On a daily basis in the United States, patients overdosing on opioids fill our emergency rooms, intensive care units, and, sadly, our cemeteries. Overdose and subsequent death from opioid addiction has reached astonishing numbers and death rates by opioid overdoses continue to rise annually. Nurses are in front line positions to provide assessment for patients with opioid use histories and subsequently connect them to resources that save lives. All nurses face the challenges of caring for patients with addiction issues and have the opportunity to change the stigma regarding addiction. Nurse engagement can influence positive outcomes when addicted individuals are reaching out for resources and treatment. This article reviews changes in opiate usage over time; related information in the Affordable Care Act; and other changes in federal, state and local policy that affect current opiate treatment. Also discussed are considerations for nurses to effect change and potential future policy. In conclusion, with the ever increasing numbers of individuals with opioid addiction, and insufficient availability of opiate treatment programs, our nation is in a race against time to positively impact and reverse this crisis.
Key Words: Opiate crisis, opioid, healthcare reform, nurse, opiate treatment program, policy, Affordable Care Act
Nurses are confronted daily with the current crisis of opioid use in this country. Nurses are confronted daily with the current crisis of opioid use in this country. The impact of this epidemic affects all individuals and families across the lifespan, whether due to direct drug use or the effects on the family unit (Copello, Templeton, & Powell, 2010; Pagliaro & Pagliaro, 2004). Patients with substance abuse issues are seen in every area of nursing practice (Bartlett, Brown, Shattell, Wright, & Lewallen, 2014), allowing nurses the opportunity to develop rapport through the nurse-patient relationship and provide a safe platform for patients to disclose drug use. Nurses can raise awareness in communities by sharing the realities of this epidemic, advocating for change, and working with families reeling from the negative impact.
...91 people in the United States die as a result of overdose on a daily basis. The effects of drug use include ever increasing costs to healthcare providers, public services, criminal justice systems, and impact on families and communities (Fox, Oliver, & Ellis, 2013). According to Frieden and Houry (2016), prescription overdose deaths in America have quadrupled over a 15 year period. The Centers for Disease Control and Prevention (CDC) confirm opiate related death is a public health crisis, stating 91 people in the United States die as a result of overdose on a daily basis (CDC, 2016b). Opiate use, whether prescribed or used illicitly, has the highest number of drug related deaths (CDC, 2016a). The emotional and financial impact of this epidemic reaches every level of society. Accordingly, federal, state, and local policies have been proposed and certain programs implemented with the hope of seeing these numbers begin to decline (Murthy, 2016).
Over the last 100 years, the United States has led the way to establish global drug policy. Societal perceptions about substance use issues have changed (American Society of Addiction Medicine, 2015). Replacing outdated models of care with evidence based practice models has occurred in some practices as a result of these recent insights (Murthy, 2016). Over the last 100 years, the United States has led the way to establish global drug policy. The focus has now transitioned toward current and future policy directed from a public health concern, rather than strictly criminalization (Drucker et al., 2016). Change, it appears, has evolved as a result of perceptions evolving over time. The decriminalization of addiction seems to have challenged outdated thinking, although the stigma remains (National Institute on Drug Abuse, n.d.).
According to Johannson and Wiklund-Gustin (2016), negative attitudes by nurses working with patients who have addiction may at times appear as judgmental and controlling behaviors. Chu and Galang noted, “A baseline understanding of nurses’ attitudes toward patients with illicit drug use may indicate both the quality of the nurse-patient relationship formed and the quality of care provided, as well as identifying aspects of the nursing role that could be enhanced” (2013, pg.1). Supporting utilization of evidence-based interventions by practitioners working with the addicted population assists patients to achieve better health (Bartlett et al., 2014).
Changes in Opiate Usage over Time
The largest numbers of heroin users are young adults (Cicero, Ellis, Surratt, & Kurtz, 2014). Currently, heroin use is equally prevalent among men and women, and reports indicate that 75% of users are in their early 20s and live in rural areas (Fogger & McGuiness, 2015). A study by Cicero et al. (2014) concluded that heroin is easier to obtain and less expensive than illicit use of opiates, which may explain the increase of its use. Users believe the high from heroin is more intense when compared to the high from opioid pills (Fogger & McGuiness, 2015; Kerr, Small, Hyshka, Maher, & Shannon, 2013).
