利用护理劳动力来推进美国对成瘾危机的国家响应

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On 29 December 2022, President Biden took a crucial step toward improving addiction services by signing the bipartisan Mainstreaming Addiction Treatment (MAT) Act. This Act expanded access to the life-saving medication buprenorphine, which is used to treat opioid use disorder, by eliminating the X waiver, legislation that restricted prescribing. This important measure was one component of the 2022 National Drug Control Strategy aimed at mitigating untreated addiction, which was identified as a ‘critical driver of the opioid epidemic’ (Office of National Drug Control Policy [ONDCP], 2022). In the United States, approximately 37 million people diagnosed with substance use disorders (SUDs) have not received care (Substance Abuse Mental Health Services Administration [SAMHSA], 2021). The 2020 National Survey on Drug Use and Health (NSDUH), a national dataset that provides information on substance use and substance use disorder treatment and that is used to inform policy and service delivery, reports that about 15% of Americans aged 12 or older (41.1 million people) need addiction treatment. However, only 1.4% of Americans (4.0 million people) have received any treatment for substance use (SAMHSA, 2021). This unmet need in the treatment of SUDs is known as the ‘treatment gap’, which must be addressed since the cost of maintaining the status quo is tremendous (ONDCP, 2022).

Untreated SUDs have a significant impact on the health of Americans, resulting in excess morbidity and premature mortality. Drug overdoses have claimed more than one million lives since 1999 and currently take a life every 5 min (ONDCP, 2022). In this sense, the treatment gap has a staggering impact on human life, and it also costs the country economically. In 2020, the opioid epidemic alone cost 1.5 trillion US dollars, a figure that does not include the impacts of tobacco, alcohol or other drugs (Heinrich, 2022). While the removal of the X waiver represents a first step to increasing access to medication, the healthcare workforce must be mobilized to provide SUD treatment interventions. Notably, the Biden–Harris Administration has recognized the need to increase the nation's SUD treatment workforce; however, to mitigate an epidemic that has been growing for the past 25 years, it is also necessary to optimize and align the healthcare workforce.

In the US today, the addiction healthcare workforce is disjointed and specialized. The workforce consists of addiction specialists, including physicians, psychiatrists, psychologists, nurses, social workers and counsellors from the public and private sectors, amounting to approximately 248,000 individuals in total (Bureau of Labor Statistics, Quarterly Center of Employment and Wages (BLS, QCEW, 2022). This workforce is inadequate in size and unable to meet the needs of the 37 million individuals eligible for SUD treatment (SAMHSA, 2021). In order to curb the addiction epidemic, a reimagined, generalized, sustainable healthcare workforce prepared to manage the care of individuals with SUD is sorely needed. This reimagined workforce should leverage the 4.2 million nurses currently working in the United States, who represent the largest untapped resource for providing care to individuals experiencing SUDs (BLS, QCEW, 2022). Nurses can advance the national response to the addiction crisis through three key dimensions: expertise, reach and efficacy (Table 1).

1 EXPERTISE

Nurses have expertise across fundamental areas of patient-centred, whole-person health. An integrated neurobiological, socio-contextual approach is needed to provide interventions for individuals experiencing symptoms of addiction. Nurses are equipped to provide the full range of evidence-based treatments and, beyond that, they are educated to provide interventions based on pathophysiological presentations while also considering the context of the individual's life. These services can be medication-focussed, counselling-based or a combination of both.

2 REACH

As the largest group in the healthcare workforce, nurses have reach. They have locational flexibility across the healthcare continuum, and nurses can work in a range of settings and geographical locations. All nurses can be trained to assess for and deliver interventions in whatever specialty and setting they work. In addition to their core competencies, nurses can be trained to deliver assessment and intervention strategies tailored to the specialty. For example, nurses working in the emergency department, wound care and cardiology can initiate crisis interventions such as medications and treatment linkages; nurses working in surgery can implement multimodal pain management strategies that include non-opioid interventions to enhance pain relief; nurses in neonatal settings can work with families who are experiencing neonatal abstinence syndrome to allocate resources.

