CURRENT U.S. OPIOID EPIDEMIC 9/25/2018 LEVERAGING NURSES TO EXPAND ACCESS TO TREATMENT IN THE OPIOID EPIDEMIC DISCLOSURES

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1 LEVERAGING NURSES TO EXPAND ACCESS TO TREATMENT IN THE OPIOID EPIDEMIC DISCLOSURES I have no personal or financial conflicts of interest to disclose Colleen LaBelle MSN, RN-BC, CARN Directors STATE Office-Based Addiction Treatment Training and Technical Assistance Boston Medical Center October 11, 2018 Funding support provided by Massachusetts Department of Public Health, Bureau of Addiction Services people die in our country each day from a drug overdose.. 3 RATE OF DEATH FROM OVERDOSE VS. OTHER MAJOR CAUSES CURRENT U.S. OPIOID EPIDEMIC 5 Josh Katz, New York Times, Just How Bad is the Drug Overdose Epidemic? 10/26/

2 SUBSTANCE USE DISORDERS IN THE US The Addiction Crisis 20.1 million Americans meet the criteria for a substance use disorder that s one in every 12. Approximately 11.8 million persons misused opioids in close to one million of those individuals reported using heroin/fentanyl. 630,000 overdose fatalities between 1999 and Only 1 in 10 people who need treatment for a substance use disorder is actually receiving it. HHS, 2016 CDC, 2017 Mass Gov, Risk of opioid overdose death following incarceration is 56x higher than for the general public Risk is greatest during first following release Of those incarcerated, young people (18-24) are 10x more likely to die than those >45 An Assessment of Opioid-Related Deaths in Massachusetts ( ). MA Department of Public Health. September Accessed at: file:///c:/users/alventu1/downloads/dph-legislative-report-chapter-55-opioid-overdose-study pdf 9 OVERDOSE DEATHS CONTINUE TO RISE: EPIDEMIC RAPIDLY EVOLVING We are HERE: Polysubstance use the norm, rather than exception Drug supply more lethal and unpredictable Heavy focus on reducing supply = abandonment of many chronic pain patients Identifying high risk populations easier than serving them Addiction workforce must evolve in parallel to the needs of populations impacted 10 HEALTH ECONOMICS OF TREATMENT Substance use disorders cost the US > $600 billion annually and unquantifiable human suffering Every dollar invested in addiction treatment programs yields a return between $4 - $7 in reduced drug-related crime and criminal justice costs When savings related to healthcare are included, total savings can exceed costs by a ratio of 12 to 1. Average cost for 1 year of methadone maintenance treatment $4,700 Average cost 1 year imprisonment $30,000-50,000 HISTORY OF OPIOIDS Utilized throughout the world for various uses for thousands of years 1800 s: Morphine and Heroin were marketed commercially as medications for pain, anxiety, respiratory problems Invention of Hypodermic syringe allowed for rapid delivery to the brain NIDA, PCSS,

3 BAYER HEROIN 1898 FLORENCE NIGHTINGALE: ADDICTIONS NURSING PIONEER 1855: Florence Nightingale develops principles of addiction nursing still in place today: 1) Nurses roles in the promotion of health and prevention 2) The focus of nursing on the client, within family and community contexts. 3) The recognition of addiction as a disease rather than an expression of moral failing. 4) Political activism that impacts health and wellbeing as a means of achieving changes in systems that have a direct impact on health 13 Naegle, M. (1991). Florence Nightingale:. Addictions Nursing Pioneer. Journal of Addictions Nursing, 3(4), HARRISON NARCOTICS ACT OF 1914: IGNITES ERA OF PROHIBITION Banned physicians from nonmedical use of narcotics Addiction not considered to be a medical condition MARY BRECKENRIDGE AND THE FRONTIER NURSING SERVICE (FNS) 1917 Set up 8 clinics, covering 78 square miles of Appalachia treating thousands of patients: home visit, no on site medical supervision, medical advisory committee Harrison Narcotics Act did not restrict nurses from carrying narcotics saddlebags, nor did it prohibit nurses from administering narcotics according to physician s standing order Allowed FNS to continue to administer medications as indicated and work at the top of their license Cockerham et al. (2012). Rooted in the mountains, reaching to the world: Stories of nursing and midwifery at Kentucky s frontier school, Keeling et al. (2005) The history of advanced practice nursing in the United States. Advanced nursing practice: An integrative approach (p.1-21). Source: New York Times. America s Addiction. Photos from Library of Congress AMERICAN NURSING ASSOCIATION 1955 constrain nursing profession Neither diagnosis nor prescribe Creates interdisciplinary conflict: medicine/nursing Implementation of NP role in 1965: collaborative, collegial relationships not as physician substitutes based on the FNS role The role and scope of practice studied 1970 Advocated standardized licensure and certification nationally ANA amended the nurse practice act: NP diagnosis and prescribe

