Addressing the Opioid Crisis

Feb 5, 2018 12:22:04 PM / by UC College of Nursing

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The latest numbers foretell a grim future for America and its drug problem.

In 2016 alone, the number of deaths from drug overdose climbed 20 percent to 64,000, according to preliminary counts. That’s more than the worst years on record for motor vehicle accidents, HIV and guns. The driving force behind the increase are opioids—especially fentanyl, heroin and commonly prescribed pain killers.

It’s not about to get better, either. Several leading public health experts predict opioids could cause half a million more deaths in the next decade as the crisis worsens.

As opioid dependence and overdose deaths continue to wreak havoc on communities—requiring more police, medical and foster care resources—the federal government has designated the epidemic a public health emergency to dedicate more funds, personnel and services to the problem.

For its part, the University of Cincinnati College of Nursing has put forth efforts to improve education, training and research related to opioids in the form of curriculum revisions and expanded addiction bias presentations. With new grant funding, faculty are studying common factors of opioid abusers and drug overdose response procedures.

These endeavors support a broader Academic Health Center Opioid Taskforce, an interdisciplinary collaboration between the colleges of allied health, medicine, nursing and pharmacy, and UC Health.

The nursing profession stands to make a substantial impact on the opioid crisis, says Angela Clark, PhD, RN, assistant professor and member of the taskforce.

"It’s important that nursing is represented in these efforts because we are so uniquely positioned at the front lines of patient care," she says. Registered nurses often are the first to administer care for an opioid overdose and the final link to care management resources when a patient is discharged.

"The role of the nurse is continuously changing, and we want to make sure that all of our nurses are practicing to the fullest extent of their licenses, as well as utilizing evidence-based practices to provide high quality patient care," Dr. Clark says.

Education & Training

The College of Nursing started to review and revise its curriculum last April, after signing on with 190 other American Association of Colleges of Nursing member schools in a pledge to verse advanced practice nurses on the Center for Disease Control and Prevention’s Guidelines for Prescribing Opioids for Chronic Pain, released in March.

Sherry Donaworth, ACNP, FNP, associate professor of clinical nursing, worked to imbed the guidelines in the college’s curriculum and inventoried all coursework related to drug prescription and addiction treatment.

For her part, Dr. Donaworth now requires her advanced practice nursing students to take three hours, in addition to the standard six hours, of instruction on prescribing schedule II drugs, which include opioids, such as Percocet® and OxyContin®.

"Providers have an obligation to prescribe in a way that doesn’t perpetuate the problem," says Dr. Donaworth, a member of the Opiate Taskforce of Clermont County, Ohio.

A 2015 review published in the journal Pain found that 21 percent to 29 percent of patients prescribed opioids for chronic pain misused them. When medications become too difficult to procure or too expensive to buy, individuals turn to cheaper alternatives, like heroin.

"I don’t think people recognize that much of the problem sprang from prescribed opioids," Dr. Donaworth says. "I think much of the public believes people abuse heroin and other drugs from the get-go, rather than as a bridge from something else."

Ronald Lee Tyson, DNP, DMin, CNP, PMHNP-BC, ANP-BC, CARN-AP, interim coordinator for Psych-Mental Health programs and founder of Lee Side Wellness, a mental health and substance abuse treatment facility with locations in Mason and Springboro, Ohio, says he hears similar stories from opioid addicted patients.

"It usually goes something like this: 'I had chronic pain issues and my doctor prescribed me an opioid and it got to the point where I needed more and more and my doctor cut me off and I was on my own. I tried to buy prescription opioids on the street and they were really expensive and it’s a whole lot cheaper and potent to get heroin off the street.'"

Cheaper, potent and more prevalent. But, unlike heroin, and recently fentanyl, substance-abuse counselors aren’t widely available.

"The other issue is not having enough students and providers to go out and treat this," Dr. Tyson says. That’s part of the reason students in the psych-mental health programs are using telepsychiatry to reach patients. Like telemedicine, telepsychiatry leverages telecommunication to provide psychiatric care from a distance.

Along with additional opioid prescribing and addiction treatment education, students—both graduate and undergraduate—now participate in a lecture to address the social stigma tied to addiction.

Jennifer Lanzillotta, PhD(c), MSN, CRNA, clinical nursing instructor, created a presentation for students that focuses on the neurobiology of addiction and includes firsthand accounts from clinicians who have become addicted to opioids. Working with faculty and students, Lanzillotta is collecting pre- and post-presentation survey data to measure how students’ perceptions of addiction change, as a result.

"No one wakes up and says, 'I want to be a drug addict,'" Lanzillotta says. "This presentation has shown we can reduce the stigma associated with drug abuse by health care providers."

In the anonymous survey, one undergraduate student wrote, "Before, I just thought that people who did drugs did it to themselves and don’t deserve help, but now I see that addiction is truly a disease and that we should help these people instead of ignoring them."

Melita Kurahovic and Emily Asselin, Nurse Anesthesia Doctor of Nursing Practice students, and Jack Stem, CDCA, founder and CEO of Peer Advocacy for Impaired Nurses, LLC, collect and present survey results. Stem, a former nurse anesthetist, experienced addiction firsthand after a period of treating his chronic pain with prescription drugs.

For more than a decade, he has shared his story with nurse anesthesia students, putting a relatable face to the problem. Lindsay Budd, a third-year nurse anesthesia student who helped facilitate a discussion in October following Stem’s presentation, says his story is eye-opening.

