The value of harm reduction for injection drug use: A clinical and public health ethics analysis

The US is facing dual public health crises related to opioid overdose deaths and HIV. Injection drug use is fueling both of these epidemics. The War on Drugs has failed to stem injection drug use and has contributed to mass incarceration, poverty, and racial disparities. Harm reduction is an alternative approach that seeks to decrease direct and indirect harms associated with drug use without necessarily decreasing drug consumption. Although overwhelming evidence demonstrates that harm reduction is effective in mitigating harms associated with drug use and is cost-effective in providing these benefits, harm reduction remains controversial and the ethical implications of harm reduction modalities have not been well explored.This paper analyzes harm reduction for injection drug use using the core principles of autonomy, nonmaleficence, beneficence, and justice from both clinical ethics and public health ethics perspectives. This framework is applied to harm reduction modalities currently in use in the US, including opioid maintenance therapy, needle and syringe exchange programs, and opioid overdose education and naloxone distribution. Harm reduction interventions employed outside of the US, including safer injection facilities, heroin-assisted treatment, and decriminalization/legalization are then discussed. This analysis concludes that harm reduction is ethically sound and should be an integral aspect of our nation's healthcare system for combating the opioid crisis. From a clinical ethics perspective, harm reduction promotes the autonomy of, prevents harms to, advances the well-being of, and upholds justice for persons who use drugs. From a public health ethics perspective, harm reduction advances health equity, addresses racial disparities, and serves vulnerable, disadvantaged populations in a cost-effective manner.     

Understanding ED Buprenorphine Initiation for Opioid Use Disorder: A Guide for Emergency Nurses

Opioid use disorder is a critical public health problem that continues to broaden in scope, adversely affecting millions of people worldwide. Significant efforts have been made to expand access to medication therapy for opioid use disorder, in particular buprenorphine. As the emergency department is a critical point of access for many patients with opioid use disorder, the initiation of buprenorphine therapy in the emergency department is increasing, and emergency nurses should be familiar with the care of these vulnerable patients. The purpose of this article is to provide a clinical review of opioid use disorder and opioid withdrawal syndrome, medication treatments for opioid use disorder, best clinical practices for ED-initiated buprenorphine therapy, assessment of withdrawal symptoms, discharge considerations, and concerns for special populations. With expanded understanding of opioid use disorder, withdrawal, and available treatments, emergency nurses will be better prepared to deliver and support life-saving treatments for patients and families suffering from this disease. In addition, emergency nurses are well positioned to play an important role in public health advocacy around opioid use disorder, providing critical support for destigmatization and expanded access to safe and efficacious treatments.     

Hepatitis C in 2019: Are We There Yet?

Chronic hepatitis C is the most common blood-borne pathogen worldwide. Upwards of half of the individuals infected with hepatitis C have not been diagnosed, and rates of screening remain low. Incidence, which had been declining, began increasing in 2011, mirroring the current opioid epidemic. Once infected, people with chronic hepatitis C are at risk for developing complications including end-stage liver disease and hepatocellular carcinoma, leading to morbidity and mortality. These public health consequences of the hepatitis C epidemic are expected to increase over the coming decade. Innovation has resulted in highly tolerable medications of 8 to 16 weeks’ duration with over 90% efficacy. Experts have determined that the eradication of hepatitis C would be feasible and have laid out strategies to move us toward that goal. Significant and disparate barriers remain, including access to treatment and an increase in incidence related to the opioid epidemic. An underresourced approach to surveillance and screening, provider shortages, and payer restrictions are among the obstacles to eliminating hepatitis C as a public health problem in the United States.     

Slow release oral morphine versus methadone for opioid use disorder in the fentanyl era (pRESTO): Protocol for a non-inferiority randomized clinical trial

BackgroundNorth America is facing an unprecedented public health crisis of opioid-related morbidity and mortality, increasingly as a result of the introduction of illicitly manufactured fentanyl into the street drug market. Although the treatment of opioid use disorder (OUD) is a key element in the response to the opioid overdose epidemic, currently available pharmacotherapies (e.g., methadone, buprenorphine) may not be acceptable to or effective in all patients. Available evidence suggests that slow-release oral morphine (SROM) has similar efficacy rates as methadone with respect to promoting abstinence, and with improvements in a number of patient-reported outcomes among persons using heroin. However, little is known about the relative effectiveness and acceptability of SROM compared to methadone in the context of fentanyl use. This study aims to address this research gap.MethodspRESTO is a 24-week, open-label, two arm, non-inferiority, randomized controlled trial comparing SROM versus methadone for the treatment of OUD. Participants will be 298 clinically stable, non-pregnant adults with OUD, recruited from outpatient clinics in Vancouver, Canada, where the majority of the illicit opioids are contaminated with fentanyl. The primary outcome is suppression of illicit opioid use, measured by bi-weekly urine drug screens. Secondary outcomes include: treatment retention, medication safety, overdose events, treatment satisfaction, psychological functioning, changes in drug-related problems, changes in quality of life, opioid cravings, other substance use, and cost-effectiveness.DiscussionpRESTO will be among the first studies to evaluate treatment options for individuals primarily using synthetic street opioids, providing important evidence to guide treatment strategies for this population.     

