Nurse Practitioner Controlled Substances Post Survey Analysis. May, 2013

Transcription

1 Nurse Practitioner Controlled Substances Post Survey Analysis May, 2013

2 Contents Table of Figures... 1 Executive Summary... 2 Nurse Practitioner Controlled Substances Post Survey Analysis... 3 Background... 3 Survey Goals... 3 Response Rate... 4 Results and Analysis... 4 Demographic Questions... 4 Narcotics and Controlled Substances Prescribing... 6 Prescriber Competencies and Education... 9 Medical Marijuana Appendix A Table of Figures TABLE TABLE TABLE TABLE TABLE TABLE TABLE TABLE TABLE TABLE TABLE TABLE TABLE TABLE

3 Executive Summary The prescribing of narcotics and controlled substances by nurse practitioners (NP), midwives and podiatrists was approved federally through the introduction of the New Classes of Practitioners Regulation in November, In May 2013, the College of Registered Nurses of British Columbia (CRNBC) conducted a survey of nurse practitioners (NP) registered in the province to gain an understanding of their needs, opinions and perspectives in relation to narcotics and controlled drugs prescribing; as part of the policy process and in preparation for the introduction of provincial prescriptive authority. The survey was administered through the NP edition of the CRNBC e-newsletter Nursing Matters and received a response rate of 58.6% (n = 157). Key highlights of the survey are indicated below: If given the authority 85% of NPs responding to the survey would choose to incorporate narcotics and controlled drugs prescribing into their practice; with 86% and 81% stating they would choose to prescribe narcotics and benzodiazepines respectively. 92% of survey respondents expressed a need for further education or review to support the introduction of narcotics and controlled substances into their prescribing practices. 43% of NPs responding to the survey indicated that a formalized education program such as a short course or workshop would be their preferred method of learning about narcotics and controlled substances. Areas of educational focus identified include assessment techniques and decision making, population/substance specific pharmacology, dosing and titration, psychosocial aspects of prescribing and documentation. 24% of survey respondents expressed the need to have further education related to pain management, including the pathophysiology of pain, prescribing practices for acute, chronic and cancer pain and appropriate substance selection for pain management. 37% of NPs responding to the survey, report having completed a specific course or some form of education relevant to prescribing narcotics and controlled substances. If given the authority 40% of survey respondents indicated that they were unsure about incorporating medical marijuana prescribing into their practice. Primary reasons cited include a lack of scientific evidence to support medical marijuana and a need for more knowledge and information to support a decision. 2

4 Nurse Practitioner Controlled Substances Post Survey Analysis Background The prescribing of narcotics and controlled substances by nurse practitioners (NP), midwives and podiatrists was approved federally through the introduction of the New Classes of Practitioners Regulation in November, In preparation for the approval of this prescriber authority at the provincial level and as part of the policy process, a survey was conducted with NPs registered in British Columbia to ascertain their perspectives, anticipated needs and opinions related to narcotics and controlled substances prescribing. Integral to the information gathered within this survey is the application of an overarching policy lens, which gives consideration to how this new aspect of practice can be introduced in a manner that is safe both for the public and the practitioner. The survey was created by a working group of CRNBC staff and an external nursing policy consultant. Technical expertise, survey construction and data collection were completed by Verita Strategy Group Inc. A pilot of the survey questions was conducted with volunteers (n=4) from the NP on-site review assessors group. Volunteers were located in other jurisdictions and were therefore not part of the final survey sample. Minor adjustments were made to some questions based on pilot feedback, including the addition of a definition for the term palliative pain. Although considered a controlled substance, medical marijuana is governed under separate regulation, (Marihuana for Medical Purposes Regulation). Questions were added which asked about medical marijuana as the survey provided a prudent opportunity to capture NPs perspectives on prescribing this substance in anticipation of future policy work. The survey was administered through the CRNBC e-newsletter Nursing Matters, NP edition and consists of 15 questions. Survey questions focused on demographic information (Q1-3), questions related to prescribing narcotics and controlled substances (Q4-10), prescriber competencies and education (Q11-12), medical marijuana (Q13-14) and additional comments (Q15). Survey Goals Four goals were identified by the CRNBC working group which encapsulate the information which was to be gathered through the survey: 1. Identify the areas of practice of NPs and how the prescribing of narcotics and controlled substances will be incorporated into their practice. 2. Identify the extent to which NPs, in collaboration with physicians, are already diagnosing and managing patients with pain and with addictions. 3