3 EFFICACY

Nurses are not always used to their full scope in addiction treatment. Despite this, nurses in the addiction specialty have led successful initiatives. Two nurse-led programmes in Massachusetts and New York have improved addiction outcomes (Fiore-Lopez & Shea-Lewis, 2020; LaBelle et al., 2016). The Massachusetts Model of Office-Based Opioid Treatment was put forward as a collaborative model of care coordinated by the nurse care manager (NCM). The NCM conducts an initial assessment for medication, which is confirmed by a physician through chart review, and supports the buprenorphine induction process with weekly ongoing visits until the patient stabilizes. This programme uses the nurse to their full scope of practice and thereby expands treatment for individuals with opioid use disorder (LaBelle et al., 2016). Meanwhile, at St. Charles Hospital in New York, nurse-led interdisciplinary teams on an innovative withdrawal and stabilization unit deliver education and coaching to individuals with SUDs, which have improved recovery outcomes, prompting an increase in the number of beds for the programme (Fiore-Lopez & Shea-Lewis, 2020).

4 CONCLUSION

As the addiction epidemic outpaces the capacity of the substance treatment workforce, we must leverage nurses across all specialties and settings to close the treatment gap. If the addiction epidemic is left unaddressed, it will continue to place significant strain on individuals, families, communities and society. Nurses have the necessary expertise, reach and efficacy to provide interventions for SUDs. However, the nursing workforce is underused in the treatment of SUDs. Failing to mobilize nurses to provide this care represents a missed opportunity to advance addiction treatment.

CONFLICT OF INTEREST STATEMENT

M.A is a member of the Early Career Researcher JCN Editorial Advisory Board.

V.G.R. reports grants and personal fees from ViiV Healthcare and personal fees from Gilead Sciences, all outside the submitted work; serves as a member of the US Presidential Advisory Council on HIV/AIDS, the CDC/HRSA Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment, and the HHS Panel on Antiretroviral Guidelines for Adults and Adolescents; and serves on the board of directors of the HIV Medicine Association and of the Latino Commission on AIDS.

全文翻译（仅供参考）

2022年12月29日，拜登总统签署了两党《主流成瘾治疗法》（MAT），朝着改善成瘾服务迈出了关键一步。该法案通过取消限制处方的X豁免立法，扩大了用于治疗阿片类药物使用障碍的救生药物丁丙诺啡的可及性。这一重要措施是2022年国家药物管制战略的一个组成部分，旨在减轻未经治疗的成瘾，这被确定为“阿片类药物流行病的在美国，约有3700万被诊断患有物质使用障碍（SUD）的人没有接受治疗（物质滥用精神卫生服务管理局[SAMHSA]，2021）。2020年全国药物使用和健康调查（NSDUH）是一个全国性的数据集，提供有关药物使用和药物使用障碍治疗的信息，并用于为政策和服务提供提供信息，该数据集报告说，约15%的12岁或以上的美国人（4110万人）需要成瘾治疗。然而，只有1.4%的美国人（400万人）接受过任何药物使用治疗（SAMHSA，2021）。SUD治疗中未满足的需求被称为

未经治疗的SUD对美国人的健康有显著影响，导致过度发病和过早死亡。自1999年以来，药物过量已经夺去了100多万人的生命，目前每5分钟就有一人死亡（ONDCP，2022）。 从这个意义上说，治疗差距对人类生活产生了惊人的影响，也使国家付出了经济代价。2020年，仅阿片类药物流行就花费了1.5万亿美元，这一数字不包括烟草，酒精或其他药物的影响（Heinrich，2022）。虽然取消X豁免是增加药物可及性的第一步，但必须动员医疗保健人员提供SUD治疗干预措施。值得注意的是，拜登-哈里斯政府已经认识到需要增加全国的SUD治疗工作人员;然而，为了减轻过去25年来不断增长的流行病 ，还必须优化和调整保健工作人员队伍。

