Secondary Logo

A Population Health Approach to America's Opioid Epidemic

Salmond, Susan; Allread, Virginia

doi: 10.1097/NOR.0000000000000521
Original Articles
Open
CE

The United States is in the midst of a nationwide public health emergency: an epidemic of opioid misuse and abuse that has been called the deadliest drug crisis in American history. This article reviews the current status of the opioid epidemic, the trends over the last 30-40 years that may have contributed to the epidemic, and a population health approach to addressing the epidemic. The epidemic is conceptualized from a population health perspective—an upstream and midstream perspective focusing on prevention and a downstream perspective targeting access to evidence-based interventions and maximizing health whether using or abstaining. Within the context of acute care, this approach will include patient screening for opioid use and other risk factors for addiction, use of opioid-sparing analgesics, and follow-up care that addresses pain and pain relief without opioids. For individuals who need addiction treatment, a gradualism philosophy is put forward. Gradualism recognizes the incremental nature of behavior change and recommends strategies to maximize health and functioning—through harm reduction—at all points along the journey to overcome addiction. Working within communities to address the broad factors that contribute to opioid-related substance use disorder is also essential.

Susan Salmond, EdD, RN, ANEF, FAAN, Executive Vice Dean and Professor, School of Nursing, Rutgers, The State University of New Jersey, Newark, NJ, and Research Editor for Orthopaedic Nursing.

Virginia Allread, MPH, Executive Assistant, School of Nursing, Rutgers, The State University of New Jersey, Newark, NJ.

The authors certify that they have no affiliations with or involvement in any organization or entity that has influenced the development of this article.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

The misuse of and addiction to opioids, including prescription opioids, heroin, and synthetic opioids such as fentanyl, is a serious problem that affects not only the health of many Americans but social and economic welfare of our country (National Institute on Drug Abuse [NIDA], 2018a). Across America, “individuals, communities and health care systems are struggling to cope with substance use, misuse, and substance use disorders” (U.S. Department of Health and Human Services, 2016, p. 1) and the problem is becoming deadlier than ever. In 2013, the U.S. Department of Health and Human Services declared the misuse of prescription opioids an epidemic. In October 2017, President Trump declared the opioid epidemic a national public health emergency (Mercia, 2017). It is critical that all clinicians understand the scope of the opioid epidemic and recognize that medical treatment, although important, is only part of the solution. Awareness of upstream, population, and community health approaches to arrest the growing epidemic is needed.

Back to Top | Article Outline

Current Status of the Opioid Epidemic

Opioid addiction includes the abuse of prescription, nonprescription, and illegal pain relievers that are derived from the opium poppy plant or man-made using the same chemical structure. Opioids include oxycodone, hydrocodone, codeine, fentanyl, tramadol, morphine, and heroin. The current opioid crisis is officially the deadliest drug crisis in American history (Katz, 2017). Nearly 200 Americans die each day from drug overdose (NIDA, 2018b). In August 2018, the NIDA reported that there were more than 72,000 drug overdose deaths in the United States in 2017. This is more than four times the rate of overdose deaths from 1999. Drug overdoses are now the leading cause of death for Americans under the age of 50 years. Overdoses killed more Americans in 2017 than guns (37,400), car accidents (38,000), or breast cancer (40,000) (Cullen, 2017). Recent UN data show that although America has around 4% of the world's population, it experiences 27% of the world's drug overdose deaths (United Nations Office on Drugs and Crime, 2016).

The overdose rate has increased an average of 10% per year from 1999 to 2006, when the epidemic slowed down, increasing just 3% per year from 2006 to 2014. The number of drug overdose deaths began to rise again from 2014 to 2016, increasing by 18% per year; the increase from 2016 to 2017 was 13%. This increase is primarily attributable to the use of synthetic opioids, particularly illicit fentanyl either alone or mixed with other opioids such as heroin (Centers for Disease Control and Prevention [CDC], 2018).

Drug overdoses are a nationwide problem as evidenced by the national overdose death rate of 19.8 in 2016; however, there is significant variation in rates between and within states. The states with the lowest drug overdose death rates are Iowa (10.6), North Dakota (10.6), Texas (10.1), South Dakota (8.4), and Nebraska (6.4). The four states with the highest age-adjusted drug overdose death rates were West Virginia (52.0), Ohio (39.1), New Hampshire (39.0), and Pennsylvania (37.9) with the District of Columbia rounding out the top five (38.8). Twenty-six states experienced statistically significant drug overdose death rate increases from 2015 to 2016—all were in the Northeast, Midwest, and South, and none were in the West (Hedegaard, Warner & Minino, 2017).

Back to Top | Article Outline

Demographics of the Opioid Crisis

A closer examination of who is dying from opioid overdose shows that rates are higher for males than for females, although women aged 40–64 years represent the fastest growing demographic for rates of death and emergency department visits (Brandeis University Heller School for Social Policy and Management, 2013). Death rates increased for all age groups, upending the myth that the opioid crisis is solely or even primarily an issue affecting young people. As shown in Figure 1, opioid overdose rates were highest for persons aged 25–34 (34.6 per 100,000), 35–44 (35.0), and 45–54 (34.5) years.

Figure 1

Figure 1

Seventy-nine percent of individuals who overdose on opioids are non-Hispanic White, 10% are Black and non-Hispanic, and 8% are Hispanic (Henry J. Kaiser Family Foundation, 2018). Some attribute this to the fact that providers are more cautious in prescribing opioids to non-Whites perhaps from unconscious bias and prejudices that non-Whites were more likely to abuse or sell drugs (Hansen & Netherland, 2016). Consequently this “white privilege” led to Whites being more likely to get prescription opioids and the subsequent rise in opioid use, addiction, and overdose in the White population. In the past several years however, the rate of overdose death for Blacks has been rising as the pattern of the epidemic shifts from being primarily about opioid pain killers and more about heroin and fentanyl (Hansen & Netherland, 2016).

Beyond age and race, individuals who exhibit mental health conditions like anxiety and depression are three times more likely to use opioids. In a cross-sectional study using data from the Medical Expenditure Panel Survey for 2011 and 2013, it was found that of the 38.6 million Americans with anxiety and depression, 7.2 million or 18.7% took opioids (as compared with 5% in individuals who did not have anxiety or depression). Translated, this means that adults with mental health conditions receive about 51.4% (60 million of 115 million prescriptions) of the total opioid prescriptions given each year (Davis, Lin, Liu, & Sites, 2017).

