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The crucial role of all current and future nurses in addressing the continuum of substance use

      Executive Summary

      The American Academy of Nursing believes necessary measures must be taken to address the negative consequences of substance use on the health, economy, productivity, and social aspects of individuals and communities. The burden of disease attributable to alcohol and drug use varies substantially across geographic locations, yet much of the burden is due to the effects of substance use on other health outcomes. Despite the existence of evidence-based strategies, including screening, brief intervention, and referral to treatment (SBIRT), and knowledge of the impact of substances on the brain and body systems, further education is needed to identify persons who are at risk because of substance use and provide interventions to prevent and reduce substance use disease burden. To ensure the health of the public given the prevalence of substance use, the nursing profession is primed to help drive positive outcomes. Model nursing curricula exist in which substance use-related content is infused. Online programs have been deployed to provide continuing education for current nurses. These initiatives along with greater endeavors to disseminate evidence-based prevention and intervention strategies into settings in which care is provided are priorities.

      Background

      Alcohol and other drugs contribute to the morbidity and mortality of persons around the world. Globally, digestive diseases, unintentional injuries, cardiovascular diseases, and diabetes were the leading contributors to the estimated 3 million alcohol-attributable deaths in 2016 (
      World Health Organization
      Global status report on alcohol and health.
      ). In 2018, an estimated 139.8 million Americans aged 12 or older reported current alcohol use with nearly half consuming more than daily or weekly guidelines (
      Substance Abuse and Mental Health Services Administration
      Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53).
      ). Data from that 2018 National Survey on Drug Use and Health revealed that nearly 1 in 5 people surveyed used an illicit drug in the past year with non-prescribed pain relievers as the second most common form of illicit drug use in the US; marijuana use was the most common (
      Substance Abuse and Mental Health Services Administration
      Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53).
      ). Opioids were involved in more than 46,000 of the 67,367 drug overdose deaths in 2018 with synthetic opioids involved in nearly half of all drug deaths (
      Centers for Disease Control and Prevention (CDC
      New data show significant changes in drug overdose deaths.
      ).
      Substance use occurs along a continuum - from use that increases the risk of harm to the person or others (
      • Mahmoud K.F.
      • Finnell D.S.
      • Savage C.L.
      • Puskar K.R.
      • Mitchell A.M.
      A concept analysis of Substance Misuse to inform contemporary terminology.
      ) to a diagnosable disorder. While nurses are in key positions to address these risks (
      • Finnell D.S.
      A clarion call for nurse-led SBIRT across the continuum of care.
      ;
      • Mitchell A.M.
      • Fioravanti M.
      • Kane I.
      • Puskar K.
      • Hagle H.
      • Boucek L.
      A call for universal alcohol, drug screening.
      ) they may not be adequately prepared to do so. A 2014 survey of U.S. baccalaureate nursing programs identified that the mean number of contact hours related to alcohol and health was 11.3 hours, with a range of 3 to 38 hours (
      • Savage C.
      • Dyehouse J.
      • Marcus M.
      Alcohol and health content in nursing baccalaureate degree curricula.
      ). Only 10% of those schools responding reported that students were evaluated on their competence to deliver SBIRT. Federal funding (

      Substance Abuse and Mental Health Services Administration. (2020). Screening, Brief Intervention, and Referral to Treatment (SBIRT) grantees. Retrieved from https://www.samhsa.gov/sbirt/grantees

      ) and national campaigns (

      American Association of Colleges of Nursing. (2016). At White House event, AACN announces commitments by nursing schools to combat opioid use disorder. Retrieved from http://www.midwife.org/acnm/files/ccLibraryFiles/Filename/000000006014/AACN_Press_Release.pdf

      ) have helped to increase content in nursing curricula, yet this is not widespread or standard among US schools of nursing. To address this gap, nurse educators have developed model curricula in which substance use-related content is integrated into the curriculum (
      • Finnell D.S.
      • Savage C.L.
      • Hansen B.R.
      • Sanchez M.
      • White K.
      • Johnson A.J.
      • Seale J.P.
      Integrating substance use content in an “overcrowded” nursing curriculum.
      ;
      • Kane I.
      • Mitchell A.M.
      • Puskar K.R.
      • Hagle H.
      • Talcott K.
      • Fioravanti M.
      • Droppa M.
      • Luongo P.F.
      • Lindsay D.
      Identifying at risk individuals for drug and alcohol dependence: Teaching the competency to students in classroom and clinical settings.
      ;
      • Mitchell A.M.
      • Puskar K.
      • Hagle H.
      • Gotham H.J.
      • Talcott K.S.
      • Terhorst L.
      • Fioravanti M.
      • Kane I.
      • Hulsey E.
      • Luongo P.
      • Burns H.K.
      Screening, brief intervention, and referral to treatment: Overview of and student satisfaction with an undergraduate addiction training program for nurses.
      ) and provided recommendations for developing such curricula guided by the American Association of Colleges of Nursing Essentials for Baccalaureate, Master's, and Doctor of Nursing Practice programs (
      • Mitchell A.M.
      • Mahmoud K.
      • Finnell D.S.
      • Savage C.L.
      • Weber M.
      The Essentials competencies: A framework for substance use-related curricula.
      ). Recognizing the substance use-related knowledge and competence gap among nurses currently in practice, an interim measure has been the development of on-line continuing educational modules, 20 minutes to 2 hours in length, to promote the evidence base related to the substance use continuum (
      • Gonzalez Y.
      • Finnell D.S.
      • Seale J.P.
      Substance Use Screening, Brief Intervention and Referral to Treatment (SBIRT): A Self-Paced Online Program.
      ;
      • Gonzalez Y.
      • Seale J.P.
      • Hansen B.R.
      • Finnell D.S.
      Evaluation of the online self-paced program, Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Healthcare Providers.
      ;
      • Mitchell A.M.
      • Finnell D.S.
      • Kane I.
      • Haegle H.
      • Puskar K.
      • Savage C.L.
      Time conscious alcohol screening and brief intervention (alcohol SBI) for students, nurses, and nurse leaders.
      ).
      The U.S. Preventive Services Task Force (USPSTF) recommends that healthcare providers screen adults 18 years or older, including pregnant women, for alcohol use and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use (
      • Curry S.J.
      • Krist A.H.
      • Owens D.K.
      • Barry M.J.
      • Caughey A.B.
      • Davidson K.W.
      • Landefeld C.S.
      Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: US Preventive Services Task Force recommendation statement.
      ). The Substance Abuse and Mental Health Services Administration (SAMHSA) promotes substance use SBIRT as a comprehensive, integrated public health approach to the delivery of early intervention for individuals whose substance use puts them at risk. Yet, these strategies have not been widely adopted (

