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).
Viewing cancer misinformation on social media negatively influenced patients’ decisions and adversely affected their mental health, according to a new study published in the journal Cancer. While online social networks can be useful resources for cancer patients, they’re also scattered with potentially dangerous misinformation.
Researchers at Huntsman Cancer Institute at the University of Utah (U of U) created a resource for scientists that lays the foundation for building clinical and patient-friendly tools called the Online Cancer Nutrition Misinformation (ONC-M). The tool tracks and organizes cancer misinformation that comes from social media.
Echo Warner, PhD, MPH, researcher at Huntsman Cancer Institute and assistant professor of nursing at the U of U, asked patients and caregivers how they used social media during their cancer experiences. “The benefits of their social media use were mired by exposure to cancer misinformation. They were met with misinformation from many sources, all the way from well-intentioned friends and family to shadow scams selling ‘cancer cures’ to the highest bidder,” Warner says.
ONC-M provides a way for researchers to document how exposure to health misinformation online influences patients and caregivers.
“It’s the first framework to document the process by which exposure to health misinformation online influences patient and caregiver health behaviors and health outcomes,” says Warner. “Before now, the lack of a clear conceptual process, and the factors that influence that process, has been a major roadblock in the study of online health misinformation.”
The ONC-M describes how cancer misinformation is organized, and also creates potential pathways linking misinformation exposure, health behaviors, and cancer health outcomes. Researchers identified several primary cancer misinformation categories and factors that associate with each type of claim. Researchers found untrue claims about cancer prevention, treatment, and cures. These claims were backed by false disclaimers, anecdotes, and misinterpreted scientific articles.
“While still somewhat early in refinement, ONC-M has broad applicability and likely extends beyond cancer-related misinformation to other health domains as well,” says Warner. “We plan to test each part of the framework and study new ways of using technology to measure how much cancer patients are exposed to misinformation online.”
Warner recommends discussing any treatment or therapy questions with healthcare providers. Patients can also use an information quality tool to help identify potential biases, financial incentives, and misleading content about cancer treatments or therapies. One example is the CRAAP test.
The study was supported by the National Institutes of Health/National Cancer Institute including P30 CA042014, the University of Arizona Cancer Center Cancer Health Disparities Training Program (T32CA078447), University of Arizona College of Nursing Eleanor Bauwens’s Research Award, University of Arizona Postdoctoral Research Development Grant, the U.S. Department of Agriculture, Agricultural Research Service under Cooperative Agreement No. 58-3092-0-001, the MD Anderson Cancer Center Support Grant (P30CA16672), the Center for Energy Balance in Cancer Prevention and Survivorship, Duncan Family Institute, and Huntsman Cancer Foundation. Key collaborators included Margaret Raber Ramsey, DrPH, Baylor College of Medicine, Tracy Crane, PhD, University of Miami Sylvester Comprehensive Cancer Center, Terry Badger, RN, PhD, University of Arizona College of Medicine, and Karen Basen-Engquist, PhD, MD Anderson Cancer Center.
Seeing a patient smile… is a reminder that while many things can be wrong and recovery is a lifelong journey, small things like a momentary smile symbolize ongoing hope.
Patients with psychiatric problems need special care. That’s why it’s important for nurses to know that they want to pursue this facet of the nursing field before actually doing it.
What follows is our interview, edited for length and clarity.
How did you get interested in being a psychiatric NP, treating trauma and mental health? What drew you to it? How long have you been doing it?
I have been a psychiatric mental health nurse practitioner (PMHNP) since 2010.
Treating trauma and mental health was an accidental merge as I worked as a trauma nurse while completing my clinical rotations for mental health. Over time, I would see my patients recovering from head trauma and would start showing signs of mental health needs that were often untreated by the time of their discharge. I felt a sense of responsibility to my patients, with a conviction that the emergence of mental health symptoms was not coincidental. I thought pursuing research was the best way to help my patients in a strategic way.
Explain to me briefly what you do in general. What types of patients do you serve? What do you provide for them?
I am a board-certified psychiatric nurse practitioner who has worked in trauma and psychiatry. I work as the track coordinator for the Psychiatric Mental Health Nurse Practitioner Certificate program and maintain a clinical practice in Baltimore City serving families recovering from substance use. My research includes identifying biomarkers for PTSD in Veterans with a history of traumatic brain injury (TBI), which includes exploring the factors influencing seeking treatment for PTSD after a TBI.
You’re a Jonas Philanthropies Scholar. What does that mean? What do you do as one?
