Module 3 Discussion Reimbursement & Financing Issues

January/February 2020 | Volume 38 Number 1 7

Nursing Economic$

Presently, the United States is in the midst of a major, unprecedented public health opioid epidemic that traverses race, ethnicity, gender, age, health status, and socioeconomic level (Brinkley- Rubinstein et al., 2018; Chimbar & Moleta, 2018; Cox & Naegle, 2019). The opioid epidemic, now a crisis in America, reflects the deadliest in history with pre- dictions the death toll will con- tinue to escalate in years to come (Bennet et al., 2018). Despite billions of dollars allo- cated to address the opioid epi- demic, the crisis has worsened, with more deadly outcomes (Johnson, 2018). More opioid- related deaths occur per year than mortality from recent wars, motor vehicle accidents, gun violence, and human immuno - deficiency virus (Centers for Disease Control and Prevention [CDC], 2019a; Siegel, 2018; Velander, 2018). In 2016, the national death rate from opioid overdose was 21.7 deaths per 100,000, reflecting a dramatic increase since 2013 when the U.S. rate was 7.6 deaths per 100,000 (National Institute of Drug Abuse, 2019).

Recognizing that nurses are the most trusted of health pro- fessionals, account for the largest number of healthcare providers, and have the most frequent interpersonal contact with patients and families, the important role of nurses in com- batting the opioid crisis has been recognized (American Association of Colleges of Nursing [AACN], 2019a; American Nurses Association, 2016). The purpose of this inte- grative review is to examine the economic burden of the opioid epidemic based on published evidence to inform practice, education, research, and policy development in nursing to com- bat this escalating crisis.

Method

In this integrative review, the authors used interprofession- al academic and federal analysis literature published in English between 2013 and 2019. Seven electronic databases were used to identify relevant published articles and included Directory of Open Access Journals, EBSCOhost, Elsevier, Google Scholar, ProQuest Document,

The Economic Impact of the Opioid Use Disorder Epidemic in America: Nurses’ Call to Action Kathleen Neville Marie Foley

The unprecedented public health opioid epidemic in America has created a tremendous economic burden. Exorbitant costs from premature mortality, criminal justice, childcare and family assistance, lost productivity, and healthcare services are skyrocketing. Given the escalating economic burden of this national crisis, nurses as frontline providers are called to action to combat the opioid epidemic through the provision of comprehensive, cost-effective, humanistic levels of prevention, including primary, secondary, and tertiary care.

January/February 2020 | Volume 38 Number 18

PubMed, and Science Direct. Key terms for these sites includ- ed cost opioid, cost opioid crisis, history opioid cost, opioid epi- demic cost, opioid cost individ- ual, and opioid cost family.

The last search identified approximately 70 potential arti- cles; 60 abstracts were reviewed based on inclusion criteria, and eight were excluded because they were not fully relevant to the research topic of economics and the opioid epidemic. This literature review resulted in 52 articles that had the most recent data related to the cost of opi- oid use disorder (OUD) in the United States.

Background

OUDs are so prevalent in the United States that a national emergency to address this pub- lic health crisis was declared in 2017 (Broglio & Matzo, 2018; Hedegaard, Warner, & Minino, 2017). According to CDC data, there were 42,249 opioid-related deaths in 2016 (CDC, 2019b), accounting for more than 66% of all overdose deaths (CDC, 2018). Every day 115 Americans die from opioid overdoses (CDC, 2019a). The mortality rate has increased to 130 deaths per day (AACN, 2019b). More than 1,000 people are treated in emergency departments for mis- using prescription opioids (CDC, 2017). “From 1999 to 2016, greater than 630,000 individuals died from a drug overdose, with opioid-related overdoses increasing five times since 1999” (Fornili, 2018, p. 215).

The current opioid epidemic involves the misuse and abuse

of both prescription drugs and illegal drugs such as heroin and fentanyl. While it is not the first drug crisis in America, it is the deadliest and most costly in terms of lives lost, decreased life expectancy, lost productivity, crime, violence, and the devas- tating impact of addiction on families and communities. In earlier epidemics, in the 19th and 20th centuries, the liberal use of laudanum to treat pain and the influx of opium dens from Chinese immigrants in America created a state of alarm, and physicians began addiction management with the use of opioids (Velander, 2018). It was not until the Harrison Act of 1914 that restrictions of opioids for pain management existed. Similar to current, albeit hope- fully changing views, the Harrison Act depicted opioid dependence as criminal activity, representing a moral weakness, and was not viewed as a med- ical condition (Velander, 2018). Under this act, the use of opi- oids for addiction treatment was prohibited and 30,000 physi- cians were then prosecuted for unlawful use of prescribing opi- oids.

