Specific disciplines addressing substance use: AMERSA in the 21st century

In 2002, the Association for Medical Education and Research in Substance Abuse (now known as the Association for Multidisciplinary Education and Research in Substance Use and Addiction; AMERSA) released a comprehensive strategic plan for interdisciplinary faculty development through Project MAINSTREAM. This document provided health professionals working with individuals with a substance use disorder (SUD) an overview of the scientific literature, a review of discipline-specific perspectives on training, and a summary of “the core knowledge, attitudes, competencies, and skills needed by health professionals in all disciplines in order to effectively identify, intervene with, and refer patients with SUD.”¹ The proliferation of evidence related to addressing the continuum of substance use in ensuing years, particularly within the context of the current opioid epidemic, necessitated a substantial revision of the nearly two-decade old competencies. The key contents of this resulting document, entitled Specific Disciplines Addressing Substance Use: AMERSA in the 21st Century – 2018 Update, are the feature of this SAj Supplement. Levy, Alford, and Seale authored an article entitled Medicine, with a Focus on Physicians: Addressing Substance Use in the 21st Century.² Mattingly authored an article entitled Medicine, with a Focus on Physician Assistants: Addressing Substance Use in the 21st Century.³ Finnell, Tierney, and Mitchell authored an article entitled Nursing: Addressing Substance Use in the 21st Century.⁴ Bratberg authored an article entitled Pharmacy: Addressing Substance Use in the 21st Century.⁵ And Osbourne-Leute, Pugatch, and Hruschak authored an article entitled Social Work: Addressing Substance Use in the 21st Century.⁶

It is important to state, however, that in addition to Project MAINSTREAM, AMERSA has vast experience in leading the development of numerous multi-disciplinary training curricula and other clinical resources to help advance the evidence-based treatment for substance use disorders. For several years, AMERSA scientific meeting abstracts have been published in SAj.^7–10 Moreover, AMERSA members have been featured authors of special issues and articles that highlight curricular innovations to address training gaps, such as an article on screening, brief intervention, and referral to treatment published by Gordon and Alford in 2012.¹¹

The AMERSA in the 21st Century – 2018 Update features a revision of four select chapters originally included in the 2002 AMERSA Strategic Plan – medicine, nursing, pharmacy, and social work, with the addition of a new chapter specific to physician assistants and their role in caring for people across the substance use continuum. The 2018 Update is a practical document consisting of five brief discipline-specific chapters, corresponding core competencies for professionals to identify and address substance use problems and disorders, including opioid use disorders, and a comprehensive bibliography. The document provides updated guidance to health professionals, and provides a roadmap of knowledge, skills, and attitudes recommended for health professional trainees to support them in effectively assessing and treating patients who use alcohol and other drugs.

AMERSA in the 21st Century – 2018 Update was authored by a team of experts including Sharon Levy, MD, MPH, Boston Children’s Hospital (Physician/Medicine Chapter); Deborah Finnell, DNS, CARN-AP, FAAN, Johns Hopkins University, School of Nursing, Ann Mitchell, PhD, RN, AHN-BC, FIAAN, FAAN, University of Pittsburgh School of Nursing, and Matthew Tierney, MS, ANP, PMHNP, FAAN, University of California, San Francisco School of Nursing (Nursing Chapter); Jeffrey P. Bratberg, PharmD, FAPhA, University of Rhode Island, College of Pharmacy (Pharmacy Chapter); Valerie Hruschak, PhD, Brigham and Women's Hospital, Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, and Victoria A. Osborne-Leute, PhD, MSW, Sacred Heart University (Social Work Chapter); and Jill R. Mattingly, DHSc, MMSc, PA-C, Mercer University College of Health Professions (Physician Assistant/Medicine Chapter), with me as Editor and Jenny Ericksen Leary from Boston Medical Center as Second Editor.

Since the publication of the original AMERSA Strategic Plan, the United States has experienced a large increase in the use of heroin and prescription opioids. In 2017 alone, more than 70,000 people died from a drug overdose.¹² Of those deaths, approximately 68% involved a prescription or illicit opioid. Further, between 2005 and 2013, less than one in five people with an opioid use disorder (OUD) received opioid-specific treatment.¹³ In response to increases in both the prevalence of OUD and opioid-related overdose deaths, the federal government has awarded millions of dollars in funding to expand access to medical treatments for people with an OUD.

