The opioid epidemic is unrelenting. Despite heightened efforts to prevent opioid misuse and reverse the trend of opioid deaths, 42,249 individuals in the United States died from opioid overdoses in 2016, which is five times greater than in 1999.1 On October 26, 2017, Acting U.S. Department of Health and Human Services Secretary Eric Hargan, at the request of President Donald Trump, declared the opioid crisis a public health emergency.2 The declaration, however, did not include a request for funding or additional resources. Had President Trump requested declaration of a national emergency, allocation of federal funds would have been forthcoming.3 Effective for only 90 days, the public health emergency was extended by Acting Secretary Hargan effective January 24, 2018.4

Despite the lack of additional funding or resources, there are a variety of initiatives to end the opioid epidemic in which NPs can become engaged. The Drug Addiction Treatment Act (DATA) of 2000 only authorized qualified physicians to dispense or prescribe certain controlled substances, such as buprenorphine/naloxone, for substance use disorder.5 NPs were part of an effort to pass Public Law 114-198, The Comprehensive Addiction and Recovery Act (CARA), which amended DATA.

Signed into law by President Barack Obama on July 22, 2016, CARA included multiple strategies to address the nation's opioid epidemic, one of which was to improve access to medication-assisted treatment to recover from addiction.6 Section 303 amended the controlled substance act to allow qualified NPs to prescribe FDA-approved medications, such as buprenorphine/naloxone, for the treatment of opioid use disorder in office-based settings.6 This section of the law, however, expires in 2021.

Medication-assisted treatment

The Addiction Treatment Access Improvement Act seeks to make the authority of NPs to prescribe medication-assisted treatment permanent. The House of Representatives bill 3692, introduced by Representative Paul Tonko of New York, and Senate bill 2317, introduced by Senator Edward Markey of Massachusetts, would eliminate the expiration date for the controlled substance act amendment.7,8 Additionally, the bills would add clinical nurse specialists, certified nurse anesthetists, and certified nurse midwives as qualified practitioners to prescribe medication-assisted treatment. Neither bill has had a committee hearing. Contact your members of Congress and ask them to act on this important legislation.

NPs who are interested in prescribing medication-assisted therapy for substance use disorder must apply for a waiver from the Substance Abuse and Mental Health Services Administration. This is an important strategy to become part of the solution to the opioid epidemic. To be eligible for the waiver, an NP must complete 24 hours of training on specified content areas. The American Association of Nurse Practitioners, in partnership with the American Society of Addiction Medicine, provides the 24 hours of required education at no cost. The buprenorphine waiver training can be accessed online: https://aanp.inreachce.com/Details/Information/714cb0a9-73b2-4daf-8382-27cbdb70e. Information regarding all approved courses and waivers can be found here: http://www.samhsa.gov/programs-campaigns/medication-assisted-treatment/training-.

Addressing opioid abuse and misuse

NPs must embrace and advocate for strategies to address opioid abuse and misuse. Reducing opioid prescribing will in turn reduce the transition to heroin use, which is often preceded by use of prescription opioid pain relievers.9 The National Safety Council identified six key indicators of state progress to address the drug epidemic: mandatory prescriber education, opioid prescribing guidelines, eliminating pill mills, prescription drug monitoring programs, increased access to naloxone, and availability of opioid use disorder treatment. The Council's report, which analyzes state progress on these key indicators, can be accessed at: http://www.nsc.org/RxDrugOverdoseDocuments/Prescription-Nation-2016-American-Dru.

NPs must stay informed of changes in laws, rules, and policies. For example, Massachusetts Governor Charlie Baker signed into law (March 14, 2016) the first legislation in the nation that limits an opioid prescription to a 7-day supply for first-time adult prescriptions and on every opiate prescription for a minor, with certain exceptions.10 Washington State's Health Care Authority developed a clinical policy to limit opioid doses for Medicaid patients to 18 doses for individuals age 20 years or younger and 42 doses for those age 21 years or older, with some exceptions.11 The Health Care Authority extended the policy to its Uniform Medical Plan for state workers effective January 2, 2018.12

Beyond the clinic

Beyond the clinical efforts NPs expend to prevent and mitigate the opioid epidemic, long-term solutions are also necessary. Sam Quinones, author of Dreamland: The True Tale of America's Opiate Epidemic, testified before the U.S. Senate Health, Education Labor & Pensions Committee on January 9, 2018.13 His book and testimony speak to the pressing need to restore the fabric of our communities devastated by economic and social factors. His provocative book and comments provide a framework for understanding the root causes of the epidemic and a way forward. He explains in his Senate testimony that the "...roots of the national opioid epidemic lie in the regions of our nation hammered by globalization and free trade, which need to be revived while the epidemic itself stands in the way of these regions revival. Many of these regions cannot revive until enough of their people can pass a drug test to get new jobs. This is not just a story of drug addiction but one of economic affliction."

"As politicians, I suspect your natural response to a crisis like this is to look about for things to do quickly to show constituents you are taking action, and I believe that is entirely understandable. I would caution, however, in believing in short-term responses. CARA and the CURES Act make up a great start, and I thank you for them, but they are only a start. Everything I've learned about this issue has taught me the importance of long-term community responses and commitment...Focus far beyond the immediate goal of drug addiction and on the more profound problems of community destruction and the hollowing out of stretches of this country.14"

Indeed, as NPs, our commitment must be to achieve long-term solutions.

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