It was not until the 1970s that methadone became a legal opioid to treat addiction man- agement in the United States and was authorized to be dis- pensed in federally designated clinics (Velander, 2018). Buprenorphine, an opioid par- tial agonist, was developed in the 1970s as an alternative to methadone. Buprenorphine pre- vents withdrawal symptoms and cravings, prevents abuse of other opioids, and requires less

federal regulations for dispens- ing (can be prescribed in office settings) than methadone. In 2000, the Drug Addiction Treatment Act (DATA) author- ized physicians via a DATA waiver to prescribe medication- assisted treatment (MAT) for OUDs. Upon obtaining a DATA waiver, legislation has expanded buprenorphine prescribing prac- tices for nurse practitioners and physician assistants for initial treatment of 30 patients, fol- lowed by 100 patients annually (Cadet & Tucker, 2019). In sum- mary, from a historical perspec- tive, “opioid addiction has been recognized as a difficult prob- lem to treat with low recovery rates” (Velander, 2018, p. 1), and remains so today.

This current escalating epi- demic has its origins beginning in the 1980s when pharmaceuti- cal companies misinformed physicians that addiction from narcotic use was unlikely. A let- ter on the risk of opioid addic- tion published in 1980 in the New England Journal of Medicine concluded that addic- tion was indeed rare when long-term opioids were pre- scribed for pain management (Leung et al., 2017). Additionally, Purdue Pharma extensively marketed Oxycontin® (oxycodone) to physicians, providing lucrative incentives for increased pre- scription use (Macy, 2018). “In 2000, throughout the pharma- ceutical industry, $4.04 billion was spent on direct marketing to physicians” (Macy, 2018, p. 32). However, in 2007, “the manufacturers of Oxycontin, along with senior executives

Nursing Economic$

January/February 2020 | Volume 38 Number 1 9

pled guilty to misleading regula- tors, physicians and patients regarding the risks of addiction with Oxycontin” (Leung et al., 2017, p. 2194).

Other major factors respon- sible for this escalating crisis relate to practice changes that occurred in the 1990s. In response to the need to more effectively treat pain, pain assessment as a fifth vital sign became a standard nursing prac- tice initiative in acute care set- tings, followed by the liberal use of prescribing narcotics to treat patient-reported pain. What followed was a dramatic increase in opioid prescription use, accompanied by highly publicized false security and the myth opioid addiction was not probable and highly unlikely when used for pain manage- ment. It is now well known that addiction can occur quickly, even with short-term use; the possibility exists that some indi- viduals can become addicted with only one opioid prescrip- tion (Barnett et al., 2017). Consequently, along with increased prescription use came significantly increased mortality affecting children, teens, adults, and even newborns, who were exposed to opioids in utero and born suffering from neonatal abstinence syndrome.

Especially vulnerable to the risks of opioid use are the elder- ly, who due to opioid-sedating effects, may succumb to falls, fractures, and other potentially life-threatening events as well as addiction (Barnett et al., 2017). Young adults, equally prevalent among males and females, rep- resent the largest numbers of

heroin users (Cicero et al., 2014; Fogger & McGuiness, 2015). However, the greatest mortality due to opioid-analgesia has occurred in the 55-64 age group (Chen et al., 2014). Between the years 1999 and 2013, the mortal- ity rate from opioid use for anal- gesia resulted in a nearly quadrupled overdose rate (Sofer, 2019; Substance Abuse and Mental Health Services Administration [SAMHSA], 2019a). Over the last 3 years, there has been a decline in the rate of opioid prescriptions, a 19% reduction since 2006 (Sofer, 2019). However, this decrease in prescribing has not significantly impacted opioid use and related overdoses.

Additional factors fueling the epidemic are illicit drugs. These drugs include the influx of hero- in from Mexico, as well as the rise of extremely potent synthet- ic opioids such as fentanyl and carfentanil, which is 10,000 times more potent than mor- phine, and tramadol (CDC, 2019c; Velander, 2018). Once prescription drugs became unat- tainable, a typical pattern result- ed in illicit street drug use, con- sisting of predominantly heroin, but frequently combined with additional potentially lethal sub- stances resulting in an increased mortality rate from overdose since 2010 (CDC, 2017).

The Economic Consequences of the Opioid Epidemic

The opioid crisis in America has created a tremendous eco- nomic burden. According to the Council of Economic Advisors (CEA, 2017), “in 2015, the eco- nomic cost of the opioid crisis was $504.0 billion or 2.8% of the gross domestic product” (p. 1) and has risen substantially (see Table 1). Since 2001, fig- ures reflect the costs exceeding $1 trillion (Rhyan, 2017). These figures may reasonably be underestimated, predominantly due to underreporting of fatali- ties due to heroin and other illicit drug use, as well as the associated incidence of suicide.

