We’ve all heard about the opioid crisis in America. We’ve heard about the causes, the possible solutions, big pharma’s role, and the healthcare policies that either hinder progress or provide hope for the future. Amid all the static, one thing remains clear: nurses, and nurse practitioners in particular, play a vital role in easing the pain of those suffering from addiction.
What Is an Opioid?
Opioids are synthetic versions of the active molecule derived from the opium poppy. Opiates, on the other hand, are the drugs derived from the plant itself. Today, the term “opioids” usually refers to both the synthetic and the natural derivations. No matter what you call them or what form they take, opioids are powerful analgesics that are highly addictive due to the euphoria they produce upon initial use and their anxiety-relieving properties.
From Prescription to Addiction
Opioids are often prescribed to patients in serious pain from an injury or surgical procedure. These medications are often over-prescribed, leading to iatrogenic, or doctor-caused, addiction. Often, when the prescription runs out or becomes too expensive, these patient-addicts will turn to illicit (and less regulated) forms of the drug such as heroin.
What makes opioid addiction even more insidious is that users of the medication often have to continue taking it to avoid “dopesickness,” another name for opioid withdrawal. Symptoms of opioid withdrawal include anxiety, irritability, a runny nose, muscle pain, hot and cold sweats, vomiting and diarrhea. Once opioid users become physically dependent, they are no longer taking the drug to get high.
Of course, other would-be addicts — some of whom may have already had problems with addiction — come by the drug illegally. No matter the source or reason, it’s important to note that even casual users can die upon first use of OxyContin and other opioids due to the potency of the drug.
Another reason that opioid addiction has turned into a crisis is the difficulty of getting clean. “The latest research on substance use disorder from Harvard Medical School shows it takes the typical opioid-addicted user eight years — and four to five treatment attempts — to achieve remission for just a single year,” writes Beth Macy, author of Dopesick: Dealers, Doctors, and the Drug Company that Addicted America.
Marketing Addiction
Macy’s Dopesick discusses another part of the problem: The marketing tactics of companies like Purdue Pharma, makers of OxyContin (Oxy), often go after “low-hanging fruit” such as impoverished areas with high rates of unemployment and disability claims. Small towns in Appalachia were some of the first to be targeted. By the mid-90s, many mines were closing, leaving people unemployed and depressed, their lives losing meaning with the loss of a job and a consequent loss of identity. And mining is a dangerous job, so many of those citizens had chronic pain from injuries sustained at work. The manufacturer of Oxy assured doctors (and the FDA) that there was a low chance for addiction. A surprising number of doctors in these areas continued to write prescriptions for their patients, even after learning about the risks. After all, the doctors were still getting paid by Medicare and Medicaid, not to mention receiving perks from the pharmaceutical companies including vacations, free meals, and other gifts.
The Economics of Addiction
Drugs, legal or illicit, are moneymakers. Pharmaceutical companies make money; doctors make money; pharmacies make money; and drug dealers make money. And they often make money off the disenfranchised — those who have lost their jobs due to the outsourcing of blue-collar jobs, those with disabilities (often caused by those jobs), or those who were raised in a cycle of institutionalized poverty.
For example, a miner is injured at work and has to see a doctor for chronic pain. While he recovers from his injury, the mine shuts down and he loses his job. The doctor has overprescribed — it’s in his best financial interest to do so — and the ex-miner sells his extra pills to make ends meet. After all, he has no job and no prospects. All of these lead to an emotional burden that can only be eased — it seems to him — with the mind-numbing euphoria of an opioid. In this scenario, each link in the chain has made money from the sale, distribution, and use of an FDA-approved medication.
Shared Accountability
Parents and families — and the addicts themselves — also bear some of the responsibility. The stigma of having an addicted family member can often isolate the family and keep them from seeking treatment. The same stigma can prevent addicts from talking about their problem before it’s too late. No one wants to be judged. The solution — easier said than done — is to take away the stigma so more people will seek help earlier. Those seeking treatment for themselves or loved ones will also find out they are not alone in this struggle. Not only can others provide emotional support, but they can also share information. To paraphrase Macy, survival has to trump shame.
The Numbers
According to Macy, “Opioids are now on pace to kill as many Americans in a decade as HIV/AIDS has since it began, with leveling-off projections tenuously predicted in a nebulous, far-off future: sometime after 2020.”
If that’s not enough to get your attention, consider these facts from a 2018 article in The New York Times:
- 72,000 Americans died from drug overdoses in 2017.
- There have been almost twice as many deaths in 2018 from synthetic opioids as there were from heroin.
- Approximately 2.1 million Americans had self-reported opioid use disorders in 2016.
- The CDC estimates a 9.5 percent increase in overdose deaths between 2016 and 2017.
