In an attempt to halt the current epidemic of overdose deaths, the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) recently came forward with strong new stances on opioid pain medications. Their recommendations follow similar guidelines from such key organizations as the New York City Department of Health and Mental Hygiene and the American College of Emergency Physicians (ACEP). These organizations are urging providers to first try nonopioid agents, such as acetaminophen or ibuprofen. If opioids, such as oxycodone or hydromorphone, are prescribed, most patients should receive only a few days’ worth.
The FDA’s latest recommendations, announced in February and March 2016, include revising the label of immediate-release opioid pain medications to include additional warnings and safety information, improving access to naloxone to reverse opioid overdose, and reviewing the risk-benefit ratio of prescription opioids in terms of public health. The CDC’s newest guideline, released in March of this year, is aimed at primary care clinicians who prescribe opioids for chronic pain. It addresses the risks and potential harms of prescribing opioids and advises a cautious approach that focuses on using nonopioids first for chronic pain. The agency describes prescription pain medication overdose as an epidemic and has begun a major campaign emphasizing public awareness and cautious, evidence-based opioid prescribing. Its new guideline represents an effort to balance pain relief with the negative consequences of opioid overuse, including addiction and accidental overdose.
For emergency department (ED) and other outpatient nurses, this topic has vitally importance. EDs are the largest outpatient source of opioid prescriptions; up to 39% of all pain medications are prescribed from EDs. And nurses are at the tip of the spear, charged with assessing patients’ pain, administering drugs, and providing patient education.
It’s not surprising that public health agencies have issued new guidelines. In 2014, overdoses of opioids (such as oxycodone and hydrocodone) and related drugs (such as heroin) caused 28,647 deaths, up 14% from the year before. About one in 550 people who received opioids for chronic pain not linked to cancer died from opioid-related overdoses a median of 2.6 years after the first prescription.
But even in 2012, the statistics were troubling. In that year:
- drug overdose was the leading cause of injury-related deaths; among Americans ages 25 to 64, it caused more deaths than motor vehicle traffic crashes
- prescription drugs, particularly opioids, caused more than half of those deaths
- healthcare providers wrote 259 million prescriptions for painkillers—enough for every American adult to take home a bottle of pills.
Potential signs of opioid addiction
Signs of opioid addiction may include:
- running out of a prescription early
- saying the prescription is lost
- asking for a specific painkiller by name
- “borrowing” pain medication from others
- using multiple providers to get pain medications (“doctor shopping”).
However, research shows that more often than not, drug-seeking patients don’t fit the stereotypes. So we have no single, clear-cut way of screening for opioid addiction based on the behaviors listed above. Trying to identify patients solely from certain key behaviors isn’t just inaccurate; it also can lead to discrimination and mistrust.
Therefore, many experts conclude that the best practice is to follow safe prescribing guidelines universally. If we treat all patients with respect and use caution by following those guidelines, patient outcomes improve. (See Guidelines for safe opioid prescribing.)
Nurses caught in the middle
As a nurse, you may feel caught in the middle between patients requesting pain medications and providers who may be reluctant to prescribe them. It’s your job to assess the patient’s pain; providers rely on your assessment to guide their medication orders, especially in a busy setting.
So how do you navigate the rocky channel between ensuring patients that you’ll manage their pain and safeguarding them against possible opioid abuse? The following tips can boost your confidence in talking to patients about appropriate opioid use.
- Work with providers who can prescribe opioid medications. Discuss the topic of opioid abuse openly. Ask them if they’re aware of the new ACEP and other guidelines on pain medication prescribing. Find out how they implement them.
- Know which medications are most often abused and which can cause the most harm. The list includes morphine, fentanyl, codeine, hydrocodone (Vicodin, Lortab, Xodol), and oxycodone (OxyContin, Percolone, Oxyfast).
- Don’t rely on “pain numbers.” It’s easy to just ask a patient, “Can you tell me your pain level on a scale of 1 to 10?” But some patients quickly learn to report, “It’s a 10.” This type of assessment isn’t adequate and can lead to overprescribing. Instead, conduct a thorough pain assessment using the “PQRST” mnemonic: What Provokes the pain? What is the Quality of the pain (sharp, dull, stabbing)? Does the pain Radiate? Rate the severity of the pain using the pain S Or better yet, have patients describe pain severity: Is this the worst pain they’ve ever felt? Can they ignore it? Finally, what Time did the pain start?
