Chapter 1.0: Introduction
The following content (Ch 1.3) by Patricia Stoddard-Dare et al. is licensed under a CC-BY 4.0 International License. The original article, published in Advances in Social Work 20(2), can be found here. Patricia Stoddard-Dare et al. (2020) wrote:
The United States is in the midst of an opioid epidemic. Multiple factors are responsible for this epidemic, and sadly the healthcare system maintains some responsibility for this current situation. Leading up to the opioid epidemic, well-intentioned changes in the healthcare system contributed to an increase in opioid use disorders. Specifically, pain was conceptualized as the 5th vital sign (Phillips, 2000), and coordinated efforts at that time focused on reducing patient self-reported pain (Baker, 2017). Concurrently, the misconceived notion that prescription opioid medications were safe with a low potential for misuse and addiction proliferated (Van Zee, 2009). There was increased reliance on opioid medication rather than other approaches to address and manage patient pain (Fields, 2011), adding to the rise of physical dependence and subsequent opioid use disorders (Compton et al., 2016; Edlund et al., 2014). Most healthcare professionals are aware today that prescription opioids are highly addictive, and efforts have been taken to reduce reliance on prescription opioids to treat pain and to monitor use when they are indicated (Dowell et al., 2016).
Numerous systems are responsible for the opiod epidemic, and thus dedicated involvement of multiple systems is required to resolve the crisis. Reviews of the records of people who have experienced an opioid overdose suggest these individuals are likely to interact with at least one health professional in the six months preceding their overdose (Wagner et al., 2015). As such, all health professionals should be prepared to screen for problematic substance use and refer patients to assessment, treatment, and harm reduction resources. Additionally, health professionals should understand how pain plays into the initiation, continuation and relapse of substance misuse. Finally health professionals should form a solid understanding of the roles and responsibilities of interprofessional team members working together to address opiod misuse.
Interprofessional collaborative practice (IPCP) is a concept previously referred to as “multidisciplinary care” or “interdisciplinary care.” IPCP is characterized by healthcare professionals of diverse disciplines working together to make decisions regarding patients’ health while applying their specific discipline’s knowledge and skills (Bridges et al., 2011). Research indicates that IPCP is effective in stimulating collaborative care between healthcare professionals to improve the quality of care and outcomes for clients or patients (Schwindt et al., 2017). Interprofessional education (IPE) is defined by the World Health Organization (2010) as “students from two or more professions learning about, from and with each other to enable effective collaboration and improve health outcomes: (p.7). Previous studies have indicated the potential for IPE to create positive attitudes toward future interprofessional work and collaboration, and to promote a reduction in clinical errors while improving the quality of team functioning, patient care, and patient outcomes (Sytsma et al., 2015; Wamsley et al., 2012). To aid entry-level healthcare professionals in learning the concepts of IPCP, exposing students to IPE is valuable.
Table 1. Accreditation Standards by Discipline
|Discipline||Accreditation Body||Accreditation Standard(s)|
|Social Work||CSWE (2015)||Competency 1, 6, 7, 8|
|Pharmacy||ACPE (2016)||Standard 11, Key Elements: 11.1, 11.2, 11.3|
|Medicine||LCME (2020)||Standard 6.4, 7.9 AOA 2014|
|Nursing||ACEN (2019)||Standard 4.6|
|Occupational Therapy||ACOTE (2013)||Standard B.5.21|
|Physical Therapy||CAPTE (2016)||6F, 6L3, 7D7, 7D12, 7D13, 7D34, 7D39|
|Speech-Language Pathology||ASHA/CAA (2019)||Standard 1 (1.1, 1.2, 1.3)|
Individuals struggling with substance misuse have unique bio-psycho-social-spiritual needs. Interprofessional health care workers provide patients with access to a wide variety of services and treatment options tailored to their specific needs. In the section below each profession’s role pertaining to substance misuse treatment is described (see Table 2 for a summary). It is of value to note that professionals may have overlapping roles. An important contribution of interprofessional education is understanding the roles of various professions and learning to communicate and collaborate in an interprofessional team to advance patient well-being.
Social workers partner with individuals, groups, families, and communities to promote well-being and enact social change. The core values of social work include “service, social justice, dignity and worth of a person, importance of human relationships, integrity and competence” (National Association of Social Workers, 2017, p. 1). Social workers, advocate for people who are poor, vulnerable, or disenfranchised providing counseling and engaging in community organization, administration, policy advocacy, research, and education.
