About this course:
This 1-hour course discusses prescription opioid drugs, including alternatives to opioids for managing and treating pain, and the risks and signs of opioid abuse, addiction, and diversion. The purpose of this activity is to review terminology regarding the opioid epidemic and examine the pathophysiology, contributing factors, clinical manifestations, evaluation, and evidence-based management strategies of opioid misuse.
After this activity, the learner will be prepared to:
- define the terms opioid, drug misuse, opioid use disorder (OUD), medication-assisted treatment (MAT), morphine milligram equivalent (MME), and prescription drug monitoring programs (PDMP)
- discuss the background of the opioid epidemic, including risk factors for opioid misuse
- describe the pathophysiology of opioid pain management and OUD
- describe the clinical manifestations of OUD, including relevant history and physical examination findings
- discuss evaluation and treatment strategies for patients with OUD, including alternative management of chronic pain
- recognize the most common examples of opioid diversion and the nurse's role in education and advocacy related to the opioid epidemic
Since the 1990s, the use of prescription and illicit opioids has increased to epidemic proportions. Understanding the contributing factors and management strategies for this epidemic requires comprehension of relevant terminology. Key terms are as follows (Centers for Disease Control and Prevention [CDC], 2021a; Strain et al., 2021):
- Opioid refers to natural, synthetic, or semi-synthetic substances that act on 1 of 3 opioid receptor systems (mu, kappa, delta) in the body and brain. Opioids can have analgesic effects and depress the central nervous system. Examples include illegal heroin and opioid analgesics.
- Opioid analgesics, commonly referred to as prescription opioids, are used to treat moderate to severe pain and can include natural opioid analgesics (morphine and codeine), semi-synthetic opioid analgesics (oxycodone, hydrocodone, and hydromorphone), and synthetic opioid analgesics (methadone, tramadol, and fentanyl).
- Drug misuse refers to the use of illegal drugs or prescription drugs in a manner other than directed by a provider (e.g., greater amounts, more frequently, beyond the prescribed period).
- Tolerance occurs when there is a reduced response to a drug with repeated use. Tolerance requires an increase in the dose to achieve the same effect.
- Dependence refers to the adaptation to a drug that produced withdrawal symptoms when the drug is stopped abruptly.
- Opioid use disorder (OUD) is the preferred term for problematic opioid use patterns that cause significant impairment or distress. A diagnosis of OUD is based on unsuccessful efforts to control or reduce use or the emergence of social problems (e.g., failure to fulfill obligations at work, school, or home).
- Medication-assisted treatment (MAT) refers to medications (e.g., methadone, buprenorphine, or naltrexone) used to treat OUD in combination with counseling and behavioral therapies.
- Morphine milligram equivalent (MME) is the milligrams of morphine an opioid dose is equal to when prescribed and is calculated to standardize differences between opioid drug type and strength.
- Prescription drug monitoring programs (PDMPs) are state or territorial-run electronic databases that track controlled substance prescriptions. PDMPs alert providers about patients at risk for opioid misuse, OUD, or overdose based on concerning behaviors (e.g., overlapping prescriptions, high dosages, or co-prescribing of opioids with benzodiazepines; CDC, 2021a).
The Opioid Epidemic: Background
OUD affects over 16 million people worldwide, resulting in over 120,000 death annually (Dydyk et al., 2021). The opioid epidemic began in the 1990s when attitudes toward pain management and opioid safety shifted from conservative prescribing to more widespread use (Lyden & Binswanger, 2019). Previously, these medications were primarily reserved for end-of-life care and severe cancer pain. However, patient advocate groups and pain specialists, including the American Pain Society (APS), began to raise awareness of the inadequate treatment of non-cancer pain and the underutilization of pharmaceutical opioids, leading a movement to treat pain known as the "fifth vital sign." As a result, in 2001, the Joint Commission (TJC) set new pain management standards, which tied patient satisfaction and healthcare quality to pain control (Baker, 2017). In addition, pharmaceutical companies reassured the medical community that patients would not become addicted to the therapeutic use of opioids (US Department of Health and Human Services [HHS], 2021). The increased awareness of pain management and the widespread marketing campaigns of pharmaceutical companies resulted in an alarming escalation in providers prescribing opioids. In 2010, opioid prescribing peaked at 225 million prescriptions dispensed, equating to 81.2 prescriptions per 100 persons. In addition, between 1999 and 2009, opioid misuse began to increase, and death rates involving pharmaceutical opioids rose nearly fourfold (Guy et al., 2017).
