Expanding access to nurse-managed medication for opioid use disorder

BackgroundAdvanced practice registered nurses (APRNs) are increasingly caring for individuals with opioid use disorder. Advances have been made to increase APRN education, outreach, and prescribing privileges, but as demand for medication for opioid use disorder (MOUD) grows, evidence suggests that policy and care barriers inhibit the ability of APRNs to support MOUD.PurposeThis paper highlights the significant challenges of expanding access to buprenorphine prescribing by APRNs.FindingsBarriers and recommendations were derived from the culmination of literature review, expert consensus discussions among a diverse stakeholder panel including patient representatives, and feedback from community webinars with care providers.DiscussionWe provide an overview of existing care barriers, promising practices, and proposed recommendations to enhance the care of individuals and communities with opioid use disorder.     

A novel social work approach to emergency department buprenorphine induction and warm hand-off to community providers

Study objectiveMedications for opioid use disorder (MOUD) is considered gold standard treatment for persons with an opioid use disorder and can be successfully initiated in emergency departments (EDBUP). Perceived provider barriers to EDBUP adoption include increased provider work, lack of provider knowledge about outpatient MOUD resources, and a lack of viable MOUD treatment options within health systems. We evaluated the feasibility of a novel EDBUP institutional design that utilizes the social work team to drive ED care for patients with OUD and coordinate MOUD referral to existing community resources.MethodsThis is a retrospective, cohort, single-center study describing patient outcomes in a social work driven EDBUP program with referral to community MOUD providers. ED patients with OUD were identified via patient request, standardized nurse screening, or ED provider concern. All identified patients received an urgent social work consult to explore willingness to seek treatment for OUD. Social workers developed individualized follow up plans with participating patients. Clinical data was abstracted from the Electronic Health Record. Social workers tracked continuity with outpatient MOUD services in a clinical care database.ResultsFrom June 1, 2018 through August 31, 2019, 120 patients opted for ED buprenorphine induction. 61% presented to initial outpatient intake appointment and 39% remained engaged in treatment after 30 days.ConclusionsEDs can effectively utilize the expertise of social workers to drive EDBUP and coordinate outpatient MOUD referrals. Our interdisciplinary EDBUP program structure is feasible and has the potential to yield meaningful reductions in physician workload and ED cost.     

Emergency Nurse Perceptions of Pain and Opioids in the Emergency Department

The opioid crisis is a national health emergency with immense morbidity, mortality, and socioeconomic cost. Emergency department (ED) pain management is tightly linked to the issue of opioid use disorder (OUD), because opioid exposure is necessary for development of OUD. Emergency nurses are on the frontlines of this complex problem, yet little, if any, attention has been paid to the role they play in the prevention and management of either pain or OUD in this unique and important setting. A framework that conceptualizes and optimizes emergency nurses as change agents in the opioid epidemic is urgently needed. While ED pain management and OUD prevention is dependent on the entire care team, this innovative study qualitatively characterizes emergency nurse perceptions of pain management, OUD prevention, and their potential role in each. Content analysis produced 14 categories that were clustered into two themes, “nurses influence ED pain management” and “adjustments in ED pain management”, and an overarching message that “pain management depends on the care team.” By generating a more comprehensive and nuanced understanding of the role played by emergency nurses, our findings provide essential insights into potential interventions and frameworks.     

Recommendations for Emergency Departments Caring for Persons with Opioid Use and Opioid Use Disorders: An Integrative Review

IntroductionThe emergency department is a primary portal to care for persons after an opioid overdose and those with an opioid use disorder. The aim of this integrative review was to provide best practice recommendations for nurses caring for this highly stigmatized and often undertreated population.MethodsAn integrative review was conducted using studies focusing on adults treated with opioid agonist-antagonist medications in the emergency department. The integrative review method by Whittemore and Knafl was used to guide this review and enhance its rigor.ResultsTwelve studies were included in the review. Opioid care begins with identifying opioid use risk, followed by implementing tailored strategies including opioid agonist-antagonist treatment if indicated, referral to treatment when warranted, and follow-up opioid use monitoring when feasible. Eleven recommendations provide guidance on integrating best practices into routine emergency care.DiscussionThe emergency department is an ideal setting for addressing the opioid crisis. Nurses can use the recommendations from this review to lead system change and more effectively manage the care of persons with opioid use and opioid withdrawal, and those at risk for opioid overdose.     

