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
