As the opioid epidemic continues to grow throughout the nation, it’s not surprising that this kind of addiction, as well as others, can also affect nurses. If you’re a nurse in New Jersey and have a problem with addiction, however, there’s a treatment program specifically designed to help you.
Established in 2003, the New Jersey State Nurses Association (NJSNA) Recovery and Monitoring Program (RAMP) has helped more than 2,000 impaired nurses since its inception, says Terri Ivory, RN, MSN, Director of NJSNA. “RAMP is the only program for registered nurses and licensed practical nurses of its kind contracted through the Board of Nursing,” explains Ivory. “RAMP is important because it supports impaired nurses and protects their licenses so they will be able to work again with monitoring once they have completed evaluation and treatment. What makes the program special is that nurses are taking care of nurses who understand the challenge of being a nurse.”
Ivory agreed to answer questions about the program. Following is an edited version of our interview.
Tell us about RAMP.
The goals of the program are to provide safety to the public though early detection and monitoring, reduce the time between identification and treatment, and provide a process for the nurse to recover that is non-punitive and non-public.
Entering the RAMP program, which is voluntary, protects the nurses’ licenses. While in the recovery phase, the nurses’ licenses may become inactive, but not revoked, which protects the licenses. The licenses can be re-activated once the process is completed and the return to work is issued.
How does it work? Is it a rehab/detox? Do you provide counseling?
RAMP is a recovery and monitoring program, which means it makes referrals for treatment, detox, and counseling. It is not rehab and detox nor does it do counseling.
The RAMP process includes evaluation, toxicology screenings, referral for treatment, weekly peer support group meetings, monthly reports, check-ins, monitoring, and a return to work process. There are peer support groups that RAMP participants must take part in during their time in the program.
Are all nurses accepted into the program? Do they need to apply? Does their employer get notified?
All RNs and LPNs practicing in New Jersey are eligible for the program and can be self-referred or referred by their employer or the public (such as family, attorney, friend). After a nurse self-identifies or is referred to RAMP, the first thing that happens is an evaluation process, which includes a psychological evaluation and random toxicology testing that can take up to 90 days. Nurses must check in with RAMP every day during the evaluation phase. During this time, the nurses do not need to disclose to their employers that they are in the program.
After evaluation, the nurse will get recommendations—whether to stay in the program or discharge—based on the results of the evaluation. If it is recommended a nurse stay in the program, the nurse must disclose the program participation to her/his employer.
Participation in the program may last up to five years.
RAMP notifies the New Jersey Board of Nursing (NJBON) as soon as the referral comes in, and the NJBON works with RAMP throughout the process. Dialogue with NJBON happens every two weeks or more often as needed. If nurses do not comply with recommendations, they are discharged from the program and reported to the BON.
It is within the nurses’ scope of practice to report fellow nurses.
Do the nurses pay for the program or is it covered by insurance?
Insurance does not pay for the program itself, which includes lab fees, evaluation fees, peer group fees, and therapist fees. All fees must be paid up front.
Hard medical costs, such as a lab fee or therapist, might be covered by medical insurance.
If they complete the program, how do they get back to working as a nurse? What tends to happen?
During their time in the program, a return-to-work program is implemented. Sometimes there are restrictions on work hours (no overtime), medication administration, and on specialty or place of employment. Nurses are monitored while they are working and monthly reports are sent to RAMP. Monitoring can be done for up to 5 years. Upon return to work, the only person that knows about the nurses’ participation in RAMP is the potential supervisor and human resources.
What have your outcomes been?
The overall success rate of the program is 60%. There are a total of 607 nurses in the program as of October 31, 2017: 493 nurses being monitored, 27 in intake stage with 23 monitoring out-of-state with 36 peer support groups, and five mental health groups. Two hundred thirty participants have been discharged as of October 31, 2017.
The most important thing for nurses to know is not to be afraid to report, either self-reporting or peer reporting. This helps close loop and gets the nurse the help they need. The main goal of the program is to have nurses to practice safely, protect the public, and protect the nurse.
RAMP has a 24-hour hotline for questions: 800-662-0108.
Overdose deaths related to prescription opioids have quadrupled since 1999, according to the Centers for Disease Control and Prevention (CDC), which has made it a topic of dinner conversation as well as a top priority in health care. Nurses can play an important role in reducing these deaths, as well as addiction problems, through their assessments and monitoring of patients. But it’s also important for nurses to be well aware of steps they can take to help protect themselves from possible legal action stemming from opioids.
