MORE AMERICANS will experience addiction and overdose as more prescriptions for opioids are written.1,2 In 2016, the CDC issued guidelines that encouraged prescribers to limit the use of opioid pain medication to treat chronic pain.3 The guidelines were intended to encourage providers to thoughtfully evaluate the use of opioid medication in their treatment plans and to reduce the use of opioids when possible. However, many providers, lawmakers, and insurance companies interpreted the guidelines as rules for avoiding opioid treatment for most patients.4 This has led to several serious consequences in healthcare. For example, because providers are now reluctant to treat pain with opioids amid the opioid crisis, some patients are left with unrelieved pain. This article examines issues surrounding using opioids to treat chronic pain and discusses how nurses can advocate for their patients to receive adequate pain management.
New guidelines, new consequences?
The CDC found that as prescriptions for opioid pain relievers grew in the 1990s, so did the number of opioid-related deaths.5 Deaths from opioid overdoses have since climbed at exponential rates. More than 47,000 people died from opioid overdoses in 2017 alone.5 Although not all who are prescribed opioids for pain relief misuse them, Vowles and colleagues found that 21% to 29% of patients with chronic pain who were prescribed opioids reported misusing them and 8% to 12% became addicted.6 It comes as no surprise that the federal government saw a need to act.
In August 2016, former US Surgeon General Vivek Murthy sent a letter to millions of physicians and posted it on the American Academy of Family Physicians website, asking each provider to take a pledge to reduce the number of opioid prescriptions and to treat patients' pain using other means.7 The letter encouraged providers to weigh the risks and benefits of using opioids and to avoid using opioids as a first-line treatment.7 The accompanying pocket guide established the guideline of prescribing no more than 90 morphine milligram equivalents per day and suggested better patient assessment and consideration of other treatment options to help providers decrease opioid prescriptions.8 Also in 2016, the College of Psychiatric and Neurologic Pharmacists created guidelines encouraging community pharmacists to assess patients for substance misuse and to question the need for any opioids prescribed.9 Insurance companies cited the CDC Guidelines and the former Surgeon General's letter when notifying providers that the number of opioid prescriptions written would affect the companies' review of medical practices, threatening providers' payments if too many opioid medications were prescribed.10,11 In an effort to protect their citizens, most states created prescription-limiting laws to make it unlawful to prescribe more opioids than the state legislatures deemed appropriate.12
This harsh interpretation of the CDC's prescribing guidelines, pressure from insurance companies and lawmakers, and widespread concern about the growing opioid use epidemic made many providers uncomfortable with prescribing opioids or continuing to prescribe high doses of opioids to patients who had been using these medications to control chronic cancer pain.4,13 Many of these patients found that pain treatment was no longer available to them. Some were asked to sign contracts with their provider that they would not abuse their medication.13 This took a toll on many patients' trust in their providers, with patients feeling their provider was assuming they were doing something wrong by asking for pain medication.
Some patients were told that opioids were simply not an option for them and that they instead had to seek alternative treatments for pain relief.4,13 However, alternative treatments may not provide adequate pain relief for patients with moderate to severe chronic pain and some severe acute pain.4
New issues have come to light in the few years since the 2016 CDC guidelines were released. (See CDC's guidelines for prescribing opioids for pain: Important takeaways.) Some patients with chronic pain are turning to illicit drugs when their healthcare team will not provide adequate pain relief, and some have turned to suicide.4,13 Patients with untreated pain may find that performing activities of daily living or activities that help maintain quality of life are difficult to accomplish. Besides decreased functioning, unrelieved pain can result in limited sleep, depression, and impaired healing, threatening mental and physical health.14 The question of how we treat our patients' pain while preventing the danger of opioid addiction and overdose has been challenging to answer.
Finding clarification and compromise for patients
In March 2019, Healthcare Professionals for Patients in Pain, a group of 318 providers and three former US drug czars, wrote an open letter to the CDC asking for clarification on the 2016 guidelines.4 The CDC responded boldly in April, stating that the guidelines were not meant to be a set of unyielding rules to be applied uniformly to all patients. The CDC pointed out that the guidelines suggested evaluating individual patients' needs and working with patients to create a treatment plan. Specifically, the CDC's response mentioned that “strict application” of the 2016 guidelines was inappropriate for patients experiencing pain from cancer, sickle cell disease, and surgeries. The CDC acknowledged that some patients had been dismissed from their providers' care or had their opioid prescriptions ended abruptly, causing significant safety issues.15 These are situations many nurses have witnessed and been unable to change.
