Keeping up with the fast-changing medication landscape is important for nurses at all levels of care.
For advanced practice nurses, staying abreast of pharmacology is required, and nurse practitioners and clinical nurse specialists need to take an advanced practice nurse pharmacology course every two years to renew their licenses and national certification. The rationale for requiring nurses to update their knowledge of medicines and be aware of trends in new drugs and biological agents is important, said one of our advanced practice nurse pharmacology course authors, Paul Arnstein, RN, PhD, FAAN, a clinical nurse specialist at Massachusetts General Hospital. That importance is stressed by the lay media and direct-to-consumer advertising always touting new therapeutic options.
Nurse practitioners increasingly are being granted full prescriptive authority, which is accompanied by the responsibility to be knowledgeable about black box warnings and potential drug-to-drug interactions, he said.
We asked Arnstein about the need for pharmacology knowledge for today's healthcare professionals.
The advanced practice nurse pharmacology course allows nurses to fulfill the American Nurses Credentialing Center 25-contact hour pharmacotherapeutics requirement for certification. Why is it so important for advanced practice nurses today?
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Paul Arnstein, RN, PhD, FAAN[/caption] Drugs are always changing, and there are always new drugs coming to market. There are new black box warnings of existing drugs. There are new generics and therapeutic alternatives. Older, unfamiliar drugs may make a comeback. Common medicines may be found to be unsafe or less effective than originally thought, or some may be repurposed for off-label uses. Ketamine, for example, was used for a long time as an anesthetic. When using it in opioid-tolerant patients, it was found to be an effective analgesic at lower the dose of opioid needed to be effective. Subsequently, it has been shown to be effective in low doses for intractable chronic pain, while another line of research demonstrates its utility for difficult-to-treat depression. So, the rapid expansion of drug-related research is providing new insights into the potential effects and side effects of medications.
Do healthcare trends make it more important for nurses to have a strong grasp of commonly prescribed medications and therapeutic alternatives?
Cost is always a factor. Prior authorization is another. What often happens is patients who are prescribed medications in the hospital sometimes can't get those medicines when they're back in the community because of regulatory reasons or prior authorization.
One of the other things we're seeing that we didn't see as much five years ago is how drug shortages are impacting what we can prescribe to patients. That's forcing us to think more broadly about therapeutic alternatives.
In hospitals, there was an intravenous (IV) opioid shortage last year. Right now, there are immunoglobulin shortages and looming heparin shortages. That really creates a conundrum for prescribers trying to meet patients' needs with different types or combinations of drugs.
What do nurses need to know about the opioid crisis?
Everyone's concerned about the dramatic rise in opioid overdose deaths and the rates of opioid use disorder. Since 2012, we've seen a steady decline in opioid prescribing, which accelerated with the release of the 2016 CDC opioid prescribing guideline for primary care treatment of chronic pain. Since then we've seen a 37% to 65% reduction in opioid prescribing. With regulators and payers codifying the guidelines as policy and going beyond the CDC's original intent, many have stopped prescribing opioids.
Now, an estimated 40% of primary care practices will not accept a chronic pain patient taking opioids. This has created chronic pain refugees who were on opioids and functioning well on them, who have lost access to basic primary care.
This practice of involuntary tapers and abandonment has left many patients with no legitimate access to care or sub-optimal therapeutic alternatives. What a lot of people don't realize is that 0.02% of patients will die from opioids if they're using opioids as prescribed, whereas 1% of patients who take nonsteroidal anti-inflammatory drugs (such as ibuprofen or naproxen) will die of a heart attack, stroke or major GI bleed when taking these medicines as prescribed for a year.
Sadly, many have believed their only options to stop the pain were to commit suicide or purchase illicit opioids. Counterfeit opioid pills are often laced with illicitly manufactured fentanyl.
In Massachusetts over the past two years, 90% of opioid overdose deaths had illicit fentanyl in their system, compared to 14% whose toxicology showed the presence of prescription opioid drugs. There's no perfectly safe drug. We have to view all medicines as a balancing act. How do we treat the disease or symptoms while also improving function and minimizing toxicity or the side-effect burden?
What should nurses know about newer biologic medications becoming available?
We're seeing a rapid expansion of biologics, which raises a whole host of learning needs. As with any medicine, nurses need to understand the mechanism of action that may be more theoretical than factual. When biologics are manufactured and studied, researchers eliminate patients with comorbidities.
Now we're starting to see side effects, toxicities and adverse responses to these biologic medications when used in a broader population for longer periods of time.
There are also some "me-too drugs" coming up in the form of biologics. They're not being produced in the same way, and it's really hard to say they are therapeutic equivalents. There's a growing appreciation that we need to study effectiveness trials in the real world, as much as we need to study and efficacy in carefully selected groups. Effectiveness trials are needed that span several years to understand the late effects of specific drugs in real-life settings. This includes gaining a better understanding of both the desired and undesired effects.
The advanced practice nurse pharmacology course includes education about black box warnings. What do nurses generally need to know about these warnings?
Black box warnings are the strictest warning ... issued by the Food and Drug Administration when evidence shows a potential serious hazard associated with taking the drug.
[Black box warnings] need to be followed. For example, I just mentioned the problems with pain medicines where patients have been tapered to zero and discharged from practices.
The FDA decided to add a black box warning addressing the hazard of sudden or involuntary tapers that have harmed patients. I also have done legal expert testimony in cases where an advanced practice prescriber renewed a two-week prescription started by a physician. Despite a black box warning about limiting the duration of exposure to this medication to two weeks maximum, it was refilled repeatedly until the patient developed the irreversible harm described in the black box warning. Unfortunately, this practice is not legally defensible.
Thus, if nurse practitioners have full prescribing authority and they prescribe without a familiarity of black box warnings, they might be placing themselves and patients they serve at risk.
When monitoring response to therapy, it's important for nurses at all levels to be familiar with black box warnings and drug interactions. We do a tremendous disservice to patients if we fail to know those critical pieces of information that change over time.
Electronic health records (EHRs) provide some information about drug-to-drug interactions, but is that enough?
That might be enough, but many EHRs have different thresholds to trigger an alert. They may not take nutritional or herbal supplements the patient is taking into account that might cause a drug interaction. Drug interactions are getting more important and complex. Polypharmacy (taking five or more medicines) significantly increases the risk of an adverse event or a drug interaction. Each additional medication further increases the risk, with many patients now taking 20 or more medications a day in my practice setting. So, especially in the older adults, it's important to consider 'subtraction therapy' to see if patients can get by on fewer medications or find a therapeutic alternative that won't require adding on additional medicines to treat side effects.
Take our Advanced Practice Nurse Pharmacology course today.