5 3. Understand the perceptions of NPs regarding their need for education and other supports in order to safely prescribe narcotics and other controlled substances. 4. Identify whether NPs have been pursuing courses or other educational options (and if so, which ones) to learn about the prescribing of narcotics and controlled substances. Response Rate The survey received a total of 157 responses, providing an overall response rate of 58.6%. Respondents were given the option of not answering any chosen question within the survey. All percentages presented within this report represent a percentage of the entire survey sample. This report provides a summary and analysis of the survey results. A copy of the survey can be viewed in Appendix A at the end of this document. Results and Analysis This section summarizes the results of each survey question including response rates, percentages and themes identified within free-text dialogue boxes. Themes were identified through content analysis of free-text responses using word repetition and synonym identification. Demographic Questions 1. How long have you been a practicing nurse practitioner? Table 1.0 # of respondents % of respondents 0-2 years = years = 25.6% 3-5 years = years = 34.6% 6-8 years = years = 32.1% 9 or more = 12 9 or more = 7.7% 2. In which nurse practitioner stream are you registered? Table 2.0 # of respondents % of respondents Family = 134 Family = 85.4% Adult = 16 Adult = 10.2% Pediatric = 6 Pediatric = 3.8% 4

6 3. In what practice setting(s) do you currently work? Table 3.0 Practice Setting # of respondents % of respondents Hospital (acute care) Rehab/Convalescent Extended Care Long Term Care/ Nursing Home Mental Health Centre Community Health Agency/Centre Educational Institution Association/Government Physician s Office/ Family Practice Unit Self Employed/ Private Practice Private Agency/ Private Duty Nursing Station/ Outpost Nursing Clinic Business/Industry/ Occupational Health Other % 0.0% 3.8% 7.6% 5.1% 35.0% 2.5% 2.5% 26.8% 3.2% 0.0% 3.2% 3.2% 3.2% 22.3% The Other category was utilized primarily by NPs who (1) were not employed as an NP at the time of survey completion, (2) to explain in further detail their place(s) of work; (3) NPs working in outpatient clinics/specialty clinics (e.g. travel medicine). 4. In which Health Authority do you work? Table 4.0 Health Authority # of respondents % of respondents Vancouver Coastal Interior Vancouver Island Fraser Northern Provincial Health Services First Nations % 11.8% 16.3% 19.0% 6.5% 13.1% 0.75% 5

7 Health Authority # of respondents % of respondents Other % The Other category was utilized primarily by NPs who (1) were not employed as an NP at the time of survey completion, (2) are privately or self-employed, (3) hold primary employment within another jurisdiction (e.g. United States). Narcotics and Controlled Substances Prescribing 5. Within the past 12 months have you assessed, diagnosed or managed patients/clients experiencing the following? Table 5.0 Condition # of respondents % of respondents Chronic non-cancer pain 1 Acute pain 2 Palliative Pain 3 Addictions Mental Health Disorders Requiring Testosterone replacement Other % 86.0% 53.5% 69.4% 82.2% 35.0% 6.4% 1 Defined as pain with a duration lasting greater than 3 months. 2 Defined as pain with a duration lasting less than 3 months. 3 Defined as pain experienced as a result of an advanced illness, includes cancer pain. Conditions identified as Other by respondents included the following: Attention Deficit Hyperactivity Disorder (ADHD) Irritability not yet diagnosed, requiring benzodiazepines Seizure disorders requiring emergency benzodiazepines and/or routine barbiturates Treatment or disease related nausea, insomnia, appetite changes and taste alteration Clients with prescriptions for dehydroepiandrosterone (DHEA). 6. Do you currently or have you ever had authority to prescribe narcotics or controlled substances in another jurisdiction? If yes please explain. Table 6.0 Response # of respondents % of respondents Yes % No % 6

