Every health care provider should be prepared to take action, at a minimum, as an advocate and a prevention "specialist" with all patients at risk for or already experiencing an opioid use disorder (OUD). We know that a single prescription or a single hit of heroin may set off a cascade of events in the brain's opioid receptors and begin craving and loss of control. Nurses must have the knowledge and skills to take action in a compassionate and nonjudgmental manner. Our goal is to reduce the stigma surrounding opioid use and protect our patients from potential detrimental outcomes including death by accidental overdose.
As an educator of psychiatric/mental health nurse practitioners for over 20 years and as an active member of the International Nurses Society on Addiction for over 30 years, I developed strategies to teach addiction content to all nurse practitioner students and provide them with a clinical experience in an addiction treatment center. More advanced content and extensive clinical experiences are essential for the psychiatric/mental health nurse practitioner students. A list of 10 pearls for practice will be covered, and I encourage nurses and advanced practice nurses to seek certification in addictions nursing as a certified addiction registered nurse or certified addiction registered nurse-advanced practice (http://www.intnsa.org).
1. Assess risk factors for OUD: Every patient should have a thorough history of his or her drug and alcohol use as a new patient and at follow-up visits. Medical history should be reviewed for prescription opioid use both past and current. Assess type, dose, frequency of use, reason for taking, duration of use, tolerance, and withdrawal symptoms. Ask if they have bought and used opioids for nonmedical use and if they have had treatment for an OUD. Have they used opioids intravenously? For teens, it is important to ask if their friends use opioids and if they have used them.
2. Educate patients and family members (and friends) at every opportunity about tolerance, that is, the need for increasing amounts over time to get the same effect. Patients using opioids must be informed that tolerance quickly decreases once their dose decreases or if they stop using even for brief periods. During the withdrawal and craving that follow, they may seek relief at the same dose of heroin, for example, that they were taking before. This is very dangerous. They need to restart very small amounts and seek professional help. This applies to prescription and nonprescription opioids. Inform patients that this is the most common type of accidental overdose that may cause respiratory depression and death. Provide a prescription for naloxone to every patient and/or family member along with educational tools on administration and use. This intervention should be done whether or not the Advanced Practice Registered Nurse (APRN) is prescribing the opioid. A common courtesy is to notify the pain management provider of your action and intent and work collaboratively.
3. Assess and treat co-occurring disorders. Most persons with OUD have co-occurring psychiatric disorders. There are data to support using psychiatric medications for craving and for withdrawal symptoms, although most use is off-label. Medications to treat co-occurring anxiety, depression, bipolar disorder, posttraumatic stress disorder, and obsessive-compulsive disorder while addressing drug and alcohol use in an integrated treatment plan will help to improve the quality of life for the patient and promote healthy choices.
4. Avoid prescribing benzodiazepines to patients taking prescription or nonprescription opioids. The combination is additive and may contribute to accidental overdose and death. Alcohol should be avoided because of the additive effects on the central nervous system. The Prescription Drug Monitoring Program (PDMP) in each state provides a record of all the controlled substances the patient has been prescribed. Many times, another provider will start the patient on a controlled sleep medication, for example, not recognizing the additive effects it could have for the patient on opioids.
5. Educate patients and families about methadone and buprenorphine options for medication-assisted treatment (MAT). Explain the differences in the drugs and treatment protocols. Encourage patients to enroll in a methadone clinic if that is their best option. Get to know prescribers of buprenorphine/naloxone in your area, and teach patients how to locate a certified prescriber (http://www.samhsa.org). Consider becoming a prescriber of buprenorphine/naloxone, if eligible, and take the required 24 hours of MAT Waiver Training to apply to obtain a DEA waiver from Substance Abuse and Mental Health Services Administration (SAMHSA) through the American Psychiatric Nurses Association (http://www.apna.org) or the American Association of Nurse Practitioners (http://www.aanp.org). Most prescribers adhere to the safety rule that only one prescriber should prescribe all the psychiatric medications to one individual. If the buprenorphine/naloxone prescriber is not a psychiatric specialist, then there should be coordination of care.
6. Order drug screens to assess drug use and promote accountability.
7. Register for the state PDMP and review findings with your patient to promote safety. In many states, this is mandatory before prescribing any opioids. Note that heroin and nonprescribed opioids will not appear on the PDMP.
8. Assist patients to find treatment programs that focus on safe withdrawal and MAT options for the patient with OUD (http://www.findtreatment.samhsa.gov). If a slow taper is the method of choice for your patient, develop a plan to help the patient withdraw slowly and safely. Inform the patient of expected withdrawal symptoms and over-the-counter strategies to promote comfort during withdrawal.
9. Offer continuing support and encouragement to promote safety. Refer the patient with chronic pain to the appropriate specialist depending on the type of pain (e.g., neurologist for headaches). Collaborate with a prescribing pain management provider on the treatment plan. Help the patient develop an exercise program, and teach mindfulness and breathing techniques. Acupuncture and massage therapy provide additional options.
10. Refer patient and family to 12-step programs of support. Narcotics Anonymous and Alcoholics Anonymous can be life changing for the patient recovering from OUD, and they can provide mutual support and recovery for family members and friends. Spiritual recovery helps the person gain hope where there was no hope and freedom when there was no choice but to use drugs. Involvement in a 12-step program is one approach to spiritual recovery. Individual and group therapies can help manage emotions and confront problems, change thought patterns that make recovery difficult, and manage grief and loss issues. Preventing suicide is paramount on the journey of recovery. A program of recovery will include trauma-informed treatment.
We each bear a responsibility to take action to address the opioid problems wherever we work, wherever we have influence. Our voices of compassion as nurses and other health care providers can make a difference today and everyday in the lives of all the people we serve.