Nursing Education in the Midst of the Opioid Crisis

Pain Management Nursing xxx (xxxx) xxx

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Pain Management Nursing journal homepage: www.painmanagementnursing.org

Review

Nursing Education in the Midst of the Opioid Crisis Peggy Compton, PhD, RN, FAAN *, Suzan Blacher, PhD, MSN, RN, CARN y * y

School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania

a r t i c l e i n f o

a b s t r a c t

Article history: Received 30 January 2019 Received in revised form 11 June 2019 Accepted 11 June 2019

Objectives: The current opioid addiction crisis highlights two chronic health conditions which have traditionally received relatively little emphasis in nursing curricula: addiction and chronic pain. In an effort to provide direction to nursing programs in the US on the curriculum needed to prepare students to care for patients and meaningfully intervene in the opioid crisis, this paper presents an overview of the curricular elements which require integration. Design and Data Sources: Specifically, the state of current nursing education in pain and addiction are reviewed, followed by foundational knowledge for nursing practice to address the opioid crisis. Review/Analysis Methods: Practice competencies for generalist registered nurses as well as advanced practice nurses will then be detailed, and, recognizing the role nurses play in policy development and implementation, policy interventions to address the opioid crisis will also be presented. Result and Conclusions: Both addiction and chronic pain are sources of suffering for patients; the key role nursing can play in reducing the experience of these illnesses in these vulnerable populations is critical to addressing the opioid addiction crisis. © 2019 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

The United States is in the midst of an opioid crisis. Opioid misuse, addiction, and overdose have reached unprecedented levels in the United States. Between 1999 to 2017, more than 700,000 Americans died from a drug overdose, and approximately 68% of the more than 70,200 drug overdose deaths in 2017 involved an opioid. In 2017 the number of overdose deaths involving opioids (including prescription opioids and illegal opioids like heroin and illicitly manufactured fentanyl) was six times higher than in 1999. On average, 130 Americans die every day from an opioid overdose (Centers for Disease Control and Prevention [CDC], 2017). Although prescription opioids have played a role in the addiction crisis, an evolving illicit drug market is causing an increasing number of deaths as a result of overdose, most recently deaths from synthetic opioids (e.g., illicit fentanyl), from 3,100 deaths in 2013 to more than 19,400 in 2016 (Jones, Einstein, & Compton, 2018). The rapid rise of heroin and illicit fentanyl overdose in the United States is not unrelated to prescription opioid abuse; 45% of people who

This study was funded by The Van Ameringen Foundation and a grant from the NIH, NIDA R21DA046364. Address correspondence to Peggy Compton, PhD, RN, FAAN, School of Nursing, University of Pennsylvania, 418 Curie Blvd, Claire M. Fagin Hall, Room 402, Philadelphia, PA 19104-4217. E-mail address: [email protected] (P. Compton).

use heroin report their first opioid exposure to be a prescription opioid analgesic, albeit not necessarily prescribed to them (CDC, 2015, 2018). Thus, although the majority of overdose deaths are attributed to illicit opioids, prescription opioids have been found to play a critical role in the crisis, serving as “gateway” opioids to more harmful illicit opioid use. To address in this substantial public health crisis, it is imperative that nurses at all practice levels and in all practice settings possess the necessary knowledge and skills to effectively intervene with individuals at risk for the untoward effects of opioid use. Unfortunately, existing nursing curricula, both at the undergraduate and graduate level, is shockingly sparse in the very content necessary to provide nurses with the competencies to deliver such intervention. In an effort to provide direction to nursing programs in the United States on the curriculum needed to prepare students to care for patients with opioid use issues, this paper will present an overview of the curricular elements that require integration. Specifically, the state of current nursing education in pain and addiction will be reviewed, followed by foundational knowledge for nursing practice to address the opioid crisis. Practice competencies for generalist registered nurses (RNs) as well as advanced practice nurses will then be detailed, and, recognizing the role nurses play in policy development and implementation, policy interventions to address the opioid addiction crisis will also be presented.

https://doi.org/10.1016/j.pmn.2019.06.006 1524-9042/© 2019 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Please cite this article as: Compton, P., & Blacher, S., Nursing Education in the Midst of the Opioid Crisis, Pain Management Nursing, https:// doi.org/10.1016/j.pmn.2019.06.006

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Current State of Nursing Education

Addiction-Related Content

To prepare nurses to effectively intervene in the opioid crisis, they must receive content in two key areas: pain (and more specifically, chronic pain) and addiction (or, as referred to in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5; American Psychiatric Association, 2013], substance use disorder). In that opioids are commonly prescribed for the management of pain, their role and safe and effective use, must be considered. Related to their reinforcing effects, nurses must be able to recognize and manage problematic opioid use behaviors, whether used in the presence of pain or for recreational or illicit purposes. Finally, reflecting a holistic perspective of the patient, nursing education should include the care of the patient who suffers from both pain and addiction because these patients are at specific risk for poor treatment of both disorders.

