Study: Tapering Opioids Can Send Patients Into a Mental Health/SUD Minefield

Study: Tapering Opioids Can Send Patients Into a Mental Health/SUD Minefield

Opioid therapy is complex. In recent years, a rise in opioid-related deaths and changing prescribing guidelines and regulatory policies have led many physicians to reduce daily doses for patients prescribed stable opioid therapy for chronic pain.

Some patients  have reported that this dose reduction process—called tapering –has been difficult, sometimes involving worsened pain, symptoms of opioid withdrawal and depressed mood.

In a study published Aug. 3 in JAMA, a team of UC Davis Health researchers examined the potential risks of opioid dose tapering. Their study found that patients on stable opioid therapy who had their doses tapered had significantly higher rates of overdose and mental health crisis, compared to patients without dose reductions.

“Prescribers are really in a difficult position. There are conflicting desires of ameliorating pain among patients while reducing the risk of adverse outcomes related to prescriptions,” said Alicia Agnoli, assistant professor of Family and Community Medicine at UC Davis School of Medicine and first author on the study. “Our study shows an increased risk of overdose and mental health crisis following dose reduction. It suggests that patients undergoing tapering need significant support to safely reduce or discontinue their opioids.”

De-prescribing opioids for patients on long-term therapy

The study used enrollment records and medical and pharmacy claims for 113,618 patients prescribed stable higher opioid doses (the equivalent of at least 50 morphine milligrams per day) for a one-year baseline period and at least two months of follow-up.

It looked at emergency department visits or inpatient hospital admissions for any drug overdose, alcohol intoxication, or drug withdrawal and for mental health crisis events such as depression, anxiety, or suicide attempts.

The researchers compared outcomes for patients after dose tapering to those for patients before or without tapering. They found a 68% increase in overdose events and a doubling of mental health crises among tapered as compared to non-tapered patients. The risks of tapering were greater in patients who had faster dose reductions and higher baseline doses.

To taper or not to taper

Guidelines from the Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) advise clinicians to monitor patients carefully during tapering and provide psychosocial support. They caution about the potential hazards of rapid dose reduction, including withdrawal, transition to illicit opioids, and psychological distress.

“Our study results support the recent federal guidelines for clinicians considering opioid dose reduction for patients,” said Joshua Fenton, professor and Vice Chair of Research in the Department of Family and Community Medicine and senior author on the study. “But I fear that most tapering patients aren’t receiving close follow-up and monitoring to make sure they’re coping well on lower doses.”

The researchers emphasized the need for clinicians and patients to carefully weigh the risks and benefits of both opioid continuation and tapering in decisions regarding ongoing opioid therapy.

“We hope that this work will inform a more cautious and compassionate approach to decisions around opioid dose tapering,” Agnoli said. “Our study may help shape clinical guidelines on patient selection for tapering, optimal rates of dose reduction, and how best to monitor and support patients during periods of dose transition.”

Duke University School of Nursing Promotes Turn the Tide Rx Movement to End Opioid Epidemic

Duke University School of Nursing Promotes Turn the Tide Rx Movement to End Opioid Epidemic

Following the US Surgeon General’s call to action to end the national opioid epidemic through a movement called Turn the Tide Rx , the Duke University School of Nursing is taking steps to help promote it. Surgeon General Vivek Murthy launched the effort in August 2016, calling for healthcare providers to be educated on how to treat pain effectively without over-prescribing opioids and how to direct opioid users to alternate forms of treatment.

Opioid addiction has increased over the past 15 years, becoming a national epidemic. According to the Centers for Disease Control and Prevention, 91 people per day died from opioid overdose in the US in 2016.

Duke’s School of Nursing is addressing the epidemic by hosting a discussion on how emergency healthcare providers can unite against opioid abuse.  Students from the accelerated bachelors of science in nursing (ABSN) program organized the event and hope it will be the first in a number of efforts to bring the Turn the Tide Rx movement to North Carolina.

The School of Nursing is focused on 21st century healthcare needs and preparing the next generation of transformational leaders in nursing. Two students from the ABSN program and members of Duke Emergency Nursing Students brought the idea for the Turn the Tide Rx discussion to the nursing Dean who was thrilled to support their idea. After being personally affected by the opioid epidemic, these students wanted to start spreading awareness and educating others on alternative pain management.

Turn the Tide Rx is a movement for the entire healthcare community, not just nurses. Duke is hopeful that their event will open up the conversations to begin reducing opioid abuse in North Carolina and across the country. To learn more about Duke Nursing’s efforts to end the opioid epidemic, visit here.

How Nurses Can Help Prevent Opioid Addiction

How Nurses Can Help Prevent Opioid Addiction

Opioid addiction is an epidemic in every US state. A new study in the New England Journal of Medicine has linked opioid-addicted patients to the very first provider who prescribed the medication. The researchers found a correlation between the pain-prescription habits of emergency room physicians and the frequency of their patients becoming opioid-addicted. (You can read an article in the New York Times about the research here .) The bottom line? The risk of opioid addiction begins with a single exposure to narcotic pain medications—which frequently occurs during an emergency room (ER) visit.

