Tackling the Opiate Epidemic

August 03, 2016
School of Nursing Instructor Donna White talking to Hope House Director Fred Newton

School of Nursing Instructor Donna White talking to Hope House Director Fred Newton. She brings students to the Boston sober house to see the devastating effects of people becoming addicted to opiates.

By Lawrence Harmon

It wasn’t until Cara Brown went to Hope House as part of her community nursing class this summer that the Bachelor of Science in Nursing student truly began to understand the extent of the prescription drug and heroin abuse crisis that is gripping Massachusetts.

“What made an impact on me was seeing people who are struggling every day with addiction,” she says about her visits to the Boston sober home where there are 95 residential beds as well as an outpatient day program that serves dozens more who are addicted to opioids (such as Percocet or Vicodin) or opiates (heroin). “Meeting with these clients put a face to the disease.”

The class is taught by Instructor Donna White, an internationally renowned expert with 40 years of experience in treating opiate-related disorders. She is one of several MGH Institute faculty members who are educating student nurses and physician assistants about what to look for, and how best to treat, addiction disorders.

“Opioid addiction has been a major concern for years, but until recently it was considered an inner-city problem,” says White, who serves on the board of the International Nurses Society on Addictions and who also takes students to Lemuel Shattuck Hospital, where she has worked for several years, and other locations. “Now that it’s moved to the suburbs, there’s a lot more media attention because it affects people from all walks of life. It doesn’t discriminate.”

Faculty members Merson, left, and Lucey have seen during their work in emergency rooms a dramatic rise in the number of people with opiate addictions.

Faculty members Merson, left, and Lucey have seen during their work in emergency rooms a dramatic rise in the number of people with opiate addictions.

Institute faculty, including Assistant Professor Jason Lucey and Instructor Tom Dolan in the School of Nursing, and Physician Assistant Studies Instructor Josh Merson, are on the front lines battling the epidemic that in 2014 claimed the lives of almost 1,100 people in Massachusetts—a 63 percent increase in just two years. But even such a shocking statistic doesn’t begin to measure the impact of an insidious disease so closely associated with fractured lives, heartbroken families, diminished productivity, and lost hope.

Because faculty members work regularly with “people who have an addictive disorder” (as White prefers to call them), they are educating Institute students as well as current health care providers that people hooked on opiates and opioids have a chronic disease, not a character flaw.

Good Intentions Gone Awry

When Lucey began his nurse practitioner studies at the Institute in 1998, the prevailing wisdom was that pain should be liberally treated with prescription opiates. Few could have predicted a future in which these actions would lead to a sharp increase in addiction, or that people who became hooked after their pain eventually ended often would turn to heroin (which on the street costs as little as $3.50 a bag versus $30 a pill) as a much cheaper replacement.

“Most people during that period didn’t recognize the depth of the problem,” says Lucey, who teaches a course on advanced assessment and diagnostic reasoning and works as a nurse practitioner at Wentworth-Douglass Hospital in New Hampshire. “Sadly, many more people know about it now.”

Lucey, who has appeared as an expert panelist on New Hampshire Public Radio, teaches his students a method called compassionate refusal when dealing with those battling addiction who often will go to extreme measures in their attempts to convince a health care provider to write an opioid prescription. Rather than dismissing patients as “hopeless addicts,” he shows students how to ask questions such as whether the person has previously abused opioids, and steer them toward drug recovery treatment programs and healthier lifestyles.

Both White and Lucey also introduce their students to motivational interviewing—a form of goal-directed counseling that encourages patients to make positive changes in their lives. The nursing profession’s holistic approach to health and wellness dovetails with the treatment of people with substance abuse disorders. It can be a different situation when educating physician assistants, according to Merson.

“Traditionally, physician assistants operate on a medical model where providers take a disease-oriented approach to the patient,” says Merson, who teaches a course on physical assessment and also works at a North Shore hospital emergency room. But he notes that faculty are training PA students to adopt a more holistic approach in dealing with the psychological and social implications of substance abuse disorders, including motivational interviewing. “You have to look at the whole person for an illness so complex,” he explains.

Physician assistant student Hannah  Kobett worked extensively one on one with patients with an addiction disorder in Washington, D.C. on harm reduction strategies, including syringe exchange programs, before starting her studies at the Institute in May 2015. Mock clinical settings, she says, teach students how to take extensive social histories and identify sociocultural factors influencing the patient’s health. It’s difficult, she notes, to understand the full scope of what patients deal with on a day-to-day basis—especially the complex challenges extending beyond the clinic that she encountered while working with homeless chronic substance users. “We treat these patients like all our other patients—as people,” Kobett says.

Significant Gaps Remain

Students learn that public policy has a major role to play in managing the opiate epidemic. For example, pressure from first responders and family members of substance abusers has prompted several pharmacy chains to now offer the opiate-reversing drug Naloxone without a prescription. White makes sure her students are trained to administer the inhalant, commonly known as Narcan, which has been credited with saving the lives of hundreds who have overdosed.

But significant gaps remain. Many addiction specialists see great potential in medications such as buprenorphine, a partial opioid agonist that prevents cravings and withdrawal symptoms but does not produce the same high as such drugs as methadone and suboxone, and is therefore less subject to abuse. However, nurse practitioners and  physician assistants currently are prohibited from prescribing buprenorphine, which White sees as a barrier to effective treatment.

Massachusetts Governor Charlie Baker recently introduced several bills to address the crisis, including limiting to three days the amount of pills in a patient’s first opioid prescription— studies indicate that as many as 75 percent of people who become addicted initially receive the narcotic for legitimate reasons—and under certain scenarios giving hospitals the power to mandate treatment for patients who pose a danger to themselves or others. These ideas have not been met with universal agreement in the medical community or the Legislature.

But tackling this epidemic, says White, will require a new generation of practitioners with open minds, sharp clinical skills, and political savvy to help reverse this growing health epidemic—someone like Megan Mahoney, a BSN student scheduled to graduate in 2016. “While not all of us will work in community settings, we will all come across patients with addictions,” says Mahoney. “Realizing how little dignity and respect these patients receive has made me want to be an active participant in the movement to help those who are suffering.”