Addressing patients' pain
Although state laws, insurance mandates, and some providers' ideas about strictly limiting opioid prescriptions to all patients may not have softened yet, this recent clarification of the CDC's intentions gives nurses more tools when working with patients and the healthcare team to relieve patients' pain. As nurses, how do we advocate for our patients who are suffering from real pain while trying to prevent misuse? How can nurses communicate a patient's need for stronger pain relief to other members of the healthcare team who, although with good intentions, are unwilling to consider opioid medication?
As with everything in nursing, the nurse must begin by assessing the patient and the situation. Using a standardized validated pain assessment tool, such as the WILDA pain assessment tool, the FACES scale, or a numerical scale, the nurse should assess the patient's pain intensity level. The pain assessment should include onset, location, duration, characteristics, associated factors, aggravating factors, relieving factors, treatment to date, and response. If a patient's report of pain does not seem to match the patient's demeanor or activity level, consider if cultural norms or demands of the patient's social role may be an influence. For example, a mother caring for her children while she reports pain may not want to show her children that she is in pain. The nurse may also ask if the patient has ever experienced that level of pain before and inquire about that situation to help the patient clarify the pain level. Most important, the nurse must establish a trusting relationship with the patient and convey that the nurse believes the patient's pain is real.
If the nurse has concerns that the patient may be exaggerating pain to receive pain medication for misuse, these concerns should be shared with the healthcare team. However, healthcare professionals must be cautious about assuming a patient has a hidden agenda based solely on feelings that the patient is not expressing pain in a way that the nurse would expect. People with chronic pain often learn how to function while experiencing severe pain. Being able to carry on a conversation and smile does not mean the patient is not in severe pain.16
Then, the nurse should review the pain treatment that the patient has received. Some interventions work by blocking the brain's perception of pain (opioids or drugs such as gabapentin that target nerve conduction are examples). Some pain treatments, such as nonsteroidal anti-inflammatory drugs, steroids, and ice, work by reducing inflammation.17 Complementary and alternative medicine, such as acupuncture, reiki, and massage, work by manipulating the body's own tools for healing.18 The success of any of these interventions depends on many individual factors. Considering what pain treatment the patient has tried and the patient's response to that treatment will help the nurse communicate with the provider about other treatment options.
Pain treatment may not work for various reasons, including the length of time the intervention has been used. For example, some medications that address neuropathic pain may not relieve symptoms for 1 to 4 weeks. Other treatment strategies are expensive and may not be covered by insurance. Copays for physical therapy and complementary therapies can add to a patient's costs, so the nurse should consider if finances or insurance coverage are an issue. Other barriers to pain management include the patient's inability to get to a pharmacy to fill prescriptions, travel to therapy, or attend follow-up provider appointments due to factors such as lack of transportation. If a patient experiences severe pain, has limited transportation, or lives far from a pharmacy or the provider's office, the patient may never have a chance to see if the treatment plan works. Nurses who ask patients about these and other barriers to care will help them obtain better pain relief.
If a pain treatment suddenly becomes less effective, consider if a new complication has developed. For example, a patient whose leg has limited movement after knee surgery is at risk for deep vein thrombosis, which may cause pain to increase. In the case of cancer or autoimmune disorders such as rheumatoid arthritis, disease progression may cause a patient to experience increased pain. A patient experiencing mental stress, chronic fatigue, hunger, or thirst may also experience pain to a greater degree.19 Assessing for a reason pain has increased is important but should not delay a plan to address it.
If the nurse feels that a different treatment strategy is needed after assessing the patient and the patient's response to the treatment plan, the nurse must communicate this to the appropriate members of the healthcare team. For example, a physical therapist should be informed that the patient is having severe pain so that the therapy can be modified or cancelled. Another example is asking the provider to adjust the medication regimen, such as increasing the analgesic dosage or prescribing a different analgesic.
