Opioids have become a leading cause of uninten­tional injury death in Washington, even more than motor vehicle accidents or firearm fatal­i­ties, according to 2016 state data. Nation­wide, the Centers for Disease Control and Preven­tion (CDC) reports that overdose deaths related to prescrip­tion opioids have quadru­pled since 1999. Nurses can play an impor­tant role in reducing these deaths, as well as addic­tion problems, through their assess­ments and monitoring of patients.

The depth and breadth of prescrip­tion opioid abuse is far-reaching. A 2016 study published in the Journal of the American Medical Associ­a­tion (JAMA) by Baker and colleagues notes that there is signif­i­cant variability in the amount of opioids prescribed. The most commonly dispensed opioid was hydrocodone (78 percent), followed by oxycodone (15.4 percent).

Every day, more than 1,000 people are treated in emergency depart­ments for misusing one of these prescrip­tion opioids. In 2014, almost 2 million people in the United States abused or were depen­dent on prescrip­tion opioids. At least half of all opioid overdose deaths involve a prescrip­tion opioid and strike a wide adult popula­tion, with prescrip­tion opioid overdose rates between 1999 and 2014 highest among people age 25 to 54, according to the CDC.

But there may be a course correc­tion underway. A 2015 study in the American Journal of Preven­tive Medicine reported a decrease in the rate of prescribing opioids (- 5.7 percent), perhaps indicating that more health­care providers are becoming aware of the addic­tion issue.

At the same time, it’s impor­tant for nurses to be well aware of steps they can take to help protect themselves from possible legal action stemming from opioids.

Assess the patient carefully

Pain medica­tion should be matched to the individual patient’s needs. This begins with a detailed medical history, including a list of currently prescribed and past medica­tions. Ask about a history of substance use or substance use disor­ders in the patient and the patient’s family. If opioids are being consid­ered, assess the patient’s psychi­atric status.

A physical exam should also be completed, keeping in mind signs and symptoms of possible substance abuse, such as advanced periodon­titis, traumatic lesions and poor oral hygiene. If patients are already being managed for chronic pain, the nurse should consult with the appro­priate provider.

Screen and refer patients

One model for follow-up of possible substance abuse is Screening, Brief Inter­ven­tion and Referral to Treat­ment (SBIRT) from the Substance Abuse and Mental Health Services Admin­is­tra­tion. SBIRT is a method for ensuring that people with substance use disor­ders and those at risk for devel­oping these disor­ders receive the help they need.

Nurses also can help detect patients with substance misuse with the National Insti­tute on Drug Abuse (NIDA) Quick Screen. If a substance use disorder is suspected, the nurse should remain nonjudg­mental while refer­ring patients for further evalu­a­tion and treat­ment, so they receive the care they need.

Nurses need to closely monitor patient use of controlled drugs to avoid overde­pen­dence or poten­tial addic­tion, and refer chronic pain patients to a pain manage­ment center or specialist. Be sure to document the referral in the patient’s health record. Nurses also should consider referral for patients who seek opioids beyond when they are likely to be needed.

Apply evidence-based pain management

To provide optimal patient care, as well as to protect themselves from legal action, nurses should practice evidence-based pain manage­ment. That includes consid­ering non-steroidal anti-inflam­ma­tory drugs (NSAIDs), such as ibuprofen, as first-line pain medication.

NSAIDs have been shown to be at least as effec­tive (if not more so) than opioids for managing pain, partic­u­larly in combi­na­tion with aceta­minophen. Before patients begin taking NSAIDs, verify that they are not taking other antico­ag­u­lants, including aspirin, and check for hepatic or renal impairment.

Nurses should complete contin­uing educa­tion courses in pain manage­ment and document they did so, which can provide evidence of their knowl­edge in event of legal action.

Educate patients

Nurses have an oppor­tu­nity to educate patients about the role of pain medica­tion in their care. This educa­tion should include pain medica­tion options and the reasons why non-opioids are preferred.

Verbal and written instruc­tions after the proce­dure need to contain name of drug, dosage, adverse effects, how long the drug should be taken and how to store it. Results from a 2016 survey published in JAMA Internal Medicine found that more than half (61 percent) of those no longer taking opioid medica­tion keep it for future use, so patients need to be told to dispose of unused drugs and how to do so. Patients can search for places that collect controlled substance drugs through the Drug Enforce­ment Admin­is­tra­tion at www​.deadi​ver​sion​.usdoj​.gov.

