Every day Americans are dying from an opioid overdose. And the numbers only continue to increase.
According to the National Institutes of Health (NIH), 33,000 people died from an opioid overdose in 2015. In 2018, just three years later, that number jumped to nearly 42,000 annually—115 deaths per day—representing a 27 percent increase (Rudd, et al., 2015; NIH, 2018).
The opioid crisis affects people from all walks of life, regardless of age, gender or socioeconomic class, and the heartache that comes with it not only affects its victims, but their loved ones as well. Some opioid overdose victims are lucky and are revived with naloxone, but others who are not able to receive pharmaceutical intervention in time, do not survive.
The unfortunate reality is that those who are resuscitated are often unable to break the addiction cycle even after a near-death experience, and many go on to experience multiple overdoses. As we continue to use opioids to treat chronic pain, the number of patients who develop opioid use disorder increases. Of the 25 million Americans who suffer from chronic pain, 2 million have an opioid use disorder (NIH, 2018).
As a nurse who has spent many years on the front-line of care, I know that these individuals are some of the most emotionally taxing patients to care for because we frequently see them back in the emergency department and admitted to the hospital with another overdose.
As one of the most developed nations in the world, many question how the U.S. was able to find itself in this predicament. Can nurses and other care professionals help change this precarious course?
We’ve all seen patients in pain and know that it’s real. But something has happened in the healthcare industry over the past 20 years that has unintentionally led to this crisis: we decided that patients should be pain-free always, no matter what the cause. We’ve even considered pain to be a fifth vital sign, although it was never meant to be one (Morone & Weiner, 2013). What we should have been doing instead of simply treating pain is focusing on educating our patients that pain management does not mean being pain free. Pain management is about decreasing pain incrementally so that one can function and maintain quality of life on the way to better health.
The onset of the opioid crisis
With the availability of opioid medications expanding in the 1990’s, healthcare providers finally had a plethora of drugs available to help manage acute and chronic pain. As a result, the number of opioid prescriptions, and the length of time they were prescribed, increased, resulting in a sharp increase in addictions. When an addicted patient’s prescription ran out, many turned to less costly street drugs like heroin to get their fix. In fact, 80 percent of all heroin users today previously had an opioid prescription (Muhuri, et al., 2013).
When addictive behavior forms, many patients will go to great lengths to obtain opioids. For example, they’ll often use a family member’s or friend’s medication, or resort to buying them on the street. Today, between 21 percent and 29 percent of patients prescribed opioids for chronic pain misuse them, and 8-12 percent will develop an opioid use disorder (Vowles, et al., 2015; Muhuri, et al., 2013; Cicero, et al., 2014; Carlson et al., 2016).
Opioids obtained on the street are often produced in foreign countries and lack oversight to insure quality of product, or the security of knowing nothing has been added to the drug. So, although these synthetic opioid street drugs may look the same, the risk to the user is very high.
National and state level response to the opioid crisis
The U.S. government is addressing the opioid epidemic through several means. The Department of Health and Human Services is working to improve access to drug treatment programs, promoting the use of overdose-reversing drugs (such as naloxone) to first responders and those who are prescribed opioids, as well as improving public health surveillance. The National Institutes of Health (NIH) has devoted funding for research on innovative pain management and addiction treatment. The NIH Helping to End Addiction Long-Term (HEAL) Initiative is focused on researching ways to manage pain more effectively and decrease the number of people afflicted with an opioid use disorder. In addition, healthcare providers who wish to prescribe controlled substances must apply for a Drug Enforcement Administration (DEA) number which must be renewed every three years. Any limits on the ability to prescribe controlled substances are based on individual state requirements. Prescribers of opioids now check the Prescription Drug Monitoring Program (PDMP) Database before writing the prescription to investigate the patient’s opioid prescription history.