Communicating clearly and directly is essential to successfully advocate for a patient. Communication strategies such as TeamSTEPPS help give a framework for effective communication. (See What is TeamSTEPPS?) The Situation, Background, Assessment, and Recommendation (SBAR) tool is another way to convey a change in a patient's pain to a provider. SBAR can help nurses thoughtfully report who the patient is, what treatments the patient has tried, and what the nurse thinks may help. (See What is SBAR?)
If the provider or another healthcare team member disagrees with the nurse's recommendation, the nurse should consider why. Sometimes another team member's perspective and experience may lead to a more effective resolution for the patient's pain. TeamSTEPPS' CUS words (concerned, uncomfortable, safety) can be used if a nurse feels the provider should consider the concern further.20 For example:
- Concerned: “I am concerned that our patient cannot afford the treatment prescribed. Can we try something different?”
- Uncomfortable: “I am uncomfortable letting our patient go home without pain medicine.”
- Safety: “This is a safety issue—our patient seems to be becoming depressed from the pain. I think we should reevaluate our treatment plan.”
If the nurse sees a safety issue that is not being addressed (for example, unresolved pain or adverse reactions to pain treatment), the nurse should voice the concern to the provider or a supervisor twice to be sure that the individual heard and considered the concern. This is called the two-challenge rule.20 If the nurse feels that the concern is valid and still is not being addressed, the nurse should follow the chain of command and continue to professionally advocate for the patient.
Many providers are reluctant to prescribe opioids with good reason. However, sometimes opioids can provide pain relief that no other pain treatment can offer. As nurses, we need to advocate for the most effective pain relief possible for our patients.
CDC's guidelines for prescribing opioids for chronic pain: Important takeaways8,21
- Opioids are not the drug of choice to treat chronic pain. Avoid prescribing opioids for chronic conditions when possible.
- Consider the pros and cons of opioid therapy. Critically analyze the cause of the patient's pain, consider whether other treatments may work better, and weigh the patient's unique risks against the potential benefits of opioid therapy (for example, risk for addiction, ability to tolerate adverse reactions).
- If using opioid therapy, use judiciously. Consider using the lowest dose possible to relieve pain and only for a short period of time.
- Consider the patient's needs and safety. Avoid cutting opioid doses too severely or too quickly in patients who have been using high doses of opioids. Also, any change in a long-standing regimen should be undertaken as a partnership with the patient, not by simply removing the option of opioids. The individual patient's pain relief and safety must be protected regardless of social, financial, or legal pressures to reduce opioid use.
What is TeamSTEPPS?22
Developed by the Department of Defense's Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality, TeamSTEPPS is an evidence-based teamwork system that aims to improve patient safety and optimize outcomes by improving communication and teamwork skills among healthcare professionals. The system is based on five key principles: team structure, communication, leadership, situation monitoring, and mutual support. TeamSTEPPS offers healthcare systems ready-to-use materials and a training curriculum to integrate teamwork principles into a variety of settings. For more information, see www.ahrq.gov/teamstepps/curriculum-materials.html.
What is SBAR?23
The SBAR technique provides a framework for communicating to physicians and other healthcare professionals about a patient's condition. SBAR stands for the four key components that must be conveyed when discussing a patient's condition:
- S = Situation (a concise statement of the problem)
- B = Background (pertinent and brief information related to the situation)
- A = Assessment (analysis and considerations of options — what you found/think)
- R = Recommendation (action requested/recommended — what you want).
This easy-to-remember technique gives nurses a simple and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety. For more information, see www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx.
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6. Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain
11. Centers for Medicare and Medicaid Services. CMCS informational bulletin: Medicaid strategies for non-opioid pharmacologic and non-pharmacologic chronic pain management. 2019. http://www.medicaid.gov/federal-policy
12. Davis CS, Lieberman AJ, Hernandez-Delgado H, Suba C. Laws limiting the prescribing or dispensing of opioids for acute pain in the United States: a national systematic legal review. Drug Alcohol Depend
15. Dowell D, Haegerich T, Chou R. No shortcuts to safer opioid prescribing. N Engl J Med