The paucity of pain content in nursing curricula is accentuated by a lack of content on substance use disorders. The current state of addiction content in nursing curricula is inconsistent at best, with some programs offering only a mention of substance use in a mental health course. Curricula on substance use-related content are less than optimum, and schools of nursing have been described as not keeping up with the increasing public health concerns related to substance use disorders (Finnell et al., 2018; Knopf-Amelung et al., 2018; Smothers et al., 2018). Some reasons for the lack of inclusion of substance use education may be due to concerns that the curriculum is an already oversaturated; assumptions that substance use is being taught in the psychiatric nursing or other courses; or that faculty do not have proficiency to teach the subject matter (Smothers et al., 2018). Nurses are the health care employees who have the most contact with patients, which places them in an ideal position to screen for substance use (Knopf-Amelung et al., 2018; Nash et al., 2017; Oermann, 2018; Savage, Dyehouse, & Marcus, 2014), and providing undergraduate nursing students’ with substance use education has been found to build their confidence and competence, as well as reduce stigmatizing attitudes (Koetting & Freed, 2017; Lewis & Jarvis, 2019; Mahmoud et al., 2018; Nash et al., 2017; Smothers et al., 2018). There is evidence that some undergraduate programs have introduced substance use education classes and programs; however, these efforts are lacking consistency and it is not known what other substance useerelated content may be included (SBIRT [Screening, Brief Intervention, and Referral to Treatment]; alcohol, tobacco, pain management; stigma; or special populations), how many hours are included, or where in the curriculum the education occurs. Similar to the absence of substance use education seen in nursing undergraduate programs, graduate nursing programs are also deficient in substance use education (Covington et al., 2018; Moore et al., 2017; Savage et al., 2018). A survey of 233 advanced practice nurses across specialties found that respondents reported receiving 1.67 (standard deviation [SD] ¼ 1.13) hours of didactic content related to addiction in their graduate programs, with the modal response that no addiction-related content had been included in the curriculum (Campbell-Heider et al., 2009). In this respect, nursing students fare worse than the preparation of our medical colleagues. Curriculum deans at 66 accredited medical schools in the United States reported an average of 5 lecture hours on alcohol- and comorbid drug-related disorders; however, 41% of schools indicated neither lecture nor discussion hours on substance use disorders (Miller, Sheppard, Colenda, & Magen, 2001). With up to 10% of Americans experiencing an addictive disorder in the past year (Substance Abuse and Mental Health Services Administration [SAMHSA], 2018), it is particularly concerning that a substantial number of nursing and medical schools provide no content on the disease. There are recent concerted efforts to increase the amount of opioid-related content in advanced practice registered nurse (APRN) programs. To this end, APRN programs across the country have begun to launch a variety of courses to educate students on opioid use disorders, particularly including courses in opioid prescribing. One such program was developed by the state of Arizona Department of Health Services in conjunction with deans and curriculum representatives from “all eighteen [medical doctor] MD, doctor of osteopathy [DO], [physician assistant] PA, [nurse practitioner] NP, [doctor of medicine in dentistry] DMD, [doctor of podiatric medicine] DPM and [naturopathic doctor] ND programs in Arizona” for all prescribers (Arizona Department of Health Services, 2018). APRNs, with proper education, will be able to have a significantly positive role in addressing problematic substance use. However, as with the undergraduate substance use additions to the curriculum, it is not known what other substance

Pain-Related Content Despite the importance of these curricular elements in preparing nurses to address the opioid crisis, data indicate that limited curricular hours are devoted to the management of pain and substance use disorders. With respect to mandatory formal pain content, Watt-Watson and colleagues (2009) found that in prelicensure nursing programs in Canadian universities, faculty reported that students received an estimated 31 hours of pain content across the curriculum, ranging from 0 hours to 109 hours. Although this was essentially double the number of hours reported by medical, dental, and pharmacy schools in the survey, both physical therapy and veterinary schools reported providing more formal pain content (41 hours and 87 hours, respectively) than that provided nurses. The majority of hours in the nursing programs referencing pain were devoted to neurophysiology, assessment, and pharmacologic therapies, with less emphasis on nonpharmacologic interventions and the multidimensional qualities of pain, suggesting that acute versus chronic pain was the predominant focus. It was concerning that the majority of health science programs (67.5%) were unable to specify designated hours for pain, with only 32.5% of the respondents able to identify specific hours allotted for pain course content and/or additional clinical conferences. In a more recent survey of undergraduate pain curricula for health care professionals in the United Kingdom (Briggs, Carr, & Whittaker, 2011), nursing programs reported dedicating only 10.2 curricular hours (range: 2-36 hours) to pain-related content, which was less than that reported by medical (13 hours), occupational therapy (14 hours), physical therapy (37.5 hours), and veterinary (27.4 hours) programs. Comparing the percentage of curricular hours devoted to pain content in health sciences curricula, a survey by Doorenbos and colleagues (2013) of six prelicensure health sciences programs in five U.S. states found that approximately 1% of nursing curriculum hours were related to pain topics. This percentage was half that reported by medical and pharmacy programs and was dwarfed by the percentages reported dental (6%) and physician assistant (17%) programs. The authors noted that suggested curriculum topics identified by the premier professional pain organization (the International Association for the Study of Pain) were missing from the curricula and that there was limited use of innovative teaching methods such as problem-based and team-based learning in delivering this content. Compounding the lack of hours devoted to teaching nurses about pain is the finding that nursing faculty themselves have received little training in pain management and thus are not well equipped to deliver this content (Duke, Haas, Yarbrough, & Northam, 2013).