In 2018, the estimated costs to the U.S. economy from the opioid epidemic rose to $631 billion (Siegel, 2019). Critical components of this financial burden and estimates of per- centage of specific expenditures are as follows: health care (33%), premature death (40%), criminal justice (6%), child and family assistance and education- al programs (6%), and lost pro- ductivity (15%) (see Table 2).

The cost of premature fatali- ties is due to lost potential earn- ings. It is estimated by the “value of a statistical life” (CEA, 2017, p. 3), which is age-depen-

Nursing Economic$

Table 1. U.S. Economic Cost of the Opioid Epidemic

Year

2015 2018

Cost $504 billion $631 billion

Source: Siegel, 2019.

January/February 2020 | Volume 38 Number 110

dent and can range from $221.6 billion to $549.8 billion. It was estimated the total cost of non- fatal opioid use as a result of lost productivity, health care, and criminal justice system costs were $72.7 billion in 2015 (CEA, 2017) and an estimated overall societal cost of $78.5 billion in 2016 (Leslie et al., 2019). Lost productivity, specifically, absen- teeism and work impairment, involves not only the abuser, but also family members, close friends, and associates.

Criminal Justice Costs A substantial cost related to

nonfatal consequences involves the criminal justice system, which consists of the following components: police protection, legal and adjudication, correc- tional facilities, and property loss due to crimes (Florence et al., 2016; Rhyan, 2017). Crime and violence as a sequela to opioid use is a significant cost and involves both the abusers and the victims. It is estimated the opioid epidemic has increased criminal justice costs in America by $7.8 billion (Florence et al., 2016), and a more recent finding reveals the current cost to be $8 billion (Ropero-Miller & Speaker, 2019).

Healthcare Costs The opioid epidemic has

fueled an excessive financial burden to the nation, including federal, state, and local govern- ments as well as private health- care plans and society at large. Between the years of 2001 and 2017, U.S. healthcare expendi- tures topped $215.7 billion (Litton, 2018). Federal costs (Medicare, Medicaid, SAMHSA, and CHAMPVA) accounted for 14% of the financial burden related to the epidemic. Combined with the criminal jus- tice costs, this accounts for 25% of the total economic weight funded by society (Florence et al., 2016). Additionally, health- care plans have endured signifi- cant financial burdens. Two fed- eral laws, the Affordable Care Act and the Mental Health Parity and Addiction Equity Act, expanded behavioral health plans and provision of services, and eliminated lifetime mone- tary limits, substantially increas- ing the use of services.

Concomitantly with the opi- oid epidemic, new drug treat- ment programs developed nationwide, some of which engaged in unscrupulous and unethical practices to increase revenue (Johnson, 2018). In

many cases, these private treat- ment programs were out of net- work, and individuals and fami- lies incurred excessively high financial costs. Similar to the pharmaceutical industry, these private treatment programs uti- lized skillful marketing tech- niques to attract vulnerable patients with financial resources.

Rates and costs of opioid- related admissions have increased dramatically and the escalation in numbers, and costs of hospitalizations indicate a threat to the financial solvency of U.S. hospitals (Hsu et al., 2017). These costs stem primari- ly from emergency services, emergency room visits to man- age overdoses, hospital admis- sions, and the increased costs of associated illnesses (Litton, 2018). In comparison to treat- ment costs for other illnesses such as diabetes or renal disease (range $3,560-$5,624), MAT for OUDs reflects substantially high- er costs ($5,980-$14,112) per year (Agency for Healthcare Research and Quality, 2016).

International Opioid Epidemic

While OUDs exist world- wide, the United States is facing a substantially larger epidemic. While the United States repre- sents 4% of the world’s popula- tion, 27% of the world’s mortali- ty from drug overdose occurs in the United States (United Nations Office on Drugs and Crime, 2016). Residents in the United States consume more opioids than any other popula- tion in the world. For example, in France and Italy, the inci-

Nursing Economic$

Table 2. Financial Burden of Opioid Epidemic

Expenditures Costs from 2015-2018

Health care $205 billion Premature deaths $253 billion Criminal justice $39 billion Childcare/Family assistance $39 billion Lost productivity $96 billion

Source: Managed Healthcare Executive Staff, 2019; Siegel, 2019.

January/February 2020 | Volume 38 Number 1 11

dence of chronic pain is similar to the per capita rate in America. Yet, consumption of opioids in the United States is six to eight times greater (Humphreys, 2018). Nearly 100% of hydrocodone and 81% of oxycontin are consumed by Americans and are prescribed

for pain management. Another contributing factor related to over-prescription in the United States is that fewer regulations exist for drug manufacturers and distributors, as compared to other developing nations (Humphreys, 2018).

