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Opioid Epidemic

Combs, Bryan; Hughes, Michele M.; Ariagno, Jill; Turcotte, Elizabeth

doi: 10.1097/NOR.0000000000000542
Naon Position Statement
Free

Bryan Combs, MSN, CRNP, FNP-BC, CNL, ATC, University of Alabama at Birmingham School of Nursing, Birmingham, AL.

Michele M. Hughes, DNP, APRN, ACNP-BC, ONP-C, Memorial Regional Medical Center, Mechanicsville, VA.

Jill Ariagno, MSN, RN, CPNP, Children's Mercy Hospital, Kansas City, MO.

Elizabeth Turcotte, MSN, RN-BC, ONC, Central Maine Medical Center, Lewiston, ME.

The authors have disclosed no conflicts of interest.

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Introduction/Background

Opioid use, misuse, and abuse have been on the rise over the past several decades, and increased scrutiny has been placed on the prescribing and use of opioids. Increased opioid usage has led to several unintended consequences for individual patients and society at large. Opioid use can lead to tolerance and addiction and result in worse treatment outcomes (Morris & Mir, 2015). This phenomenon, now known as the opioid epidemic, has been wreaking havoc in the general healthcare population, specifically in the orthopaedics patients with acute and chronic pain from genetic, acquired, or traumatic musculoskeletal conditions.

The rise in opioid prescriptions began in the 1990s when pain was declared as the “fifth patient vital sign,” and today the United States consumes an estimated 80% of the global opioid supply. Subsequently, the diversion of opioids for nontherapeutic use began to dramatically increase as well (Morris & Mir, 2015). Nearly 30 years later, opioid overdose is now the leading cause of accidental death in young adults. Opioids are associated with a higher risk of postoperative death, contribute to postoperative complications, and increase the risk of fall and fracture in the elderly (American Academy of Orthopaedic Surgeons [AAOS], 2015).

Nurses, especially those caring for patients who have used or abused or are currently being prescribed opioids for chronic or acute musculoskeletal conditions from trauma or surgery, are in a unique position to directly impact the continued spread of the opioid epidemic.

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Position

  • Increase provider and patient education
  • Utilize multimodal and alternative therapies
  • Increase research investigating the opioid crisis
  • Increase patient advocacy
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Recommendations

Education of Healthcare Providers

Nurses and medical professionals, armed with the appropriate information, can play an integral role in facilitating the proper use of opioids. Educating healthcare professionals about the opioid crisis is a primary prevention strategy to promote more responsible and effective opioid prescribing practices. Healthcare providers should maintain competence in opioid management, proper pain assessment, managing pain, and the safe use of opioids through continuing medical education courses so that they can stay abreast of new and developing information (Centers for Disease Control and Prevention [CDC], 2018; The Joint Commission, 2017).

To appropriately manage pain in a perioperative setting, healthcare providers must properly assess patients for the risks of opioid use, guide pain management, and address the harmful effects of opioid misuse (Community Anti-Drug Coalitions of America [CADCA], 2016; Kee, Smith, & Barnes, 2016). Prescription Drug Monitoring Programs help governing bodies gather information about the opioid crisis and provides prescribers with additional clinical decision support (CDC, 2018), aids in decreasing the inappropriate prescribing and dispensing of opioids, and has been directly correlated with decreasing oxycodone-related deaths (Kee et al., 2016).

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Education/Setting Expectations for Patients

Patient education is needed to understand the potential dangers associated with the misuse of opioids including more pain, addiction, and even death (AAOS, 2015). Healthcare providers have a responsibility to educate the public about safe pain management to shift the cultural expectations that have evolved.

Patient education should emphasize:

  • The risks of addiction, opioid abuse, and overdosing (Academy of Managed Care Pharmacy, 2018)
  • The connection of opioid prescriptions to illicit drugs such as heroin
  • Misuse and abuse lead to continued worsening pain, and can also result in the diversion of opioids and risking other lives (Kee et al., 2016).
  • Patients should be counseled on setting reasonable and attainable pain goals and expectations (Morris & Mir, 2015).

There are many tools to assist in patient education. The U.S. Department of Health and Human Services developed the Pathways to Safer Opioid Use, which emphasizes the use of health literacy strategies when educating patients and their families so that they can better understand the medications they have been given, the risks of use and related adverse drug events. The Risk Evaluation and Mitigation Strategy for Opioid Analgesics aids in the education and counseling of patients for the proper use and tapering of opioids as well as appropriate follow-up (CADCA, 2016).

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Multimodal and Alternative Therapies

The use of multimodal analgesia and an alternative method of pain control can be highly effective and can decrease the burdens of opioid use on patients and their families.

Multimodal analgesia is defined as using nonopioid medication as the foundation for pain control, usually two or more, and only adding opioids on a limited and as-needed basis (Savarese & Tabler, 2017). The common medications used as a nonopioid foundation are nonopioid analgesics (e.g., acetaminophen), nonsteroidal anti-inflammatory drugs (e.g., ibuprofen, indomethacin, ketorolac), local/regional anesthetics (e.g., surgical blocks, topical analgesics, iontophoresis), and psychotropics (e.g., duloxetine, amitriptyline) (Bonakdar, 2017; Dale & Stacey, 2016).

Acute pain and chronic pain should be managed differently and should be individualized. Long-acting or extended-release opioids should be reserved for patients with chronic pain and should address the physical and psychosocial component of pain (NIH Pain Consortium, 2018; Monitto et al., 2017).

Alternative therapies for pain management have been shown to be very beneficial (e.g., diet/nutrition, acupuncture, cryotherapy, massage, or osteopathic manipulation) (Nahin et al., 2016).