Please cite this article as: Compton, P., & Blacher, S., Nursing Education in the Midst of the Opioid Crisis, Pain Management Nursing, https:// doi.org/10.1016/j.pmn.2019.06.006

P. Compton, S. Blacher / Pain Management Nursing xxx (xxxx) xxx

useerelated content (SBIRT; alcohol, tobacco, pain management; stigma; or special populations) has been added or how many hours are included and where in the curriculum the education occurs. For both undergraduate and graduate nursing programs, it is incumbent on faculty initiating these programs to publish the results so that others may benefit in the creation of new educational interventions (Smothers et al., 2018).

Nursing Curriculum to Address to the Opioid Crisis In their 2018 “Response to the Opioid Epidemic,” the American Association of Colleges of Nursing (AACN, 2018) identified as one of their future goals that all nursing schools adopt enhanced curriculum to address the opioid epidemic. As nurse educators know, AACN also provides the key competencies that underlie the necessary curricular elements for prelicensure (AACN, 2008) and advanced practice (AACN, 2011) nursing education. These so-called Essentials reflect national consensus by providing the elements and framework for building quality nursing curricula, preparing students for licensure examinations, and serving as standards for nursing program accreditation. However, the Essentials documents do not dictate the amount of curricular emphasis that should be devoted to specific topics (e.g., pain, addiction) but rather leave it up to individual programs to determine what learning is necessary to prepare students for baccalaureate generalist nursing practice or master's-level nursing practice. Similarly, the nursing licensure examination (NCLEX-RN) blueprint is relatively silent on the requisite emphasis on content specific to pain and addiction (National Council of State Boards of Nursing, 2016). Although pain is never specifically mentioned in the test plan, there is a category of items described as related to “Basic Care and Comfort” (9% of NCLEX-RN test items) under which presumably pain would fall; under the category of “Psychosocial Integrity” (9% of NCLEX test items), substance use disorder is referred to as related content; however, it appears within a list of 16 other content areas, suggesting that it does not receive substantial emphasis. Direction for pain content to be integrated into prelicensure nursing curriculum is provided by the Interprofessional Consensus of Core Competencies for Prelicensure Education in Pain Management (Fishman et al., 2013). An expert panel of nurses synthesized these competencies across four core domains (the multidimensional nature of pain; pain assessment and measurement; management of pain; and clinical contextual conditions that affect management) with the AACN Baccalaureate Essentials referenced earlier, suggesting learning objectives and teaching strategies specific to nursing education (Herr et al., 2015). Of clear relevance to the opioid crisis, the content domain related to the management of pain includes an objective that students be able to differentiate among physical dependence, substance use disorder, misuse, tolerance, addiction, and nonadherence. These curricular recommendations have been integrated into the suggested foundational and leveled practice content presented next. Unfortunately, similar levels of pain-related curricular guidance are not available for advanced practice nursing education, nor for addiction content at either the prelicensure or advanced practice program levels. Core curricula are available for those nurses seeking specialty certification in either pain management (American Society of Pain Management Nurses, 2018) or addiction (Rundio & Lorman, 2015); however, these competencies go beyond the scope of what can be included in a typical nursing school curriculum. Presented next are recommendations for foundational content to prepare nurses to intervene in the opioid crisis, followed by key competencies for generalist RN nursing practice and advanced practice nursing practice.

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Foundations for Nursing Practice to Address the Opioid Crisis A helpful framework with which to approach the public health problems of chronic pain and opioid addiction is that of public health. In this model, primary prevention interventions would be aimed at preventing exposure to severe pain (which could develop into chronic pain) and unnecessary exposure to opioids, secondary prevention would be aimed at preventing acute care from becoming chronic and opioid exposure from becoming opioid use disorder, and tertiary prevention aimed at preventing the serious sequela (including death) from un(der)treated chronic pain and opioid use disorder.

