Nurses who think tapering opioid patients entails a long period of Defcon 2 or 3 vigilance now have more data to support that position.
Researchers from the UC Davis Center for Healthcare Policy and Research conducted a 10-year study to examine the potential long-term risks of opioid dose tapering. They found that patients on stable but higher-dose opioid therapy who had their doses tapered by at least 15% had significantly higher rates of overdose and mental health crisis in the second year after tapering compared to their pre-tapering period.
Opioid therapy and the push to reduce the dose of pain medication
Changes in prescribing guidelines and regulatory policies driven by the rise in opioid-related deaths have led many physicians to reduce daily doses for patients on stable opioid therapy for chronic pain. The dose reduction process – called tapering – has been linked to worsened pain, symptoms of opioid withdrawal and depressed mood among some patients.
“While patients may struggle during the early tapering period, we reasoned that many may stabilize with longer-term follow-up and have lower rates of overdose and mental health crisis once a lower opioid dose is achieved,” said Joshua Fenton, professor and vice-chair of research in the Department of Family and Community Medicine at UC Davis School of Medicine and lead author of the study. “Our findings suggest that, for most tapering patients, elevated risks of overdose and mental health crisis persist for up to two years after taper initiation.”
Pain management and the risks of dose changes
To draw associations between dose reductions and changes in the risk for overdose and mental health visits, the researchers used a database covering a 10-year period (2008-2017) for more than 28,000 patients prescribed long-term opioids. They examined enrollment records and medical and pharmacy claims for patients prescribed stable high opioid doses (the equivalent of at least 50 morphine milligrams per day) and who had their doses reduced by at least 15%.
From this patient cohort, they selected those who had at least one month of follow-up during the second year of their post-tapering period. They identified a total of 21,515 tapering events for 19,377 patients.
Those events included emergency department visits or inpatient hospital admissions for drug overdose, withdrawal, or mental health crisis events, such as depression, anxiety or suicide attempts. The team compared rates of these events in the pre-tapering period with those during the second taper year of follow-up after tapering initiation.
“We used an innovative observational study design to understand the patients’ experience before and after opioid dose reduction. We compared outcome rates in pre- and post-taper periods with patients serving as their own controls,” said pediatrics professor Daniel Tancredi, co-author of the study. “This design has the advantage of controlling for patient characteristics that may influence relationships between tapering and adverse events.”
The study found that for every 100 patients, there was an average of 3.5 overdose or withdrawal events and 3 mental health crises during the pre-tapering period, compared to 5.4 events and 4.4 crises in the 12-24 months post-tapering period. That’s a 57% increase in overdose or withdrawal incidents and a 52% increase in mental health crises. The risks of tapering were greatest in patients with the highest baseline doses.
Long-term follow-up and support for patients on reduced pain therapy
In 2018, the Department of Health and Human Services (HHS) issued guidelines to advise clinicians to monitor patients carefully during tapering and provide psychosocial support. They recommended close follow-up and cautioned about the potential risks of rapid dose reduction, including withdrawal, transition to illicit opioids, and psychological distress.
This new study emphasized the need for clinicians and patients to discuss dose reduction and carefully weigh the risks and benefits of opioid continuation and tapering. Tapered patients would benefit from close follow-up and monitoring not only in the short term but in the long term too, to make sure they’re coping well on lower doses.
“We hope this work will inform a more cautious approach to decisions around opioid dose tapering,” Fenton said. “While our results suggest that all tapering patients may benefit from monitoring and support up to two years after taper initiation, patients prescribed higher doses may benefit from more intensive support and monitoring, particularly for depression and suicidality.”
Other UC Davis Health collaborators include Elizabeth Magnan, Iraklis Erik Tseregounis, Guibo Xing and Alicia Agnoli. The study was supported by a University of California–OptumLabs Research Credit, the Department of Family and Community Medicine at UC Davis, and the UC Davis School of Medicine Dean’s Office (Dean’s Scholarship in Women’s Health Research BIRCWH/K12).