The depression–opioid connection may be linked to what some have argued—that opioid overdose deaths may, in fact, be “deaths of despair,” similar to suicides and alcoholic liver disease (Dasgupta, Beletsky & Ciccarone, 2018). Examining death rates, economists have found that the hardest hit have been white Americans without college degrees in rural areas and regions where manufacturing and construction jobs have been decreasing over the past decades. Financial strain associated with job loss and wage stagnation is associated with pain, distress, social dysfunction, and desperation and may explain why these areas have the starkest increase in premature mortality due to preventable deaths (Case & Deaton, 2017 ; Hoban, 2017).

Another at-risk group for possible opioid misuse are individuals with physical ailments—a back or knee injury, for example—for which a narcotic analgesic is prescribed as well as patients who have had surgical procedures. Højsted and Sjøgren's (2007) literature review of addiction to opioids in patients with chronic pain reported that up to 50% of patients who take opioids for chronic noncancer pain become addicted. An older but one of the few prospective studies on the problem reported that 24% of patients who were taking opioids for chronic pain for an average of 36 months became addicted (Bouckoms et al., 1992). Brummett et al. (2017) found that of 36,177 surgical patients, the incidence of new persistent opioid use after surgical procedures was between 5.9% and 6.5%. They also found that the incidence did not differ between major and minor surgical procedures. Even when opioids were prescribed for low-pain, outpatient, or short-stay surgeries, there was an increased risk of persistent opioid use. They concluded that persistent opioid use can be considered one of the most common complications after elective surgery.

Back to Top | Article Outline

Tip of the Iceberg

One must keep in mind that overdose deaths are the most visible and easily enumerated symptom of this crisis, the proverbial tip of the iceberg. The portion of the iceberg above the water represents the approximately 72,000 deaths per year; the portion of the iceberg below the water's surface represents the number of nonfatal overdoses (estimated to be 30 nonfatal overdoses for every opioid-related death; Hsu, 2017) as well as the many biopsychosocial and economic consequences of opioid use. A 2003 Australian study estimated that the ratio of nonfatal to fatal overdoses is 31.3:1 (with a range of 23.8:1–37.5:1; Darke, Mattick, & Degenhardt, 2003). Generalizing the study to the United States would mean that more than 2.26 million people experienced a nonfatal drug overdose in 2017.

Although most individuals recover from the effects of an opioid overdose, some have persistent long-term consequences, including injuries such as fractures, muscle tissue breakdown, peripheral neuropathy, kidney failure, heart problems, seizures, nerve damage, temporary motor paralysis, fluid build-up in the lungs, pneumonia from inhaling vomitus, stroke, and other neurological consequences (Clark, 2014). Larochelle et al. (2018) examined overdose survivor data and found that there was an increased risk of death in the 12 months after an overdose.

Opioid misuse impacts one's ability to concentrate, causes mood fluctuations, and is likely to be accompanied by changing interests as drug cravings become compulsive. This leads to social consequences, which often encompass job loss, relationship changes, divorce, and isolation from friends, family, and normal activities. Other indirect consequences of opioid misuse include risky behaviors that impair judgment and contribute to driving under the influence, unprotected sex, and needle/syringe sharing. Using 2013 data, it was estimated that America's prescription opioid epidemic cost our country $78.5 billion, including $26 billion in healthcare (Florence, Luo, Xu, & Zhou, 2016). That number is most certainly much higher today.

Back to Top | Article Outline

Context Leading to the Opioid Epidemic

The term “opioid epidemic” conflates two related issues: one is the misuse and abuse of prescription drugs, and the other is the abuse of illegal opioid drugs such as heroin and fentanyl. A history of the current epidemic, as well as a description of the natural history of addiction for the typical overdose victim, is warranted.

It is well established that the roots of our current opioid epidemic date back to the 1980s when physicians were incorrectly reassured that the risk of addiction was low when opioids were prescribed for chronic pain. A one-paragraph letter appeared in the New England Journal of Medicine in 1980 claiming that there were only four cases of documented addiction out of 11,882 patients who were given at least one narcotic preparation. The article concluded that “despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction” (Leung, MacDonald, Stanbrook, Dhalla, & Juurlink, 2017). Despite the fact that this short article was not evidence-based, it has been cited hundreds of times in the literature and even more often by representatives of drug manufacturers (Meier, 2007) who used it to aggressively market drugs like OxyCotin (oxycodone HCL). Likewise, the Joint Commission, in a book published in 2000 targeting doctors as part of required continuing education seminars, cited studies claiming, “there is no evidence that addiction is a significant issue when persons are given opioids for pain control” (Moghe, 2016); the book was sponsored by Purdue Pharma. It is now widely accepted that addiction is a significant issue when prescribed for pain.

Others have also blamed the increasing use of opioids for chronic pain on the more recent emphasis on pain as the fifth vital sign (Mandell, 2016 ; Volkow, 2014. May 14). In the mid-1990s, the American Pain Society aggressively encouraged the concept of pain as the fifth vital sign. Their aim was to raise awareness that patients with pain were undertreated, in part because pain was not regularly assessed in either primary or tertiary care. In late 1990s, the Joint Commission and others who joined the campaign emphasized that pain needs to be assessed regularly and that as pain is a subjective measure, that providers should respect patient self-reporting of pain. Given that providers were told that prescription opioids were unlikely to be addictive, the number of prescriptions in the United States skyrocketed from about 76 million in 1991 to nearly 207 million in 2013 (Volkow, 2014).

Another aspect of the opioid epidemic that is often raised, but not understood, is the role that patient satisfaction plays in “over”-prescribing. Patient satisfaction is one of the pillars of patient-centered care. Although patient feedback generally promotes improvements in care and practice, it may, at the same time, promote overprescribing of unnecessary medications, including opioids and other addictive medications. A study by Fenton, Jerant, Bertakis, and Franks (2012) concluded that “In a nationally representative sample, higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall healthcare and prescription drug expenditures, and increased mortality.” Not that anyone would recommend treating patients in a way that decreased their satisfaction with the care they receive, but it does emphasize the importance of following evidence-based guidelines and excellent patient–provider communication, particularly when following the guidelines means making a decision with which your patient might disagree.