Naturally, prescribers are in the most control: They can limit the quantity of pills prescribed after an incident, or change their prescription habits to restrict the instances warranting their use. For example, instead of patients leaving the ER with a prescription for 30 oxycodone tablets after a sprained ankle, they can prescribe 5 pills. Better still, they can prescribe ibuprofen, ice, and rest; if that becomes insufficient for pain control at home, pharmacologic methods can then be addressed.

Although physicians and advanced practice providers write the prescriptions, it is the nurses who most often provide medication education to patients at the time of discharge. It is therefore the nurse’s responsibility to ensure adequate patient education and to stress the dangers of taking opioids to their patients—even before they ever start taking the medication. Now more than ever researchers are discovering that a single exposure to these dangerous medications is enough to put opioid-naive patients at risk for addiction.

Set expectations. Patients may have a right to pain control, but they also have a right to know just how many risks opioids bring. After an injury, many patients seem to think they will be instantly pain free. It is important to manage expectations that some degree of pain after an injury or illness is normal, as their body heals and recuperates. It is when the pain become unbearable that they should turn to pharmacological relief.

Discuss alternatives. After a musculoskeletal injury, other methods of pain control can be useful. Consider teaching patients to RICE (rest, ice, compress, and elevate) their injuries, and offer other methods of pain control such as distraction, positioning, massage, heat, and ice.

Lay out the risk of addiction. Narcotic drugs are very risky medications. Teach your patients that they are dangerous and may cause addiction even in small uses. Tell your patients to take the medications very sparingly, and be firm with your language. Patients trust nurses, and their cautious attitudes can affect patient perceptions and behaviors.

Review the unpleasant side effects. Opioid pain medications have a number of serious side effects and complications. Emphasize that your patient may experience sedation, constipation, dry mouth, tolerance or dependence, confusion, nausea, dizziness, or itching as a result of using the drug. Remind them that they cannot drive while taking the medication. Teach also that they may experience withdrawal symptoms after use.

Teach the symptoms of overdose and addiction. If the patient feels like they need more of the pills to feel normal or relief, this is a sign of increasing dependence and tolerance on the drug, and they should seek medical advice. If the patient has slurred speech; feels lethargic, foggy, or confused; is difficult to arouse or has loss of consciousness; or experiences a decreased respiratory rate, small pupils, or cold clammy skin, they may be experiencing an overdose and need immediate medical attention.

Nurses may think that since they do not prescribe the medications, they have no contribution to the opioid epidemic in this country. However, as some of the most trusted professionals in health care, it is the nurse’s role to properly educate, set realistic pain management expectations, and relay the serious risks of taking these medications.

What Every Nurse Needs To Know About Pain Management

What Every Nurse Needs To Know About Pain Management

The patient who watches the clock and requests their pain medication at the top of hour. The patient who always rates their pain a “10” out of 10. The patient who requests a specific narcotic like Dilaudid. Some nurses might view such behavior as red flags and will label those patients as potential “drug seekers”—but pain management experts like Bobbie Norris, BSN, RN, CNRN, BC-RN, a pain resource nurse at Johns Hopkins Department of Neurology and Neurosurgery in Maryland, says nurses who jump to those conclusions are often wrong and do a disservice to their patients.

The patient specifically asking for Dilaudid, for instance, isn’t necessarily an addict. In fact, a patient returning to the hospital for his umpteenth surgery most likely is an expert on what medications work best for him. “Just because a patient knows what works for them, that doesn’t mean they’re drug-seeking,” says Norris.

Susan McMillan, PhD, ARNP, FAAN, a nursing professor at the University of South Florida who has researched pain in oncology patients, echoes Norris’ concerns. “Nurses today are very concerned about drug-seeking,” she says, recalling a study in which nurses were asked what made them decide if a patient was “drug-seeking,” as opposed to suffering. “Their answers were: ‘If their pain was unrelieved, if it’s overwhelming, or if they ask too frequently,’” says McMillan, though in reality, each of those behaviors is an indicator that a patient’s pain is not being well managed.

Indeed, if Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores are an effective measurement, patients are not getting enough pain relief during their hospital stays. According to HCAHPS patient survey data, only 71% of those surveyed said their pain was “always” well controlled in 2014-2015. Other studies, meanwhile, show that pain is often undertreated in pediatric patients, in older adults in long-term care, and among certain minority populations.

Experts believe the highly publicized global epidemic of opiod abuse is likely contributing to the conundrum. Nurses and other members of the health care team may worry about patient addiction and tolerance. Patients, too, often worry about addiction and side effects. As a consequence, some are reluctant to take pain medications or even report their pain.