The increase in lethality of certain illicit drugs appears to be a result of combining different concentrations of opiates. Drug overdose has surpassed death from motor vehicle accidents in the United States (Rudd, Aleshire, Zibbell, & Gladden, 2015). The increase in lethality of certain illicit drugs appears to be a result of combining different concentrations of opiates. According to Karensky and Walley (2017), the alarming increase in the number of opiate overdoses is due to the increase in use of heroin laced with fentanyl, or its derivatives.
In 2015, the state of Ohio was listed as one of the top five states experiencing a large percentage of deaths (29.9 per 100,000) from opiate overdose (CDC, 2016a). In Cleveland, CBS News (2017) recently reported an estimated 517 deaths from opiates in 2016 alone, and to a large extent, illicit fentanyl use was to blame. Community leaders, medical centers, and practitioners are collaborating and working fervently to develop naloxone programs throughout the state. Ohio nurses have sponsored one notable opioid-overdose-prevention program titled 'Prevention not Permission,' utilizing naloxone to prevent ever increasing fatalities (Clark, 2014).
The Affordable Care Act
The Substance Abuse Mental Health Service Administration (SAMHSA) noted that, “The Affordable Care Act in conjunction with the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 has already provided an opportunity for new or expanded behavioral health benefits to approximately 60 million Americans and has created programs designed to help states and communities prevent illness and promote health” (SAMHSA, 2014, pg. 3). The Patient Protection Affordable Care Act. ([ACA] Public Law 111-148, 2010) has included drug treatment as a health benefit and extended parity to healthcare plans (Knudsena, Lofwallb, Jennifer, Havensc, & Walshd, 2015). Although millions of Americans have coverage through the ACA, millions more remained uninsured, especially in states in which Medicaid has not been expanded (Murthy, 2016).
As a result of the escalation in opiate overdoses and subsequent deaths, there have been various changes in federal policy over recent years. As a result of the escalation in opiate overdoses and subsequent deaths, there have been various changes in federal policy over recent years. A part of President Obama’s Fiscal Year 2016 budget addressed the opiate epidemic with $133 million dollars, to include prevention and a type of opiate treatment program (OTP) called medication assisted treatment (MAT) and other issues related to the opiate crisis (Office of National Drug Control Policy, 2015). Policymakers are making efforts to ensure that OTPs are evidence based, with appropriated financial support by the federal government, to support individuals with addiction in this country (Murthy, 2016).
Other Changes in Federal, State and Local Policy
Federal Level Initiatives
In March 2015, the Department of Health and Human Services (DHHS) announced three priorities to assist in containing the opiate crisis. The subsequent initiatives addressed the need to radically change current treatment programs and increase resources for both practitioners and patients (DHHS, 2016).
Initiative 1: Safer Prescribing. The first initiative considered both patient care and safety and resulted in the CDC Guidelines for Prescribing Opioids for Chronic Pain, released in March 2016 (DHHS, 2016). The initiative supported enhancing education and training for safer prescribing practices for all prescribers (DHHS, 2016). The published guidelines were the result of collaboration by various federal agencies, peer reviewers, practitioners, and professional/advocacy groups; review of scientific literature; and patient and public support statements (Frieden & Houry, 2016).
To support safer practice, electronic databases have been created to track opiate prescriptions... To support safer practice, electronic databases have been created to track opiate prescriptions and allow practitioners and pharmacies to monitor history of patient use and identify potential abuse (National Institute on Drug Abuse, 2015). “Prescription drug monitoring programs (PDMPs) are state-run electronic databases of prescriptions for controlled substances and are among the most promising clinical tools to curb prescription opioid abuse” (Office of the Assistant Secretary, 2015, p.4). According to recent research, these databases assist practitioners to practice more safely; however, only 8% of practices are utilizing this system (Gawande, 2017).