Americans consume prescription opioids at a greater rate than any other population in the world (Humphreys, 2018). The United States consumes almost 100% of the world's hydrocodone and 81% of the world's oxycodone (Volkow, 2014). The CDC reported that between 1999 and 2010 there was a fourfold increase in opioid prescriptions. In 2012, providers wrote 259 million prescriptions for analgesics, enough for every American adult to have their own bottle of pills (CDC, 2014). In a study examining chronic pain and opioid use in developed and underdeveloped countries, the United States was found to have similar age standardized prevalence of chronic pain as in France and Italy. However, per capita daily opioid consumption was 6–8 times more in the United States than in Italy (6,246) and France (8,706) (Humphreys, 2018), with a staggering per capita figure of 50,142 (Humphreys, 2018).

One of the unanticipated problems with the level of prescribing is the volume of prescribed opioids diverted for recreational use. Drug diversion occurs when unused prescription drugs are stolen from home medicine cabinets (typically by family or friends), when medication is traded at school, and when drugs are shorted “(undercounting), pilferage, and recycling of medications at pharmacies”; as a result of the illegal sale of prescriptions by providers and pharmacists; when patients “doctor shop” wherein patients visit multiple physicians to obtain multiple prescriptions; when prescriptions are “doctored”; and from theft or cross-border smuggling (Inciardi, Surratt, Lugo, & Cicero, 2007). Hydrocodone and oxycodone are the most frequently diverted opioids followed by fentanyl, hydromorphone, and methadone. Lankenau et al. (2012) interviewed a sample of young, urban injection drug users and found that 86% had used opioids recreationally before using heroin, and their initiation into recreational use was characterized by three main sources of opioids: family, friends, or personal prescriptions.

The availability of opioids is not surprising when one considers that 72% of opioids prescribed after general surgery go unused. Hill, McMahon, Stucke, and Barth (2017) speculated that providers overprescribe because they do not know how many pills most patients actually take to relieve postoperative pain and tend to estimate on the basis of the needs of the patients requiring the most. Another reason might be the desire to avoid the inconvenience (to both the patient and the provider) of a return trip to obtain a refill; this is particularly an issue in rural communities where patients might live far from their provider. Unused opioids left in the medicine cabinet are easy fodder for diversion. Data from the CDC (2017, par. 6) state that “Most people who abuse prescription opioids get them for free from a friend or relative.” Individuals at the highest risk of overdose “get opioids using their own prescriptions (27%), from friends or relatives for free (26%), buying from friends or relatives (23%), or buying from a drug dealer (15%).”

Back to Top | Article Outline

The Connection Between Prescription Drugs and Heroin

Diversion, misuse, and abuse of opioids resulted in a 493% increase in the rate of opioid use disorder between 2010 and 2016 (Lopez, 2017). Prescription medications make up about 63% of overdose cases (Hedegaard et al., 2017). Cicero, Ellis, Surratt, and Kurtz (2014) did a retrospective analysis of heroin use in the United States over the past 50 years and documented a shift over the last two decades in the demographics of heroin users from an inner-city, minority population to one of a wider suburban geographical spread, involving primarily White women and men in their late 20s. Of note is that approximately 75% of heroin users in treatment started their opioid misuse with prescription analgesics.

Muhuri, Gfroerer, and Daies (2013) pooled data from the National Survey on Drug Use and Health, the primary source of statistical information on the use of illicit drugs, alcohol, and tobacco by the U.S. civilian noninstitutionalized population aged 12 years or older and reported that the incidence of heroin initiation was 19 times higher among people who reported prior recreational pain reliever use. Similarly, a 2015 CDC report found that people who are addicted to prescription opioids are 40 times more likely to be addicted to heroin. Figure 2 shows that the connection between heroin use and use of pain killers is stronger than with alcohol, marijuana, and cocaine.

Figure 2

Figure 2

Trajectory analysis of patterns of recreational use of prescription opioids shows that people generally start with oral opioids. As tolerance develops to oral opioids, the individual must use more medication to achieve the same effect (Compton, Jones, & Baldwin, 2016). An alternative to the expense of using more medication is changing the route of administration. More powerful effects can be achieved through inhalation, smoking, or injection. A shift to illegal opioids such as heroin may ultimately occur as it is readily available, more potent, cheaper, and easier to manipulate for nonoral administration (Compton et al., 2016).

Despite the fact that the majority of current heroin users have a history of using prescription opioids nonmedically prior to heroin use, the trajectory from recreational opioid use to heroin use is the exception, rather than the rule. Muhuri et al. (2013) reported that 3.6% of recreational opioid users initiated heroin use within 5 years after beginning recreational use of prescription opioids; Jones, Mack, and Paulozzi (2013) found a rate of 4.2%. Although these percentages are small, the fact that there are a large number of recreational users means that several hundred thousand persons may be on a trajectory to heroin use. According to national surveillance data, 914,000 people reported heroin use in 2014, a 145% increase since 2007 and mortality due to heroin overdose more than quintupled, from 1842 deaths in 2000 to 10,574 deaths in 2014 (Compton et al., 2016). In 2016, prescription drugs were involved in 23% of all deadly overdoses, heroin in about a quarter, and synthetic opioids such as fentanyl played a role in nearly a third (Kounang, 2017). In 2017, fentanyl was responsible for nearly 42% of overdose deaths (NIDA, 2018a). So, although the bulk of overdose opioid deaths are from illegal drugs, many of the individuals addicted to street drugs actually started, innocently enough, with a prescription as the “gateway drug.”

Back to Top | Article Outline

Where Is the Epidemic Heading?