An additional factor con-

tributing to the increase in opi- oid use in the United States is related to the healthcare indus- try’s focus on addressing patient needs and satisfaction, which has resulted in health profes- sionals’ liberal overprescribing and often resulting in unused medications including opioids.

Nursing Economic$

Table 3. Call to Action: Advocacy in Nursing

Policy 1. Endorse organizational initiatives and advocate for policy development to address the opioid epidemic through local, regional, state, and national development of OUD programs.

Education 1. Develop and implement curricula based on best practice for treatment of OUDs in undergraduate and graduate nursing programs nationwide.

2. Introduce a new paradigm of OUD as a chronic neuropsychobiological disease capable of recovery to decrease stigma.

3. Increase the number of nurse practitioners to prescribe medication-assisted treatment.

Nurse leaders 1. Design and provide continuing education programs for practicing nurses to treat individuals with OUDs with best evidence interventions.

2. Foster assimilation of the new paradigm of OUD as a disease with recovery, rather than moral defect.

3. Establish health economics competencies to manage exorbitant costs of OUD treatment.

Research 1. Engage in the conduct of diverse research methodologies to expand broad body of nursing knowledge in humanistic treatment of OUDs, including psychosocial aspects of treatment.

2. Conduct research investigations on stigma, and development of interventions to mitigate stigma among individuals, families, communities, societal, and healthcare professionals.

Practice: Levels of prevention 1. Primary Prevention a. Protect the public through education on risks, challenges, and need for

support/community services for those in recovery from OUDs. b. Provide education to mitigate stigma to improve access to treatment for

individuals with OUDs. 2. Secondary Prevention

a. Facilitate early detection and intervention for those at risk (biophysical, psychological, or social determinants) for all subgroups of population in all healthcare settings.

3. Tertiary Prevention

a. Provision of nursing services to maximize health states, despite living with a chronic illness.

b. Provide supportive services to reduce long-term sequelae of OUDs.

OUD = opioid use disorder

January/February 2020 | Volume 38 Number 112

These unused opioids, available in household medicine cabinets nationwide, have facilitated increased recreational use of opioids by patients, family members, and friends (diver- sion); thereby, furthering the escalation of opioid addiction in the United States.

Nurses’ Call to Action

Because nurses represent the largest number of healthcare providers, are the most trusted among health professionals, have the greatest interaction with patients and families, and deliver comprehensive, excel- lent, cost-effective care, nurses are ideally suited to engage in action to address the opioid epi- demic in America. To combat the opioid epidemic, there is a call to action for nurses in all settings, including academia and practice at all levels of preven- tion, to engage and advocate for change to advance science, poli- cy, education, and practice (see Table 3).

Policy Recognizing the severity and

magnitude of the opioid epi- demic, national healthcare organizations from diverse disci- plines have joined forces to identify solutions for this public health crisis. The National Academy of Medicine’s Action Collaborative on Countering the U.S. Opioid Epidemic along with the AACN and 55 private and federal participating net- work organizations have engaged in partnerships to develop solutions to the opioid crisis and to ultimately improve

individual, family, and commu- nity outcomes for those impact- ed by the opioid crisis (AACN, 2019b). Through policy, AACN has focused on workforce development and further access to MAT for individuals with OUD. Goals include increasing healthcare professional educa- tion and training; advancing research and adoption of evi- dence-based substance use dis- order (SUD) treatment, provid- ing safe guidelines for prescrib- ing opioids for acute and chron- ic pain, and increasing outreach to disseminate the urgent need to address this growing epidem- ic (AACN, 2019b).

The American Nurses Association (ANA) has communicated similar goals as AACN, including expanded access to MAT and prescriber education and training. Additionally, ANA (2016) has called for further prevention research, increased utilization of prescription drug monitoring programs, and increased availability of naloxone (Narcan®), an opioid antagonist used to counter the effects of opioid overdose, for first responders, family, friends, and caregivers of individuals with OUD. All nurses in practice and academia need to endorse these initiatives and advocate for policies to support these services at the local, regional, state, and national levels to improve outcomes for individuals with OUD.

