Nurse Practitioners and Suboxone Rachel Bodansky Liliana Bogin

Nurse Practitioners and Suboxone Rachel Bodansky, Liliana Bogin, Amanda Hudak, Sarah Lord, Hilary Glass, Hannah Maxwell, Hannah Pajolek, Summer Richardson NURS 5009 - Winter 2016 Seattle University College of Nursing

Outline History of opioid addiction treatment and methadone Suboxone DATA 2000 TREAT Voices from the community Nursing leadership positions Proposal for change

Scope of Problem What was the leading cause of death in the US in 2009?

Scope of Problem In 2003, an estimated 1. 5 million people aged 12 years and older met criteria for opioid abuse or dependence; by 2012, this had increased to 2. 3 million people. The rate of past-year opioid abuse or dependence increased significantly from a rate of 634. 1 per 100, 000 people aged 12 years and older in 2003 to a rate of 891. 8 in 2012. 2009: CDC reported 4, 000 methadone prescriptions written for pain (Hong, Gikas & Connelly, 2014) Opioid agonist medication-assisted treatment with Methadone or Buprenorphine (Suboxone) is the most effective treatment for opioid use disorder (WHO, 2009) What is methadone? What is suboxone?

What is Methadone? Long acting opioid used to treat non-cancer pain Morphine developed in 1800 s from the poppy plant, 1947 methadone commercially available. Started being used in the 50 s to treat opioid addiction only in federally approved Opioid Treatment Centers. Currently used for treatment of addiction and for pain, high potential for abuse (Schedule 2). Substitute a less addictive opiate (e. g. Methadone, stored in liver and metabolized more slowly than injected opiates) for a more addictive opiate (e. g. heroin) to reduce illicit opiate use. Patients must present daily to federally-approved programs with limited geographic coverage that have long restricted waiting lists and not always covered by insurance

Problems with Methadone Treatment Methadone has a high potential for abuse, misuse, or diversion. Addictive Used to treat pain, so creates a problem for providers to distinguish need Has street value It can only be accessed from approved treatment centers, which do not have the capacity to treat all of the individuals in need. Treatment centers are often only in urban centers, leaving rural areas with a lack of resources.

Suboxone? Buprenorphine and Naloxone- used specifically for opioid addiction, NOT pain management Buprenorphine: high affinity to mu receptors in CNS → analgesic effect, partial mu agonist and weak kappa antagonist As a partial agonist, buprenorphine has a ceiling effect-- after a certain point taking more will not increase any of the effects. Because buprenorphine has a high affinity for the mμ receptor, it reduces the effects of additional opioid use. Naloxone: opioid antagonist → displaces opioids at opioid receptor sites Has typical opiate agonist effects but less euphoric effects of full agonists such as Methadone and heroin Does NOT require patients to go to treatment centers, can be done in many office-based settings (Schedule III). Ceiling effect and poor bioavailability make overdose safer than full agonists Effective in low-dose opiate users who can be monitored on a less frequent basis

Cons of Suboxone Adverse effects: CNS depression → monitor mental status, CNS depression Respiratory depression → monitor respiratory status Hepatic impairment → monitor LFTs Orthostatic hypotension Pregnancy Category C Different formulations have different bioavailability → easy to overdose/underdose patients when switching formulations May precipitate rapid narcotic withdrawal in patients addicted to opioids How do you get methadone? Suboxone?

DATA 2000 Drug Addiction Treatment Act of 2000 Permits qualified physicians to prescribe FDA-approved schedule III-V narcotic controlled substances Credentialing includes 8 hour opioid addiction training unless previous clinical research experience or if certified in addiction medicine Designed to expand opioid addiction treatment to settings beyond Opioid Treatment Programs (OTP) Allows office based treatment, excludes hospitals, excludes ARNPs/PAs DATA Waived Physicians - approved/qualified physicians are issued a waiver that allows them to treat up to 30 patients (up to 100 if approved by SAMHSA) Required to keep documents re: records, reports, inventories, theft, disposal, and security

TREAT Recovery Enhancement for Addiction Treatment Act (S. 1455/H. R. 2536 - introduced to Senate July 2014 and the House May 2015 ) Amends Controlled Substances Act to increase the number of patients a provider can treat from 30 to 100 (or unlimited if qualified) Revises “qualified provider” to include board certified ARNPs and PAs with experience/training to prescribe schedule III, IV, V for pain AND with experience or specialization to treat patients with opioid-dependency “(cc) the nurse practitioner prescribes opioid addiction therapy in collaboration with a physician who holds an active waiver to prescribe schedule III, IV, or V narcotic medications for opioid addiction therapy” Must work in a DATA waived facility. ARNPs and PAs are required to receive no less than 24 h of training or experience in opioid addiction treatment from a Secretary approved training program. this is separate from prescribing opioids for pain or other conditions.

TREAT Should NPs be able to prescribe and treat independently of physicians? Apply for their own DEA waiver? What impact will TREAT have on primary care offices? Treatment centers? How will that change if TREAT allowed NPs to manage opioid addiction patients on their own?

Voices from the Community Dr. Tracy Klein, Ph. D, FNP, ARNP, FAANP, FRE, FAAN (WSU Professor, AANP board of directors) Supports TREAT Act because “incremental change is better than no change at all” but she would ideally like the language to change Encourages nurses to reach out to AANP Government Affairs to address their role in TREAT advocacy Reports that Government Affairs meets regularly with legislative sponsors and Senator Markey’s office, issues briefs to AANP state representatives, and offers to assist in sponsorship growth Reached out to her representative (Blumenaur) to sponsor and request language modification to address incongruency with scope of practice - they “have indicated a willingness to do so”

Voices from the Community Jackie Brolsma, ARNP at Evergreen Treatment Center In her experience, physicians are eager to increase patient access and support ARNP/PA collaboration, but she acknowledges that she “is in an urban setting which may not be representative of the more rural and conservative areas of the country or oven our state. ” Did not do any personal advocacy because a colleague who was actively involved at the state/national level indicated that it was very likely to pass, so she did not feel called upon to do so. “This is great progress and of course we can always do more. . . this will move opioid use disorders more into mainstream medicine, no matter who treats them. ” She feels that she has had great MD colleagues who have supported expanding the NP role in treating patients with addiction, so she doesn’t feel the need to challenge MDs and legislators on the language of TREAT at this time.

Nursing Leadership AANP - 2015 Issue Brief The AANP supports the TREAT Act and calls on Members of Congress to support it as well Federal barriers to prescribing & managing opioid addiction treatments should be lifted APNA Fully supports the expansion of advanced practice registered nurses' prescriptive authority to include the prescription of buprenorphine and buprenorphine/naloxone (Suboxone) in the treatment of persons who are addicted to opiates.

Proposal for Change We support the passing of the TREAT Act because even though it doesn’t allow ARNPs to be fully autonomous, it is a step in the right direction. But… are there parts of TREAT Act we don’t like?

Questions for Consideration What can we do to advocate for TREAT? For NP scope not addressed by TREAT? How can we continue to support efforts to reduce stigma of addiction/the use of medications to treat addiction? Increase clinician training on addiction? Increase requirements to be qualified prescribers?

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