Accidental Pill Pusher

In this article the author discusses some of the positive steps nurses can take now to help change the direction of the opioid epidemic.

Accidental Pill Pusher

In the early 80's nursing education about pain management took a turn. Gone were the days of observing the patient for non-verbal signs of pain or of watching the clock to see when the next dose of Demerol and Phenergan were due. In its place came the pain scale that we use today and the altogether new approach, "A patient's pain is what they say it is." Unspoken was the undercurrent that pain is the enemy to be removed completely whenever possible.

At the same time, we began to see the development of long-acting narcotics and a plethora of opioid presentations that seemed to promise to wipe out all physical pain. While helping our patients get through post-operative pain or chronic pain, we saw opioids as our allies in the battle, and actively participated in educating our patients in using them for pain management.

Then came the problems. They started slow but have snowballed to mammoth proportions in the past few years. We live in a nation that takes pills for everything. The evidence is everywhere: even the evening news slot advertises for pills to help people have a bowel movement when they have narcotic induced constipation-like this is a normal thing that we should all know about!

The statistics are appalling

Since 1999, the number of overdose deaths involving opioids (including prescription opioids and heroin) quadrupled. From 2000 to 2015 more than half a million people died from drug overdoses. 91 Americans die every day from an opioid overdose. [CDC]

Drug overdoses are now the leading cause of death among Americans under 50. [NYTimes: 6/5/17]

Over two million Americans are estimated to be dependent on opioids, and an additional 95 million used prescription painkillers in the past year - more than used tobacco. [NYTimes,6/5/17]

Neonatal Abstinence Syndrome (NAS)Among 28 states with publicly available data during 1999-2013, the overall NAS incidence increased 300% (CDC)

Whether or not we are moved by the statistics, we all know people around us who have been affected by the epidemic: family members, neighbors, co-workers.

It is important in any discussion of pain management that we differentiate between acute pain, chronic pain and end of life pain. The approaches for treatment of each type vary widely, and our discussion here centers around acute and chronic pain.

The question for us, as professional nurses becomes one of urgency: what can we do to help stem the tide, to make a difference?

Teach better

We can start now with modifying how we teach our patients about narcotic use for post operative pain and chronic pain. Simply taking time to discuss non-narcotic pain relief legitimatizes it and helps it be the first line of defense when pain begins. NSAIDs, Tylenol, ice, heat, distraction, music, topical analgesics are all part of our orificenal of tools for addressing pain. The simple expectation that narcotics are a second choice can open doors for patients who are looking to manage their pain in ways that don't promote dependency.

Chronic pain requires chronic help

Chronic pain is in a category of its own. It cannot be overstated how debilitating and life-altering it is to suffer from chronic pain. We don't ever want to go back to the days of not treating pain or not feeling with someone who is hurting, but we must also adjust our thinking when it comes to using narcotics to address long-standing chronic pain. An attitude of compassionate care, gentle teaching and measured use of narcotics can together add up to a potential plan for addressing long term pain. This together with a call for the development of wholistic measures and new classes of drugs to help.

Give fewer

Encourage providers to write for fewer numbers of narcotics. Studies show that initial dependency often happens after surgery for orthopedic problems, wisdom teeth or other "routine" procedures. Young people end up with too many pills and use them. Sometimes they share them with others which further multiplies the crisis. Additionally, with heroin becoming more readily available, users may transfer from pills to IV drug use when their supply runs out. This transference to heroin has increased dramatically in recent years and adds exponentially to the overdose deaths. Also, teaching family members to monitor the pills themselves and know where to dispose of them once they are finished with the particular surgery or illness, is crucial to keeping the drugs out of the wrong hands and off the street.

Empower your patient

Know where and how to dispose of narcotics in your area. When people ask, be ready to tell them or include that in your teaching. Also, point out how many pills are in the prescription and let the patient know that they don't have to fill the total amount if they don't feel they will need that number. These measures, along with emphasizing narcotics as a second choice for pain management, may help prevent an initial addiction.

Study more

Nurses are very often on the forefront of change that improves their patient's lives. Just as we sought to approach pain differently back in the 1980's, so now we are faced with the daunting challenge of re-inventing our overall approach to pain management. What we are facing will involve us directly: making us spend more time with actual bedside pain control measures with less reliance on narcotics as the primary answer to a complaint of pain.

