Nurse Practitioners in Addiction Medicine: Leaders in Training Future Health

Care Providers

Melinda Ramage, FNP-BC, CARN-AP, CDE

Elisabeth Johnson, PhD, FNP

Carriedelle Fusco, FNP-BC

Disclosures

• None of these speakers have any conflicts of interest related to the content of this activity.

Objectives

1. Describe the history of education and training of substance use disorders in health care

2. Compare our history to the current training needs and gaps identified in delivering these needs

3. Identify the role of the nurse practitioner in addiction medicine

4. Discuss three spheres of training led by Addiction trained Nurse Practitioners: clinical, pre-graduate and graduate learners, and community

5. Evaluate tools, curricula, and lessons learned for practical application in your health care setting

Where Have We Been?

Historical Context of Substance Use Disorders (SUD)

“The study of history can help one gain insights into the nature of a current problem. Teaching health care providers the evolution of the disease concept of addiction might help them to better understand present treatment approaches, and give them the freedom to explore new models“

Karen Egenes, RN

Addiction Treatment: A Historical Nursing Perspective By Karen Egenes, R.N., Ed.D. Journal of Addictions Nursing: 1995-Volume 7-Issue 1-ppg 2-7

Historical Context of SUD• 1784: Benjamin Rush classified “intemperance” as a

disease

• 1879: Dr. Leslie Keeley announces that "Drunkenness is a disease and I can cure it." >120 Keeley Institutes across the U.S., 1st franchised, private, for-profit addiction treatment institutes/sanatoria

• 1914: The Harrison Tax Act brings opiates and cocaine under federal control -physicians gatekeepers for access to these drugs.

• 1919: A Supreme Court decision (Webb v. the United States) declares that for a physician to maintain an addict on his or her customary dose is not in "good faith" medical practice under the Harrison Act and thus an indictable offense. 25,000 physicians are indicted for violations of this act through1935.

White, W. (1998). Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington, IL: Chestnut H ealth Systems.

Historical Context of SUD continued

• Mid 1920s: Substance use disorders became criminal justice issues

• 1950: AMA created a committee to develop program for medicine’s participation in the work around alcoholism. Defined alcoholism is 1952.

• 1963: American Public Health Association released official statement that alcoholism is a treatable illness

• 1967: AMA defines alcoholism as a disease

• 2010: Patient Protection and Affordable Care Act: ended segregation of substance use disorders from the rest of health care

White, W. (1998). Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington, IL: Chestnut Health Systems.

History of Education and Training in SUD

• Following the 1914 Harrison Narcotic Act, the treatment of substance use disorders was segregated from mainstream medical practice

• 1943: First university-based education about alcoholism offered by Yale Center of Alcohol Studies Summer School

• 1954: Ruth Fox, MD created New York City Medical Society on Alcoholism (predecessor of ASAM)

• 1974: American Nurses Association’s (ANA) supported the establishment of the National Nurses Society on Alcoholism (NNSA)

• 1983: First certification exam for addiction medicine

• 1989: First certification exam for professional addictions nursing practice given

Rundio, A & Lorman, W (2015) Core Curriculum of Addictions Nursing: Official Publication of the International Nurses Society on Addictions. Phi ladelphia Lippincott Williams & Wilkins

History of Education and Training in SUD: GAPS

1. The missing SUD competencies in health care education curricula:• Assessment

• Treatment

• Prevention

2. Lack of available comprehensive training programs to learn and practice evidence-based substance use disorder care

Specialized training programs would facilitate the translation of recent advances in substance use research into routine clinical practice

Voon et al, 2017; The National Center on Addiction and Substance Abuse at Columbia University, 2012

So let’s talk more about addiction medicine training

Carriedelle Wilson Fusco, MSN, FNP-BC Family Nurse Practitioner Department of Family Medicine