Nurses role in the opioid epidemic
Nurses are often the professionals who request analgesic orders for their patients in acute, primary, ambulatory, community, and long-term care, so consequently, we need to recognize the difference between acute and chronic pain, and work with the interdisciplinary team to determine the best way to manage pain. We must advocate for responsible opioid prescribing, which means only prescribing them when absolutely necessary, and administering them to patients for the shortest duration possible. We also need to ensure that patients engage in frequent follow-up visits with healthcare providers to assess their progress and current pain level as well as initiate alternative pain management regimes if necessary, especially if their pain is due to neuropathic or hypersensitivity and is not nociceptive in nature.
We now know that giving patients opioids with benzodiazepines has been shown to increase overdose risk. Consequently, providers need to avoid this practice whenever possible. We need to encourage patients to seek treatment for an opioid use disorder and help them find reputable resources and treatment centers that can provide sufficient oversight and medical and nursing management. We also need to teach patients how to properly dispose of their used opioid medications when they are finished taking them, which can decrease drug diversion.
It’s important to remember that nursing is both an art and a science, and using basic principles can help guide our pain management practice through:
- Evaluating which type of interventions are best to help manage the patient’s pain – this could be alternative drugs to opioids or a low dose opioid with other therapies
- Educating patients that reducing pain—not completely alleviating it—is the goal of therapy
- Coming to an agreement with patients on what is a tolerable level of pain, one where the patient can be functional and still have quality of life
- Initiating contracts with patients prescribed opioids
- Evaluating and managing the patient’s anxiety through relaxation techniques
- Using correct patient positioning
- Using ice or heat when appropriate
- Using compression and elevation for sprains or strains
- Encouraging rest
- Consulting physical therapy and utilizing modalities such as a transcutaneous electrical nerve stimulation (TENS) unit for joint and muscle pain
- Using acupuncture, Tai Chi, yoga, mindful meditation, and other complementary or naturopathic techniques
- Offering other types of medications to help manage pain such as gabapentin, pregabalin, or duloxetine for neuropathic pain; ibuprofen or naproxen for pain due to inflammation from a sprain or strain; and acetaminophen for pain such as headache
- Recognizing when a patient has an opioid use disorder and needs access to vetted resources to manage the addiction
The opioid crisis has brought too much heartache to this country. As nurses, we must recognize we are integral to assessing and managing pain appropriately, as well as identifying patients who need addiction therapy and helping them gain access to needed resources. We must also be a voice for responsible prescribing. Together with the interdisciplinary team, we can help to alleviate the opioid crisis. We owe it to our patients!
Rudd RA, Seth P, David F, Scholl L. (2016). Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. MMWR Morb Mortal Wkly Rep. 2016;65. doi:10.15585/mmwr.mm655051e1.
National Institutes of Health, (2018). HEAL Initiative Research Program. https://www.nih.gov/research-training/medical-research-initiatives/heal-initiative
Morone NE, & Weiner DK. (2013). Pain as the fifth vital sign: exposing the vital need for pain education. Clin Ther. 2013;35(11):1728-1732. doi:10.1016/j.clinthera.2013.10.001.
Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, & van der Goes DN. (2015). Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156(4):569-576. doi:10.1097/01.j.pain.0000460357.01998.f1.
Muhuri PK, Gfroerer JC, & Davies MC. (2013). Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. CBHSQ Data Rev. August 2013.
Cicero TJ, Ellis MS, Surratt HL, & Kurtz SP. (2014). The Changing Face of Heroin Use in the United States: A Retrospective Analysis of the Past 50 Years. JAMA Psychiatry. 2014;71(7):821-826. doi:10.1001/jamapsychiatry.2014.366.
Carlson RG, Nahhas RW, Martins SS, & Daniulaityte R. (2016). Predictors of transition to heroin use among initially non-opioid dependent illicit pharmaceutical opioid users: A natural history study. Drug Alcohol Depend. 2016;160:127-134. doi:10.1016/j.drugalcdep.2015.12.026.