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Insights from the verge: examining opioid use disorder treatment in primary care

In 2021, over 8,000 people in Canada died from opioid-related causes. In the United States, where Martha Whitfield currently lives and works as a nurse practitioner, the number of deaths related to opioid poisoning exceeded 40,000 that year.

For primary care clinicians who may need to treat opioid use disorder in their daily practice, these numbers aren’t just sobering statistics; they highlight the challenging reality of practicing health care on the frontlines of a public health crisis.

A fourth-year PhD student at Queen’s School of Nursing, Whitfield’s personal experience caring for patients with opioid use disorder helped inspire her current doctoral research. Identifying nurse practitioners (NPs) as an underutilized resource for improving access to opioid use disorder treatment, she began studying how NPs become more capable in doing this work over time.

“My research looks at how NPs experience the development of capability—that is the ability to synthesize prior knowledge and experience in order to address newly encountered problems, or provide care in unfamiliar environments,” says Whitfield.

“Nurse practitioners in North America have only been able to prescribe treatment for opioid use disorder within the past five to seven years. I wanted to understand how they experienced the development of their own capability as they learned to do this work."

Whitfield interviewed NPs from across Ontario and the New England region of the United States. She asked them when they first started treating opioid use disorder, what they learned from the experiences, and how their practice evolved over time. Most NPs Whitfield spoke to for her research study said they received limited training on addiction or opioid use during their education. Furthermore, they reported that clinical practice guidelines can’t always keep up with the rapidly changing realities of street drug supply. As one nurse practitioner Whitfield interviewed described it, sometimes treating substance use disorders in her clinical practice felt as if she was ‘practicing on the verge.’

Whitfield is happy to see new curriculum and policy updates are starting to improve this initial knowledge gap.

“That lack of training is changing now, as new NPs receive more education about substance use in general, as part of their basic training. Hopefully more [nurse practitioners] will feel comfortable providing this treatment, especially if we normalize screening and treatment for substance use disorders as a routine part of providing primary care.”

Whitfield's research also highlights another significant practice trend: as the nurse practitioners enhanced their capability and flexibility in treating opioid use, an interesting shift occurred—patients had the opportunity to become active partners in their own care. Adopting patient-centered approaches, several of the NPs interviewed emphasized the role of patients as experts in their own care, providing valuable education and insights to the NPs. Some even had patient advisors who they reached out to when facing new or unfamiliar situations in the clinic.

With her research study now in the analysis stage, Whitfield recently shared some of the work at the Queen’s University Three Minute Thesis (3MT) competition. Her presentation, “Practicing on the Verge: Treatment of Opioid Use Disorder in Primary Care” was awarded second out of 37 participants. She says the experience was incredibly valuable to her as a growing academic researcher.

“The process of preparing for the 3MT helped me further synthesize my thoughts about my work, and also helped me rework my ‘academic speak’ to be more accessible. And of course, the time limit meant that every word had to count. It’s definitely still a work in progress, but very much worth the time I put in. I would encourage anyone to give it a go.”

While her research questions focus on nurse practitioner capability, Whitfield hopes there will be room for further analysis on opioid use treatment as well. Medications like buprenorphine and methadone can be effective, life-saving treatments for opioid use disorder, but they are not always widely accessible. Furthermore, addressing social determinants of health—access to affordable housing, non-pharmaceutical treatments (like physiotherapy and counselling), and food security—is critical to the larger picture of opioid use disorder and reducing the number of opioid-related poisonings.  

“As healthcare providers, we need to work to address health inequities, provide trauma-informed care, offer treatment without stigmatizing, and approach individuals from the standpoint of treating the whole person, rather than focusing on one issue, such as opioid use, to the exclusion of all other care. I am hoping to continue my work exploring the NP role with a focus on substance use disorders. I am especially interested in rural practice environments, which bring their own set of challenges and rewards.”