By Anne Dabrow Woods, Wolters Kluwer, Health
A 21-year-old male patient goes into respiratory and cardiac arrest at a bar. A 32-year-old female who has a history of chronic pain from a motor vehicle accident two years ago, collapses on the street. An 18-year-old female who went to a football game and is found unresponsive and apneic in the bathroom. A 36-year-old male who has chronic back pain from a construction accident three years ago, is found unresponsive by his children in the bedroom.
What do all these people have in common? They all overdosed on opioids. They were not trying to commit suicide, they were simply trying to get high or find relief from chronic pain. Naloxone was administered to all of them, and two lived. The other two weren’t as lucky. The bottom line—emergency rooms across the U.S. probably took care of someone just like them in the past few weeks.
The nation’s opioid crisis touches every area of healthcare. Consequently, proactive management of the epidemic has shifted to priority status and a top quality and safety issue in today’s healthcare organizations. Now the leading cause of accidental death in the U.S., 115 people die daily from opioid overdoses, with staggering costs—$78.5 billion annually for prescription opioid misuse in the U.S. alone (Rudd et al., 2015; NIH, 2018).
Healthcare industry leaders recognize that the current economic burden is unsustainable, and while the opioid problem is complex and multi-faceted, clinicians working on the frontlines of care play an important role in changing the dynamic. It’s one reason why current initiatives aimed at improving the outlook focus on changing prescribing patterns through standardization of evidence-based practice.
The reality is that nurses play a significant role in the opioid crisis. In healthcare institutions, nurses are the ones who administer analgesics to patients, which include opioids. As such, it is more important than ever to equip nurses and other healthcare professionals with the proper educational resources and point-of-care guidance to improve decision making, support proactive identification and empower patients in their care.
Recognizing The Problem
Patients who misuse opioids or become addicted to them may be at risk for problems related to their addiction such as withdrawal, or overdose. Nurses are often the first healthcare professionals to recognize the patient has an opioid problem and therefore, need to be properly educated on how to identify a person at risk.
Patients who misuse opioids can develop opioid use disorder (OUD), which is defined as a problematic pattern of opioid use leading to clinically significant impairment or distress (CDC, 2018). Opioid use disorder is characterized by taking more drugs than intended, craving opioids and having the inability to control or cut down on opioid use, having the inability to preform important tasks at work, school or home, tolerance to opioid use and withdrawal if the patient does not take opioids (CDC, 2018).
Due to the tolerance the patient develops to opioids over time, a higher dose of opioid is required to achieve intoxication and to prevent withdrawal symptoms (CDC, 2018). Patients who are withdrawing from opioids will often experience nausea and vomiting, diarrhea, abdominal cramps, rhinorrhea, diaphoresis, insomnia, myalgias, anxiety, agitation and depression (CDC, 2018).
Patients who overdose on opioids will have miosis (constricted pupils), become unresponsive, go into respiratory failure and will develop respiratory and cardiac arrest (CDC, 2018). People who use illicit street drugs are more at risk and particularly vulnerable to overdose since the quality of the substance is unknown and it often laced with other substances.
Improving Prescribing Patterns
For years, healthcare providers have prescribed opioids for acute and chronic pain management. When those prescriptions are administered for chronic pain, they often lead to misuse by 21-29 percent of patients, up to 12 percent of whom will develop an opioid disorder (NIH, 2018).
In 2016, the U.S. Surgeon General launched the “Turn the Tide” Rx campaign, which prioritized the use of opioids in the 2016 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain. For opioid prescribing outside of cancer pain and end-of-life therapy, the guidelines established:
- Preference for non-opioid therapy and the need to weigh benefits against risk for addiction
- Importance of establishing treatment goals prior to prescribing opioids
- Parameter setting of no more than three days of opioid therapy, for most cases, and no more than seven, except in rare instances
- Preference for immediate-release versus extended-release formulas
- High risk designation for dosages exceeding 50 morphine milliequivalents
- Strategies to mitigate risk of overdoses
- Strategies for monitoring patients receiving chronic opioid therapy
All healthcare institutions and professionals should align practice with these standards to improve the outlook on the opioid epidemic. As the professionals who most often request analgesic orders for patients across care settings, nurses are in a unique position to advocate for responsible opioid prescribing based on current best practices. For instance, giving patients opioids with benzodiazepines can increase overdose risk and should be avoided. Nurses can advocate for using alternative non-opioid analgesics and other treatment modalities instead of going straight to an opioid for pain relief. Real-time access to educational resources and evidence-based guidance can equip nurses with the knowledge to advocate against these practices.
People misuse opioids because they were either exposed to them by their peer groups or they were prescribed opioids for pain management. According to the Substance Abuse and Mental Health Services, once a person becomes addicted, 53 percent will obtain the opioids from a friend or relative, 37.5 percent through a prescription or stealing from a healthcare provider, and 6 percent from a drug dealer or stranger (Ahrnsbrak, et al., 2017). Nurses need to educate all their patients, but especially young people to say no to drugs and avoid situations where drug use is prevalent. This can be difficult for many since drug experimentation often occurs in their social circles.
Nurses can impact opioid misuse through patient education focused on alternative approaches to pain management, such as non-narcotic pain medications, physical therapy and meditation (Morone, & Weiner, 2013). For instance, patients can be educated to ask for and use other types of medications to help manage pain such as gabapentin, pregabalin, or duloxetine for neuropathic pain; ibuprofen or naproxen for pain due to inflammation from a sprain or strain; and acetaminophen for pain such as headache.
By evaluating each patient’s unique situation, nurses can partner with patients to help them determine a tolerable level of pain—one where the patient still maintains quality of life—and then guiding them to effective alternatives. First, though, nurses must have access to the right resources to increase their own knowledge of opioids and the opioid crisis so that they can appropriately assess and manage pain, and advocate for responsible opioid use. They must also gain a deeper understanding of the physical and emotional impact of chronic pain, as well as the physiological and psychological aspects of addiction.
In addition, nurses can help manage the opioid epidemic on the frontlines by proactively identifying patients that have opioid use disorder and encouraging them to seek treatment with reputable, vetted resources and treatment centers. Nurses also can teach patients how to properly dispose of their used opioid medications to decrease drug diversion.
Effective management of opioids in today’s healthcare organizations requires a multi-disciplinary effort—one where the role of nurses is elevated, and practice reflects the latest evidence related to prescribing, administering analgesics, and patient education. Simply put, standardization of best practice across clinical disciplines is vital to turning the corner to an improved outlook in a sustainable way. Healthcare organizations are wise to consider deploying systems that deliver best-practice guidance to nurses and then fostering organization-wide accountability to promote a culture of high reliability.
About The Author
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN is the Chief Nurse of Wolters Kluwer, Health. She is also a critical care nurse practitioner at Penn Medicine, Chester County Hospital and she is Adjunct Faculty for Drexel University, College of Nursing and Health Professions.
Ahrnsbrak, R. et.al., (2017). Key substance use and mental health indicators in the United States: Results from 2016 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services. U.S. Department of Health and Human Services.
Centers for Disease Control and Prevention. (2018). Opioid Use Modules. CDC. www.cdc.gov.
NIH, (2018). HEAL Initiative Research Program.
Morone, NE. & Weiner DK. (2013). Pain as the fifth vital sign; exposing the vital need for pain education. Clin Ther. 2013;35(11)1728-1732.
Rudd, RA, Seth P, David, F. & Scholl, L. (2016). Increases in Drug and Opioid-Involved Overdose Deaths – United States, 2010-1016. MMWR Morb Mortal Wkly Rep. 2016;65.