Unrelieved pain, however, can cause serious problems and ultimately jeopardize an individual’s recovery from surgery or illness. Patients with poorly controlled pain are less likely to walk around and breath deeply, increasing their risk for atelectasis and other complications of immobility. Not addressing a patient’s pain also opens a nurse up to legal liability.

Experts say that nurses can better serve their patients by following these five strategies:

1. Believe Your Patient

Margo McCaffrey transformed the nursing profession’s approach to pain management when she declared in 1968 that pain is “whatever the experiencing person says it is, existing whenever he says it does.” While that’s the prevailing philosophy nurses learn in school, it doesn’t always carry over into clinical practice. “Nurses will say to me, ‘They can’t be in this much pain. Their blood pressure’s not up. They’re not tachycardic, they’re not tachypneic,’” says Norris. In fact, patients who’ve suffered from chronic pain for many years often show no objective systemic signs of distress because their central nervous system has “autoregulated.” While the risk of addiction is a valid concern, it does not negate the RN’s responsibility to accept the patient’s report of pain and respond to it with compassion and prompt intervention.

2. Better Monitoring

Measuring pain is an integral part of managing it. That’s why the VA developed an initiative in the 1990s to promote pain as the “fifth vital sign.” The concept of measuring pain as a vital sign—along with heart rate and blood pressure—was intended to get health care professionals in the habit of routinely screening, assessing, and documenting pain levels. One area where nurses continue to struggle, though, is with pain reassessment post-intervention. While every hospital has its own policies about when to reassess pain, ideally pain should be reevaluated at around the time it takes for a drug to reach its peak effect: that’s about 15 to 20 minutes after an IV bolus of morphine, and 60 to 90 minutes after an oral narcotic. Close monitoring also allows the RN to keep an eye on a patient’s sedation level and respiratory status and make any necessary adjustments to the patient’s treatment plan—and that should ease the anxiety of the RN who is worried about overmedicating their patient.

3. Expanding Therapies

Multimodal pharmacology is the optimal approach to managing pain. This means patients do better if they receive a combination of pain medications targeting different pain pathways, such as a narcotic pain reliever that directly decreases transmission of pain signals to the brain—and an NSAID to reduce swelling and inflammation at the site of injury. Drugs aren’t the only way to combat pain. Sandra Siedlecki, PhD, RN, CNS, a senior nurse scientist at Cleveland Clinic, has found that music therapy can be an effective tool to reduce chronic pain, which is notoriously difficult to treat. In fact, when patients suffering from chronic neck, back, and arm pain listened to an hour of music each day, their pain dropped by about 21% according to Siedlecki’s study published in the Journal of Advanced Nursing. A number of hospitals, including Johns Hopkins, have also introduced “Pain Control and Comfort” menus offering patients ‘a la carte’ therapies, ranging from warm packs and icepacks, to handheld fans, repositioning, stress balls, and handheld massagers. While many of the items on the menu have always been available, presenting them in this format gives the patients a feeling of “empowerment,” says Suzanne Nesbit, PharmD, CPE, a clinical pharmacy specialist and pain management research associate at Johns Hopkins.

4. A Tailored Approach

Patients don’t just differ in how they feel pain—they also differ in their response to pain medications. For example, studies have shown that approximately one-third of patients with cancer-related pain don’t respond well to morphine and develop intolerable adverse effects or fail to get any significant pain relief. Researchers, however, are beginning to unravel some of the mysteries of pain and providing scientific explanations for idiosyncrasies in drug response. Genetic variability in the cytochrome P450 (CYP450) system, the enzyme system in the liver that breaks down medications, can dramatically influence how well a drug works. If a CYP450 enzyme metabolizes a medication too quickly, for instance, the patient might require a higher dose for effective pain relief. If the patient’s CYP450 system is sluggish, they might require a smaller dose, otherwise toxicity can occur. Age, gender, and lifestyle can also impact drug response. In the future, hospitals will use genetic testing to help personally tailor pain treatment regimens for patients. Until then, nurses will have to rely on their assessment skills and clinical judgment to implement pain interventions adapted to each patient’s needs.

5. Examine Bias

Research has shown that ethnic minorities are routinely and systemically undertreated for pain when compared to white patients. One study by researchers at Emory University found that 43% of African American patients presenting at an Atlanta emergency department with long bone fractures received no pain medications. By contrast, only 26% of white patients with the same injuries “went untreated for pain.” A 2015 study published in JAMA Pediatrics found that black children with appendicitis were 20% less likely than white children to receive painkillers in the ED. A 2016 study by the University of Virginia on the topic attributed the disparate treatment to erroneous beliefs about biological differences among the two races. Awareness and acknowledgment that such bias exists is a first step to rooting out unconscious bias. The Joint Commission also recommends health care providers perform “teach back,” utilize educational and training techniques to “de-bias” care, and “assiduously” practice evidence-based medicine.