Dealing with opioid addiction is one of the most significant issues the U.S. health system faces today, and nurses are playing a key role in our nation’s efforts to deal with the crisis.
For health care professionals, many aspects of opioid addiction present challenges – not least the danger that they themselves may have succumbed. To aid in managing and reducing the opioid epidemic, the American Nurses Association (ANA) has created a series of helpful resources outlining best practices, a more general overview of the role of ineffective pain management in fueling the opioid epidemic, and proposals for how the situation can be improved on a national level.
Stakeholders / Position Statement
One thing you can't hide—is when you're crippled inside.
A host of treatment/deterrence options are available to health care practitioners when dealing with patients suffering from an opioid addiction, from medication-assisted treatments to voluntary monitoring programs. An understanding of the methodologies, benefits, and drawbacks of each approach is of critical importance for nurses.
More About Treatment/Deterrence Options
Medication-Assisted Treatment (MAT) for Opioid Use Disorders:
- The most effective form of treatment for opioid use disorders
- Includes the use of medication (buprenorphine, and buprenorphine and naloxone combination [Subutex®, Suboxone®]) along with counseling and other support
- Combined with behavioral therapy, effective MAT programs for opioid addiction can decrease overdose deaths, be cost-effective, reduce transmissions of HIV and hepatitis C related to IV drug use, and reduce associated criminal activity
- Current limitations:
- The Drug Addiction Treatment Act of 2000 (DATA 2000) was intended to address that problem and improve access for patients with substance abuse disorder outside of the usual treatment facilities, like the traditional methadone clinic.
- When originally passed, DATA 2000 allowed qualified physicians to apply for a waiver to prescribe Schedule III, IV, and V narcotic drugs for maintenance treatment or detoxification treatment in the private-office setting.
- Unfortunately, primary care physicians have been slow to apply for the waiver and can only accept a limited number of patients.
- Reasons for not participating in MAT include:
- Inadequate reimbursement by insurance plans
- The service is beyond the scope of practice of office-based physicians
- Addicted patients are considered undesirable for their clinic settings
Prescription Drug Monitoring Programs (PDMPs)
- State-run electronic databases that can provide a prescriber or pharmacist information regarding a patient’s prescription history.
- Identifies patients who are potentially knowingly or unknowingly misusing medications.
- Forty-six states and Washington, D.C. can legally share PDMP data across state borders. Many states allow out-of-state health care professionals to query their databases directly.
- Inability to distinguish whether providers are working together in the same practice, thereby creating false image of drug seeking behavior
- Incompatible database systems
- Prescription Drug Take-Back Programs: combine media and other educational efforts to promote safe use, storage, and disposal of potentially dangerous drugs, and include opportunities for the public to return “expired, unused, and unwanted prescription drugs” to collection centers.
- Suicide Prevention: chronic pain and depression, as well as other emotional disorders, often go hand in hand, and all of these conditions may increase the likelihood that a person has available prescription drugs that could be used for suicide.
- Voluntary strategies:
- Clinician’s assessment in a history and physical exam that includes psychosocial factors, family history, and risk of abuse
- Clinician’s regular monitoring of the progress of patients on opioids and assessment for aberrant behavior that may indicate abuse
- Random urine drug screening and pill counts for patients at risk
- Opioid “contracts” or “treatment agreements” between health care providers and patients, under which medication use by high-risk patients is closely monitored
- Netherland, J., Botsko, M., Egan, J. E., Saxon, A. J., Cunningham, C. O., Finkelstein, R., Fiellin, D. A. (2009). Factors affecting willingness to provide buprenorphine treatment.
Journal of Substance Abuse Treatment, 36(3), 244-251. doi:10.1016/j.jsat.2008.06.006
- Office of National Drug Control Policy. (2011). Fact Sheet: Prescription drug monitoring programs.
- Substance Abuse and Mental Health Services Administration. (2000). Drug Addiction Treatment Act of 2000.