Scope of the Problem
The depth and breadth of prescription opioid abuse is far reaching. In 2014, almost 2 million people in the United States abused or were dependent on prescription opioids. At least half of all opioid overdose deaths involve a prescription opioid. Every day, more than 1,000 people are treated in emergency departments for misusing prescription opioids.
The most common drugs associated with prescription opioid overdose deaths are methadone, oxycodone, and hydrocodone. According to the CDC, prescription opioid overdose rates between 1999 and 2014 were highest among people aged 25 to 54.
Role of the Nurse
A 2016 study published in the Journal of the American Medical Association (JAMA) by Baker and colleagues notes that there is significant variability in the amount of opioids prescribed, and the most commonly dispensed opioid was hydrocodone (78%), followed by oxycodone (15.4%). Interestingly, a 2015 study in the American Journal of Preventive Medicine reported a decrease in the rate of prescribing opioids (-5.7%), perhaps indicating that more health care providers are becoming aware of the addiction issue.
Nurses are well positioned to detect patients with substance misuse. One simple screening tool is the National Institute on Drug Abuse (NIDA) Quick Screen. If a substance use disorder is suspected, the nurse should remain nonjudgmental while referring patients for further evaluation and treatment, so they receive the care they need.
One model for follow-up of possible substance abuse is Screening, Brief Intervention, and Referral to Treatment (SBIRT) from the Substance Abuse and Mental Health Services Administration. SBIRT is a method for ensuring that people with substance use disorders and those at risk for developing these disorders receive the help they need.
Assess the Patient Carefully
Pain medication should be matched to the individual patient’s needs. This begins with a detailed history, including a list of currently prescribed and past medications. Ask about a history of substance use or substance use disorders in the patient and the patient’s family. If opioids are being considered, assess the patient’s psychiatric status.
A physical exam should also be completed, keeping in mind signs and symptoms of possible substance abuse such as advanced periodontitis, traumatic lesions, and poor oral hygiene. If patients are already being managed for chronic pain, the nurse should consult with the appropriate provider.
Apply Evidence-Based Pain Management
To provide optimal patient care, as well as to protect themselves from legal action, nurses should practice evidence-based pain management. That includes considering non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, as first-line pain medication.
NSAIDs have been shown to be at least as effective (if not more so) than opioids for managing pain, particularly in combination with acetaminophen. Before patients begin taking NSAIDs, verify that they are not taking other anticoagulants, including aspirin, and check for hepatic or renal impairment.
Nurses should complete continuing education courses in pain management, and document they did so, which can provide evidence of their knowledge in event of legal action.
Nurses have an opportunity to educate patients about the role of pain medication in their care. This education should include pain medication options and the reasons why non-opioids are preferred.
Verbal and written instructions after the procedure need to contain name of drug, dosage, adverse effects, how long the drug should be taken, and how to store it. Results from a 2016 survey published in JAMA Internal Medicine found that more than half (61%) of those no long taking opioid medication keep it for future use, so patients need to be told to dispose of unused drugs and how to do so. Patients can search for places that collect controlled substance drugs through the Drug Enforcement Administration at www.deadiversion.usdoj.gov.
The same survey found that about 20% shared the opioid with another person, so education material should mention not to do this. Nurses should also discuss the perils of driving or undertaking complex tasks while taking an opioid. Document in the patient’s health record that this information was provided and the patient acknowledged receipt and understanding. An office visit can also provide the opportunity for nurses to address opioid abuse on a larger scale.
Refer Patients as Indicated
Nurses need to closely monitor patient use of controlled drugs to avoid overdependence or potential addiction, and refer chronic pain patients to a pain management center or specialist. Be sure to document the referral in the patient’s health record. Nurses also should consider referral for patients who seek opioids beyond when they are likely to be needed.
Pain Medications Cautions
Below are some considerations for the use of pain medication in patients:
Use non-steroidal anti-inflammatory drugs (NSAIDs) as the first option. Consider a selective NSAID to avoid increased risk of bleeding. Know that using acetaminophen in combination with NSAID may have a synergistic effect in pain relief. (Do not exceed 3,000 mg/day in adults.)
Provide patient education.
Document patient communications, education, and referrals in the health record.
Protecting Patients and Nurses
Nurses who assess and monitor patients for treatment of pain are encouraged to be mindful of and have respect for their inherent abuse potential. Doing so helps protect patients from harm and nurses from potential liability.
