School of Nursing

January 24, 2018

Legislative update: Opioid epidemic

Azita Emami

During Nurse Legislative Day on Jan. 22, 2018, many legislators engaged with UW School of Nursing students, faculty and advocates, as well as nurses and students across the State of Washington. Many legislators expressed an interest in having nurses’ input about the opioid crisis, and I appreciate the opportunity to amplify those discussions.

The opioid situation is, a tragic, costly, and complicated problem that sits at the intersection of medical and social factors. More than 5,000 people a month are dying of opioid overdoses. The UW Alcohol & Drug Abuse Institute estimates there are more than 33,000 people in Washington state who are using and abusing injectable drugs; addicts using ingestible opioid medications is unquestionably several times that number. The Institute found that more than half the people using injectable drugs say they got “hooked” on prescription-type opioids before starting heroin. This emphasizes the need to address the problem at its root cause. There are neither easy explanations for nor easy solutions to a challenge that is having a negative effect on almost every state, and everywhere in our state.

One question posed by legislators was about the idea of limiting the prescribing of opioids. Any attempt to impose such limits would undoubtedly have many unintended consequences. Pain management is an extremely complex undertaking. People differ greatly in their perception and response to pain. Some people have acute pain, due to surgery or other condition that can be remedied; others have chronic pain due to conditions ranging from cancer to scoliosis, which are not amenable to cure.

Any arbitrary limit will inevitably be incorrect for some patients, and runs the risk of keeping prescribers from helping those most in need of pain relief. Already there are many examples of patients with chronic pain who are suffering because of the shift in attitudes about the use of opioids. There is now widespread recognition among prescribing nurses and doctors that legitimate use of opioids for acute or chronic pain treatment often is a precursor to abuse and addiction, and there is much more caution about prescribing them. Yet there are many people for whom there is no equally effective substitute. Drawing that line is probably best done by a prescriber who sees and knows a patient, rather than by any attempt to legislate arbitrary limits on prescribing.

There is certainly an opportunity to minimize misuse of opioids through far better tracking and control of these medications from the point of manufacturing through dispensing. There is ample evidence that in many cases manufacturers are selling — and distributors are distributing — quantities far in excess of what would reasonably be needed by a given pharmacy. And of course there have been many cases where prescribers are writing script in such quantities that they are obviously mills, not healthcare facilities.

A statewide database that at least tracked opioid prescriptions written and dispensed might be a helpful first step, but any significant solution must include the manufacturers and that would require action at the federal level. An effective solution will have to address each node at which medications change hands—manufacturer-to-distributor; distributor-to-pharmacy; prescriber-to-patient; and pharmacy-to-patient. Of course, having the data is meaningless unless there is funding for adequate analysis, investigation and (where necessary) prosecution.

Legislators inquired about counseling before prescribing. A more effective result would probably be achieved by investing in a prescriber education campaign. The prescribers—physicians and nurses with prescribing privileges—are the gatekeepers. It is they who can best evaluate each patient and decide the nature and extent of advice to give about addiction risks.

A related issue in which nursing has a major role to play is recognition and treatment of both pain and addiction. Nurses are adept at dealing with chronic conditions. They offer compassionate, capable care that takes into account social, cultural and other factors. This is part of their education, and it is particularly pertinent in the case of opioid abuse where a bond of trust between patient and caregiver is a necessary foundation for meaningful treatment.

Which brings me to the third point raised—safe injection sites, and the closely-related “syringe exchange programs” (SEPs). The former offer a safe space in which people can use injectable drugs, while the latter offer an exchange of clean syringes and other drug-related equipment for offsite use.

The Institute identified 25 SEPs operating in 18 Washington state counties, through public health departments, community groups, and tribal entities. Studies on the effectiveness of such programs have been mixed, though on balance the majority show that needle exchange is a cost-effective strategy for reduction of blood-borne diseases such as HIV and hepatitis C. But disease reduction is partial mitigation, at best. It does not return addicts to functional status, it does not reduce the crime that pays for their habits, and it ultimately does little to save their lives. What would be most effective are centers staffed primarily with nurses and dedicated to dealing at all levels with what is truly a healthcare crisis. Syringe exchange should be offered in the context of a larger set of service options for those who want an opportunity to break the cycle of addiction. The presence of recovering addicts who have had success getting clean would be a powerful type of advocacy that is far more effective than pre-prescription counseling. The ability of nurses to educate, listen, counsel and treat could help build a community of recovery.

The significance of both safe injection sites and syringe exchange programs (SEPs) is that they are, or have the potential to be the foundation of a multifaceted substance abuse service center. The Alcohol & Drug Abuse Institute found that “Syringe exchanges have established trusting relationships with people who inject drugs and increasingly with diverse community stakeholders as well. SEPs are the experts on working with PWID and, via an array of federal and state funded projects, are increasingly providing valuable resources, including overdose education and naloxone to other services providers, first responders, and the broader community. SEPs are also becoming part of opioid treatment networks by directly providing treatment education, referrals and, in one instance, onsite treatment medications. Staff at SEPs are uniquely poised to provide onsite linkage for HIV, hepatitis C and substance use treatment; help clients navigate social service entry points; and facilitate the use of primary health care over more costly emergency department care. Public health and safety can be substantially improved by the services SEPs provide and by community agencies collaborating with SEPs and recognizing their vital role in community health.”

It is my belief that creating and expanding comprehensive addiction service centers would prove highly cost effective. The financial and human cost of the current epidemic is staggering. Drug addiction almost inevitably leads to criminal activity to support the spiraling expense of the addict’s habit. It removes people, often those in the prime of life, from the pool of those contributing to economic and social growth. It disrupts and often destroys families. For a particularly poignant description of the latter, see the enclosed article that ran a few days ago in the New York Times. The impact of opioid addiction ripples outward and touches all those who are or were connected to the addicted person.

We could make Washington state a model for the country on how to confront this immense challenge. We could demonstrate that the dollars invested in compassionate care are returned in not only economic benefits but also human benefits. We could make an impact on opioid addiction and all of its negative consequences.

The UW School of Nursing stands ready to help legislators promulgate and promote a positive opioid strategy for the state, ensuring our knowledge and expertise is at their disposal.