Discuss ways in which nurses can advocate for more high-quality training for prescribers of opioids, access to Prescription Drug Monitoring Programs (PDMPs) in every state, development of abuse deterrent formulations (ADFs), naloxone access for the public, and access to medication-assisted treatment programs (MATs) for this with opioid use disorder
Prepare nurses to be educators for their patients, the public, and fellow healthcare providers about this national epidemic of opioid use
Train nurses to assess for risk factors of opioid misuse, to know the red flags, signs, and symptoms of opioid misuse in order to recognize them in patients, coworkers, family and friends, and properly reconcile medications safely and consistently as a safeguard against medication diversion
- Assist nurses in the basics of naloxone use for the rescue treatment and reversal of an opioid overdose, and methods of locating local resources for anyone (including themselves) suffering from opioid use disorder, such as approved MAT programs.
The Opioid Crisis
The United States has been in an opioid crisis for years, one that the medical and healthcare industry was aware of far before the general public became aware. According to the Centers for Disease Control and Prevention (CDC), there were over 42,000 deaths attributed to opioids in 2016, an all-time record in this country (2017). Of those, 40% involved a prescription opioid (CDC, 2017). According to the National Emergency Medical Services Information System (NEMSIS), the rate of emergency medical services (EMS) naloxone administration events increased 75.1%, from 573.6 to 1,004.4 administrations per 100,000 EMS events from 2012-2016, which seems to correspond well with 79.7% increase in opioid overdose mortality during those same years (Cash et al, 2018). As the public’s perceived most honest, ethical, and trustworthy members of the medical field, nurses are in a key position to affect change and help manage this crisis on a national level and save thousands of lives (Brenan, 2017). Due to their varied and pervasive roles in direct patient care, core-coordination, leadership, education, and executive functions, nurses are uniquely positioned to help create attitudinal, institutional, and functional changes in the world of pain management.
Advocacy and Support
A cornerstone of nursing education is the important role that nurses play as advocates, both for our patients, our coworkers, and the public. We are trained that the best interest of our patients should be our overall goal, and especially for those that cannot advocate for themselves, the vulnerable and the silent. Standing up for as well as doing what’s right in this situation means speaking out and offering solutions that could possibly decrease the rampant growth of this epidemic.Nurses should advocate for more training, both for nurses at the bedside, in the community, and advanced practice nurses and physicians that are doing the prescribing. Education regarding the risks of drug misuse, the signs and symptoms to look for, rescue treatments available for overdose situations, and long-term treatment options available is crucial. As nurses, we need to be students of that education, and ask for it if it does not already exist in our area. The American Nurses Association (ANA), which is a powerful advocacy and education group, recently joined forces with 40 other provider groups in a pledge to train more than 540,000 opioid prescribers over the next two years (ANA, 2016). States with independently prescribing advanced practice nurses have also shown to have less controlled substance prescriptions than states with less or no advance practice nurse independence (Schirle, 2016).PDMPs are designed to allow prescribers and pharmacists to track controlled substance prescription activity and history for their patients. They are now active in 49 states and are designed to prevent access to inappropriate controlled substance prescriptions. This allows registered users to more easily track patients that may be doctor shopping or pharmacy hopping in order to obtain prescriptions for certain controlled substances. Nurses should advocate for further development and improvement of these databases in their state, and eventually on a national level, and help with awareness, mandatory registration, and consistent usage (Cipriano, 2016). Nurse prescribers should of course become registered and trained to utilize their PDMP as a useful tool in their prescribing toolbox (CDC, 2017). Abuse deterrent formulations (ADFs) of medications are typically manufactured to prevent or deter people from misusing them by crushing, snorting, or injecting them. They achieve this by adding physical or chemical barriers, adding antagonists that counteract the opioid if manipulated, adding aversive substances to deter misuse, long-acting injections or implants, or molecular entities or prodrugs that render them inactive unless taken orally. Unfortunately, the development of long-acting patches and tablets has not been as useful or helpful as expected, as these patches/pills are sometimes still manipulated by crushing, snorting, melting, or chewing them to achieve a euphoric rush (NIDA, 2018). Nurses are in a unique position to assist with research and development of these newer, safer formulas, to lobby pharmaceutical manufacturers to develop more of these, and to provide direct feedback to the many pharmaceutical sales representatives that visit their medical offices educating providers and prescribers about these medications. Anything that allows legitimate relief of pain while also protecting the public against misuse of that drug should be something that nurses advocate for.Naloxone, the medication used for reversal and rescue after an opioid overdose, is an additional opportunity for nurses to act as advocates. While the medication works well when given soon enough, nurses need to continue to advocate for quick access to this medication when needed and for the necessary legal protections for bystanders that administer the medication to help someone in good faith against civil liability. Nurses