Abstract

This paper compares and contrasts the “crack epidemic vs. the “opioid epidemic and how our country is still impacted by the war on drugs. The similarities between the two epidemics are that families are impacted by these substances. People who are addicted to drugs will put the substance ahead of anything that is meaningful to them. The only thing that matters to them is how to get that next one. People who are addicted to drugs need help. Also, the fatalities of the substances are alarming, in particular people who are addicted to opioids. 90 Americans die every day because of opioids. The differences of the two substances could be controversial as many view it is a black vs. white issue. It seems that people who are addicted to opioids are given plenty of avenues to get their life back on track compared to people in the grips of the “crack” epidemic. People were given harsh sentences, violence ensued throughout communities, and instead of treatment they were more likely to end up incarcerated. It seems we learned our from our mistakes and people who are addicted have a much greater opportunity to get help in order to combat their addiction.

As a country we have always be tough on drug use, stemming from the 1960s war on drugs. The war on drugs is a huge failure with devasting consequences. It led to mass incarceration as they sky rocketed as a result, corruption, and systemic human rights abuse across the world. It negatively affected the lives of millions of people. Federal agencies increased their presence and mandatory sentencing was established for drug offenders, however, drug offenders did not stop using drugs. Federal funding projects for drug prevention programs took place. And Nancy Reagan’s “Just say No” campaign and Dare Programs were established. After years of trying to reduce and stop drug use, we shifted towards a more sensible drug policy.

During the 1980s, a more profitable drug came into existence. This was known as crack. It is a party version of the drug cocaine. It increased riots and violence throughout our country. According to the Journal of American History, “From 1982 to 1985 the number of minorities in California prisons increased 400%.” According to Dunlap, Golub, and Johnson (2006), “For many, continual crack use became an obsession that dominated their lives. Many crack users organized their lives around their drug habits and their extended binges. Dedicated crack users sold drugs, committed various hustles, and stole from family members to support their habits. Crack markets emerged in the inner city to serve users 24/7” (p. 115). In addition, this is similar to the “opioid” epidemic because like any drug, the drug comes first above anything else that may be of importance. Furthermore, this epidemic is the deadliest drug crisis in American history, which kills about 90 Americans every day! It is almost equivalent to the same number of car crashes. The truly sad thing about the crack and opioid epidemic is the devastation it has caused communities regardless of race. Consequently, the crack epidemic caused almost immediate devastation to the individual, his or her community. Keller (2017) states that, “According to new research published in the Annals of Internal Medicine, for the first time, the rate of opioid-related overdose deaths among non-Hispanic white Americans is comparable to the rate of cocaine-related overdose deaths among African Americans” (n.p.). As a result, blacks were more disproportionately affected, and crime was more rampant almost from the get-go. Similarly, the opioid epidemic, which in many ways is causing just as much devastation regardless of whether the individual is locked up or not. Families and communities behind locked doors are dealing with these substances that may not lead to immediate crime but gradually destroys everything in its path. Another similarity between the “crack” epidemic and the “opioid” epidemic is According to the Associated Press (2017), “The good news, though, is that drug epidemics do fade considerably — usually because reduced supply and demand eventually diminish the number of new addictions, experts say. And that history offers some hope for the future” (n.p.).

In addition, the “opioid” epidemic started in the 1990s with over prescription of opioid painkillers like, Oxycontin, Vicodin, and Percocet. America is facing an epidemic of addiction like heroin and prescription painkillers. With many, what started as pills, ultimately became a heroin addiction. It starts, it can get out of hand fast. These pills are getting used or falling into the hands of others. From those who are already addicted or bored teenagers. The question has to become less what did we do wrong and more what do we do now. According to Cohen (2015), “Between 2006 and 2013, federal records reveal that the number of first-time heroin users doubled from 90,000 to 169,000. The Center for Disease Control and Prevention announced last month that the rate of deadly heroin overdoses nearly quadrupled between 2002 and 2013” (n.p.). These drugs are still the most efficient to treat certain types of pain and many patients need them. We can’t get rid of them, but we have to be much more careful about how they’re prescribed. But we cannot just work to prevent future addicts, we are going to need to do more to help the millions that already exist. Therefore, we need to put more investment in treatment programs.

