ANA works to ensure nurses are equipped to treat their patients’ pain effectively

  

As the largest healthcare provider group in the country, nurses are no strangers to treating pain, including chronic, acute, and emotional pain. Nurses are also subject to their own personal pain, and they are not alone. Today, there are approximately 50 million adults in the US living with chronic pain and over a third of those adults’ pain interferes with their daily activities. ANA is monitoring and advocating along with our nursing partners, around the Department of Health and Human Services Pain Management report due to be finalized later this year, that promises to help providers use evidence based treatments to manage their patients’ pain while considering the nationwide opioid epidemic.

In 2011, the Institute of Medicine recommended that pain and relieving pain should be a national priority. The report goes on to say that pain is a chief driver for visits to physicians and other healthcare providers, a major reason for taking medications, a major cause of disability, and a key factor in quality of life and productivity. We have all experienced pain and for many, if not all nurses, we have had to decide how and to what degree to treat that pain.

The Code of Ethics for Nurses with Interpretative Statements (the Code) mandates that nurses have an ethical obligation to treat their patients’ pain without bias. To minimize biases, the nurse must identify the influences and intentionally set them aside. However, the Code does not say how they must treat pain. For many what first comes to mind is treatment that involves opioids. For some diagnoses, opioids are part of the best clinical practices for treatment; for others, it may be a combination of pharmacological, restorative, and alternative therapies. Patient adherence, access, coverage, and social determinants may all affect the best option for the individual.

More recently, there has been a renewed interest in the role of pain with regards to the opioid epidemic. Pain is a separate disease from the addiction and dependence that can come from opioid use, a fact which has been recognized by the Department of Health and Human Services Pain Management Best Practices Inter-Agency task force. Encouraging to nurses, the task force recommends an individualized and multidisciplinary approach to chronic pain that also includes increased insurance coverage for Complex Management Situations. It also calls for safer opioid stewardship through a risk assessment based on the patients’ medical, social, and family history.

Nurses are also positioned to provide care coordination activities for improved patient outcomes to patients and their families suffering from chronic pain conditions and associated co-morbidities. ANA commented on the draft pain management report and will continue to advocate the role of nursing in treating chronic pain to the task force and agency. The task force will meet on May 9th and 10th to vote on final recommendations.

Recognizing pain as not just a symptom, but rather a disease for some patients, may help shape the patient-provider relationship and higher quality outcomes of care. Pain can have devastating personal, financial and social consequences. Reshaping how nurses talk about pain with their patients and taking the time to learn about and advocate for alternative therapies available in the community, can help in the immediate care of a patient and the long-term ability to complete activities of daily living.

Opioid Bill Contains Victories for Medicaid – as the Administration Undermines Medicaid Access

  

This week the Senate passed a landmark piece of legislation, the SUPPORT for Patients and Communities Act, that aims to curb the nation’s ongoing opioid-use disorder crisis. The legislation includes a critical provision that enables nurse practitioners and physician assistants to prescribe buprenorphine permanently – once they obtain a waiver required by any provider to prescribe medication-assisted treatment (MAT) – and expands MAT prescribing authority for five years to other advanced practice registered nurse (APRN) specialties: certified nurse-midwives, clinical nurse specialists and certified registered nurse anesthetists.

Medicaid Provisions in the SUPPORT for Patients and Communities Act

The bill also includes several critical Medicaid provisions aimed at treating individuals who suffer from an opioid-use disorder and preventing others from developing an opioid-use disorder. Taken together, these provisions will significantly increase access to opioid-use disorder treatment and counseling services for some of the nation’s most vulnerable populations and will decrease the rate of new opioid-use disorders.

These provisions include:

  • A temporary suspension (from Fiscal Year 2020 through FY 2023) of the Medicaid institution for mental disease (IMD) exclusion for short-term stays (less than 30 days per year) and the codification of regulations that allow managed care organizations to receive federal funding for patients who are in an IMD for 15 days or less per month (current law does not allow federal payment for patient stays in IMD facilities with greater than 16 beds);
  • A requirement for states to cover MAT, including methadone and counseling services, for opioid-use disorders from FY 2021 through FY 2025;
  • A provision that allows states to cover care for infants with neonatal abstinence syndrome at a residential pediatric recovery center and an extension of enhanced federal match provided under Medicaid for health home services to treat individuals with substance use disorders;
  • A requirement for state Medicaid programs to not terminate coverage for juvenile inmates under the age of 21 while they are incarcerated and an extension of Medicaid coverage for former foster youths ages 18 to 26 who move states, and;
  • A requirement for states to comply with drug review and use requirements as a condition of receiving federal Medicaid funding and a provision that allows state Medicaid programs access to state prescription drug monitoring programs.

Trump Administration Approval of Medicaid Work Requirements

It is ironic, then, that as the SUPPORT for Patients and Communities Act heads to President Trump’s desk, his administration is actively taking steps that will create barriers for Medicaid beneficiaries to remain covered under the program. CMS Administrator Seema Verma recently defended the administration’s policy of approving Medicaid waivers for demonstration projects that impose work requirements on certain Medicaid populations (i.e., the Medicaid expansion population of low-income, childless adults).

CMS recently faced criticism after 4,300 Arkansans lost Medicaid coverage in September as a result of not meeting the state’s new work requirements; this is the first time in the Medicaid program’s 53-year history that beneficiaries have lost coverage for not meeting work requirements. The administration has approved work requirements for Indiana and New Hampshire, and waivers to impose work requirements are pending in South Dakota, Kansas, Mississippi, Ohio, Maine, Utah and Arizona. Kentucky’s work requirements waiver was struck down in federal court in July, though the administration is currently working with Kentucky to revise implement those requirements nonetheless.

