In the 1990’s, pain was introduced as the fifth vital sign. As a result, opiate prescriptions, addictions and overdoses have since spiraled out of control: “Drug overdose death rates in the United States have more than tripled since 1990 and have never been higher.” (CDC, 2013). When Purdue Pharma introduced OxyContin in 1996, it was aggressively marketed and highly promoted as a viable non-cancer pain management solution with “small risk of addiction.” OxyContin sales grew from $48 million in 1996 to almost $1.1 billion in 2000, and by 2004 it had become a leading drug of abuse in the United States. (Van Zee, 2009). Today's opiate epidemic involves both legally prescribed and illegally obtained opiates. Nurses play an important and developing role in this epidemic, and every nurse is called to accept the challenges of observation, education and advocacy. Nurses haves a professional and ethical responsibility to protect patients from suffering, and pain management is certainly a significant part of that. However, nurses are also responsible for providing the right care in an efficient, equitable and ethical way. Nurses are just as responsible for advocating for non-pharmaceutical pain management as they is for opiate pain management if needed. What can a nurse do?Assess and observe
Nursing requires observation. The nature of addiction is constantly changing, and the keen use of observation can identify patterns of at-risk behaviors that may not be noticed by other providers. A grandmother can struggle with addiction, as can your co-worker. Addiction is pervasive and knows few boundaries. Nurses are direct patient care providers and are rated “the most trusted profession.” Taking the time to assess, observe, engage and interact is essential. While it is true that anyone can be an addict and that the stereotypical presentation of symptoms is a myth, there are certain red flags, and opioid risk screening tools should be used in adolescent medicine, urgent care and primary care settings when available. Supplement your observation by familiarizing yourself with and using the tools available to you.The Opioid Risk Screening Tool assesses the following:
- Personal history of substance abuse
- Family history of substance abuse
- Mental health issues-particularly if untreated
- History of pre-adolescent sexual abuse
In addition to the screening of risk factors, nurses need to know the signs of aberrant behavior which include the following:
- Doctor shopping
- Multiple pharmacies, multiple locations, multiple refills, multiple spellings of names
- Frequent doctor visits, increasing doses, early refills, lost scripts
- Self-paying for office visits or prescriptions. Each prescription pill is worth money on the street. Drug diversion, or when a legally prescribed medication is sold or given to another person, is a huge problem in the opiate epidemic.
Use universal precautions for opiate prescriptions: According to Gourlay and Heit (2005), universal pain precautions should be used for all patients in pain and involve the following steps:
- Identify the cause of the pain. Pain is not a disease but a symptom. Be diligent in finding, diagnosing and addressing the cause of the pain.
- Screen for addiction, anxiety and mental health disorders that can lead to addiction such as depression.
- The patient and family should be educated on the benefits versus the risks of opiate therapy, and also on the non-pharmaceutical management of pain.
- Pain assessment scores and functional activity scores completed at each visit.
- Each patient should have a detailed treatment plan outlining the plan for weaning or discontinuation or need for continued treatment.
Awareness and education are essential Nurses are responsible for educating themselves on current trends and issues, in addition to educating patients and caregivers. The average age of a first-time substance user is 11 years old. Drugabuse.gov starts tracking drug use and abuse at age 12. Most parents sitting at their kid’s little league games are not thinking about their kids using substances. It’s not on their radar. It’s not on most pediatrician’s radar, but it should be. Education geared towards children, parents, schools, communities and providers is most effective. Education must be broad-based and strike at multiple systems to be effective in this epidemic. Nurses should stay up to date on current information, trends and issues. For example, a new form of a lethal opiate overdose in western PA involves the use of veterinary opiates. RN’s need to educate patients on the proper use, storage, and disposal of prescription pain medication. For some kids, an opiate is as close as their grandma’s medicine chest. Advocate Advocate for awareness and acceptance and reduce the social stigma of addiction. Often the first time a person’s addiction becomes known is with overdose or when they become involved in the criminal justice system. Many people who suffer from addiction have undiagnosed mental health issues that they are self-medicating. A nurse should assess for underlying mental health conditions and stressors that may trigger substance use in her patient, and request appropriate referrals for outpatient or inpatient assistance. RN’s should first advocate for both non-pharmaceutical or non-opiate pain management. Opiate medications should then be used when other forms of pain control have been found ineffective. The opiate epidemic in the United States is an evolving crisis. Most of the current data obtained from overdose records and involvement in the criminal justice system do not illustrate the extent of the problem. Sometimes the first statistic collected on an individual is their death by overdose because their illness or substance abuse was not known by the people who interacted with them the most. Nurses are front-line direct care providers and have a unique opportunity to affect change through intervention, education and advocacy. Nurses can do much to help by becoming informed and involved in best care practices for management of this public health crisis.