Working in small northern and interior First Nations communities scattered across hills and winding valleys, registered nurse Kate Hodgson says finding treatment options for people who use substances can be just as difficult as navigating the landscape itself.
Many communities are visited by a family doctor only one or two days a week. Travel to larger centres with more resources can be expensive, dangerous or even impossible with bad weather.
Family physicians can also be hesitant to adopt safer supply approaches like prescribing pharmaceutical alternatives to illicit drugs, even to people at extremely high risk of overdosing.
“We have mountains and forests and rivers, and we have so much to work through to get people the care that they need,” said Hodgson, the practice consultant for substance use with the First Nations Health Authority.
But soon she will have one more option for patients who use substances.
Hodgson is among 30 registered and psychiatric nurses in British Columbia who will be able to prescribe Suboxone, a prescription opioid substitute, by the end of the month, the province announced.
The approach is part of a new effort to prevent overdoses and deaths made possible by a September order from provincial health officer Dr. Bonnie Henry granting nurses prescribing powers to treat substance use.
“This can really save someone’s life,” said Hodgson. “Because in that moment, when we are having those pressing conversations with people, to be able to just offer it without having to get in the boat and row across the river and hike up the mountain, it’s life-changing.”
Registered nurses and registered psychiatric nurses are joining physicians, pharmacists and nurse practitioners as points of access for pharmaceutical alternatives to street drugs, a move experts say will benefit rural and remote communities in particular.
Amanda Lavigne, a registered psychiatric nurse in Kamloops who supports nurses throughout Interior Health in treating substance use, said it’s an important change.
“This is just new ways of practising. Our scope has been broadened quite drastically, compared to what I think nursing has really ever been used to seeing,” she said.
A range of approaches are included in discussions around safer supply programs. The nurses will be able to prescribe substances like Suboxone with the aim of reducing people’s use of illicit street drugs.
Critics say that falls short of true safer supply, which would provide pharmaceutical-grade versions of illicit substances instead of alternatives.
The first cohort is only trained to prescribe buprenorphine/naloxone, known as Suboxone, but training for other alternatives like slow-release oral morphine and methadone will come in later phases.
Research from the BC Centre on Substance Use suggests around 83,000 people have opioid dependence in B.C., while only about 23,000 people in B.C. have access to any form of opioid substitute treatment.
Just under 4,000 of those have access to pharmaceutical-grade versions of street drugs through safer supply programs, the vast majority of which are prescribed the oral tablet hydromorphone.
Last year, 1,548 people died of overdoses between January and November, placing 2020 on track to be the deadliest year for overdoses in B.C.
Lavigne said seeing the crisis worsen during her more than decade-long career has made her and her colleagues keen to do more, even before the pandemic undid much recent progress to curb deaths.
“Seeing the numbers and the bigger picture, that really anchored me as a clinician.”
Emma Garrod, a registered nurse and clinical project manager with the BC Centre on Substance Use, says the decision to start with Suboxone was made because it is usually the first opioid replacement treatment tried with a new patient.
“It’s a pretty big leap to prescribe a controlled substance as opposed to starting someone with Tylenol,” said Garrod. “It’s a large leap for the college and it’s precedent-setting in North America.”
Garrod led the development of the training in concert with the BC College of Nurses and Midwives and said it was a challenge because prescribing isn’t really part of a nursing education.
But the training is “really building on a very strong foundation that nurses already have,” said Garrod.
This first cohort of nurses did pre-existing online opioid prescribing training for physicians and pharmacists and then completed a specially designed workbook on the prescribing process during distanced, in-person training in smaller groups last month.
In the next few weeks they are finishing their in-person training with current prescribers and substance use experts throughout the province.
The training will continue to quickly scale up the number of nurse prescribers available.
All three said nurses have a unique role that puts them in a strong position to help people who use substances access alternatives, particularly in smaller communities where they may be the only full-time health-care professionals.
“Nurses have a differently facing role with clients than physicians do,” Lavinge said. “They’re in a position to reach out to clients, for creating those relationships in the community.”
“Many nurses here… they just wish they could do more.”
Providing expanded substance use care is particularly important in First Nations communities and for Indigenous people in urban centres who experience frequent and systemic racism in health care.
Indigenous people in B.C. are much less likely to have access to primary care, which a recent report found results in poorer health outcomes across the board, especially for women.
First Nations people account for 16 per cent of overdose fatalities despite making up only 3.3 per cent of the B.C. population. First Nations women are nearly twice as likely to die of an overdose as non-First Nations women, according to the report.
“For us, having nurses prescribing safer supply, we’re really helping address those gaps,” said Hodgson.
Garrod said the training will evolve based on feedback and questions from nurses as they begin to prescribe and that will shape training for expanded prescription abilities to provide safer alternatives to other substances.
Garrod said the work also begins to break down stigma around substance use and remove barriers to care for the people who need it most.
“There are many other elements of care and changes needed, and this is one part of it,” said Garrod. “It’s a really big step for a lot of more rural and remote places that need access to prescribers.”