Once patients invest in opiate treatment they can find success. Initiative 2: Naloxone. The second DHHS (2016) initiative supported the use of naloxone for opiate overdose emergencies. Once patients invest in opiate treatment they can find success. Naloxone allows the opportunity for patients to recover from overdose and hopefully, seek further treatment (Clark, 2014). Although the lifesaving principles of naloxone use are supported and documented in the literature, education of practitioners and lay people about administration of naloxone continues to be a challenge due to decreased standardization across training programs, as well as lack of trainers within communities (Kerensky & Walley, 2017).
...most states are not able to provide MAT programs for the number of opiate users. Initiative 3: Medication Assisted Treatment. The third DHHS initiative incorporated the expansion of medication assisted treatment (MAT), an all-encompassing approach to issues that addicts face, such as increased support in coping strategies, emotional rehabilitation along with medication to assist with cravings. This approach combines medication management with therapies to provide a foundation of support when individuals chose recovery (DHHS, 2016). According to National Institute on Drug Abuse, most states are not able to provide MAT programs for the number of opiate users (National Institute of Drug Abuse, 2016). With the epidemic numbers of individuals requiring treatment, it is not surprising the availability of resources continues to lag behind.
State Level Initiatives
On a state level, current initiatives are aimed to consistently align evidence based opiate treatment programming from state to state. SAMHSA released a list of components to assist with state uniformity in support of the MHPAEA, and noted, “States identified five primary components that they considered critical for the successful implementation and monitoring of parity: (1) open channels of communication, (2) standardization of materials, (3) creation of templates, workbooks and other tools, (4) implementation of market conduct exams and network adequacy assessments, and (5) collaboration with multiple agencies and stakeholder groups” (SAMHSA, 2016b, p.3).
Communities across the nation have been affected by the increasing numbers of opiate overdoses. There are various ways that communities can work together to bring about change. The CDC suggests continued training for administering naloxone; increasing preventive programs and access to sterile supplies for IV users; and targeting high risk areas to ensure resources are available (CDC, 2015). Nurses can assist communities to develop and implement these effective programs. Community-based and public health organizations have educated the public about overdose issues and naloxone distribution with the hope of preventing fatalities for prescribed and illicit use of opiates (Mueller, Walley, Calcaterra, Glanz, Binswanger, 2015). SAMSHA has developed a toolkit for communities to understand opioid use, offering essential tools to utilize within a given community (SAMHSA, 2013)
Medications to Treat Opiate Addiction
Naloxone has shown its potential to reverse effects of opioid overdose and has saved many lives (SAMHSA, 2013). In addition, there are other medications available that are changing the course of opiate treatment. Buprenorphine has received much attention because it can be dispensed on an outpatient basis, thus increasing treatment access (SAMHSA, 2016a). Research has supported the safety and effectiveness of Buprenorphine, allowing the extension of treatment on an outpatient basis and expanding options for patients everywhere (Kelly et al., 2012).
...medication combined with therapy improves effective outcomes and reduces risk for patients dealing with opiate addiction. Extended release naltrexone has also been trialed, and in one noted study demonstrated less incidence of relapse when compared to usual treatment (Lee et al., 2016). In general, medication combined with therapy improves effective outcomes and reduces risk for patients dealing with opiate addiction (Percoraro, Ma, & Woody, 2012).
Considerations for Nurses
Nurses can offer support by giving families a safe platform to work through the devastating process of loss, and offering resources for ongoing healing. Patients treated for addiction are adolescents, young adults, middle aged, and elderly. Research has indicated no age limit on individuals suffering from addiction (Koechl, Unger, & Fischer, 2012). One can turn on the news any given day and hear local or national media reporting individuals found dead or overdosed in parking lots, private homes, and places of business. Human lives are changed in a moment’s notice, and families are left to suffer through guilt, shame, isolation, and disbelief. Nurses can offer support by giving families a safe platform to work through the devastating process of loss, and offering resources for ongoing healing. This section will discuss several considerations important to the nurse role in effecting positive change to address the opiate crisis, such as nurse attitudes; education and support; safe spaces and caring behaviors; and minimization of power struggles.