Arguments for and Against a New Diagnostic Entity for Patients With Chronic Pain on Long-Term Opioid Therapy for Whom Harms Outweigh Benefits

The goal of this study was to understand perspectives on whether a new diagnostic entity, distinct from Diagnostic and Statistical Manual – 5 (DSM-5) opioid use disorder (OUD), is needed for patients with chronic pain on long-term opioid therapy (LTOT) for whom the harms of continued opioid therapy outweigh the benefits. Data were collected as part of a larger Delphi study. We used rapid and thematic qualitative methods to analyze data from 51 panelists with expertise in internal medicine, psychiatry, psychology, and related fields. Three-quarters of panelists supported a new diagnostic entity; common themes included recognizing distinct experiences of patients prescribed LTOT, addressing problems with DSM-5 OUD criteria, facilitating research and improved treatment, and reducing stigma. Thirteen panelists opposed the creation of a new diagnostic entity; common themes included similarities in biological underpinnings of patients prescribed LTOT and diagnosed with OUD, belief that the continuum of OUD captured patients’ experiences, finding better ways to address problems with DSM-5 OUD criteria, and concerns about stigma. While this expert panel disagreed about the need for a new diagnostic entity, there was an overall acknowledgement that the current implementation of DSM-5’s OUD diagnosis is not meeting the needs of LTOT providers or patients.PerspectiveThe DSM-5’s OUD diagnosis may not adequately meet the needs of patients on LTOT for whom the harms of continued opioid therapy outweigh the benefits. Experts do not agree on how to address this problem; more work is needed to determine if a new diagnostic entity would be beneficial.     

Improving access to care through Advanced Practice Registered Nurses: Focus on perinatal patients with Opioid Use Disorder

Perinatal substance use disorders, and all of the associated sequelae, continue to be a national health crisis that is further impacted by shifts in access to obstetrical care, particularly in rural areas. Opioid Use Disorder (OUD) specifically presents as a medical condition for which evidence‐based guidelines support the use of medication treatment for opioid use disorder (MOUD) in the form of Methadone or Buprenorphine for both non‐pregnant and pregnant women. However, the overall rates of access for those treatment modalities remain sparse. There is a public call to increase access to MOUD in the pregnant population affected by OUD. This article discusses the history of the Advanced Practice Registered Nurse (APRN) and how across legislative differences, these professionals are perfectly positioned to answer this call.     

How Patient Education Influences Utilization of Nonpharmacological Modalities for Persistent Pain Management: An Integrative Review

ObjectivesOpioid analgesic misuse and abuse has given rise to an epidemic that has added to an increase in opioid-related overdoses and deaths. Adults with persistent noncancer pain (PNCP) are primarily treated with opioid analgesics. Many remain on these medications long term. Most of these patients are unaware of other effective measures for managing PNCP, such as nonpharmacologic modalities (NPMs). This lack of familiarity with NPMs presents a key contributor to the problem of NPM underuse among adult PNCP patients. This integrative review sought to identify key factors that contribute to NPMs underuse and the effect of education on patients’ adoption or use for PNCP management.DesignIntegrative review.Data SourcesA literature search was conducted using PubMed, CINAHL, Embase, Cochrane, and hand-searching of the literature published between 2002 and November 2017.Review/Analysis MethodsSystematic screening using the Johns Hopkins Nursing evidence appraisal tools yielded articles that were analyzed and synthesized to identify themes, and patterns.ResultsNineteen research articles were identified with these main themes: NPMs are effective in PNCP management, lack of familiarity with NPMs influences patients’ willingness to try them, and access to local NPMs must be addressed to facilitate use.ConclusionsFindings suggest that patient education about NPMs has the potential to motivate patients to try these modalities, which may increase overall use of NPMs for PCNP. Nurses could play a vital role in ensuring evidence-based NPMs are introduced to PNCP patients, which could increase patients’ use of these measures and improve outcomes.     