4 Withdrawal Normal Euphoria 9/25/2018 NATURAL HISTORY OF OPIOID DEPENDENCE NATURAL HISTORY OF OPIOID USE DISORDER Using to feel good Acute use Tolerance and Physical Dependence Chronic use Needing to use more to feel normal Using to keep from getting sick NO SINGLE FACTOR CAN DETERMINE WHETHER A PERSON WILL DEVELOP A SUD Some contributing factors Genetics Structure of brain Psychological influences Environmental influences Age of first substance use Genetics Gene Environment Interaction Environment The National Center on Addiction and Substance Abuse. (2013). Addiction Medicine: Closing the Gap between Science and Practice 22 ACES MAJOR DETERMINANT OF WHO DEVELOPS SUD The 10 Adverse Childhood Events Forms of abuse 1.Sexual 2.Emotional 3.Physical Forms of neglect 4.Emotional 5.Physical Forms of household challenges 6.Household substance use 7.Mental illness in house 8.Parental separation or divorce 9.Criminal household member 10.Mother treated violently Each ACE increased the likelihood of early drug initiation 2x to 4x 90% of people with SUDs began using before age 18 THE TEENAGE BRAIN: HIGH RISK TIME FOR DEVELOPING A SUD Substance use before age 15 leads to 6.5 times the risk of developing a SUD compared to those delaying use until age 21 Dube SR et al. (2003). Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics. 23 Gopnik, 2012, WSJ, What s Wrong with the Teenage Mind 24 4

5 Symptom Severity Symptom Severity 9/25/2018 Isolate of individuals and families STIGMA CAN Encourage people to deny a fatal illness and ignore its symptoms Keep desperately ill people from seeking help Increase risk of overdose or relapse Result in late or no prenatal care Persuade society to choose far more expensive and ineffective alternatives to treatment 1. Person first language FINDING THE RIGHT WORDS Non-stigmatizing, emphasizes individual over health condition 2. Medically accurate terminology Substance use disorders are chronic health conditions and should be referred to in professional manner just as any other health condition 3. If you don t know ask! Your desire to understand conveys empathy and humility EXAMPLES OF PREFERRED LANGUAGE SUBSTANCE USE DISORDER DEFINITIONS: Say this Person with a substance use disorder, person with addiction, person who uses drugs Risky or unhealthy alcohol or drug use Medication for addiction treatment (MAT), treatment, opioid agonist therapy, Negative or positive urine toxicology test Addiction survivor, in remission, in recovery Infant with NAS or SEN Instead of this Addict, junkie, crackhead, user, abuser, pillpopper, alcoholic Misuse or abuse* Medication-assisted treatment (MAT), replacement therapy, substitution therapy Dirty or clean urine Recovering addict, clean Addicted baby Primary, progressive, permanent, predictable, terminal (1956) Compulsive seeking and use, despite harmful consequences Pathological pursuit of reward and/or relief with biological, psychological, social and spiritual manifestations. Characterized by periods of relapse and remission. *Unless in reference to DSM-IV diagnosis substance abuse disorder Evaluation of A Hypothetical Treatment MOST IMPORTANTLY HYPERTENSION Pre During During During Post ADDICTION Just Like Hypertension, Addiction Is A Chronic Disease That Requires Continued Care but the RESULTS are usually measured AFTER THE TREATMENT CONDITION HAS BEEN WITHDRAWN! Detox is not treatment! Pre During During During Post Stage of Treatment Source: McLellan, AT, Addiction 97, ,

