The Problem of Pain: Prescribing Opioids to Addicted Populations

The Problem of Pain: Prescribing Opioids to Addicted Populations

Between 2006 and 2012, more than 32 million prescription pain pills circulated through Berkshire County, Massachusetts, a rural area of about 130,000 people.

Patients recovering from opioid addiction are seen at the local emergency department every day, according to Martha Roberts, a critical care Nurse Practitioner (NP) and Georgetown University School of Nursing & Health Studies alumna. Roberts works in Berkshire’s emergency department, which sees 50,000 patients per year — more than a third of the county’s population.

“It’s challenging,” she said. “It’s also an opportunity to help those patients in a way that may improve their outcomes.”

Patients in addiction recovery aren’t exempt from the need for pain relief in the case of acute injuries, surgical operations, or chronic pain. Providers like Roberts are tasked with finding and offering alternatives to opioids.

How can clinicians balance the weight of ethical responsibility with a patient’s need for immediate relief?

Opioid Dependence and Addiction in the United States

About 21% to 29% of individuals who are prescribed opioids misuse them, and 8% to 12% of them develop an addiction, according to the National Institutes of Health. Though only a small percentage of patients are likely to develop an addiction, there is still a chance of dependence, which is characterized by a physical reliance on the medication that, if unaddressed, can lead to addiction.

Even if the patient is not demonstrating symptoms of addiction, providers look for specific signs of dependence, according to Dr. Jill Ogg-Gress, assistant Family Nurse Practitioner (FNP) program director at Georgetown University.

“Opiate medications have side effects of dependence,” said Ogg-Gress, who works as a board-certified emergency NP in several Iowa and Nebraska emergency rooms. “If a provider recognizes that a patient is experiencing dependence, or if a patient demonstrates behaviors of dependence, it should be recommended to the patient they should talk to their primary care provider or the prescriber of the opioids.”

Signs of opioid dependence
  • Taking painkillers more frequently than prescribed
  • Taking higher doses than prescribed
  • Seeking a euphoric effect to counter physical pain
  • Experiencing excessive sleepiness or irritability

Taking these signs into account, providers can evaluate patients’ needs on an individual level to assess the magnitude of pain. If the patient is likely to develop a dependence, the providers may need to help them find an alternative treatment plan that is effective and sustainable.

Ruling out opioids altogether isn’t a realistic approach, Roberts said.

“There are still some painful injuries that will benefit from short-term opioid use,” she said.

Her key to implementing an effective treatment plan is working with the patient to assess their needs and openness to non-opioid pain medication.

Commonly Used Alternatives to Opioids

Opioids are a class of drugs that can be prescribed for pain relief but are highly addictive and illegal for consumption when not prescribed by a health care provider.

Individuals recovering from drug addiction might encounter injuries or surgical operations that require management of immediate acute pain or chronic pain in the long term. Providers can evaluate a patient’s needs when creating a treatment plan to manage that pain.

Pharmacological alternatives to opioids

Analgesics: Some of the most common painkillers can be obtained over the counter in small doses or prescribed in high doses by a health care provider. Roberts and Ogg-Gress agreed that these are the most common alternatives to opioid prescriptions.

Acetaminophen can be used for pain relief and fever reduction, but it does not reduce inflammation. It’s one of the most common pain relievers among Americans, used by roughly 23% of adults each week.

Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can treat acute pain and inflammation. A 2018 report found that NSAIDs make up 5% to 10% of all medications prescribed each year.

Gabapentinoids: This class of drugs includes gabapentin and pregabalin and has been historically used for seizure prevention. It is available by prescription to address pain but only in circumstances set by the Food and Drug Administration. While these painkillers can be an alternative to opioids, Roberts said they are not her intervention of choice because studies show there are other, more effective alternatives.

When medication isn’t appropriate or preferable, many non-pharmacological options exist to relieve pain and suffering.

“There are a lot of other nonpharmacological therapies that are available, if people are willing to try it,” Ogg-Gress said. “Providers need to educate patients regarding these pain therapies instead of the common thought of, ‘Here, take a pill, swallow it, and you’ll feel better.'”

Non-pharmacological alternatives to opioids
  • Localized numbing
  • Ice
  • Massage
  • Exercise
  • Physical therapy
  • Acupuncture
  • Relaxation

Supporting Patients in Recovery

Every patient deserves time and attention to explain their case and their needs to a provider who is listening thoughtfully. Providers treating addicted populations must keep a constant eye out for identifying drug seeking behaviors, without stereotyping or wrongly assuming a patient’s motives. A 2016 report published by the National Institutes of Health described several types of drug-seeking behaviors:

Common Drug-Seeking Behaviors
Requests and complaints
  • Describing a need for a controlled substance
  • Asking for specific opioids by brand name
  • Requesting to have a dose increased
  • Citing multiple allergies to alternative pain therapies
Inappropriate self-medicating
  • Taking more doses than recommended by the provider
  • Hoarding a controlled substance
  • Using a medication despite not being in pain
  • Injecting an oral formula instead of consuming orally
Inappropriate use of general practice
  • Visiting multiple providers for controlled substances
  • Calling clinics when providers who prescribe controlled substances are on call
  • Frequent unscheduled visits, especially for early refills
  • Consistently disruptive behavior
Patterns of resistance
  • Hesitancy to consider alternative pain treatments
  • Declining to sign controlled substances agreement
  • Resisting diagnostic workup or consultation
  • Being more interested in the medication than solving the medical problem
Illegal activity
  • Obtaining controlled drugs from family members or illicit sources
  • Using aliases or forging prescriptions
  • Pattern of lost or stolen prescriptions

Clinicians who have identified these behaviors can use electronic medical records and crossover notes from other providers to see how many times a patient has sought medication for the same problem.

“People are here for assistance, but they’re not taking personal responsibility,” Roberts said. Engaging with patients to help them understand treatment plans can build a sense of agency over their own care.

Roberts said providers can help patients identify ways to care for themselves before writing a prescription for opioids. She recommended a gradual approach to trying different types of treatment:

A Step-Wise Approach for Pain Management

  1. Get to know the patient
  2. Use analgesics to address pain symptoms
  3. Use non-pharmacological treatments as intervention for side effects
  4. Encourage patient to stop smoking and drinking alcohol
  5. Eliminate foods that irritate the stomach or digestive system
  6. Reflect on previous steps: Did you really exhaust everything?
  7. Consider opioids as a last resort, and only enough to support immediate pain relief

Nurse Practitioners who work with a multidisciplinary team are uniquely positioned to provide holistic care. Clinicians serving communities with large addicted populations have to be familiar with law enforcement, social work organizations and, in the case of making a referral outside the clinic or emergency department, recovery programs and child protective services.

Roberts also acknowledged that providers working in communities fraught with addiction are at a high risk for fatigue. “If you have three back pain patients in a row, you’re going to be pretty burned out within two hours of working your shift, so you really, truly have to look at each case individually,” she said.

Taking time to self-reflect on personal motivations for treating patients can help remind providers of why caring for others is important to them.

“It’s hard to walk in and do a good job if you’re upset about the work you’re doing,” Roberts said. “Make sure you can do this without letting your own bias get in the way.”

Please note that this article is for informational purposes only. Individuals should consult their health care professionals before following any of the information provided.

Citation for this content: [email protected], the online DNP program from the School of Nursing & Health Studies

From Forensics to Advocacy: What it’s Like to be a SANE (Sexual Assault Nurse Examiner)

From Forensics to Advocacy: What it’s Like to be a SANE (Sexual Assault Nurse Examiner)

When people experience sexual assault, they may sustain more than just physical injuries; trauma also affects short- and long-term mental health. The medical treatment needed may require a provider to examine parts of the body that were recently violated, which can cause more distress. When reporting an assault, survivors often lack the information they need about how to proceed.

Sexual assault nurse examiners (SANEs) are trained to help survivors across this spectrum of patient care. From providing evidence-based treatment to performing assessments to collect forensic evidence that can be used in a criminal trial, these nurses play a critical role in supporting survivors at the beginning of their recovery process.

What Is the Role of a Sexual Assault Nurse Examiner?

When a sexual assault survivor comes to a SANE-certified hospital or community health center, a sexual assault nurse examiner is the first point of care, according to Kim Day, forensic nursing director for the International Association of Forensic Nurses (IAFN). SANEs ask the patient if they would like a forensic exam, which can be completed even if the patient decides to not report their assault to law enforcement.

“Just going through the process with someone and providing holistic patient-centered care for that patient during a traumatic time in their life can really impact the way they leave the hospital,” Day said.

Forensic exams are meant to document trauma from the assault and collect evidence that could be used in a criminal trial. This includes taking a medical history; documenting scratches, bruises, abrasions, and other injuries on a body map diagram; taking photos of injuries; collecting DNA swabs to be processed; and observing the patient’s behavior. In cases where toxicology information is relevant, SANEs will also perform those tests on a patient.

In addition to performing a forensic exam, the main duty of a SANE is to provide holistic nursing care for the patient. Survivors of assault may need access to testing for pregnancy, as well as prophylactic antibiotics to prevent the contraction of diseases. Depending on the patient’s needs, SANEs also provide referrals to see other specialists, such as a licensed professional counselor, who can help them in their recovery process.

The SANE in Court: It’s Not Like “Law and Order”

Beyond working in the clinical setting, SANEs are qualified to testify in court if a patient’s case goes to trial. The specialized training SANEs receive prepares them to effectively answer questions regarding evidence discovered during a forensic exam. However, while SANEs can play a critical role in the trial process, the legal aspect of the job is not the main focus, Day said.