Chronic Pain Although this is changing, over the past two decades, opioids have become a mainstay in the treatment of chronic pain. In fact, it is currently estimated that between 5 and 8 million Americans use opioids on a daily basis for chronic pain relief (Chou et al., 2015), with estimates indicating that more than half of all opioid prescriptions written in the Veterans Health Administration system are for veterans with chronic pain (Jonas & Schoomaker, 2014). Data indicate that patients with chronic pain prescribed opioids are at no higher risk for developing a substance use disorder than the general public (Volkow & McLellan, 2016); however, the use of opioids to manage ongoing pain requires that nurses understand the unique characteristics of chronic pain. First, it is important to communicate to students that chronic pain is a highly prevalent chronic disease. It affects the daily lives of fully one third of Americans older than age 45, and the prevalence of the disorder will increase as the population ages. Based on data from the 2016 National Health Interview Survey, an estimated 20.4% of U.S. adults (50 million) had chronic pain with 8.0% (19.6 million) reporting high-impact chronic pain; higher prevalence of both chronic pain and high-impact chronic pain were reported among women, older adults, previously but not currently employed adults, adults living in poverty, adults with public health insurance, and rural residents (Dahlhamer et al., 2018). These rates of chronic pain dwarf the rates of diabetes, heart disease, and cancer in the United States; however, much more emphasis in nursing curricula are given to these less common diseases. Nurses also need to understand that chronic pain is qualitatively different from acute pain and therefore requires different management approaches. Specifically, chronic pain recruits neurologic systems beyond simple nociceptive sensory pathways to include much greater contribution of the affective and cognitive components of pain. Therefore, analgesic medications play a less important role in chronic pain management, and interventions aimed at addressing the thoughts and emotions associated with the pain are those with greatest efficacy. For example, cognitive behavioral therapy, mindfulness-based therapy, and acceptance and commitment therapy have been found to be particularly effective in helping patients manage their chronic pain. In addition, interventions that promote physical restoration, including weight loss, graded exercise, physical therapy, and yoga, can improve functionality in these patients. So-called multimodal interventions, combining medications with nonpharmacologic strategies and including complementary therapies (e.g., mindful meditation) are the hallmarks of effective chronic pain treatment. It is important to note that improvements in function (activity, sleep, work, mood) are the meaningful outcomes to evaluate in patients with chronic pain; pain severity (which is typically evaluated in the case of acute pain management) may not change significantly over time; however, the ability of the patient to maintain a good quality of life in the presence of pain is evidence of effective chronic pain management.

Please cite this article as: Compton, P., & Blacher, S., Nursing Education in the Midst of the Opioid Crisis, Pain Management Nursing, https:// doi.org/10.1016/j.pmn.2019.06.006

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Substance Use Disorder It is estimated that 1 in 10 Americans older than age 12 have used an illicit drug in the past 30 days (SAMHSA, 2018), making it a highly prevalent behavior. The most commonly abused drug in the United States is marijuana, with 24 million people reporting use in the past month (although recreational marijuana use is legal in many states, it is still classified as illegal by the federal government), followed by the misuse of prescription pain relievers at 3.3 million past month users. However, the abuse of an illicit substance does not mean that the user meets the diagnostic criteria for a substance use disorder (SUD) or addiction, which is an important distinction for students to understand. Students should have a working knowledge of the DSM-5 diagnostic criteria for substance use disorder (APA, 2013), complete with an understanding that neither tolerance nor physical dependence should be considered indicative in patients taking opioids for pain and that the great majority of the criteria are behavioral in nature, suggesting that behaviors are the fodder for assessment. With respect to the prevalence of SUD, in 2017 approximately 7.5% of the U.S. population (or 20.1 million persons) older than age 12 met the DSM-5 diagnostic criteria (SAMHSA, 2018). Being legal and highly marketed, it is not surprising that the drug to which most Americans are addicted is alcohol; far fewer are addicted to marijuana (4 million) and prescription pain relievers (1.8 million). Combining rates of prescription opioid and illicit opioid use disorders, approximately 2.4 million Americans were addicted to opioids in 2017. However, students should understand that it is not only persons addicted to opioids who are at risk for opioid overdose; patients who do not meet diagnostic criteria but who have respiratory compromise (e.g., chronic obstructive pulmonary disease [COPD], sleep apnea) and are coprescribed benzodiazepines or combine opioid use with alcohol use are also at high risk for opioidinduced respiratory depression and overdose. Perhaps most importantly, nurses must appreciate that SUD is a chronic disease and therefore not unlike diabetes or heart disease in many respects; it is a disorder that is never “cured” but can be managed over time. As with any chronic illness, SUD has a pathophysiologic basis, and the brain systems disrupted with the disorder (including the subcortical reward pathways, the hippocampus, and prefrontal cortex) have been well described. There are known risk factors for the disorder, which include a family history of SUD, comorbid psychiatric disorders, and use of drugs or alcohol before the age of 13. Increasingly appreciated is the role of childhood sexual, physical, or emotional trauma, or so-called adverse childhood experiences, in the development of SUD (Chandler, Kalmakis, & Murtha, 2018; Tilson, 2018). As with any chronic disease, addiction has a predictable course, and if left untreated, it will progress and worsen, eventually leading to death. There are treatments with good efficacy for SUD, but as with diabetes or heart disease, medications alone cannot treat the disorder and behavioral changes are required. Further, treatment must be ongoing and lifelong, which is why the episodic nature of the addiction treatment delivery system too often results in poor outcomes. Finally, like any chronic illness, addiction is characterized by remissions and exacerbations (i.e., it can be better or worse controlled over time); in the case of SUD, exacerbations are called relapses and are often precipitated by episodes of personal stress. Interestingly, when defined as the recurrence of symptoms that requires additional medical care, rates of relapse in addiction (40%-60%) are actually lower than those in hypertension and asthma (50%-70%) (McLellan, Lewis, O'Brien, & Kleber, 2000). Opioid Pharmacology A final competency required by nurses to intervene in the opioid crisis is a good understanding of opioid pharmacology, which is a

