Guest Post By David Griffiths, Nurses Service Organization – a benefit partner of the Ohio Nurses Association
Overdose deaths related to prescription opioids have quadrupled since 1999, according to the Centers for Disease Control and Prevention (CDC). That makes this a top priority in health care. Nurses can play an important role in reducing these deaths, as well as addiction problems, by assessing and monitoring patients. In taking these steps, nurses can also protect themselves from possible legal action stemming from opioids.
Scope of the problem
Statistics illustrate the depth and breadth of prescription opioid abuse:
- At least half of all opioid overdose deaths involve a prescription opioid.
- In 2014, almost 2 million people in the United States abused or were dependent on prescription opioids.
- Every day, more than 1,000 people are treated in emergency departments for misusing prescription opioids.
The most common drugs associated with prescription opioid overdose deaths are methadone, oxycodone, and hydrocodone. According to the CDC, prescription opioid overdose rates between 1999 and 2014 were highest among people age 25 to 54.
Role of the nurse
A 2016 study by Baker and colleagues notes that there is significant variability in the amount of opioids prescribed, and the most commonly dispensed opioid was hydrocodone (78 percent), followed by oxycodone (15.4 percent). Interestingly, a 2015 study in the American Journal of Preventive Medicine reported a decrease in the rate of prescribing opioids (-5.7 percent), perhaps indicating that more healthcare providers are becoming aware of the addiction issue.
Nurses are well positioned to detect patients with substance misuse.
One simple screening tool is the NIDA or National Institute on Drug Abuse Quick Screen. If a substance use disorder is suspected, the nurse should remain nonjudgmental while referring patients for further evaluation and treatment, so they receive the care they need.
One model for follow-up of possible substance abuse is Screening, Brief Intervention, and Referral to Treatment (SBIRT), from the Substance Abuse and Mental Health Services Administration. SBIRT is a method for ensuring that people with substance use disorders and those at risk for developing these disorders receive the help they need.
Assess the patient carefully
Pain medication should be matched to the individual patient’s needs. This begins with a detailed history, including a list of currently prescribed and past medications. Ask about a history of substance use or substance use disorders in the patient and the patient’s family. If opioids are being considered, assess the patient’s psychiatric status. A physical exam should also be completed, keeping in mind signs and symptoms of possible substance abuse such as advanced periodontitis, traumatic lesions, and poor oral hygiene. If patients are already being managed for chronic pain, the nurse should consult with the appropriate provider.
Apply evidence-based pain management
To provide optimal patient care, as well as to protect themselves from legal action, nurses should practice evidence-based pain management. That includes considering non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, as first-line pain medication. NSAIDs have been shown to be at least as effective (if not more so) than opioids for managing pain, particularly in combination with acetaminophen. For example, in a 2013 review by Moore and Hersh, the authors wrote that the combination “may be a more effective analgesic, with fewer untoward effects, than are many of the currently available opioid-containing formulations.” Before patients begin taking NSAIDs, verify that they are not taking other anticoagulants, including aspirin, and check for hepatic or renal impairment.
One resource for managing pain is the algorithm available from the Institute for Clinical Systems Improvement. Nurses should complete continuing education courses in pain management and document they did so, which can provide evidence of their knowledge in event of a legal case.
Nurses need to educate patients about the role of pain medication in their care. This education should include pain medication options and the reasons why non-opioids are preferred.
Verbal and written instructions after the procedure need to contain name of drug, dosage, adverse effects, how long the drug should be taken, and how to store it. Results from a 2016 survey published in JAMA Internal Medicine found that more than half (61 percent) of those no long taking opioid medication keep it for future use, so patients need to be told to dispose of unused drugs and how to do so. (Patients can search for places that collect controlled substance drugs at www.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e1s1). The same survey found that about 20 percent shared the opioid with another person, so education material should mention not to do this. Nurses should also discuss the perils of driving or undertaking complex tasks while taking an opioid. Document in the patient’s health record that this information was provided and the patient acknowledged receipt and understanding. An office visit can also provide the opportunity for nurses to address opioid abuse on a larger scale.
Refer patients as indicated
Patients who need pain management beyond the acute phase should be referred to another provider with this expertise. Be sure to document the referral in the patient’s health record. Nurses also should consider referral for patients who seek opioids beyond when they are likely to be needed.
Pain medications cautions
Below are some considerations for the use of pain medication in patients:
- Use non-steroidal anti-inflammatory drugs (NSAIDs) as the first option. Consider a selective NSAID to avoid increased risk of bleeding. Know that using acetaminophen in combination with NSAID may have a synergistic effect in pain relief. (Do not exceed 3,000 mg/day in adults.)
- Provide patient education.
- Document patient communications, education, and referrals in the health record.
Protecting patients and nurses
Nurses who assess and monitor patients for treatment of pain are encouraged to be mindful of and have respect for their inherent abuse potential. Doing so protects patients from harm and nurses from potential liability.
About the author
David Griffiths is senior vice president of Nurses Service Organization (NSO), where he develops strategy and oversees execution of all new business acquisition and customer retention for the group’s allied healthcare professional liability insurance programs. With more than 15 years of experience in the risk management industry, he leads a team covering account management, marketing and risk management services. More at www.nso.com.
This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 650,000 nurses since 1976. INS endorses the individual professional liability insurance policy administered through NSO and underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to firstname.lastname@example.org or call 1-800-247-1500. www.nso.com.
Baker JA, Avorn J, Levin R, Bateman BT. Opioid prescribing after surgical extraction of teeth in Medicaid patients, 2000-2010. JAMA. 2016;315(15)1653-1654.
Centers for Disease Control and Prevention. Prescription opioid overdose data. 2016. www.cdc.gov/drugoverdose/data/overdose.html.
Kennedy-Hendricks A, Gielen A, McDonald E, et al. Medication sharing, storage, and disposal practices for opioid medications among US adults. JAMA Int Med. June 13, 2016.
MCauley JL, Leite RS, Melvin CL, Fillingim RB, Brady KT. Opioid prescribing practices and risk mitigation strategy implementation: identification of potential targets for provider-level intervention. Substance Abuse. 2016;37(1):9-14.
Prescription Drug Monitoring Program Training and Technical Assistance Center. Prescription drug monitoring frequently asked questions (FAQ). www.pdmpassist.org/content/prescription-drug-monitoring-frequently-asked-questions-faq.
Substance Abuse and Mental Health Services Administration. Screening, brief intervention, and referral to treatment (SBIRT). 2016. www.samhsa.gov/sbirt.
Thorson D, Biewen P. Bonte B, et al. Acute pain assessment and opioid prescribing protocol. Institute for Clinical Systems Improvement. 2014. www.icsi.org/_asset/dyp5wm/opioids.pdf
Volkow ND, McLellan TA, Cotto JH. Characteristics of opioid prescriptions in 2009. JAMA. 2011;305(13):1299-1301.