Opioid prescribing rates stabilized in 2012 and slowly declined over the next 5 years (Lyden & Binswanger, 2019). However, as providers attempted to control the overprescribing of pharmaceutical opioids, many patients turned to illicit opioids (e.g., heroin) and synthetic opioids (e.g., fentanyl). According to the 2019 National Survey on Drug Use and Health, 9.7 million Americans over the age of 11 reported misusing prescription opioids in the last year (US Substance Abuse and Mental Health Services Administration [SAMHSA], 2020). In addition, 42,000 Americans died from an opioid overdose in 2016, representing a 27% increase from 2015 to 2016. The CDC estimates that over 80% of these deaths involved heroin or a synthetic opioid, equating to a 4-fold increase in heroin deaths and a 20-fold increase in synthetic opioid deaths from 1999 to 2016 (O'Donnell et al., 2017). As a result, the HHS (2017) declared a public health emergency related to the opioid epidemic and announced a 5-point strategy to combat the crisis. However, even with the initiation of various techniques to target the opioid epidemic, 3 million people in the US suffer from OUD, and more than 500,000 are dependent on heroin (Azadfard et al., 2021). The CDC (2021c) estimates that 71,000 people died in 2019 from a drug overdose.
Opioids are prescribed to control pain, decrease coughing, or relieve diarrhea (Dydyk et al., 2021). Opioids bind to receptors (delta, kappa, and mu) in the central and peripheral nervous systems, leading to a feeling of euphoria (Azadfard et al., 2021). Delta receptors act on the central nervous system, inducing physiological effects (e.g., analgesic, antidepressant, respiratory depression, convulsant, and physical dependence). Kappa receptors also act on the central nervous system, inducing physiological effects (e.g., analgesic, anticonvulsant, hallucination, diuresis, dysphoria, miosis (pinpoint pupils), neuroprotection, and sedation). Mu receptors induce physiological effects on the central nervous system (e.g., analgesic, physical dependence, respiratory depression, miosis, reduced gastrointestinal motility, euphoria, and vasodilation) and peripheral nervous system (e.g., depressed cough reflex and constipation). Opioids can be endogenous (e.g., endorphins), naturally occurring opium alkaloids (e.g., morphine, codeine), semi-synthetic (e.g., heroin, made from morphine), and synthetic (e.g., fentanyl and methadone, which have chemical structures that differ from opium alkaloids but bind to the same receptors; Lyden & Binswanger, 2019).
Chronic opioid use causes alterations in receptor sensitivity, leading to changes in pain perception and medication tolerance (Azadfard et al., 2021). Opioid tolerance, dependence, and OUD are distinct phenomena with markedly different clinical implications. Both opioid tolerance (diminis
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OUD is a multifaceted disorder, with biological, environmental, genetic, and psychosocial risk factors contributing to the opioid crisis. Biologically, patients with a deficiency in neurotransmitters such as dopamine are more likely to seek external sources of endorphins. Genetically, there is a 50% heritability to OUD. For example, when a first-degree relative has a substance abuse disorder. Environmentally, OUD is more likely to occur when there is exposure or pressure from peer relationships. Psychosocially, patients with a history of depression, post-traumatic stress disorder (PTSD), or anxiety are more likely to experience OUD (Dydyk et al., 2021). Additionally, risk factors for opioid misuse include initiation at a young age (prescribed or illicit), previous history of illicit drug or alcohol abuse, sexual abuse in females, white race, and psychological comorbidities (bipolar disorder and attention deficit hyperactivity disorder; Azadfard et al., 2021). Finally, the misuse of prescription opioids is a risk factor for subsequent heroin use, as research has shown that the first opioid abused is most often a prescription opioid (Cicero et al., 2014).
The clinical manifestations of OUD may vary depending on the duration and intensity of opioid use. Therefore, providers and nurses should obtain a detailed history and physical examination for anyone with suspected OUD. However, obtaining a thorough history can be challenging as patients may withhold or minimize the details of their opioid use for fear of stigma (Azadfard et al., 2021).
Taking a history of drug use from a patient with suspected opioid misuse or OUD should include identifying the substance/s used, frequency of use, amount consumed, and problematic consequences of use (e.g., treatment history and age at first use; Strain et al., 2021).
- Consumption: The amount of drug consumed influences the likelihood and severity of withdrawal symptoms if the opioid is stopped. Ask patients about the consumption of prescription opioids, non-medical use of opioids, and illicit use of synthetic or semi-synthetic opioids. Additionally, ask patients about co-dependency with other drugs or alcohol.