Despite intensive efforts to reduce the risks from prescribed opioids with prescribing guidelines, prescription-monitoring programs, and other risk mitigation programs, the opioid epidemic is worsening. However, the illicit manufacturing of synthetic opioids has presented a new, more dangerous problem. In 2016, synthetic opioids surpassed prescription opioids as the leading cause of drug overdose deaths. Increased availability of illicitly manufactured fentanyl and heroin laced with fentanyl (100 times more potent then morphine and 50 times more potent then heroin) (The Recovery Village, 2018) and carfentanil (10,000 times more potent and deadly with a dose the size of a grain of salt) (“A New Front,” 2016) is a major treatment and public health crisis. The potency of fentanyl and carfentanil presents multiple dangers. Individuals are often unaware of the potency of what they are taking, leading to accidental overdosing on fentanyl-laced heroin and synthetic opioids (Hayes & Manos, 2018). This presents treatment challenges: individuals tolerant to such high-potency opioids may appear to be resistant to naloxone when in fact they need extremely large doses (Rao & Nelson, 2017).

Stopping the deadly trend in the use of highly potent synthetic opioids will require stopping the inflow of synthetic opioids. A recent Senate Homeland Security subcommittee investigation found that synthetic opioids are readily available and cheap and can be purchased on the web (darkweb) predominantly from China and delivered through the U.S. Postal Service, which does not have the regulations that private carriers have requiring information about packages (where it is from, where it is going, and what is in it) (Portman, 2018).

Back to Top | Article Outline

Addressing the Epidemic: A Focus on Population Health, Prevention, and Risk Reduction

Given the status of the epidemic, nearly everyone knows someone (or knows someone who knows someone) who is addicted or has died from an opioid overdose. Those who do not know anyone personally certainly know of celebrities who have died from opioid abuse—Tom Petty, Philip Seymour Hoffman, Bruce Lee, Elvis Presley, Heath Ledger, and Prince, to name a few. Many of us wonder what we can do to help, personally and professionally.

Efforts must be taken to consider the opioid crisis from a population health perspective from an upstream and midstream perspective focusing on prevention to a downstream perspective targeting access to evidence-based interventions and maximizing health whether using or abstaining. This requires proactive partnerships across sectors involving government agencies, healthcare clinicians and providers, pharmaceutical industries, police and judicial personnel, emergency management personnel, and individuals and families within the community. Such coalitions can examine their own population/community to address prevalence, disparities, root causes, system and care gaps, and community knowledge and attitudes to prevent opioid misuse and abuse, implement evidence-based policies and treatment practices, and ensure that there are affordable and accessible community-based treatment and recovery supports.

Traditional approaches to addiction therapy have mandated abstinence from all drugs. This has left individuals who were using but unwilling or unable to abstain outside the care system, exposed to growing risks because of the dangers associated with opiate use. A newer philosophy known as gradualism has gained greater recognition in the addiction field (Brandeis University Heller School for Social Policy and Management, 2013). Gradualism recognizes the incremental nature of human behavior change and recommends strategies to maximize health and functioning at the different points or stages of addiction recovery such as currently addicted and using, trying to cut down on use, or trying to control/abstain. At each point, the focus is on maximizing health and reducing harm for the individual through harm-reduction strategies.

The aim of harm-reduction strategies is to minimize tragic deaths, injuries, and disability related to opioid use, misuse, or abuse (Brandeis University Heller School for Social Policy and Management, 2013). Harm reduction is not an alternative to treatment but rather a support to people who use drugs to improve health and functioning through safer practices. Harm reduction acknowledges that when people are unable or unwilling to abstain from drug use, they can make positive choices to protect their health and well-being and the well-being of their communities (Brandeis University Heller School for Social Policy and Management, 2013). Harm reduction is both a philosophy and a set of activities inclusive of “medical services, public health interventions, expanded access to treatment, and social services, as well as activities designed to counteract adverse consequences from policies that rely on prosecution and incarceration of drug users” (Brandeis University Heller School for Social Policy and Management, 2013, p. 6). In the United States, harm reduction is often met with resistance based on the perception that it supports drug behavior. Harm-reduction activities aim to move the person who uses drugs toward healthier behaviors. As shown in Figure 3, strategies aim to improve health at each point in the continuum, from active user to trying to reduce to trying for control/abstinence.

Figure 3

Figure 3

The goal of all care is to improve or maintain health, whether that should be to prevent a problem or maximize health once a problem exists. Table 1 illustrates the population-health prevention continuum extending from health to disease and encompassing primary, secondary, and tertiary prevention or what public health refers to as upstream, midstream, and downstream.

Table 1

Table 1

Back to Top | Article Outline

Primary Prevention

Primary or universal prevention is an upstream approach—addressing broad factors that contribute to opioid-related substance use disorder (ORSUD). It targets the entire population whether that is a neighborhood, school, community, state, or nation. The primary goal of primary prevention is to thwart the onset of ORSUD by raising community knowledge and awareness, improving communication and coordination across agencies, disseminating surveillance information, and policy and infrastructure development that supports harm reduction (Brandeis University Heller School for Social Policy and Management, 2013).

A key aspect of primary prevention is confronting the stigma associated with the ORSUD and its treatment with medications. Stigma limits the availability of care and discourages people with opioid misuse problems from seeking effective services (Olsen & Sharfstein, 2014; Gourevitch, 2017). To overcome stigma, we must educate the community that ORSUD is a medical illness, not a moral weakness. Recovery is not simply a matter of willpower and treatment programs that mandate abstinence may be fine for some but block recovery for other individuals with ORSUD. Access to medication-assisted treatment (MAT) services, along with behavioral health counselling, is an important addition to the services available in the community. Extended treatment that includes prescribed medications has been shown to enhance recovery and has a lower risk of relapse. In fact, “there is no other treatment approach supported by the same level of evidence” (Olsen & Sharfstein, 2014, p. 1393).

Much of primary prevention is public education such as raising awareness of the risks of opioids and ORSUD and approaches to preventing harm and treating the problem (see Table 1). Although nurses in any specialty may care for persons with ORUSD, they may not be up-to-date on risk-reduction approaches and treatment. Box 1 provides resources for educating professionals and the community on the opioid epidemic and treatment.

Box 1

Box 1

Educating the community about harm reduction is important so that communities can develop resources to maximize the health of users that are either not yet ready for treatment or for whom treatment is a challenge. Table 2 provides information on proposed harm-reduction programs for active drug users. There is some resistance in the United States to harm-reduction programs because of the belief that such programs support drug use. In actuality, harm-reduction programs “help the drug community to be safer and help society as a whole by reducing death, hospitalizations, and the tremendous subsequent cost” (Dubois, 2017, p. 41). Harm-reduction programs provide opportunities for people who are addicted to be safe while working toward or considering recovery. Such programs give drug users a fighting chance to change and to be safer.