can also help advocate for better insurance coverage through third party payers, Medicare, Medicaid, and via free clinics and pharmacies for those without prescription drug coverage. Access to this drug in schools, and inclusion in the school’s emergency preparedness plan, for example, was part of a 2015 position paper from the National Association of School Nurses (NASN, 2015). Does your local high school have Naloxone access in an emergency if needed? Finally, advocating for those patients that are showing suspicious signs or symptoms of drug misuse, or have a history of drug overdose, or those that request naloxone, to ensure they receive a prescription for a naloxone kit to have on hand at home may just save that patient’s life. (Calas, 2016)The standard of care for the treatment of opioid use disorder is medication-assisted treatment (MAT), but access to this type of program is still difficult. This treatment combines a behavioral therapy, such as cognitive-behavioral therapy, with a medication to reduce cravings and limit withdrawal symptoms such as buprenorphine, naltrexone, or methadone. Unfortunately, the Drug Enforcement Agency (DEA) requires specialized licensure, after completing additional education, to prescribe buprenorphine, and even then, there are limits on how many patients these providers may treat at any one time such as 30-250 depending on the type of licensure approved by the DEA. In 2016, advanced practice nurses were added to the Drug Addiction Treatment Act’s (DATA) list of prescribers who could apply for and obtain this specialized license, but with smaller patient caps. Methadone, for the purposes of opioid use disorder treatment, can only be administered by a specially licensed drug treatment program, commonly called methadone clinics. For these reasons, even if the existing programs and prescribers were operating at full capacity across the US, there are likely more than a million patients currently suffering from opioid use disorder than could be treated by the existing MAT programs in this country. Nurses advocating for continued expansion and investment into this well-tolerated and proven-effective treatment program would save potentially thousands of lives (SAMHSA, 2015).
Nurses are educators. It is at the core of their beings and intrinsically woven into their education and therefore their development as professionals. It starts first though by educating oneself. A point that was previously stated, but cannot be overemphasized, is the simple fact that nurses need to soak up and devour any available educational programs, continuing nursing education (CNEs) hours, conferences, or remote learning modules that they have access to regarding the opioid crisis, opioid pharmacology, and opioid use disorder and its treatment (ANA, 2016). Nursing schools need to make these topics part of their core curriculum. If these programs are not readily available on a local level, nurses need to be asking for them, or finding people who will help them develop the education themselves (St. Marie, 2018). It is one’s duty to first educate oneself, so that one may then teach others. One such training program, Screening, brief intervention, and referral to treatment (SBIRT), is an evidence-based program designed to teach nurses to screen and redirect patients that appear high risk towards further treatment and resources. It is designed to be implemented in any community health setting, including doctors’ offices and emergency departments (EDs). There are free online trainings, and even a free smartphone application, that give nurses the basics on performing the screening and even includes coding and billing information related to the service. Nurses need to share information learned during these courses with co-workers. Present all new and important knowledge at the next staff meeting so everyone benefits or hand out important materials. Nurses, always willing to jump in and help out a fellow nurse, need to volunteer to cover shifts for co-workers so they too can attend these important courses, so everyone is prepared and ready to fight this monster together as a team (SAMHSA, n.d.).
Once fully educated on the topic themselves, the nation’s over 3 million nurses are next tasked with educating patients and the public at large. According to national polling, the 82% of the public overwhelmingly trusts our nation’s nurses as the most ethical profession, and that trust needs to be met with a commitment to honesty and truthfulness (Brenan, 2017). Patients in pain need to be educated on how to communicate about their pain with care providers, alternative pain management treatments including non-pharmacological and nonopioid options, the pathophysiology and risk factors of addiction, safe medication use and storage, available local drug back programs, and treatment options available for those with use disorders and addiction. Nurses are ideal to educate patients on alternative treatments available such as physical therapy, chiropractic care, massage therapy, acupuncture, yoga, mindfulness, and others (ANA, 2018). Advocacy also continues, with the help of nurses, to improve insurance coverage for these nonopioid and nonpharmacological treatments available for pain (Cipriano, 2016). The elderly is a particularly vulnerable population due to polypharmacy in this age group and the potential for heightened sensitivity to opioids as well as decreased clearance due to slower metabolism and decreased liver and kidney function that occurs with age. Elderly patients are more likely to be hard of hearing or have difficulty with short term memory and require important facts written down for them. The extra time a well-informed nurse takes to explain the new pain medication being prescribed to them may just be the difference between that patient using the opioid correctly to achieve adequate pain control and fear or confusion that increase the patient’s risk for misuse. Nurses are also uniquely and well-qualified to engage in larger scale public education campaigns to address the stigma and common misperceptions about chronic pain and opioids (ANA, 2016).