- Route of administration: Prescription opioids and heroin can be consumed via various routes, including intravenous (IV), intranasal, oral, and Inhalation. IV administration produces a rapid, high bioavailability of the opioid and is the route by which most overdoses of heroin occur.
- Tolerance: Chronic use of opioids will lead to opioid tolerance, in which larger doses are required to achieve the desired effect. Patients who report increasing the frequency and strength of opioids are at risk for opioid withdrawal if stopped abruptly.
- Last use: The date of last use, dose, frequency, and pattern of use are essential information to obtain during the history taking
- Treatment history: Ask the patient about past treatment for OUD (e.g., medically supervised withdrawal; opioid maintenance with medications such as methadone; inpatient, residential, or outpatient counseling). Additionally, ask about past and present physical and psychiatric conditions and the impact of OUD on employment and relationships (Strain et al., 2021).
A physical examination, including a complete head-to-toe assessment, should be performed to evaluate signs of opioid misuse and OUD. Patients who sporadically misuse opioids in small amounts may appear healthy on physical examination. However, patients with chronic opioid use may appear sedated and display miosis and a hyperactive response to pain. Physical examination findings for a patient with opioid intoxication can include confusion, miosis, hypersomnia, and slurred speech. In addition, patients with suspected chronic opioid use should be assessed for signs of acute opioid withdrawal (e.g., watery eyes, runny nose, yawning, muscle twitching, hyperactive bowel sounds, piloerection, agitation, diaphoresis, vomiting, and elevated blood pressure and heart rate). In addition, the nasal septum should be examined for perforation from repeated intranasal opioid use. Finally, for patients with repeated IV opioid use, physical exam findings may include track marks (callouses and scars along a subcutaneous vein, usually on the dorsal aspect of hands, antecubital fossae, legs, and neck), poor dentition, lack of IV access, abscess, or cellulitis (Azadfard et al., 2021; Dydyk et al., 2021; Strain et al., 2021).
Evaluation and Treatment
A diagnosis of OUD is primarily based on the findings from the history and physical exam. A urine drug screen can detect metabolites of morphine and heroin, usually 1 to 3 days after the last use. However, some opioid analgesics are not always detected by this test (e.g., oxycodone and methadone), and there is a potential for false-positive and false-negative tests. In addition, if OUD is suspected, a complete blood count (CBC) and liver function tests (LTFs) may be ordered to screen for infection and liver dysfunction. Patients with suspected or confirmed IV heroin use should be screened for human immunodeficiency virus (HIV), hepatitis (A, B, and C), syphilis, and tuberculosis. The nurse should monitor vital signs frequently, perform neurological checks, and continually assess for signs and symptoms of opioid withdrawal (Clinical Opiate Withdrawal Scale [COWS] score greater than 10). Patients experiencing opioid withdrawal can be treated with antiemetics, antidiarrheals, and IV hydration. If a patient is unconscious or obtunded, a respiratory assessment (e.g., listen to lung sounds) should be monitored for aspiration. If opioid overdose is suspected based on respiratory depression or cardiac arrest, treatment with naloxone should be initiated immediately. Naloxone (Narcan) can be administered intravenously, intranasally, or intramuscularly, usually starting at 0.4 to 0.8 mg. For patients who have taken large amounts of opioids, larger and more frequent doses of naloxone may be indicated. Naloxone rapidly displaces opioids from opioid receptors and prevents opioid activation of these receptors (Azadfard et al., 2021; Dydyk et al., 2021; Strain et al., 2021).
All patients with OUD should be offered inpatient or outpatient substance use disorder (SUD) treatment (Azadfard et al., 2021). In addition, several medications have shown promising results in the treatment of OUD (e.g., buprenorphine, methadone, and naltrexone; Bart et al., 2020). MAT refers to using medications described previously combined with counseling and behavioral therapies (e.g., cognitive-behavioral therapy [CBT]). The goal of MAT is to limit opioid use to the minimum level needed to provide pain relief and prevent relapse for patients who are no longer using opioids. PDMPs offer an online database listing all prescribed controlled substances dispensed to each patient by pharmacies in the region. All states have PDMPs, and prescribers should search the database as per state policies before prescribing controlled substances. OUD or diversion could be suspected when a patient does not disclose an existing or recent controlled substance prescription (Becker & Starrels, 2021). Finally, naloxone kits (Figure 1) are recommended for individuals who take chronic opioids or those who may witness an opioid overdose (e.g., first responders or substance abuse programs (SAP); Dydyk et al., 2021).
