The opioid epidemic knows no boundaries. It has devastated individuals and families across all socioeconomic, ethnic, age, gender, and regional demographics. This point was demonstrated at the Commission for Case Manager Certification's (CCMC's) 2018 New World Symposium, where one of our speakers asked an audience of several hundred case managers how many had been touched personally by the opioid crisis-a family member, a friend, a family they know. More than half of the hands in the room went up. Most recently, I learned that the daughter of a family known to my family had died of an overdose. This epidemic hits home and it hits hard.
Statistics tell a sobering story: More than 115 Americans die every day after overdosing on opioids. The number of opioid overdose deaths (involving prescription opioids and heroin) in 2016 was five times higher than in 1999 (Centers for Disease Control and Prevention [CDC], 2017). The National Institute on Drug Abuse has called the misuse of, and addiction to, opioids-including prescription pain relievers, heroin, and synthetic opioids such as fentanyl-a "serious national crisis that affects public health as well as social economic welfare" (2018, p. 1). Starting in the late 1990s, opioid pain reliever use began to escalate, leading to "widespread diversion and misuse" of these prescription medications, until it became clear that these substances, once recommended as nonaddictive, were in fact addictive (National Institute on Drug Abuse, 2018, p. 1). By 2015, an estimated 2 million people in the United States had a substance abuse disorder linked to prescription opioid pain relievers and 591,000 had a heroin use disorder (Volkow & Collins, 2017).
Misuse, abuse, and addiction to prescription opioids have been identified as driving forces behind fatal overdoses. The CDC observed,
The amount of prescription opioids sold to pharmacies, hospitals, and doctors' offices nearly quadrupled from 1999 to 2010, yet there had not been an overall change in the amount of pain that Americans reported. Deaths from prescription opioids-drugs like oxycodone, hydrocodone, and methadone-have more than quadrupled since 1999. (CDC, 2017, p. 1)
These escalating numbers are not only heartbreaking but also a call to action for policy makers and health care practitioners across the health and human services spectrum. Case managers, on the front lines of patient advocacy and care coordination, have an important role to play in this battle.
Hospital-based case managers encounter patients with opioid addictions. Sometimes, these individuals are brought to the hospital by paramedics; in other instances, those who are intravenous drug users may seek treatment for complications from injecting drugs. In maternity units across the country, health care teams including case managers, social workers, and pharmacists are dealing with a growing population of babies born with neonatal abstinence syndrome because of their mothers' use of opioids during pregnancy.
Education and support for patients and their families/support systems are vital responses, for both prevention and intervention. In acute care, case managers working closely with physicians, nurses, and pharmacists help educate patients who are prescribed opioid pain relievers following surgery or trauma. Education and support are equally critical in workers' compensation, outpatient procedures, primary care, and other settings where individuals may be prescribed opioids because of trauma or surgical pain. In addition, case managers provide resources and support for nonopioid pain management and for alternative therapies, from yoga to mindfulness to acupuncture (Carter, Watson, & Sminkey, 2014).
Across the spectrum of responses to pain management, education is crucial because "zero opioids" is not a practical answer, according to Mark Pew, senior vice president of PRIUM, an expert in the opioid crisis and intervention, who spoke at the CCMC's 2018 New World Symposium. As Pew wrote recently, a more appropriate response is to "evaluate the appropriateness of opioids on an individual basis" (Pew, 2017, p. 4). Pew's words such as "appropriateness" and "individual basis" underscore the role of the case manager, particularly those who are board-certified and have an ethical obligation to "serve as advocates for their clients and perform a comprehensive assessment to identify the client's needs; they will identify options and provide choices, when available and appropriate" (CCMC, 2017, p. 7).
Advocacy, education, care coordination, and identifying resources and support are at the heart of what professional case managers do for patients (the clients who receive case management services). These same principles and practices apply as case managers step up to the challenge of how to respond to the opioid epidemic. This is vitally important because we at the Commission hear regularly from professional case managers that they want to move beyond learning the statistics to understanding how to respond. Time and again, we hear, "We're case managers-We are here to help. What can we do better?"
From sponsoring education such as presentations at the Symposium to undertaking an in-depth article on the opioid crisis (see "Case Managers on the Front Lines of Opioid Epidemic Response," this issue), the Commission aims to contribute meaningfully to the discussion about the opioid epidemic. The discussion must be broad reaching, involving health care practitioners, policy makers, health plans, researchers, and other involved parties. A variety of interventions and potential solutions must be aired, even those that are unpopular or controversial. My home city of Philadelphia, for example, is implementing a plan to provide safe injection sites for drug users, giving users access to clean needles and providing medical intervention for those who overdose, while also encouraging them to seek treatment of addiction ("Heroin in Philadelphia," 2018).
Professional case managers must stay informed about developments in opioid addiction responses, from the latest research to new policies and procedures such as from The Joint Commission, Centers for Medicare & Medicaid Services, and others. The more current case managers are about the crisis and effective responses to it, the more they can contribute to interdisciplinary teams. As case managers communicate and coordinate, they must access expertise from multiple disciplines, including pharmacists, pain specialists, addiction specialists, private rehabilitation, and community-based support. The opioid epidemic needs the best that everyone has to offer to address life-or-death consequences on the individual basis and, more broadly, in terms of population health.
As Nora Volkow, director of the National Institute on Drug Abuse, and Francis Collins, director of the National Institutes of Health, observed,
Extraordinary focus is being brought to the opioid crisis by all segments of our society, so now is the time to leverage this awareness to accelerate the pace of research to develop new treatments. From the standpoint of NIH and NIDA, it is "all scientific hands on deck." NIH research can help end the crisis, and we are committed to doing so. (Volkow & Collins, 2017, p. 3)
The Commission and the more than 45,000 board-certified case managers currently in practice stand ready as well, with advocacy, education, support, and identification of resources that can make a difference in people's lives and improve population health.
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