Advertisement

Opioid misuse epidemic: Addressing opioid prescribing and organization initiatives for holistic, safe and compassionate care

      Executive Summary

      The U.S.
      • Centers for Disease Prevention and Control
      Overview of the epidemic.
      ,
      • National Governors' Association
      A compact to fight opioid addiction.
      state that the misuse and illicit use of prescription analgesic drugs and use of heroin have skyrocketed to epidemic proportions. Former Surgeon General Vivek Murtha's report, Facing Addiction in America (2016) notes that 12.5 million Americans use opioid pain relievers in ways other than those intended by prescription (
      U.S. Department of Health and Human Services (HHS). Office of the Surgeon General
      Facing addiction in America: The Surgeon General's report on alcohol, drugs and health.
      ). Notably, about 61% of the US drug overdose deaths in 2014 involved an opiate (
      • Rudd R.A.
      • Seth P.
      • David F.
      • Scholl L.
      Increases in drug and opioid-involved overdose deaths-United States, 2010-2015.
      ).
      To address the opioid crisis requires the coordinated responses of all health care providers. Multiple disciplines and professional nursing organizations have recommended strategies and published policy statements. Efforts to stem the opioid crisis include the development of provider education and dissemination of opioid prescribing guidelines, protocols for adherence to these guidelines, effective use of non-opioid treatment modalities for chronic pain, and initiatives to increase access to opioid addiction treatment. Nursing leadership in these initiatives must be broad based and unequivocal in order to engage all levels of the nursing workforce and to promote collaboration among organizations and agencies.

      Background

      Emphasis on effective pain management, increased prescribing of synthetic opioids and wide marketing of opiate analgesics are among the events of the last decade which have contributed to thousands of deaths and cases of severe opioid use disorders in adults across the lifespan. Opioid overdose is now the leading cause of all premature deaths (
      • Centers for Disease Prevention and Control
      CDC Guideline for prescribing opioids for chronic pain.
      ). There is an urgent need for health care providers and policy makers to promote harm reduction strategies, disseminate evidence-based interventions and encourage adoption of best practices, including non-pharmacologic treatment for pain management (
      • National Center on Addictions and Substance Abuse at Columbia
      Addiction medicine: Closing the gap between science and practice.
      ,
      • Centers for Disease Prevention and Control
      Deaths from prescription opioid overdose.
      ). Federal and state responses to the epidemic have recently accelerated with federal agency guidelines (e.g.,
      • Centers for Disease Prevention and Control
      CDC Guideline for prescribing opioids for chronic pain.
      ), state monitoring of controlled substance prescribing, and mobilization of communities for quick response to opioid overdose, including heroin and prescription opiates (
      • Laderman M.
      • Martin L.
      Health care providers must act now to address the prescription opioid crisis.
      ). Professional organization guidelines which direct the membership to discipline-specific practices and public health interventions are strengthened by inter-professional collaboration and partnering across disciplines and organizations (
      • Ault A.
      Opioid Crisis in America: Experts Call for Action.
      ). Collaboration is urgently needed and supported by recent legislation such as the 21st Century Cures Act (2016) and the Comprehensive Addiction and Recovery Act (CARA) (2016). CARA designates $1 billion for prevention, treatment, recovery, law enforcement, criminal justice reform, and overdose reversal, supports prescription drug monitoring, treatment accessibility and the education of health care professionals in best practices.
      Policy must consider several issues which impede progress. The translation of research to practice has been slow to reach nurses and other care providers of persons with chronic pain and those with opioid use disorders (
      • Wood E.
      • Samet J.H.
      • Volkow N.D.
      Physician education in addiction medicine.
      ). In addition, public health campaigns and policy makers are poorly informed for action. Stigma around addiction is entrenched (
      • Parcesepe A.M.
      • Cabassa L.J.
      Public stigma of mental illness in the United States: A systematic literature review.
      ) and extends long standing beliefs that addiction is a matter of willpower and that evidence-based treatments cannot facilitate recovery (
      • Kendall-Taylor N.
      Rounding up the associations: How perceptions of addiction are recruited.
      ). Such beliefs pose obstacles to accepting innovative models like medication assisted treatments (MAT) which expand treatment access for persons with substance use disorders. Health professionals, as other members of society, hold preconceptions about substance use disorders and such beliefs can perpetuate stigma and impede appropriate care (
      • Van Boekel L.C.
      • Brouwers E.P.
      • Van Weeghel J.
      • Garretsen H.F.
      Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review.
      ). Recognition of opioid use disorders as medical conditions which can be researched by nurses, identified through screening and for which there are evidence-based treatments, including pharmacotherapies, is essential to decreasing stigma and human and economic costs.

      Response and Policy Options

      The response to the opioid epidemic is robust at the federal, state and service system levels. The former Surgeon General's call to all health practitioners to “turn the tide” on the opioid crisis requires that nurses, physicians and other direct care providers learn to treat pain safely and effectively. All health care professionals need to talk about and treat addiction as a chronic illness, and screen their patients for opioid use disorders as well as connect them with evidence-based treatment services. Legislators have responded with CARA to support national and state action to fight the opioid epidemic with harm reduction strategies, including increased access to medications to reverse opioid overdose and medication assisted treatment to begin recovery. The 21st Century Cures Act has now funded several of these initiatives. These strategies are also reflected in the National Governors' Association Compact, which brings treatment options, particularly greater access to pharmacotherapies at the state level by expanding the number of prescribers, including nurse practitioners (
      • National Governors' Association
      Governors' priorities for addressing national opioid crisis.
      ,
      • Centers for Disease Prevention and Control
      Prescription overdose data.
      ).

