I have practiced in pain management for 20 years and have seen many changes in how pain is perceived and treated. When I first started to practice in the late 1990s, I used the oncology model, which treated pain aggressively, and opioids were commonly given for all types of pain. However, my prescribing patterns changed as I became aware of the extent of opioid misuse and abuse. I trimmed my prescription times from 14 days to 10 days, then to 7 days, and finally to 3 to 5 days. I did not want to be responsible for a patient getting into trouble with opioid use.
Who becomes addicted?
There is evidence that some surgical patients just never give up using their opioids and become, not dependent, but truly addicted. Patients do not come with tags on saying, "I am the one who will become addicted to my pain medications," or, "I will be able to stop opioids once my pain resolves." You never know what the outcome will be.
Nightly news programs began to report the unexpected, sudden deaths of actors, musicians, and comedians due to substance abuse and overdoses of controlled substances. Great talents like Prince, Amy Winehouse, Whitney Houston, and John Belushi were all lost to addictions, which these individuals had little or no control over.
The opioid epidemic
Opioid-related deaths are on the rise in the United States. Twenty percent of all patients who go to a primary care provider for pain leave with a prescription for an opioid. The CDC estimates that more than 250 million prescriptions for opioids are written each year-enough to provide these potent pain relievers to every adult in the United States. According to the CDC, prescription opioids accounted for more than 14,000 deaths in 2014.1
I have treated heroin addicts for pain. Many of them really do not want to be addicts, but once they start, they simply cannot control their substance use. Many are polysubstance abusers and mix all types of drugs to get the effect (or "high") they are looking for. Treating pain in these patients requires patience, knowledge of opioid dosing, and a willingness to stick with the patient through the entire treatment period. The high doses of opioids some patients require to even begin to control pain cause many nurses to fear an overdose.
Opioids are by far the cleanest medications for treating severe pain. They are opium derivatives or synthetic compounds that act at the mu receptors found throughout the body. The drugs also can affect the pleasure centers in the brain, creating a sense of well-being and a desire for the pleasure stimulus. Opioids have been abused for pleasure throughout the ages. Opioid abuse is nothing new. It is the skyrocketing rates that are truly shocking.
The Opioid Risk Tool
New screening tools to identify patients who will have difficulty with opioids (such as the Opioid Risk Tool and blood and saliva tests to determine genetic susceptibility to addiction) can help NPs determine which patients need closer monitoring and oversight.2
I have prescribed large amounts of opioid drugs to cancer patients and acute care patients in my clinical practice. Acute pain is one area of practice where opioids are still indicated to help patients regain functionality and recover. However, there is little evidence that short-acting opioids provide positive outcomes for chronic pain patients. Therefore, I am now more cautious and careful in my patient assessments and reassessments.
I make it clear that the expectation is that the patients will taper themselves off of their pain meds when their pain improves. I am much quicker to send the patient for an evaluation to psychiatry to determine if the patient is becoming too dependent on opioids. I practice safe prescribing and careful monitoring because all of my patients are important to me.
Yvonne D'Arcy, MS, CRNP, CNS
Pain management NP and pain management consultant Ponte Vedra Beach, Fla.
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