Running Head: SUBSTANCE USE AND MENTAL HEALTH 1

Coexisting Substance Use Disorder and Mental Health Disorder

2147 Professional Issues and Role Development for the

Psychiatric-Mental Health Nurse Practitioner

Candice Knight, PhD, EdD, APN, PMHNP-BC

Danielle Conklin, DNP, NP-P, PMHNP-BC

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Coexisting Substance Use Disorder and Mental Health Disorder

Substance use disorder is an indiscriminate disease that affects millions of people

internationally across all ages and socioeconomic backgrounds. It often occurs in the context of

coexisting mental health disorders and impacts the lives of individuals, families, and

communities. In addition to increasing the risk of comorbidities and fatality, substance abuse

also places an enormous financial burden on the American healthcare system. According to the

National Survey on Drug Use and Health (NSDUH), 21.5 million Americans ages twelve and

older struggled with a substance use disorder in 2014 (SAMHSA, 2015). The Substance Abuse

and Mental Health Services Administration (SAMHSA) additionally published in 2014 the

statistic that an estimated 8 million American adults battled with a co-occurring mental health

disorder and a substance use disorder (2015).

During the past years, I have watched many people pass away from the lack of

resources and education from coexisting substance use disorder and mental health disorders.

Working as a nurse at the Bellevue Emergency Department, one man passed away after

receiving naloxone in the field but was not monitored closely enough once in the hospital. The

Narcan wore off, and the opioids in his system reactivated. He silently overdosed in the

emergency department. This exemplifies how health care failed to save a life because of the lack

of education and resources available.

Whether a mental health professional chooses to work directly with addiction disorders or

not, the provider should educate themselves on public policy and information literacy involving

addiction. Accidental overdose is the leading cause of death for under 50 year olds (National

Institute on Drug Abuse, 2018). The current statistics underscore the need for increased
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treatment availability and have galvanized us to explore further this population and the barriers

they face.

For this assignment, we will be focusing on adults (aged 18 and older) with a coexisting

substance use disorder and mental health disorder. Psychiatric Mental Health Nurse

Practitioners (PMHNP) in addition to psychiatrists are uniquely qualified to care for this

population as they can facilitate the detox process, provide medication management, perform

psychiatric evaluations, and continue psychotherapy throughout the recovery process.

Competencies for Coexisting Substance Use Disorder and Mental Health Disorder

Psychiatric Mental Health Nurse Practitioners working with substance use disorders need

to hold competencies with different modalities of psychotherapy and the latest evidence-based

medication management. This population will require different types of psychotherapy

depending on the various stages of recovery. The patient who actively struggles with addiction

will benefit from harm reduction and cognitive-behavior approaches. Cognitive-behavioral

counseling will help strengthen the patient's ability to make sound judgments, correct

problematic behaviors and allow the patient to start the recovery process. The therapist will

work with the client to enhance patient self-control, self-monitor to recognize cravings and avoid

high-risk situations (NIDA, 2018). Training can be completed at numerous institutes including

the Beck Cognitive Behavior Therapy (2016) institute that has a CBT for Substance Use

Disorders three-day workshop. The NP can take webinars online modules, such as the National

Health Care for the Homeless Council, to receive additional education in harm reduction (The

National Health Center for the Homeless Council, 2018).

Further challenges NPs currently face is the different state laws governing prescribing

ability, particularly in prescribing life-saving addiction medications such as buprenorphine.

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Under the Obama administration, section 303 of the Comprehensive Addiction and Recovery

Act (CARA) was signed into law in 2016. This law made changes at the federal level to allow

NPs to prescribe buprenorphine after completing a 24-hour training program and waiver

notification form. The NPs, however, are limited to prescribing buprenorphine to 30 patients at a

time but can apply for a waiver to prescribe to up to 100 patients after one year (American

Society of Addiction Medicine, 2018). Even after completing the buprenorphine training, many

states still restrict the NP to only being able to prescribe buprenorphine under physician

supervision. This creates a massive problem in many areas of America where very few

physicians are certified to prescribe buprenorphine. Therefore certified NPs are prevented from

prescribing it because of lack of physicians available for supervision. The NP must attend

conferences and read the latest research to keep up to date on how to prescribe these medications

to provide optimal care.

Issues related to Scope of Practice, Regulations, Licensing and Certification

Challenges to caring for this population include issues with the scope of practice, regulations,

and licensing. New York State (NYS) NPs have reduced practice, meaning state law requires a

career-long collaborative agreement with a physician or affiliated hospital with physicians who

are qualified to perform in the NP’s specialty of patient care. License requirements to work as a

NP in NYS include completion of an accredited graduate-level program with preparation for one

of four Advanced Practice Nursing (APN) specialties, acquired advanced clinical knowledge and

skill, clinical experience, and passing of the national certification exam (NYSED Office of the

Professions, 2017). In regards to working with adult patients suffering from substance use

disorder, there is not currently a required APN specialty to work with this population.

