Confronting the Opioid Crisis

Nurses are on the front lines of the opioid epidemic. As the first faces many patients see, nurses have the opportunity to identify individuals who are addicted, and they can also save lives by administering naloxone, an "opioid antagonist" that reverses the effects of an overdose.

But many nursing colleges are only relatively recently adding programs about preventing and treating opioid addiction.

Deborah Finnell, associate professor in the department of acute and chronic care at Johns Hopkins University's School of Nursing, said that since she arrived at Hopkins about five years ago, she’s made a concerted effort to push for more instruction on substance use, which she said is lacking in nursing programs across the country.

Finnell co-authored a report published by Nurse Educator last year that said nursing programs lacked curricula on substance use disorders, and offered ways to remedy this problem. The emergence of the opioid crisis has emphasized the need to better inform nursing students about addiction, the report says.

“Nursing curricula have not kept pace with the growing public health crises related to alcohol and other drug use and the expanding evidence base for treatments,” the report states, adding that curricula on addiction haven't changed much in four decades.

Nurses have an important role in combating the opioid epidemic because they can intervene before an addiction spirals, the report says.

New Courses Trickle In

Over the past year or so, a number of nursing schools have introduced programs to teach students to prevent and treat an opioid addiction or overdose.

At the University of Pennsylvania Nursing School, starting this fall, the nursing program will offer an undergraduate elective, Opioids: From Receptors to Epidemic, which includes a lecture on overdoses, according to Peggy Compton, an associate professor, who will co-teach the class with Heath Schmidt. The course covers acute and chronic pain, the composition of opioids, the pathophysiology of opioid addiction, treatment options, the historical foundations of the crisis, and current policies regulating opioid distribution. While the class is geared toward nursing students, it's open to all majors “because the implications go beyond health care,” Compton said via email.

Penn is also in the midst of developing two simulation programs -- one in person, and one via virtual reality. In February, Penn piloted a two-hour in-person simulation for nursing students. In the session, actors mimicked the symptoms of an opioid overdose, as well as overdoses of heroin and fentanyl, which are more potent versions of prescription opioids (many times, opioid users will switch to heroin or fentanyl if their prescription is not renewed). Students were able to practice treating these patients, including dealing with their reactions, which run the gamut from anger to distress to fear, according to Ann Marie Hoyt-Brennen, Penn’s simulation education specialist. The pilot was deemed a success and starting this summer will be a requirement in two courses, one graduate and one undergraduate.

A February 2017 study by the National Bureau of Economic Research found that when states increased access to naloxone, opioid fatalities declined by 9 to 11 percent. Despite this, naloxone has received some negative press: critics say the opioid antagonist encourages addicts to use again. Because of this perception, said Clare Whitney, a Ph.D. candidate in Penn's school of nursing, many nurses are not aware of the medication or do not know how to administer it.

“This is a really problematic narrative,” Whitney said. “The problem is not that we have a drug that can save a life. The problem is that we don’t have proper care.”

Marymount University will also pilot an opioid-related simulation this month for 90 students in the health department, including the nursing program. Catherine Hillberry, director of the college's nursing lab, will show students a video of an opioid overdose and follow up with a discussion on treatment and prevention strategies. Nurses need to learn to work as a team with other medical professionals, Hillberry said.

"We don't work in silos, we work with other people, so we have to know how to talk to other people, how to interact with them," Hillberry said.

The University of Cincinnati Nursing School started reviewing its curricula on addiction a year ago after joining 190 other American Association of Colleges of Nursing members in an agreement to teach advanced-practice nurses about the Centers for Disease Control and Prevention's "Guidelines for Prescribing Opioids for Chronic Pain," released in 2016. In response, Sherry Donaworth, associate professor of clinical nursing at Cincinnati, wove the guidelines into the college curriculum. Donaworth now requires her advanced-practice nursing students to take three hours, in addition to the usual six, of instruction on prescribing opioids. "Providers have an obligation to prescribe in a way that doesn't perpetuate the problem," Donaworth wrote in a blog post.

Some community colleges are also focusing on the opioid epidemic, too.

At Washington State Community College, in Ohio, Alicia Warren, director and associate professor of practical nursing education, said the nursing department recently introduced more information on opioid use. In June, faculty members were urged to take a four-hour course called Understanding Substance Use Disorder in Nursing, offered by the National Council of State of Boards of Nursing. This semester, students were required to watch a short video released by the board called "Substance Use Disorder in Nursing" and take part in discussions on opioid addiction in introductory and ethics courses. Students are also taught to administer naloxone, which is becoming increasingly accessible, Warren said.

Overcoming Stigma

Many nursing instructors cite stigma as a key challenge. To Craig Sellers, director of the master’s program at the University of Rochester School of Nursing, subverting perceptions of addiction begins with language.

“We know that addiction is a health-care problem. It’s not about a lack of character, if you will,” Sellers said. “We really try to avoid the term ‘addict.’”

Stephen Strobbe, clinical associate professor at the University of Michigan, echoed Sellers’s point, cautioning against using the word “abuse.”

“The term ‘abuse’ has fallen out of vogue in our field, and is now seen as negative, judgmental and pejorative,” Strobbe said.

Cincinnati recently started offering nursing students a presentation about the neurobiology of addiction, aiming to subvert negative attitudes tied to substance use disorder. Jennifer Lanzillotta, a clinical nursing instructor, created the session, which includes firsthand accounts from clinicians who became addicted to opioids themselves -- an issue that isn’t unusual in the medical profession. Lanzillotta is surveying students before and after the course to determine how their perception of addiction shifted after viewing the presentation.

“No one wakes up and says, ‘I want to be a drug addict,’” Lanzillotta wrote in a blog post. “This presentation has shown we can reduce the stigma associated with drug abuse by health-care providers.”