6 Withdrawal Normal Euphoria 9/25/2018 OPIOID DETOXIFICATION OUTCOMES Low rates of retention in treatment High rates of relapse post-treatment < 50% abstinent at 6 months < 15% abstinent at 12 months Increased rates of overdose due to decreased tolerance PROTRACTED ABSTINENCE SYNDROME Protracted abstinence syndrome Secondary to derangement of endogenous opioid receptor system Symptoms Generalized malaise, fatigue, insomnia Poor tolerance to stress and pain Opioid craving Conditioned cues (triggers) Priming with small dose of drug MOUD: MEDICATION FOR OPIOID USE DISORDER EVIDENCE-BASED TREATMENT FOR SUBSTANCE USE DISORDERS Goals: Alleviate physical withdrawal. Alleviate substance craving. Opioid blockade. Normalize disrupted brain changes and physiology. Expect improvements in: Substance use. Criminal activity. Needle sharing: HIV/HCV. Pro-social activities. Employment. Physical and mental health WHAT IS EVIDENCE-BASED CARED FOR OPIOID USE DISORDER? Methadone: full opioid agonist Only available in specially licensed opioid treatment programs Buprenorphine: partial opioid agonist Commonly combined with naloxone, an opioid antagonist (to deter injection) Use in office-based setting requires DEA waiver 8 hour training for MDs per DATA hours of training for NPs and PAs per CARA Act Naltrexone: opioid antagonist Use in office-based setting without special certification Evidence of efficacy in specific populations Overall efficacy not well established NIDA (2012). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). SAMSHA (2015). Federal Guidelines for Opioid Treatment Programs. HHS Publication No. (SMA) PEP15-FEDGUIDEOTP. Kampman & Jarvis (2015). American Society of Addiction Medicine (ASAM) National Practice Guideline for the use of medications in the treatment of addiction involving opioid use. Journal of addiction medicine, 9(5), GOAL OF MEDICATION TREATMENT FOR ADDICTION Acute use Tolerance & Physical Dependence Chronic use OAT 35 6

7 METHADONE HYDROCHLORIDE TREATMENT OF OPIOID USE DISORDERS: METHADONE Full opioid agonist available in tablets and oral solution Schedule II, Category C Onset of action minutes Duration of analgesic action is much shorter than half-life 6-8 hrs analgesia Typically tid dosing hrs to prevent opioid withdrawal and craving and block effects of illicit opioid use Daily supervised dosing Adverse Reactions: QT prolongation and arrhythmia (torsades de pointes), CNS Depression, Neonatal Abstinence Syndrome (NAS) 37 METHADONE OTP Evidence-based treatment using the medical model Interdisciplinary care Counseling, Nursing, Provider visits Very strict regulations Daily observed dosing Typically random toxicology screening In MA: must be 18y/o and have one year documented OUD BUPRENORPHINE Buprenorphine/Naloxone DATA 2000 Buprenorphine is a partial opioid agonist medication Alleviates opioid cravings, withdrawal, and causes opioid blockade at appropriate doses Reduces illicit and risky substance use, protective against overdose Cannot be prescribed for pain, but does have analgesic properties Will cause opioid dependence Relatively safe medication Risk of NAS, overdose, misuse, and diversion, but less than full agonists Can be prescribed by a waivered provider and filled at a pharmacy Allowing a person to have their OUD treated like any other chronic illness!!! 2000: Drug Addiction Treatment Act (DATA 2000) Made office-based addiction treatment by physicians legal Must complete 8-hour training and obtain federal waiver Schedule III-V substances FDA approved to treat OUD 2002: Suboxone (buprenorphine/naloxone) FDA approved Outcomes much superior to psychosocial treatment alone Longer treatment duration is more effective 7