Psychiatrists, non-psychiatric physicians, Family NPs, Adult Primary Care NPs, and PMHNPs
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are presently all working with this population in hospital and outpatient settings. Addiction

specialty certifications are available for NP’s and Physicians who can be board certified in

addiction medicine; however, it is not required to treat this population. Although it is helpful to

increase the number of providers offering addiction services despite their specialty, it raises the

concern of what qualifications should be needed to work with this population. Considering the

high number of patients suffering from coexisting mental health and substance use disorders, it is

critical for providers with specialty psychiatric training and experience to be working with this

population.

Addiction medications such as naltrexone do not require specific licensure or a waiver to

prescribe. NPs outside the PMHNP specialty can prescribe antidepressants and addiction

medication as well. However, this population needs long-term adjunctive psychotherapy and

pharmacological treatment, making PMHNP and psychiatrists more appropriate and effective

treatment providers. Overall, challenges in treating this population are persistent due to current

prescribing limitations, lack of physicians with buprenorphine licensing, and a lack of consensus

as to which specialty should be managing this population.

Public Policy Issues

Substance use population will benefit from public policy reform that treats this condition

like a disease rather than a fault in character that can be seen in outdated laws such as criminal

persecution for users. An analysis from 2007 shows that the cost of alcohol, tobacco, and illicit

drug use related to health care, the criminal justice system, and lost work productivity, is

estimated to be $740 billion annually (National Institute on Drug Abuse, 2017). With the current

escalation of the nation’s drug epidemic related to the opioid crisis, the overall cost is projected

to be much higher. In 2016, a report from the National Center for Health statistics showed a
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decrease in life expectancy in the United States related to deaths from opioid overdoses. Patients

with substance use disorders make up a high percentage of the population and use billions of

dollars every year. However, there is still a lack of public policy reform to address these issues

and advocate for better resources and healthcare in a recovery model.

Individuals with dual diagnosis currently experience many barriers to accessing care.

Financially, many insurances do not cover or only cover part of addiction services and

medications, leaving patients with large deductibles they cannot meet. This often leads

individuals to choose to attend group meetings such as Alcoholics Anonymous (A.A.) or

Narcotics Anonymous (N.A.) and not seek mental health services. This puts them at a

disadvantage as they may be suffering from a mental health disorder that left untreated, will

contribute to relapses and further the addiction cycle. Further compounding the issue, individual

recovery groups have different definitions of sobriety. Many A.A. and N.A. groups consider

medication-assisted treatment such as buprenorphine maintenance or Vivitrol administration not

to be sober. Individuals, therefore, may be encouraged at certain groups not to take any

medications. There are many topics of contention within the addiction and recovery community,

leading to divisions among treatment providers and a lack of consensus on best practice. This

ultimately leads to confusion and often ineffective treatment.

Legal and Ethical Issues

Legal and ethical issues in working with all patients in a psychiatric setting apply to this

population. This includes the importance of maintaining confidentiality, adhering to boundaries,

recognizing conflicts of interest, and practicing with beneficence, autonomy, and genuineness. It

is critical for the PMHNP to show compassion and treat all patients with respect. This is

particularly important in working with the substance abusing population who are often in a
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vulnerable position and subjected to stigmatism. Competency is another issue, as providers from

various specialties are treating substance abuse disorders in private practices or primary care

offices. Providers in primary care and hospital settings have a responsibility to ensure patients

are appropriately referred for psychiatric evaluation and adjunctive psychotherapy. It is crucial

for providers to understand that substance abuse disorder is a disease that needs a comprehensive

care plan and is not isolated to acute detox and medication management.

Technology and Information Literacy Requirements

The technology needed for practice with this population would include medical

equipment such as vital sign machines, toxicology screening, complete blood count testing and

any additional lab testing for specific patients on medications that would potentially affect

patient’s health. The patient may be prescribed atypical antipsychotics or mood stabilizers to

treat underlying disease that can compromise health if not properly monitored.

Other technology that would be useful in treating this population is the use of the Internet

and mobile phone-based assessment, prevention, treatment, and recovery programs. These

programs can be used in tandem with psychopharmacology, allow for access anywhere, can be

tailored to the client, available at any time and are extremely cost effective. Smartphone-based

recovery support system programs now have Bluetooth accessible breathalyzers accompanied by

the app ‘SoberDiary’ that use positive reinforcement and behavioral interventions to aid recovery

(You, et al., 2017). GPS in smartphones can be programmed to notify patients when they are

near environments that were high risk for them and encourage behavior modification and risk

factors (Marsch, 2012).

