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The opioid crisis

      Opioids shortening Americans’ lifespans

      The Academy Board of Directors identified five areas of priority including violence prevention, reproductive rights, opioid addiction, environmental health, toxic stress in children, and violence prevention. This month's message focuses on the Opioid crisis. I am pleased to co-author it with Madeline A. Naegle, PhD, CNS-PMH, BC, FAAN.
      America's opioid crisis— which according to reports from the Centers for Disease Control and Prevention (CDC), claimed 70,000 lives in 2017 (

      Centers for Disease Control and Prevention (CDC). (2018). Vital Statistics for Rapid Release: Provisional Drug Overdose Death Counts. Retrieved from https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm#.

      )— is the major reason why the national life expectancy has declined for the second year in a row.
      Consider these staggering statistics from a single year (2016):
      • 1
        Opioid use killed 42,249 Americans – that number is equal to seven Parkland shootings per day, a September 11th attack every three days (Forbes, 2018) or more than all those lost in the recent wars combined (Time, 2018).
      • 2
        Opioid deaths exceeded those from breast cancer (41,070), auto accidents (37,461) and guns (38,000) (Forbes, 2018).

      Opioids: A single prescription can trigger danger

      The broad sweep of opioid misuse affects all socioeconomic groups, genders, races and ethnic groups across the U.S. In addition, pregnant women make up a significant portion of the opioid-consuming community (they are still fewer than several other groups). Every 25 minutes, an infant experiencing neonatal abstinence syndrome is born ().
      Rates of overdose from opioid pain relievers were the highest in 45-to-54-year olds and the elderly in more recent years (Chen, Heddegaard & Warner, 2014). Shockingly, for vulnerable populations (this mostly affects people who are predisposed, although many people can become addicted after using the drug a week or two) a single prescription of an opioid analgesic can lead to addiction for some (Barnett, Olenski & Jena, 2017).

      Non-medical use continues to rise

      While the overprescribing of opioids peaked in 2010 (
      Centers for Disease Control and Prevention (CDC)
      CDC Guideline for Prescribing Opioids for Chronic Pain.
      ) the non-medical use of opioid analogues has continued to rise. Non-medical use (medication use without prescription, in ways other than prescribed, or for the experience or feeling produced) peaked in 2002 (
      • Kolodny A.
      • Courtwright D.T.
      • Hwang C.S.
      • Kreiner P.
      • Eadie J.L.
      • Clark T.W.
      • Alexander G.C.
      The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction.
      ) but use of fentanyl and fentanyl analogues is now widespread with associated deaths and injury (
      • Kolodny A.
      • Courtwright D.T.
      • Hwang C.S.
      • Kreiner P.
      • Eadie J.L.
      • Clark T.W.
      • Alexander G.C.
      The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction.
      ). Nearly 14% of persons reporting past-year nonmedical use of a prescription drug met the criteria for prescription drug use disorder ().