foundational content area and probably the best addressed in current nursing curriculum. Students understand that analgesic tolerance and physical dependence can develop over time but may need increased competency in identifying the signs and symptoms of opioid withdrawal, its management, and the role it plays in the continuance of use. It is also important that nurses appreciate the significant risks of drug interactions with other central nervous system depressants (including alcohol) with respect to respiratory depression and overdose. Finally, because the medications used to treat opioid addiction (medication-assisted therapy [MAT]) and overdose (naloxone) are in fact themselves opioids, it is important that students understand the pharmacodynamic properties and differences between full agonists, partial agonists, and antagonists at the m-opioid receptor. To ensure that nurses can knowledgably intervene in the opioid crisis, current pharmacology courses must go beyond discussion of opioids in the setting of acute pain treatment to consideration of their use and effects in SUD and addiction treatment contexts. Key Competencies for Generalist RN Nursing Practice Interventions for Chronic Disease Management To manage chronic illnesses, there are specific independent nursing interventions nurses can be trained to provide, which generalize across chronic conditions, including chronic pain and addiction, and emphasize the role of the patient in selfmanagement of the disease. For example, motivational interviewing and cognitive behavior therapy are techniques nurses can implement without a physician's order to facilitate behavioral change or decrease engagement in unhealthy behaviors. Acceptance and commitment therapy (ACT), a newer form of cognitive behavioral therapy, appears especially promising in helping pa, & tients manage their chronic conditions (Graham, Gouick, Krahe Gillanders, 2016). ACT promotes psychological flexibility to engage in behaviors that facilitate achieving life goals and optimal functioning within the realities of the limitations imposed by the chronic illness. Other strategies to assist with chronic illness selfmanagement are teaching patients stress management techniques and nursing assessment for psychiatric illness or symptoms that may make the chronic illness experience more difficult to manage. In general, the better nurses are able to focus on optimal function in the midst of illness, as opposed to concentrating on cure or attempts to achieve an absence of symptoms, the more effective their interventions will be in the management of chronic diseases, including chronic pain and SUD. Renewed Emphasis on Nonpharmacologic Comfort Interventions Managing pain is fundamental to nursing practice (American Nurses Association, 2018; American Nurses Association & American Society for Pain Management Nursing, 2016). Often, early in their training, nurses are introduced to nonpharmacologic measures to provide comfort; however, these quickly give way to learning about more pharmacologic or interventional strategies. Nurses learn that independent nursing interventions such as massage, heat/cold compresses, positioning, and distraction can be effective ways to help patients manage discomfort, but rarely do they see them used in the clinical setting, where an emphasis on analgesic provision predominates. To the degree that nurses can be reminded throughout the curriculum and their clinical experiences to implement nonpharmacologic comfort interventions each time a patient reports pain, they will learn to be less reliant on opioid provision, thereby limiting the risks associated with opioid exposure. Other independent nursing interventions to minimize discomfort include environmental approaches (e.g., providing a

Please cite this article as: Compton, P., & Blacher, S., Nursing Education in the Midst of the Opioid Crisis, Pain Management Nursing, https:// doi.org/10.1016/j.pmn.2019.06.006