      The Academy's Position

      The American Academy of Nursing recognizes the public health risks of overreliance on opiates for pain management, their use when medically indicated, and their non-medical use by vulnerable populations. These risks elevate the importance of professional accountability in prescribing practices and monitoring narcotic analgesic use and educating the public about all drugs which place the user at risk for substance use disorders. The Academy seeks to inform its constituents, organizational partners and the public of nursing's commitment to comprehensive, evidence-based, best practices for substance use disorders prevention, treatment and recovery, pain management and opiate related harm reduction. We recommend the following actions to address the opioid epidemic by facilitating collaboration among health care providers and with consumers and patients, promoting roles of advanced practice nurses (APNs) in increasing access to treatment, and forging pathways essential to the dissemination of best practices. Leadership to promote coordinated responses from nurses at all levels will help mitigate the crisis and promote safe and effective care for persons affected by opioid use.

      Recommendations

      • a.
        Support state level implementation of CARA to increase prevention, harm reduction for at-risk populations and access to treatment of addicted individuals.
      • b.
        Collaborate with the Substance Abuse Services Administration (SAMHSA) to support nurse practitioners who obtain SAMSHA issued waivers to prescribe buprenorphine for opioid use disorders, and expand the advanced practice registered nursing workforce eligible for waivers, with the goal of increasing access to this evidence-based pharmacotherapy.
      • c.
        Support the “Compact to Fight Opioid Addiction” endorsed by 38 members of the Washington D.C. based National Governors' Association.
      • d.
        Support the dissemination of evidence-based information on substance use disorders/addiction to health professionals and the public to improve understanding, motivate behavior change and decrease stigma.
      • e.
        Explore alliances with professional organizations to identify similar policy statements and strengthen the potential for collective action.
      • f.
        Continue collaboration with CMS and DHHS to promote the integration of behavioral care/substance use interventions into primary care, across health care facilities.
      • g.
        Collaborate with the National Council of State Boards for Nursing and state boards of nursing to evaluate evidence of practice competency of generalist and advanced practice nurses regarding opioid use screening, treatment, prescribing of buprenorphine, and referral to specialty substance use treatment.
      • h.
        Collaborate with nursing organizations in support of action and a nursing quality agenda for the opioid epidemic (e.g., ANA, AANP, AACN, ACNA, and APNA).
      • i.
        Collaborate with offices of the federal government executive branch (i.e. Office of the Surgeon General, Office of National Drug Control Policy [ONDCP]) in the development and dissemination of policy statements on alcohol, drugs, tobacco and health.

      Acknowledgments

      The authors thank the members of the Primary Care and Psychiatric Mental Health expert panels for their review and thoughtful suggestions on this policy brief.

      References

        • Ault A.
        Opioid Crisis in America: Experts Call for Action.
        Medscape, LLC, New York, New York2017 (Retrieved from http://www.medscape.com/viewarticle/878336)
        • Centers for Disease Prevention and Control
        CDC Guideline for prescribing opioids for chronic pain.
        (Retrieved from)
        • Centers for Disease Prevention and Control
        Deaths from prescription opioid overdose.
        (Retrieved from)
        • Centers for Disease Prevention and Control
        Overview of the epidemic.
        (Retrieved from)
        • Centers for Disease Prevention and Control
        Prescription overdose data.
        (Retrieved from)
        • Kendall-Taylor N.
        Rounding up the associations: How perceptions of addiction are recruited.
        The Frameworks Institute, Washington, DC2010 (Retrieved from)
        • Laderman M.
        • Martin L.
        Health care providers must act now to address the prescription opioid crisis.
        New England Journal of Medicine. 2017; (Catalyst. Retrieved from)
        • National Center on Addictions and Substance Abuse at Columbia
        Addiction medicine: Closing the gap between science and practice.
        Columbia University Center for Addiction and Substance Abuse, New York, NY2015
        • National Governors' Association
        A compact to fight opioid addiction.
        (Retrieved from)
        • National Governors' Association
        Governors' priorities for addressing national opioid crisis.
        (Retrieved from)
        • Parcesepe A.M.
        • Cabassa L.J.
        Public stigma of mental illness in the United States: A systematic literature review.
        Administration and Policy in Mental Health and Mental Health Services Research. 2013; 40: 384-399
        • Rudd R.A.
        • Seth P.
        • David F.
        • Scholl L.
        Increases in drug and opioid-involved overdose deaths-United States, 2010-2015.
        MMWR Morbidity and Mortality Weekly Report. 2016; 65 (https://www.cdc.gov/mmwr/columes/65/wr/mm655051e1htm): 1445-1452
        • U.S. Department of Health and Human Services (HHS). Office of the Surgeon General
        Facing addiction in America: The Surgeon General's report on alcohol, drugs and health.
        HHS, Washington, D.C.2016 (Retrieved from)
        • Van Boekel L.C.
        • Brouwers E.P.
        • Van Weeghel J.
        • Garretsen H.F.
        Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review.
        Drug and Alcohol Dependence. 2013; 131: 23-35
        • Wood E.
        • Samet J.H.
        • Volkow N.D.
        Physician education in addiction medicine.
        Journal of the American Medical Association. 2013; 310: 1673-1674