Information literacy means the ability to recognize when specific information is needed

for patients and that the provider can locate, evaluate, and apply the knowledge necessary.
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Patients with coexisting substance use disorder and mental health disorder will require specific

information about addiction, recovery and risk factors that all providers should know how to

access this information. Government websites include Substance Abuse and Mental Health

Services Administration(SAMHSA) that has a national hotline that is open 24/hr a day and 365

days a year. SAMHSA exemplary Consensus Statement states “Mental health recovery is a

journey of healing and transformation enabling a person with a mental health problem to live a

meaningful life in a community of his or her choice while striving to achieve his or her full

potential (SAMHSA, 2018).”

Interview with Dr. Michelle Knapp

To gain more insight into working with this population, we interviewed Dr. Michelle

Knapp. Dr. Knapp is a PMHNP with a Doctorate of Nursing Practice. She is the program

director of the New York University Substance Abuse Disorders specialty sequence and has

extensive experience working with the substance abusing population. Dr. Knapp echoed

concerns previously noted in regards to division amongst the professional community as to best

treatment models. This includes divisions amongst providers, counselors, and support groups

over which medications should be used or not used, and which type of provider should care for

this population. She discussed the concern of provider qualifications. There is currently not a

required addiction and substance use disorder specialty or certification needed for NPs or

PMHNPs. The development of a necessary specialty competency can help to unify the field.

Other concerns mentioned include accessibility of care, prescribing issues, and treatment of

subspecialty populations within substance abuse. She noted that Medicaid often covers addiction

medications but many other insurance plans do not.

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Additionally, many providers in private practice are not accepting Medicaid or individual

insurance plans. A prescribing issue she emphasized was that certain opioid medications, mainly

buprenorphine, does not require the same prescribing limitations and regulations if being

prescribed for pain management as it does for addiction management. In regards to subspecialty

groups of concern and stigma, Dr. Knapp identified the hurdles of pregnant women struggling

with opioid addiction. She also reported the role of the PMHNPs in clinics is more focused on

medication management, whereas in private practice there is more of an opportunity for

psychotherapy. From our interview, I have a better understanding of treatment models and

settings used in caring for this population, the role of the PMHNP, and the cultural and

socioeconomic barriers faced by patients and providers.

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References

American Society for Addiction Medicine. (2018). Nurse practitioners and physician assistants
prescribing buprenorphine. Retrieved from https://www.asam.org/resources/practice-
resources/ nurse-practitioners-and-physician-assistants-prescribing-buprenorphine

Beck Cognitive Behavior Therapy (2016). CBT for Substance Use Disorders. Retrieved from
https://beckinstitute.org/cbt-for-substance-abuse/#toggle-id-5-closed

Marsch, Lisa. (2012). Leveraging technology to enhance addiction treatment and recovery.
Journal of addictive diseases, 31(3), 313-8.

National Institute on Drug Abuse. (2017). Trends and statistics. Retrieved from
https://www.drugabuse.gov/related-topics/trends-statistics

National Institute on Drug Abuse. (2018, August 09). Overdose Death Rates. Retrieved from
https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

New York State Education Department Office of the Professions. (2017). Certification
requirements: Nurse practitioner. Retrieved from http://www.op.nysed.gov/
prof/nurse/np.htm

NIDA. (2018, January 17). Principles of Drug Addiction Treatment: A Research-Based Guide
(Third Edition). Retrieved from https://www.drugabuse.gov/publications/principles-drug-
addiction-treatment-research-based-guide-third-edition

The National Center for Health Statistics. (2016). Mortality in the united states, 2016. Retrieved
from https://www.cdc.gov/nchs/data/databriefs/db293.pdf

The National Health Center for the Homeless Council. (2018). 2018 Virtual Spring Training.
Retrieved from https://www.nhchc.org/virtual

The Substance Abuse and Mental Health Services Administration. (2015). Behavioral health
trends in the united states: Results from the 2014 national survey on drug use and health.
Retrieved from https://www.samhsa.gov/data/sites/default/files/...2014/NSDUH-FRR1-
2014.pdf

You, C.W., Chen, Y.C., Chu, H.H., Chen, C.H., Huang, M.C., Lee, C.H., & Kuo, P.H. (2017).
Smartphone-based support system (SoberDiary) coupled with a Bluetooth breathalyser
for treatment-seeking alcohol-dependent patients. Addictive Behaviors, 65, 174–178.