Table 2

Table 2

Back to Top | Article Outline

Secondary Prevention

Secondary prevention, or indicated prevention, are midstream approaches addressing subsets of the population who are at a higher risk for ORSUD because of biological, psychological, or social risk factors common to that group or capturing people in the early stages of the problem. The goal is early recognition, prevention of high-risk behavior and for individuals who have initiated opioid use, halting progression to opioid dependence or harm.

Secondary prevention looks at Interventions targeting the entire at-risk subgroup, regardless of the identified need or risk of any individual within the group. People are recruited to participate in prevention activities based on their high-risk subgroup characteristic. For example, secondary prevention may target children at risk and strategies may include groups for children of substance abusing parents or families living in high crime or impoverished neighborhoods. Other high-risk groups may be children or adolescents experiencing academic failure, interpersonal social problems, antisocial behaviors, and behavioral health issues such as depression. At-risk youth may be linked to a program to increase school performance, decrease drug involvement, and decrease emotional stress. Building resiliency in the high-risk indicated group may prevent progression toward ORSUD (SAMHSA, 2018).

Secondary prevention also involves screening approaches in primary care or settings that target high-risk populations. Screening in primary care can use multiple approaches as indicated in Table 1 “Secondary/During Development of Condition.” A screening is a brief process that should occur for all persons in the setting and indicates whether the individual is likely to have or be at risk for a substance use disorder. Individuals who screen positive should then receive an in-depth assessment.

To reduce the supply of opioids vulnerable to misuse and mitigate risks of opioid use, efforts promoting safe prescribing of opioids are a key midstream strategy (Duke University Margolis Center for Health Policy, 2018). (Preservice education can be considered an upstream approach, whereas in-service training is a midstream approach.) Education of prescribers and clinicians is critical to this approach. There are many programs available to educate clinicians on substance abuse recognition and care. Some examples include the Opioid Prescribing Course for Health Care Providers through the Substance Abuse and Mental Health Services Administration, the Food and Drug Administration (FDA) Scope of Pain program (www.scopeofpain.org) developed to meet the template guidelines from the Federal Drug Administration risk evaluation and mitigation strategy, and Harvard University's comprehensive online course on the opioid epidemic for professional and nonprofessional audiences, OpioidX: The Opioid Crisis in America. Participating in educational programs has been shown to improve knowledge, attitudes, confidence, and safe-opioid prescribing (Alford et al., 2016).

Preventing initial exposure to opioids should be considered whenever possible and is particularly warranted for minor surgical procedures in which nonopioid modalities can provide effective postsurgical analgesia (Mancini, 2017). Patients with preexisting psychiatric comorbidities or those with family histories of opioid dependence would also benefit from opioid-sparing analgesic strategies. For the acute care surgical patient, the use of multimodal analgesic regimens, including the use of long-acting local anesthetics, has become an approach for expediting movement away from opioid-centric prescribing practices for postsurgical pain management (Chou et al., 2016). Clinicians should follow the CDC guidelines for prescribing opioids for chronic pain (https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm) and incorporate the free CDC resources (fact sheets, user-friendly checklist decision aids, and smartphone apps for clinicians; https://www.cdc.gov/drugoverdose/prescribing/clinical-tools.html). For patients who are prescribed opioids, clinicians must provide an overview of the alternatives, benefits, risks, and how to minimize the risks. Table 3 provides guidelines for education when prescribing opioids for short-term use or for chronic pain.

Table 3

Table 3

Another strategy to facilitate safe prescribing and monitoring of opioids is Prescription Drug Monitoring Programs (PDMPs). The purpose of PDMPs is to help prevent and detect the diversion and abuse of pharmaceutical controlled dangerous substances (CDSs), including opioids, by enhancing the ability of state-level regulatory and law enforcement agencies to collect and analyze CDS prescription data through a centralized, state-administered database. PDMPs focus on the retail level where prescribed medications are purchased. As of June 2018, all U.S. states with the exception of Missouri had a PDMP, as does the District of Columbia (Prescription Drug Monitoring Program Training and Technical Assistance Center, 2018). Accessing this information online can identify if a patient is “doctor shopping”—visiting multiple providers in a short time span and receiving opiates. The effectiveness of PDMPs is limited in states where providers are not required to check the PDMP before prescribing an opioid. Efforts to embed PDMPs into the electronic medical record could decrease the burden of needing to check and facilitate this becoming part of normal workflow. Although the establishment of the PDMP is an upstream approach, encouraging its use by prescribers is a midstream approach.

Back to Top | Article Outline

Tertiary Prevention

Downstream treatment of the person with an addiction requires respectful, nonjudgmental care and treatment of substance use as a chronic disease. Howard and Chung's 2000a , 2000b , 2000c) comprehensive research on healthcare professionals' attitudes toward alcohol and drug misusers showed that nurses were more judgmental than other professionals toward patients who misuse drugs. Emergency room nurses regarded patients with drug use disorders as troublesome and disliked caring for them. Replacing negative attitudes with evidence-based interventions is paramount to helping patients reach the highest level of health possible (Bartlett, Brown, Shattell, Wright, & Lewallen, 2013).

Replacing negative attitudes with evidence-based interventions to treat persons with ORSUD is key in helping them achieve the highest level of health possible. Education of all care providers about the risk factors for opioid overdose; the signs of tolerance, dependence, and addiction; signs of overdose; naloxone rescue; other harm-reduction strategies; the nature of and treatment for addiction, with a focus on MAT; and where to refer patients for treatment are needed to improve healthcare.

