Ms. Villani is a Family Nurse Practitioner who has been working with the Penobscot Indian Nation Health Services in rural Maine for approximately 2 ½ years. She joined the Penobscot Nation Health Services team with a hope to apply her special focus on diabetes to the needs of this population. As a Family Nurse Practitioner she treats a wide range of patient needs, including the complexities of opiate addiction treatment and shares her perspective on the importance of distinguishing addiction versus dependence and how we can apply concepts of diabetic treatment approach to helping remove the stigma of addiction.
Q. How does the Penobscot Indian Nation Health Services approach opiate addiction in its community?
Like many other places, we have significant drug addiction in the entire Penobscot county area. At the Penobscot Indian Nation Health Services, we have a good treatment program that a lot of thought went into. We do the whole bio-pyscho-social approach to treatment. People are enrolled in counseling to heal spiritually, we have our own suboxone program, and there are lots of options in the community for people to go for support. The Native community has bonding ceremonies where people can meet that include drumming and dancing. It is a healing journey with social support that addresses not just the addiction, but the whole person.
Q. What do you consider to be a key strategy for providers when it comes to treating opiate addiction?
It is important for providers to know the difference between a patient with a dependency versus addiction. Their behavior is different and the treatment approach is different.
A patient with dependency will take the medication as prescribed because they don’t want to run out. They count their pills, are careful not to take too many, and keep their pills in a safe place. And if their medication was stopped it is likely they would experience withdrawal. These are usually patients with long time chronic pain (knee, hip, back).
On the other hand, a person with an addiction to opioids does not take the medication as prescribed. They aren’t seeking to make it last and take more than necessary in order to get “high”. When the pills run out they begin looking for other sources because they know they cannot can’t get more of their own prescription. In many cases they resort to heroin, stealing others prescriptions, or other activities to meet their addictive need.
When treating dependency, our goal is to try to wean them off their opioids. As a medical community we now know that, long term, opiates don’t treat chronic pain effectively. So we are now faced with the very difficult task of working with patients who have been taking opioids for years to manage pain and saying “we need to wean you off your pain medication”. This is a very scary idea to the patients. We are still working on our language and approach for this and getting financial support for alternative pain management approaches such as acupuncture, Reiki, and massage. Currently much of this isn’t reimbursed and that can really limit the treatment options, which is a big barrier.
For those who are addicted and ready for recovery we work to get them into the suboxone program. We have one provider (MD) who can administer suboxone to patients, but we hope that soon Nurse Practitioners will also to be able to prescribe. There is legislation that is currently on President Obama’s desk that would allow for this so we are really hopeful since our physician is currently at the limit of what he can safely manage and this change would allow us to bring more into the program.
Q. What do you feel is an important change needed with regards to opiate addiction and dependence treatment?
I would like to see payers reimbursing for some of the alternative pain management therapies such as reiki, acupuncture and massage. We need to significantly decrease opioid use for pain, but we need to have alternatives to offer. Without insurance covering these alternatives they become out of reach for many and we are left without options.
Additionally, I would like to see the stigma of addiction change. It is human nature for us to look down on people with addiction if we believe it is choice based. But addiction is a disease – like diabetes is a disease. This stigma associated with addiction makes the person feel alienated and can fuel the addiction further as they feel they are not socially accepted.
One thing we have tried hard to do is look at a person with addiction similar to how we address a person with diabetes. For example – If a diabetic has their Hemoglobin A1C (blood/sugar test) done and the results are “out of range”, we don’t tell the person that they failed their diabetes test, we discuss what might have caused them to be out of range, discuss changes that could be made.
When a patient with an addiction comes in and takes their urine drug screen and there are other substances found in the test, many say “you failed your drug screen”. You failed. What if instead we changed the approach to “I see your drug screen has other substances….what happened?” Attempt to understand the circumstances that created the results and offer treatment approach to address those issues – group therapy, additional counseling, or whatever is needed in order for them to be successful.