|Social workers||Prevention, screening, assessment, diagnosis, counseling, crisis intervention|
|Pharmacists||Assist in medication selection, dispense medication, dose adjustment, monitor efficacy, adverse effect management|
|Licensed physicians||Examine patients, complete a medical history, order tests, diagnose conditions, provide treatments and medical counseling, prescribe medication|
|Nurses||Assessment which includes physical exam and review of symptoms and concerns; referral; education; provide treatments and medications; advocacy|
|Occupational therapists (OTs)||Prevent or adapt to injury, illness, or disability; help adapt environments, conserve energy, and decrease pain; promote engagement in meaningful life activities|
|Physical therapists (PTs)||Restore function and reduce reoccurrence of pain through exercise, manual therapy, patient education, and stress management|
|Speech-language pathologists (SLPs)||Work with infants with neonatal abstinence syndrome on feeding difficulties and later possible deficits in language and/or literacy;
Provide therapies to improve cognition, speech, language, and swallowing for overdose survivors with brain injuries
Specific to problematic substance use, social workers provide school, community, and family-centered interventions aimed at prevention (Ramos et al., 2018). Social workers also play an integral role in the diagnosis and treatment of substance use disorders. Using a bio-psycho-social-spiritual approach, social workers provide screening and assessments to help identify the needs of clients who are struggling with substance misuse. Social workers serve as case managers, facilitate intake, develop treatment plans, provide psychoeducation, and facilitate individual, group, and family counseling for substance misuse and co-occurring mental health disorders. Social workers make referrals to and consult with other professional entities. For instance, social workers collaborate in interprofessional teams to determine the appropriate level of care for a client struggling with substance misuse based on a variety of factors including housing stability, interpersonal relationships, co-occurring mental and physical health conditions, and history of relapse. Finally, social workers have expertise in crisis intervention and help with crisis planning (American Society of Addiction Medicine [ASAM], 2020).
Pharmacists have expertise in optimizing patient-centered medication treatment outcomes that are safe and cost-effective. Pharmacists monitor and dispense medication and provide education. Part of their monitoring includes checking and updating the Prescription Drug Monitoring Program (PDMP). The PDMP is a state-wide prescription registry designed to track when, where, and who prescribes and fills certain prescription medications that have a high propensity for misuse. This information can be used to identify and intervene when misuse is suspected.
Palliative care and mental health pharmacists provide consultation, assist in medication selection, dose adjustment, monitoring of efficacy, adverse effect management, and medication regimen considerations such as drug interactions for pain or treatment of opioiduse disorder. In an interprofessional team, pharmacists serve as experts on the use of medications in a treatment plan which is salient for a person at risk for, or struggling with an opioid use disorder. Some patients perform better in treatment when comorbid psychiatric conditions are treated with medication; therefore, consultation with a Psychiatrist is suggested for dually diagnosed clients.
Medication-assisted treatment (MAT) is a therapeutic approach that combines medication and counseling and is a best practice for treating opioid use disorders (National Institute on Drug Abuse [NIDA], 2016). Use of MAT may decrease the amount and frequency of illicit drug use, decrease crime and the spread of contagious disease, reduce cravings and the euphoric effects of a drug, and improve treatment retention (Substance Abuse and Mental Health Service Administration [SAMHSA], 2018). Interprofessional team members should be familiar with common medications that are used by patients struggling with opioid use disorders and pain such as Buprenorphine/Naloxone (Suboxone), Naltrexone (Vivitrol), Methadone, and Naloxone (Narcan) which should be routinely prescribed as part of a safety planning protocol to patients at risk of opioid overdose (NIDA, 2016).
Licensed physicians and other providers such as nurse practitioners and physicians assistants examine patients, complete a medical history, order tests, diagnose conditions, and provide treatments and medical counseling. Primary care providers, emergency room physicians, and psychiatrists are especially likely to interact with clients struggling with opioid use disorders. Medical doctors confirm an opioid use disorder diagnosis and help to diagnose and treat the patient’s co-morbid medical conditions and physical dependency, which is essential in determining the appropriate level of care for the patient. Physicians review past medical history and test results to develop a treatment plan. Physicians carefully consider pain management strategies, weighing the need to reduce pain enough to minimize the risk of improper self-medication of pain with the risk inherent in opioid use.
Prescribers are urged to follow recommended guidelines for opioids to reduce the risk of misuse and increase positive patient outcomes (Dowell et al., 2016). Although it is considered an evidence-based intervention, MAT has been underutilized (Jones et al., 2015). To encourage and support physicians SAMHSA sponsors the Provider Clinical Support System (PCSS), which is an online portal that provides free training, mentoring, and other resources for DEA waivered providers to promote the use of medication-assisted treatment and best practices for patient pain management (PCSS, 2020).
In the traditional role of caregiver, nurses provide treatments and medications prescribed by state-authorized providers; assist the patient physically; gather health data and symptoms; and educate the patient and family members about their health and medications. Specific to substance use disorders, both social workers and nurses engage in assessment, referral, education and advocacy. A nurse’s assessment of a patient includes a physical exam and a review of psychosocial concerns, familial history, and current and past drug use (Dahn, 2016). Like other members of the interprofessional team, nurses also provide education about the dangers of opioids and proper and responsible use of prescribed opioids, including disposal of unused medications (Waszak et al., 2018). Bothsocial workers and nurses advocate for patients and for policies that support people impacted by opioid use disorders (Clark, 2014; Messer, 2017). Overall, nurses are a valuable part of the interprofessional healthcare team that implements evidence-based practices to address substance misuse in emergency, inpatient, and primary care settings (Agency for Healthcare Research and Quality, 2016; Korthuis et al., 2017).