A majority of American men who die by suicide don’t have any known history of mental health problems, according to new research by UCLA professor Mark Kaplan and colleagues.
“What’s striking about our study is the conspicuous absence of standard psychiatric markers of suicidality among a large number of males of all ages who die by suicide,” said Kaplan, a professor of social welfare at the UCLA Luskin School of Public Affairs.
For the study, published online in the American Journal of Preventive Medicine, Kaplan and his co-authors from the Centers for Disease Control and Prevention tracked recent suicide deaths among U.S. males aged 10 and older. They found that 60% of victims had no documented mental health conditions.
Further, males without a history of mental health issues died more frequently by firearms than those with known mental health issues, and many were found to have alcohol in their systems, the researchers noted.
The report highlights the major public health challenge of addressing suicide among males, who are far more likely to die by suicide and less likely to have known mental health conditions than females. In 2019, for instance, males accounted for 80% of all suicide deaths in the U.S., the authors said, and suicide is the eighth leading cause of death among males 10 and older.
Kaplan and his colleagues examined data from the Centers for Disease Control and Prevention’s National Violent Death Reporting System for the most recent three-year period available, 2016 to 2018, during which more than 70,000 American males died by suicide. More than 42,000 of them had no known mental health conditions, they found.
The researchers then compared characteristics of those with and without known mental health conditions across their life span in four age groups: adolescents (10–17 years old), young adults (18–34), middle-aged adults (35–64) and older adults (65 and older). Identifying the various factors that contribute to suicides among these groups is crucial to developing targeted suicide prevention efforts, especially outside of mental health systems, the team emphasized.
Among their findings, they discovered that across all groups, those without known mental health conditions were less likely to have had a history of contemplating or attempting suicide, or both, than those with such issues. In particular, young and middle-aged adults without known mental health conditions disclosed suicidal intent significantly less often, they said.
In addition, males with no mental health history who died by suicide in three of the four age groups — adolescents, young adults, and middle-aged men — more commonly experienced relationship problems, arguments or another type of personal crisis as precipitating circumstances than for those with prior histories.
The researchers emphasized the importance of focusing on these kinds of acute situational stressors as part of suicide prevention efforts and working to discourage the use of alcohol, drugs, and guns during times of crisis — particularly for teens and young adults, who may be more prone to act impulsively.
Kaplan and his colleagues said the findings highlight the potential benefits of strategies to create protective environments, provide support during stressful transitions, and enhance coping and problem-solving skills across the life span.
“Suicide prevention initiatives for males might benefit from comprehensive approaches focusing on age-specific stressors reported in this study, in addition to standard psychiatric markers,” the researchers wrote.
“These findings,” Kaplan said, “could begin to change views on the non–mental health factors driving up the rate of suicide among men.”
There have been many reports about health care workers, especially nurses, leaving the profession because of emotional and even physical abuse wrought by pandemic-fueled overwork, lack of resources and combative COVID patients in hospitals.
But University of Michigan School of Nursing faculty Deena Kelly Costa and Christopher Friese argue in a New England Journal of Medicine Perspective piece that the problem isn’t necessarily a nursing shortage caused by the pandemic: It’s a shortage of safe hospital working environments–a problem that predates the pandemic.
You argue there’s not a nursing shortage but a shortage of hospitals that provide safe working conditions. What would you like patients to understand about working conditions that they don’t currently know?
Deena Kelly Costa, Ph.D., RN, FAAN
Since March 2020, the public has been inundated with images of nurses working in unsafe conditions during the pandemic—garbage bags as PPE, reusing masks, reports of wildly unsafe workloads. But unsafe staffing and work conditions predate the pandemic.