Jonas Philanthropies and its Jonas Scholars program support nurse scholars across the country who have transitioned into roles as faculty, clinical leaders, and researchers. The goal of the program is to improve health care by investing in doctoral nursing students, such as myself, who are pursuing PhD, EdD or DNP degrees, and whose research and clinical focus addresses the nation’s most pressing healthcare needs. As a Jonas Scholar, I’m given financial assistance, leadership development, and networking support for my work as a psychiatric nurse practitioner and my research on biomarkers for PTSD in Veterans.
What do you like most about your work? Why?
I love working with individuals and their families, and I feel really lucky that I get to explore multiple aspects related to mental health through research, my clinical practice, and teaching.
What are the biggest challenges in your work?
Waiting for science to catch up with reality. Research is often very slow and tedious to find supportive evidence to enact change. It is necessary, but so many people are in need of it, and it is often difficult to be patient with the process.
What are your greatest rewards?
Seeing a patient smile. It is a reminder that while many things can be wrong and recovery is a lifelong journey, small things like a momentary smile symbolize ongoing hope.
If you could fix/cure one thing in your line of work (could be with patients or whatever), what would it be and why?
Take away the stigma related to mental health – it hinders so much, and so many people who deserve help are often unwilling to seek it because they do not want to be labeled negatively.
Is there anything I haven’t asked you that is important for our readers to know?
Research for TBI and mental health has made incredible exposure and progress in the last few years, yet so much needs to be done to help individuals who desperately need it. It makes the difference between just existing and having an opportunity to live a fulfilling meaningful life, and that’s what we all deserve regardless of a diagnosis or injury.
A University of Arizona College of Nursing researcher was one of only four recipients of a $4 million American Cancer Society grant to develop a “Cancer Health Equity Research Center” with the goal of improving health equity for Hispanic cancer survivors and family care givers.
“We will be developing and testing interventions that can be incorporated into clinical practice,” said principal investigator Terry Badger, PhD, RN, professor and Eleanor Bauwens Endowed Chair in the University of Arizona College of Nursing and UArizona Cancer Center member. “By looking at health care utilization and many social determinants of health, we’re hoping to come up with ideas of how we can decrease health disparities and enable people to access the health care they need.”
According to the American Cancer Society, which designated the funds for Minority-Serving Institutions, the centers will implement solution-based research addressing cancer health disparities that will contribute to achieving health equity and reducing cancer mortality. The University of Arizona is designated as a Hispanic-Serving Institution by the U.S. Department of Education.
UArizona Health Sciences researchers will focus on three areas:
assessing care and treatment needs of kidney and liver cancer patients
assessing the impact of diet and physical activity interventions on lifestyle behaviors
symptom management and health care utilization in rural and urban underserved populations.
“Terry has laid the foundation and is a national leader in supportive care, research and training,” said Joann Sweasy, PhD, the Nancy C. and Craig M. Berge Endowed Chair and UArizona Cancer Center director. “She is most deserving of this prestigious award.”
Dr. Badger will use her experience to increase participation in clinical intervention trials for underrepresented cancer survivors and their caregivers.
“We are going to work with our communities to develop and test effective, accessible interventions that will benefit cancer survivors and caregivers,” Dr. Badger said. “I have a very successful history of including underrepresented cancer survivors and their caregivers in my trials. We have over 450 cancer survivors and their caregivers in one of my studies right now and about 40% of those are Hispanic.”
Additionally, the grant will allow Dr. Badger and her team to train the next generation of researchers and develop synergistic relationships with other UArizona Health Sciences and UArizona researchers to foster more projects focused on cancer health equity.
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.
The research explores nurses’ values, perceptions, and perspectives on MAiD and demonstrates a need for more guidance on the expectations of the nurse’s role to provide competent and quality care where MAiD is legalized.
“Nurse respondents to the study held concerns about the process, policy, potential psychological harm, legal risk, and the need to learn more about MAiD,” said Bosek, an associate professor and registered nurse. The findings suggest that nurse educators should assist nursing students to understand both their personal and professional values related to the subject, added Bosek.
“Organizations in states where MAiD is a legal option need to assist nurses to understand MAiD and carefully construct policy/standards to minimize conflict, moral distress, and psychological harm amongst nurses,” said Bosek.
MAiD is currently legal in 10 states including Vermont, plus Washington D.C., and legislation is pending in Connecticut, Arizona, and Massachusetts.
Bosek was part of the team that drafted the 2019 American Nurses Association (ANA) position statement, The Nurse’s Role When a Patient Requests Medical Aid in Dying, which addresses the growing ethical questions and challenges that nurses face when responding to a patient’s request for MAiD.
I have been a psychiatric mental health nurse practitioner (PMHNP) since 2010.