Like other chronic diseases such as asthma and diabetes, addiction is generally refractory to cure, but effective treatment and functional recovery are possible (Volkow, Frieden, Hyde & Cha, 2014). Medication-assisted treatment for substance use disorders involves the use of medications (methadone, buprenorphine, and naltrexone) that target the brain, and psychosocial interventions (e.g., counselling, skills development) aimed at improving treatment outcomes. Evidence has shown that treatment with methadone or buprenorphine reduces risk of death by 60% and 40%, respectively (Larochelle et al., 2018). Medication-assisted treatment has also been shown to increase patients' retention in treatment, improve social functioning, reduce the risks of infectious-disease transmission, and decrease engagement in criminal activities (Volkow et al., 2014). Yet despite excellent outcomes, only about 30–34% of eligible patients receive MAT (Larochelle et al., 2018 ; Volkow et al., 2014). Low adoption of MAT may be related to a long-held preference for abstinence models. In line with the gradualism model and the strong evidence on the benefits of MAT, the FDA as well as SAMHSA has prioritized the expansion of treatment using MAT.

Psychosocial interventions are an important part of the care of the person with opioid use disorder. Motivational interviewing is a recommended technique for moving persons along the continuum toward taking action. Addiction counseling, mutual help groups, cognitive and behavioral therapies, and contingency management have been the most common counselling approaches. However, there are very few studies testing the efficacy of psychosocial approaches (SAMHSA, 2005).

Back to Top | Article Outline

Conclusion

With more than 700,000 drug overdose death between 1999 and 2017, the United States is facing the deadliest drug crisis in its history. A crisis that could claim 1 million lives by 2020 unless the course of the epidemic can be changed (Mitchell, 2018). In the wake of this devastating epidemic, it is important for nurses and other healthcare professionals to consider how they can use their training and skills to make a positive impact.

The FDA Commissioner, Dr. Scott Gottlieb, stated that this crisis would require concerted action by a number of actors in federal, state, and local governments, healthcare providers, the medical products industry, policymakers, patients, and their families to address the crisis from both supply-and-demand perspectives (Gottlieb, 2017). Concerted action is most effective if led by multisectoral coalitions at national, state, and local levels that ensure that reduction in demand for opioids is addressed with a population health perspective that considers upstream, midstream, and downstream factors for individuals and the population as a whole. Such a holistic approach must embrace prevention, including responsible prescribing, harm minimization for individuals who are using but not yet willing or able to abstain as well as MAT as a component or mode of treatment. Nurses have an important role to play at all points in the population health spectrum from patient education to screening, identification of opioid-sparing alternatives, reviewing the PDMP before prescribing, and referral to care and services.