Education The need to educate nurses

in practice and academia to treat individuals with OUD with inter-

ventions based on best evidence is well documented (ANA, 2016; American Psychiatric Nurses Association, 2016; Klimas, 2017; Livingston et al., 2011; Martello et al., 2018; Neville & Roan, 2014). The American Society of Addiction Medicine (ASAM, 2015) has advocated for a change in perspective in how society and healthcare providers view individuals with OUD; transitioning from the negative perception of moral weakness to a treatable chronic neuropsy- chobiological disease. In essence, ASAM addresses the need to decrease stigma and use best scientific evidence to treat patients with OUD using the most humanistic approach to confront this disease. Through this changed perspective, educa- tion focusing on treating SUDs and OUD as a disease will ulti- mately result in lessening stig- ma, more positive healthcare professional attitudes, and improved recovery rates (van Boekel et al., 2013).

In academia, the call to action is to impart knowledge of best practice for treatment of individuals with OUD. This encompasses knowledge acqui- sition of OUD risk factors, etiol- ogy, psychosocial components, and treatment modalities, using the framework of OUD as a chronic condition, characterized by exacerbation, remission, and recovery. Nurse faculty need to embrace this new paradigm supportive of recovery, and develop and implement curricu- la in undergraduate and gradu- ate nursing programs. An imper- ative call to action is for nurse faculty nationwide to compre-

Nursing Economic$

January/February 2020 | Volume 38 Number 1 13

hensively integrate OUD content into nursing curricula.

Research To advance science, nurses

should engage in research using diverse methodologies to expand the body of knowledge in OUD. A shortage of literature exists related to the role of nurs- es in the care and treatment of individuals with OUD. Further inquiry regarding barriers, inter- ventions to reduce stigma, and the design and efficacy of com- prehensive nursing interven- tions, including the use of MAT, along with psychosocial support services, is needed.

Practice Nurses, as frontline practi-

tioners, are ideally situated to address the opioid epidemic through their close interactions with patients and families in community and healthcare set- tings. However, consistent with public stigma, many healthcare professionals have negative atti- tudes toward working with patients with SUDs, including perceptions of aggression, manipulation, and lack of moti- vation as factors that impede effective care delivery (van Boekel et al., 2013). Furthermore, van Boekel and colleagues substantiate that healthcare professionals are unable to empathize, and report dissatisfaction when caring for patients with SUDs, ultimately resulting in suboptimal care. Literature supports that many nurses have condemnatory atti- tudes and negative beliefs such as distrust, powerlessness, anger, futility, and intolerance when

working with patients with SUDs and OUD (Tierney, 2016). Neville and Roan (2014) report- ed nurses perceived patients with addictions as “manipula- tive, rude, aggressive and unsafe” (p. 344). However, these practicing nurses also identified being unprepared to care for this population and a need for increased education.

In healthcare agencies, there is a call to action for nurse lead- ers to address this epidemic. Based on the identified factors of stigma and need for further education, nurse leaders should advocate for continuing educa- tion, providing state of the art best evidence to guide practice to improve outcomes for indi- viduals with OUD. Additionally, the creation and monitoring of a therapeutic milieu to support nurses during the transition toward the adoption of this par- adigm of recovery is vital.

In addition to the need for nurses to provide excellent care to individuals with OUD, nurse leaders need to be aware of costs related to OUD treatment. Recently, Platt and colleagues (2019) identified the importance for nurses to gain understanding of economics in health care to promote cost-effective delivery of care. Given the tremendous economic burden the opioid epi- demic has created nationwide, health economics competency is of paramount importance for nurses, especially nurse leaders.

Levels of Prevention Nurses promote and maxi-

mize health states across the lifespan and health and well- being continuum, including pri-

mary, secondary, and tertiary prevention. Nurses in primary care, community health, and school settings can be key advo- cates in protecting the public by education on the risks of sub- stance abuse, as well as the challenges and need for support of individuals in recovery, the changing perception of individu- als with OUD, and the impor- tance of mitigating public and health professionals stigma to facilitate individuals with OUD to seek and receive adequate treatment to prevent relapse.

Nurse educators in the com- munity can serve as highly valu- able resources in the prevention of drug misuse, as well as pro- vide naloxone training and edu- cation to first responders, teach- ers, family members, and care- givers. Additionally, nurses can provide extensive education to teachers, counselors, coaches, and students on prevention and identification of risk and individ- uals confronting this disease.

In secondary prevention, knowledge and recognition of persons with OUD should not be confined to mental health professionals but should include education for all healthcare pro- fessionals. Early detection and intervention must be available to identify those at risk (biophysi- cal, psychological, or social determinants) for all subgroups within the population across all ages and in all types of health- care settings. Increased efforts to promote safe prescribing prac- tices are underway, and pre- scriber and clinician education on safe opioid use and detec- tion of potential misuse is essen- tial (Salmond & Allread, 2019).