Better nurse staffing saves lives and ensures hospitals can function; investing in safe working conditions for nurses is a public health priority. Seminal work in the early 2000s demonstrated that every one patient added to a nurse’s workload in acute care settings was associated with a 7% increase in risk of death for patients. Yet, since then, California is the only state to enact legislation to mandate patient-to-nurse ratios. Massachusetts has ICU nurse staffing regulations but a similar bill mandating specific ratios in other care settings did not pass about five years ago for various reasons.
You’ve listed several measures that could help attract and retain nurses on the state and federal levels. Which of these measures is most attainable in the short term and could make the biggest impact?
Reducing regulatory and documentation burden is likely the quickest short-term approach that would have the greatest impact in retaining nurses. The COVID-19 pandemic has doubled or even tripled acute care nursing workloads.
Christopher R. Friese, Ph.D., RN, AOCN®, FAAN.
There is considerable evidence supporting limits to the number of patients a nurse can care for in the hospital setting. Legislation can take time, but in the short term, the Centers for Medicare and Medicaid Services could penalize hospitals that do not meet established patient-to-nurse ratios or exceed maximum amounts of mandatory overtime. This has been done in nursing homes, so there is precedent.
“Seminal work in the early 2000s demonstrated that every one patient added to a nurse’s workload in acute care settings was associated with a 7% increase in risk of death for patients. Yet, since then, California is the only state to enact legislation to mandate patient-to-nurse ratios.”
States may have more flexibility for nimble policy implementation. For example, there is considerable data demonstrating the negative impact COVID has had on women’s careers, and more than 90% of U.S. nurses are women. To encourage nurses to remain in the profession and not quit due to family care pressures, states could incentivize hospitals to offer on-site child care, dependent care programs, or other grants to encourage safer workplaces. This approach is similar to how employer-sponsored insurance emerged as an employee retention tool in the mid-1950s.
Every year, tens of thousands of students are turned away from nursing schools. How big a problem is this, and what’s the solution?
Structural barriers in the education system create a bottleneck. Many nursing schools must cap enrollment due to shortages of qualified faculty to teach in undergraduate and graduate programs. And more than a third of current nursing faculty plan to retire in the next few years, which will worsen the bottleneck. It can be challenging to attract experienced nurses to teach in associate or bachelor degree programs since often the schedule and pay aren’t as competitive as full-time clinical positions. This hurts our ability to grow the supply of high-quality registered nurses.
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States could help with state tuition forgiveness programs for nurses and nurse educators, low-interest rate loans for state nursing school students, or expansion of the graduate nurse education demonstration project, which funds nurse practitioner education, to increase the number of qualified nurse practitioners who could in turn become educators.
In Michigan, nurse industry groups argue that enacting the bipartisan Safe Patient Care Act and easing the scope of practice restrictions on Advanced Practice Registered Nurses would accomplish these safety goals. These measures are opposed by some hospital and physician groups. Where do these stand?
Michigan has one of the strictest scope of practice regulations in the country, meaning that APRNs must be overseen by physicians to a greater extent than in most other states, and can’t function independently to the full extent of their education and training. Thus, some nurses leave Michigan to practice in other states with friendlier scope of practice regulations. If Michigan were to implement full practice authority to APRNs, as was temporarily done during the pandemic by Gov. Whitmer’s office and as is currently proposed in Senate Bill 680, this could attract APRNs to Michigan, which would boost the supply of nurses in the state and possibly assist with other staffing shortages that have recently been documented.
The bipartisan Safe Patient Care Act would require hospitals to disclose staffing ratios and adhere to specific patient-to-nurse ratios as well as eliminate mandatory overtime and enact restrictions on overtime. In many other labor environments, such as the airline industry or police and fire departments, there are regulations around hours worked, overtime, etc. They currently do not exist in nursing, and are needed to protect patients and retain and recruit nurses. This bill hasn’t yet passed.
BSN student Valeria Soria Guzman has been translating for her parents for as long as she can remember. She knows three languages so far – and is learning two more – and she aspires to use her polylingual abilities to increase access and equity for health care patients through the nursing field.