Naloxone: a word of caution

Naloxone (Narcan), a semisynthetic opioid antagonist, has approved therapeutic use for the treatment of opioid-induced central nervous system depression. With the implementation of epidural and intrathecal opioid analgesia, naloxone has been used for the treatment of side effects associated with these methods of analgesia. Consequently, there has been greater utility of naloxone for postoperative orthopaedic, noncritical patients. Naloxone was thought to be devoid of any intrinsic activity and, therefore, thought to have few side effects. There have been several reports of cardiovascular complications associated with naloxone administration that have disputed this view. Since use of naloxone is increasing in orthopaedic nursing practice, orthopaedic nurses need to understand the potential complications associated with its use.     

Back With a Vengeance: The Reappearance of Methamphetamine and its Implications for Health Care Providers

A great deal of attention has been placed on the opioid epidemic that the United States is currently experiencing; however, a resurgence in methamphetamine (METH) use has been occurring during the past 5 years. METH is an addictive stimulant that primarily affects the central nervous system by increasing dopamine, norepinephrine, and serotonin. Ranking second to opioids, METH use has had a significant impact on mortality, morbidity, and health-related costs and remains a serious public health problem in the United States. Individuals who use METH often use an emergency department or community-based organization for health care. Therefore, nurses and other health care providers must be knowledgeable about the harmful physical and psychological health effects of METH.     

Opioid Use Disorder: Challenges During Acute Hospitalization

Opioid use is a major public health concern increasing the volume of need for medical care and the national tragedy of accidental overdose deaths. Patients with opioid use disorders have higher numbers of emergency department visits, acute hospitalizations, and complications secondary to opioid use. Acute care nurse practitioners are challenged to manage increasingly complicated patient encounters related to opioid use. This article addresses effective strategies for inpatient management of opioid use disorder including identification and the use of measurement-based tools, as well as providing supportive care.     

Managing Pain in the Setting of Opioid Use Disorder

Specific Clinical IssueHealthcare providers are challenged with managing pain and minimizing morbidity and mortality associated with opioid use disorder.Major Practice Recommendations Based on Best EvidenceThe purpose of this article is to guide acute and ambulatory care clinicians in managing pain in patients with opioid use disorder. Included in this article is a review of medications used for opioid use disorder, a discussion of the management of patients with active opioid use disorder and acute or chronic pain, and a discussion of the management of acute and chronic pain in people in recovery both on and off medications for opioid use disorder.     

Innovative Approaches to Educating Future Clinicians about Opioids,Pain, Addiction and Health Policy

BackgroundOpioid use disorder and overdose have reached unprecedented levels in many countries across the globe, including the United States, and pain is one of the most common reasons American adults seek healthcare. To address the interrelated public health crises of opioid use disorder and chronic pain, it is vital that clinicians practicing in diverse roles and settings possess the ability and knowledge to effectively manage pain, responsibly prescribe and monitor opioid analgesics, educate patients about harm reduction techniques, and treat opioid use disorder. However, future healthcare professionals are not receiving the training needed to competently provide this care. This gap in curriculum may lead to clinicians being unwilling and unprepared to address the current opioid and overdose crises, which requires a clinical understanding of pain and substance use disorders as well as knowledge about public health and policy interventions. To address this gap, we designed and are teaching an innovative transdisciplinary elective course titled “Opioids: From Receptors to Epidemic” for undergraduate nursing and premedical students.AimIn this paper, we present the course curriculum in detail, with the hope that educators at other institutions will design similar courses for their health professions students.     

The burden of chronic pain: A cross-sectional survey focussing on diseases,immigration, and opioid use

Chronic pain is currently considered a public health problem with high costs to the individual and society. To improve prevention and treatment of chronic pain, epidemiologic studies are mandatory for assessing chronic pain. The aims of this study were to estimate the prevalence of chronic pain in the adult Danish population and to analyze associated factors such as diseases, immigration, and opioid use. This cross-sectional survey combines individual-based information from the Danish Health Survey (2010) and official Danish health and socioeconomic, individual-based registers. The simple random sample consisted of 25000 individuals (?16 years old) living in Denmark. In all, 60.7% completed a mailed or online questionnaire. Associations were examined with multiple logistic regression analysis. The study population consisted of 14925 individuals in whom a high prevalence of chronic pain (26.8%, 95% confidence interval: 26.1 to 27.5) and a high prevalence of opioid consumption (4.5%) were observed. Other aspects of particular note: (1) a higher prevalence of chronic pain occurred among individuals with cardiovascular and chronic pulmonary diseases than among individuals with cancer; and (2) individuals with a non-Western background reported a higher pain prevalence, higher pain intensities, and more widespread pain than individuals with Danish background; however, opioids were more frequently used by native Danes. The prevalence of chronic pain as well as opioid use in Denmark are alarmingly high, and the relevance of opioid consumption is unknown.     

