More than 63,000 individuals died from drug overdoses in the United States in 2016 (Centers for Disease Control and Prevention [CDC], 2018). The reality of the increased incidence of drug overdose is all too familiar to professionals and the public alike. Much focus has been on the opioid epidemic, but misuse of other classes of drugs, singly or in combination with alcohol or other prescription or illicit drugs, can also result in harm.
Eighteen percent of the population reports use of illicit substances or misuse of prescription medications (CDC, 2018). Prescribing medications that have a high potential for patient harm, especially when combined with illicit substances or alcohol, can pose significant risks of patient morbidity and mortality, and can expose prescribers and organizations to liability. Interprofessional health care teams are increasingly being called on to help mitigate these risks and to work together to relieve symptoms of medical and psychiatric disorders safely and effectively.
Opioids and benzodiazepines, due to their capacity to induce tolerance and dependence, are two risky medication classes that are especially dangerous when taken together, or in combination with alcohol. Use of these medications in individuals with an existing substance use disorder (SUD) can precipitate relapse. Although benzodiazepines have some use in the treatment of anxiety disorders and insomnia and opioids can help manage acute pain, new guidelines recommend that these medications be used less frequently, and not combined (CDC, 2016; Dowell, Haegerich, & Chou, 2016).
Certain patient populations have a higher risk of harm in using these medications, including those at higher risk of SUD. Individuals with psychiatric disorders have higher rates of SUD; approximately one half of individuals with a lifetime incidence of mental illness will also experience a SUD (National Institute on Drug Abuse, 2018). Having a psychiatric diagnosis is an independent risk factor for developing SUDs (Kurti et al., 2016). Risk for overdose among medical users of prescription opioids is increased when individuals have concurrent depression or another psychiatric disorder (Nadpara et al., 2018). Individuals with mental illness also have a higher incidence of medical comorbidities, including those associated with chronic pain (Tegethoff, Belardi, Stalujanis, & Meinlschmidt, 2015), which may lead to treatment with opioids.
The severity of the overdose epidemic has heightened awareness of potential harm from controlled substances in the general population as well as members of the health professions. Nurses are often key team members in addressing this problem and, along with an integrated team approach to care, can help minimize the risks of opioid and benzodiazepine use for individuals with mental illness.
Integrated Health Approaches for Individuals with Serious Mental Illness
There are various definitions of integrated health care for individuals with mental illness. These definitions all involve combining primary care and mental health care, often co-locating these services; a high level of collaboration among team members; and attention to communication and coordination of care (National Institute of Mental Health, 2017). Integrated health programs and teams come in various forms and include models ranging from a psychiatric specialist embedded in a primary care practice with an on-site pharmacy, to a co-located community mental health center and primary care clinic with an academic practice partner (Geis & Delaney, 2010), to provision of tele-psychiatry services in a rural health clinic. Advanced practice mental health nurses are well-poised to deliver behavioral health care alongside primary care providers (PCPs) in many of these models (Jordow, 2014). Team members can include not just clinic-based providers, but others such as case managers, occupational therapists, pharmacists, or social workers.
Integrated health approaches have been shown to help providers manage the care of individuals with cooccurring serious mental illness (SMI) and medical comorbidities (Laderman, 2015) as well as co-occurring SMI and SUD (Anastas et al., 2018; Annamalai, Staeheli, Cole, & Steiner, 2017). Staff competencies in care coordination, team communication, and collaboration (Hoge, Morris, Laraia, Pomerantz, & Farley, 2014) that are hallmarks of integrated health care can be applied to teams working in various settings to help prevent the dangers associated with opioid and benzodiazepine use.
Effective strategies for increasing safe use of opioids and benzodiazepines within the context of an interprofessional team with a focus on serving individuals with mental illness and at higher risk of SUDs can be broken down into several categories: building consensus on the team, providing education for all stakeholders, and enhancing care coordination and patient access to effective treatments.
Building Consensus on the Team
Members of different disciplines or those working in different sectors of the health care system often have varying ways of approaching clinical issues or patient populations. For example, developing shared protocols between psychiatric providers and PCPs can be challenging (Scharf et al., 2013). Views on the treatment of pain can differ, especially in the context of a patient's current or past substance use, and consensus on treatment approaches is lacking in the literature (Voon, Karamouzian, & Kerr, 2017). Concerns about mental illness symptoms can alter a prescriber's use of controlled medications. Whether in an inpatient or outpatient setting, interprofessional teams grapple with the need to provide safe and consistent care when using these medications.
Using team meetings and other communication channels to develop consensus on approaches to care and workflows is an important strategy. Such meetings can be conducted in person or via videoconferencing when team members are at different sites. Implementing patient treatment contracts when prescribing controlled substances is a widely used practice and, although thought to be of limited usefulness in terms of preventing medication misuse (Starrels et al., 2014), can serve to educate patients on rights and responsibilities and potential risks, and inform them of the need to participate in the use of clinical management tools, such as urine drug screens.