The State Targeted Response (STR) to the Opioid Crisis Grants, funded by the Center for Substance Abuse Treatment (CSAT) and Center for Substance Abuse Prevention (CSAP) at the Substance Abuse and Mental Health Services Administration (SAMHSA) provide funding to the Single State Authority for Substance Abuse Services in all 50 states and an additional seven territories/jurisdictions. The aim of this funding support is to address the opioid crisis by “increasing access to treatment, reducing unmet treatment need, and reducing opioid overdose related deaths through the provision of prevention, treatment, and recovery activities for OUDs.”¹⁴ The effort started in July 2017 and was originally set to conclude in June 2019, but at the time of the writing of this article, funding has been extended through September 2020.

In February 2018, SAMHSA funded the American Academy of Addiction Psychiatry (AAAP) to lead an interprofessional consortium of key stakeholders and partners to connect with communities in addressing the growing opioid epidemic by enhancing access to evidence-based prevention, treatment, and recovery resources for people with OUDs. This effort, known as the Opioid Response Network (ORN), delivers customized training and intensive technical assistance (TA) to STR grantees, communities, and others to help organizations and individuals deliver evidence-based prevention, treatment, and recovery services to better address the nation’s opioid crisis.

The ORN, previously known as the State Targeted Response-Technical Assistance, STR-TA, is a consortium comprised of five core partner organizations – the Addiction Technology Transfer Center Network (ATTC; expertise in SUD training/TA), the Center for Social Innovation (C4; expertise in recovery), Communities for Anti-Drug Coalitions of America (CADCA; expertise in prevention), Boston Children’s Hospital (expertise in prevention and youth treatment), and Columbia University Medical Center (expertise in addiction and treatment), and nearly 20 additional national professional organizations.¹⁵ The ORN effort is being evaluated by Research Triangle International (RTI), an expert in monitoring and evaluation. As part of ORN, AAAP supported the development of the AMERSA in the 21st Century – 2018 Update and this SAj Supplement.

Addiction has been recognized for several decades as a “chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.”^16,17 In 1997, Dr. Alan I. Leshner, former Director of the National Institute on Drug Abuse, authored a brief but seminal article in Science where he described addiction as a brain disease and made the case that the most effective treatment approaches are multi-dimensional, and include biological, behavioral, and social-context components.¹⁸ Similar to other diseases, such as diabetes and hypertension, if not recognized early and treated adequately, substance use disorders can disrupt an individual’s normal, healthy functioning and result in serious adverse consequences that can last a lifetime.^16,19 Moreover, as there are many evidence-based behavioral and medical treatments to assist people with diabetes, hypertension, or other heart disease to effectively manage their disease and live healthy and productive lives, there are many evidence-based medical and behavioral interventions to address substance use disorders. Several FDA-approved medications are available for use with persons with alcohol, nicotine, and opioid use disorders that can help individuals live healthy and productive lives. SAMHSA’s tagline summarizes this point perfectly – “Behavioral Health is Essential to Health, Prevention Works, Treatment is Effective, and People Recover.”²⁰

With the implementation of the Patient Protection and Affordable Care Act (ACA),²¹ integrated care has become the gold standard of healthcare delivery models, and providers who previously operated in separate systems are now encouraged to provide mental health, substance use, and primary care services in a seamless, coordinated manner, regardless of a patient’s entry point into the broader healthcare system.^22–24 Effective and comprehensive integrated care relies upon the development of a multi-disciplinary team, in which all members are well trained and well prepared. In turn, this team must possess the following four essential elements: (1) leadership and organization commitment (e.g., commitment to the philosophy of integrated care, risk taking, vision, and team values); (2) team development (e.g., team relationships, cross training, and system and operational support); (3) team process (e.g., effective communication); and (4) team outcomes (e.g., clinical outcomes and patient satisfaction).²⁵