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quiet, dimly lit room), encouraging rest and sleep, and general stress management techniques. Screening, Brief Intervention, and Referral to Treatment Contained within the Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008), and the Essentials of Baccalaureate Nursing Education for Entry Level Community/ Public Health Nursing (Association of Community Health Nursing Educators, 2009) are practice competencies for prevention and health promotion. Certainly, the use of evidence-based SBIRT method (Murphy-Parker, 2013) falls securely within these competencies (Puskar, Mitchell, Kane, Hagle, & Talcott, 2014) and can be used by nurses in a variety of settings. SBIRT is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs, and both the CDC (Dowell, Haegerich & Chou, 2016) and U.S. Preventive Services Task Force (2016) endorse its use for screening of risky alcohol and other drug use and prescribing opioids. SBIRT consists of three major components: (1) screening, or assessing a patient for risky substance use behaviors using standardized screening tools; (2) brief intervention, or engaging the patient showing risky substance use behaviors in a short conversation, providing feedback and advice; and (3) referral to treatment, or providing a referral to brief therapy or additional treatment to patients who screen in need of additional services. Students can be introduced to the brief alcohol and drug use screening tools recommended by the National Institutes of Health (SAMHSA-HRSA, n.d.) and, if screened as positive, trained on the administration of more in-depth screening tools, such as the AUDIT (available at https://www.integration.samhsa.gov/clinical-practice/sbirt/AUDIT. pdf) or the ASSIST (available at https://www.integration.samhsa. gov/clinical-practice/sbirt/ASSIST.pdf). For patients screened to be at risk of substance abuse and related health problems, nurses can independently deliver brief interventions to motivate individuals to change their behavior by helping them understand how their substance use puts them at risk and to reduce or give up their substance use. Nurses can also use brief interventions to encourage those with more serious SUDs to accept more intensive treatment or a referral to a specialized alcohol and drug treatment agency. Brief interventions can last from 5 minutes of brief advice to 15-30 minutes of brief counseling and typically consist of brief versions of cognitive behavioral therapy and motivational interviewing or some combination of the two. The referral to treatment process consists of assisting patients to access specialized treatment, selecting treatment facilities, and navigating barriers such as treatment cost or lack of transportation that could hinder treatment in a specialty setting (SAMHSA-HRSA, n.d.) and may require consultation with social work resources in the practice setting. Affective and Ethics Education Perhaps most importantly, to effectively intervene in the opioid crisis, nurses need to internalize an empathetic and nonjudgmental perspective of patients experiencing SUD. In the United States, moral and criminal models of the disease continue to predominate, resulting in attributions of shame, blame, and stigma, as well as creating barriers to effective treatment. Nurses are not immune from these perspectives and may have their own experiences with addiction in themselves, their family members, or acquaintances who reinforce these negative attributions. In addition to emphasizing the chronic disease model of SUD, it is important to encourage students to examine their own feelings and values about addiction in a safe context, as well as to consider the ethics of providing highquality and effective nursing care to patient with SUD. Not unrelated is ensuring that nursing students are prepared to recognize SUD-related impairment in their coworkers and

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understand their responsibilities for reporting their concerns. In addition to the well-being of the impaired health care professional, nurses must consider the welfare of patients under their care, acknowledging that SUD-induced impairment can lead to the delivery of poor care and result in patient safety issues. Learning that many institutions and most state licensing boards offer nonpunitive approaches and resources to treat the impaired health care professional will result in nurses in being more willing to report problematic coworker behaviors and feeling empowered to intervene. Key Competencies for Advanced Practice Nursing Management of Chronic Pain An expert panel from the American Academy of Nursing on Policy (2017) reinforced professional nursing organizations in support of APRNs expanding their prescriptive practice and comprehensive knowledge and skills for the prevention and treatment of substance use disorders. Because of their extensive clinical training and prescriptive authority and the high prevalence of chronic pain, APRNs are likely to be called on to independently manage it, especially those working in primary care and geriatric settings. For this reason, all APRNs should have a working knowledge of the principles of chronic pain management promulgated in the recent CDC Guideline for Prescribing Opioids for Chronic Pain (Dowell, Haegerich, & Chou, 2016, 2019; Hamnvik, Alford, Ryan, Hardesty, & Drazen, 2019); in fact, according to the AACN, 200 member schools have pledged to educate their students on the guideline. Not only does the guideline promote nonpharmacologic and opioid-sparing strategies to manage pain, it also emphasizes the need to assess for risk for opioid misuse before initiating an opioid prescription. Related to the risks associated with opioid use, it suggests that providers obtain informed consent after a discussion of the risks and benefits associated with opioid therapy, including the expectations that opioids are used as prescribed and are safely stored and disposed of; and that random, intermittent urine drug testing and consultation of the state prescription drug monitoring programs will be performed on a regular basis to ensure patients are using opioids as prescribed (i.e., not being diverted), not using other illicit drugs (indicating risk for abuse of opioids), and not obtaining opioids from other providers. In addition, consideration of the use of abuse-deterrent opioids, coprescription of naloxone to all patients receiving an opioid prescription, and strategies for opioid tapering to minimize harm associated with opioid prescription are reviewed in the Guideline. However, APRN students should also be required to use critical thinking skills when implementing the CDC Guideline with their patients with chronic pain. Although the opioid-sparing approaches make sense, the Guideline recommendations are not evidence based and were designed to be voluntary and not prescriptive (Darnall et al., 2019; Stanton & McClughen, 2017) (although some health and pharmacy systems have treated them as such). Importantly, the Guideline was not intended to limit prescriber discretion or decision making in opioid provision, or to encourage withholding opioids from patients who are receiving benefit with no evidence of problematic use. Advanced practice nursing students should be encouraged to engage in thoughtful implementation of the Guideline, with optimal patient outcomes as opposed to nonopioid therapy being the ultimate treatment goal. Management of Acute Pain in Patient with a History of Opioid Addiction Because of the scope of the opioid crisis, not uncommonly a patient with a history of opioid use disorder will require a surgical procedure or suffer an injury requiring acute pain management. These are complex patients APRNs should have the skills to