“It’s so hard when you’re sick and when you’re at your lowest point and to not have somebody who understands you,” says Guzman. “To not have somebody who can share that compassion with you in your own language is difficult.”
Guzman moved to the U.S. from Mexico with her family when she was two years old. She is a first-year nursing student at the Bill and Sue Gross School of Nursing at the University of California Irvine (UCI), and she is also the first in her entire family to attend college.
After learning English in the third grade, Guzman found that her background in Spanish made it easy for her to pick up other languages as well. Aside from English and Spanish, Guzman also knows French, is working on American Sign Language and has just begun to dip her toes into Portuguese. As a child, Guzman became her family’s translator at more than just the grocery store – she found herself translating at medical offices, filling out complicated documents with her limited children’s vocabulary of English, and trying to get both her parents and the physicians to understand each other.
“I feel like that’s why I want to go into nursing specifically so that I can walk a patient through the treatment and help them along the way, even if they don’t speak the language,” she says.
Guzman is constantly seeking opportunities at UCI to help those facing a language barrier, especially in the medical field. Currently, she works on the translating team for a research study that is looking for ways to help dementia patients through technology.
“A lot of their patients are lower income and Spanish-speaking only,” Guzman says. “So what I do is translate documents, like ones from the research, into Spanish so the researchers can have focus groups with these Spanish-speaking participants.”
Guzman sees the accessibility of documents in languages other than English as a major point in achieving accessible care. In the future, she plans to use her abilities to serve non-English speaking communities wherever she is most needed. She especially wants to serve areas lacking in non-Spanish speakers, even if it means leaving the large Spanish-speaking community that she values so much behind.
“The thing I’ve missed most since coming to UCI is speaking Spanish in a community setting, and I feel like that’s why I like to seek out a bunch of different Spanish speaking opportunities because I want to have that again,” says Guzman.
For 30 years, E. Alison Holman, Ph.D., professor of nursing at the University of California Irvine Bill and Sue Gross School of Nursing, has focused her research on collective trauma stemming from such climate-related disasters as wildfires and hurricanes, global events like the pandemic and wars, and other human-caused tragedies such as terrorist attacks, mass shootings and bombings. “I’ve always been interested in large-scale events,” she says. “As healthcare professionals, we need to understand how people’s mental health responses impact their physical health in the moment and long-term.”
“Collective trauma” refers to an event that is shared by an entire community, not just an individual. Media – both traditional and social – has expanded community borders beyond a specific geographic location to encompass anyone anywhere in the world who consumes coverage of the crisis. “The role that media plays in the link between mental and physical health following collective trauma is a critical part of my work,” Holman says.
“The healthcare profession has grown to understand that people’s mental health responses to acute stressors are linked to physical health – particularly cardiovascular ailments – down the road. My research has also identified the role that media can play in perpetuating long-term symptomology.”
Her understanding of that is personal as well as professional. The 9/11 terrorist attacks on the U.S. occurred while she was in Nigeria with her family, including two young children. News of this reverberated around the world, and during the six days they waited to return to the States, they experienced the event through media coverage. “I wasn’t there; I didn’t know anyone who was there. And yet it affected me personally, wondering what our country was in for and what it meant for my kids,” Holman says.
Media matters
Back in the U.S., she was a co-principal investigator on the UCI research team that conducted a large, nationally representative study funded by the National Science Foundation on how early reactions to 9/11 (e.g., psychological responses and media exposure) affected participants’ mental and physical health for three years following the attacks. Says Holman: “Because it was such a big event, people were watching it over and over and over, and that was linked to a lot of distress and health problems over time. We realized that we needed to find a way to prevent overconsumption of media.”
Her research into the 2013 Boston Marathon bombings revealed, surprisingly, that media exposure was a more powerful predictor of acute stress symptoms than being at the site of the blasts. “We found that people who were watching hours and hours of media coverage were more distressed soon after the attack than those who had actually experienced the event in person,” she says. “This was a very unusual discovery then.”