- Don’t be afraid to voice your concerns to the providers you work with. In many hospitals, ED physicians belong to float pools and work in your department only occasionally. They may not recognize patients who are well-known to you. So don’t hesitate to tell a provider that while the patient was in the waiting room, you observed her talking on her cell phone, walking around and drinking a soda—even though she’s now doubled over, reporting “10/10” abdominal pain. Remember—functional assessments can be more meaningful than pain-scale ratings alone.
- Talk with patients about safe prescribing. The more you do this, the easier it becomes. Explain that new prescribing guidelines exist because of the high rate of pain medication overdoses. (For more information, read “How to Talk to Your Patients about Safe Prescribing.”)
- Know that many patients are relieved to be offered a nonnarcotic medication. The California ACEP chapter suggests telling patients, “This is the same treatment I would give my own family” or “I will provide you with good and safe medicine and not do something unsafe even if you’re asking me for that.”
- Educate patients. Some may come in asking for a specific medication, such as cough syrup with codeine, which has a high abuse potential; if the provider instead prescribes an inhaler or antibiotics, they may be upset. Inform them that cough syrup doesn’t reduce inflammation; it just suppresses the cough. Be frank; state that the medication they’re requesting has a high abuse potential and won’t help treat their cough.
- If the patient tells you a particular medication doesn’t work, ask how he or she uses it. Some patients wait 8 or 9 hours between ibuprofen doses and then complain that the medication doesn’t stop the pain.
- If your patient tells you his pain medication was stolen, ask if he filed a police report. California ACEP recommends stating, “We don’t refill lost or stolen prescriptions. If your prescription was stolen, contact the police.”
- Try to avoid the word “no.” Instead, make positive statements, such as, “I’m sorry. We follow safe prescribing guidelines” when patients request prescription refills. Practice will make these conversations easier.
- When discharging patients with opioid prescriptions, inform them about safe storage and disposal of these drugs. In 2011, 22% of 12th graders reported using prescription drugs without medical supervision at least once. In many cases, these drugs were diverted from parents’ or grandparents’ medicine cabinets.
- Finally, if the patient becomes angry or wants to talk to your manager, use this as a teaching opportunity. Bring your charge nurse, manager, or the physician into the conversation. Emphasize the need for safety and inform the patient that new opioid prescribing guidelines have been issued. Some EDs have prepared letters and handouts for this purpose.
Remember—pain is subjective. No biological marker or other test can determine a patient’s pain level. A universal safe prescribing approach toward all patients is the fairest, most ethical, and, ultimately, the safest way to treat patients and prevent opioid abuse and overdose.
American College of Emergency Physicians, California chapter. How to Talk to Your Patients about Safe Prescribing.
Cantrill SV, Brown, MD, Carlisle RJ, et al; American College of Emergency Physicians Opioid Guideline Writing Panel. Clinical policy: critical issues in the prescribing of opioids for adult patients in the emergency department. Ann Emerg Med. 2012;60(4):499-525.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. MMWR Recomm Rep. 2016;65:1-49.
Food and Drug Administration. Califf, FDA top officials call for sweeping review of agency opioids policies [press release]. February 5, 2016.
Grover CA, Elder JW, Close RJ, et al. How frequently are “classic” drug-seeking behaviors used by drug-seeking patients in the emergency department? West J Emerg Med. 2012;13(5):416-21.
Johnston LD, O’Malley PM, Bachman JG, et al. Monitoring the Future National Survey Results on Drug Use, 1975-2010. Volume I, Secondary School Students. Ann Arbor: Institute for Social Research, The University of Michigan; 2011.
Rudd RA, Aleshire N, Zibbell JE, et al. Increases in drug and opioid overdose deaths—United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64(50):1378-82.
Dorothy James Moore is an emergency department staff nurse at Kaiser Medical Center in Oakland, California and an adjunct lecturer at California State University in Hayward, California.