8 NPs responding yes to the above question identified the following: Current or previous training and/or licensing in the United States (Alaska, California, Minnesota, Washington), including Drug Enforcement Administration (DEA) narcotics licencing and ability to prescribe and dispense narcotics and controlled substances in accordance with state laws. Experience working as advanced practice nurses or NPs in outpost stations in the Northwest Territories and Yukon Territory. Writing orders for narcotics in collaboration with a physician. 7. If NPs are given the authority, would you choose to incorporate narcotics and controlled substances prescribing into your practice? Please explain why you selected this response. Table 7.0 Response # of respondents % of respondents Yes No Unsure at this time % 3.2% 11.5% Themes Question 7 Themes identified within free-text explanations provided by NPs in relation to question seven are indicated below: Prescribing narcotics and controlled substances will increase comprehensiveness, timeliness and continuity of care provided by NPs. The current need to consult with a physician, places providers and patients in difficult situations: o Patients must wait, sometimes for extended periods of time while a physician who can sign off on prescriptions is contacted or located. o Physicians are placed in the position of signing off on a prescription for a patient with whom they may be unfamiliar. Anticipating that prescribing would occur only under very specific conditions or for specific populations (e.g. palliative care). The ability to prescribe narcotics and controlled substances is integral to providing primary care. In addition to the themes identified above 45 free-text responses were provided in which NPs identified areas where there is a need for narcotics and controlled drugs prescribing within their individual practice settings. Examples included: 7

9 Prescribing medications for ADHD The provision of pain relief in the emergency setting Opioids for the management of palliative and cancer pain Benzodiazepines for seizure management. Managing pain and anxiety in geriatric populations 8. If you answered yes to question 7, would you anticipate prescribing any of the following? Table 8.0 Drug/Drug class # of respondents % of respondents Amphetamines Barbiturates Benzodiazepines Methadone Narcotics 1 Testosterone Other, please explain % 14.6% 81.5% 28.7% 86.0% 35.0% 65.0% Other substances identified include: 1 Defined as opioid and non-opioid analgesics Nabilone Medical cannabis Dehydroepiandrosterone (DHEA) Non-benzodiazepine sedative hypnotics Etomidate or similar agents Suboxone 9. Within the past 12 months approximately how many times have narcotics or controlled substances been prescribed by a physician colleague for the patients/clients under your care? Table 9.0 Frequency # of respondents % of respondents Daily Weekly Monthly Other, please explain % 37.5% 19.1% 15.1% Other responses included the following: 8

10 Never New to practice Not currently employed as NP Clinic policy prevents practitioners from prescribing narcotics Practice is independent of physicians Every 2-4 months Unsure 10. Do you have adequate access to consultation and referral supports within your practice to prescribe for patients/clients requiring narcotics and controlled substances? If no, please explain. Table 10.0 Response # of respondents % of respondents Yes No Unsure at this time % 14.3% 16.9% Free-text responses to question 10 indicate that for many NPs the answer to this question is both yes and no, with access to consultation and referral supports being available (1) for a limited number of hours or days per week, (2) by telephone only; or (3) through outpatient clinics. Prescriber Competencies and Education 11. Based on your current competencies (knowledge, skills and judgement) in what areas would you require additional learning in order to manage and prescribe for patients/clients requiring narcotics and controlled substances? Please describe. In total, 92% of survey respondents expressed a need for some type of further education or review to support the introduction of narcotics and controlled substances into their prescribing practices. Table 11.0 highlights themes and sub-themes identified within question 11. Table 11.0 Theme Sub-themes % of respondents Addictions and Mental Health Management of specific mental health disorders (e.g. ADHD) 14.0% Alcohol withdrawal Management of patients with a history of 9

11 Theme Sub-themes % of respondents addictions Recognizing and assessing for addictions and reducing risk Managing narcotics misuse Dosing and titration Equianalgesic conversions 25.0% Switching medications Cross-titration short to long-acting medications Dose tapering/titration Safe discontinuation Formalized Education Short course or workshop 43.0% Assessment tools and decision making Documentation Initial course with ongoing CME Psychosocial role play Refresher or review course Education specific to a drug (e.g. methadone) or population (e.g. palliative) Legal Responsibilities How to write triplicate 8.0% prescriptions Review of legal obligations Review of standards and guidelines Methadone Prescribing methadone for 14.0% addictions Prescribing methadone for pain control Pain management Pathophysiology of pain 24.0% Prescribing practices for chronic pain/chronic disease management Prescribing practices for cancer pain Prescribing practices for acute pain 10