Exploring the effectiveness of a regional nurse practitioner led,long-acting injectable buprenorphine-based model of care for opioid use disorder

The introduction of long-acting injectable buprenorphine preparations for opioid use disorder has been widely heralded as a breakthrough treatment, with several studies indicating positive results when using these medications. In many locations, nurse practitioners prescribe, administer, and monitor long-acting injectable preparations. The objective of this paper is to explore whether a reduction in dispensed needles and syringes is attributable to increased nurse practitioner prescribing of LAIB. We used a retrospective audit of needles dispensed through the health service needle and syringe program vending machine, and individuals treated with long-acting injectable buprenorphine by the nurse practitioner led model. In addition, we examined potential factors that may influence changes in the number of needles dispensed. Linear regression found that each individual with opioid dependence treated with long-acting injectable buprenorphine was associated with 90 fewer needles dispensed each month (p < 0.001). The nurse practitioner led model of care for individuals with opioid dependence appears to have influenced the number of needles dispensed at the needle and syringe program. Although all confounding factors could not be discounted entirely, such as substance availability, affordability, and individuals obtaining injecting equipment elsewhere, our research indicates that a nurse practitioner led model of treating individuals with opioid use disorder influenced needle and syringe dispensing in the study setting.     

A randomized controlled trial of buprenorphine for probationers and parolees: Bridging the gap into treatment

BackgroundBuprenorphine can be effective in a variety of community substance use treatment settings outside of methadone programs, including outpatient programs and medical practices. In these settings, it has been found to be effective in reducing opioid use and retaining patients in treatment. Despite its effectiveness and safety, it is rarely provided to individuals with opioid use disorders in probation and parole settings.MethodsMale and female individuals under probation or parole supervision (N = 320) with histories of opioid use disorder will be enrolled in this randomized controlled trial. Participants will be randomized to one of two study arms: Buprenorphine Bridge Treatment (BBT): Participants will begin buprenorphine using the MedicaSafe dispensing device immediately after an on-site intake at a community supervision office and continue such treatment until they are transitioned to a community program; or Treatment as Usual (TAU): Participants will receive a referral to buprenorphine pharmacotherapy treatment in the community. Treatment outcomes will be: (a) illicit opioid oral saliva drug test results; and (b) treatment adherence (i. entered community based treatment; ii. number of days receiving opioid treatment).ResultsWe describe the background and rationale for the study, its aims, hypotheses, and study design.ConclusionsIf shown to increase compliance rates with conditions of probation and parole, buprenorphine treatment co-located at community supervision field offices could have a major impact on delivery of buprenorphine treatment to the criminal justice population. The public health impact of the proposed study would be widespread because this intervention could be implemented throughout areas of the US.     

Methodological issues in the evaluation of the quality of public health nursing: a case study of the maternal and child health centres in Hong Kong

The demand for the evaluation of the quality of patient and client care has increased in public health nursing as in all disciplines of nursing. In Hong Kong this demand led to the development of a collaborative study with the Department of Health to evaluate the quality of public health nursing in the maternal and child health centres. A multiple case study design was developed to undertake the research using both qualitative and quantitative methods of data collection. The findings from the study demonstrated not only implications for clinical practice which have been reported elsewhere, but also methodological issues for the evaluation of care. These findings indicate three major issues for consideration. The first issue is that of the cultural context of care which includes perceptions of care such as demands on the service and expectations of care. The second issue is the use of health data, including both the methods of recording as well as the sources of data. The final issue is that of the method of data collection, in particular the implications of the use of language in data collection tools. The findings suggest that both the use of professional language and the need for translation have implications for data collection methods. Indeed in the author's view the development of methodologies for the evaluation of care must address culturally specific issues, particularly where English is not the first language of subjects in the study. In addition the use the use of language in the method of data collection highlights more general issues raised by the use of translation in the collection and analysis of qualitative data.     

High burden and low awareness of toxoplasmosis in the United States

Toxoplasmosis, a disease with diverse clinical manifestations, caused by infection with the Apicomplexan parasite, Toxoplasma gondii (T. gondii), is a major source of morbidity and mortality in the United States. Although toxoplasmosis prevalence and mortality have declined over the past two decades, the CDC considers this disease a neglected parasitic infection requiring public health action. Here, we overview the literature to bring attention to the prevalence of the disease in the United States, and high economic burden associated with the disease. The conclusions to be drawn are clear: there is low awareness and underestimation of the disease burden amongst healthcare professionals; a high economic burden associated with the disease; relapse rates to treatment represent additional mortality and morbidity and further costs for the healthcare system; and better treatments are necessary to combat this public health threat.