“I lost my prescription when I moved.” “I am allergic to everything except morphine.” “I’m out of my percocets and I can’t see my primary doctor until next month.” 

We hear these statements from patients every day in the emergency room (ER). Naturally, pain—chronic or acute—is one of the chief complaints for patients presenting to an ER. But among the patients with acute illness, we also encounter many who exhibit drug-seeking behaviors, who abuse prescription painkillers, and who will visit several ERs per week with various different complaints in order to obtain prescriptions. These drug-seeking patients are often demanding or aggressive. They can also be very challenging to properly treat. Health care providers have an obligation to help treat pain as it is reported to us, but we are also obligated to protect patients’ safety and to participate in the control and regulation of dangerous substances.

According to the Centers for Disease Control and Prevention (CDC), the number of opioid prescriptions is on the rise in the United States, with a concurrent increase in the number of opioid addictions and overdoses each year. In a 2014 study published in Academic Emergency Medicine, researchers found a dramatic increase in the prescribing of opioid analgesics in emergency rooms—an increase of 10% from 2001 to 2010—to nearly one-third of all ER visits resulting in an opioid prescription, regardless of complaint. The same study found no correlated rise in either pain-related ER complaints nor in the prescription non-opioid analgesics. Alarmingly, the CDC reports that since 1999, deaths as a result of painkiller overdoses increased more than 400% for women and more than 265% among men.

What does this mean? It means that more physicians and health care providers are prescribing narcotic pain medications to their patients in both the ER setting and beyond for less severe complaints of pain. Therefore, we as health care providers shoulder a portion of the blame for the rise of opioid addiction, abuse, diversion, and deaths.

One possible reason for the rise of prescriptions written by providers in the last few years could be the new focus on patient satisfaction. With the passing of the Affordable Care Act, hospital reimbursements are now partially tied to patient satisfaction scores as rated on the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. The survey version tailored toward ER experiences (the EDPEC, or Emergency Department Patient Experiences with Care) asks patients about pain medications and the pain control they received in a startling eight out of the survey’s 30 total questions. 

Because of pressure from hospital administrators to achieve high patient satisfaction scores on these surveys, many providers may feel compelled—whether implicitly or explicitly—to prescribe opiate painkillers in order to “keep the satisfaction scores high.” For instance, instead of emphasizing non-pharmacological pain control or writing the majority of prescriptions for non-opioid analgesics, providers may jump right to the narcotic painkillers for less severe injuries or for mild to moderate pain.

Another problem is that many patients feel that they are entitled to be pain free, and patients are not encouraged to set realistic pain goals. Pain is usually a symptom of an underlying condition or problem, and although uncomfortable, it is not itself a medical emergency. In many cases, the expectation that a patient will be pain-free is not only unrealistic but also near impossible. Of course patients have a right to be reasonably pain-controlled, but they may not be able to be pain-free, and there is a difference.   

Although as bedside nurses we obviously do not prescribe these medications, we still play an important role in the prevention of drug dependence and addiction. The most important thing you can do for a patient is provide comprehensive information and clear pharmacological education on prescription pain medications.

Patients should be informed about the risks associated with taking opiates for mild to moderate pain. They should be instructed to take the medications only as needed, and for as short a time period as possible. They should be warned about the serious potential for drug overdoses, something that happens more easily than many think—both in and out of the hospital. They also need to be aware of the side effect profile of these medications, as many patients are being readmitted for a problem that we as providers have helped cause (e.g., opioid-induced constipation, or more serious withdrawal symptoms). Finally, when patients leave with a prescription opioid, they must understand that the potential for dependence and addiction while taking the medication is extremely high.

Additionally, as a nurse, you can request that a doctor or pharmacist use available electronic databases to track prescriptions for controlled substances if you suspect you are caring for a patient who may be misusing their prescriptions or who may be at risk for overdose.

Nurses must advocate for their patients’ safety both in and out of the hospital, and the first step to doing so is to empower patients with the appropriate education on the use of their prescriptions for pain.

Laura Kinsella

Laura Kinsella, BSN, RN, CEN, is an emergency room nurse in Washington, DC.

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