12 Theme Sub-themes % of respondents Selecting appropriate narcotics for pain management Palliative care Prescribing practices for palliative patients 5.0% Palliative symptom management/pain control Pharmacology General pharmacology review of controlled substances Common drug interactions and contra-indications Pharmacokinetics Safe prescribing practices Appropriate use of medications Review of safe prescribing practices Review of bestevidence/best practice guidelines Ensuring safety in the practice setting Safeguards to reduce inappropriate use Monitoring and contracting 17.0% 17.0% 12. Have you completed any specific courses or education relevant to prescribing narcotics and controlled substances? If yes, please describe. Table 12.0 Response # of respondents % of respondents Yes No % 61.1% The following table indicates the breakdown of education formats identified by NPs who answered yes to question

13 Table 12.1 Themes Sub-themes % of respondents Continuing Medical ADHD medication 6.0% Education Neuropsychology and chronic pain Opioid management Opioids in non-cancer care Opioid tolerance Conferences/Workshops BC Cancer Agency Hormone replacement therapy Pain conferences Pain management Palliative medicine conferences Course related to a specific Addictions drug or aspect of prescribing Methadone Pain management Palliative care Suboxone Testosterone and DHEA 12.0% 13.0% Knowledge obtained through degree program Advanced pharmacology BScN courses Degree in pharmacology Through NP program 8.0% Online Education COUPN course Medscape online MD briefcase Suboxone online course Preceptorship/Practicum Preceptorship with addictions specialist Practicum in chronic pain clinics Self-study Read books on addictions/pain management Read journal articles Reviewed best practice 4.0% 3.0% 6.0% 12

14 Themes Sub-themes % of respondents guidelines Specific Education Courses The following education courses were identified by NPs in relation to question 12: COUPON/University of Ottawa online course Chronic Pain course through the BC Pain Society Prescribe, Deny or Refer? Honing your skills in prescribing scheduled drugs University of Washington. Medical Care of the Dying Victoria Hospice College of Physicians and Surgeons Methadone course UBC course on pain management Care of the Dying Child Canuck Place Children s Hospice Methadone 101 Suboxone Education Program ( Addictions and Childhood Adversity: An Evidence-based Biopsychosocial Perspective Dr. Gabor Mate Harm Reduction Course Sarah Young, Provincial Chief Coroner Medical Marijuana 13. If NPs are given the authority, would you choose to include the prescribing of medical marijuana in your practice? Please explain. Table 13.0 Response # of respondents % of respondents Yes No Unsure at this time % 28.7% 40.1% Question 13 Themes Four primary themes were identified amongst the free-text responses to question 13: Lack of scientific evidence NPs identified that a lack of scientific evidence to support the therapeutic benefits of medical marijuana would impact their decision to include its prescribing within their individual practices. Benefits in specific settings Medical marijuana may be beneficial in some practice settings or with specific populations, e.g. HIV patients, cancer and palliative care. The potential benefits with specific populations were 13

15 identified by NP s who stated they would prescribe medical marijuana, as well as those who felt that they would not or were unsure at the time of survey completion. Relevance to practice NPs identified that prescribing medical marijuana was not relevant within their current practice setting or was contra-indicated in their practice population. Lack of knowledge NPs expressed a need for further knowledge and information before making any decisions about medical marijuana. 14. What are your perspectives on medical marijuana being introduced into nurse practitioner practice? Free-text responses provided by NPs in relation to question 14 were reflective of the themes identified in question 13, with perspectives on medical marijuana expressed ranging from an absolute yes, or no, to being unsure about its inclusion, requiring more information or giving consideration only with specific populations or practice settings. 15. Is there anything else you would like to add about this survey? Two primary themes were identified within free-text responses to question 15. Expressions of appreciation that the opinions of NPs were being sought prior to decision making. The positive impact that the authority for prescribing narcotics and controlled substances will have on NP practice and the subsequent effects on quality and continuity of care. 14