On the other hand, a difference between the “crack” epidemic and the “opioid” epidemic is that hundreds of thousands of African-Americans across the country ended up with prison records because of minor drug violations. According to Glanton (2017), “In 1986, Congress passed the Anti-Drug Abuse Act establishing, for the first time, mandatory minimum sentences for those convicted of having specific amounts of cocaine. The sentences, however, were much tougher for crack cocaine than powder cocaine cases — which disproportionately affected African-Americans (n.p.).” Conversely, people who are addicted to opioids, seem to be given an opportunity with the emphasis placed on treatment rather than to incarcerate. According to Peterson and Armour (2017), “Research has shown that minorities are now more likely to be in prison and to serve longer sentences than white offenders for comparable crimes. Many lawmakers say it is time for the sentencing guidelines established during the crack epidemic to be further revised. Congress has already made clear that targeting opioid addiction is one of its top priorities. In February, lawmakers passed a two-year budget deal that set aside $6 billion over two years for opioid and mental-health issues” (n.p.).

Officials thought they could arrest their way out of the crack cocaine crisis and it would go away. According to Lopez (2017), “As crack addiction strangled black communities in particular, policymakers didn’t reach to more treatment to deal with the problem; instead, the response to the crack epidemic was built almost entirely around the criminal justice system” (n.p.). These excessive punishments put a generation of Black men and women behind bars, destroying families and devastating urban communities and in reality, accelerating the poverty and crime the laws were meant to combat. However, the opioid epidemic has inspired a different response. According to Lopez (2017), “the media coverage of the epidemic is much more sympathetic of people struggling with drug addiction. New Jersey Gov. Chris Christie, who’s leading President Donald Trump’s opioid commission, in 2015 gave a passionate speech urging Americans to treat addiction as a medical issue, drawing from a friend’s story to argue that “we need to start treating people in this country, not jailing them. We need to give them the tools they need to recover, because every life is precious” (n.p.). Disproportionately, this wasn’t the case for crack addicts. They were viewed as people who were dispensable. The crack epidemic and opioid epidemic was viewed as black vs. white. It shouldn’t matter, because addiction is addiction. Addicts need help to try and combat their disease not to be incarcerated.

Like many drug addicts, most of them care about the drug over anything. Whether it be their families, children, jobs, the drug will always come first, and it will be the top priority. Crack was cheaper and easier to access than traditional cocaine. It took lower income areas by storm, it turned communities into warzones, and it became a national crisis. In 1986, Reagan signed The Anti- Drug Abuse Act which pushed harsher sentences on crack than cocaine use. This led to a debate that the law was unfairly targeting minorities and lower income neighborhoods. Families were broken, and violence erupted. According to Stetzer (2017), “Americans were consumed with disgust and fear of the drug rather than concern for the people who had become ensnared by it. Terrified by the drug’s potential destruction, Americans were bent on stomping it out; unfortunately, this morphed into stomping out those gripped by addiction or those who made their livelihoods selling drugs. Instead of getting rid of a drug, we tried to get rid of people” (n.p.). In 2010, Obama put an end to Reagan’s Anti-Drug Abuse Act and passed The Fair Sentencing Act of 2010. Many feel it was too little too late, it was a step toward correcting a racial divided prison system. Stetzer (2017) continues by articulating, “In our rush to protect our communities, our families and our values, we sought to put distance between “us” and “them.” The crisis in the 1980s was the same as one today that screams one message: People who are addicted to drugs need help. That help must come from a solution-driven government, and it must come from compassion-driven churches and other faith communities” (n.p.). Addiction is a health crisis because it affects people of all backgrounds. We can treat it as such.

Reference Page

• Associated Press. (2017). Opioid epidemic shares chilling similarities with the past. Retrieved from https://www.cbsnews.com/news/opioid-epidemic-shares-chilling-similarities-with-the-past/ on October 17, 2018
• Cohen, A. (2015). How White Users Made Heroin a Public-Health Problem.  https://www.theatlantic.com/politics/archive/2015/08/crack-heroin-and-race/401015/ on October 18, 2018.
• Dunlap, E., Golub, A., & Johnson, B. D. (2006). The Severely-Distressed African American Family in the Crack Era: Empowerment is not Enough. Journal of Sociology and Social Welfare, 33(1), 115–139.
• Glanton, D. (2017). Race, the crack epidemic and the effect on today’s opioid crisis. Retrieved from http://www.chicagotribune.com/news/columnists/glanton/ct-opioid-epidemic-dahleen-glanton-met-20170815-column.html on October 18. 2018
• Keller, J. (2017). A Tale of Two Drug Wars. Retrieved from https://psmag.com/social-justice/a-tale-of-two-drug-wars on October 18, 2018
• Lopez, G. (2017). The deadliness of the opioid epidemic has roots in America’s failed response to crack. Retrieved from https://www.vox.com/identities/2017/10/2/16328342/opioid-epidemic-racism-addiction on October 18, 2018
• Peterson, K & Armour, S. (2017). Opioid vs. Crack: Congress Reconsiders Its Approach to Drug Epidemic. Retrieved from https://www.wsj.com/articles/opioid-v-crack-congress-reconsiders-its-approach-to-drug-epidemic-1525518000 on October 17, 2018
• Stetzer, E. (2017). Lock them up:’ My double standard in responding to the crack crisis vs. the opioid epidemic. Retrieved from
  
