A short dive into addiction
The world of addiction is a complex one where providers typically treat a chronic relapsing disease without addressing underlying issues beyond choice and willpower. Alumna Hannah McKay (Master of Nursing: Nurse Practitioner ’13) shares her story about working in this challenging world.
To say that the world of addiction is fascinating is an understatement. When I stepped outside of the world of primary care, I was not prepared for the challenges that awaited me.
I have always worked for the Nova Scotia Health Authority and joined the Eastern Zone’s Opioid Recovery Program in September 2017, during the midst of an opioid crisis. My mandate is to increase access to opioid agonist treatment, build collaborative relationships with primary care providers in order to enable transition of stable patients back to their primary care providers, build capacity within our health care system to identify and manage opioid use disorder, and provide medical coverage if needed. My funding came from the Nova Scotia Department of Health. My manager believed that adding a nurse practitioner to an already diverse team would not only promote access but facilitate collaboration and enhance patients’ outcomes. Her vision of collaborative care, providing an additional nursing lens to growing problem, was insightful and optimistic.
What I did not appreciate was the magnitude of this crisis or the stigma that surrounds it.
I arrived to a find 600 patients in the program, which operates from four sites, and a waitlist of over 100 people. We decided to address the waitlist first, acknowledging that agonist treatment is most likely to prevent relapse and decrease mortality and morbidity associated with illicit opioid use. We admitted 100 patients in a matter of five months and discovered the need for treatment had grown. Our waitlist was growing not because the need grew (the need was always there), but because patients who were desperate for help were seeing movement in our wait times. The light at the end of the tunnel was growing brighter.
I was not able to prescribe Methadone in those early days. I was patiently waiting for Health Canada to accept the College of Registered Nurses of Nova Scotia (CRNNS) proposal for NPs to prescribe in Nova Scotia. I was, however, able to prescribe Buprenorphine/Naloxone. So began a journey with my collaborative physician, Dr. Jennifer Johnston. We began to admit patients rapidly through our Rapid Access Clinic. Our goal was to stabilize patients on medication and then transfer them to one of our four sites, where they could then have access to clinical therapists, psychologists, nurses and community outreach workers. Whether or not they chose to engage those other services did not affect their ability to access opioid agonist treatment. Patients could choose to enter our program without judgment. We adopted a simple harm reduction approach.
I began to provide progress notes to providers and started to reach out to providers who had stable patients who no longer required the services of a structured program, but required refills and support. Patients who had remained on stable doses, had not relapsed and had also returned to work or school or reconnected with loved ones, but who needed follow-up for prescription renewals and random drug screens, could now be transferred back to their primary care providers. Acknowledging addiction is a chronic disease, we would be available for consultation and transfer should the patient require more treatment.
It seemed like a simple concept, but it is still ongoing. It requires support, education and resources in order to not only increase primary care providers’ prescribing confidence, but also to increase their ability to offer a service and be compensated appropriately. The Department of Health changed the billing codes to reflect the time required to offer this service, and I offered to assist providers with building their knowledge base and even offered to come to their clinic to support them.
On March 26, 2018, the federal Minister of Health announced the restrictions on prescribing Methadone and Heroin would be lifted in order to increase access to treatment. We would no longer need an exemption from Health Canada, but would require an opioid dependence course around Methadone maintenance and have some formal mentorship with a Methadone prescriber in addictions. Hallelujah!
“With each admission, I am humbled and sometimes horrified to hear the patient’s life story … the trauma they endured, the hardships they faced and the stigma they have come up against.”– Hannah McKay
But while the provincial and federal governments have addressed the barriers to treatment, they are still not addressing the cause.
With each admission, I am humbled and sometimes horrified to hear the patient’s life story. It is sad to hear about the trauma they endured, the hardships they faced and the stigma they have come up against. Yet, we ignore the social determinants of health, spend obscene amounts of money on law enforcement to respond to criminal activity — which is most often a result of poverty or addiction — and on acute care beds to treat the consequences of opioid use disorder. The money spent on addressing harm reduction in Nova Scotia is 2% of the health care budget, but we dwell on the things we see (needles left on playgrounds), the things we can’t possibly conceive (prostitution or sharing needles), or the things we have not experienced ourselves (Why do they choose to use? Why can’t they just stop?).
My role is evolving to include advocacy, leadership and education. I think we have much more work to do to bridge the gap between those in treatment and those needing treatment, but we also need to work on understanding the cause of drug use, the misconceptions that surround “use” and the role we all play in managing chronic disease. This is my world. My days are never boring … and my patients are being treated!