      Goplerud, E., & McPherson, T. L. (2015). Implementation barriers to and facilitators of screening, brief intervention, referral, and treatment (SBIRT) in Federally Qualified Health Centers (FQHCs). Report Prepared for the Office of Disability, Aging and Long Term Care Policy Office of the Assistant Secretary for Planning and Evaluation US Department of Health and Human Services, Washington, DC. Retrieved from https://aspe.hhs.gov/report/implementation-barriers-and-facilitators-screening-brief-intervention-referral-and-treatment-sbirt-federally-qualified-health-centers-fqhcs

      ). This lack of widespread dissemination means that there is a gap in practice, meaning that newly licensed registered nurses lack role models for these best practices related to substance use.
      Every few years, the National Council Licensure Examination or NCLEX is updated to align with activities that newly registered nurses encounter in their practice. Subject matter experts, who include newly licensed registered nurses, identify activities they frequently encounter in practice. In 2017, a survey constructed of these activities was sent to newly registered nurses, with 2,275 responses (
      National Council of State Boards of Nursing
      2017 RN Practice Analysis: Linking the NCLEX-RN ® Examination to Practice U.S. and Canada.
      ). In that survey, two of the 142 activities related to substance use were:
      • (1)
        Report unsafe practice of health care personnel and intervene as appropriate with substance abuse was provided as one example; and
      • (2)
        Assess clients for substance abuse, dependency, withdrawal, or toxicities and intervene as appropriate.
      The words “abuse” and “dependency” are not currently accepted diagnostic terminology (
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders.
      ). More concerning is that the NCLEX lags in evaluating knowledge about activities that address the needs of both persons who are at risk for substance use and those with a diagnosable disorder. Until substance use is universally and routinely addressed in healthcare, it is likely that it will not be addressed on the NCLEX.

      Responses and Policy Options

      The Association for Multidisciplinary Education and Research in Substance Use and Addiction (AMERSA) led the development of core competencies for specific disciplines addressing substance use in the 21st century. The competencies for the registered nurse and the advanced practice nurse were developed in accord with the American Nurses Association's (ANA) 17 standards of practice and performance for nursing (
      American Nurses Association
      Nursing: Scope and Standards of Practice.
      ). These standards are intended to inform and guide nursing practice with a focus on prevention, intervention, treatment, and recovery supports for persons who are affected by substance use (
      • Finnell D.S.
      • Tierney M.
      • Mitchell A.M.
      Nursing: Addressing substance use in the 21st century.
      ). Noteworthy for nurse educators and nurse administrators, the competencies apply to students who are entering the nursing profession, to students at every level of advanced practice, and to all nurses at every level in the current workforce.

      Academy's Position

      Because persons across the lifespan – from the fetus to older adult (irrespective of gender, culture, ethnicity, and race) can be negatively affected by substance use, the American Academy of Nursing endorses the position that all nurses, across specialties and settings in which care is provided, must be able to competently and confidently identify persons who may be at risk because of substance use, prevent the progression to a diagnosable disorder, and support those in recovery from substance use. In the face of a global opioid epidemic (
      • Porubcansky M.
      The opioid epidemic is a global problem. And it's getting worse.
      ) and with the harmful use of alcohol causing more than 5% of the global burden of disease (
      World Health Organization
      Global status report on alcohol and health.
      ), nurses can and should lead practice and licensure changes for this profession.

      Recommendations

      • Engage with the National Council of State Boards of Nursing to bring subject matter experts from the Academy to inform the next practice survey.
      • Launch a nationwide campaign to promote widespread uptake of screening and intervention strategies recommended by the USPSTF, CDC, SAMSHA and as endorsed by multiple professional organizations.
      • Disseminate evidence-based screening and intervention into practice by removing barriers to implementation and enhancing incentives to provide such care.
      • Join with SAMHSA in their work with the Centers for Medicare and Medicaid Services to educate nurses and other practitioners about the importance of SBIRT implementation, billing rules, and for increased reimbursement.

      References

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