New approaches to pain control are critical in the battle against the opioid issue, and the use of multimodal analgesia and alternative therapies is an integral step in that direction (Thomas et al., 2016).

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Research

More than 11.5 million Americans, aged 12 years or older, reported misusing prescription opioids in 2016 (CDC, 2018). With opioid misuse and abuse being responsible for nearly 115 deaths per day and on the rise evidence-based research aimed at identifying key strategies for combating the opioid epidemic is paramount (National Conference of State Legislators, 2018; Energy and Commerce Committee, 2018).

Research is centered on five predominant themes:

  1. Patient-focused: Identify and produce clinically relevant and useful tools to help evaluate pain.
  2. Provider-focused: Identifies tools and programs to teach providers about pain management and safe prescribing today and in the future.
  3. Safe prescribing: More information is needed on safe prescribing and standardization for acute and pediatric pain management (Centers for Disease Control and Prevention, 2016; National Institute on Drug Abuse, 2017).
  4. Alternative pain management strategies: Research in alternate pharmacologic agents for treating pain is at an all-time high.
  5. Outcomes evaluations: Outcomes research is necessary to evaluate the effectiveness of the tools and programs in use.
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Advocacy

The single most significant congressional effort against a single drug crisis in history occurred this year with a total of $10.7 billion appropriated at the federal level to combat the opioid crisis (Energy Commerce Committee, 2018). Legislative efforts develop programs that help battle the crisis from the inside with programs directed at treatment, education, and prevention. Furthermore, legislative efforts focused at the state level have successfully put into place continuing education for prescribers, prescribing guidelines, prescription drug monitoring programs, and safe disposal of controlled substances.

Advocacy plays an important role in ensuring that legislative bills are created and passed to meet the needs of the nation and the affected communities. We must refute inappropriate legislation as well as support legislation that advances the platform of providing successful pain management (acute and chronic) for all (adults and pediatrics), while protecting against opioid misuse and abuse (Raney, et al., 2018). While there is no simple answer to the opioid epidemic in this nation, significant efforts are in motion to mitigate and minimize this crisis. A comprehensive approach to heighten awareness through patient and provider education, use of multimodal pain management, new knowledge and research generation, and patient advocacy are symbiotic initiatives to shift the attention and approach to this rampant issue.

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Acknowledgment

Special thanks to Deborah Valentine, MSN, RN, CCM, ONC for her work as facilitator for this position statement.

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References

Academy of Managed Care Pharmacy. (2018). Opioid summary. Retrieved from http://www.amcp.org/WorkArea/DownloadAsset.aspx?id=23763
American Academy of Orthopaedic Surgeons. (2015). Opioid use, misuse, and abuse in orthopaedic practice. Retrieved from https://www.aaos.org/uploadedFiles/PreProduction/About/Opinion_Statements/advistmt/1045%20Opioid%20Use,%20Misuse,%20and%20Abuse%20in%20Practice.pdf
Bonakdar R. A. (2017). Integrative pain management. Emergency Medicine Clinics of North America, 101(5), 987–1004. doi:10.1016/j.mcna.2017.04.012
Centers for Disease Control and Prevention. (2016). Guideline for prescribing opioids for chronic pain. Retrieved from https://www.cdc.gov/drugoverdose/prescribing/guideline.html
Centers for Disease Control and Prevention. (2018). 2018 annual surveillance report of drug-related risks and outcomes—United States. Surveillance Special Report 2. Retrieved from https://www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surveillance-report.pdf
Community Anti-Drug Coalitions of America. (2016). The Comprehensive Addiction and Recovery Act (CARA). Retrieved from https://www.cadca.org/comprehensive-addiction-and-recovery-act-cara
Dale R., Stacey B. (2016). Multimodal treatment of chronic pain. Medical Clinics of North America, 100(1), 55–64. doi:10.1016/j.mcna.2015.08.012
Energy and Commerce Committee. (2018). H.R.6—SUPPORT for Patients and Communities Act. Retrieved from https://www.congress.gov/bill/115th-congress/house-bill/6
The Joint Commission. (2017). Pain assessment and management standards for hospitals. Retrieved from https://www.jointcommission.org/assets/1/18/R3_Report_Issue_11_Pain_Assessment_8_25_17_FINAL.pdf
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Nahin R. L., Boineau R., Khalsa P. S., Stussman B. J., Weber W. J. (2016). Evidence-based evaluation of complementary health approaches for pain management in the United States. Mayo Clinic Proceedings, 91(9), 1292–1306. doi:10.1016/j.mayocp.2016.06.007
National Conference of State Legislators. (2018). Prescribing policies: States confront opioid overdose epidemic. Retrieved from http://www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.aspx
National Institute on Drug Abuse. (2017). Improving opioid prescribing. Retrieved from https://www.drugabuse.gov/publications/improving-opioid-prescribing/improving-opioid-prescribing
NIH Pain Consortium. (2018, 12/13/2018). HHS pathways to safer opioid use. Retrieved from https://painconsortium.nih.gov/Resource_Library/Pathways_Safer_Opioid_Use
Raney E. M., van Bosse H. J. P., Shea K. G., Abzug J. M., Schwend R. M. (2018). Current state of the opioid epidemic as it pertains to pediatric orthopaedics from the Advocacy Committee of the Pediatric Orthopaedic Society of North America. Journal of Pediatric Orthopedics, 38(5), e238–e244. doi:10.1097/bpo.0000000000001143
Savarese J. J., Tabler N. G. Jr. (2017). Multimodal analgesia as an alternative to the risks of opioid monotherapy in surgical pain management. Journal of Healthcare Risk Management, 37(1), 24–30. doi:10.1002/jhrm.21262
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