Disclaimer:This article is provided for general informational purposes only and is not intended to provide individualized business, risk management, or legal advice. It is not intended to be a substitute for any professional standards, guidelines or workplace policies related to the subject matter.
This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 650,000 nurses since 1976. INS endorses the individual professional liability insurance policy administered through NSO and underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to [email protected] or call 1-800-247-1500.
It seems like we see articles and hear news reports about opioid addiction on a daily basis. Unfortunately, many of these stories are no exaggerations.
According to the United Nations Office on Drugs and Crime’s 2015 World Drug Report, it is estimated that 32.4 million people around the world struggle with opioid abuse. Additionally, results from the Substance Abuse and Mental Health Services Administration’s 2014 National Survey on Drug Use and Health estimate that 1.9 million Americans struggle with addictions to prescription opioids and 435,000 more have addictions to heroin, an illegal opioid.
Opioid abuse is clearly a problem in the United States and abroad. Different organizations, institutions, and agencies have taken different approaches to combat this problem, as have individual rehab centers across the country. Several of these approaches involve nurses.
If the opioid epidemic is a war, nurses are serving on the front lines. Emergency room nurses often treat people who have overdosed or are suffering from the ill effects of opioids, other drugs, and alcohol.
Nurses work at rehab centers to treat opioid abuse and other forms of abuse. They work at clinics and hospitals that provide medication-assisted treatment (MAT). They work in a wide variety of health care settings to help people recognize and treat their addictions. They also work to educate others about substance abuse and hope that such preventative measures can help people avoid addiction in the first place.
At Boston Medical Center, doctors do not administer programs that treat opioid abuse. Instead, nurses administer such programs. This tactic allows the clinic to see more patients (and ultimately treat more patients). Other health centers in Massachusetts and across the United States are utilizing nurses to administer such programs.
Other programs might provide specific training that relates to addiction. In 2016, the U.S. federal government awarded a grant to train student nurses at the College of Nursing at the University of Massachusetts in Amherst, Massachusetts. This program trains nurses in SBIRT, which stands for screening, brief intervention, and referral to treatment. The program aims to diagnose addictions early and help people find treatment for them.
National organizations are also tackling addiction. The American Nurses Association (ANA), the American Association of Colleges of Nursing, and others have pledged to provide more training for people who prescribe opioids. The ANA has also pledged to encourage more health care providers to register with their states’ drug monitoring programs.
The ANA has also pledged to launch a campaign to raise awareness of opioid addiction. It has already established resources about opioid addiction and other forms of substance abuse. Additionally, ANA provides resources that can help nurses with their substance abuse problems if they are addicted themselves.
The government has also joined nurses in the fight against opioid abuse. The U.S. Centers for Disease Control and Prevention (CDC) created and published guidelines regarding the prescription of opioids. Several nursing schools across the United States have pledged to teach these CDC guidelines, many of which address the use of opioids for long periods of time.
State boards of nursing have also created similar recommendations. The Michigan Board of Nursing, for example, has issued guidelines for nurses in regards to using controlled substances to treat pain. These guidelines recognize that nurses need to effectively treat pain. They also recognize the potential danger of certain medications.
There are also other government efforts relating to opioid abuse and nurses. The Comprehensive Addiction and Recovery Act of 2016 is a federal law that permits nurse practitioners and physician assistants to prescribe buprenorphine to patients who are addicted to opioids. It also allows doctors to see higher numbers of patients who need such drugs.
Speaking of government action, the U.S. Drug Enforcement Administration (DEA) sponsors National Prescription Drug Take-Back Day. During this event, people bring unneeded prescription drugs to designated areas. DEA agents and other law enforcement agents take these drugs and educate the public about drug abuse. During one such day in April 2016, authorities took back almost 447 tons of prescription drugs.
Nurses educate the public about Prescription Drug Take-Back Day. They also play a vital role in other government efforts to end addiction by participating in community-based opioid overdose prevention programs (OOPPs). As their name indicates, OOPPs work to prevent substance abuse problems from ever occurring. Other nurses and nursing organizations are interested in government matters as advocates. They encourage other nurses to take political action or support candidates who take particular views on health care matters.
These efforts demonstrate that while the opioid epidemic is huge, different organizations, institutions, government bodies, rehab centers, and people are committed to helping fight it. Nurses have played—and will continue to play—a vital role in this battle.
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