Beth Rutkowski, MPH
Co-Director, Pacific Southwest ATTC
In 2002, 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 in order to provide 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 resulting document, entitled Specific Disciplines Addressing Substance Use: AMERSA in the 21st Century – 2018 Update, is the feature of this ATTC Messenger article.
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 with a SUD. The resulting product 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 single, 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, RN, NP, FAAN, University of California San Francisco, School of Nursing (Nursing Chapter); Jeffrey P. Bratberg, PharmD, University of Rhode Island, College of Pharmacy (Pharmacy Chapter); Valerie Hruschak, MSW, University of Pittsburg, School of Social Work, 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 Chapter), and edited by myself and Jenny Ericksen Leary from Boston Medical Center. Quotes from several of the authors are included throughout this article to provide context and highlight the importance of providing updated discipline-specific guidance to medical professionals.
“The AMERSA competencies for physicians set the expectation that all practicing physicians, regardless of specialty, will understand core principles of addiction and have basic skills in managing substance use disorders in their patients. The timing of these standards, in conjunction with the recognition of Addiction Medicine by the American Board of Medical Specialties represents a great stride in advancing our conceptualization of substances use disorders as medical problems, encourages a “whole-patient”, ‘patient-centered’ approach and helps to further integrate the treatment of substance use disorders with other medical problems.” ~Sharon Levy
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. While more than 42,000 people died from an opioid-involved overdose in 2016 alone2, between 2005 and 2013, less than one in five people with an opioid use disorder (OUD) were in receipt of opioid-specific treatment3. In response to increase in both the prevalence of OUD and opioid-related overdose deaths, the federal government has awarded millions of dollars in funding to combat the opioid epidemic by expanding access to medical treatments for people with OUDs.
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 up to two years of funding to the Single State Authority for Substance Abuse Services in all 50 states and an additional seven territories/jurisdictions. The aim of the Program 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.”4 The two-year efforts started in July 2017 and are set to conclude in June 2019.
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. As part of this two-year project, AAAP supported the development of the AMERSA in the 21st Century – 2018 Update.
“I have worked within a multidisciplinary team throughout my nursing career. The AMERSA document, ‘Specific Disciplines Addressing Substance Use: AMERSA in the 21st Century - 2018 Update,’ underscores the essential knowledge and skills that all nurses should have in working with our colleagues from medicine, pharmacy, social work, and other members of the health care team to address the global burden of alcohol and other drug use. It was a privilege working with my colleagues Ann Mitchell and Matt Tierney in documenting core competencies for the generalist and advanced practice nurse. Our goal for this document was to convey that all nurses across specialties and healthcare settings need to provide competent care to persons who may be at risk because of alcohol and other drug use including the use of prescription medications for non-medical reasons.” ~Deborah Finnell
“Nursing competencies establish a foundation for nursing education and practice and are those abilities that are required to fulfill one’s role as a nurse. The ‘Specific Disciplines Addressing Substance Use: AMERSA in the 21st Century - 2018 Update’ clearly identify those core substance use-related competencies we believe every nurse needs in order to protect the safety and promote the health of all of our patients.” ~Ann Mitchell
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), and 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 organizations5. The ORN effort is being evaluated by Research Triangle International (RTI), an expert in monitoring and evaluation.
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.”6,7 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 components8. 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 lifetime6,9. 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.”10
With the implementation of the Affordable Care Act11, 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 system12-14. 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)15.
“Numerous opportunities exists for achieving these interprofessional and pharmacy-specific competencies during four years of didactic and experiential pharmacy education. Students and practicing pharmacists interact with patients and addiction providers along every segment of the SUD care cascade, from prevention to recovery. Pharmacists competent in addiction care can recommend judicious psychoactive medication prescribing, efficiently screen patients for SUD, provide and promote compassionate, stigma-free harm reduction via naloxone and sterile syringe sales, and collaboratively treat and follow patients with SUD’s using patient-centered, evidence-based pharmacotherapies. It's best when generalist student pharmacists are given ample opportunities to interact and care for people living with addiction themselves, or who experience addiction in their families.” ~Jeffrey Bratberg
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 five- to 10-minute, 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 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.
“Social workers regularly encounter individuals, families, and communities affected by substance use disorders and are an integral component of the multidisciplinary team. The profession is a valued discipline within the substance use field and is uniquely positioned to influence service delivery while evolving psychosocial and behavioral based approaches to this population. Specific Disciplines Addressing Substance Use: AMERSA in the 21st Century is a comprehensive and insightful document that provides a robust understanding of the social work role in substance use and how the profession operates in coordination with the other disciplines in the field.” ~Valerie Hruschak
The nation’s opioid epidemic has further thrust the treatment of substance use disorders into the healthcare system at-large, and a significant amount of federal funding is now 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 SUD 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 substance use disorders and connect that patient 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.
“It is a new frontier for Physician Assistants in the area of addiction. Raising awareness and ability in PAs practicing in all fields of health care, from the generalist to the specialist, is a primary goal of this document. When given the tools to identify, diagnose, and treat patients at risk for substance use disorder, there is an opportunity for timely treatment and enhanced care. Competencies provide fertile soil for inter-professional collaboration and improved patient outcomes.“ ~Jill Mattingly
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 SUD core competencies shared by two or more disciplines (a comprehensive listing of core competencies appear at the conclusion of each discipline-specific chapter in the AMERSA in the 21st Century document):
In summary, the intention of the AMERSA in the 21st Century document is to serve 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.
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