Deaths From Overdose Are Preventable
One of the saddest parts of this story is that many of these deaths are preventable. The anti-overdose drug naloxone (NARCAN) is an opioid antagonist; it binds to the opioid receptors in the brain and reverses and blocks the effects of opioids. It can restore breathing in an overdose victim, preventing death. Some states allow friends and family members of opioid-dependent loved ones to buy naloxone at pharmacies without a doctor’s prescription, while other states require a prescription. The problem is obvious: there is no time to go see a doctor in the middle of an overdose. A policy shift is necessary to allow anyone to buy naloxone at any time.
What else is being done to help?
- Educating healthcare providers
- Educating policymakers
- Educating the public
- Educating law enforcement
- Increasing access to treatment
- Allowing nurse practitioners to work at the full scope of practice
- Reducing the stigma attached to addiction
Medication-Assisted Treatment
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), Medication-Assisted Treatment (MAT) is “the use of medications with counseling and behavioral therapies to treat substance use disorders and prevent opioid overdose.”
The following medications are used for treatment of opioid dependence:
Buprenorphine: This medication reduces cravings for opioids while the active addict attempts to get clean. According to SAMHSA, “Buprenorphine is an opioid partial agonist. This means that, like opioids, it produces effects such as euphoria or respiratory depression.” The most crucial effect of this medication may be its ability to prevent dopesickness.
There are a number of FDA-approved medications containing both naloxone and buprenorphine. These medications prevent withdrawal symptoms, but have a nominal amount of the intoxicating effects caused by opioids:
- Bunavail
- Suboxone
- Zubsolv
This sounds like a great option, and it is, but there are restrictions. Physicians can treat up to 30 patients after being authorized under the Drug Addiction Treatment Act 2000. To treat more than 30 and up to 100 patients, doctors can apply to SAMHSA. They must also complete an online form to increase the patient limit after one year. After another year, they can apply to treat up to 275 patients.
Until 2016, nurse practitioners and physician assistants did not have prescribing privileges for buprenorphine. Now they follow roughly the same guidelines as physicians to prescribe buprenorphine.
On the other hand, anyone licensed to prescribe medication can prescribe OxyContin or other prescription opioids. Some states do require a substance-abuse-disorder assessment before the doctor can prescribe an opioid, though these assessments are sometimes nothing more than self-reported questionnaires.
Naltrexone: This medication blocks the receptors to which opioids and alcohol bind. The drug is reported to decrease opioid cravings as well. There are no restrictions for licensed providers to prescribe naltrexone.
Writing about the importance of MAT in her book Dopesick, Macy refers to her interview with Dr. Marc Fishman, Johns Hopkins researcher and MAT provider: “In a treatment landscape long dominated by twelve-step philosophy, only a slim minority of opioid addicts achieve long-term sobriety without the help of MAT, Fishman reminded me. ‘AA is not a scalable solution in an epidemic like this, and most opioid addicts just can’t do it without MAT,’ he said.”
Where Do Nurse Practitioners Come In?
Nurses see more patients on a daily basis than any other healthcare providers, which is why it’s so important for them to be well-informed about the current opioid crisis. Nurse practitioners have the knowledge to be proactive on all fronts, and the tools to help are well within their scope of practice.
Northern Kentucky University (NKU) offers two online MSN-Nurse Practitioner programs to prepare nurses with the education they need to help curb the opioid epidemic: The MSN-Family Nurse Practitioner program and the MSN-Psych-Mental Health Nurse Practitioner program.
For example, Health Care Policy and Economics in Population Health explores healthcare issues, policies and economic factors influenced by technological, social, economic and political factors; availability of and access to health care for varied populations; social distribution of health care, actions for dealing with healthcare dilemmas, federal and state regulatory programs, and health care financing.
Another course offered by NKU is Advanced Clinical Pharmacology and Intervention for APRNs. This class covers the pharmacological physiology of selected therapeutic agents; pharmacological management of clients, including drug selection, client/family education, and monitoring and evaluating pharmacological interventions.
Armed with the right knowledge and education, FNPs can be frontline warriors in the battle against opioid addiction.
Learn more about NKU’s online MSN-FNP program.
Sources:
The New York Times: Bleak New Estimates in Drug Epidemic: A Record 72,000 Overdose Deaths in 2017
National Institute on Drug Abuse: Opioid Overdose Reversal with Naloxone (Narcan, Evzio)
SAMHSA: Medication-Assisted Treatment (MAT)
Practical Pain Management: Risk Assessment: Safe Opioid Prescribing Tools
American Society of Addiction Medicine (ASAM)
Addictions and Recovery: Opioids: Addiction, Withdrawal and Recovery
Macy, B. (2018). Dopesick. New York: Little, Brown and Company.