Back to Top | Article Outline

References

Alford D. P., Zisblatt L., Ng P., Hayes S. M., Peloquin S., Hardesty I., White J. L. (2016). SCOPE of pain: An evaluation of an opioid risk evaluation and mitigation strategy continuing education program. Pain Medicine, 17(1), 52–63.
Balhara Y. P. S. (2016). What is the difference between buprenorphine, Subutex and Suboxone?http://luxury.rehabs.com/suboxone-addiction/vs-subutexbuprenorphine
    Bartlett R., Brown L., Shattell M., Wright T., Lewallen L. (2013). Harm reduction: Compassionate care of persons with addictions. Medsurg Nursing, 22(6), 349.
    Beach House. (2018). Harm reduction policies and the rise of safe injection houses. https://www.beachhouserehabcenter.com/learning-center/harm-reduction-policies-and-the-rise-of-safe-injection-houses/
      Bouckoms A. J., Masand P., Murray G. B., Cassem E. H., Stern T. A., Tesar G. E. (1992). Chronic nonmalignant pain treated with long-term oral narcotic analgesics. Annals of Clinical Psychiatry, 4(3), 185–192.
      Brandeis University Heller School for Social Policy and Management. (2013). Upstream opportunities for reducing the harm of alcohol and drug use. https://sihp.brandeis.edu/ibh/pdfs/OSI-Final-Report-10302013-MJL.pdf
      Brummett C. M., Waljee J. F., Goesling J., Moser S., Lin P., Englesbe M. J., Nallamothu B. K. (2017). New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surgery, 152(6), e170504. https://jamanetwork.com/journals/jamasurgery/article-abstract/2618383
      Case A., Deaton A. (2017, September 12). The media gets the opioid crisis wrong. Here is the truth. The Washington Post. https://www.washingtonpost.com/opinions/the-truth-about-deaths-of-despair/2017/09/12/15aa6212-8459-11e7-902a-2a9f2d808496_story.html?noredirect=on&utm_term=.d01157910174
      Centers for Disease Control and Prevention. (2014, July). Opioid painkiller prescribing. CDC Vital Signs. https://www.cdc.gov/vitalsigns/opioid-prescribing/
      Centers for Disease Control and Prevention. (2017) Opioid overdose. https://www.cdc.gov/drugoverdose/data/prescribing.html
      Centers for Disease Control and Prevention. (2018). U.S. drug overdose deaths continue to rise; increase fueled by synthetic opioids. https://www.cdc.gov/media/releases/2018/p0329-drug-overdose-deaths.html.
      Chou R., Gordon D. B., de Leon-Casasola O. A., Rosenberg J. M., Bickler S., Brennan T., Wu C. L. (2016). Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. The Journal of Pain, 17(2), 131–157.
      Cicero T. J., Ellis M. S., Surratt H. L., Kurtz S. P. (2014). The changing face of heroin use in the United States: A retrospective analysis of the past 50 years. JAMA Psychiatry, 71(7), 821–826.
      Clark H. W. (2014, September 2). Even non-fatal overdoses can lead to severe consequences. SAMHSA. https://blog.samhsa.gov/2014/09/02/even-non-fatal-overdoses-can-lead-to-severe-consequences/#.WtURVS7wZhE
      Coffin P. O., Behar E., Rowe C., Santos G. M., Coffa D., Bald M., Vittinghoff E. (2016). Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Annals of Internal Medicine, 165(4), 245–252.
        Compton W. M., Jones C. M., Baldwin G. T. (2016). Relationship between nonmedical prescription-opioid use and heroin use. New England Journal of Medicine, 374(2), 154–163.
        Cotten-Oldenburg N. U., Carr P., DeBoer J. M., Collison E. K., Novotny G., (2001). Impact of pharmacy-based syringe access on injection practices among injecting drug users in Minnesota, 1998 to 1999. JAIDS, 27(2), 183–192.
          Cullen T. (2017, December 1). Opioid overdoses kill more people in U.S. than guns or breast cancer. New York Daily News. http://www.nydailynews.com/news/national/opioid-overdoses-kill-people-u-s-car-accidents-article-1.3713354
          Darke S., Mattick R. P., Degenhardt L. (2003). The ratio of non-fatal to fatal heroin overdose. Addiction, 98(8), 1169–1172. https://onlinelibrary.wiley.com/doi/pdf/10.1046/j.1360-0443.2003.00474.x
          Dasgupta N., Beletsky L., Ciccarone D. (2018). Opioid crisis: No easy fix to its social and economic determinants. American Journal of Public Health, 108(2), 182–186.
          Davis M. A., Lin L. A., Liu H., Sites B. D. (2017). Prescription opioid use among adults with mental health disorders in the United States. The Journal of the American Board of Family Medicine, 30(4), 407–417.
          Drug Policy Alliance. (2015, August 10). NJ Governor Chris Christie signs bill expanding access to evidence-based drug treatment for participants in drug courts. http://www.drugpolicy.org/news/2015/08/nj-governor-chris-christie-signsbill-expanding-access-evidence-based-drug-treatment-pa;
            Dubois T. (2017). Harm reduction. Journal of Addiction Nursing, 28(1), 42.
            Duke University Margolis Center for Health Policy. (2018). Public Workshop: Strategies for promoting the safe use and appropriate prescribing of prescription opioids. Retrieved February 5, 2019 from https://healthpolicy.duke.edu/events/public-workshop-strategies-promoting-safe-use-and-appropriate-prescribing-prescription
            Egan K. L., Gregory E., Sparks M., Wolfson M. (2017). From dispensed to disposed: Evaluating the effectiveness of disposal programs through a comparison with Prescription Drug Monitoring Program data. The American Journal of Drug and Alcohol Abuse, 43(1), 69–77.
              European Monitoring Centre for Drugs and Drug Addiction. (2015). Preventing fatal overdoses: A systematic review of the effectiveness of take-home naloxone.
                EMCDDA Papers, Publications Office of the European Union, Luxembourg. Retrieved February 5, 2019 from http://www.emcdda.europa.eu/system/files/publications/932/TDAU14009ENN.web_.pdf
                  Fenton J. J., Jerant A. F., Bertakis K. D., Franks P. (2012). The cost of satisfaction: A national study of patient satisfaction, health care utilization, expenditures, and mortality. Archives of Internal Medicine, 172(5), 405–411. https://www.ncbi.nlm.nih.gov/pubmed/22331982
                  Florence C., Luo F., Xu L., Zhou C. (2016). The economic burden of prescription opioid overdose, abuse and dependence in the United States, 2013. Medical Care, 54(10), 901.
                  Gottlieb S. (2017). Remarks from FDA Commissioner Scott Gottlieb, M.D., as prepared for delivery at the FDA OCI Meeting, November 14, 2017. Retrieved February 5, 2017 from https://www.fda.gov/newsevents/speeches/ucm584978.htm
                  Gourevitch M. (2018). Inflection point: Taking a population health approach to the opioid crisis. Interdisciplinary Association for Population Health. Retrieved February 2, 2019 from https://iaphs.org/inflection-point-taking-population-health-approach-opioid-crisis/
                    Hansen H., Netherland J. (2016). Is the prescription opioid epidemic a White problem? American Journal of Public Health, 106(12), 2127–2129.
                    Hayes T. O., Manos R. (2018, January 30). The opioid epidemic: Costs, causes, and efforts to fight it. American Action Forum. https://www.americanactionforum.org/research/opioidepidemic/
                    Hedegaard H., Warner M., Minino A. M. (2017, December). Drug overdose deaths in the United States, 1999-2016. NCHS Data Brief No. 294. https://www.cdc.gov/nchs/data/databriefs/db294.pdf
                    Hill M. V., McMahon M. L., Stucke R. S., Barth R. J. (2017). Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Annals of Surgery, 265(4), 709–714.
                    Hoban B. (2017, October 25). The far-reaching effects of the US opioid crisis. Brookings Now. https://www.brookings.edu/blog/brookings-now/2017/10/25/the-far-reaching-effects-of-the-us-opioid-crisis/
                    Hilton B. A., Thompson R., Moore-Dempsey L., Janzen R. G. (2001). Harm reduction theories and strategies for control of human immunodeficiency virus: A review of the literature. Journal of Advanced Nursing, 33(3), 357–370.
                      Højsted J., Sjøgren P. (2007). Addiction to opioids in chronic pain patients: A literature review. European Journal of Pain, 11(5), 490–518.
