The opioid epidemic continues to claim lives, disrupt families and challenge communities, but nurses are hardly standing idly by. In many settings, they are creating solutions, implementing new programs, and driving change that is good for nurses, patients, health systems and communities.
By Maggie Ginsberg
By now, the story of the opioid epidemic is brutally familiar and exhaustively documented: where it began, why it took hold and how it rages on. Although overdose deaths continue to rise—opioids accounted for two thirds of the 66,632 overdose deaths in 2016, an overall number up 21.5 percent from the previous year and now the leading cause of death in Americans under 50—the public health response is gaining traction.
The Comprehensive Addiction and Recovery Act of 2016 spurred states into action, and most now mandate compliance with their respective Prescription Drug Monitoring Programs. Federal funding for and access to Medication-Assisted Treatment and Opioid Overdose Reversal (naloxone) has increased. Prescriptions and “doctor shopping” are down, patient engagement is on the rise, and providers are ordering more comprehensive and varied pain treatment plans that focus on whole health. In fact, as more health care organizations implement multidisciplinary response protocols, the shape of the solution is looking especially familiar to nurses. Case management. Care coordination. The community and family as a patient.
Unfortunately, that doesn’t mean nurses are always invited to the high-level-planning and decision-making table, or that they’re given the necessary authority in the field.
“The definition of what is an epidemic, and the treatment of those things, speaks to everything nursing is. Nurses are uniquely positioned, but we’re not being utilized at high enough rates in these roles,” says Dr. Gina Bryan ’99, MS ’02, DNP ’12.
Bryan is an advanced practice psychiatric nurse who is also a clinical professor and director of the Post-Graduate Psychiatric Certificate Program and psychiatric mental health track of the DNP program. Active in state and national policy work regarding opioids and addiction, Bryan knows the data on opioids and addiction, and she knows the proposed solutions to stem the epidemic. In her work both in clinical settings and with legislators and other advocates, she sees a constant and concerning trend: a propensity to overlook the patient and community knowledge that nurses have.
“Bachelor-prepared registered nurses are by far the most underutilized health care providers in the health profession,” she says. “You have this group of uniquely educated people, meaning they’ve had all the science education, all the direct patient care education, plus they’ve had health policy, medical ethics, community-based health, population health, global health. There is no other health care provider educated like that.”
“We need to allow any high-quality, trained, educated healthcare provider to do their job to the full scope of their training and education, and that absolutely is implicated in substance use disorders and the opiate crisis. Because if people do not have access to treatment, we don’t slow down these epidemics.” —Dr. Gina Bryan, DNP, RN
Barriers to Accessing Opioid Medication-Assisted Treatment
As providers on the front lines, and the largest segment of America’s healthcare workforce, nurses spend the most face time, garner the most trust, and are arguably best positioned to assess which patients may need intervention. While the American Nurses Association has recommended expanding nursing’s role in addressing the nation’s opioid crisis, including expanding access to MAT, many states, including Wisconsin, still limit APRNs from prescribing MAT without an (often expensive) collaboration agreement with a physician. This limits access to treatment, particularly in rural communities where an APRN may be the only provider available.
“We need to allow any high-quality, trained, educated healthcare provider to do their job to the full scope of their training and education, and that absolutely is implicated in substance use disorders and the opiate crisis,” says Bryan. “Because if people do not have access to treatment, we don’t slow down these epidemics.”
Lisa Bullard-Cawthorne is the Prescription and Non-Prescription Opioid Harm Prevention Program Coordinator in the Division of Public Health at the Wisconsin Department of Health Services. She is currently part of a five-member team funded by the federal CDC’s Prescription Drug Overdose Prevention for States grant, tasked with community and healthcare interventions such as provider education on prescribing practices and overdose fatality reviews, improving the Prescription Drug Monitoring Program, policy evaluation particularly related to Naloxone, and efforts to provide comprehensive care for pregnant and postpartum women who use opioids. She says DHS works closely with other state agencies and has partnerships with pharmacy, medical and dental licensing and professional associations. Efforts have also included input from groups of advanced practice nurse prescribers, like Bryan, but Bullard-Cawthorne is not aware of formal channels for gleaning insight from RNs.
“I really do think that it’s important for nurses to be at the table,” says Bullard-Cawthorne. Her team examines root causes of substance use disorder, intersections with mental and behavioral health, equity and access to care, trauma or adverse childhood events—all things bachelor-prepared nurses are already trained to look for. “They’re a really important team member, and they’re usually the first providers to develop a rapport and relationship with a patient, and so I think there’s a huge role.”
