During the presidential political season, it is often challenging to break through the activity to bring to the nation's attention an important health policy issue. Advocates and policymakers have successfully accomplished this with the opioid use and abuse issue in the United States. Although healthcare providers have been seeing the trends of opioid use and abuse in their practices, it was the January 1, 2016, Morbidity and Mortality Weekly publication announcing the statistics that galvanized the nation's concern for this growing epidemic. The unassuming title, "Increases in Drug and Opioid Overdoses Deaths-United States, 2000-2014," by Rudd et al1 certainly has put a spotlight on the pain management practices of healthcare providers. The statistics are stunning-since 2000, the rate of deaths from drug overdoses has increased 137%, including a 200% increase in opioid use-related deaths. This includes the use of opioids and heroin. (Heroin is entangled with the opioid statistics because opioid-addicted individuals may move to heroin if their supply of opioids is no longer available).
There are other important details in this study, such as the types of opioid and opioidlike drugs that are involved in the epidemic. There are natural and semisynthetic opioids, methadone, fentanyl, and other synthetic opioids, as well as heroin, that are implicated as the culprits of prescription opioid overdoses. The authors highlight that law enforcement has reported an increase in illicitly manufactured fentanyl-categorized as a synthetic opioid. Overall, the authors called for action in the prevention of opioid abuse, dependence, and death; the increased availability of treatment of opioid use disorders; and the need to address the illegally available heroin and fentanyl.
Pain is the most common reason for individuals to seek care from their healthcare provider. Because not everyone with pain seeks treatment, we can assume that there are individuals who seek methods to treat their own pain. This can range from taking someone else's leftover pain medication to using illicit drugs. The statistics show that this issue has been building; the Morbidity and Mortality Weekly article summarized the epidemic's proportions. Here are some highlights on what has been conducted on the policy side before and after the publication of this important study:
* In 2010, the Administration released its inaugural National Drug Control Strategy, which contains a wide array of actions and sets specific goals for reductions in drug use, including heroin. The strategy noted overdoses from opioids as a growing national crisis and directed the Department of Health and Human Services to assist healthcare providers and first responders with training on how to respond to overdose. In addition, for the first time, the strategy contained support for the overdose-reversal medication naloxone.2
* In 2011, the Administration published a Prescription Drug Abuse Action Plan, which announced the goal of reducing overdose deaths involving opioids by 15%. The plan supports the expansion of state-based prescription drug monitoring programs and more convenient and environmentally responsible disposal methods for unused opioid medications.3
* In August 2013, the Substance Abuse and Mental Health Services Administration released an Opioid Overdose Prevention Toolkit, which equips communities and local governments with materials to develop policies and practices to help prevent opioid-related overdoses and deaths. The toolkit addresses issues specific to first responders, treatment providers, and those recovering from opioid addiction.4
* The Obama Administration is also encouraging first responders to carry the overdose-reversal drug naloxone. When administered quickly and effectively, naloxone immediately restores breathing to a victim in the throes of an opioid overdose. Because police are often the first on the scene of an overdose, the Administration strongly encourages local law enforcement agencies to train and equip their personnel in the use of this drug. Used in concert with "Good Samaritan" laws, which grant immunity from criminal prosecution to those seeking medical help for someone experiencing an overdose, the use of naloxone is expected to decrease deaths due to opioid overdose.5
* The Centers for Disease Control and Prevention's (CDC) Guideline for Prescribing Opioids for Patients with Chronic Pain: This guideline is being heralded as the most currently available standard for primary care providers to use when they prescribe pain relief for their patients with chronic pain. The guideline does not cover treatment of chronic pain for patients with active cancer, palliative care, and end-of-life care. Primary care prescribers were targeted because prescription painkillers are prescribed by primary care and internal medicine doctors and dentists, not specialists. Roughly 20% of prescribers prescribe 80% of all prescription painkillers.6 The NACNS provided comments on these guidelines when they were published in draft. Our main concern was their recognition of the clinical nurse specialist (CNS) as a provider and a potential prescriber.
