It’s time to tell the truth about the opioid crisis
May 6-12 is National Nurses Week, and as we celebrate the numerous accomplishments of Kentucky nurses, it’s also time to acknowledge their commitment to quality care. Education plays a key role in the delivery of excellent care that nurses provide to patients. Let’s take a moment to understand the facts in the opioid crisis versus the myths.
As political rhetoric, grandstanding and baseless claims have swirled about who is to blame for the opioid epidemic, the crisis itself rages onward, harming—and even killing—Kentuckians in its destructive path. It’s time to embrace solutions for this crisis, and one solution stands above the rest: enable Advanced Practice Nurse Practitioners (APRNs) to reduce the opioid crisis by removing collaborative agreement restrictions. (A collaborative agreement, or CAPA-CS, requires the APRN to produce a signed agreement with a physician in order to prescribe controlled substances.) To put this solution into practice and begin the process of abating this epidemic, first, we must cut through the noise and myths and discuss the truth about the opioid crisis with regard to APRNs.
Myth Number 1: APRNs’ over-prescribing is to blame for the opioid crisis
The idea that APRNs are responsible for the swell of the opioid crisis is inherently false. A review of 2017 KASPER (Kentucky All Schedule Prescription Electronic Reporting System) data reveals that over the past two years, APRNs have reduced their number of prescriptions for the opiate hydrocodone by more than double the number of other prescriber groups combined. As of June 2017, Kentucky APRNs had reduced their number of hydrocodone prescriptions by 58 percent, while dentists and physicians combined had reduced their hydrocodone prescriptions by 26 percent.
Jessica Estes
Amidst these reduced prescribing rates, the number of APRN prescribers has increased by a staggering 169 percent since 2011. This bump in prescribers far outpaces physicians and dentists, whose numbers of prescribers have increased by 13 percent and decreased by 2 percent, respectively—and yet their opioid prescribing rates have reduced at a much smaller rate. From these numbers emerges an inescapable fact: APRN prescribers have increased—expanding Kentuckians’ access to care—and yet their opioid prescribing rates have not risen.
These numbers paint a starker comparison at the county level.
Northern Kentucky, in particular, has been devastated by the opioid epidemic, and yet 2017 KASPER data from counties in the area demonstrate APRNs’ diminished opioid prescribing:
• In Boone County, APRNs wrote 1,169 opiate prescriptions for a total of 114,163 dosages. Alternatively, physicians wrote 56,166 prescriptions for a total of 4,484,363 dosages.
• In Campbell County, APRNs wrote 633 prescriptions for 11,117 dosages. Physicians wrote 32,946 prescriptions for 1,982,765 dosages.
• In Kenton County, APRNs wrote 6,532 prescriptions for 181,692 dosages. Physicians wrote 114,372 prescriptions for 8,484,413 dosages.
The recurrent argument for collaborative agreements is that APRNs have been recklessly overprescribing opioids and need to be monitored when it comes to Schedule II drugs—a myth that crumbles in the face of the data and hard facts. Instead, collaborative agreements and restricted prescribing authority for APRNs have the potential to worsen the opioid crisis.
Buprenorphine, which is used in medication-assisted treatment to help people reduce or quit their opioid use and addictions, is labelled a Schedule III controlled substance under Kentucky regulation. To prescribe buprenorphine, APRNs with special training must obtain a signed CAPA-CS, from a buprenorphine-certified physician—an arbitrary barrier to care that constrains APRNs’ ability to prescribe the medication and help Kentuckians suffering from substance use disorders and addictions. This limitation is part of why a Pew Family Trust study revealed that laws like the CAPA-CS requirement worsen the opioid epidemic.
Myth Number 2: Removing collaborative agreements would increase opioid prescribing
Removing the CAPA-CS requirement will neither enhance APRN prescribing nor increase access to opioids. There are already prescribing limits for controlled substances in Kentucky statute, which would not change with the elimination of CAPA-CS. Removing CAPA-CS requirements would merely remove an arbitrary barrier to care. Safety guidelines for prescribers would remain the same as regulated by the Kentucky Board of Nursing.
Additionally, there is no demonstrable correlation between opioid prescription rates and APRN prescriptive authority. In fact, according to Center for Disease Control (CDC) data, some states with the strongest prescribing restrictions for APRNs, such as Tennessee, Alabama, Arkansas and Kentucky, also have the highest rates of opioid abuse. Alternatively, several states where APRNs have full prescribing authority also have the lowest rates of opioid prescription, including North Dakota, South Dakota, Iowa, Nebraska, Minnesota, and Vermont. Here again, the facts reveal the truth. The myth that APRN prescribing authority will lead to a flood of opioid prescriptions is just that: a myth.
The truth about nurses and APRNs is simple: they provide responsible, quality care to all regions of Kentucky and are able to help the opioid epidemic but are deadlocked by unnecessary restrictions. Additionally, APRNs already work and collaborate with physicians and other healthcare providers daily to coordinate patient care, making the CAPA-CS even less necessary.
This National Nurses Week, let’s put these myths about APRNs and opioids to rest and put the patients first, by removing the unwarranted CAPA-CS requirement and finally make a positive change in combating the opioid crisis. With the reality of its devastation on our state becoming clearer every day, it would be harmful and reckless not to do so.
Jessica Estes, DNP, APRN, is president, the Kentucky Coalition of Nurse Practitioners & Nurse-Midwives