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manage, understanding that interventions will vary depending on if the history of use is remote (i.e., the patient is in drug-free recovery) or if the patient is actively using or is on medicationassisted therapy (e.g., methadone, buprenorphine, naltrexone) (Giron, Olson, Griffis, & Compton, 2018). In all cases, nonopioid pharmacologic approaches should be used to decrease reliance on or exposure to opioids, including parenteral nonsteroidal antiinflammatory drugs, gabapentinoids, local analgesics, and, in certain cases, ketamine. Further, nonpharmacologic comfort interventions, described earlier, should be implemented. APRNs must expect patients actively abusing prescription or illicit opioids to present with some degree of tolerance and physical dependence and thus likely require higher doses of opioids than opioid-naïve patients to achieve adequate analgesia. Because opioid withdrawal brings with it hyperalgesia, it should be actively monitored for and avoided. Provision of adequate pain control enables the development of trust and a therapeutic relationship with the patient, which may open the door to a teachable moment and referral to treatment. Doing so also models to other care providers an empathetic and professional approach to those with this stigmatized disorder. Understanding the pharmacology of different medication-assisted treatments, tolerance, and physical dependence can also be anticipated for those on full (methadone) and partial (buprenorphine) agonist therapy. Dose and type of medication should be confirmed with the provider and continued during the acute pain episode. For those on naltrexone, APRNs should expect that opioid analgesia will not be effective until the antagonist dissociates from the opioid receptor and thus rely on nonopioid analgesia approaches and involvement of an addiction treatment specialist on the treatment team. Referral to Specialized Treatment Specialized treatment services for both chronic pain and opioid addiction can be difficult to access; thus APRNs will need to develop sophisticated referral skills to ensure these patients receive the care they need. Students should be familiar with barriers to treatment, including a general lack of providers and poor insurance coverage. In the case of chronic pain, there are only approximately 3,500 qualified pain specialists in the United States available to treat the estimated 50 million patients with chronic pain, and nonpharmacologic evidence-based interventions, such as acupuncture, cognitive behavioral therapy, and yoga, are not covered by many insurance companies. Similarly, MAT to treat opioid addiction can be difficult for patients to access; in addition to long waiting lists, 85% of U.S. counties do not have a MAT provider. In addition, not all medications are covered by all insurance companies (including Medicaid), prior authorization may be required, or treatment may be limited to 1-3 years, inconsistent with the need for ongoing treatment. Complicating the situation, insurance companies may cover noneevidence-based treatment services (e.g., detoxification) with poor outcomes. APRN students need to fully understand different treatment models and delivery systems and develop skills to identify resources and services available and accessible to patients in their community. Provision of Medication-Assisted Therapy In light of the lack of adequate numbers of MAT providers in this country, perhaps the most powerful way APRNs can intervene in the opioid crisis is to be prepared to provide MAT to patients experiencing opioid addiction, especially those practicing in primary care settings. The Addiction Treatment Access Improvement Act of 2018 extended the Comprehensive Addiction Recovery Act of 2106 to allow APRNs, including nurse practitioners, certified nursemidwives, clinical nurse specialists, and certified registered nurse anesthetists, to prescribe buprenorphine to support patients

struggling with addiction. Before prescribing, APRNs must obtain a prescribing waiver, which requires 24 hours of training from one of several professional organization providers. The length of the training precludes integrating it into advanced practice nursing programs, but students can be familiarized with the practice and oriented to the expectation that they obtain the waiver on graduation. Further, APRNs can provide naltrexone to treat opioid addiction without specific certification and thus should receive instruction on methods to transition patients from active opioid use to antagonist therapy. Because they graduate with skills in providing cognitive behavioral therapy and motivational interviewing, APRNs may be better equipped to provide MAT than their physician colleagues. Although APRNs may prescribe methadone for the treatment of pain, they may not do so for the treatment of opioid use disorder because it can only be dispensed in approved outpatient treatment programs to patients on a daily basis. Health Policy to Address Opioid Crisis The AACN Essentials documents that direct nursing curricula include a competency related to health care policy for both generalist RN and APRN nursing practice, it is important that nursing students be able to identify policy initiatives and changes to better address the opioid crisis. Specifically, nurses should appreciate the importance of evidence-based addiction treatment being available and accessible on demand. This includes financial support for the preparation of addiction treatment providers and improved reimbursement for addiction treatment services, including for those who are uninsured. Typically, addiction treatment has been marginalized from general health care delivery systems, making it difficult to access and allowing the growth on noneevidence-based treatment settings. Better integration of addiction services into existing acute and primary care settings will improve access as well as quality. Policy to support harm reduction approaches is also essential to addressing the opioid crisis. Because they will often be involved in providing opioid prescriptions, nurses should be familiar with and able to teach patients about how to best dispose of unused opioids, the policies governing which vary from state to state and could be better served with national consensus. Policy efforts to make naloxone readily available, as well as to support the opening of safe injection facilities (Kerr, Mitra, Kennedy, & McNeil, 2017; Marshall, Milloy, Wood, Montaner, & Kerr, 2011), will go a long way in decreasing rates of opioid overdose deaths. Broader policy changes, including the decriminalization of addiction (the only disease for which incarceration is an outcome) and directed mental health intervention for children who have suffered trauma or physical, emotional, and sexual abuse, are additional public health efforts nurses can be encouraged to support. Conclusions Including addiction content into the nursing curricula, whether in undergraduate or graduate programs, does not need to be an overwhelming task. Whether the school's pedagogy supports online, hybrid, or face-to-face learning, there are innovative modalities with which to introduce addiction content into the nursing curricula. First and foremost, both lecture and clinical faculty need to feel confident and competent when delivering substance use education. Puskar and colleagues (2014) implemented a program that promotes faculty training that encourages buy-in to addiction education. This program is currently accessible in an online module, “Addiction Training for Nurses,” and available for continuing education credit (http://nursing.pitt.edu/academics/ce/SBIRT.jsp) (Puskar et al., 2014). Nurse educators can employ live lectures,