Occupational therapists (OTs) work with people across the lifespan to improve health and wellbeing and to prevent or adapt successfully to live with injury, illness, or disability (American Occupational Therapist Association, 2014). Occupational therapists help patients at risk of becoming opioid dependent improve quality of life, coping, and self-management skills by helping them engage in activities they need and want to perform (Chikwanha, 2019; Costa, 2016; Jedlicka et al., 2011; Rojo-Mota et al., 2017; Rowe & Breeden, 2018). Since chronic pain is often a precursor to substance misuse, OTs use therapeutic modalities to help adapt environments, conserve energy, and decrease pain (Lagueux et al., 2018). OTs can also provide education on safe medication management, secure medication storage in the home, and signs to recognize substance misuse and overdose while also educating about the effects of substance use in daily life (McCombie & Stirling, 2018). Additionally, OTs can focus on improving engagement in meaningful life activities for those who have spent excessive time on substance use routines and patterns (Wasmuth et al., 2014). People struggling with substance spend a considerable amount of time trying to obtain and using drugs, OTs help those individuals repurpose their time to instead engage in meaningful activities.
Physical therapists (PTs), as movement specialists, work to optimize function for movement-related tasks (American Physical Therapy Association [APTA], 2018, 2019 2020). After a comprehensive examination, PTs implement a plan of care that includes various interventions such as aerobic training, strengthening exercises, manual therapy, functional training, adaptive equipment, posture/balance training, and patient education (APTA, 2009, 2018, 2020). PTs consult with an interprofessional team to maximize the clinical impact of services provided while working to enhance the quality of life of patients (APTA, 2018). A plan of care is selected for individuals with or at risk for opioid misuse to restore function and reduce reoccurrence of pain through exercise, manual therapy, education on healthy sleeping habits, and stress management (APTA, 2018; Fernández-de-Las Peñas, 2015; Finan et al., 2013; Holth, 2008). By promoting a lifestyle that embraces regular exercise, PTs can help patients lessen the need for pharmacological alternatives (APTA, 2011, 2018).
Speech-language pathologists (SLPs) work with individuals across the lifespan to prevent, assess, diagnose, and treat deficits in communication (including speech, language, voice, and stuttering), social skills, cognition, and swallowing (American Speech-Language Hearing Association, 2019). SLPs assist individuals impacted by the opioid epidemic, serving both pediatric and adult populations. For example, SLPs work with infants suffering from neonatal abstinence syndrome (NAS) on feeding difficulties such as poor feeding efficiency, uncoordinated sucking, rejection of the nipple, cough, and reflux (Proctor-Williams, 2018). A portion of infants with NAS go on to experience developmental, behavioral, and educational challenges as children (e.g., deficits in language and/or literacy) and receive treatment from SLPs. In the adult population, SLPswork as part of an interprofessional team to treat patients who have an acquired brain injury. Anoxic and hypoxic brain injuries, common in individuals who have survived an opioid overdose, can result in devastating impairments in the areas of cognition, speech, language, and swallowing (Adams et al., 2019).
Addressing Pain in Those at Risk or Struggling with Opioid Use Disorder
Chronic pain management is a complex task best managed by an interprofessional team (Evans et al., 2016). Using a bio-psycho-social-spiritual approach helps deliver a well-rounded, individualized treatment for those patients who live with chronic pain and either have an opioid use disorder or are at risk for one (Eccleston et al., 2013). The interprofessional approach addresses the multiple needs of the individual with chronic pain including but not limited to physical and mental health, socialization, school or work-related tasks, sleep hygiene, mindfulness, acceptance and coping, and leisure reintegration (Ali et al., 2017; Black & Kashikar-Zuck, 2017; Cohen et al., 2017; Dysvik et al., 2010; Fisher et al., 2014; Hesse et al., 2015; Simons et al., 2010).
The interprofessional team’s approach should focus on the engagement of the individual with chronic pain to activities that interest them, such as leisure or sport. The team can help by slowly reintegrating the patient into actions that are either modified or adapted to make them successful and achieve a feeling of accomplishment. Meanwhile, the treating team needs to focus on teaching mindfulness skills that help the patient better cope and/or accept the chronic pain and improve her ability to move forward in life with reduced reliance on, or cessation of opioids. Mindfulness activities can include yoga, guided meditation, and positive affirmations (Society, 2019).
The interprofessional team members need to recognize that failing to address or under-treating pain can lead to self-medicating and can be a barrier for achieving and maintaining abstinence from illicit drug use. Correspondingly, trauma, depression, anxiety, and poor sleep are pain facilitators that also need to be assessed and addressed by interprofessional team members (Harding et al., 2018). One overarching goal for all providers is to keep the substance-using patient engaged in treatment. One evidence-based approach, Motivational Interviewing, helps to evoke motivation for treatment and builds and supports a strong therapeutic relationship that improves treatment engagement and retention (Miller & Rollnick, 1991; Providers Clinical Support System, 2017).
Overall, interprofessional efforts are needed to help address the opioid epidemic.