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Opioid Epidemic

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 and other Substance Use Disorders (SUD) 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.

ANA Issue Brief: The Opioid Epidemic 2018 [pdf]

One thing you can't hide—is when you're crippled inside.

John Lennon

Treatment/Deterrence

A host of treatment/deterrence options are available to health care practitioners when working with patients suffering from a Substance Use Disorder (SUD) including medication-assisted treatments, prescription drug monitoring programs, and 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 Subutex® (buprenorphine) and Suboxone® (buprenorphine and naloxone combination) along with counseling and other support
  • Effective MAT programs for opioid addiction can decrease overdose deaths and reduce costs, transmissions of HIV and hepatitis C related to IV drug use, and associated criminal activity when combined with behavioral therapy
  • Prescribing MAT: The Drug Addiction Treatment Act of 2000 (DATA 2000) and subsequent FDA approvals allow qualified providers in private office settings to apply for a waiver to prescribe Schedule III, IV, and V narcotic drugs and the combination of bunprenorphine and naloxone (Suboxone) for maintenance or detoxification treatment
  • CARA expands prescribing privileges of nurse practitioners (NPs) and PAs to include office-based opioid addiction treatment with buprenorphine.
    • Until October 1, 2021, NPs and PAs may obtain a DATA 2000 waiver for up to 30 patients in states where they are authorized to prescribe Schedule III, IV, or V medications for pain after completing 24 hours of required training.
  • Providers have been slow to apply for the waiver and can only accept a limited number of patients. Barriers to participation in MAT include:
    • Inadequate insurance reimbursement
    • The need for detailed training and treatment protocols and access to referral agencies
    • The service is beyond the scope of practice of office-based physicians
    • Opioid-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.
  • Identify patients who are potentially knowingly or unknowingly misusing medications.
  • Fifty states, Washington, D.C., and Guam have a PDMP program. Limitations include:
    • No standard related to drugs monitored, data collected, or data shared
    • Provider use of the PDMPs varies according to state mandate and ease of system access

Treatment Resources

The greatest evil is physical pain.

Saint Augustine

Pain Management

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 Pain Management

Summary

  • 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.

Treatment Strategies

  • Complementary and Alternative Medicine (CAM)
    • Acupuncture
    • Aromatherapy
    • Chiropractic manipulation
    • Guided imagery
    • Herbs and dietary supplements; nutritional support
    • Magnets
    • Massage therapy and muscle manipulation
    • Yoga, Tai chi, movement therapies
  • Medications
    • 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
    • Biofeedback
    • Meditation and relaxation techniques
    • Hypnosis
  • Regional anesthetic interventions
    • Invasive
    • 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
    • Hydrotherapy
  • Surgery
    • 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

Treatment Barriers

  • 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.

Pain Management Resources

Legislation

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. For more information on legislative priorities of ANA, visit RN Action

To learn more about state actions or plans, see NCLS Deep Dive Opioid Addiction and Prescribing Policies.

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 SUD a central aspect of our Health Nurse, Healthy NationTM campaign.

More about SUD in Nursing

Help for Nurses and Nursing Students with Substance Use Disorder (SUD)

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 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 (IntNSA), the Emergency Nurses Association (ENA), and the American Association of Nurse Anesthetists (AANA), 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:

  1. International Nurses Society on Addictions
  2. Emergency Nurses Association
  3. American Association of Nurse Anesthetists

Resources

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 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 Nursinginforms nurses of their ethical and professional responsibilities about reporting suspected or know SUD in colleagues.

For Employers
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.

Education and Resources

Educational resources are available to nurses who want to teach or learn more about the dangers of the opioid crisis, as well as prevention and treatment strategies.

Advocates and Partners

Education Resources

References

References

Hostetter, M. and Klein, S. (2017). In Focus: Expanding Access to Addiction Treatment Through Primary Care, The Commonwealth Fund. Retrieved from: https://www.commonwealthfund.org/publications/newsletter/2017/sep/focus-expanding-access-addiction-treatment-through-primary-care

Prescription Drug Monitoring Program Training and Technical Assistance Center (PDMP TTAC). (2017) Status of prescription drug monitoring programs (PDMPs). Retrieved from: http://www.pdmpassist.org/pdf/PDMP_Program_Status_20170824.pdf

Substance Abuse and Mental Health Services Administration. (2000). Drug Addiction Treatment Act of 2000. https://www.samhsa.gov/programs-campaigns/medication-assisted-treatment/legislation-regulations-guidelines

Substance Abuse and Mental Health Services Administration. (2017). Qualify for Nurse Practitioners (NPs) and Physician Assistants (PAs) Waiver. Retrieved from: https://www.samhsa.gov/programs-campaigns/medication-assisted-treatment/training-materials-resources/qualify-np-pa-waivers

 

Pain Management References

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