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I'm Worried About People in Pain

Curtiss, Carol P. MSN, RN-BC

AJN The American Journal of Nursing: January 2016 - Volume 116 - Issue 1 - p 11
doi: 10.1097/01.NAJ.0000476145.19908.f4
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Efforts to address prescription opioid abuse may lead to unintended consequences.

Carol P. Curtiss is a clinical nurse specialist and consultant in pain management. She has been a paid speaker or produced educational materials for the biotechnology company Genentech. Contact author: curtiss.carol@gmail.com. The author has disclosed no potential conflicts of interest, financial or otherwise.

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According to a 2011 Institute of Medicine report, chronic pain is a public health crisis, with more people experiencing chronic pain than heart disease, cancer, and diabetes combined. Well-intended efforts to address prescription drug abuse—another public health crisis—may place heavy burdens on people with pain who benefit from opioids and use them responsibly as part of a comprehensive treatment plan.

Gains made in pain treatment are at risk. New regulations threaten access to opioids for people with pain. A proposed Centers for Disease Control and Prevention guideline for persistent pain, including cancer pain, recommends caution with opioid doses greater than the equivalent of 50 mg of morphine per day. In addition, the Food and Drug Administration's current indication for controlled-release/long-acting opioids is for “the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.” Such valid reasons for using controlled-release opioids as improving nighttime sleep for those in chronic pain, decreasing patients’ pill burden, and increasing adherence no longer meet this indication.

In 2014, hydrocodone products, the most frequently prescribed medications in the United States, were rescheduled from Schedule III to Schedule II. Written prescriptions no longer include an option for refills, and prescribers cannot phone in or fax orders. An office visit is required for each refill. Clinicians must adapt their schedules to accommodate the increase in patient visits and time to comply with regulatory requirements. Many providers are reluctant to prescribe opioids at all.

At the same time, patients feel stigmatized by increased scrutiny of their analgesics. Pain and advocacy organizations report an upsurge in calls from patients experiencing difficulties getting prescriptions from health care practices and pharmacies. Some retail pharmacists are required to determine if opioid therapy is appropriate before filling prescriptions. Some states and insurers restrict doses or numbers of tablets and others require trials of alternate medications before opioids can be prescribed. Insurance prior authorization is required for many opioids. Meanwhile, patients wait in pain or experience opioid withdrawal.

Controlling prescription drug abuse is critical, as is improved access to mental health and addiction treatments. But there is no “quick fix” for these complex problems. State prescription drug monitoring programs must collaborate to make databases available to clinicians across state lines. Prior authorization processes must be more efficient and more transparent. Clinicians should follow current guidelines that recommend comprehensive assessment and ongoing screening before and during opioid therapy; initiating opioids after risk–benefit analysis and as part of an individualized plan; measurable treatment goals; and follow-up based on individual risk stratification. Treatment agreements are also recommended to set clear expectations for providers and patients.

Alleviation of suffering is a foundational element of nursing practice. Nurses in practice, policy, and community settings, with and without prescriptive authority, must advocate for measures that alleviate suffering associated with pain and facilitate communication among patients, caregivers, and multiple providers to prevent misunderstandings about pain management from becoming impediments to care.

Pain management education, including responsible opioid prescribing, should be a core competency for all health care providers. Pain clinicians and people with pain must be at the table when new regulations affecting pain care are proposed and debated. Additional research into the risks and benefits of long-term opioid therapy is important, as is a comprehensive approach to identify and treat substance use disorders. But denying or making access to pain medications more difficult for people with pain is not the solution.

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