The same survey found that about 20 percent shared the opioid with another person, so educa­tion material should mention not to do this. Nurses should also discuss the perils of driving or under­taking complex tasks while taking an opioid. Document in the patient’s health record that this infor­ma­tion was provided and the patient acknowl­edged receipt and under­standing. An office visit can also provide the oppor­tu­nity for nurses to address opioid abuse on a larger scale.

Below are some consid­er­a­tions for the use of pain medica­tion in patients:

  • Use non-steroidal anti-inflam­ma­tory drugs (NSAIDs) as the first option. Consider a selec­tive NSAID to avoid increased risk of bleeding. Know that using aceta­minophen in combi­na­tion with NSAID may have a syner­gistic effect in pain relief. (Do not exceed 3,000 mg/​day in adults.)
  • Provide patient education
  • Document patient commu­ni­ca­tions, educa­tion and refer­rals in the health record

Nurses who assess and monitor patients for treat­ment of pain are encour­aged to be mindful of and have respect for their inherent abuse poten­tial. Doing so helps protect patients from harm and nurses from poten­tial liability.

About the author

David Griffiths is senior vice presi­dent of program manage­ment for Nurses Service Organi­za­tion (NSO), where he develops strategy and oversees execu­tion of all new business acqui­si­tion and customer reten­tion for the group’s allied health­care profes­sional liability insur­ance programs. With more than 15 years of experi­ence in the risk manage­ment industry, he leads a team covering account manage­ment, marketing and risk manage­ment services. 

This risk manage­ment infor­ma­tion was provided by Nurses Service Organi­za­tion (NSO), the nation’s largest provider of nurses’ profes­sional liability insur­ance coverage for over 650,000 nurses since 1976. INS endorses the individual profes­sional liability insur­ance policy admin­is­tered through NSO and under­written by American Casualty Company of Reading, Pennsyl­vania, a CNA company. Repro­duc­tion without permis­sion of the publisher is prohib­ited. For questions, send an e‑mail to service@nso.com or call 1 – 800-247‑1500. More at www​.nso​.com.

This article is provided for general infor­ma­tional purposes only and is not intended to provide individ­u­al­ized business, risk manage­ment or legal advice. It is not intended to be a substi­tute for any profes­sional standards, guide­lines or workplace policies related to the subject matter.

Resources

  1. Governor Jay Inslee. Opioid Epidemic Policy Brief, 2016. http://​www​.governor​.wa​.gov/​s​i​t​e​s​/​d​e​f​a​u​l​t​/​f​i​l​e​s​/​e​x​e​_​o​r​d​e​r​/​O​p​i​o​i​d​E​p​idemic.pdf
  2. Baker JA, Avorn J, Levin R, Bateman BT. Opioid prescribing after surgical extrac­tion of teeth in Medicaid patients, 2000 – 2010. JAMA. 2016;315(15)1653 – 1654. 
  3. Centers for Disease Control and Preven­tion. Prescrip­tion opioid overdose data. 2016. www​.cdc​.gov/​d​r​u​g​o​v​e​r​d​o​s​e​/​d​a​t​a​/​o​v​e​rdose.html.
  4. Kennedy-Hendricks A, Gielen A, McDonald E, et al. Medica­tion sharing, storage, and disposal practices for opioid medica­tions among US adults. JAMA Int Med. June 13, 2016. 
  5. MCauley JL, Leite RS, Melvin CL, Fillingim RB, Brady KT. Opioid prescribing practices and risk mitiga­tion strategy imple­men­ta­tion: identi­fi­ca­tion of poten­tial targets for provider-level inter­ven­tion. Substance Abuse. 2016;37(1):9 – 14. 
  6. Levy B, et al. Trends in opioid analgesic – prescribing rates by specialty, U.S., 2007 – 2012.” Am J Prev Med 2015; 49(3): 409 – 413.
  7. Substance Abuse and Mental Health Services Admin­is­tra­tion. Screening, brief inter­ven­tion, and referral to treat­ment (SBIRT). 2016. www​.samhsa​.gov/sbirt.
  8. Thorson D, Biewen P. Bonte B, et al. Acute pain assess­ment and opioid prescribing protocol. Insti­tute for Clinical Systems Improve­ment. 2014. https://​www​.cdc​.gov/​m​m​w​r​/​v​o​l​u​m​e​s​/​6​5​/​r​r​/​r​r​6501e1.htm