"Hearing someone so educated—and who we can relate to—talk about his personal struggle with addiction helps keep us from being in denial about it," Budd says. "It helps to not only make you aware that we're not above it, but also to know the signs and symptoms so we can recognize it."

Lanzillotta's lecture was introduced to undergraduate students in the past year at the suggestion of instructor Jamie Leslie, PhD. Dr. Leslie and instructors Myrna Little, M.Ed., and Jeanine Goodin, MSN, assist with survey data collection on the undergraduate level.

Jack Stem, CDCA, talks to students about his experience with opioid addiction and treatment.

Jack Stem (center) frequently shares his experience with opioid addiction with nursing students.

Research

Lanzillotta is one of a handful of faculty and staff involved in grant-funded opioid research. She received a $10,000 Kay Wagner Fellowship from the American Association of Nurse Anesthetists to identify prescribing practices and personal characteristics common among patients still using opioids 90 days after surgery.

Of patients prescribed opioids for post-surgery pain management, 6.5 percent to 13 percent continue to use them more than 90 days later, which is considered prolonged post-operation opioid use. At that point, "you shouldn’t still be taking those," Lanzillotta says.

Results of the study will help prescribers better determine the likelihood a patient will become addicted to opioids and decide when to use alternative pain treatments.

"Our prescribing practices have to be modified, but we don’t want to withhold pain medication from people who need it," says Lanzillotta, who also participates on the Hamilton County Heroin Coalition Task Force.

On the opposite end of the issue, Dr. Clark received a $7,400 grant from the American Nurses Foundation to develop an iOS-based intervention for emergency department nurses responding to opioid overdoses outside of the ED.

Researchers plan to study whether nurses trained on the intervention can implement it with fidelity in a group setting and determine the size of the effect. Matt Rota, PhD, Director of the Center for Academic Technology, Educational Resources and Instructional Design, Emily Myers, M.S.Ed., Senior Instructional Designer, and Steve McKinney, Video and Classroom Services Technologist, helped develop the video training series. ED nurses at TriHealth Bethesda North Hospital in Cincinnati will implement the intervention.

Dr. Clark says this initiative began because of clear changes in nursing practice, and this proposed research represents an important step in the process to develop guidelines for ED nurses responding to opioid overdoses, which have skyrocketed in the past decade, accounting for more than two-thirds of ED visits in the U.S. in 2010, according to an analysis published online by JAMA Internal Medicine.

"(Nurses) are often the first to see patients in the ED, especially if they arrive via personal automobile, and we are often the ones discharging patients after care following an opioid overdose," Dr. Clark says. “These points of contact are critical to linking the patient to services and promoting long-term addiction treatment and disease management."

University & Community Collaboration

The college’s opioid-related education and research efforts align with the AHC Opioid Taskforce, formed in May to pull together educators, researchers, clinicians and local advocates from the university and UC Health dedicated to making an impact on a regional and national level.

While the nation’s addiction and overdose rates are alarming, in 2015, Ohio, Kentucky and West Virginia represented three of the five states with the highest rates of death from drug overdose, according to the CDC.

"This group was charged by leadership at UC and UC Health to respond to this major public health crisis, knowing that Cincinnati is really at the epicenter of this," says Neil MacKinnon, BSc, MSc, PhD, professor and dean of the James L. Winkle College of Pharmacy. Dr. MacKinnon serves as co-chair of the taskforce with Melissa DelBello, MD, professor and chair of psychiatry in the College of Medicine.

The taskforce, which publicly kicked off in November, set forth five goals:

  • Align expertise and resources to be competitive for research opportunities to continue as a national leader in opioid-related research;
  • Formalize pathways to care across our health care systems, clinics, programs and agencies;
  • Advocate for best practices in evidence-based treatments and prevention;
  • Enhance interprofessional training of health care providers and students about innovative approaches to the identification and treatment of chronic pain and opioid addiction; and
  • Improve the health of the community through partnerships and engagement.

To address those goals, the group’s more than 40 members meet regularly in one of four committees: education, research, practice and external relations. Members include Dr. Clark and Marie Garrison, MSN, from the College of Nursing, who serve on the education and research committees, respectively.

"Nursing plays a critical role in this—from addiction prevention through treatment. It’s certainly a stronger taskforce because we have nurses on it," Dr. MacKinnon says.

The taskforce’s early work involved compiling an inventory of opioid-related educational content offered by the health colleges to evaluate students’ exposure to the topic. Soon, Dr. MacKinnon says, committees will make recommendations for ways to meet short-term goals.

I’m confident all students have some sort of (opioid-related) touchpoint before they graduate,” Dr. MacKinnon says. “Now, we’ll be looking at how we build upon that and have all of the colleges work together on it."

Dr. MacKinnon hopes to see new interprofessional course offerings and resources for students, additional research dollars focused on the region and measurable improvements in provider training and patient care—all with the mammoth objective of curbing opioid abuse and overdose deaths in the U.S.

"The ultimate outcome for society would be getting rid of the scourge of opioid addiction. That’s the big picture," Dr. MacKinnon says. "In reality, can we impact that for our country and region? Maybe a bit. I think we have attainable outcomes that will make a difference."

Collaboration is key, because the crisis cuts across the health care industry, he says. "It’s the kind of problem that will require interprofessional thinking and multifaceted intervention."

By: Laura Toerner



Ready to learn more? Download our free webinar, The Role of Primary Care Providers in the Opioid Crisis, led by Chrisine Colella, DNP, APRN-CNP, FAANP, Associate Professor of Clinical and Executive Director of Graduate Programs.

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