In a recent study of 62 ED nurses, researchers found that outcomes for patients improved when nurses were trained in SBIRT within the ED. Benefits continued as long as supportive follow up was continued until the screening practice was fully established (Mitchell, 2017). As mentioned above, the public views nurses as being the most ethical profession and are therefore the most logical choice for obtaining an honest and upfront history of present illness from patients. Nurses are trained to assess patient’s pain as one of the vital signs, but perhaps nursing could even improve this. Nurses should be assessing functional status, sedation, agitation, as well as pain knowledge and coping strategies. Assessments should also include what medications are being taken and how they are being taken along with what nonpharmacological treatments are being utilized or have been tried previously. Risk factors for opioid misuse should be assessed and include a personal or family history of alcohol or drug abuse disorder, younger age, female sex, and current psychiatric condition. Potential for risk of misuse should also be formally assessed prior to starting an opioid using a tool such as the Opioid Risk Tool (ORT). While an opioid is being used, signs and symptoms of misuse should be assessed at follow-up visits using a tool such as the Current Opioid Misuse Measure (COMM). Red flags that indicate a higher tendency toward opioid misuse include:
- Requests for quick prescription adjustments without time for appropriate screening
- Ongoing delays for surgical procedures, thus extending the time on pain medication
- A heistory of early refills due to lost prescription/medications, travel, or using extra doses
- Resistance to nonpharmacological or nonopioid treatment options
- Poor security emasures to protect medications at home, thus frequently lost/stolen
- Frequent after-hours calls/emergency room visits with legitimate complaints that often require pain medication
Care should be taken to avoid the common trap of assuming a patient is not suffering from opioid use disorder simply because they are well-liked, well-known, or do not fit whatever stereotype exists of the drug abuser. Pseudoaddiction, which is a common phenomenon in which intense fear of pain causes patients to behave as if drug-seeking, needs to be identified and differentiated from true addiction behaviors. This is especially common in hospitalized post-surgical patients. The adequate control of pain and constant reassurance typically calms these fears and corrects these behaviors (Hudspeth, 2016).
Finally, nurses are well-equipped and educated to handle the assessment of themselves and their colleagues. Taking a careful stock of all medication counts and ensuring that these counts are done at the beginning and end of every shift, or per your facilities guidelines, will help nurse administrators in a hospital or facility setting to identify any patterns or concerns. Drug use disorder prevalence among nurses is no higher than in the general public, but access to medications certainly makes the nurses who suffer from drug use disorder more likely to divert medications at work. Symptoms that a coworker may be diverting medications or suffering from drug use disorder include diminished competence, changes in behavior or performance, consistent inequities seen in the medication reconciliation worksheet when that particular nurse is working, or a nurse who regularly requests to perform the medication count themselves and insists it is perfect. Drug use disorder, even when it is accompanied by drug diversion, can usually be effectively treated using an alternative-to-discipline (ATD) approach with goals of retention, rehabilitation, and re-entry into practice instead of a previously-common discipline approach which involved termination, a suspended or revoked license, and potentially even prosecution. The older punitive system did little to help the nurse or other healthcare professionals treat and manage the underlying disorder (Strobbe, 2017).
As previously stated, it is recommended that any high-risk patient have access to naloxone, a rescue treatment to be used in the case of opioid overdose to reverse the respiratory depression seen in overdose situations. Depending on insurance coverage, this can be prescribed for and obtained through a traditional pharmacy, or through community access programs. The nurse should make sure the patient and any caregivers are well trained on the signs and symptoms of an opioid overdose and the safe administration of naloxone (Calas, 2016). If opioid misuse disorder is suspected, a patient should be referred to a treatment program for further evaluation after an honest conversation explaining the concerns to the patient. As previously mentioned, advanced practice nurses are now available to be trained and licensed to prescribe buprenorphine as a component of a MAT program, and methadone can only be dispensed through specialized clinics. In general, these resources are more scarce than desired, but there exist state and national databases, such as through the Substance Abuse and Mental Health Services Administration (SAMHSA) to help nurses locate local MAT programs in their area (SAMHSA, 2015).
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