Studies show that work requirements for Medicaid beneficiaries have little to no impact on employment and, as demonstrated in Arkansas, result in coverage losses. According to a December 2017 Kaiser Family Foundation issue brief, roughly 6 in 10 of the 22 million non-disabled adults receiving Medicaid benefits are employed either full- or part-time, while 8 in 10 of these adults live in a working family. Most of these individuals work either for small firms or in low-paying industries which do not offer healthcare coverage and thus rely on Medicaid for such. Further, among those adults who are not working, most report a major barrier to employment such as illness, disability, or care-giving duties. According to the same Kaiser issue brief, Medicaid expansion has not negatively impacted labor market participation; in fact, some research demonstrates that Medicaid coverage supports work.

ANA Commends Congress and Urges Its Members to Vote in the Midterms

ANA applauds Congress for its hard work and dedication in passing the SUPPORT for Patients and Communities Act and for recognizing the role that RNs and APRNs play in patient care for those with an opioid-use disorder.

However, ANA firmly believes in universal access to comprehensive and affordable healthcare services for all Americans. The recent moves by both the Trump administration and state governments fly directly in the face of that goal and represent major steps backward in the effort to ensure that all Americans – especially vulnerable populations such as low-income women and those with pre-existing conditions – have access to all necessary healthcare services. These moves also undermine the progress made in Congress with the SUPPORT for Patients and Communities Act.

Healthcare stands to be a major issue in the upcoming 2018 midterm elections – 22 percent of respondents to a June 2018 NBC News/Wall Street Journal poll named healthcare as the most important factor in deciding their vote. These elections are right around the corner and are an incredibly important opportunity for ANA’s members to make their voices heard when it comes to determining the future of healthcare in this country. When nurses vote, lawmakers in Washington, DC, and in statehouses across the country listen. Visit ANA’s #NursesVote Action Center today and help us make this the most meaningful election for nurses yet.

A bump in the road for APRNs and Patients: The Senate Opioid SUD Legislative Package

  

ANA and other associations representing advanced practice registered nurses (APRNs) have been lobbying for years to make permanent the authority for nurse practitioners (NP) to prescribe medication-assisted treatments (MAT) for opioid-addicted patients and to extend the authority to the other three APRN specialties. The latest Senate package does not include this policy. ANA government affairs staff has been informed there are Senators with “holds” on this package meaning it can’t move forward until there are more negotiations. While we are disappointed the package does not currently include this provision, we still have several more bites at the apple.

The Comprehensive Addiction and Recovery Act of 2016 (Public Law No: 114-198.), commonly referred to as CARA, included a provision that allowed NPs and Physician Assistants (PAs) to take 24 hours of training to prescribe MAT for opioid-addicted patients. (This is referred to as “DATA 2000 waved” or just “DATA waved” authority.) This prescribing authority sunsets in 2021. The reason the prescribing authority is set to expire in 2021 was developed as a budgeting gimmick by Congress to keep the overall projected cost associated with CARA low. This provision was never intended to be a demonstration project – it was because Congress couldn’t find a way to offset the projected cost for permanent prescribing authority.

In June, the U.S. House of Representatives passed the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (H.R. 6), or the “SUPPORT for Patients and Communities Act” for short. Section 3003 of this bill has an agreed upon compromise version of what we have been lobbying for. It permanently extends the MAT prescribing authority for NPs and PAs and allows the other three APRN specialties the authority for five years. It also instructs the Department of Health and Human Services to conduct a study on the efficacy of prescribing MAT, and possible associated narcotics diversion issues, on all providers, including physicians. This would give the opportunity to for us to have data showing how important it is to have more access points for patients and that APRNs are just as qualified to treat opioid substance use disorder as physicians.

While this latest development is disappointing, it’s not over. Both the House and the Senate need to come together to pass identical legislation before any of this is signed into law. We have a large coalition of bipartisan legislators in the House and Senate who all agree that this is good policy. The current disagreement is over how to offset the projected cost estimated by the Congressional Budget Office (CBO). The ANA, along with the other associations representing APRNs, are on top of this issue and will be fighting for the inclusion of Section 3003 into any final package. It’s not over.

Further Reading

The CBO’s scoring rules for determining the cost of legislation are very complicated, convoluted, and don’t always make logical sense. The U.S. Drug Enforcement Agency (DEA) isn’t held to CBO’s scoring rules, and in January 2018, published an economic impact study on CARA. They found that from when the DATA 2000 waiver began through February 21, 2017, there were 33,663 DATA-waived physicians compared to 1,247,716 total physicians. Since February 2017, when NPs could first obtain the DATA 2000 waiver until May 5, 2018, 5,649 NPs have obtained a DATA 2000 waiver compared to 248,000 total NPs. That means proportionately, in less than two years, NPs have received almost as many waivers as physicians received in 17 years (2.3 percent of NPs v. 2.7 percent of physicians).

The DEA estimates that the total economic burden of the opioid epidemic is $75.7 billion, which amounts to $41,000 per patient. They also estimate that the net economic benefit of authorizing NPs and PAs to provide MAT, primarily due to increased labor productivity and decreased healthcare and legal costs, will be $640-729 million dollars over five years. Based on the DEA’s estimate that 5,235 NPs and PAs would obtain the waiver, this amounts to an average costs savings of approximately $122,254-139,255 for every NP or PA obtaining the waiver.

ANA strongly believes that extending the prescribing authority to the other APRN specialties will only further the success of this policy. ANA advocates for all RNs and APRNs to practice to the full extent of their education and practice authority, allowing individualized treatment plans for all patients and increased access to health care services, including MAT.

For additional information or comments, please contact Sam Hewitt, ANA’s senior associate director for federal government relations at Samuel.hewitt@ana.org