Nurse Practitioners Stuck In The Middle Of Opioid Dilemma

Oct 26, 2017

A change in federal law in 2014 made it more difficult for advanced practice registered nurses to provide pain relief for patients. The law effectively removed nurses’ ability to prescribe schedule 2 drugs, such as hydrocodone.

For her doctoral dissertation, nurse practitioner Rachel Mack studied how nurses adapted to the law change.

The Journal Record’s Sarah Terry-Cobo writes eight nurse practitioners participated in Mack’s research. Mack found that many nurses had begun recommending alternative therapies, like acupuncture, chiropractic care and massage. Some nurses would combine therapies with Tylenol 3 or Tramadol, a narcotic-like painkiller.

But many insurance providers won’t cover alternative therapies, and SoonerCare limits the number of physical therapy sessions its recipients can get each year. That leaves her recommending over-the-counter remedies such as analgesic balms and adhesive heating patches.

“That limits access to health care to a group of patients that needs it,” Mack said.

That can lead some to recommend that patients see a pain management specialist, which could lead to more opioid prescriptions, she said.

Dr. Kevin Taubman, president of the Oklahoma State Medical Association, agreed that more holistic therapies can help relieve pain, and he believes that taking alternative therapies into consideration will be critical in reducing the number of opioid prescriptions. However, he does not believe expanding prescribing authority to nurse practitioners would be good move.

“He's really wary of allowing anyone else to be able to prescribe those kinds of drugs because the state is already facing an opioid crisis,” Sarah Terry-Cobo told KGOU. “He makes the argument, which is fairly common during the legislative battles, that physicians have more training and more education when it comes to be able to prescribe these medications.”


Jacob McCleland: It's the Business Intelligence Report, a weekly conversation about business news in Oklahoma. I'm Jacob McCleland. I'm talking today with Sarah Terry-Cobo. She's a senior reporter for The Journal Record newspaper. Hi Sarah. Thanks for joining us.

Sarah Terry-Cobo: Thanks for having me Jacob. Glad to be here.

McCleland: Now I want to talk about a couple stories you wrote this week about opioids and addiction. You spoke with Rachel Mack, a nurse practitioner who studied how Oklahoma's nurses responded to 2014 federal law that removed nurses ability to prescribe opioids like hydrocodone. What did she find?

Terry-Cobo: Well it has become more complicated for a nurse practitioners to help patients get pain relief. So they are recommending things like chiropractic care massage acupuncture. And if there's a supervising doctor in the office then the M.D. can recommend physical therapy. That's because nurse practitioners can't refer a patient out to physical therapy, Rachel Mack says. So that is a holistic approach. And that may work for some people who can pay for those things out of pocket and don't have immediate pain issues like broken bones. But for people on SoonerCare, that's the state issued Medicaid insurance. It doesn't cover those things.

McCleland: That's really interesting because a lot of these alternative therapies that you mention aren't covered by insurance. So when that's the case what can nurses do to help people manage pain?

Terry-Cobo: Well so they have a couple of options. There's Tylenol 3 which is a stronger prescription version and it has codeine in it. And then there's a medication called Tramadol. But Tramadol lowers the seizure threshold. So it's not for every patient. And some people have allergies to codeine. Codeine that's in the Tylenol 3 so there's that.

Terry-Cobo: Rachel Mack believe that nurse practitioners should be able to prescribe hydrocodone and other opioid painkillers again?

Terry-Cobo: Well she says the holistic approach is really important in general, but she like other members of her trade group they think that being able to prescribe hydrocodone will help those who work in rural areas and have patients who suffer like a farm injury over the weekend and can't get in to see a specialist for several days.

McCleland: You also spoke to Dr. Kevin Taudman. He's a surgeon and president of the Oklahoma State Medical Association and he doesn't think nurse practitioners should have the authority to prescribe opioids. Why not.

Terry-Cobo: Well he's really wary of allowing anyone else to be able to prescribe those kinds of drugs because the state is already facing an opioid crisis. He makes the argument, which is fairly common during the legislative battles, that physicians have more training and more education when it comes to be able to prescribe these medications.

McCleland: Now in what ways does Dr. Taubman agree with some of Rachel Mack's findings.

Terry-Cobo: He did agree with her that the holistic approach is very important to combating the opioid epidemic. And doctors should consider those approaches too. So in fact his group will be hosting continuing education coming up next month that will train all health care providers, doctors and nurses alike, to use those alternative therapies to manage pain.

McCleland: But you also wrote this week about the groundbreaking for a new substance abuse treatment center in Edmond that will be adjacent to the Integris hospital there. It's called the Integris Arcadia Trails Center for Addiction Recovery. There's obviously a huge need for addiction treatment in Oklahoma. I mean what's the concept for this particular treatment center?

Terry-Cobo: Think of like a Betty Ford Center. But fewer beds and more affordable than that renowned recovery center. The treatment will be customized but they're recommending a three month stay there. Patients will be treated by addiction specialists therapists and they're also encouraged to get in touch with their spirituality whatever that means for the person.

McCleland: And treatment will cost about $56000 for for 90 days as you mentioned of inpatient care. And you mentioned that nobody will receive free care. Why not?

Terry-Cobo: Well research shows that people have better outcomes if they have a financial stake or an investment in their own recovery.

McCleland: You described this as a passion project by Dr. Merali Krishna. Why so?

Terry-Cobo: His mother had severe mental illness when he was a child. So he grew up watching his mother struggle and even saw her try to take her own life. So looking back he says he believes she had severe seasonal affective disorder and bipolar disorder. It's very close to his own life.

McCleland: Sarah Terry-Cobo is a senior reporter for The Journal Reagan newspaper. Sarah thank you so much.

Terry-Cobo: Great to be here Jacob. Thanks for having me.