  https://www.washingtonpost.com/news/acts-of-faith/wp/2017/10/26/lock-them-up-my-double-standard-in-responding-to-the-crack-crisis-vs-the-opioid-epidemic/?noredirect=on&utm_term=.d5003e4a9e5c
  
  on October 17, 2018

Introduction and Rationale

Evidence based practice is fundamental to modern nursing care, and can be described as the application of appropriate research findings to practice. There are challenges with integrating research into practice, partly due to a tendency to cling to historic (and arguably, outdated) models of intuitive practice, which are being superceded by evidence based-practice (Rosswurm and Larrabee, 1999). Successfully identifying and applying research to practice can be effected by three central facets of the research, which include the quality of the evidence being used, the clinical area or clinical context into which the research evidence is to be integrated, and the projected processes of implementation (with associated implications for changing practice ) (Kitson et al, 2000; Elliott, 2001). The most important of these factors might be the quality of the evidence, which requires the individual nurse to have the knowledge and critical skill to be able to determine if the research provides a sufficient level of evidence to improve practice (Kitson et al, 2000). According to Reigle (1989), this is linked to patient-centred nursing decision making and client respect, which can be linked to the ethics of nursing practice (Austin, 2001).

Ultimately, the issue is whether or not the research will benefit patient care, by improving the patient experience and/or clinical outcomes in some way, including through the better use of resources (Crockett et al, 1997). Certain areas of practice can be identified by previous research as requiring exploration and improvement. This paper examines the quality of evidence pertaining to a very topical issue, the compliance with cardiac rehabilitation programmes for clients post myocardial infarction,. There is evidence to suggest that cardiac rehabilitation programmes both benefit patient outcomes and reduce morbidity and mortality, and also therefore contribute to a reduction in resource use consequent to a reduction in serious health consequences of myocardial infarction (Taylor et al, 2006; Davies et al, 2007). The literature debates whether or not this is due purely to the exercise-based rehabilitation, or the reduction in other major risk factors, such as smoking (Taylor et al, 2006; Ferdinandy et al, 2007), but whatever the reason, the links between improved outcomes and cardiac rehabilitation programmes of this type have been established (Dalal et al, 2007).

The NHS Plan (DoH, 2000) also underlines a requirement to improve practice through the judicious application of evidence alongside a reorientation towards patient-centred care which is responsive and inclusive, and takes into account the patient (and carer) perspective. According to some theorists, therefore, application of evidence to practice must take place within a model which combines the evidence from qualitative and quantitative studies, from clinical expertise and from contextual evidence (Rosswurm and Larrabee, 1999), and it is this contextual evidence which must also contain the user perspective. The first stage to this would therefore be to appraise the evidence, both from a point of view of the standards of evidence as defined by the current theoretical and critical literature, and from the point of view of the professional and the service user (Florin and Dixon, 2004). This paper focuses on the critical review of two papers pertinent to this chosen question, which has been an interest of the author due to the very real benefits which can be demonstrated from the adherence to the cardiac rehabilitation programmes available to patients post MI, but which paradoxically are afflicted by poor compliance rates. The author is also motivated by some of the other paradoxes, such as the fact that not only are the poorer socioeconomic groups more affected by coronary heart disease (Wood et al, 2006), but that these are also the groups which display poorer compliance with cardiac rehabilitation programmes (Wyer et al, 2001). This would suggest to this author that there are specific patient needs which may not be met with current care provision, of which this is an important example. The choice of a both a qualitative and a quantitative paper reflects the desire to reflect nursing philosophies as well as the scientific, medical principles which underline evidence-based practice (Thompson, 2000; Johnson et al, 2000; Corben, 1999).