- Substance Abuse and Mental Health Services Administration. (2016). Opioid overdose prevention toolkit.
The greatest evil is physical pain.
Ongoing chronic pain lasting more than three months is reported annually by between 11% - 40% of the U.S. population. While prescribed opioid use can be a very effective treatment to deal with acute pain, few studies have assessed the long-term benefits of opioids in reducing pain.
More About Alternatives to Opoid Prescribing for Pain Management
- Between 11% and 40% of the U.S. population report some level of chronic pain, pain lasting > 3 months.
- Evidence supports short-term efficacy of opioids for reducing pain and improving function in noncancer nociceptive and neuropathic pain.
- Few studies have assessed the long-term benefits of opioids for chronic pain.
- Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.
- Complementary and Alternative Medicine (CAM)
- Chiropractic manipulation
- Guided imagery
- Herbs and dietary supplements; nutritional support
- Massage therapy and muscle manipulation
- Yoga, Tai chi, movement therapies
- Adjuvant analgesic medications: anticonvulsants, muscle relaxants, serotonin and norepinephrine reuptake inhibitors
- Non-opioid analgesic medications: acetaminophen, NSAIDs
- Psychological therapies
- Cognitive-behavioral treatment and behavioral treatment alone
- Meditation and relaxation techniques
- Regional anesthetic interventions
- Sacroiliac joint injections; epidural steroid injections; facet joint nerve blocks; implantable devices
- Rehabilitative/physical therapy
- Physical and functional restoration techniques
- Massage ultrasound
- Neurostimulators and TENs
- Joint replacement
- Nerve decompression (e.g., for carpal tunnel syndrome or trigeminal neuralgia)
- Spinal decompression procedures (e.g., laminectomies, discectomy), disc replacement, and spinal fusion
- System-Level Barriers:
- Clinical services (and research endeavors) generally are organized along disease-specific lines. Acute and chronic pain are features of each of these specialties; in a sense, however, because pain belongs to everyone, it belongs to no one.
- The existing clinical (and research) silos prevent cross-fertilization of ideas and best practices.
- Pain clinics that implement comprehensive, interdisciplinary approaches to pain assessment and treatment that appear to work best in managing chronic pain are few in number and increasingly constrained by a reimbursement system that discourages interdisciplinary practice.
- Clinician-Level Barriers:
- Well-validated evidence-based guidelines on assessment and treatment have yet to be developed for some pain conditions, or existing guidelines are not followed.
- Health care professionals are not well educated in emerging clinical understanding and best practices in pain prevention and treatment.
- Should primary care practitioners want to engage other types of clinicians, including physical therapists, psychologists, or complementary and alternative medicine practitioners, it may not be easy for them to identify which specific practitioners are skilled at treating chronic pain or how they will do so.
- A lack of understanding of the importance of pain management exists throughout the system, starting with patients themselves and extending to health care providers, employers, regulators, and third-party payers.
- Regulatory and law enforcement policies constrain the appropriate use of opioid drugs.
- Restrictions of insurance coverage and payment policies, including those of workers’ compensation plans, constrain the ability to offer potentially effective treatment.
- Patient-Level Barriers:
- Adequate pain treatment and follow-up may be thwarted by a mix of uncertain diagnosis and the societal stigma that is applied, consciously or unconsciously, to people reporting pain, particularly if they do not respond readily to treatment. Is he really in pain? Is she drug seeking? Is he just malingering? Is she just trying to get disability payments?
- Religious or moral judgments may come into play: Mankind is destined to suffer…
- Popular culture: Suck it up; No pain, no gain.
- CDC Guideline for Prescribing Opioids for Chronic Pain
- Complementary and Alternative Medicine (CAM)
- IOM, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research
- National Pain Strategy
- Pain Links
- American Association of Nurse Anesthetists (AANA) — Pain Management Resources
- PainEDU — PainEDU is an educational website for clinicians, to enhance understanding of pain management through interviews, articles, educational courses, and case studies.