Creating a position statement or set of protocols endorsed by the full team is a strategy that can help develop needed consensus. This statement could include recommended time limits on prescriptions for opioids and benzodiazepines or workflows for referring to nonpharmacological treatments. Discussions in team meetings, morning huddle meetings, or case conferences can be used to glean different points of view. Some providers may express concern about prescribing certain opioids. Nurses may be reluctant to call in refills for benzodiazepines due to concerns about patient misuse. Discussing such issues openly, with respect for everyone's opinions, can increase team cohesion and result in a shared framework for care. Such openness to diverse opinions and an understanding of each other's roles are key competencies for individuals working in integrated health programs (Hoge et al., 2014), and these principles can be applied to other types of systems. Subgroups of the team can be tasked with developing elements of the shared approach, to be brought back to the full team for discussion and approval. Leadership in this initiative does not need to be restricted to formal leaders or members of certain disciplines. As Golden and Miller (2014) noted when describing integration of behavioral health into medical homes, leaders need not be “physician only.” A pharmacist or nurse may provide the initiative necessary to push past disagreements on the team.
Education for Providers, Staff, and Patients
An approach that includes provider, staff, and patient education is necessary when attempting to change not just workflows, but longstanding provider practices, patient expectations of prescribers, and organizational cultures. As with all significant behavior change, information is necessary but insufficient to enact the change.
Professionals tend to update knowledge and skills continuously, and this propensity can be used to refine practice. Articles and other resources about pain treatment, SUDs, medication-assisted treatment, safe use of benzodiazepines, and the potential risks of even short-term use of opioids can be made available on shared electronic platforms or included in annual competency updates. Interprofessional case conferences or external speakers can be used to reinforce knowledge.
This attention to updating knowledge and skills is crucial to successful implementation of clinical practice changes. Clinician attitudes must also be addressed. Even providers who work with highly stigmatized groups of individuals, such as those with SMI or SUDs, may continue to hold stigmatizing attitudes toward one or the other subgroup of patients (Avery et al., 2013), and supporting providers to incorporate non-judgmental chronic disease management approaches can aid in patient recovery (Green, Yarborough, Polen, Janoff, & Yarborough, 2015). In addition, including education in team collaboration is vital and has also been noted to be an important element of addressing the psychiatric workforce shortage (National Council for Behavioral Health, 2017), which threatens the availability of appropriate treatments for individuals with SMI and SUD. Starting this team collaboration with a session on describing and understanding team roles can expose and resolve misunderstandings regarding the responsibilities and role functions of each team member. Developing agreed-upon methods for resolving conflicts is essential to this process.
Remembering to include all staff in the education plan is vital. Social workers, medical assistants, case managers, pharmacists, and occupational therapists do not prescribe opiates or benzodiazepines, but helping these team members understand prescribing rationale may ultimately support patients in accepting a less wanted treatment, such as physical therapy, rather than a pharmacological approach that has been deemed unsafe.
Most importantly, patient education using techniques such as motivational interviewing is crucial to safe and effective use of controlled substances. Learning about drugs, including alcohol, can support patients in quitting or limiting use of substances and aid in the recovery process (Green et al., 2015).
Care Coordination and Providing or Linking to Effective Treatments
Coordination of care is an essential component of health care systems. A patient with SMI, chronic pain due to unaddressed orthopedic problems, and a SUD may be followed by a PCP, psychiatric provider, pain specialist, orthopedic service, and more, and will have complex coordination needs. Coordination within the team is the responsibility of all, and designated team members must be responsible for coordination with external providers and services.
Even excellent coordination of care cannot mitigate lack of appropriate services. Individuals with chronic pain; concurrent mental illness, such as depression; and a SUD are likely to benefit in all of these problem areas from the availability of behavioral interventions such as interpersonal or cognitive-behavioral therapy (Barrett & Chang, 2016). These treatments are not always readily available. Similarly, patients can lack access to effective psychotherapy or other nonpharmacological treatments for anxiety. Long-term use of benzodiazepines for anxiety disorders is still far too common, despite evidence that these drugs should not be used routinely for these disorders due to their significant risks (Bandelow, Michaelis, & Wedekind, 2017; CDC, 2016). The team must therefore be alert to opportunities to provide, or refer to, evidence-based behavioral or complementary therapies. For example, pairing group acupuncture for individuals with pain syndromes or anxiety with a psychiatric or primary care provider clinic visit may make the service reimbursable by insurance, whereas acupuncture alone may not be covered.
The availability of medication-assisted treatment for individuals with SUDs is essential to decreasing risks associated with the use of prescribed controlled substances. An initiative using interprofessional collaboration to disseminate office-based opioid treatment with buprenorphine, which teamed nurses with specialized training with PCPs, was associated with an increase in providers rendering this service and patients referred for it (LaBelle, Han, Bergeron, & Samet, 2016). Assessing available resources and developing referral relationships or partnerships is another important strategy for success in implementing a comprehensive interprofessional approach to safe use of controlled substance medications.
Having a champion for the process, or multiple champions in systems with partner organizations, is key, as is soliciting input from all stakeholders, from providers to patients. An “everybody in, nobody out” (Physicians for a National Health Program, 2016) approach to addressing these complex problems, such as that espoused by Dr. Quentin Young in relation to health care for all, takes time, but can result in sustainable change.
Using an integrated care approach when caring for individuals with SMI, medical comorbidities, and SUDs can decrease the risks of controlled substance use. Strategies to address these risks include building interprofessional team consensus in clinical approach; attending to educational needs of patients, staff, and providers; and ensuring patient access to needed comprehensive services.
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