Screening, brief intervention, and referral to treatment (SBIRT) is a useful framework for guiding the delivery of care related to the continuum of substance use. Screening tools for alcohol use and for drug use can be feasibly used in healthcare settings to detect a person’s level of associated risk. Informed by the results of the screening, the healthcare provider can engage the patient in a brief intervention, which is a 5- to 10-min, motivationally-driven conversation that focuses on development of health behavior goals with supporting patient autonomy. While conversations with healthcare providers may be an initial path towards motivation to change, evidence-based behavioral (e.g., cognitive-behavioral treatment, motivational enhancement therapy) and/or pharmacological treatment may be indicated. Such treatments may be provided by the healthcare provider who has engaged the patient in that motivational conversation or this may require a referral to a specialty provider. In making such a referral to treatment, the healthcare provider engages the patient in a conversation about possible options such as scheduling a follow-up with a specialty provider for further evaluation and/or specific treatment, recommending mutual support programs, or referring the patient to a higher level of care such as inpatient or residential substance use treatment.

The nation’s opioid epidemic has further thrust the treatment of substance use into the healthcare system at-large, and as was previously mentioned, a significant amount of federal funding is focused specifically on expanding access to available evidence-based behavioral and medical treatment interventions and approaches. While the enormous burden of the current opioid crisis has led to a focus on treatment for OUD, the AMERSA competencies broadly address the continuum of substance use and are not focused on a single substance.

It is unacceptable to ignore a patient’s substance use when there are evidence-based tools for screening. Further, it is not appropriate to identify a patient at-risk because of substance use and then do nothing. At a minimum, providers need to identify the level of risk associated with the individual’s substance use and intervene accordingly to prevent the progression of substance use. For persons at the highest risk with a substance use disorder, this means connecting them with lifesaving behavioral and pharmacological interventions. Professionals who represent disciplines across the continuum of care must be better equipped with the tools necessary to move beyond initial assessment and fully engage their patients in the broader healthcare system to provide them with the evidence-based medical and behavioral treatment and support they need to achieve long-term health, wellness, and recovery. Professionals should work in interdisciplinary teams to optimize their patient outcomes and best leverage their unique and specialized, discipline-specific skills.

While physicians, nurses, pharmacists, social workers, and physician assistants all bring their unique perspective and a specific set of knowledge, skills, and attitudes to the multi-disciplinary healthcare team, numerous core competencies extend across multiple disciplines. The following is a list of select substance-use related core competencies shared by two or more disciplines (a comprehensive listing of core competencies appear at the conclusion of each discipline-specific article in this SAj Supplement):

• Recognize the signs and symptoms of SUD

• Utilize evidence-based measures to perform age, gender, and culturally appropriate substance use screening and assessment

• Intervene with patients whose health is at-risk due to alcohol or drug use, and reinforce healthy behaviors for those who are at low risk

• Utilize established protocols to ensure safe care (CIWA-Alcohol, COWS, CIWA-Benzodiazepines)

• Prescribe medications, treatment, and therapies in accordance with the healthcare consumer’s values, preferences, and needs and according to state- and federally-mandated scope of practice

• Identify and address the legal and ethical issues involved in the care of patients with SUD (e.g., 42 CFR Part 2, confidentiality, minor consent, etc.)

• Use patient-centered language to mitigate the stigma associated with substance use

• Identify referral sources and ensure linkage to treatment for those in need

• Promote the use of statewide peer assistance programs/groups and the use of alternative to discipline programs for health professionals whose practice is impaired because of substance use

In summary, AMERSA in the 21st Century serves as a practical guide to assist physicians, nurses, pharmacists, social workers, and physician assistants in all practice settings to enhance their SUD knowledge, skills, and attitudes. By doing so, they can better engage their patients in a change-oriented, bi-directional conversation to meet the patient where he/she is; help the patient understand the risk of using alcohol and other drugs; provide evidence-based treatment, and, if needed, encourage the patient to accept a referral to holistic, well-coordinated care for his/her substance use, mental health, and/or medical problems. The articles that follow in this SAj Supplement will provide the reader with a comprehensive review of each discipline-specific chapter and corresponding competencies.

Additional information

Funding

This work was supported by State Targeted Response Technical Assistance [1HT79 TI080816-01S1].