8 BACKGROUND: NURSE CARE MANAGER MODEL FOR OBAT Nurse Care Managers increase patient access to treatment and retention in care Efficient and effective utilization of waivered prescribers High quality management of chronic medical condition Able to address social determinants of health THE BMC NURSE CARE MANAGER (AKA MASSACHUSETTS) MODEL FOR OFFICE BASED ADDICTION TREATMENT (OBAT) Nurse Care Managers (NCMs) increase patient access to treatment Nurses working at top of their license Efficient and effective utilization of buprenorphine-waivered prescribers NCM role includes: Case management Brief counseling, social support, patient navigation NCMs able to address Urine toxicology results Insurance issues Prescription/pharmacy issues Pregnancy, acute pain, surgery, injury Concrete service support Intensive treatment, legal/social issues, safety, housing Alford et al. Arch Int Med. 2011;171: INCREASING ACCESS TO LIFE-SAVING MEDICATION: CREATING A NETWORK OF OBAT PROVIDERS ACROSS MASSACHUSETTS BMC OBAT TTA In 2007 State Technical Assistance Treatment Expansion (STATE) OBAT Program created to expand BMC model to 14 CHCs across MA First 5 years of outcomes: Between 2007 and 2013, 14 CHCs successfully initiated OBAT Physicians waivered increased by 375%, 24 to 114 over 3 years Annual admissions of OBAT patients to CHCs increased from 178 to 1, % of OBOT patients enrolled in FY 2013/2014 remained in treatment 10 months 45 Walley et al. (2008). Journal of General Internal Medicine. 23(9): BARRIERS TO PRESCRIBING BUPRENORPHINE IN OFFICE-BASED SETTINGS N=156 waivered physicians; 66% response rate among all waivered in MA as of 10/2005 Insufficient Nursing Support Insufficient Office Support Payment Issues Insufficient Institutional Support Insufficient Staff Knowledge Pharmacy Issues Low Demand Office Staff Stigma Insufficient Physician Knowledge [VALUE]% [VALUE]% [VALUE]% [VALUE]% [VALUE]% 55% of [VALUE]% waivered [VALUE]% providers reported 1 or [VALUE]% more [VALUE]% barriers Only DEAwaivered clinicians can prescribe buprenorphine but it takes a multidisciplinary team approach for effective care. 46 CARA LEGISLATION: NPS AND PAS ABLE TO PRESCRIBE BUPRENORPHINE! NPs and PAs must obtain waiver As of July 2016: allowed to prescribe Requirements include: 24 hours of education in addiction 8 hours of a waiver training (maybe a part of 24hour requirement) Supervised practice by waivered provider in states with supervised practice 30 patient limit year one Maximum 100 limit can apply after year one Approval for period of time then a review by HHS 47 American Association of Nurse Practitioners. (2017). The Pew Charitable Trusts. 48 8

9 Waivered MDs and DOs by State N = 43,850 (as of 8/14/2018) States with Highest % of Waivered MDs/DOs* Vermont = 14.7% Maine = 13.1% Alaska = 10.9% New Mexico = 9.7% Rhode Island = 8.3% Massachusetts (#12) = 7.2% VT = 320 NH = 333 CT = 886 MA = 2466 RI = 395 NJ = 1381 DE = 141 MD = 1326 DC = 165 Waivered Nurse Practitioners by State N=6,656 (as of 8/14/2018) States with Highest % of Waivered NPs* Maine = 12.7% Vermont = 12.4% New Mexico = 11.3% Maryland = 11.1% DC = 10.7% Massachusetts (#23) = 5.8% VT = 46 NH = 105 MA = 360 RI = 54 CT = 205 NJ = 185 DE = 34 DC = 38 MD = 370 States with Lowest % of Waivered MDs/DOs* Iowa = 1.6% Nebraska = 1.9% North Dakota = 2.3% Arkansas = 2.3% Kansas = 2.4% 198 HI = 163 GU = 2 MP = 1 PR = 528 VI = 2 States with Lowest % of Waivered NPs* Tennessee = 0% Alabama = 0.9% Nebraska = 1.0% Kansas = 1.0% Arkansas = 1.0% 49 HI = 24 PR = 0 GU = 0 MP = 0 VI = 0 *Not including U.S. Territories SAMHSA August 2018 *Not including U.S. Territories SAMHSA August 2018 EVIDENCE OF COMPARABLE CARE NP VS. MD Evidence for Quality Improvement, high quality care Similar patient outcomes to physician-provided care Patients report high levels of satisfaction. NPs can address shortfall of primary care providers Empowering NPs to diagnose and prescribe without physician oversight is important to ensuring there is an adequate primary care workforce to serve this new population NPs are more likely than MDs to treat patients in settings where provider resources are scarce McCleery et al. Evidence Brief: The Quality of Care Provided by Advanced Practice Nurses Sep. In: VA Evidence-based Synthesis Program Evidence Briefs [Internet]. Washington (DC): Department of Veterans Affairs (US); EVIDENCE OF COMPARABLE CARE NP VS. MD Evidence for Quality Improvement, high quality care Similar patient outcomes to physician-provided care Patients report high levels of satisfaction. NPs can address shortfall of primary care providers Empowering NPs to diagnose and prescribe without physician oversight is important to ensuring there is an adequate primary care workforce to serve this new population NPs are more likely than MDs to treat patients in settings where provider resources are scarce McCleery et al. Evidence Brief: The Quality of Care Provided by Advanced Practice Nurses Sep. In: VA Evidence-based Synthesis Program Evidence Briefs [Internet]. Washington (DC): Department of Veterans Affairs (US); STATE OBAT TRAINING AND TECHNICAL ASSISTANCE (OBAT TTA) INITIATIVE IN CHCS: PROJECT GOALS ACCESS Expand treatment & access to buprenorphine Increase number of waivered MDs Increase number of individuals treated for opioid addiction Integrate addiction treatment into primary care settings DELIVERY Modeled after BMC s Nurse Care Manager Program Focus on high risk areas, underserved populations SUSTAINABILITY Effective delivery model for buprenorphine Post-program funding Develop a long-term viable funding plan Collect & analyze outcomes data NALTREXONE 53 9