Nursing Economic$

January/February 2020 | Volume 38 Number 114

In tertiary prevention, nurses have a vital role in helping indi- viduals with OUD maximize health despite living with a chronic disease. In the past, drug dependence was character- ized by individuals from lower socioeconomic classes and was considered a sign of moral weakness. It is now imperative that a change in perception by society and, importantly, by health professionals must occur. Stigma, associated with negative attitudes, can dramatically impact treatment, recovery, and ultimately relapse. Recognizing that addiction is a brain disease, individuals with OUD must be treated with respect and com- passion as a patient with a dis- ease, without judgment and not viewed as morally deficient.

Although multiple treatments are available, evidence reveals that only an approximate 11% receive specialty care in treat- ment centers (Busch et al., 2017). Based on the escalating opioid misuse crisis, there is a dire need to educate practition- ers on MAT, the safest and most effective treatment for OUD. MAT efficacy is increased with a holistic approach, including therapeutic counseling and other behavioral therapies (Moore, 2018; SAMHSA, 2019b). According to Moore (2018), sur- vival rates are improved, patients remain in treatment longer, have increased levels of employment, and have improved overall quality of life with MAT. While deemed the most effective treatment for OUD, MAT underutilization con- tinues to exist predominantly due to the inadequate number

of providers and lack of OUD education among healthcare professionals.

To address the need for increased providers, in 2016 the U.S. Congress, through the Comprehensive Addiction and Recovery Act, facilitated expan- sion of prescriptive privileges for nurse practitioners to pro- vide MAT (SAMHSA, 2019b). Through education, increased numbers of nurse practitioners who can treat individuals with OUD will dramatically assist in combatting the opioid epidemic.

Conclusion

The need to address this unprecedented opioid epidemic is increasingly being recognized. Finding ways to treat OUD has become a national priority (Mumba et al., 2018). OUD affects individuals across the lifespan, including those of diverse ethnic, racial, and socioeconomic backgrounds, in rural, urban, and suburban set- tings throughout the country. As frontline providers of care, it is imperative nurses take compre- hensive action to combat this epidemic to improve outcomes as well as to mitigate the rising healthcare costs associated with this crisis. $ Kathleen Neville, PhD, RN, FAAN Associate Dean of Graduate Studies and

Research Seton Hall University College of Nursing Nutley, NJ Marie Foley, PhD, RN Dean and Professor Seton Hall University College of Nursing Nutley, NJ

References Agency for Healthcare Research and Quality.

(2016). Mean expenses for person with care for selected conditions by type of service: United States, 2014. Medical expenditure panel survey household component data.

American Association of Colleges Nursing (AACN). (2019a). Commitment state- ment on countering the US opioid epi- demic. https://nam.edu/wp- content/uploads/2019/04/AACN_Com mitment_Statement_on_Countering.pdf

American Association of Colleges of Nursing (AACN). (2019b). AACN joins action col- laborative countering the U.S. opioid epidemic. https://www.aacnnursing. org/News-Information/News/View/ ArticleId/23550/action-collaborative- opioids

American Nurses Association (ANA). (2016). Nursing’s role in addressing nation’s opioid crisis. https://www.nursing- world.org/~4ae212/globalassets/docs/ ana/ana_nursings-role-in-opioid- crisis_2016.pdf

American Psychiatric Nurses Association. (2016). American Psychiatric Nurses Association introduces new education to combat opioid epidemic. https://www.apna.org/i4a/pages/index. cfm?pageID=6089

American Society of Addiction Medicine (ASAM). (2015). Patients with addiction need treatment – not stigma. https://www.asam.org/resources/publi- cations/magazine/read/article/2015/12/ 15/patients-with-a-substance-use-disor- der-need-treatment—-not-stigma

Barnett, M., Olenski, A., & Jena, A. (2017). Opioid-prescribing patterns of emer- gency physicians and risk of long-term use. The New England Journal of Medicine, 376(7), 663-673.

Bennet, J., Kingsbury, K., Appelbaum, B., Cottle, M., Gay, M., Giacomo, C., ... & Fox, N. (2018). An opioid crisis foretold. The New York Times. https://www. nytimes.com/2018/04/21/opinion/an- opioid-crisis-foretold.html

Brinkley-Rubinstein, L., Zaller, N., Martino, S., Cloud, D.H., McCauley, E., Heise, A., & Seal, D. (2018). Criminal justice continu- um for opioid user at risk of overdose. Addictive Behaviors, 86, 104-110.

Broglio, K., & Matzo, M. (2018). Perspectives on palliative nursing: Acute pain man- agement for people with opioid use dis- order. American Journal of Nursing, 118(10), 42-56.

Busch, S., Fiellin, D., Charwarski, M., Owens, P., Pantalon, M., Hawk, K., Bernstein, S., O’Connor, P., & D’Onofrio, G.

