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. Nurses General Nursing Article

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

Check out last night's 60 Minutes segment on the cozy relationships between Republican lawmakers and the drug distribution companies. I don't think that Jarrod gonna be able to fix this one.

I saw that - it was really interesting. I hadn't considered the distributors being part of the problem.

Specializes in CRNA, Finally retired.
I saw that - it was really interesting. I hadn't considered the distributors being part of the problem.

Yes, I didn't either. What was I thinking? Hard to believe that any entity involved in patient care is so blatantly evil. Of course, I thought I already KNEW that but guess I was still a naif.

Specializes in Oncology; medical specialty website.

Articles like this scare me. I'm afraid the day may come when I'll just be given bullets to bite for my chronic pain from cancer.

Specializes in Faith Community Nurse (FCN).
Some of the "old-ish- articles and studies and texts (including what some of us were given in school) were funded and influenced by the manufacturers of opiate drugs. Sadly the public and The Joint Commission and other "official" sources parroted this contaminated info for years before the corruption came to light.

IMO the problem with seeing pain as an enemy to be eliminated is that it leads many to the conclusion that pain CAN be eliminated, especially chronic pain. The CDC now states that there is insufficient evidence to treat chronic pain from headaches and fibromyalgia and chronic low back pain with opiates AT ALL. Not because it isn't noble to relieve suffering and not because these peoples' pain isn't real but because opiates are not effective in improving many of the things you cite as consequences of pain (namely function which is what leads to many of the physical consequences you listed like PE. The studies that show some improvement in average pain rating also show that this does not have the same effect with inproving function.)

I don't think anyone wants to revert to not treating pain. But per the CDC while prescriptions for opiates have quadrupled over the past years the number of patients reporting chronic pain and the average pain level and functional measures (employment, mobility) have NOT improved. Perhaps throwing opiates at pain when there is only anecdotal evidence ("I have chronic pain and it works for me and I'm not an addict" is an anecdote) for effect isn't the answer either? Perhaps we don't HAVE a good answer, but this scares us so we refuse to see the evidence about the lack of effect of opiates or any modality? Perhaps we want to believe we can eliminate pain when really we can't in most cases? As the morphine equivalent unit dose of chronic opiates increases the pain level doesn't decrease and especially function doesnt improve...but we don't want to tell people we can't help so we sell them ineffective therapies?

Thank you for your thoughtful comment. The difficulty with narcotics is that they often do work --and quite well--but only initially. The patient feels such relief that they begin to anticipate and expect this relief as a continual state. We all hate to be in pain. And we also want very much to relieve pain whenever possible. It is beyond difficult that this class of drugs, that promise so much, simply do not deliver well over the long-term and cause a multitude of unintended consequences. That is hard for patients to see when they remember how much it helped--at first.

Specializes in Faith Community Nurse (FCN).
Articles like this scare me. I'm afraid the day may come when I'll just be given bullets to bite for my chronic pain from cancer.

This article's discussion centers around acute pain and chronic pain, specifically, and does not address oncological pain. We will never revert to not treating pain. My hope is that we are asking questions, probing what is happening with pain treatment, and looking for new ways to address pain management. Joy

Specializes in Oncology; medical specialty website.
This article's discussion centers around acute pain and chronic pain, specifically, and does not address oncological pain. We will never revert to not treating pain. My hope is that we are asking questions, probing what is happening with pain treatment, and looking for new ways to address pain management. Joy

Unfortunately, what I'm afraid will happen is knee-jerk responses to treating pain, and soon we'll be back to the bad to the "bad old days" where patients with cancer pain will be left to suffer. It happened before, so there's no reason to doubt it could happen again.

I got interested in treatment of chronic non-malignment pain when I had the opportunity to meet Margo McCaffrey years ago; she was generous with her time in mentoring me. When I started working with cancer patients, that was a whole other world. And then when cancer came knocking on my door..., well, you know the rest of the story.

Specializes in Faith Community Nurse (FCN).
Unfortunately, what I'm afraid will happen is knee-jerk responses to treating pain, and soon we'll be back to the bad to the "bad old days" where patients with cancer pain will be left to suffer. It happened before, so there's no reason to doubt it could happen again.

I got interested in treatment of chronic non-malignment pain when I had the opportunity to meet Margo McCaffrey years ago; she was generous with her time in mentoring me. When I started working with cancer patients, that was a whole other world. And then when cancer came knocking on my door..., well, you know the rest of the story.

Thank you for sharing so personally. My sincere hope and prayer is that we won't have a "knee-jerk" response as a country but one that is thoughtful and careful. In our area, East TN, we are suffering from an unprecedented wave of addiction and overdose deaths that require a compassionate and well thought through response. Again, this article is not meant to address cancer pain. As a former hospice nurse, I am very familiar with the treatment of oncological pain in hospice and never want that approach to change.

Specializes in Anesthesia.

I always try to educate patents on long term opioids that the opioids actually will make the pain worse not better. Then I talk to them about hyperalgesia and alloydonia.

I have even started doing my baratric surgery Anesthesia cases using multimodal analgesia with no opioids preoperatively or intraoperatively. It's more work to set up and run, but the patients seem to do better and the pain is still well controlled when they get to pacu.

In the clinic I used to work in I had a 16-year-old come in because he had been to the ER a couple of days before and gotten Percocet for his sore throat, and wanted more. Physical exam negative, sent him home to do warm salt water gargles and use throat lozenges. THIS is how addiction/abuse starts!

BTW, I do understand chronic pain. I have a back injury, and for the last 27 years I have lived in chronic pain (5 to 6 on the pain scale) every day of my life. I have accepted that this is my normal, and continue to work every day. On days when it gets to 7 or 8, I take two Ibuprofen and two acetaminophen 500mg, and it brings it back to a 5 or 6. I am lucky that I have found something that works, but to say that opioids are required for chronic pain is not true.

Specializes in Faith Community Nurse (FCN).
I always try to educate patents on long term opioids that the opioids actually will make the pain worse not better. Then I talk to them about hyperalgesia and alloydonia.

I have even started doing my baratric surgery Anesthesia cases using multimodal analgesia with no opioids preoperatively or intraoperatively. It's more work to set up and run, but the patients seem to do better and the pain is still well controlled when they get to pacu.

Thank you for your comment and for sharing your insights. I looked up "multimodal Analgesia" and found the following interesting article. http://www.iars.org/assets/1/7/11_RCL_Buvanendran.pdf

Joy

Specializes in Geriatrics, Dialysis.

I work in a SNF and I've seen our narcotic prescriptions vastly decrease. It wasn't that long ago that I couldn't hardly fit any more cards of pills in the narc drawer, now there are only a few. Frankly with few exceptions I sure haven't noticed any increase in pain in the residents that were weaned off opioids.

On the other hand, I work in a SNF and the majority of the people under my care are never leaving. It's become their home for the remainder of their lives, they are for the most part quite elderly. If one of my residents in is pain after an opioid wean and OTC pain meds aren't cutting it you bet I'll advocate for getting those opioids back. The medication delivery is controlled by the nurses so there's no chance of overuse and I'm really not too concerned about a 90 year old lady becoming addicted to pain pills. As long as the meds are prescribed and used appropriately there is definitely a place in medicine for their use in chronic and acute pain control.

While I don't deny there is definitely a huge issue in this country with prescription med addiction I am also afraid that the pendulum is swinging too far in the opposite direction. Providers are getting afraid to prescribe opiates even when it is clearly the best choice for the patient and patients are needlessly suffering. But that doesn't mean I think we should ever return to the days of providers handing out Norco, oxy, Percocet and dilaudid like candy at Halloween.