10 NALTREXONE Full MU opioid receptor ANTAGONIST Very high affinity for opioid receptor EXTENDED RELEASE INJECTABLE NALTREXONE (VIVITROL) FDA approved October 2010 for Opioid Dependence Approximately day duration Office setting: Not a scheduled medication and therefore does not require a special licensure, certification, or waiver to prescribe. There is no limit to the number of patients that a provider could legally treat with naltrexone. No opioid effect NALTREXONE BENEFITS Blocks the effects of all opioids for the duration of the medication Long acting One pill last 24hrs, One injection lasts 28 days Generally well tolerated Naltrexone is not an opioid No dependence or withdrawal Helps prevent relapse Helps with Alcohol Available in office-based treatment settings Naltrexone group 72% successfully inducted Patients not inducted on medication Patients successfully inducted XRN VS. BUPE Patients less likely to successfully start naltrexone than bupe. Buprenorphine group 94% successfully inducted Slide courtesy of NYC DOHMH Born with decreased pain tolerance with higher risk of opioid addiction Opioid addiction altered nervous system resulting in lower pain tolerance Opioid Debt Patients who are physically dependent on opioids (i.e. methadone or buprenorphine) must be maintained on daily equivalence before ANY analgesic effect is realized with opioids used to treat acute pain Opioid analgesic requirements are often higher due to increased pain sensitivity and opioid cross tolerance Patients on buprenorphine/naloxone maintenance should be comanaged with their buprenorphine/naloxone provider during the pre- and post-procedure period. Peng PW, Tumber PS, Gourlay D: Can J Anaesthesia 2005 Alford DP, Compton P, Samet JH. Ann Intern Med

11 OPIOID AGONIST THERAPY Methadone or Buprenorphine (Subutex) Reduces risk for overdose death by 70% Not recommended to wean off in pregnancy Stable dose of opioid for the fetus Decreased risk for fetal distress, preterm birth, growth restriction, and pregnancy loss NEONATAL ABSTINENCE SYNDROME An individual pathologically pursues reward and/or relief by substance use Drug addicted newborns -> Substance exposed newborns PROTECTIVE FACTORS SCREENING AND TREATMENT FOR OPIOID USE DISORDER 64 HAVING DIFFICULT CONVERSATIONS VALUE OF MEDICATION FOR ADDICTION TREATMENT (MAT) Foundation is to establish rapport Attitude Non-judgmental, curious, empathetic Respectful Recognize adversity Recognize strengths Use non-stigmatizing language Ask permission Honesty Medicaid medical costs decreased by 33 % over 3 years following engagement in treatment Decline in expenditures: hospitals, emergency departments, and outpatient services Baltimore study 50% decrease mortality with buprenorphine and methadone treatment Massachusetts decrease ED, and hospital admissions with retention in treatment Alford DP, LaBelle CT, Kretsch N, et al. Arch Int Med. 2011;171: Walter, L. et al (2006). Medicaid Chemical Dependency Patients in a Commercial Health Plan, Robert Wood Johnson Foundation, Princeton, New Jersey Schwartz et al. American Journal of Public Health. 2013; 103(5): Medication for addiction treatment Overdose deaths ED and hospital admissions Medical costs PCSS,