Perceptions about mindfulness-based interventions among individuals recovering from opioid and alcohol use disorders: Findings from focus groups

ObjectivesMindfulness-based interventions (MBIs) have been used as an intervention to support recovery from alcohol use disorder (AUD) and opioid use disorder (OUD). We sought to identify attitudes and experiences toward standardized MBIs among individuals recovering from these substance abuse disorders (SUD) through a qualitative approach.DesignWe conducted three 60-minute focus groups among people with history of SUD (6-months to 3 years in recovery): two groups with those with alcohol use disorder (AUD) history and one with individuals with history of opioid use disorder (OUD). Each group had eight participants.ResultsMost participants of the OUD focus group had tried some variations on mindfulness training or meditation-like therapies during treatment. Participants expressed perceived benefits for MBIs’ non-pharmacological property, while expressing concerns related to perceived barriers of cost, scheduling conflicts with work and child/family care needs, and possible lack of provider empathy. Gift cards and other rewards were recognized as useful participation and retention incentives for completing the described program; the training itself was perceived as an “incentive” if able to deliver significant benefits related to supporting continued recovery from SUD. An overarching theme across all groups was that participants reported their own altruistic behavior and social connectedness as important motivators to help them maintain recovery.ConclusionThe importance of perceived provider empathy and the patient’s social connectedness in SUD interventions was underscored as incentives for participation and retention, providing valuable information for the implementation of MBIs among patients recovering from SUD.     

A Scoping Review of Nursing's Contribution to the Management of Patients with Pain and Opioid Misuse

BackgroundNursing brings a unique lens to care of patients with pain and opioid misuse.AimsThis scoping review describes nursing's contribution to the literature on the management of patients with pain and opioid misuse, generating evidence to guide clinical care.DesignThe scoping review was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews guideline.Data SourcesUsing combined key terms (“opioid misuse,” “pain,” “nursing”) in systematic searches in PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) electronic databases, snowball technique, and personal knowledge resulted in 108 relevant articles, reports, and websites.Analysis MethodSummative approach to content analysis was used to quantify and describe nursing's contribution to the literature.ResultsContributions of nurses emerged in the areas of research, clinical practice, policy, and education. The highest number of publications addressed research (50%, 54 of 108), whereas the fewest number of publications involved education (7%, 8 of 108).ConclusionResults provide a picture of the breadth of expertise and crucial leadership that nurses contribute to influence management of patients with pain and opioid misuse.Implications for NursingThis scoping review indicates the importance of continued support from key stakeholders, including training and interprofessional collaboration opportunities supported by the National Institutes of Health, to sustain nursing's contribution to quality care of patients with pain and opioid misuse. Ultimately, all health care professionals must collaborate to conduct rigorous research and construct evidence-based guidelines to inform policy initiatives and education strategies to solve the complex co-occurring epidemics of pain and opioid misuse.     

Are Opioid Risk Evaluation and Mitigation Strategies (REMS) Interrupting Your Sleep?

ABSTRACT

The article entitled “Risk Evaluation and Mitigation Strategies (REMS) for Extended-Release and Long-Acting Opioid Analgesics: Considerations for Pain and Palliative Care Practice” that appears in this issue of the journal addresses the important new Food and Drug Administration (FDA) REMS program. This commentary expands on themes introduced by Dr. Gudin, projects future directions for REMS, and discusses possible benefits, limitations, and risks associated with the extended-release long-acting opioid REMS.     