16 Appendix A CRNBC - College of Registered Nurses of British Columbia Survey of Nurse Practitioners in B.C. on the Future Introduction of Prescribing of Narcotics and Controlled Substances Hello, and thank you for taking part in this survey. Your input is a key element of CRNBC s work around the New Classes of Practitioner Regulations. Read more about this work. The goals of this survey are: To learn about NPs areas of practice and how prescribing narcotics and controlled substances will be incorporated into their practice To understand NPs perceptions regarding their need for education and other supports in order to safely prescribe narcotics and other controlled substances The questionnaire is being administered by Verita, a Vancouver-based survey firm. The questionnaire will be available until 5:00 PM Monday May 20, Your responses are confidential. For questions about the survey content please contact Chris Daly, Nursing Policy Consultant at daly@crnbc.ca or ext. 304 (Vancouver) or (Canada). If you have technical questions about the survey, please contact Adam Hunter, Verita Strategy Group at adam@veritagroup.com or This survey will take 5 to 10 minutes to complete. Demographic Information 1. How long have you been a practicing nurse practitioner? 0-2 years 3-5 years 6-8 years 9 or more years 15

17 2. In which nurse practitioner stream are you registered? Family Adult Pediatric 3. In what practice setting(s) do you currently work? (Please select all that apply) Hospital (Acute Care) Rehabilitation/Convalescent Centre Extended Care Long Term Care/Nursing Home Mental Health Centre Community Health Agency/Centre Educational Institution Association/Government Physician s Office/Family Practice Unit Self-employed/Private Practice Private Nursing Agency/Private Duty Nursing Stations/Outpost Nurse Clinic Business/Industry/Occupational Health Other, please explain. 16

18 4. In which health authority do you work? Vancouver Coastal Interior Vancouver Island Fraser Northern Provincial Health Services First Nations Other, please explain. 5. Within the past 12 months have you assessed, diagnosed or managed patients/clients experiencing the following? (Please select all that apply) Chronic non-cancer pain Acute pain Palliative pain Addictions Mental Health disorders 17

19 Requiring testosterone replacement Other, please explain. 6. Do you currently or have you ever had authority to prescribe narcotics or controlled substances in another jurisdiction? Yes No If yes, please explain. 7. If NPs are given the authority, would you choose to incorporate narcotics and controlled substances prescribing into your practice? Yes No Unsure at this time Please explain why you selected this response. 18

20 If you answered yes, continue on to Questions 8. If you answered no, or unsure, continue on to Question If yes, would you anticipate prescribing any of the following? (Please select all that apply) Amphetamines Barbiturates Benzodiazepines Methadone Narcotics (opioid and non-opioid analgesics) Testosterone Other, please explain. 9. Within the past 12 months approximately how many times have narcotics or controlled substances been prescribed by a physician colleague for the patients/clients under your care? Daily Weekly Monthly Other, please explain. 19

21 10. Do you have adequate access to consultation and referral supports within your practice to prescribe for patients/clients requiring narcotics and controlled substances? Yes No Unsure at this time If no, please explain. 11. Based on your current competencies (knowledge, skills and judgement) in what areas would you require additional learning in order to manage and prescribe for patients/clients requiring narcotics and controlled substances? Please describe. 12. Have you completed any specific courses or education relevant to prescribing narcotics and controlled substances? Yes No If yes, please describe. In addition to prescribing narcotics and controlled substances the federal government has proposed changes to the Marijuana for Medical Purposes Regulations. No changes to the Regulations have been approved; however CRNBC is 20

22 aware that there is the potential for changes to have an impact on nurse practitioner practice. The purpose of the following two questions is for CRNBC to gain an understanding of your view as a nurse practitioner in relation to medical marijuana. 13. If NPs are given the authority, would you choose to include the prescribing of medical marijuana in your practice? Yes No Unsure at this time Please explain. 14. What are your perspectives on medical marijuana being introduced into nurse practitioner practice? 15. Is there anything else you would like to add about this survey? May we contact you about the information you have given us? Yes No If yes, please provide your contact information: 21

23 Name Day time phone number Thank you again for completing this survey CRNBC. All rights reserved. 22