On Wednesday, October 24, 2018, House Resolution 6, the Support for Patients and Communities Act, became law. Section 3201 makes permanent the authorization for NPs and physician assistants to prescribe medication-assisted treatments (MATs). In addition, certified nurse midwives, clinical nurse specialists, and certified registered nurse anesthetists are authorized to prescribe MATs through October 1, 2023.1
H.R. 6 provides an opportunity for NPs to offer much-needed buprenorphine to patients experiencing opioid use disorder. To prepare students for this potential aspect of clinical practice, the Washington State University College of Nursing convened a panel presentation for its annual Doctor of Nursing Practice (DNP) Day, a meeting intended to educate DNP students and a special topic, on October 4, 2018, regarding the opioid epidemic. The panel members included Jason McGill, senior health policy advisor to Washington State Governor Jay Inslee, Washington State Department of Health officials Chris Baumgartner and Blake Maresh, and Jacquelyn Brolsma, MN, ARNP, an NP at Evergreen Treatment Services (ETS) in Seattle.
Ms. Brolsma has been with ETS since 1990. Her entire professional career has been in addiction treatment and substance use disorder programs, both inpatient and outpatient. Her presentation informed students of her work helping individuals overcome substance use disorder with medication, treatment for co-occurring conditions, and social supports. The goal was to prepare and inspire students to serve individuals with substance use disorder by providing evidence-based, compassionate care. This article is an excerpt of her remarks.
MAT for opioid use disorder
MAT for opioid use disorder (OUD) is a comprehensive approach that combines FDA-approved medications (currently methadone, buprenorphine, or naltrexone) with counseling and other behavioral therapies to treat patients who have OUD. Regular adherence to MAT:
- reduces opioid withdrawal symptoms and the desire to use opioids without causing the cycle of highs and lows associated with opioid misuse or abuse
- stabilizes patients so they can benefit from counseling to address the issues that may have led them to addiction
- at proper doses, decreases the pleasurable effects of other opioids, making continued opioid use less attractive
- according to the Substance Abuse and Mental Health Services Administration, the risk of death from all causes is cut in half for patients receiving MAT for treatment of their OUD.2
MAT has been shown to improve patient survival, increase retention in treatment, decrease opioid use and other criminal activity, increase a patient's ability to maintain employment, improve birth outcomes among pregnant women with OUD, and lower risk for infectious diseases by reducing the potential for relapse.3
How treatment is delivered
Office-based opioid treatment consists of healthcare professionals prescribing buprenorphine, an oral medication, or naltrexone, a long-acting injectable medication. This is typically done with provider appointments as one component of care weekly during the induction of treatment followed by monthly intervals or longer once stable. Medication alone is not sufficient.3 An opioid treatment program (OTP) is the most intensive form of treatment available for OUD. These programs must be accredited and certified by the Substance Abuse and Mental Health Services Administration. An OTP requires daily visits to receive medication (methadone or buprenorphine), mandatory counseling, urine drug screens, regular provider visits, and vocational and education counseling.3
It is important to remember that MAT works and patients do recover. It is also important to note the reasons why patients do not seek treatment. These reasons can include lack of access, fear of rejection by family and friends, fear of losing a job, or fear of failure.4
Advances in the science of addiction
According to Volkow and Boyle, addiction is a severe form of substance use disorder now understood as a chronic brain disorder. This disease develops from biosocial factors, which cause devastating consequences to individuals, their families, and society. Scientific advances have contributed to an understanding of the neurobiological processes through which biological and sociocultural factors contribute to resilience against or vulnerability for drug use and addiction.
New knowledge of the brain circuits that mediate reward and motivation, executive control, and emotional processing are the basis for understanding the “nonsensical” behaviors displayed by individuals with addiction and has provided new targets for prevention and treatment.5 We see disruptions of an individual's ability to prioritize behaviors that result in long-term benefit over those that provide short-term rewards and the increasing difficulty exerting control over these behaviors—even when associated with catastrophic consequences.
We know that genetic factors account for approximately half of the risk of addiction.6 Also, the progress made on understanding trauma and adverse childhood events has also helped guide treatment efforts. We now view addiction as:
- a chronic, relapsing medical disorder
- a disease of the brain's reward system
- being similar to hypertension and diabetes mellitus in that they are chronic diseases for which pharmacologic and behavioral approaches are used.
Medication helps stabilize the disorder and should not be viewed as replacing one drug for another. Addiction does not get cured; it is managed. Treatment permits a return to more normal cognitions, and individuals undergoing treatment are able to engage in recovery and work through past experiences and their consequences. Medication is life-saving. The duration of treatment is indefinite, and for many or most, it can become lifelong. The best outcomes are associated with longer time in treatment and treatment of coexisting medical and psychiatric conditions.
How the treatment field is changing
There is more focus on patient retention and not discharging a patient from treatment because of ongoing drug use. This has resulted in the programs changing rather than programs viewing the problem of relapse as one of patient motivation. The approach and philosophy that views substance use disorder (SUD) as a health problem supports not discharging patients who continue to suffer symptoms from continued drug use.
As treatment moves toward patient-centered care, the best results are seen when the patient is treated with compassion and motivated by hope. The move toward fully integrated care is an important shift in care delivery. At ETS, there are multiple challenges to achieve this, including inadequate staffing for OUD treatment, insufficient physical space, and the shift to value-based care, which holds significant risk for nonprofits that do not have sufficient cash reserves.
What is needed to improve OUD treatment
There is a need for better Medicaid reimbursement so we can better treat those in need. We need more NPs to work in treatment programs and provide office-based treatment. As a provider, create an atmosphere in which patients can talk to you about their substance use. Be nonjudgmental, offer to be a part of their recovery team, communicate hope that recovery is possible, support MAT patients rather than recommend they stop using medication, protect patients' recovery, and manage patients' pain.
Practice the science, not an ideology. Language matters. Instead of thinking of patients as “junkies,” “addicts,” or “druggies,” think of patients as people with SUDs. Rather than thinking of someone's urine drug test as being “dirty” or “clean,” substitute that phrasing with “positive” or “negative.” Instead of thinking of someone as being “clean and sober,” substitute that phrase with “a person in recovery.” Avoid referring to a person as a methadone patient. No one refers to a person as an insulin patient or lisinopril patient.
We applaud the Surgeon General's office for calling on this nation to end the stigma surrounding the disease of addiction and for recognizing that evidence-based treatment for OUD includes the use of FDA-approved medications combined with psychosocial supports.4 Evidence shows that no area of the US is exempt from the opioid overdose crisis. Visit the ETS website for resources and to watch patient stories (www.evergreentx.org). Sign up for the ETS newsletter. Consider becoming a provider for patients with SUD. Treatment saves lives.