      Limited treatment access

      Despite the prevalence of opioid addiction, fewer than 0.9% of all people aged 12 or older and only 10.8% of the 21.7 million people who need substance use treatment receive it (
      Substance Abuse and Mental Health Services Administration (SAMHSA), center for behavioral health statistics and quality
      ). When opioid users do seek treatment, they often find that the health professional workforce, including nursing, lacks sufficient skill, education and certification to implement the most effective, evidence-based treatment for opioid use disorders: medication assisted treatment (MAT) ().
      In many regions, substance abuse treatment need exceeds both residential- and community-based treatment capacity. Support for long-term recovery is lacking. The uninsured, the elderly, pregnant women, persons of color and prison populations face the greatest disparities in access to evidence-based treatment including MAT, medical detox and nursing care. In 2016, the Comprehensive Addiction and Recovery Act became law [P.L. 114-198]. Advocates in the addiction and provider community applauded the bipartisan effort. At the same time, they cautioned legislators on the need to still address funding, particularly for prevention, as well as early intervention and the treatment necessary to combat this deadly and pervasive public health crisis.
      Major health care professions as well as leading nursing organizations, joined forces to advocate for policy development to address:
      • 1
        Expanded educational content on substance use disorders (addiction is severe substance use disorder).
      • 2
        Evidence-based pain assessment and management, and inclusion of pain management in formal education programs and experiential training.
      • 3
        Removing barriers to providers being able to prescribe MAT.
      Important work has been achieved at the federal level and states have taken up policy to reverse the alarming trend. For example, states around the nation have passed legislation to support the CDC's 2016 recommendations, which include limiting prescribing practices which impact vulnerable populations using opioid analgesics. In Washington, legislation has limited Medicaid recipients’ access to this class of drugs, and last year a new Health Care Authority clinical policy pertaining to opioid prescriptions took effect for Apple Health (Medicaid). This applies to fee-for-service and managed care. Additionally, a similar policy for the Uniform Medical Plan for public employees and retirees in Washington state became effective January 2, 2018.
      In the fall of 2018, Congress passed another bipartisan bill, Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, which was signed into law (PL 115-271) on October 24, 2018. This new law supports improved interdiction of synthetic and other drugs; greater use of naloxone by first responders; permanently authorizes nurse practitioners and physician assistants to prescribe MATs and a five-year authorization to certified nurse-midwives, certified registered nurse anesthetists, and clinical nurse specialists to prescribe MATs; and expanded treatment access and community awareness. Again, while Congress and the Administration have worked to make funding a priority for the opioid epidemic during this critical time, more resources will be necessary to see sustained improvements.
      A Policy Dialogue, “The Opioid Crisis through the Lens of Social Justice,” took place at our recent Annual Meeting November 2, 2018. During that session, AAN leveraged its influence and collaborated with other nursing organizations to: 1) raise public awareness of the opioid epidemic; 2) emphasize nursing's responsibility for safe and effective pain management; 3) educate nurses about the crisis; 4) protect the public; and 5) promote public health and safety; 6) advocate for just access to opioid analgesics for individuals in need; and 7) champion opioid use treatment for vulnerable populations such as pregnant women, older adults, persons of color, sexual minorities and the seriously mentally ill.
      AAN's collaboration with other professional organizations, federal agencies, and policy representatives can help balance constraints on opioid prescribing, just dispensation of opioid analgesics, and equitable access to treatment for persons in need of treatment for opioid use disorders. This cooperation is a critical focus for populations experiencing disparate prevalence of these disorders and disparities in health care in general. AAN policy reflects the need for health systems reform to include integrated care models, which will advance the treatment of all mental health disorders, including substance use disorders. A number of leading health care organizations are implementing a wide range of initiatives designed to better manage the opioid crisis including:
      • “Facing Addiction in America: The Surgeon General's Report, Alcohol Drugs and Health” noted the shortage of a health professional workforce prepared to deliver evidence-based treatment for addiction and the failure of health professional schools to integrate adequate curricular content on the topic ().
      • USDHHS and SAMSHA promoted models of behavioral care for addiction and other mental health disorders, as well as the integration of these models into health systems.
      • State policies initiated by the National Governors Association, state legislatures, single state agencies and regulatory agencies, particularly those with Prescription Monitoring Drug Programs, have constrained prescribing practices.
      • In 2017, The National Academies of Science, Engineering, and Medicine published Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use and has partnered with a coalition of more than 35 organizations, including the Aspen Institute, to form an Action Collaborative on Countering the U.S. Opioid Epidemic.
      Nursing leaders have a responsibility to weigh in on significant health issues of our time. The abuse and misuse of opioids is a public health crisis of epidemic proportions. A balanced goal is to address the impact of this crisis while also ensuring that those with acute and chronic pain have access to needed medications. The profession must to continue generate and use scientific evidence in this space to inform policy and practice so that we truly promote health and wellness and reverse this devastating trend.

      References

      1. Centers for Disease Control and Prevention (CDC). (2018). Vital Statistics for Rapid Release: Provisional Drug Overdose Death Counts. Retrieved from https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm#.

        • Centers for Disease Control and Prevention (CDC)
        CDC Guideline for Prescribing Opioids for Chronic Pain.
        (Retrieved from)
        • Kolodny A.
        • Courtwright D.T.
        • Hwang C.S.
        • Kreiner P.
        • Eadie J.L.
        • Clark T.W.
        • Alexander G.C.
        The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction.
        Annual Review of Public Health. 2015; 36 (Retrieved from): 559-574
        • National Institute on Drug Abuse (NIDA)
        Prescription Drug Abuse.
        (Retrieved from)
        • Substance Abuse and Mental Health Services Administration (SAMHSA), center for behavioral health statistics and quality
        Dramatic Increases in Maternal Opioid Use and Neonatal Abstinence. 2017; (Retrieved from)
        • U.S. Department of Health and Human Services (USDHHS)
        (Retrieved from)