Sedation - Effects of disorders of abuse on therapeutic efficacy (SEDATE): A retrospective cohort study

BackgroundThe impact of alcohol or opioid use disorders on medication dosing for procedural sedation in the emergency department (ED) is unclear, as most of the literature is from gastrointestinal endoscopy. Exploring how these patient factors affect sedative and analgesic medications may inform more nuanced sedation strategies in the emergency department.MethodsThis was a retrospective chart-review cohort study across five EDs from 2015 to 2020. Included were adult patients who underwent procedural sedation in the ED, categorized into three a priori groups: alcohol use disorder (AUD), opioid use disorder (OUD), and individuals with neither (non-SUD). Wilcoxon test was used to compare the time-averaged dose of agents between groups. Logistic regression was used to model multi-agent sedations. The propofol time-averaged dose was the primary outcome. Secondary outcomes included other agents, sedation duration, and switching to other agents.Results2725 sedations were included in the analysis. 59 patients had a history of AUD, and 40 had a history of OUD. Time-averaged doses of medications did not differ significantly between AUD and non-SUD patients. Likewise, patients with OUD did not receive different doses of medications compared to non-SUD. The propofol doses for non-SUD, AUD, and OUD were 0.033 IQR 0.04; 0.042 IQR 0.05; and 0.058 IQR 0.04 mg/kg*min, respectively. Sedation duration was not different across groups. Having AUD or OUD is not associated with increased odds of requiring multiple sedative agents.ConclusionAlthough sedation in patients with AUD or OUD may be associated with significant case bias, these patient factors did not significantly alter outcomes compared to the general population. This study suggests there is no evidence to proactively adjust medication strategy in ED patients with AUD or OUD.     

The SOMATICS collaborative: Introduction to a National Institute on Drug Abuse cooperative study of pharmacotherapy for opioid treatment in criminal justice settings

BackgroundAmong the nearly 750,000 inmates in U.S. jails, 12% report using opioids regularly, 8% report use in the month prior to their offense, and 4% report use at the time of their offense. Although ample evidence exists that medications effectively treat Opiate Use Disorder (OUD) in the community, strong evidence is lacking in jail settings. The general lack of medications for OUD in jail settings may place persons suffering from OUD at high risk for relapse to drug use and overdose following release from jail.MethodsThe three study sites in this collaborative are pooling data for secondary analyses from three open-label randomized effectiveness trials comparing: (1) the initiation of extended-release naltrexone [XR-NTX] in Sites 1 and 2 and interim methadone in Site 3 with enhanced treatment-as usual (ETAU); (2) the additional benefit of patient navigation plus medications at Sites 2 and 3 vs. medication alone vs. ETAU. Participants are adults with OUD incarcerated in jail and transitioning to the community.ResultsWe describe the rationale, specific aims, and designs of three separate studies harmonized to enhance their scientific yield to investigate how to best prevent jail inmates from relapsing to opioid use and associated problems as they transition back to the community.ConclusionsConducting drug abuse research during incarceration is challenging and study designs with data harmonization across different sites can increase the potential value of research to develop effective treatments for individuals in jail with OUD.     

Nursing Education in the Midst of the Opioid Crisis

ObjectivesThe current opioid addiction crisis highlights two chronic health conditions which have traditionally received relatively little emphasis in nursing curricula: addiction and chronic pain. In an effort to provide direction to nursing programs in the US on the curriculum needed to prepare students to care for patients and meaningfully intervene in the opioid crisis, this paper presents an overview of the curricular elements which require integration.Design and Data SourcesSpecifically, the state of current nursing education in pain and addiction are reviewed, followed by foundational knowledge for nursing practice to address the opioid crisis.Review/Analysis MethodsPractice competencies for generalist registered nurses as well as advanced practice nurses will then be detailed, and, recognizing the role nurses play in policy development and implementation, policy interventions to address the opioid crisis will also be presented.Result and ConclusionsBoth addiction and chronic pain are sources of suffering for patients; the key role nursing can play in reducing the experience of these illnesses in these vulnerable populations is critical to addressing the opioid addiction crisis.     

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.