This is a call to action for us as professional nurses. We can help. Reversing the tide of the drug epidemic can begin with us-as we do our part to continue to relieve pain and suffering, we must also re-double our efforts to combat a growing problem by being effective teachers and by working, within our realm of influence, to make a difference.

Joy Eastridge, RN, BSN, CHPN

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jeastridge

About jeastridge, BSN, RN

(Columnist)

Joy has been a nurse for 35 years, practicing in a variety of settings. Currently, she is a Faith Community Nurse. She enjoys her grandchildren, cooking for crowds and taking long walks.

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Specializes in IMC, school nursing.

Timely delivery. I am a school nurse in a K-8 of only 125 students. Even at this young age, very few will endure a little inconvenience of pain. I have one today with a gum ulcer who has been in 5 times for Oragel. He then returned because it wasn't working. The look when I told him he may have to live with this discomfort was priceless. Where do they get this? Parents. Assessments ask what tolerable pain level a pt can withstand, my most common answer was zero, even after an attempt to clarify. We are a coddled society that demands comfort above even safety.

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Specializes in Faith Community Nurse (FCN).
Timely delivery. I am a school nurse in a K-8 of only 125 students. Even at this young age, very few will endure a little inconvenience of pain. I have one today with a gum ulcer who has been in 5 times for Oragel. He then returned because it wasn't working. The look when I told him he may have to live with this discomfort was priceless. Where do they get this? Parents. Assessments ask what tolerable pain level a pt can withstand, my most common answer was zero, even after an attempt to clarify. We are a coddled society that demands comfort above even safety.

We do ourselves and others a disservice when we establish "zero" as the desirable level of pain relief. Your story adds some humor but it also points out that the process of training --and now retraining--people in how we think about pain, begins very young. Joy

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Saw this coming for 10 years now. Giving Dilaudid like candy to patients. Seeing a post op patient go from acute pain to drug dependence within days, watching the clock. Asking for meds before they are due and doctors giving into them bc pain is subjective right. Its terrible what this epidemic has become!

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Specializes in Faith Community Nurse (FCN).
Saw this coming for 10 years now. Giving Dilaudid like candy to patients. Seeing a post op patient go from acute pain to drug dependence within days, watching the clock. Asking for meds before they are due and doctors giving into them bc pain is subjective right. Its terrible what this epidemic has become!

I feel like we have a real role to play in reversing the trend but it will require that all of us--all nurses and the whole country--make an effort. Joy

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Specializes in Adult Internal Medicine.

This is something I deal with on a daily basis in my primary care clinic. I can't even count the number of individuals, parents, children, and extended families I have seen affected by this, it extends far beyond the one individual. I have drastically changed my prescribing practices over the past few years and every time I reflect on it I think perhaps I can do more.

I will say on the other side, nurses and prescribers both need to understand that there is a sizable portion of our chronically ill that are fully dependent on these medications, often dating back to the 80s and 90s ,and those patients can't simply have their meds held because someone is concerned about addiction, especially in the acute care setting.

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Specializes in Critical Care and ED.

I hate this article and others like it because this endless discussion about opioid addiction has made pariahs and outcasts of genuine chronic pain patients. It has become trendy to immediately reject any notion of pain relief for "fear of addiction". While I do not condone pain pill misuse or over-prescription of medication, I absolutely rue the day this became a conversational topic in America. Why? Because I live with chronic pain. I am lucky to have an excellent doctor but I fear for those who can find no relief because of the few who abuse. If they don't have pills then they'll abuse something else...I'm not concerned with those decisions, but I am concerned with those who live in agony because they are denied legitimate treatment because of some draconian view that no one can received adequate medication because they'll become a drug-addled addict if they take opioids. It is coloring the way young nurses look at pain relief and I don't like it one bit. You've already seen the discussion on here where nurses are looking down on patients who request their meds.

I just pray that I can have a day without pain. I'd like to wake up and be able to have zero pain, to stand for more than 5 minutes without my back giving out, to know what it's like not to be rolling around the bed in agony because someone accidentally knocked my chair while I was sitting in it. Until then I have to take medication so I can function. Don't take it away please.

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Specializes in Faith Community Nurse (FCN).
This is something I deal with on a daily basis in my primary care clinic. I can't even count the number of individuals, parents, children, and extended families I have seen affected by this, it extends far beyond the one individual. I have drastically changed my prescribing practices over the past few years and every time I reflect on it I think perhaps I can do more.