Formal partnerships aside, Bullard-Cawthorne has seen the way involving nurses has elevated various projects, such as providing valuable perspective in the multidisciplinary Overdose Fatality Reviews with the Department of Justice and community partners. When the PDMP was updated to the ePDMP in 2017, one of the critical shifts was that providers can now assign delegates—nurses—to check the PDMP for them. The PDMP has its limits, and nurses are uniquely positioned to dig deeper with each patient. They can recognize a history of use disorder, know to ask whether a woman of reproductive age plans to get pregnant, or pick up red flags for contraindicative prescriptions that could
prove fatal in combination with opioids.
“Nurses in their traditional role care about the person as a whole being,” says Bullard-Cawthorne. “They’re asking questions about the rest of that person’s life, not just isolating a symptom.”
“While we met some resistance or skepticism from the older patient population, it also opened up a whole new conversation with them about safe handling and dependence and efficacy. I think they responded better to nursing because we spent more time with them explaining the whys, and they felt less threatened by nurses doing the agreements.” —Rita Swanson, RN, Monroe Clinic
A Nurse-Led Shift in Care Delivery
In 2012, before the changes ushered in by CARA or the existence of Wisconsin’s PDMP, Rita Swanson and her colleagues were facing a problem like none they’d ever seen.
Swanson is a registered nurse and population specialist practicing at Monroe Clinic, where she has worked for 19 years. While Monroe Clinic is headquartered in its namesake rural Wisconsin community, it has satellite locations throughout southern Wisconsin and northern Illinois. Swanson was in family practice at the Freeport, Illinois, branch when the opioid crisis hit there. As the epidemic took hold, it created a sense of urgency as patients struggling with addiction were increasingly interacting with the clinic. “It was getting so that they were calling us three, four times a day, and it was so time consuming for nurses. We saw escalating behaviors. I don’t want to say threatening, but they were pretty aggressive in their calling. And there was a lot of fragmentation in the care, too.”
The staff organized. In an effort Swanson says was led by nurses, they formed a multidisciplinary team that invited doctors, pharmacists, risk management and marketing specialists to strategize solutions. They collaborated with the medical practice and executive committees to get as much input as possible. The result was the Chronic Pain Management Agreement, which Monroe Clinic instituted system-wide, and which Swanson says has been a true game changer.
“While we met some resistance or skepticism from the older patient population, it also opened up a whole new conversation with them about safe handling and dependence and efficacy,” she says. “I think they responded better to nursing because we spent more time with them explaining the whys, and they felt less threatened by nurses doing the agreements.”
With some exceptions such as post-surgical and hospice patients, all who are prescribed opiates must sign a CPMA that holds both providers and patients accountable for their care. The extensive agreement not only reinforces the goals of chronic pain management and educates patients on alternative interventions, it also turns patients into accountability partners. What began as a time saver for nurses has translated into stronger patient relationships. Swanson also says having a CPMA in place gives nurses a way to act on the information they glean about patients through assessment and interaction. It provides an authority and autonomy they were lacking before, and it gives them a sense of agency in addressing the opioid crisis.
“Nurses didn’t always feel comfortable approaching a provider to say hey, let’s get a urine drug screen on this person,” says Swanson. It also relieved the pressure for those times when patients would call and needle the nurses to fill prescriptions early, a difficult position for natural caretakers whose first instinct is to help relieve their patients’ pain. “Now it was like, sorry, this is the agreement. It took the onus off the nurse as the bad guy.”
A National Model for Opioid Risk Mitigation
Veterans are one of the opioid epidemic’s hardest hit populations, reporting chronic pain at two to three times the rates of civilians. Sixty percent of veterans of operations in Iraq and Afghanistan report chronic pain, as do 75 percent of all female veterans, so it follows that rates of opioid prescription have historically, naturally, been higher. In 2014, the U.S. Department of Veterans Affairs launched its Opioid Safety Initiative, and in 2018, they rolled out the Stratification Tool for Opioid Risk Mitigation (STORM), resulting in a progressive pain management response that could serve as a model for civilian healthcare.
STORM is a dashboard that synthesizes everything from a patient’s medical history to his or her mental health, comorbidities including other medications aside from opioids, and more—essentially anything that helps nurses assess whether a patient would be at higher risk for overdose or suicide if an opioid were prescribed. STORM also suggests risk mitigation strategies based on individual patient information, and it is linked to all EMRs throughout the country, ensuring continuity of care.
“Instead of looking at prescriptions and what opioid doses patients were on, we’re now looking more at patients and what puts them at higher risk for potential overdose, intentional or unintentional,” says Emily Anderson ’07, a registered nurse and case manager for the multidisciplinary pain clinic at the William S. Middleton Memorial Veterans Hospital in Madison. Anderson advises providers and sees patients, who now receive a comprehensive pain assessment and a more tailored treatment plan to ensure safe and effective use of opioids.