在今天的美国，成瘾医疗保健工作人员是脱节和专业化的。劳动力由成瘾专家组成，包括来自公共和私营部门的医生，精神病学家，心理学家，护士，社会工作者和顾问，总计约248，000人（劳工统计局，就业和工资季度中心（BLS，QCEW，2022）。这一劳动力规模不足，无法满足3700万有资格接受SUD治疗的人的需求（SAMHSA，2021）。为了遏制成瘾流行病，迫切需要一个重新想象的，普遍的，可持续的医疗保健工作人员准备管理与SUD个人的护理。这种重新构想的劳动力应该利用目前在美国工作的420万护士，他们代表了为经历SUD的个人提供护理的最大未开发资源（BLS，QCEW，2022）。护士可以通过三个关键方面推进国家对成瘾危机的应对：专业知识、覆盖范围和功效（表 1）。

1专业知识

护士在以患者为中心的全人健康的基本领域拥有专业知识。一个综合的神经生物学，社会背景的方法是需要提供干预的个人经历的成瘾症状。护士有能力提供全方位的循证治疗，除此之外，他们还接受教育，根据病理生理学表现提供干预措施，同时考虑个人生活的背景。这些服务可以是以药物为重点的，以咨询为基础的，或者两者兼而有之。

2 REACH

作为医疗保健劳动力中最大的群体，护士具有影响力。他们在整个医疗保健连续体中具有位置灵活性，护士可以在一系列环境和地理位置中工作。所有护士都可以接受培训，以评估和提供干预措施，无论专业和设置他们的工作。除了他们的核心能力，护士可以接受培训，以提供评估和干预策略量身定制的专业。例如，在急诊科、伤口护理和心脏科工作的护士可以启动药物和治疗联动等危机干预措施;在外科工作的护士可以实施多模式疼痛管理策略，包括非阿片类药物干预，以加强疼痛缓解;新生儿护理机构的护士可以与正在经历新生儿戒断综合征的家庭一起工作，以分配资源。

3疗效

护士并不总是习惯于在成瘾治疗中发挥全部作用。尽管如此，成瘾专业的护士还是成功地采取了行动。马萨诸塞州和纽约州的两个护士主导的项目改善了成瘾结果（Fiore-Lopez Shea-Lewis，2020; LaBelle等人，& nbsp;2016年）。马萨诸塞州办公室阿片类药物治疗模式是由护理经理（NCM）协调的护理协作模式。NCM对药物进行初步评估，由医生通过病历审查确认，并通过每周持续访视支持丁丙诺啡诱导过程，直至患者稳定。该计划使用护士的全部实践范围，从而扩展了对患有阿片类药物使用障碍的个体的治疗（LaBelle等人，& nbsp;2016年）。与此同时，在圣。在纽约查尔斯医院，护士领导的跨学科团队在一个创新的退出和稳定单位提供教育和辅导，以个人与SUD，这已经改善了恢复结果，促使增加床位的计划（菲奥雷洛佩兹&谢刘易斯， 2020年）。

4结论

由于成瘾流行超过了物质治疗工作人员的能力，我们必须利用所有专业和设置的护士来缩小治疗差距。如果成瘾流行病得不到解决，它将继续给个人、家庭、社区和社会带来巨大压力。护士有必要的专业知识，范围和有效性，为SUD提供干预措施。然而，护理人员在SUD的治疗中未得到充分利用。未能动员护士提供这种护理代表着错过了推进成瘾治疗的机会。

利益冲突声明

MA是早期职业研究员JCN编辑顾问委员会的成员。

VGR报告ViiV Healthcare的赠款和个人费用以及吉利德Sciences的个人费用，所有这些都在提交的工作之外;担任美国总统艾滋病毒/艾滋病咨询理事会会、CDC/HRSA艾滋病毒、病毒性肝炎和性病预防和治疗咨询委员会以及HHS成人和青少年抗逆转录病毒指南小组的成员;并担任艾滋病医学协会和拉丁美洲艾滋病委员会的董事会成员。

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