I will say on the other side, nurses and prescribers both need to understand that there is a sizable portion of our chronically ill that are fully dependent on these medications, often dating back to the 80s and 90s ,and those patients can't simply have their meds held because someone is concerned about addiction, especially in the acute care setting.

You make some good points here. As with any societal problems, there are no quick fixes or "sure-fire" solutions. This is about intentionally examining our current practices and working toward change. As nurses, we all have a responsibility to help where we can. Joy

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Specializes in Faith Community Nurse (FCN).
I hate this article and others like it because this endless discussion about opioid addiction has made pariahs and outcasts of genuine chronic pain patients. It has become trendy to immediately reject any notion of pain relief for "fear of addiction". While I do not condone pain pill misuse or over-prescription of medication, I absolutely rue the day this became a conversational topic in America. Why? Because I live with chronic pain. I am lucky to have an excellent doctor but I fear for those who can find no relief because of the few who abuse. If they don't have pills then they'll abuse something else...I'm not concerned with those decisions, but I am concerned with those who live in agony because they are denied legitimate treatment because of some draconian view that no one can received adequate medication because they'll become a drug-addled addict if they take opioids. It is coloring the way young nurses look at pain relief and I don't like it one bit. You've already seen the discussion on here where nurses are looking down on patients who request their meds.

I just pray that I can have a day without pain. I'd like to wake up and be able to have zero pain, to stand for more than 5 minutes without my back giving out, to know what it's like not to be rolling around the bed in agony because someone accidentally knocked my chair while I was sitting in it. Until then I have to take medication so I can function. Don't take it away please.

Thank you for sharing your story and your concerns. I tried to point out in my article that chronic pain is a separate category and that there are no easy fixes--no one size fits all--when it comes to pain management. I hope that I was clear in pointing out that one of our primary concerns as nurses is for us to begin to shift our teaching--especially with acute pain--so that narcotics become second line drugs instead the go-to answer for short term pain management. And I certainly hope that patients with chronic pain will never be the victims of judgement but instead recipients of intense compassion and professional care.

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Opioid Addiction Is a Huge Problem, but Pain Prescriptions Are Not the Cause

Cracking down on highly effective pain medications will make patients suffer for no good reason

By Maia Szalavitz on May 10, 2016

"But the simple reality is this: According to the large, annually repeated and representative National Survey on Drug Use and Health, 75 percent of all opioid misuse starts with people using medication that wasn't prescribed for them-obtained from a friend, family member or dealer.

And 90 percent of all addictions-no matter what the drug-start in the adolescent and young adult years. Typically, young people who misuse prescription opioids are heavy users of alcohol and other drugs. This type of drug use, not medical treatment with opioids, is by far the greatest risk factor for opioid addiction, according to a study by Richard Miech of the University of Michigan and his colleagues. For this research, the authors analyzed data from the nationally representative Monitoring the Future survey, which includes thousands of students."

Opioid Addiction Is a Huge Problem, but Pain Prescriptions Are Not the Cause - Scientific American Blog Network

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Specializes in Adult Internal Medicine.
If they don't have pills then they'll abuse something else...I'm not concerned with those decisions

We should all be concerned with the amount of opioid abuse in this country, whether that is from a public health standpoint or, at least, a financial standpoint.

but I am concerned with those who live in agony because they are denied legitimate treatment because of some draconian view that no one can received adequate medication because they'll become a drug-addled addict if they take opioids.

I hear your concern with this. I have seen the evidence of nursing posting here that seem to not understand what their role in the opioid epidemic is. The title of this thread itself can be leading down that path. The truth of the matter is that the opioid crisis really doesn't/shouldn't involve those already on long-term opioids, rather it should focus full force on those that are being prescribed opioids as new scripts.

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Specializes in Adult Internal Medicine.
Opioid Addiction Is a Huge Problem, but Pain Prescriptions Are Not the Cause

Cracking down on highly effective pain medications will make patients suffer for no good reason

By Maia Szalavitz on May 10, 2016

"But the simple reality is this: According to the large, annually repeated and representative National Survey on Drug Use and Health, 75 percent of all opioid misuse starts with people using medication that wasn't prescribed for them-obtained from a friend, family member or dealer.

And how did those prescription pills get to the friend, family member, or dealer? The title of that article says "pain prescriptions are not the cause" but they play a huge role in the epidemic. Pain scripts are getting written for too large a quantity, too long a duration, and for inappropriate use which means there are lots of extra pills making their way into other people's hands.

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