As efforts to address the opioid epidemic have intensified in recent years, Angela Clark, MSN, PhD, RN, CNE, and her research team started noticing an unprecedented trend — an increasing number of people who needed emergency services after receiving naloxone (Narcan), an opioid antagonist used for complete or partial reversal of opioid overdose.
The overdose victims were arriving outside the emergency department, which meant nurses were walking outside the emergency department to aid these incapacitated patients. Clark knew nurses had not been trained to respond to these situations, and their safety was at risk.
Clark, a professor of nursing at the University of Cincinnati, decided to develop a training program to teach nurses how to protect themselves while leveraging their medical expertise.
“Nurses are trained to put the patient first, while police are trained to put safety first,” said Clark, whose team launched the Be-SAFE program in 2017.
Nurses started learning to ask drivers if they had any weapons, to step outside the car and to drop the keys away from the car. The training also suggests asking how much Narcan had been administered, how long the patient has been unconscious and other medical questions.
Training like this is just one example of the new skills nurses are learning as they respond to the nation’s opioid epidemic, which has led to the deaths of more than 400,000 people in the U.S. since 1999, according to the Centers for Disease Control and Prevention.
Overdoses have become the leading cause of death among Americans under 55, killing more than 70,000 in the U.S. in 2017. Clark has conducted numerous studies focused on educational interventions that address the opioid epidemic, and she believes nurses have a critical part to play in the effort to tackle this national crisis.
“Nurses are in a unique role because we have close access to patients,” Clark said. “We are the first to see them when they walk in, the last to see them when they are discharged, and the caregivers who spend the most time with inpatients.”
Helping patients who are ready for treatment
Clark also recently received funding from the Ohio Department of Mental Health and Addiction Services to train nurses, pharmacists, social workers and health professional students how to use an intervention that helps them understand a patient’s willingness to pursue treatment for opioid use disorder.
The intervention, known as SBIRT (Screening, Brief Intervention and Referral to Treatment), equips healthcare providers to ask open-ended questions such as “How ready are you for treatment?” rather than “yes” or “no” questions that can quickly end a conversation. If patients are not ready for treatment, providers can use brief negotiated interview techniques to discuss and identify barriers preventing them from readiness.
“Through these conversations, nurses may discover that patients do not want to pursue treatment due to caretaker responsibilities or other barriers,” Clark said. “We can connect them with resources in the community to help support them in long-term recovery.”
Implementing alternatives to opioids
Nurses can not only help patients navigate the healthcare system to pursue recovery, but also prevent the onset of opioid use disorder and combat the opioid epidemic. At St. Joseph’s Health in New Jersey, nurses, physicians, pharmacists and administrators worked together to launch a program in 2016 that trains providers how to use alternatives to opioids when treating pain.
The program is called ALTO (Alternatives to Opioids), and the team initially developed protocols for specific conditions that have been shown to benefit from non-opioid treatments for pain: renal colic (kidney stones), abdominal pain, lower back pain, headaches, musculoskeletal pain and extremity fractures. The alternatives to opioids include lidocaine, nitrous oxide, nerve blocks and Ketamine.
Nurses have been crucial to the success of the program because they explain to patients why they are receiving alternative medications for their pain, says Cathlyn Robinson, MSN, RN, CEN, a clinical education specialist in the emergency department at St. Joseph’s Health.
“Patients learn that opioids may not be the best choice for problems like back pain because narcotics mask the pain rather than treating the problem,” Robinson said. “Anti-inflammatories and muscle relaxants are now the first line of treatment.”
For conditions like renal colic or abdominal pain, nurses have learned how to administer lidocaine intravenously, which is traditionally used to treat cardiac arrhythmias. The dosing and concentrations are different when the medication is used to treat pain, and “learning how to program the IV pumps using the new drugs can be complicated,” Robinson said.
The program has successfully decreased opioid use in the emergency department by almost 50%. Up to 75% of patients have achieved adequate pain relief with the alternative therapies, though the team still administers opioids when this medication is the best pain treatment option.
“We are being more deliberate and mindful about what we give patients in the emergency department,” said Janine Llamzon, MS, RN, AGNP-c, CEN, NEA-BC, director of nursing for emergency services at the hospital. “If someone is in acute pain from a laceration or fractured femur, we may still administer opioids. But nurses have a different mindset now about treating pain and they use a more holistic approach.”
Schooling nursing students on opioid epidemic
While training nurses to treat and prevent opioid use disorder is critical, Peggy Compton, PhD, RN, FAAN, an associate professor at the University of Pennsylvania School of Nursing, was eager to incorporate more coursework about this topic in the nursing school setting.
“All nurses should be prepared to intervene, and medical and nursing schools have been remiss in providing substance use training beyond alcohol dependency,” Compton said. “The lack of training has been pretty profound.”
In response, the nursing school launched a new interdisciplinary undergraduate elective in 2018 called “Opioids: From Receptors to Epidemic.” Students in the course learn about the history of the epidemic, the neuroscience of addiction and the larger policy issues such as lack of access to treatment. Compton also teaches students how the disease model applies to opioid addiction, which she hopes will help them adopt a therapeutic approach as opposed to a criminal or moral approach when they treat patients.
“These patients have been marginalized in our society and also in the academic curriculum, yet more people are dying from this chronic illness than diabetes,” Compton said. “My hope is that the students will become advocates for these patients in the future.”
Take these courses to learn more about opioid use:
Responsible Opioid Prescribing, Chronic Pain, and Addiction
(1.5 contact hrs)
The goal of this continuing education program is to provide nurses with information about best practices in the prescribing of controlled substances, including safe and effective prescribing, administering, and dispensing of controlled substances to the patient with chronic pain.
Patient Counseling: Preventing and Combating Opioid Misuse
(1 contact hr)
With the current opioid epidemic, learn critical information professionals need to know to assess the nature of patient’s and client’s opioid use, provide education and/or counseling for opioid use, and refer persons to applicable resources for substance misuse or abuse.
Heroin: The Illegal Opioid
(1.5 contact hrs)
The history of diacetylmorphine (heroin) along with current epidemiological data and overdose statistics together illustrate the dangers associated with use and abuse of, dependence on, and addiction to this drug. Characteristics of heroin such as its appearance, chemical structure, administration, metabolism, and mechanism of action are addressed in this continuing education module to elaborate on how the drug elicits such a strong, unique euphoric effect compared to other opioid medications. Additionally, various treatment approaches for the management of acute and chronic heroin use are discussed.