12 % of patients in STATE OBAT Program 9/25/2018 MEDICATION TREATMENT SAVES LIVES! RESULTS: HEALTH CARE UTILIZATION OUTCOMES MA OBAT SITES JUL JUN 30, 2017 (N=3,309) In Baltimore, , increased availability of methadone and buprenorphine was associated with ~50% decrease in fatal overdoses 6.7% In Tx 12 P= % 20.5% In Tx 12 mos. P< % In Tx >12 mos. Retention in OBAT Inpatient, ED admissions In Tx >12 mos. Schwartz et al. American Journal of Public Health. 2013; 103(5): night inpatient hospital (past 3 mos.) 1+ ED visit (past 3 mos.) RESULTS: URINE TOXICOLOGY OUTCOMES MA OBAT SITES JUL JUN 30, 2017 (N=3,309) RESULTS: RETENTION IN TREATMENT JULY 2016 JUNE 2017 (N=3,309) 25.2% In Tx 12 mos. P< % 15.2% In Tx 12 mos. P< % 23.0% In Tx 12 mos. P< % Retention in OBAT Positive urine toxicology screens Retention in treatment at MA DPH funded OBAT Sites Retained in care 12 months 44.8% 55.2% Retained in care >12 months In Tx >12 mos. In Tx >12 mos. In Tx >12 mos. Illicit opioids (past 3 mos.) Cocaine (past 3 mos.) Benzodiazepines (past 3 mos.) WE HAVE SHOWN SUCCESS SCALING IN MASSACHUSETTS AND ARE NOW SHARING OUR LEARNINGS NATIONALLY NIDA CTN-0074: Primary Care Opioid Use Disorders Treatment (PROUD) Trial Testing BMC Nurse Care Manager Model against standard of care in 6 health systems nationwide in ~10,000 patients

13 OVERDOSE EDUCATION Recommended for all persons at risk for overdose Risky opioid use and OUD Prescribed Opioids Especially if >100mg morphine equivalent daily Concurrent CNS depressants Individuals who have at risk persons in their life AN EVOLVING EPIDEMIC REQUIRES FLEXIBILITY AND INNOVATION Harm reduction approach: low threshold Treatment on demand: ED*, walk in, open access Expanding buprenorphine through mid-level providers Prescriptive authority of NPs in all states Prescriptive authority for all NPs under DATA 2000 (e.g., CNM) Interventions targeted to needs of high-risk populations Use of technology: (ECHO), Telemedicine/Telehealth, Electronic Prescribing, webbased resources 74 TECHNOLOGY AS A TOOL FOR WORKFORCE DEVELOPMENT Between Apr 2017 and Apr ,222 unique individuals have visited OBAT TTA website (bmcobat.org) 16,293 total sessions 74,012 total page views OBAT TTA website visitors from: 58 countries 49/50 of States 222 unique municipalities across Massachusetts LEVERAGING TECHNOLOGY: OBAT TTA WEBSITE AND RESOURCES LEVERAGING TECHNOLOGY: ADDICTION ECHO (EXTENSION FOR COMMUNITY HEALTHCARE OUTCOMES) HUBS AT BMC OBAT TRAINING AND TECHNICAL ASSISTANCE Using teleconferencing technology, primary care providers connect to other learners and expert Hub teams Hub and spoke model increases access to specialty care Community providers learn from specialists Community providers learn from each other Specialists learn from community providers as best practices emerge Two main components of all teleecho clinic: 1. Brief didactic presentation 2. Case-based learning ( pt. case by spoke participant) Boston Medical Center's (BMC) Office Based Addiction Treatment (OBAT) Training and Technical Assistance (TTA) provides education, support and capacity building to community health centers and other health care and social service providers on best practices caring for patients with substance use disorders. BMC OBAT TTA offers free addiction trainings across Massachusetts for health care and social service providers. We host scheduled trainings in various locations around the state, including: Introduction to Addiction and Treatment Essentials of Office Based Addiction Treatment Buprenorphine Waiver Training for Prescribers Overdose Education and Prevention Certified Addiction Registered Nurse (CARN) Review Course And more To register for a scheduled training event, request a training event for your organization, or request technical assistance from our experienced addiction treatment team, please visit:

14 EVERY NURSE IS AN ADDICTIONS NURSE All nurses face the challenges of caring for patients with substance use disorder and have the opportunity to change the stigma regarding substance use. Many nurses may have not received sufficient education about substance use disorder and its treatment. Nurses are in front line positions to provide assessment for patients with substance use histories and subsequently connect them to resources that save lives. Nurse engagement can influence positive outcomes when individuals with substance use disorder are reaching out for resources and treatment. 79 Painter, THE WAY FORWARD Most trusted Profession At every entry point in Health care 4.1 Million Nurses In the United States Remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to the full extent of their education and training. Increase the proportion of nurses with a baccalaureate degree to 80 percent by Ensure that nurses engage in lifelong learning. Nurses should be full partners with physicians and other health professionals, in redesigning health care in the United States. Prepare and enable nurses to lead change to advance health. 81 Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. (2011). 82 AN EVOLVING EPIDEMIC REQUIRES Investment in proven models of care and a workforce to implement them Flexibility Responsive to current and changing needs Change Agents Innovation Nurses will continue to play key role in addressing the current epidemic of addiction and overdose deaths. 83 Funded SAMHSA Led by American Academy of Addiction Psychiatry (AAAP) with large consortium including ASAM Trainings and a clinical coaching programs, PCSS s mission is to increase healthcare providers knowledge and skills in the prevention, identification, and treatment of SUD with a focus on OUD 14

15 Learn More About Opioid Use Disorder Free Online Courses CME/CE Credit Harvard Medical School Faculty Best Practices & Latest Research Self-Paced and Modular SCOPE OF PAIN Free continuing medical and nursing education activities designed to teach safe and effective management of opioids for patients with chronic pain globalacademy.hms.harvard.edu/oudep3 TREATMENT IMPROVEMENT PROTOCOL (TIP) 2018 Reviews the use of the 3 FDAapproved medications used to treat OUD methadone, naltrexone, and buprenorphine and the other strategies and services needed to support recovery for people with OUD. May be ordered or downloaded from SAMHSA s Publications Ordering webpage at store.samhsa.gov 88 REFERENCES QUESTIONS? American Society of Addiction Medicine. (2011). Public Policy Statement: Definition of Addiction. Chevy Chase, MD: American Society of Addiction Medicine. Available at Broyles LM, Binswanger IA, Jenkins JA, et al. Confronting inadvertent stigma and pejorative language in addiction scholarship: a recognition and response. Subst Abus. 2014;35(3): CDC Opioid Overdose Information Dart RC 1, Surratt HL, Cicero TJ, et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med Jan 15;372(3): doi: /NEJMsa Degenhardt L 1, Bruno R 2, Lintzeris N 3, et al. Agreement between definitions of pharmaceutical opioid use disorders and dependence in people taking opioids for chronic non-cancer pain (POINT): a cohort study. Lancet Psychiatry Apr;2(4): doi: /S (15)00005-X. Epub 2015 Mar 31. LaBelle CT, Han SC, Bergeron A, Samet JH. Office-based opioid treatment with buprenorphine (OBOT-B): statewide implementation of the Massachusetts Collaborative Care Model in community health centers. J Subst Abuse Treat. 2016;60:6 13 US Department of Health and Human Services (HHS) Office of the Surgeon General, Facing Addiction in America: the Surgeon General s Report on Alcohol, Drugs, and Health. Washington, DC, HHS, November Walley AY, Alperen JK, Cheng DM, et al. Office-based management of opioid dependence with buprenorphine: clinical practices and barriers. J Gen Intern Med. 2008;23(9): doi: /s x. Colleen.labelle@bmc.org