Alternatives to Opioids for Pain Management
Given the severity of the opioid epidemic, healthcare providers must utilize effective pain management strategies. The first step in preventing OUD is to avoid prescribing controlled substances when safer, effective alternatives are available (Becker & Starrels, 2021). According to the CDC (2021b), 11% of adults experience daily pain, with millions of Americans treated with prescription opioids. In addition, providers are often uncomfortable determining when it is appropriate to prescribe opioids. Therefore, the CDC established the Guidelines for Prescribing Opioids for Chronic Pain, seeking to improve communication between patients and providers and reduce the risks associated with long-term opioid therapy. These guidelines are not intended for patients with active cancer treatment, palliative, or end-of-life care and include 12 best practice reminders (CDC, 2016a):
- Opioids are not a first-line or routine treatment for chronic pain; nonpharmacologic and non-opioid pharmacologic therapy are preferred.
- Before starting opioid therapy for chronic pain, a patient's treatment goals should be established (e.g., realistic goals for pain and discontinuing opioid therapy).
- Before starting and routinely during opioid therapy, clinicians should discuss the risk and benefits of non-opioid treatments.
- When starting opioids for chronic pain, clinicians should prescribe immediate-release instead of extended-release opioids.
- Clinicians should prescribe the lowest effective dosage (e.g., ≤ 50 morphine milligram equivalents [MME]).
- When opioids are prescribed for acute pain management, 3 days should be sufficient and no more than 7.
- Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy and reduce or taper the medication if needed.
- Before starting and routinely during opioid therapy, clinicians should implement strategies to mitigate opioid risks (e.g., monitoring OUD and providing the patient naloxone).
- Clinicians should check PDMPs for undisclosed opioid prescriptions.
- Before being prescribed opioids and again annually, patients should undergo urine drug screening for other controlled substances or illicit drugs.
- Avoid prescribing opioids and benzodiazepines concurrently.
- Clinicians should arrange for evidence-based treatment (MAT with buprenorphine or methadone combined with behavioral therapies) for patients with OUD.
Although opioid prescriptions will be necessary to treat many patients with chronic pain, evidence suggests that non-opioid treatments (e.g., medications and nonpharmacological therapies) can be effective and safer. Practical approaches to chronic pain should include the following measures (CDC, 2016b):
- prioritize the utilization of non-opioid therapies as often as possible
- identify and address co-existing mental health conditions (e.g., anxiety, depression, and PTSD)
- focus on functional goals by actively engaging patients in their pain management
- use disease-specific treatments when available (e.g., triptans for migraines, and anticonvulsants [e.g., gabapentin (Neurontin), pregabalin (Lyrica)] or antidepressants [e.g., duloxetine(Cymbalta)] for neuropathic pain)
- use first-line medication options
- consider interventional therapies (e.g., corticosteroid injections) for patients who fail standard non-invasive treatments
- use multimodal approaches (e.g., interdisciplinary rehabilitation for patients who have failed traditional treatments, have severe functional deficits, or psychosocial risk factors)
Non-opioid medications can be beneficial for chronic and disease-specific pain. See Table 1 for non-opioid medication options and indications.
Nonpharmacologic therapies include an array of treatments that can be beneficial for treating chronic pain, including exercise therapy, psychoeducational interventions (e.g., CBT, family therapy, psychotherapy, and patient education), mind-body therapies (e.g., mindfulness-based stress reduction [MBSR]), and physical interventions (e.g., physical therapy, acupuncture, chiropractic manipulation, and massage). These therapies can be done alone or in combination with other nonpharmacologic treatments or non-opioid medications. In addition, individuals may choose a treatment based on personal preference, type of pain, access to care, and costs (Tauben & Stacey, 2020).
Drug diversion occurs when prescription medications are obtained or used for illegal purposes. Drug diversion is a complex problem involving multiple parties, including patients, providers, nurses, and pharmacists. The Office of Inspector General (OIG, n.d.) reports that investigations of opioid drug diversion are on the rise because drug users prefer prescription opioids to street drugs, and drug diverting is lucrative. For example, the OIG reports that a bottle of 30 Oxycontin 30 mg dose pills can be trafficked for $1100-$2400, which Is 12 times the price of the prescription. Opioid diversion schemes have been carried out by drug-seekers, utilizing fake names to obtain repeat prescriptions from various providers. Providers have been investigated for opioid diversion due to writing illegal or medically unnecessary prescriptions. In addition, pharmacists and pharmacy owners have stocked or re-labeled expired or counterfeit medications, selling them illegally and billing insurance companies (OIG, n.d).