                      Howard M. O., Chung S. S. (2000a). Nurses' attitudes toward substance misusers: I. Surveys. Substance Use & Misuse, 35(3), 347–365.
                      Howard M. O., Chung S. S. (2000b). Nurses' attitudes toward substance misusers: II. Experiments and studies comparing nurses to other groups. Substance Use & Misuse, 35(4), 503–532.
                      Howard M. O., Chung S. S. (2000c). Nurses' attitudes toward substance misusers: III. Emergency room nurses' attitudes, nurses' attitudes toward impaired nurses, and studies of attitudinal change. Substance Use & Misuse, 35(9), 1227–1261.
                      Hsu A. (2017, August 22). Hospitals could do more for survivors of opioid overdoses. Health News From NPR. https://www.npr.org/sections/health-shots/2017/08/22/545115225/hospitals-could-do-more-for-survivors-of-opioid-overdoses-study-suggests.
                      Humphreys K. (2018, March 23). Americans take more pain pills—but not because they're in more pain. The Washington Post. https://www.washingtonpost.com/news/wonk/wp/2018/03/23/americans-take-more-pain-pills-but-not-because-theyre-in-more-pain/?utm_term=.cc7ff12aacb1
                      Inciardi J. A., Surratt H. L., Lugo Y., Cicero T. J. (2007, November). The diversion of prescription opioid analgesics. Law Enforc Exec Forum, 7(7), 127–141.
                      Jones C. M., Mack K. A., Paulozzi L. J. (2013). Pharmaceutical overdose deaths, United States, 2010. JAMA, 309(7), 657–659.
                      Kastelic A., Pont J., Stöver H. (2008). Opioid substitution treatment in custodial settings: A practical guide. http://www.unodc.org/documents/hiv-aids/OST_in_Custodial_Settings.pdf
                        Katz J. (2017, August 10). Short answers to hard questions about the opioid crisis. The New York Times. https://www.nytimes.com/interactive/2017/08/03/upshot/opioid-drug-overdose-epidemic.html
                        Kounang N. (2017, December 21). Opioids no kill more people than breast cancer. CNN. https://www.cnn.com/2017/12/21/health/drug-overdoses-2016-final-numbers/index.html
                        Lankenau S. E., Teti M., Silva K., Bloom J. J., Harocopos A., Treese M. (2012). Initiation into prescription opioid misuse amongst young injection drug users. International Journal of Drug Policy, 23(1), 37–44.
                        Larochelle M. R., Bernson D., Land T., Stopka T. J., Wang N., Xuan Z., Walley A. Y. (2018). Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: A cohort study. Annals of Internal Medicine, 169(3), 137–145.
                        Leung P. T. M., MacDonald E. M., Stanbrook M. B., Dhalla I. A., Juurlink D. N. (2017). A 1980 letter on the risk of opioid addiction. New England Journal of medicine, 376, 2194–2195. http://www.nejm.org/doi/full/10.1056/NEJMc1700150#t=article
                        Lopez G. (2017, June 29). Americas failed response to the opioid epidemic in one statistic. CNBC. https://www.cnbc.com/2017/06/29/americas-failed-response-to-the-opioid-epidemic-in-one-statistic.html
                        Mancini G. J. (2017). Challenges and opportunities to change the course of the opioid epidemic: a surgeon's perspective. Postgraduate Medicine, 129(1), 1–4.
                        Mandell B. F. (2016). The fifth vital sign: A complex story of politics and patient care. Cleveland Clinic Journal of Medicine, 83(6), 400–401. https://www.mdedge.com/ccjm/article/109138/drug-therapy/fifth-vital-sign-complex-story-politics-and-patient-care
                        Meier B. (2007, May 10). In Guilty Plea, OxyContin maker to pay $600 million. The New York Times. https://www.nytimes.com/2007/05/10/business/11drug-web.html
                        Mercia D. (2017, October 26). Trump declares opioid epidemic national public health emergency. CNN Politics. https://www.cnn.com/2017/10/26/politics/donald-trump-opioid-epidemic/index.html
                        Mitchell J. (2018, January 26). With 175 Americans dying a day, what are the solutions to the opioid epidemic? Clarion Ledger. https://www.clarionledger.com/story/news/2018/01/26/opioid-epidemic-solutions-naloxone-overprescribing-overdose-deaths/964288001/
                        Moghe S. (2016, October 14). Opioid history: From “wonder drug” to abuse epidemic. CNN. https://www.cnn.com/2016/05/12/health/opioid-addiction-history/
                        Muhuri P. K., Gfroerer J. C., Davies M. C.; Substance Abuse and Mental Health Services Administration. (2013). Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Review. Retrieved July 10, 2018, from http://www.samhsa.gov/data/2k13/DataReview/DR006/nonmedical-pain-reliever-use-2013.pdf
                        National Institute of Drug Abuse. (2018a, March). Opioid overdose crisis. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis
                        National Institute on Drug Abuse. (2018b, August). Overdose death rates. Revised August 2018. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
                        Olsen Y., Sharfstein J. M. (2014). Confronting the stigma of opioid use disorder and its treatment. JAMA, 311(14), 1393–1394.
                        Portman R. (2018, May 23). Portman Op-Ed: The STOP Act will help keep deadly synthetic opioids out of Ohio. https://www.portman.senate.gov/public/index.cfm/2018/5/portman-op-ed-the-stop-act-will-help-keep-deadly-synthetic-opioids-out-of-ohio
                        Potier C., Laprévote V., Dubois-Arber F., Cottencin O., Rolland B. (2014). Supervised injection services: What has been demonstrated? A systematic literature review. Drug and Alcohol Dependence, 145(2014) 48–68.
                          Prescription Drug Monitoring Program Training and Technical Assistance Center. (2018). Technical assistance guide: History of prescription drug monitoring programs. http://www.pdmpassist.org/pdf/PDMP_admin/TAG_History_PDMPs_final_20180314.pdf
                          Rao R. B., Nelson L. S. (2017). The new opioid epidemic: Prescriptions, synthetics, and street drugs. Emergency Medicine, February:65–70. http://www.emedjournal.com https://www.mdedge.com/sites/default/files/em049020064.pdf
                          SAMHSA, Center for Substance Abuse Treatment. (2005). Substance abuse treatment for persons with co-occurring disorders. Treatment Improvement Protocol (TIP) Series, No. 42. https://www.ncbi.nlm.nih.gov/books/NBK64197/
                          United Nations Office on Drugs and Crime. (2016). World Drug Report 2016. United Nations Publication, Sales No. E.16.XI.7. https://www.unodc.org/doc/wdr2016/WORLD_DRUG_REPORT_2016_web.pdf
                          U.S. Department of Health and Human Services (HHS). (2016, November). Office of the Surgeon General, Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health. Washington, DC: Author. https://addiction.surgeongeneral.gov/
                          Volkow N. D. (2014, May 14). America's addiction to opioids: Heroin and prescription drug abuse. National Institutes of Health. https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse
                          Volkow N. D., Frieden T. R., Hyde P. S., Cha S. S. (2014). Medication-assisted therapies—tackling the opioid-overdose epidemic. New England Journal of Medicine, 370(22), 2063–2066.
                          Walley A. Y., Xuan Z., Hackman H. H., Quinn E., Doe-Simkins M., Sorensen-Alawad A., Ozonoff A. (2013). Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: Interrupted time series analysis. BMJ, 346, f174
                            Welham G. C., Mount J. K., Gilson A. M. (2015). Type and frequency of opioid pain medications returned for disposal. Drugs-Real World Outcomes, 2(2), 129–135.
                              Wodak A., Cooney A. (2006). Do needle syringe programs reduce HIV infection among injecting drug users: A comprehensive review of the international evidence. Substance Use & Misuse, 41, 777–813.

                                For additional continuing nursing education activities on orthopaedic nursing topics, go to nursingcenter.com/ce.

                                © 2019 National Association of Orthopaedic Nurses