1. Sofer, Dalia


Clinicians contend with a crisis of addiction as solutions remain elusive.


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About 3.8 million American teens and adults reported misusing prescription pain relievers in 2015, and nearly 329,000 said they had used heroin, according to results of a Substance Abuse and Mental Health Services Administration survey published in 2016. In 2017, according to the Centers for Disease Control and Prevention (CDC), more than 70,000 people died of an opioid overdose-an increase of 9.6% from 2016.

Figure. Ashley Gardn... - Click to enlarge in new window Ashley Gardner takes a dose of methadone at an opiate addiction treatment center in Chatsworth, Georgia. Gardner said her addiction started in the seventh grade when she wanted to numb the pain after a sexual assault. Photo by Kevin D. Liles / The Associated Press.

The overprescription of opioids was a major trigger of this current crisis, and the history of this practice has come to be better understood in recent years. In the 1990s, opioid medications were hailed as a panacea for the treatment of chronic pain. Recognizing an opportunity, pharmaceutical companies dispatched their sales representatives with incentives such as gifts and free meals, with the intention of influencing prescribers' practices. The plan worked: by 2006, notes the CDC, the rate of opioid prescriptions was 72.4 per 100 people, peaking in 2012 at 81.3. As the number of prescriptions rose, however, so did the death rate from drug overdoses for all age groups-from teens to older adults-and among both men and women. Even newborns have not been spared: every 15 minutes, a child enters the world with neonatal abstinence syndrome, a collection of problems experienced by babies who were exposed to substances such as opioids during pregnancy.



Prescription practices have somewhat improved in the last three years. In 2017, the number of opioid prescriptions decreased to 58.5 per 100 people-a 19% reduction from 2006. But, as noted in JAMA Psychiatry in 2018, improving prescribing practices is not enough. Additional measures, including greater availability of medication-assisted treatment and consideration of psychiatric comorbidities, are also crucial.


As early as 2000, Congress passed the Drug Addiction Treatment Act to facilitate medication-assisted treatment, allowing qualified physicians to prescribe narcotic controlled substances, such as buprenorphine, by applying for a waiver of the registration requirements defined in the Controlled Substances Act. The 2016 Comprehensive Addiction and Recovery Act expanded these prescription privileges to qualified NPs and physician assistants for five years (until October 1, 2021), provided their state allows them to prescribe these medications. But many prescribers haven't obtained the waiver, and many of those who have don't prescribe to capacity. The reasons, according to a study published in 2017 in the Journal of Substance Abuse Treatment, vary, ranging from providers not believing in agonist treatment to a lack of time for additional patients to insufficient reimbursement rates.



"Substance use disorder still hasn't been fully accepted as a disease," says Michael Desjardins, APRN, PMHNP-BC, a psychiatric NP and cofounder of Comprehensive Medical Addiction and Psychiatric Services, an outpatient medical and mental health clinic in Draper, Utah. "We're still treating this illness with the 1930s approach of a 12-step program." In his practice, Desjardins provides psychotherapy and medication management-including substance abuse detoxification and stabilization. He partners, when necessary, with inpatient treatment centers. Desjardins believes physicians' reluctance to offer medication-assisted treatment is an obstacle to helping patients cope with and eventually become free of addiction. Another hurdle, he says, is health care practitioners' lack of consideration of the complexity of addiction.


Not least among contributors to the opioid crisis, according to Desjardins, is polypharmacy. He recalled a patient with substance use disorder who kept coming to him with symptoms of psychosis. Though she was already taking multiple psychotropic medications, the patient repeatedly turned to her primary care provider for Adderall, which she said she needed for adrenal fatigue. Adderall (a combination of amphetamine and dextroamphetamine) can induce psychosis, but her physician kept prescribing it. "To fully address addiction," says Desjardins, "you need to build relationships with patients. But this requires time, which primary care physicians typically don't have."


A lack of insurance reimbursement and funding also exacerbate the treatment landscape. In 2016, the Affordable Care Act improved access to substance use disorder treatment through coverage expansion and a requirement that coverage of this type be as complete as that offered for any medical and surgical procedure. Yet, insurance coverage still falls short. Desjardins says it's not unusual for someone with a 10-year history of heroin use to be covered for only three days at a treatment center, after which approval for an extension must be obtained from the insurance company's physician-a person nicknamed "Dr. No," Desjardins quips, because the request is always denied.


The detrimental effects of a lack of funding are also seen when patients with substance use disorders stop answering calls from visiting nurses, says Erica Barratt, BSN, RN, a visiting nurse in Fairhaven, Massachusetts. Data from the National Institute on Drug Abuse places Massachusetts among the top 10 states with high opioid overdose deaths. These patients, she explains, eventually fall through the cracks, because after several attempts to contact them, nurses must move on-there just aren't enough resources to keep following up. A lack of funding can thus propel a vicious cycle in which withdrawal from society, which is a behavioral consequence of addiction and must be addressed if healing is to occur, can't be adequately dealt with unless resources are available for services such as those provided by visiting nurses.


Adding to the confusion is the absence of standardization of pain management. In January 2018, the Joint Commission implemented new pain assessment and management standards for its accredited hospitals. The revised protocol includes several new requirements: identifying a leader or leadership team responsible for pain management and safe opioid prescribing; involving patients in developing their treatment plans and setting realistic expectations and measurable goals; promoting safe opioid use by identifying and monitoring high-risk patients; facilitating clinician access to prescription drug monitoring program databases; and conducting performance improvement activities that focus on pain assessment and management. But these protocols, while laudable on paper, don't always materialize in reality. "Everyone is afraid," says Barratt, "and clinicians aren't sure when to prescribe pain medication, sometimes even denying a patient who truly needs it."



In the meantime, the number of people using opioids keeps rising and will likely continue to do so unless underlying psychiatric issues are addressed. Currently, synthetic opioids (including fentanyl, fentanyl analogs, and tramadol, excluding methadone) are causing the most havoc: from 2016 to 2017, the rate of drug overdose deaths involving these drugs increased by 45%. Heroin, too, is still widely used-the death rate attributed to heroin increased from 0.7 per 100,000 people in 1999 to 4.9 in 2016, where it remained in 2017. And, as Desjardins explains, people with addiction get creative. An herb named kratom, widely available on the Internet, has of late become popular for its potential psychotropic effects. Some patients are even using megadoses of the antidiarrheal drug loperamide to induce a high or cope with withdrawal symptoms.


And what of nurses themselves? About 10% of nurses are estimated to be dependent on drugs and alcohol. In a growing number of states, nondisciplinary alternatives, such as diversion programs, are available to nurses who have substance use disorders. These programs allow nurses to stay at treatment centers until they are fully rehabilitated and can safely return to practice. But there is no easy way out of this morass. As Desjardins says, "People are in pain, not just physically, but also emotionally." And unless this is recognized, we will likely continue in an endless loop-chasing the next panacea, followed by its antidote.-Dalia Sofer