Nursing Economic$

January/February 2020 | Volume 38 Number 1 15

(2017). Cost-effectiveness of emer- gency department- initiated treatment for opioid dependence. Addiction, 112(11), 2002-2010.

Cadet, M., & Tucker, L. (2019). NP roles in medication-assisted treatment for opioid use disorder. American Nurse Today, 14(1), 8-13.

Centers for Disease Control and Prevention (CDC). (2017). Addressing the prescrip- tion opioid crisis. Retrieved from https://www.cdc.gov/rxawareness/pdf/ Overview-Rx-Awareness-Resources.pdf

Centers for Disease Control and Prevention (CDC). (2018). U.S. drug overdose deaths continue to rise; increase fueled by synthetic opioids. Retrieved from https://www.cdc.gov/media/releases/20 18/p0329-drug-overdose-deaths.html

Centers for Disease Control and Prevention (CDC). (2019a). Accidents or uninten- tional injuries. https://www.cdc.gov/ nchs/fastats/accidental-injury.htm

Centers for Disease Control and Prevention (CDC). (2019b). Opioid overdose. Retrieved from https://www.cdc.gov/drugoverdose/dat a/statedeaths.html

Centers for Disease Control and Prevention (CDC). (2019c). Understanding the epi- demic. Retrieved https://www.cdc.gov/ drugoverdose/epidemic/index.html

Chen, L.H., Hedegaard, H., & Warner, M. (2014). Drug-poisoning deaths involving opioid analgesics: United States, 1999- 2011. NCHS Data Brief, 166, 1-8.

Chimbar, L., & Moleta, Y. (2018). Naloxone effectiveness: A systematic review. Journal of Addiction Nursing, 29(30), 157-171.

Cicero, T., Ellis, M., Surratt, H., Kurtz, (2014). The changing face of heroin use in the United States: A retrospective analysis of the past 50 years, JAMA Psychiatry, 7(71), 821-826.

Council of Economic Advisers (U.S.), Executive Office of the President of the United States. (CEA). (2017). The under- estimated cost of the opioid crisis. Retrieved from https://www.white house.gov/briefings-statements/cea- report-underestimated-cost-opioid- crisis/

Cox, K., & Naegle, M. (2019). Presidents Message: The opioid crisis. Nursing Outlook, 67(1), 3-5.

Florence, C.S., Zhou, C., Luo, F., & Xu, L. (2016). The economic burden of pre- scription opioid overdose, abuse, and dependence in the United States, 2013. Medical Care, 54(10), 901-906.

Fogger, S., & McGuinness, T. (2015). Adolescents at risk: Pain pills to heroin: Part II. Journal of Psychosocial Nursing

and Mental Health Services, 53(2), 27- 30.

Fornili, K. (2018). The opioid crisis, suicides, and related conditions: Multiple clus- tered syndemics, not singular epi- demics. Journal of Addictions Nursing, 29(3), 214-220.

Hedegaard, H., Warner, M., & Minino, A.M. (2017). Drug overdose deaths in the United States, 1999-2015. NCHS Data Brief, 273. https://www.cdc.gov/nchs/ data/databriefs/db273.pdf

Hsu, D.J., McCarthy, E.P., Stevens, J.P., & Mukamal, K.J. (2017). Hospitalizations, costs and outcomes associated with heroin and prescription opioid overdos- es in the United States 2001- 12. Addiction,112(9), 1558-1564.

Humphreys, K. (2018). Americans take more pain pills-but not because they’re in more pain. The Washington Post. https://www.washingtonpost.com/news /wonk/wp/2018/03/23/americans-take- more-pain-pills-but-not-because-theyre- in-more-pain/?utm_term=.be20005 e9ba4

Johnson, A. (2018). Curbing the high cost of opioid abuse treatment. Benefits Magazine, 14-19.

Klimas, J. (2017). Better medical education: One solution to the opioid crisis. http://theconversation.com/better- medical-education-one-solution-to-the- opioid-crisis-81019

Leslie, D. L., Djibril, M., Agbese, E., Xueyi, A., & Guodong, L. (2019). The economic burden of the opioid epidemic on states: The case of Medicaid. American Journal of Managed Care. https:// www.ajmc.com/journals/supplement/ 2019/deaths-dollars-diverted- resources-opioid-epidemic/the- economic-burden-opioid-epidemic-on- states-case-of-medicaid

Leung, P., MacDonald, E., Stanbrook, M., Dhalla, I., & Juurlink, D. (2017). A 1980 letter on the risk of opioid addiction. New England Journal of Medicine, 376, 2194-2195.