- Providers' Clinical Support System for Opioid Therapies (PCSS-O) — PCSS-O is a national training and mentoring project developed in response to the prescription opioid overdose epidemic.
The law is the public conscience.
While clearly a society-wide issue, the effect of the opioid epidemic on the nursing profession has been profound, and ANA has made advocating top-level solutions to alleviate the situation a high priority. Law-makers are actively engaged in introducing legislation related to opioid dependence, and ANA is fully focused on ensuring that the interests of nurses are taken into account when deliberating new legislation.
Read More About the ANA’s Action on Opioid Dependence Legislation
Opioid dependence, associated drug-related overdose and deaths is a serious public health problem in the U.S. With the intention of creating uniformity and accountability, legislative/regulatory solutions are being applied at both the state and federal levels in addressing this epidemic. Recognizing it is a multifaceted problem has resulted in a variety of approaches, including but not limited to:
- Require prescriber education both in treating of opioid overdose as well as alternatives to opioids for pain management.
- Increase effective provider use of prescription drug monitoring programs (PDMPs) and across state border collaboration.
- Regulate pain management clinics.
- Expand access to naloxone, a drug used to reverse overdose (ie, first responders, family, schools etc) with Good Samaritan protections.
- Remove barriers that limit non physician providers from providing medication assisted treatment – MAT(ability to prescribe buprenorphine).
- Expand drug take back programs.
- Fund support treatment and education/prevention measures.
- Create pretrial diversion options, including drug courts that help those with substance abuse issues get treatment in lieu of incarceration, along with lower penalties.
Over the past year, lawmakers have sought to address the crisis comprehensively by advancing bills that would expand access to the overdose antidote naloxone, reduce the prevalence of unused pain pills, expand prevention education, and increase collaboration with law enforcement and local criminal justice systems:
- Expanding access to medication-assisted treatments (MATs) has also been a central component of the reform effort.
- ANA has successfully made the case for a much needed expansion of medication-assisted treatment services. In both the House and Senate legislation is poised to expand access treatment by allowing Nurse Practitioners to prescribe buprenorphine in accordance with state law.
- Key bills in the House and Senate, the Opioid Use Disorder Treatment Expansion and Modernization Act (H.R.4981) and the Recovery Enhancement for Addiction Treatment Act (TREAT Act, S.1455), would improve treatment options by harnessing the benefits of buprenorphine, and expanding prescribing authority to Nurse Practitioners, in accordance with state law.
- Both bills will be included in negotiations between the House and Senate alongside a package of additional bipartisan bills.
To learn more about state actions or plans, go to: www.ncsl.org.
Substance use disorder in nursing
Ours can be a challenging profession, and as nurses, we are in no less danger of being personally affected by opioid dependence than the patients we treat. We want to help our colleagues who face such challenges. To that end, ANA has made dealing with Substance Use Disorder (SUD) a central aspect of our Health Nurse, Healthy NationTM campaign.
Read more about substance use disorder among nurses, and strategies to identify and assist in care
Help for Nurses and Nursing Students with Substance Use Disorder
ANA recognizes that a nurse’s duty of compassion and caring extends to themselves and their colleagues as well as to their patients. Nurses who are challenged with substance use disorder (SUD) not only pose a potential threat to those for whom they care; they are not caring for themselves.
According to the HHS, SUD refers to substance use and/or substance dependence. It is the damaging use of harmful substances, including alcohol, marijuana, opioids, and other drugs.