Nurse attitudes toward patients with addiction can impact the quality of care (Sleeper & Boachain, 2013). Negative attitudes may affect one’s ability to engage in effective assessment of substance abuse issues and may disrupt caring behaviors, leading to decreased willingness for patients to utilize our healthcare systems (Bartlett et al., 2014; Howard & Chung, 2000). Nurses have expressed feeling unsafe and challenged on an emotional level to care for patients with histories of illicit drug use (vanBoekel, Brouwers, van Weeghel, & Garretsen, 2013). It is imperative that nurses engage and know patient needs in all areas of care; if not, the patient experience, and patient safety and quality of care may be negatively impacted (Dempsey & Reilly, 2016). The Table offers some strategies to increase nurse engagement and involvement in the role of change agent while caring for this population.
Table. Strategies to Increase Nurse Engagement and Involvement in the Role of Change
Promote patient comfort
Participate in community prevention programs
Develop positive nurse patient relationship
Identify/support legislative changes
Utilize leadership role to promote change
Utilize leadership role in communities
Increase awareness of stigma and bias
Know community/institution resources
Increase knowledge regarding addiction
Implement addiction screening tools
Advocate for change in area of practice
Nurses may feel that assessment for addiction histories with patients is a social problem. Even so, notes Clark, “Nurses have a social responsibility for the holistic welfare of all individuals. Given the widespread and multifaceted reach of care delivery, nurses are uniquely positioned to combat the opioid overdose epidemic on many fronts” (2014, pg. 2). Incorporating drug use history questions, both past and present, into the assessment allows patients the opportunity to be honest regarding use.
Education and Support
More than ever before, nurse educators need to integrate content about opioid addiction prevention, overdose, and treatment information throughout current curricula, including use of naloxone (Clark, 2014). Broadening the knowledge base for nursing students regarding addiction and its effects may help prepare novice nurses for the reality of working with the addicted population. Teaching nurses about signs and symptoms of overdose and the proper use of naloxone prepares them to effectively handle an opioid related emergency. This knowledge also supports the ability of nurses to teach patients and families about how to handle an overdose outside a hospital setting.
A number of nurse participants in one study shared decreased motivation to work with patients who use illicit drugs... A number of nurse participants in one study (Chu & Galang, 2013) shared decreased motivation to work with patients who use illicit drugs; Chu and Galang suggested the need for hospitals to provide role support for nurses working with this population. Education geared toward the needs of the addicted population would provide the additional support and knowledge for nurses to become more comfortable in assessing medical needs of these patients. Nurses who work within the field of addiction and advanced practice psychiatric nurse practitioners are able to assist medical institutions and/or practices by providing these additional support services. Screening tools are available to assess individual addiction history, such as Drug Abuse Screening Test (DAST-10) and CAGE Questions Adapted to Include Drugs ([CAGE AID]; SAMHSA, n.d.); these tools equip nurses with a format for assessment when uncertainty prevents them from obtaining a complete history.
Safe Spaces and Caring Behaviors
Being mindful of tone and expression when completing an initial assessment conveys acceptance and understanding. Setting the stage by normalizing a patient’s experience may help individuals to disclose use. A practitioner’s ambivalence toward patients with addiction and their perception that an addicted person can just stop using if they desire can also lead to negative attitudes towards illicit drug users (vanBoekel et al., 2013). Being mindful of tone and expression when completing an initial assessment conveys acceptance and understanding. Patients may be more willing to express the impact of stigma and/or the experience of discrimination when they feel safe with a provider of care. Patients noted experiences of feeling less empowered when interpreting negative or minimal empathic responses from practitioners, and this affected treatment outcomes (vanBoekel et al., 2013).
Nurses are aware of the presence of self and caring behaviors when engaging with patients in their care. They are trained to stay objective in the nurse patient relationship, and yet there are times when countertransference (i.e. the provider transfers emotion to the patient) may extend to this relationship when engaging patients (O’Kelly, 1998). Raising one’s awareness of the bias or stigma nurses carry into the therapeutic relationship may change perceptions on both parts of the interaction, allowing for less tension during initial assessment (Bartlett et al., 2014). Motivational interviewing allows patients the opportunity to express their needs (Bartlett et al., 2014) and offers more dialogue between the patient and provider of care, thus decreasing barriers. Patients tended to participate in services where practitioners were more engaging or familiar with their history, and patients reported an increase in barriers if practitioners were not consistent with care or were perceived by the patient as incompetent (Drumm et al., 2003).
