Rates of opioid and first time heroin use have reached epidemic proportions in many American cities. While it may come as a surprise, almost 10 percent of full-time U.S. workers 18-64 years are dependent on, or have abused illicit substances and alcohol in the past year.
Funding For Substance Abuse Treatment And Prevention
States and the federal government spend significant dollars on emergency room visits, incarceration, litigation, and medical treatments for complications like HIV and Hepatitis.
Few dollars go to prevention and early intervention. In fact, only 2 percent of $492 billion in total costs for drug abuse go toward treating as many as 2.4 million people with prescription opioid and heroin dependence. In 2013, only half of those who needed treatment received it.
Without access to treatment and prevention, other geographic areas with limited resources and high rates of IV drug use, often initiated by abuse of opioid prescription medications, are likely to experience similar tragedies to those in Austin, Indiana.
Innovative Local Programs
Some states have passed legislation to report and monitor opioid prescribing practices, set up needle exchange programs, and established HIV outbreak prevention programs. Others have gone to grassroots, local efforts like a small town in Massachusetts (MA), a state with over 1,000 opioid overdose deaths in 2014.
The Gloucester, MA police chief recently implemented a program of guaranteed addictions treatment and amnesty, called the ANGEL Program, for anyone who surrenders drugs and paraphernalia, or for anyone who walks into a police station and requests help for opioid addiction. The pilot program ensures that individuals who seek treatment get it. Individuals are paired with a volunteer “Angel,” which is an advocate who helps the individual navigate the process from initial contact with the police officer, to the screening at the hospital emergency department, and finally to admission to a detox facility. The police officer stays with the person until the “Angel” arrives. Officers have been directed by police department policy to be “professional, compassionate, and understanding at all times.” So far, 36 persons addicted to opioids have been admitted to rehab programs through this pilot program. The program is funded through a fund that was set up with money seized from drug dealers.
Other statewide strategies focus on screening and intervention for youth 15-22 years of age. Adolescents have greater vulnerability to the immediate and long-term effects of early substance use, especially those with family histories of alcohol and drug problems. Early identification and family work with those at risk can deter long-term use, and education in middle and high school helps raise awareness of the risks and harmful effects of substance use, including opioid addiction.
But one treatment that has been shown to be effective for treating opioid addiction is a medication-assisted treatment using a medication called Suboxone (which combines Buprenorphine and Naloxone into one medication).
A Paucity Of Trained Providers
Medication-assisted treatment using Suboxone has demonstrated promising treatment outcomes for opioid users. Federal regulations (Drug Addiction Treatment Act of 2000, Public Law 106-310-106th Congress, which is an amendment to the Controlled Substances Act), however, limit the prescription and management of opioid dependence therapy to “qualifying physicians” who apply for a waiver from the requirements of the Controlled Substances Act. This waiver allows qualifying physicians who work in settings that are not methadone maintenance treatment settings, to prescribe Suboxone. Even in states that allow nurse practitioners to prescribe controlled substances are prevented from doing so with Suboxone because nurse practitioners are not qualifying physicians and therefore are not eligible for the waiver required to prescribe it.
These regulations also limit the numbers of persons that qualifying physicians can treat in their practices. So the need for medication-assisted treatment is greater than the number that can be treated by certified physician providers. But it doesn’t have to be that way.
Support Legislation For Advanced Practice Registered Nurses
According to the Bureau of Labor Statistics, there are over 150,000 nurse practitioners in the U.S. These Advanced Practice Registered Nurses (APRNs) prepared at the masters and doctoral level, are educated and licensed to provide assessment, education, and treatment to people with a wide variety of conditions including those with substance use disorders.
They can prescribe many medications and do treat people with substance use disorders — but because of the restrictions on Suboxone, APRNs’ opioid-dependent patients do not have access to the treatment that evidence shows might be their best option. In its report, The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine (IOM) made the case for allowing APRNs to practice at the full extent of their training and licensure. With regard to prescribing Suboxone, they currently are not.
To increase the number of people who can receive this care, APRNs should be allowed, with certification, to prescribe Suboxone. The Recovery Enhancement for Addiction Treatment (TREAT) Act introduced in the House by Representative Brian Higgins (D-NY) and in the Senate by Senator Edward Markey (D-MA) would do just that. The TREAT Act (H.R. 2536/S. 1455, 114th Congress) seeks to expand accessibility of medication-assisted therapy (opioid treatment with Suboxone) by changing “qualifying physician” to “qualifying practitioner” (nurse practitioner or physician assistant) and by changing the total number of Suboxone-receiving patients from “30” to “100.” In the House of Representatives, the bill was assigned to the Health Subcommittee of the Committee on Energy and Commerce, and the Crime, Terrorism, Homeland Security, and Investigations of the Committee on the Judiciary on May 21, 2015. In the Senate, the bill was assigned to Committee on Health, Education, Labor, and Pensions on May 22, 2015. Thus far, there has been no action in any of the committees.
It’s too bad, because the TREAT Act would increase accessibility to substance misuse treatment by allowing nurse practitioners to receive the waiver and certification necessary to prescribe Suboxone, thus making treatment more available. By providing access to medication-assisted treatments in combination with behavioral therapy, nurses can help save lives (decrease overdose deaths and decrease HIV and Hepatitis transmission).
More available providers means less illness and fewer negative consequences borne by our medical and legal systems — not to mention, it’s more cost-effective.
To be sure, there has long been a dispute promulgated by physicians and physicians’ groups (e.g. the American Medical Association), which argue against APRN practice and don’t support expanding such authority to nurses; however this has been disputed in the recent IOM report mentioned previously and through rigorous study. We’re ready to improve the quality of life for individuals and families where opioid addiction has had devastating effects.
Public and health professional responses to unprecedented prescription, misuse, and mortality related to opioid prescribing and diversion is essential to changing health outcomes. Unfortunately, the gap between Congressional decision-making and the science of addiction and its treatment continues to result in large disparities in funding for early intervention and treatment for substance use disorders.
Without targeted strategies to increase accessibility to medical and nursing practitioners knowledgeable about treating opioid dependence, change will be slow. We encourage vocal and informed citizens and practitioners of nursing to make their views known to your representatives.
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