ANA and many of our organizational affiliates, including the International Nurses Society on Addictions, the Emergency Nurses Association, and the American Association of Nurse Anesthetists, strongly support alternative to discipline programs offered by nurses associations, state boards of nursing, and others. These programs offer comprehensive monitoring and support services to reasonably assure the safe rehabilitation and return of the nurse to her or his professional community. In 2017, ANA and AANA endorsed IntNSA and ENA’s position statement, "Substance Use Among Nurses and Nursing Students." Please view this statement in its entirety to gain valuable insight on the description and background on this issue. ANA thanks the members of ANA’s Substance Use Disorder Workgroup; which was a collaboration of subject matter experts, constituent/state nurses associations, organizational affiliates, and other interested parties engaged to assist with updating ANA SUD policy and resources. Additionally, the following three national nursing organizations contributed to these webpages with their policy and leadership.
RESOURCES FOR ALL
Substance Use Disorder Resources - In 2017, ANA’s Substance Use Disorder Workgroup collected the following table of resources across a variety of media types. A brief description of each resource as well as authors and web addresses are provided. Resources include reference articles, pertinent directories, useful websites, and more to allow for an extensive exploration on substance use disorder in nursing and nursing students.
For Nurses with SUD
The National Council of State Boards of Nursing (NCSBN) offers an Alternative to Discipline Programs for Substance Use Disorder directory here for nurses to locate alternative to discipline programs for SUD in their state if available.
For Nurses Concerned for a Colleague
This NCSBN online brochure, What You Need to Know About Substance Use Disorder in Nursing, informs nurses of their ethical and professional responsibilities about reporting suspected or know SUD in colleagues.
See Chapter 6 of NCSBN’s SUBSTANCE USE DISORDER IN NURSING: A Resource Manual and Guidelines for Alternative and Disciplinary Monitoring Programs offers a comprehensive examination of SUD in the healthcare workplace, particularly for nurse managers.
For Nursing Students
Although not specifically for nursing students, the NIH’s National Institute of Drug Abuse College-Age & Young Adults’ webpages, contain resources for how and where to get assistance for substance abuse, as well as drug facts, infographics, and more. Currently, there is very little updated guidance for nursing students with substance use disorder. Nursing students may want to consult their health care provider, college health center, or employee assistance program.
Continue Your Education
Resources are available to nurses who want to learn more about the dangers of the opioid crisis, both in terms of prevention and treatment:
- Effective Treatments For Opioid Use Disorders. A series of webinars created by the American Psychiatric Nurses Association (APNA) created for specific nurse roles.
- ANA/PAW Informational Fact Sheets
Created by SAMHSA’s Preventing Prescription Abuse in the Workplace (PAW), these in-depth fact sheets deal with effective pain management and opioid prescribing strategies.
ANA/PAW: Chronic Lower Back Pain Series - 1
ANA/PAW: Chronic Lower Back Pain Series - 2
ANA/PAW: Chronic Lower Back Pain Series - 3
ANA/PAW: Chronic Lower Back Pain Series - 4
ANA/PAW: Keeping Prescription Pads Secure
ANA/PAW: Medication Assisted Therapy
ANA/PAW: Opioid and Narcotic Painkillers
ANA/PAW: Pregnancy and Prescription Drug Abuse
ANA/PAW: Prescription Drug Monitoring Programs
ANA/PAW: Sharing Prescription Drugs
ANA/PAW: Slippery Slope
- NCSBN SUD Toolkit. A free toolkit created by the National Council of State Boards of Nursing dealing with substance abuse disorder in the nursing profession.
- WIHI: The Opioid Crisis: How Health Care and the Community Can Act. A one-hour audio discussion around the issue of opioid abuse and solutions to the crisis.
- Medication Assisted Treatment Waiver Training For APRNs. A continuing education course from the APNA directed towards APRNs.
- Substance Use Disorders in Pregnancy. Created by the Association of Women's Health, Obstetric and Neonatal Nurses, this online resource hub focuses on the dangers of opioid use during pregnancy.
- Naloxone in Schools Toolkit
- AACN, Opioid webinar series
- NCSBN learning extension, Free CE offerings on Substance Use Disorder
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