Morning alley, downtown east side

In the last three years alone, the overdose crisis has caused more than 10,000 deaths in Canada. Overdose-related deaths reached an alarming rate in 2016 in British Columbia (BC) at which point the province was forced to declare a public health emergency – this public health emergency continues to be in effect today with an average of more than 100 overdose-related deaths per month.  Advanced practice nurses (APNs) possess the knowledge, and skills necessary to provide primary care within supervised consumption services, increase access to opioid agonist therapy, improve the care offered to people who use substances across the health care system, and support frontline nurses. They should, therefore, be playing a crucial role in the overdose crisis. So, why aren’t they?

APNs are highly trained nurses who have in-depth competencies in direct practice, leadership, consultation, collaboration, research, health systems, education, and have their boots on the ground, strategically placing them as potentially impactful group when it comes to the overdose crisis. However, APNs are currently being underutilized. While ‘pockets of excellence’ exist across the country, certain factors limit the utilization of APNs to address this crisis. Such factors include but are not limited to, varying role implementation practices and priorities across the country, limited understanding of the role and its potential contribution, lack of education specific to substance use at both the undergraduate and graduate levels, small number of available APN positions in the field, budgetary constraints or cuts, and overreliance on physicians for primary care, treatment, and follow-up.

In British Columbia, Nurse Practitioner (NPs) who undergo additional training can prescribe opioids as well as the opioid agonist treatment modalities (i.e., suboxone and methadone). It is worth noting that NPs can also prescribe, as part of these treatment modalities, injectable hydromorphone. Furthermore, the possibility of adding prescription heroin to the list is currently being studied in BC. The expansion of prescribing practices means that NPs can now increase access to treatment and management at any stage, whether it be for active substance use, acute withdrawal, or ongoing active recovery. However, some challenges remain:

  • Unlike Ontario, BC has not developed a system of NP-led clinics across the province. Such clinics are essential to scale up access to treatment and care for people who use drugs.
  • While BC is leading the way with the highest number of supervised consumption services in the country, they operate without NPs and rely on physician referrals for treatment access.
  • Overemphasis on prescription monitoring has created “an opioid chill” and NPs may be reluctant to complete the training and expand their prescribing practices.

The actual and potential contribution of Clinical Nurse Specialists (CNSs) to address the overdose crisis in BC has not received the attention it deserves. CNSs are trained to develop innovative solutions to complex problems, to increase access to care, to support frontline nurses, to develop protocols and policies, and to take part (and lead) education and research. Increasing the presence of CNSs in hospitals and beyond can help address care gaps more effectively and improve care access for people who use drugs. The contribution of CNSs in the development, implementation and evaluation of new policies, programs and practices at St. Paul’s Hospital in Vancouver is a clear example of this. And nothing demonstrates the value of the CNS role more than the implementation of their Rapid Access Addiction Clinic in 2016.

In the midst of public health emergency, the potential contribution of APNs is largely untapped. Both NPs and CNSs should be used as a primary resource to improve the care offered to people who use drugs – including primary care, wound care, infection management, substance use treatment, safe drug supply, HIV and Hepatitis C treatment, and so on. Now is the time to scale up investments in advanced practice nursing and allow APNs to work to their full capacity in addressing the needs of people who use drugs as well as frontline nurses.

Alayna Payne is a registered nurse and a student in the Master’s Program (Nurse Educator Option) and Dr. Marilou Gagnon is an Associate Professor at the School of Nursing, Collaborative Scientist at the Canadian Institute for Substance Use Research, and President of the Harm Reduction Nurses Association.  

photo: emma jackson on flicker