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narrated slides, role play, simulation, standardized patients, video clips or any combination of these teaching modalities (Finnell et al., 2018; Oermann, 2018). The education can be interwoven into other courses across the curriculum such as health assessment and health promotion, theory and didactic classes, community/public health, and pharmacology. Most important is to expose students to patients with substance use disorders across the lifespan while in the clinical environment (Finnell et al., 2018; Lewis & Jarvis, 2019; Oermann, 2018). Being the largest group of health care professionals in the country, nurses have a large and powerful role to play in addressing the opioid crisis. Thus on graduation from their nursing programs they must be well prepared with specific competencies that will enable them to do so. Foundational and leveled nursing competencies emphasizing the use of multimodal and nonpharmacologic pain treatment approaches, opioid-centric patient teaching, and identification and advocacy of patients with SUDs are significant and independent ways nurses can assist with this public health crisis. Because nurses will encounter patients struggling with addiction and chronic pain across clinical settings and specialties, this education must be provided all nurses, and integrated into both classroom and clinical learning. Too often students will graduate from a nursing program never having had a clinical experience treating a patient with addiction. Well-prepared nurses bring to their practice a complex, holistic perspective of their patients, with skills in chronic disease management and behavioral interventions. Both addiction and chronic pain are sources of suffering for patients, and nurses are the quintessential providers of relief from distress, so they are in an ideal position to meaningfully intervene. References American Academy of Nursing on Policy. (2017). Opioid misuse epidemic: Addressing opioid prescribing and organization initiatives for holistic, safe and compassionate care. Nursing Outlook, 65, 477e479. American Association of Colleges of Nursing. (2018.). AACN’s response: The opioid epidemic. Retrieved from https://www.aacnnursing.org/Portals/42/Policy/PDF/ AACN-Opioids.pdf. (Accessed 23 July 2019). American Association of Colleges of Nursing. (2011). The essentials of master’s education in nursing. Washington, DC: Author. Retrieved from http://www.aacnnursing.org/ portals/42/publications/mastersessentials11.pdf. American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. Retrieved from http://www.aacnnursing.org/portals/42/publications/baccessentials08.pdf. American Nurses Association. (2018). The ethical responsibility to manage pain and the suffering it causes (2018 Position Statement). Retrieved from https://www. nursingworld.org/~495e9b/globalassets/docs/ana/ethics/theethicalresponsibi litytomanagepainandthesufferingitcauses2018.pdf. American Nurses Association, American Society for Pain Management Nursing. (2016). Pain management nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: American Nurses Association. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. American Society of Pain Management Nurses. (2018). Core curriculum for pain management nursing (3rd ed.). St. Louis, MO: Elsevier. Arizona Department of Health Services. (2018). The Arizona pain and addiction curriculum. Retrieved from http://www.azhealth.gov/curriculum. (Accessed 21 January 2019). Association of Community Health Nursing Educators. (2009). Essentials of baccalaureate nursing education for entry level community/public health nursing. Retrieved from http://www.achne.org/files/EssentialsofBaccalaureate_Fall_2009. pdf. (Accessed 19 January 2019). Briggs, E. V., Carr, E. C., & Whittaker, M. S. (2011). Survey of undergraduate pain curricula for healthcare professionals in the United Kingdom. European Journal of Pain, 15(8), 789e795. Campbell-Heider, N., Finnell, D. S., Feigenbaum, J. C., Feeley, T. H., Rejman, K. S., Austin-Ketch, T., Zulawski, C., & Schmitt, A. (2009). Survey on addictions: Toward curricular change for family nurse practitioners. International Journal of Nursing Education Scholarship, 6. Centers for Disease Control and Prevention. (2018). Opioid overdose: Data overview. Retrieved from https://www.cdc.gov/drugoverdose/data/index.html. Centers for Disease Control and Prevention. (2017). Wide-ranging online data for epidemiologic research (WONDER). Atlanta: National Center for Health Statistics. Retrieved from http://wonder.cdc.gov.

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Please cite this article as: Compton, P., & Blacher, S., Nursing Education in the Midst of the Opioid Crisis, Pain Management Nursing, https:// doi.org/10.1016/j.pmn.2019.06.006