Critical Review

Research Question and Design

Wyer et al (2001) carried out an intervention study, based upon the Theory of Planned Behaviour, to investigate if an intervention based on this theory would affect compliance with (in terms of attendance) cardiac rehabilitation in post MI patients. They clearly outline the Theory of Planned Behaviour (TPB), hence setting the context (and underlying principles of the ‘intervention’ and therefore explaining the hypothesis or research question which underlies their study, that of designing as study to implement and evaluate a TPB founded intervention (Wyer et al, 2001). The determination of the research question in a quantitative study such as this affects the whole study (Thompson, 2000), and in this case, the focus of the study is on the intervention and its effects, with the intervention being the independent variable, and the outcome measures, acceptance, attendance or DNA (did not attend) being the dependent variable. While it is important to assess the research question in terms of its fit with the study (Burns and Grove, 1999), it is also important to look at its usefulness (Stockhausen and Conrick, 2002). Certainly, indicating whether there are theories which explain non-attendance might help to design future studies to improve rates, and this study tests whether an intervention might improve rates, giving it direct clinical significance, although only if sufficiently rigorous (Donovan, 2002).

The research design is experimental, and although the authors do not evaluate their design or methodology within this paper in any way, it does seem suitable to the research question. They define it as a rancomised control trial, but there are elements of an RCT which are not present here (Duffy, 2005). However, as Donovan (2002) suggests, “the reliability of an experimental design may be considered as the extent to which an observation is reproducible and characteristic of the association between the variables being tested” (p 2), and although basic quantitative principles are adhered to in this study, there are some significant issues in relation to validity which are not addressed within this paper.

Cooper et al (2005) carried out a qualitative study, with the aim “to elicit patients’ beliefs about the role of the cardiac rehabilitation course following myocardial infarction” (p 87). They clearly outline the context of the study, and this relates well to the research question (Thompson, 2000). Cooper et al (2005) also refer to psychological theories, in this case Leventhal’s self regulatory model (p 88) which in this study explores rationales for attendance/non attendance at cardiac rehabilitation programmes. The research design is appropriate to the question, being a qualitative design addressing an exploratory question about perceptions and experience rather than measurable outcomes (Silverman, 2004, Forchuk, 1993). The specific focus of the study on patient beliefs prior to attending any cardiac rehabilitation (Cooper et al, 2005) also demonstrates its usefulness because it may point to areas of patient need, such as education, to change their beliefs and potentially affect attendance and compliance. The methodology is reasonably clear, but could have been explained in more detail, as the rather brief summary of ‘interpretive phenomenological analysis’ (p 88) may not be sufficient for those less well-versed in research theories (Corben, 1999).

Sample

Wyer et al (2001) started with an initial sample of 113 participants, with a response rate of 88%, and 13 subsequent exclusions from the group, resulting in a final sample of 87 participants. Although this is a quantitative study, there has been no statistical determination of optimal sample size, which affects transferability (Donovan, 2002; Thompson, 2000; Burns and Grove, 1999), and no indication that it is a representative sample (Stoner and Rutledge, 2005; Russell and Gregory, 2003). However, it is a strength that the experimental and control groups were matched for age, gender and living distance from the programme (Wyer et al, 2001), and there isindication of how this relates to the fact that they were randomly assigned and there is mention of blinding of participants or researchers (Donovan, 2002). The demographic variables were statistically evaluated between the two samples, and no statistical significance was identified, which strengthens the sample used.

Cooper et al (2005) clearly define their inclusion and exclusion criteria for their sample, which seem suitable for the study design (Thompson, 2000), and define theirs as a purposive sample with some limitations, although they could have given more of a clear rationale for this sampling approach (Corben, 1999), and also outline some demographic characteristics. Purposive sampling is suitable for qualitative studies of this nature, and the sample described is suggestive of trustworthiness (Russell and Gregory, 2003).

Data Collection and Analysis and Presentation of Results

The study conducted by Wyer et al (2001) involved the distribution of two letters to the experiemental group, which consisted of the intervention, and the authors outline what was in these letters and how it related to the Theory of Planned Behaviour. This level of transparency is very useful for transferability and for replication of the study (Daggett et al, 2005). “Acceptance and attendance figures were collected for participants and for those who declined to take part in the research study”, along with compliance rates for the programme collected weekly (Wyer et al, 2001 p 156). These data collection methods match the RCT design (Russell and Gregory, 2003), because they provide statistics on the outcome measures being tested. The authors used SPSS to analyse the data, and state which version, and which statistical tests were used, but do not explain these tests or explain how/why these were appropriate for the sample and results. This could have been explained and the data collection methods and analysis tools tested using a pilot study, which was not carried out (Thompson, 2000).