Litton, S. (2018). Economic toll of opioid cri- sis in U.S. Exceeded $1 trillion since 2001. Altarum. https://altarum.org/ news/economic-toll-opioid-crisis-us- exceeded-1-trillion-2001

Livingston, J.D., Milne, T., Fang, M.L., & Amari, E. (2011). The effectiveness of interventions for reducing stigma related to substance use disorders: A system- atic review. Addiction, 107(1), 39-50.

Macy, B. (2018). Dopesick: Dealers, doctors and the drug company that addicted America. Little, Brown & Company.

Managed Healthcare Executive Staff. (2019). The financial burden of the opioid epi-

demic. Managed Healthcare Executive. https://www.managedhealthcareexecu tive.com/news/financial-burden-opioid- epidemic

Martello, J., Cassidy, B., & Mitchell, A. (2018). Evaluating emergency department opi- oid prescribing behaviors after educa- tion about mandated use of the educa- tion prescription drug monitoring pro- gram. Journal of Addictions Nursing, 29(3), 196-202.

Moore, D.J. (2018). A nurse practitioner’s perspective on prescribing Suboxone for opioid use disorder. Journal of Addictions Nursing, 29(3), 226-229.

Mumba, M.N., Findlay, L.J., & Snow, D. E. (2018). Treatment options for opioid use disorders. A review of the relevant litera- ture. Journal of Addiction Nursing, 29(3), 221-225.

National Institute of Drug Abuse. (2019). Opioid-related overdose deaths. Retrieved from https://www.drug abuse.gov/opioid-summaries-by- state/new-jersey-opioid-summary

Neville, K., & Roan, N. (2014). Challenges in nursing practice: Nurses’ perceptions in caring for hospitalized medical-surgical patients with substance abuse/depen dence. Journal of Nursing Administration, 44(6), 339-346.

Platt, M., Kwasky, A., McDonald, D., and Spetz, J. (2019). Exploring health eco- nomics course competencies’ value for nurse administrators. Nursing Outlook, 67(3), 270-279.

Ropero-Miller, J.D., & Speaker, P.J. (2019). The hidden costs of the opioid crisis and the implications for financial man- agement in the public sector. Forensic Science International: Synergy, 1, 227- 238.

Rhyan, C.N. (2017). The potential societal benefit of eliminating opioid overdoses, deaths, and substance abuse disorders exceeds $95 billion per year. Altarum. https://altarum.org/publications/poten tial-societal-benefit-eliminating-opioid- crisis-exceeds-95-billion-year

Salmond, S., & Allread, V. (2019). A popula- tion health approach to America’s opi- oid epidemic. Orthopaedic Nursing, 38(2), 95-108.

Siegel, E. (2018). Opioid epidemic so danger- ous, says CDC, it’s finally killing as many Americans as guns. Forbes. https://www.forbes.com/sites/startswith abang/2018/03/20/opioid-epidemic-so- dangerous-says-cdc-its-finally-killing-as- many-americans-as-guns/#3448b fa6c21

continued on page 51

Nursing Economic$

January/February 2020 | Volume 38 Number 1 51

Nurses Call to Action continued from page 15 Siegel, R. (2019). Opioid crises cost U.S. economy at least $631 bil-

lion, study finds. The Washington Post. https://www.washington- post.com/business/2019/10/17/opioid-crisis-cost-us-economy- least-billion-study-finds/

Sofer, D. (2019). America’s problem with opioid abuse takes its toll on nursing, too. American Journal of Nursing, 119(4), 17-18.

Substance Abuse and Mental Health Services Administration (SAMH- SA). (2019a). Apply for a practitioner waiver. https://www.samh- sa.gov/medication-assisted-treatment/training-materials- resources/buprenorphine-waiver

Substance Abuse and Mental Health Services Administration (SAMH- SA). (2019b). Medication-assisted treatment (MAT). Retrieved from https://www.samhsa.gov/medication-assisted-treatment

Tierney, M. (2016). Improving nurses’ attitudes toward patients with substance abuse disorders. American Nurse Today, 11(11), 1- 16.

United Nations Office on Drugs and Crimes. (2016). World drug report 2016. https://www.unodc.org/doc/wdr2016/WORLD_DRUG_REPORT _2016_web.pdf

U.S. Congress. (2016). S.524 - Comprehensive Addiction and Recovery Act of 2016. https://www.congress.gov/bill/114th- congress/senate-bill/524/text

van Boekel, L., Brouwers, E., van Weeghel, J., & Garretson, H. (2013). Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug and Alcohol Dependence, 131(1-2), 23-35.

Velander, J. (2018). Suboxone: Rationale, science, misconceptions. The Ochsner Journal, 18(1), 23-29.

Copyright of Nursing Economic$ is the property of Jannetti Publications, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.