“If the nurse goes into this work thinking that they’re going to get the bad guy and put him behind bars, they will fail at this… because that is not what we do,” she said. “The work we do is nursing. We take care of the patients.”

This is a key factor to consider when choosing to become a SANE. Nearly 80 percent of sexual assaults are not reported to law enforcement, according to a Justice Department analysis of violent crime in 2016 (PDF, 669 KB). While performing a forensic exam and being prepared to provide evidence in court is a requirement of the job, the emotional and medical needs of a patient come first.

SANEs are trained to work within a multidisciplinary team, also known as a Sexual Assault Response Team (SART), which includes survivor advocates, members of law enforcement, and mental health providers. Together, these professionals coordinate the response to survivors of sexual assault.

What Is a Sexual Assault Response Team?

SANEs and other trained health care providers: When an individual decides they would like to have a sexual assault forensic exam (SAFE), health care providers like Nurse Practitioners (NPs) or SANEs address the initial physical and psychological needs the patient might have as a result of their assault.

Survivor advocates: Individuals who need access to information and emotional support can work with an advocate to navigate their path to recovery. A survivor may reach out to an advocate via a crisis center, or one may be brought in to support someone who has decided to seek treatment at a hospital or report their assault to the police.

Law enforcement: In cases where an individual decides to report their assault, police officers and detectives are responsible for taking statements, coordinating with the hospital to receive the results of the forensic exam, and investigating the alleged assault.

Prosecutors: In cases where the survivor has chosen to report their assault and enough evidence is present, prosecutors are tasked with making the decision on whether to bring the case to court.

Therapists and counselors: In the aftermath of an assault, whether a case goes to trial or not, survivors need additional support to continue their recovery process. Mental health professionals trained in working with sexual assault survivors may provide care at any step in the recovery process, from coping with the immediate aftermath of an attack to navigating long-lasting trauma.

Why Is Access to SANE Care Important?

According to the Centers For Disease Control and Prevention (CDC), one in three women and one in four men have experienced sexual violence involving physical contact during their lifetimes. The effects of experiencing an assault can be both physical and psychological, necessitating specialized care that embodies the concept of cura personalis, or care for the entire person. This holistic attention to the entire individual is the expertise of clinicians like nurses.

SANE education programs are designed to train nurses to address survivors’ specific needs. After completion of this training, SANEs become uniquely qualified to treat this vulnerable patient group. This means that they can provide trauma-informed care to minimize the harm of invasive exams that may trigger a patient. In doing so, they can also equip their patients with forensic evidence that can be used if they decide to report their assault.

Not all hospitals have SANE programs. IAFN’s database of registered SANE programs   indicates that there are currently 962 in the United States. As a result, patients are sometimes required to travel long distances to access SANE care, according to a 2016 report on the availability of forensic examiners (PDF, 191 KB).   This means that the facilities with SANE expertise must be ready to do what they can to help every patient who walks in the door.

Trauma-Informed Care and Practicing Consent

One of the key challenges of completing a sexual assault forensic exam (SAFE) is examining a patient’s physical injuries without retraumatizing them. To help survivors feel comfortable, SANEs ask for consent during each step of the way while providing information on why they are doing each test.

“Consent is not just a piece of paper with a signature on it,” Day said. “It’s a process throughout the exam.”

In practice, the process of asking for consent may resemble the following:

  1. The SANE will inform the patient what body part they will examine and ask permission to do so.
    “I’m going to examine your neck now to see if there are any injuries. Do I have your permission to do so?”
  2. If the patient grants this permission and the SANE notices something that may require a sample collection, the nurse will again ask for permission to collect a specimen and explain why collecting that evidence is appropriate.
    “I notice a scratch that wasn’t mentioned when I documented your health history. There may be DNA or other materials near this wound, so I would like to swab it. Is that OK with you?”

In any instance where the patient does not want a test performed, the SANE is directed to honor the patient’s request. This integration of consent throughout the exam is meant to give the patient a sense of control, a feeling that may have been lost during their assault.

What Are the Requirements to Become a SANE?

Because SANEs work with a patient population that requires specialized care, nurses are required to meet certain expectations in order to take on this role. While some nurses go through training at the local level or through smaller programs, IAFN offers the most recognized certification for SANEs. Nurses can become certified as a SANE-A to care for adults and adolescents or a SANE-P to work in pediatrics. Some nurses elect to pursue both certifications so they can provide care to patients across all age groups.

Steps to SANE Certification
  • Education: To become a certified SANE, a nurse must have the minimum of a registered nursing (RN) license.
  • Experience: Prior to starting the certification process, a nurse must have at least two years of clinical experience working as an RN or at a higher level, such as an NP.
  • Training: As part of the certification process, nurses are expected to complete 300 hours of SANE clinical skills training.
  • Testing: The final requirement to become a certified SANE is to pass a certification examination. IAFN holds exams two times a year.

Information for Further Reading

Citation for this content: [email protected], the online MSN program from the School of Nursing & Health Studies

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