The results are presented in textual form supported by numerical/statistical data, and as a graph which demonstrates the comparisons between the percentage of participants in the experimental and control groups who demonstrated the three measured variables of acceptance, attendance and DNAs. Presenting data in graphical form makes it more accessible and understandable to the reader (Thompson, 2000), but in this case, the reader must also understand the textual explication of the statistical process, which could be rather dense for the novice reader/researcher. The sequential statistical analysis carried out to test differences between gender, distance and age are at least described, which is a strength (Robinson, 2001; Daggett et al, 2005).

Cooper et al (2005) carried out face to face, in depth, semi-structured interviews, which were audio-recorded and transcribed ‘in full’. The use of this kind of interview in exploratory, qualitative research is an accepted approach to data collection, made stronger by audio taping (Denzin and Lincoln, 2005). However, the transcription is not described as verbatim, and it is not said who transcribed the data, so the nature of the transcription, the researcher’s relationship with this process, is not made clear (Corben, 1999). The researcher’s did not carry out member checking, which could enhance the trustworthiness of the findings (Russell and Gregory, 2003).

Data analysis is described in a summary by Cooper et al (2005), and includes a description of how themes were arrived at, which is good (Emden and Sandelowski, 1998), but given the range of qualitative methodologies available within this paradigm, which include models for thematic analysis, it is a weakness that no recognised structure or model is cited or employed here (Corben, 1999). There is good transparency here, however, which would aid in replication of the study, but the authors have also not made use of any of the qualitative data analysis software available, or have not cited that they used this (Thompson, 2000).

The results are presented as Key Themes (Cooper et al, 2005) which are described, and quotes from the data are included, which enhances trustworthiness (Forchuk and Roberts, 1993). The themes are summarised in a table, and also presented within a framework which is described and discussed within the paper. The authors acknowledge their inability to establish links between participants’ beliefs, any expressions of intention to attend cardiac rehabilitation, and actual attendance behaviour (Cooper et al, 2005). This demonstrates some of the limitations of this study.

Findings

Wyer et al (2001) were able to demonstrate that their intervention, consisting of two letters based on the TPB, was effective in increasing attendance rates in their study sample.

Cooper et al (2005) ultimately conclude that “prior to course attendance some patients hold erroneous beliefs about the course content, especially the exercise component” (p 87). This suggests that the exercise element was the most off-putting for many participants. There were also co-existent cardiac misunderstandings (Cooper et al, 2005).

Conclusion and Implications for Practice

Both of these studies offer some guidance for practice in relation to improving compliance with cardiac rehabilitation programmes for patients following an MI. The Wyer et al (2001) study provides strongly conclusive results which suggest that the use of this kind of intervention would increase compliance with rehabilitation programmes and, subsequently, reduce the demand on cardiac and other services from ongoing morbidity in cardiac disease. However, there are some limitations to this study, not the least of which is a lack of clarity over the RCT design in the paper, and a small sample size which is not statistically calculated. It may be necessary to replicate this study in a larger, more representative population. Cooper et al’s (2005) study provides some insight into the beliefs which prevent patients from attending, many of which are due to erroneous understanding about the programme and its relevance for them. Therefore, this could prompt nurses to pay more attention to the kinds of information given to these patients, and to check their understanding and conceptions of the programme, a relatively simple change in practice. While there may be some nurses who would argue that a single, small, qualitative study cannot really constitute evidence for practice, the benefit for patients might be significant and the change in practice is relatively small and carries few risks for the clients.

Given that the morbidity and mortality experienced by patients following an MI can be drastically reduced by attendance at targeted cardiac rehabilitation programmes (Taylor, 2004; Taylor et al, 2006), this author believes that any evidence which supports even minor changes in practice has benefits for the patients, the healthcare providers and the resources of the NHS which are in such constant demand. However, these studies do not constitute evidence weighty or reliable enough for radical changes in practice, but they do indicate ways in which practice might be changed. However, this author also believes that these studies point to underlying, inherent issues related to the quality of nursing and other healthcare for these patients at this crucial period, and believes that nurses can, and should make changes to practice based on critically appraised research such as this. While targeted interventions would be a large scale change, improving the quality of information giving and checking understanding should be part of cardiac nursing care for all patients.

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