After the 2016 Pulse nightclub shooting in Orlando, Florida, Holman was involved in a follow-up survey of participants from the Boston Marathon study, which identified the cumulative effects of repeated exposure. “A cycle of distress can be created over time in which media consumption heightens distress, increases worries about future terrorism, and promotes further media consumption that is again tied to heightened distress,” she says. “We encourage people to limit the amount of exposure they have to traditional and social media after these collective events.”
Providers and personal biases
Over the last 20 years, the healthcare profession has increasingly recognized the link between mental health responses to acute stressors and long-term physical health effects.
“When faced with a traumatized patient, it’s really important that we understand how their trauma may have affected them both mentally and physically. That awareness, particularly with marginalized and underserved populations that generally experience higher rates of trauma, is going to help us be more compassionate and provide more effective care,” Holman says.
“We also need to reflect on our own biases and think about how they may impact our interactions with traumatized patients and, hence, their well-being. We need to learn how to overcome our biases and to support each other as we learn how to change our behavior. None of this is easy, but it’s critical for building a more equitable and effective healthcare system.”
Children’s Hospital Los Angeles (CHLA) announced one of the largest charitable investments ever made in a pediatric hospital nursing program—a landmark $25 million gift by an anonymous donor that will greatly enhance the education, professional development and research endeavors of CHLA’s nursing workforce.
“Nurses are the indispensable foundation of our hospital—a key component of the compassionate, family-centered care for which Children’s Hospital Los Angeles is known,” says Paul S. Viviano, CHLA President and CEO. “Here and across the nation, COVID-19 has placed significant stress on nurses and the clinical workforce. This gift is an unqualified testament to the priority that this generous donor, CHLA and the philanthropic community as a whole have made to supporting our nurses, especially during the challenges of the ongoing pandemic.”
The anonymous gift will support important investments in programs targeting nursing certification, mentorship, training and research funding, including:
Expansion of CHLA’s New Graduate RN Residency and Transition Fellowship nurse training programs, which help prepare early and mid-career nurses for pediatric specialty care
Increased research funding for CHLA’s Postdoctoral Nursing Fellowship program
Support and sponsorship for nurse certification education (examples include Trauma, Neonatal and Nephrology certifications)
Experienced Nurse (“Wisdom Worker”) support
Additional early career support of new nurses through mentorship enhancements and other professional development opportunities
Expanded funding for nurses’ research projects
“This transformative gift allows us to invest in the education and advancement of nurses at every phase of their careers, whether they are new nursing graduates, mid-career RNs looking to transition to pediatric care, or experienced clinical workers who bring an incomparable wealth of knowledge and mentorship to the table,” says Nancy Lee, RN, MSN, CHLA’s Chief Clinical Officer and Chief Nursing Officer. “These investments are being made based on feedback we have received from nurses themselves, who have asked for more opportunities to learn and grow.”
CHLA has announced several initiatives to support the growth, health and resilience of clinical team members. In addition to the anonymous gift, CHLA recently was awarded a workplace resiliency training grant from the federal Health Resources and Services Administration, totaling $2.1 million over three years, that will help CHLA enhance its ongoing commitment to the wellness and mental health of our team members.
“CHLA owes a remarkable debt of gratitude to the anonymous donor for this act of selfless philanthropy and visionary leadership,” says Viviano. “With this $25 million gift, CHLA will be able to make a considerable and meaningful difference in the lives of our nurses and, in turn, the hundreds of thousands of precious children entrusted to our care every year.”
It is CHLA’s goal to foster an environment that is supportive of a diverse and highly skilled clinical workforce, one that helps them achieve their professional goals and feeds their passion for the lifesaving work they provide our patients and their families. The American Nurses Credentialing Center recently re-designated Children’s Hospital Los Angeles as a Magnet® hospital, one of the highest recognitions given to world-class nursing and patient care, and an honor reserved for the top 10% of U.S. hospitals.