Nurses have also been part of drug diversion schemes, primarily in the hospital setting. When healthcare providers divert controlled substances, they put patients at risk of harm (e.g., substandard care delivered by an impaired healthcare provider, denial of pain medication, medication errors, and risk of infection). The CDC and state and local health departments have investigated outbreaks of infection stemming from drug diversion or tampering with injectable drugs (e.g., hepatitis C virus and bacterial pathogens; CDC, 2019). The US SAMHSA and American Nurses Association (ANA) have documented that 10% of healthcare workers abuse drugs (TJC, 2019). Due to the availability of opioid medications in healthcare organizations, drug diversion can be difficult to detect and prevent. Healthcare organizations that dispense opioids should have a comprehensive controlled substances diversion prevention program (CSDPP) and an organizational culture that empowers staff to speak up when something seems abnormal or unsafe.
According to TJC (2019), healthcare organizations should focus on three critical components for drug diversion: prevention, detection, and response:
- Prevention is the priority. Healthcare systems must have safeguards such as CSDPPs and must educate staff on these programs and protocols.
- Healthcare facilities must have systems to facilitate early detection (e.g., video monitoring in high-risk areas, active monitoring of pharmacy and dispensing record data, and fostering staff awareness of and reporting signs of potential diversion).
- Facilities should create a patient-safety culture and empower healthcare workers to report any unusual or suspicious behavior (e.g., "see something, say something"). Healthcare workers should watch for abnormal behaviors, altered physical appearance, and poor job performance of coworkers. In addition, drug diversion should be suspected when controlled substances are removed with no order, product containers are compromised, medication is documented as given but not administered, excessive medication pulls are noted (e.g., one nurse administering significantly more opioid medications compared to colleagues), waste is not appropriately witnessed, and patients continue to report excessive pain despite documented administration of pain medication.
A Nurse's Role in Prevention and Advocacy
While efforts have successfully decreased the number of opioid prescriptions, synthetic and semi-synthetic agents remain high. In 2019, 71,000 people died from drug overdoses, making it a leading cause of injury-related death in the US. In addition, the rate of overdose deaths involving synthetic opioids was 11 times higher in 2019 compared to 2013. Many national organizations have created strategies to combat this opioid epidemic. The CDC has outlined five key strategies to guide its mission to prevent opioid misuse, overdose, and death. These strategies include the following:
- conducting surveillance and research (providing high-quality, timely data to track opioid deaths)
- building state, local, and tribal capacity (providing support for PDMPs, regulating controlled substances, licensing healthcare providers, responding to drug overdose outbreaks, and running public insurance programs)
- supporting providers, health systems, and payers through guidelines for prescribing opioids for chronic pain
- partnering with public safety entities to reduce drug overdoses
- empowering consumers to make safe choices by raising awareness about the risk of opioid misuse (CDC, 2021c)
The ANA (2018) recognizes the central role that nurses play in addressing the opioid epidemic. Nurses are frontline care workers who are pivotal to advocating for effective pain management while preventing opioid overuse and dependence. In addition, as educators and patient advocates, nurses can assist patients with holistic approaches to pain management, including nonpharmacologic treatments and non-opioid medications. The ANA stresses the importance of a comprehensive approach that focuses on:
- eliminating barriers to effective pain management (e.g., system, clinician, patient, and insurance)
- viewing prescribers as gate-keepers for prescription opioids (e.g., improving clinician education and enhancing PDMPs)
- using naloxone for prescription and illicit opioid overdose
- expanding access to MAT for OUD
- promoting the safe storage of prescription opioids and disposal of unused opioids
- addressing the stigma associated with OUD (ANA, 2018)
Finally, the American Sentinel College of Nursing and Health Services (ASCNHS, 2016) outlined additional ways in which nurses can help address the opioid epidemic, including:
- using the medication reconciliation process to educate patients about opioid tolerance, misuse, and diversion
- educating patients that sharing opioid prescriptions could result in serious harm
- reviewing proper storage (to prevent diversion) and disposal of opioids
- reviewing safe prescribing practices and monitoring of opioids (for advanced practice nurses [APNs])
- advocating for expanded access to MAT and responsible naloxone distribution (ASCNHS, 2016)
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