The third new continuing education course for Advance Practice RNs fromNursingCE.com on the subject of pain management covers the topic of opioid prescribing. This is the third in the 3-part series of CE courses on pain management for nurses and APRNs designed to help enhance nursing education, knowledgebase and improve quality of patient care and outcomes.
What are opioids?
Opioids are a group of analgesics that are listed as controlled substances. They are commonly prescribed to control moderate to severe pain. Opioids bind to the mu-opioid receptors throughout the central nervous system and thereby block (or reduce) the pain signals to the brain. This then alters the body’s pain perception and responses to the pain stimulus. Opioids are classified as either agonist, partial agonist or mixed agonist-antagonists.
Agonists such as Norco, Vicodin, OxyContin, Morphine, MS-Contin, and Dilaudid, produce the strongest biologic effect between binding to the receptors and pain relief response. There is also a strong potential for respiratory depression and this risk must be weighed against positive pain management effects. There is also an opioid effect on receptors in the respiratory system as well as the gastrointestinal system and opioids can be effectively prescribed for severe cough or diarrhea.
Partial agonists are somewhat weaker and have a submaximal response between the receptor binding and pain relief response. These include drugs such as Tramadol and Suboxone. These are more often prescribed for chronic pain due to the fact that they have a lower potential for abuse and addiction. They also have a lower probability of respiratory depression. They do have side effects of dizziness, vertigo, nausea, constipation and headaches.
The mixed agonist-antagonist opioids have a mixed effect on receptors. They will bind to one receptor for a specific response and then bind to another to prevent a response. Common drugs in this category include Talwin and Stadol.
Opioids can be administered in a variety of ways including orally, transdermally, and by injection including IM, SQ and IV. Oral administration is not only the cheapest route, but it is also the easiest to administer. Oral administration also allows the best-case scenario for monitoring. However, this is usually the shortest acting route which may have contraindications for effective pain management.
Best practice for obtaining appropriate level of pain control with opioids depends on nurses having a solid understanding of terms related to the use of opioids. These terms include addiction, dependence and tolerance. Each of them can be easily misconstrued or misunderstood and this can adversely affect the pain management.
By definition, tolerance indicates that the body, upon exposure to the opioid, has adapted to the changes and biological effects induced on the body over time. The body will therefore require increasing doses of the opioid in order to achieve the same level of response.
There are two basic aspects to dependence; one is physical and the other is psychological. Physical dependence is based on the body’s experience of physically adapting to the presence of the opioid in the system and the pain relief achieved and a return to normal bodily function. It is also defined as causing withdrawal symptoms caused by sudden cessation of the drug, rapidly reducing the dosage or use of an antagonist such as Narcan.
Psychological dependence is defined as when the body becomes aware of the reduction of symptoms with ingestion/administration of the opioid. Anxiety and depression may also be reduced, and the drug creates a calming, reassuring sensation similar to that of other comfort measures or feelings of security.
The US Substance Abuse and Mental Health Services (SAMHSA) lists seven criteria for dependence and defines dependence when at least three of these criteria are met:
- The patient spends a lot of time engaging in the activities that are related to the opioid
- The patient uses the opioid in higher quantities for longer length of time than intended
- Patient has developed a tolerance for the opioid
- Patient makes unsuccessful attempts to cut down on the use of the opioid
- Patient continues to use the opioid despite physical or mental problems associated with use
- Patient experiences decreased or even elimination of participation in other activities because of the use of the opioid
- Patient experiences withdrawal symptoms when cutting back or ceasing use of the opioid
Opioid addiction is a medical crisis in the US. Many steps have been taken to reduce addiction. Some of them have cause problems for patients with acute illness and injury as well as chronic pain because opioids are not being prescribed. Addiction is a complicated process involving many factors including physical, genetic, psychosocial and environmental factors affecting the neurobiological makeup. Addiction is most often manifested in behaviors that include the presence of physical and psychological cravings for the opioid, inability to control use of the opioid and a compulsive continuation of use of the opioid despite any physical or emotional harm.
Effective pain management with opioids involves understanding the pain, the risks, the effects on quality of life and the patient’s goals. It also involves patient education and ability work together with practitioners to avoid complication and addiction. There is a lot more to learn from this course and the entire 3-part series on pain management.