accessibility. High-income, high-education areas have a lower concentration of alcohol retail outlets than low-income, low education geographic locations (Knickman & Kovner, 2015).

         The Iowa Department of Public Health (2018) asserts that residents (19.8%) report binge drinking within the last month, which exceeds the national average. Iowa ranks 5th in the nation for binge drinking (Iowa Department of Public Health, 2018). Considering that Iowa is a sparsely populated state, with approximately 3 million residents, the prevalence of binge drinking is statically significant. Working in community mental health, I see patients who struggle with AUD on a daily basis. The cultural attitude that drinking excessively is socially acceptable further compounds the problem. Patients frequently suffer with mental illness and a substance abuse concurrently. However, there are very few dual diagnosis treatment centers in the state. Even in the outpatient setting services are geared towards either mental health or substance abuse, but rarely both.

Downstream Interventions

            Downstream interventions occur at the individual level and include education, counseling, community programs, and pharmacological treatments. Downstream interventions focus on behavioral changes, rather than risk prevention (Knickman & Kovner, 2018). It is a common misconception that addiction is a character flaw rather than a disease. This incorrect and counterproductive logic often inhibits addicts from seeking help. Swift and Aston (2015) contend that AUD is a genetic, neurobiological disease state. However, like many psychiatric disorders, the pathophysiology is not well understood by the public (Swift & Aston, 2015). Downstream interventions to treat AUD commonly include psychotherapy, group participation, and medication management.

As previously stated, treatment for mental illness and substance abuse are typically separated in my area. Ideally, creating more dual diagnosis treatment centers would improve health outcomes by synergistically addressing concurrent problems simultaneously. However, because there is a shortage of qualified providers and financial resources, this is not realistic. A more immediate solution would be for mental health centers to partner with substance abuse centers to create a network of services in communities. Leaders from organizations of both types should meet and exchange information about their respective programs such as available services, financial costs, and referral processes. Information will then be disseminated from leaders to employees in both organizations, and in turn, patients with dual diagnosis will be referred to the program that best suits their situation. This would be effective because it does not require a significant investment, and would utilize the providers that already practice in the community. Moreover, given the stigma associated with both mental health and substance abuse, coordination of resources would decrease barriers to treatment.  

Midstream Interventions

                Midstream interventions address a specific segment of the population, with the goal of changing or preventing behavioral risk factors. These types of interventions are community driven and often use screening tools to identify high-risk individuals for targeted treatment (Knickman & Kovner, 2015).  Dr. Montes de Oca (2018) maintains that untreated mental illness frequently leads to drug and alcohol abuse. Symptoms of psychiatric disorders commonly occur in early adulthood (Montes de Oca, 2018). Additionally, many adolescents experiment with illicit substances during high school. It is imperative that young people are aware of mental health disorders and substance use disorder in high school and college. School health screenings are commonplace for physical health disorders, but, often lack a holistic approach that includes mental health screenings. Self-screening tools for depression, anxiety, substance abuse, and other mental health disorders should be administered to students annually, and on an as-needed basis. School nurses and counselors should serve as a resource for psychological well-being and should work with parents to coordinate services for students in need. Early identification and treatment will optimize outcomes for young people, and decrease the prevalence of dual diagnosis in our communities.

Upstream Interventions

               Upstream interventions are systematic and employ public policy to promote healthy behavior and deter unhealthy behavior. Examples include financial disincentives such as excise taxes, national media campaigns, and reducing access to unhealthy products (Knickman & Kovner, 2015). Xuan et al. (2015) assert that binge drinking behavior leads to around half of all alcohol-related deaths in the United States annually. Binge drinking rates vary significantly by state. Research indicates that decreasing the availability and increasing the cost of alcohol curbs the frequency of binge drinking behaviors (Xuan et al., 2015).  Because of geographical differences, policies enacted at the state level are more effective. In Iowa, policymakers should increase excise taxes on alcohol products and limit the number of alcohol permits to businesses based on population density. The state should also sponsor a public media campaign to increase awareness about binge drinking behaviors. I did not realize that Iowans engage in binge drinking at a higher rate than 90% of the United States. An approach that enacts policies and provides a rationale to state residents through a media campaign will be effective in decreasing binge drinking.

              It is imperative to recognize that the population-based interventional model has the potential to elicit positive, healthy changes and prevent unhealthy behaviors because it is comprehensive and addresses risk behaviors at multiple levels. Reforms do not need to cost a lot of money to be successful. Simple communication, early identification, and increasing awareness through education can reduce risky behaviors and promote health for the population. As health care providers, we often become hyper-focused on a specific specialty or population segment. It is beneficial to take a step back and look and the big picture. Holistic care requires cooperation, collaboration, knowledge sharing, active listening, critical analysis, and action. 

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