Nurse practitioners applaud recent enactment of legislation that empowers them to better address the nation’s opioid crisis.
The Comprehensive Addiction and Recovery Act (CARA) of 2016 gives nurse practitioners the ability to prescribe buprenorphine, a medication for the treatment of addiction to opioids, such as heroin or prescription painkillers. It can quell withdrawal symptoms, reduce cravings, and lower the risk of relapse.
The Act also seeks to increase the access of naloxone to first responders and law enforcement in order to reverse the effects of opioids.
Federal officials have called opioid addiction a national crisis.
Every day, over 1,000 people are treated in emergency departments for misusing prescription opioids, according to the Centers for Disease Control and Prevention.
“[The American Association of Nurse Practitioners] has been very supportive of this legislation to increase access to care for these patients,” says Anne Norman, DNP, APRN, FNP-BC, FAANP, vice president of education at the AANP.
“We are pleased that appropriately trained and educated NPs will be allowed to prescribe the necessary medications for these patients according to their state prescribing regulations and…contribute to the reduction of drug overdose deaths,” Norman says.
Allowing NPs to “treat addiction is a novel solution to bridge the gap in medication-assisted treatment for addiction,” says Peggie Powell, MSN, APRN, FNP-BC, a family nurse practitioner at VCU Health Community Memorial Hospital Pain Management Services in South Hill, Virginia, an affiliate of Virginia Commonwealth University.
“Educating patients about their addiction and the need for self-care are very much within the scope of practice for nurse practitioners. The Act empowers NPs to practice to their full extent, but it also increases access to medication-assisted treatment for those in need,” says Powell, a nurse for 23 years, the last 13 working as a NP.
CARA’s enactment extends prescriptive authority to advanced practice registered nurses such as women’s health nurse practitioners. “This is particularly significant as opioid use in pregnancy can have profound implications for both maternal and infant death,” says Susan Kendig, JD, MSN, WHNP-BC, FAANP, director of policy of the National Association of Nurse Practitioners in Women’s Health (NANPWH).
“When buprenorphine is utilized under careful supervision, pregnant women who are affected by substance abuse disorders have a mechanism to address their addiction while working to achieve a healthy pregnancy outcome. WHNPs often work side by side with our colleagues in OB/GYN and maternal fetal medicine in co-managing these conditions,” Kendig says. “Extension of prescriptive authority for buprenorphine to WHNPs can help to improve access to important care for women.”
Studies show that buprenorphine, a form of medication-assisted treatment, cut the risk of death in half from all causes—from overdoses to car accidents.
Educating the Public
Nurses are in a good position to help educate the public about opioid abuse since they practice in a variety of settings, from schools and clinics to home visiting agencies and community-based settings where “they are the face of health care and may indeed be the only health care provider interacting with an individual at any given time,” says Kendig. “This provides opportunity for assessment, education, and referral for opioid use and misuse.”
Nurses help the public learn the signs and symptoms of opioid abuse, which include sedation, slurred speech, itching, euphoria, constricted pupils, mood changes, and difficulty meeting work or school obligations. Signs of withdrawal include anxiety, nausea, and inability to sleep.
Nurses also teach the public how to safely store opioid pain medication and properly dispose unused opioids. “Never give or sell [it] to others as this is a felony, but also unsafe,” explains Powell.
“Educating the public about the signs and symptoms of opioid abuse is one of the best things we can do as nurses,” says Lorraine Byrnes, PhD, RN, FNP-BC, PMHNP-BC, FAANP, CNM, an associate professor and director of the undergraduate nursing program at Hunter-Bellevue School of Nursing.
“We must also advocate for access to treatment programs that use an evidence-based approach to treatment, which is essential in addressing this public health crisis. Community access and education about naloxone to reverse the effects of a drug overdose and save lives is a critical element in treating opioid abuse. We must also avoid stigmatizing opioid addiction by providing patient-centered care that meets the long-term and short-term needs of our patients and their families,” says Byrnes, who serves on the board of NANPWH.
To help reduce the opioid epidemic, patients treated with opioids must use the medication for a limited time to prevent dependence, opioid addiction must be treated as a chronic condition, and the stigma of addiction must be eliminated, nurse practitioners say.
“Although everyone who uses pain medication will not become addicted, we do know enough about how genetics, temperament, environment, and personal situation to develop individualized, tailored treatment plans for those who may become addicted,” says Byrnes. “Education in the proper use of opioids to manage pain must occur among prescribers and alternatives must be part of every pain management plan.”
Counseling is another crucial recovery component as well as the availability of naloxone without a prescription to families and communities dealing with addiction, says Byrnes.
Powell agrees that “Increasing access to naloxone and providing training on its proper use can save lives. Nurses, pharmacists, and nurse practitioners can be instrumental in educating the public on all these aspects.”
Other changes to address the epidemic include policy changes in insurance and medication drug coverage to reduce the opioid load in the public arena, says Powell. Insurance companies need to include abuse-resistant opioid formulations on their formulary and provide coverage for abuse-resistant opioids for chronic pain.
A Doctorate of Nursing Practice (DNP) student at VCU School of Nursing, Powell’s DNP project focuses on opioid safety in patients on chronic opioid therapy. She recently published an article on opioid safety on the Physician-Patient Alliance for Health & Safety blog.
Prescription opioid related deaths have quadrupled since 1999 in the United States and approximately 80% of deaths are due to unintentional overdose, according to Powell.
“In 2014, opioid overdose death from prescription opioids increased to approximately 19,000 deaths in the United States; this is more than three times the number reported in 2001,” she wrote. “Such statistics are staggering and indicate a need for action to help curb this epidemic. Utilization of risk assessment tools and mitigation strategies to detect and reduce the risk of opioid overdose are needed in clinical practice.”
The only tool that provides an actual quantitative score of opioid overdose risk is the Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression (RIOSORD).
“I plan to utilize the RIOSORD to determine each patient’s risk of possible accidental overdose or serious opioid induced respiratory depression,” Powell says. “Patients determined to be ‘high risk’ will be given a prescription for naloxone that can be used in an opioid-related emergency to prevent death. The aim is to increase naloxone-prescribing practices among the providers at my clinic.
“Use of this tool will provide a quantitative risk stratification that is based on the patient’s medical history, opioid formulation, morphine equivalent dose, and the presence of concurrent prescriptions for benzodiazepines or antidepressants.”
“Every day, 78 Americans die from opioid overdoses,” President Obama said when he signed the CARA legislation into law this summer.
Among those ages 12 to 25, illegal opioid use more than doubled between 1991 and 2012. Yet nine out of 10 of drug-addicted youth ages 12 to 17 receive no treatment at all, according to the 2012 National Survey on Drug Use and Health.
Nora Volkow, MD, director of the National Institute on Drug Abuse, has called prescriptions such as buprenorphine “an essential component of an ongoing treatment plan” that allow people to “regain control of their health and lives,” according to USA Today.
Nurses are in a unique position to help patients reap the analgesic benefit of opioids without encountering the dangers since they are experts in non-pharmacological interventions to manage pain, including the use of mental imagery and relation therapy, nurse practitioners say.
Nurse practitioners, Powell says, are among the best qualified health professionals to help patients dealing with pain and addiction. “We are vigilant in our monitoring; we are able to demonstrate empathy, but also ensure compliance with safe use; and we focus on educating the patient on the risks as well as possible benefits of opioid use,” she adds.