Minimization of Power Struggles
At times, power struggles may exist between healthcare providers and addicted patients. At times, power struggles may exist between healthcare providers and addicted patients. This may be a result of various differences among healthcare providers in the viewpoint and treatment of addicted patients. Providers may project assumptions, such as the idea that we as providers know what patients need and they should comply with our perceptions about how they should recover (Szott, 2015). As nurses, we can raise our awareness in regard to how we carry ourselves into the lives of addicted patients and how our role is perceived. Murthy (2016) expressed the need for providers to let go of bias toward addicted individuals to promote patient comfort and subsequently allow them to reach out and get the help they require.
Leaders in the federal government are making numerous efforts to support necessary shifts in handling the opiate epidemic. Murthy (2016) supports the Obama administration for the position taken to address the issue of opioid use. At the start of a new political administration, health coverage issues remain a top priority. It seems the opiate epidemic has garnered bipartisan support in government. The new administration has shown movement towards policy adjustments to revise and/or abolish the current Affordable Care Act. Should this happen, state and federal agencies will need to reassess and advocate once again to assure continued resources to combat the ongoing epidemic (Stoltzfus Jost & Lazarus, 2017).
As bipartisan work continues on multiple levels, it is important for providers to advocate for patient needs and keep aware of ongoing policy changes. Changes in policy and implementation of revisions will evolve over time, although it appears that congress continues to move forward on this critical issue. Within a short time into this new Presidential administration, changes are already occurring. For example, the Expanding Opportunities for Recovery Act of 2017 (HB992) was introduced to the House in February of 2017. HB992 would allow for an increase in grant funding in order for states to provide MAT services for 60 days for opiate users who are not insured or services not covered due to barriers in the patient insurance plan (CONGRESS.GOV: HB992, 2017). As bipartisan work continues on multiple levels, it is important for providers to advocate for patient needs and keep aware of ongoing policy changes.
Nurses both need support and must provide support, while working with this vulnerable population. As a result of healthcare reform and other programs, including the ACA, there has been some alignment in federal, state, and local policy to ensure evidence based practices are being implemented in OTPs across this country (ACA, 2010; SAMHSA, 2014). However, several challenges remain. Despite efforts at each of these three levels to increase access, there remains a lack of opiate treatment programs in the United States. Even with positive strides regarding access to care, the number of opiate overdoses and fatalities continue to rise (CDC, 2016b; Frieden & Houry, 2016). We are in a national crisis.
Current changes in healthcare policy have made a positive impact in the development of evidence based OTPs. However, providing evidenced based treatment for all individuals on a state and local level will take time and likely require restructuring of current programs. Remaining inconsistencies from state to state in availability of resources for individuals with addiction continues to be a problem.
Nurses must continue to advocate for individuals with addiction along the continuum of care. Nurses both need support and must provide support, while working with this vulnerable population (Chu & Galang, 2013). Interprofessional collaboration amongst practitioners is imperative due to the complexity of treatment for addiction. Nurses must continue to advocate for individuals with addiction along the continuum of care. As healthcare reform continues, nurse providers must inform legislative efforts, with a goal to communicate the needs of addicted individuals and families as priorities for all stakeholders.
As healthcare leaders and role models in our communities, nurses can to reduce the stigma of addiction by bringing insight and openness into the minds of legislators specifically and society in general (American Society of Addiction Medicine, 2015). Resolving the opiate crisis requires everyone to address addiction with empathy and awareness; to provide a safe environment for individuals to reach out for help; and to ultimately guide them toward the evidence based programs allowing an opportunity to begin a new life.
Susan G. Painter, DNP, PMHNP-BC
Susan G. Painter DNP, PMHNP-BC is lead faculty in the Family Systems Psychiatric Nurse Practitioner program in the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, OH. She received her MSN/PMHNP and DNP from University of Illinois at Chicago. In clinical practice, she serves as a consult liaison nurse practitioner for patients with chronic severe mental illness, family violence, and substance abuse issues across the lifespan and its effects on communities and families.
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