* The US Surgeon General announced the #TurnTheTide Campaign, which is a pledge designed for the 2.3 million healthcare providers, including nurses, to step forward to combat the opioid epidemic by treating pain appropriately. There is a public relations aspect of this initiative that includes tours by the Surgeon General to talk to community leaders about the strategies that have been most effective in facing the opioid crisis.7
* On September 16, 2016, President Obama announced the establishment of Prescription Opioid and Heroin Epidemic Awareness Week. In addition to calling for $1.1 billion more in funding for this epidemic, President Obama stated, "During Prescription Opioid and Heroin Epidemic Awareness Week, we pause to remember all those we have lost to opioid use disorder, we stand with the courageous individuals in recovery, and we recognize the importance of raising awareness of this epidemic" (Proclamation by President Obama, September 16, 2016, p 1).8
* The Office of Women's Health held a 2-day meeting on September 29 and 30 to discuss the issues specific to women and opioids. The meeting titled "Office on Women's Health (OWH) National Meeting on Opioid Use, Abuse, and Overdose in Women." This meeting attempted to highlight the complex factors that may add to a woman's use and abuse, including domestic violence.9 Many of the sessions from this meeting are available as YouTube videos.10
* Building on the national concern, in November 2016, the US Surgeon General Vivek H. Murthy, MD, MBA, Vice Admiral, US Public Health Service, released a national report on addiction, "Facing Addiction in America." This report provides a broad review of alcohol and drug addiction in America. The report not only characterizes the range of substances abuse but also includes a review of the neurobiology of substance abuse, use, misuse, and addiction. The report ends with a summary of the depth and breadth of the work being conducted on treatment and rehabilitation of abusers.11
The opioid use epidemic is an important public policy issue that requires a response from healthcare providers, and NACNS like many other associations has stepped forward to be involved in this work. On April 29, 2016, the American Association of Colleges of Nursing (AACN) announced an effort to have APRN schools of nursing take a pledge and enhance the education students receive with education based on the CDC's opioid prescribing guidelines. In addition, the AACN called for APRN groups, including NACNS, to join a coalition to combine efforts to provide quality continuing education to APRNs on these guidelines.12
The NACNS is actively engaged in working with national coalitions and providing information to members to improve the treatment of chronic pain while reducing the risk of increasing the opioid use and abuse epidemic. The coalition of APRN groups that planned the national nursing-focused opioid Webinar series was composed of NACNS, AACN, the American Association of Nurse Anesthetists, the American Association of Nurse Practitioners, the American College of Nurse-Midwives, the American Nurses Association, and the National Organization of Nurse Practitioner Faculties. This group developed an educational series for nursing faculty, students, and clinicians on prescribing and administering these crucial but easily abused drugs. These Webinars are free, have continuing education and pharmacology CE assigned, and are available at http://www.nacns.org/html/cont-ed.php. These Webinars are archived and may be accessed at your convenience. Please see the Sept/Oct NACNS CNS Communique for more details.13
The NACNS is a member of the Department of Health and Human Service Administration's External Opioid Working Group. This group meets to discuss how the organizations are working to disseminate the information on appropriate opioid prescribing practices to their members, as well as highlight other efforts to support the appropriate treatment of pain. The NACNS has joined the federal-level Coalition to Stop Opioid Overdose. This coalition was formed to bring advocates together to promote public policy to curtail the opioid overdose epidemic. This coalition will be engaged at the federal level in reviewing and advocating for legislation.
On September 21, 2016, NACNS announced the appointment of the Opioid/Pain Management Task Force. The charge of this task force is to identify resources that the CNS needs to address appropriate opioid use/pain management in their practice. The task force is also asked to make recommendations to the NACNS Board of Nursing for the practice, research, education, and legislative/regulatory committees to develop policy or resources to address this national healthcare crisis. Sharon Horner, PhD, RN, MC-CNS, FAAN, President of the NACNS commented, "Opioid addiction has become a public health crisis in our nation. Fortunately, clinical nurse specialists are well-positioned to take a leadership role in preventing and treating such addiction. We are so pleased to have these dedicated and experienced CNSs step up and take the lead in helping combat opioid abuse while ensuring that people get appropriate and necessary pain management" (NACNS Press Release, September 20, 2016, p 1).14
Other efforts NACNS has engaged in to raise awareness of the opioid epidemic and appropriate pain management techniques are the following:
* In our bimonthly (every other month) electronic membership newsletter, the CNS Communique has featured articles on the national opioid work in 2015 and 2016 and will continue to cover activity in this area in this publication. We have featured information from the CDC on naloxone and will be writing more articles to highlight the resources available for providers.
* Our 2015 Webinar series featured a Webinar on appropriate opioid use. We will also provide at least 2 sessions in our 2016 and 2017 Webinar series on pain relief/opioid issues.
* During our 2016 Annual Meeting on March 3 to 5, 2016, in Philadelphia, Pennsylvania, we devoted four 1-hour sessions to different aspects of pain management; of course, opioid use was a prominent part of these discussions.
* We have entered into an educational arrangement with the Association for the Advancement of Medical Instrumentation Foundation to provide CE seminars to our members. One of these sessions focuses on respiratory compromise related to in-hospital opioid use. This session will be archived and available through the Association for the Advancement of Medical Instrumentation Foundation and NACNS.
* The NACNS Legislative/Regulatory Committee is reviewing different bills introduced by the Congress related to the opioid issues. They will be recommending endorsement of specific legislation that supports the wise and efficacious use of opioids and other pain-related methodologies. In addition, we will work to ensure that the CNS is included whenever providers/prescribers are included in the legislation.
* At the July 2016 Board Meeting, the NACNS Board of Directors appointed a Task Force of NACNS CNS experts to help further identify how NACNS should respond to this important national epidemic. It is anticipated that this Task Force will work through 2017 to assess the needs of NACNS members related to the care of patients, need, pain management, and opioids.
The NACNS will continue to circulate information about resources, policy issues, and continuing education on this issue to our members. It is essential that all CNSs become aware of the impact of opioid use on your patient population and clinical specialty.
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