Project Foundations

For RN/RPNs working at Kamloops Regional Correctional Centre (P), what is the effect of including nurse prescribers for Opioid Agonist Therapy (OAT) initiation and maintenance (I) compared to limited NP/MD clinics and provider-on-call access (C) on provider workload, Clinical Opioid Withdrawal Scale scores, and OAT attachment (O) within an eight-week trial (T)?

Problem Statement

Persons who use substances entering the British Columbia (BC) correctional system frequently experience suboptimal management of substance withdrawal syndromes (Torres-Lockhart et al., 2022). Registered Nurse (RN) and Registered Psychiatric Nurse (RPN) prescribers offer opportunistic care grounded in holistic nursing practice. They are well positioned to provide prompt, guideline-informed opioid agonist therapy (OAT) for inmates experiencing acute withdrawal within the BC Corrections setting (Banka-Cullen et al., 2023; BC Ministry of Health, 2021).

Purpose Statement

The DNP quality improvement project (QIP) will develop, introduce, and evaluate utilization of RN/RPN OAT prescribers within BC Corrections Kamloops Regional Correctional Centre (KRCC). Certified RN/RPNs will initiate, continue, and restart OAT for clients accessing the correctional centre. This will be done with support from BC Mental Health and Substance Use Services (BCMHSUS) Nurse Practitioners (NP) and Physicians (MD). Informed by Orem's Self-Care Deficit Nursing Theory, the writer's transformational-servant leadership style will enact change through Kotter’s Eight-Step Change Model (Divya & Suganthi, 2017; Harrison et al., 2021; Hartweg & Metcalfe, 2021). This evidence-based approach will increase timely access to opioid withdrawal management, promote adherence to harm reduction strategies, reduce contraband medication diversion, reduce mortality rates, and contribute to lower rates of re-incarceration (Evans et al., 2024; Kaplowitz et al., 2022; Van Hout et al., 2018).

PICOT Question

Population

RN/RPNs working for British Columbia (BC) Corrections at Kamloops Regional Correctional Centre (KRCC) will have opportunities for Opioid Agonist Therapy (OAT) nurse prescriber training prior to the trial period. The BC Centre on Substance Use (BCCSU) Certified Practice Opioid Use Disorder (CP-OUD) education pathway requires three months to complete didactic and preceptorship coursework. This qualifies the nurse for BC College of Nurses and Midwives (BCCNM) certified practice designation (BCCSU, 2023b).

Intervention

OAT nurse prescribers with BCCNM certified practice have well-defined role and competency regulations to initiate, continue, restart, and titrate doses of opioid agonist therapy medications including buprenorphine/naloxone, extended-release morphine, and methadone (BCCSU, 2025a).

Comparison

KRCC currently has a total of 16 hours NP/MD provider coverage weekly. Nurses are on-site 19 hours per day, seven days per week. They utilize the provider-on-call (POC) who services all BC correctional facilities for urgent needs not covered by on-site clinics. There are delays in POC response times and nurses may experience difficulty advocating for the patient’s presentation or preferences through phone report. Acute withdrawal management can be negatively affected, leading to patient suffering (Berk et al., 2025).

Outcome

There are four outcome measurements for this project.

Effect on Physician/Nurse Practitioner workload: Number of weekly appointments booked for the OAT Clinic provider.
Effect on Physician/Nurse Practitioner workload: Number of weekly calls to the POC after-hours service.
Effect on patient experience: Average Clinical Opioid Withdrawal Scale (COWS) scores (BCCSU, 2023a) of inmates initiating OAT prescriptions at day two.
Effect on patient outcomes and mortality: Percentage of inmates on OAT at KRCC using weekly reports.

Time

The site-wide trial will run for eight weeks.

Clinical Questions

On-Call Service

In the BC Corrections healthcare setting, will including nurse prescribers for OAT initiation, maintenance, and titration reduce provider-on-call workload?

Not all BC correctional facilities have daily providers on-site, although inmates arrive every day. On-call services are accessed by intake nurses for initial OAT orders. Clinic nurses then make multiple calls as withdrawal symptoms arise and clients require dose titration between clinic dates. Nurse prescribers can provide initial orders for clients entering BC Corrections and titrate medications when needed to support sobriety, potentially relieving the workload for on-call providers and nursing staff.

Withdrawal Severity

In the BC Corrections healthcare setting, will including nurse prescribers for OAT initiation, maintenance, and titration result in decreased withdrawal severity?

Withdrawal from short-acting opioids can last up to eight days. Treating withdrawal symptoms early with OAT plus side-effect moderators decreases negative health outcomes and improves quality of life (CRISM, 2024). Nurse prescribers can provide earlier opioid withdrawal support and titrate doses according to their BCCNM-regulated competencies and BCCSU guidelines (BC Ministry of Health, 2021).

Harm Reduction Retention

In the BC Corrections healthcare setting, will including nurse prescribers for OAT initiation, maintenance, and titration increase retention in-centre for OAT and harm reduction strategies?

Corrections RN/RPNs bring holistic perspectives to OAT prescribing and are well-placed to develop therapeutic relationships with inmates. Through regulated OAT prescribing, nurses can bridge the gap in correctional facilities, providing timely engagement with OAT programs that continues beyond inmate release dates (Banka-Cullen et al., 2023). Effective withdrawal management increases engagement in future medical care and reduces mortality risk (Berk et al., 2025; Torres-Lockhart et al., 2022).

References

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Berk, J., South, A.-M., Martin, M., James, M.-E., Miller, C., Haber, L., & Rich, J. (2025). Medication for opioid use disorder service delivery in carceral facilities: Update and summary report. Health & Justice, 13(1), 8. https://doi.org/10.1186/s40352-025-00317-9.

British Columbia Centre on Substance Use. (2025a). Decision support tool: For registered nurse opioid use disorder certified and registered psychiatric nurse opioid use disorder certified prescribing of methadone and slow-release oral morphine. https://www.bccsu.ca/wp-content/uploads/2023/11/DST-Certified-Practice-SROM-Methadone.pdf.

British Columbia Centre on Substance Use. (2023a). A guideline for the clinical management of opioid use disorder: 2023 update. https://www.bccsu.ca/wp-content/uploads/2023/12/BC-OUD-Treatment-Guideline_2023-Update.pdf.

British Columbia Centre on Substance Use. (2023b). Registered nurse/registered psychiatric nurse opioid use disorder certified education and training pathway. https://www.bccsu.ca/provincial-opioid-addiction-treatment-support-program-poatsp/authorized-registered-nurse-and-registered-psychiatric-nurse-education-and-training-pathway/.

British Columbia Ministry of Health. (2021). Service delivery framework: Registered nurse and registered psychiatric nurse prescribing as a provincial overdose response initiative. https://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/office-of-the-provincial-health-officer/service-delivery-framework-rn-rpn-prescribing.pdf.

Canadian Research Initiative in Substance Matters. (2024). Update to national guideline for the clinical management of opioid use disorder. https://crism.ca/wp-content/uploads/2024/11/2024-Update-to-CRISM-Update-to-National-OUD-Guideline-20241111.pdf.

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Kaplowitz, E., Truong, A. Q., Berk, J., Martin, R. A., Clarke, J. G., Wieck, M., Rich, J., & Brinkley-Rubinstein, L. (2022). Treatment preference for opioid use disorder among people who are incarcerated. Journal of Substance Abuse Treatment, 137, Article 108690. https://doi.org/10.1016/j.jsat.2021.108690.

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