“Looking specifically at individual patients and their risk factors is where I think nurses can really play a role,” says Anderson, citing the strong relationships built with patients from pre-op education to post-op follow-up care. “There’s a huge amount of trust in the nursing staff. Nurses are uniquely poised to provide this education. We have a unique perspective and unique training as far as patient education goes, that other disciplines simply don’t have.”
She says although the Madison VA was not overwhelmed by the opioid crisis, STORM has helped the hospital effectively reduce prescriptions. But, Anderson cautions, the issue is not that simple. Reducing prescriptions is not necessarily the end goal, and an overemphasis on prescription rates could prove harmful in other ways. For example, a recent national VA report says patients are at increased risk of suicide and overdose in the six months immediately following initiation or discontinuation of chronic opioids.
“They’re not benign medications, and taking them away is not necessarily a benign process,” Anderson says. “It’s a fragile, potentially destabilizing time, and I think we need to look at each patient individually and assess function overall.”
While looking at the whole patient aligns naturally with nursing education, the Madison VA’s Rochelle Carlson MS ’89 says there is still a significant learning curve when it comes to treating pain.
“In my era, as healthcare providers and as nurses, we were trained that pain is a fifth vital sign, and that we should really focus on treating pain,” says the advanced practice nurse who is the VA’s chief nurse overseeing most of the 50-some practicing APRNs in Madison. “That all came at a time when we were taught that there was no evidence that addiction would be a significant issue if we gave patients opioids to control non-cancer pain. But what we were taught then isn’t true now, and our focus on pain at the time helped create the perception that we could make patients pain-free.”
“Looking specifically at individual patients and their risk factors is where I think nurses can really play a role. There’s a huge amount of trust in the nursing staff. Nurses are uniquely poised to provide this education. We have a unique perspective and unique training as far as patient education goes, that other disciplines simply don’t have.” Emily Anderson, RN, case manager, multidisciplinary pain clinic, William S. Middleton Memorial Veterans Hospital, Madison
A Holistic Approach to Chronic Pain Management
Instead of trying to eliminate a patient’s pain, nurses now work to help patients manage pain while restoring function. This shift required both providers and veterans to reevaluate their expectations. It also necessitated addressing mental health, since stress, anxiety and depression can either manifest as or exacerbate pain. Overall, it is a move away from thinking about symptom relief and toward a more holistic approach to wellbeing—something intrinsic to nursing practice, which makes nurses well suited to this kind of approach.
“I think as nurses and nurse practitioners, we have always tried to look at the whole person, but now we have more tools to do that,” says Carlson. “We are learning to work with our other colleagues like pharmacy and mental health and some of the other whole-health professionals, and they are helping us to learn more. We’re learning about other complementary and alternative ways to treat pain, like talking to patients about yoga and meditation. Some of our nurse practitioners are even learning more specifically about battlefield acupuncture.”
Patients at the VA can also opt to enroll in something called Pain University, which further educates them about the vast non-pharmaceutical pain management strategies and engages them in decision making regarding their care. Pain University includes group sessions, mindfulness practices, and opportunities to learn yoga, tai chi and other body work practices. It is part of the whole-health wellness framework that the VA has been using to help veterans recognize that the vast majority of their healthcare occurs outside the clinic and hospital, and also to empower veterans to adopt behaviors that promote health.
Jim Williams served in the army in the early 1970s. Although he avoided combat in Vietnam, he developed debilitating hip and lower back pain a decade ago. His service qualified him for VA benefits. He had several surgeries to address the cause of his distress and various other health issues. While he had some improvement, he continued to struggle with pain despite a prescription for the maximum dose of the opiate Tramadol. Eventually his mental health began to deteriorate.
Upon the recommendation of his care team, Williams found his way to a mental-health group therapy class affiliated with Pain University. From there he began to explore a wide range of VA wellness programming. He started with a mindfulness and body movement class and soon was driving regularly to Madison from South Beloit to take tai chi, yoga twice a week, and art classes.
Earlier this year Williams successfully stopped taking Tramadol, graduated from Pain University, and went back to work for the first time since 2009. He credits the breadth of programming, and particularly the new ways of thinking he learned in Pain University, for the vast improvements he has seen in his health and his life. “I was on my opiate for five years—the max load,” he says. “I didn’t think I could get off it. But this has been life changing. I am able to do things I thought I wouldn’t do again.”
Ultimately, Carlson says, that is what the program is about: helping veterans learn not only how to handle their pain, but also to recognize how much power they have to make personalized changes in their behaviors, habits and mindset that improve their overall quality of life.
“Really our goal is to use all of the tools to provide a more individualized approach to help patients manage their pain,” Carlson says, “to think about everything: their function, their sleep, their physical activity—everything.”