121 Hendersonville Rd, Asheville, NC 28803 Phone: 828-257-4731 / Fax: 828-257-4738 carriedelle.fusco@mahec.net

History of SUD Training

Minimal to no training on SUD despite financial impact of disease

Why?• Stigma - Viewed as a moral issue

• Precedence that education was community led• Religious and Secular

• Example: 12 steps

Rasyidi et al 2012, Klimas et al 2017

Change is Afoot

• Addiction Specialty• American Board of Addiction

Medicine 2007

• Addiction Medicine Education to Health Care Curricula• AAFP and others providing more

specific requirements

• Evidence supports Chronic Disease model• Stigma still exists

ADDICITON FELLOWSHIPS

ADDICTION MEDICINE BASICS TO

HEALTH CARE CURRICULA

ACCEPTANCE AS A

CHRONIC DISEASE

Rasyidi et al 2012, American Academy of Family Physicians. AAFP Reprint 2117. Recommended Curriculum Guidelines for Family Medicine Residents S ubstance Use Disorders. 2017

Primary Care Providers at the Frontlines

• Chronic disease management - SUD• Primary Care provides home base for chronic disease care and triage

• Educational focus on detox (inpatient), not long term management –

Example: MAHEC Family Medicine Residency program • Limited training out of clinic walls

• Fear that outside providers/educators were not providing evidence based education

• Aware of issues of “siloing” SUDS

American Academy of Family Physicians. AAFP Reprint 2117. Recommended Curriculum Guidelines for Family Medicine Residents Substance Use Disorders. 2017

Specialty/Fellowships

• Previously much of training focused on detox/rehab• Exclusively for Psych

• Evolving options for fellowship training for physician providers• ABAM – evolving to include FP, IM, Peds, and OB-Gyn

• Few options for Advance Practice RN’s• Issue of funding/GME not financial supportive

• CARN!!!

Rasyidi et al 2012, Klimas et al 2015

Silo’s

• SILOs dictate• Access to care

• Training focus

• Care available

Community Treatment

Detoxification

Addiction Specialty

Rasyidi, E., Wilkins, J. N., & Danovitch, I. Training the Next Generation of Providers in Addiction Medicine. Psychiatric Clinics of North America .2012;35(2), 461–480.doi: 10.1016/j.psc.2012.04.001

Melinda Ramage, MSN, FNP-BC, CARN-AP Medical Director Project CARA 119 Hendersonville Road / Asheville, NC, 28803 Phone: 828-768-2262 / Fax: 828-771-5479 melinda.ramage@mahec.net http://mahec.net/patient-information/ob-gyn-care/project-cara

Nursing History in Addiction Medicine

• 1975: National Nurses Society on Alcoholism NNSA (stemmed from 1974 ANA call and answer to the AMA new creation of the American Medical Society on Alcoholism)

• 1983: NNSA Changes to encompass all use disorders

• 1990 Certified Registered Nurse (CARN) certification

• 2000 NNSA merged with outside international organizations to create the International Nurses Society on Addiction (IntNSA)• Fellowship in Addiction Nursing : https://www.intnsa.org/academy/fiaan/

About Us. (2019, February 25). Retrieved September 26, 2019, from https://www.intnsa.org/about -us/.

IntNSA Mission

“To advance excellence in nursing care for the prevention and treatment of addictions for diverse populations across all practice settings through advocacy, collaboration, EDUCATION, research, and policy development”

Who are our Key Learners?

Pre/Graduate Learners

Community Learners

Clinical Learners

Tools, Curricula, and Lessons learned in Education and Training

*No physicians were actually harmed in the making of this photo*

Educational Curricula: Community Members

1. Addiction 101

2. Medication Assisted Treatment 101

3. Harm Reduction

4. Prevention

5. Service/Access Description

Community Members

Educational Curricula: Clinical Learners

1. Addiction 101

2. Medication Assisted Treatment 101

3. Harm Reduction

1. Urine Drug Screen/Testing

2. Patient Screening and Interview techniques

3. Cognitive Behavioral Therapy

Clinical Learners

Educational Curricula: Pre Graduate/Graduate Student Learners

6 week “rodeo” rotation includes:

1. Time with Addiction trained provider in OBOT setting

2. Detoxification and inpatient treatment

3. Special populations: Ex: Perinatal Substance Use Disorders

4. Opioid Treatment Program/Methadone Clinic

5. “Ride along” with Peer Support Specialist

6. DATA 2000 waiver training

Pre/Graduate Learners

Educational Curricula: Medical Residency

Educational Platform: Community Task Force

Participant target based on community. Includes but not limited to

• Medical (CNA/RN/APP/MD etc)• Think out of the box here-…

• Pharmacists, Physical Therapists…etc

• Behavioral Health/ Substance Use • Community practice, private practice, and faith based

• Case Management

• Law Enforcement/Judicial

• Community stakeholders

Education Platform : ECHO

• Hub team: need a representative from: social work, healthcare (NP/PA/MD), psychiatry at minimum

• Target audience (aka Spokes): healthcare providers currently prescribing buprenorphine or any discipline interested in learning more about MAT/SUD.

• Need web platform

Educational Platform: Buprenorphine Waiver

• CARA ACT 2016 permits NP/PAs to Rx Buprenorphine

• SUPPORT ACT 2018 permits CNMs to Rx Buprenorphine

• American Academy of Addiction Psychiatry DATA 2000 trainings

Educational Platform: Example ECHO Topics

• Integrated care

• Providing MAT in a primary care setting

• Overview of OUD

• Harm Reduction

• Infectious Diseases:

Hep C, HIV

• Pharmacology of buprenorphine

• Buprenorphine induction

• Urine Drug Screens

• Smoking Cessation

• NAS

• Buprenorphine in pregnancy• Benzodiazepines including Ashton

Protocol

• ADHD and use of stimulants in the

setting of OUD

• Interacting with CPS• Community support: NA, AA,

Oxford House

• ASAM criteria• Treatment resources

Example Tools/Resources

• Provider's Clinical Support System/PCSS:

https://www.asam.org/education/resources/pcss-mat

• ASAM Education

https://www.asam.org/resources

• IntNSA

https://www.intnsa.org/academy/

• NIDA

https://www.drugabuse.gov/parents-educators

Questions

References

1. Addiction Treatment: A Historical Nursing Perspective By Karen Egenes, R.N., Ed.D. Journal of Addictions Nursing: 1995-Volume 7-Issue 1-ppg 2-7

2. White, W. (1998). Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington, IL: Chestnut H ealth Systems.

3. Rundio, A & Lorman, W (2015) Core Curriculum of Addictions Nursing: Official Publication of the International Nurses Society on Addictions. Philadelphia Lippincott Williams & Wilkins

4. Voon, P; Johnson, C; Small, W; Wood, E; Klimas, J (2017) Fellowship in Addiction Medicine A Novel Program in a Canadian Setting. Journal of Addictions Nursing: July/September 2017 - Volume 28 - Issue 3 - p 148–149 doi: 10.1097/JAN.0000000000000179

5. The National Center on Addiction and Substance Abuse at Columbia University. (2012). Addiction medicine: Closing the gap between science and practice. New York, NY: CASA Columbia. http://www.casacolumbia.org

6. About Us. (2019, February 25). Retrieved September 26, 2019, from https://www.intnsa.org/about -us/.

7. Rasyidi, E., Wilkins, J. N., & Danovitch, I. Training the Next Generation of Providers in Addiction Medicine. Psychiatric Clinics of North America .2012;35(2), 461–480. doi: 10.1016/j.psc.2012.04.001

8. Klimas, J., Small, W., Ahamad, K., Cullen, W., Mead, A., Rieb, L., … Mcneil, R. Barriers and facilitators to implementing addiction medicine fellowships: a qualitative study with fellows, medical students, residents and preceptors. Addiction Science & Clinical Practice. 2017;12(1). doi: 10.1186/s13722-017-0086-9

9. American Academy of Family Physicians. AAFP Reprint 2117. Recommended Curriculum Guidelines for Family Medicine Residents Sub stance Use Disorders. 2017

10. Klimas, J. Training in addiction medicine should be standardized and scaled up. Bmj. 2015; 351:h4027. doi: 10.1136/bmj.h4027