Skip to main content Blog

ED Nurses Wrestle With Biases, Pressures to Limit Opioids When Treating Pain Patients


In recent years, U.S. emergency departments have prescribed fewer opioids for pain patients.

In 2005, providers prescribed opioids in 37.4% of U.S. ED visits by pain patients. The percentage rose to 43.1% in 2010, then fell to a considerably lower 30.9% in 2017, according to the CDC's January 17, 2020 Morbidity and Mortality Weekly Report. Yet some worry the pendulum might have swung too far, marginalizing and stigmatizing pain patients who legitimately benefit from the drugs.

Healthcare providers' biases, as well as pressures to find alternatives to opioids, could diminish quality of care if not kept in check.

Opioid addiction is real

Deaths from drug overdoses, including illicit and prescribed opioids, have steadily risen from 16,849 in 1999 to 70,237 in 2017, according to the National Institute on Drug Abuse. Drilling down to deaths from "any opioid," mortality was at an all-time high in 2017, the last year of the statistics, when there were 47,600 deaths from opioids. Death from prescription opioids, including methadone, climbed from 3,442 in 1999 to 17,029 in 2017, remaining stable in 2016 and 2017. In contrast, overdoses involving heroin claimed 15,482 lives in 2017, according to the National Institute on Drug Abuse. [caption id="attachment_76176" align="alignleft" width="200"]pain patients - Mike Hastings, MSN, RN Mike Hastings, RN[/caption] ED nurses grapple with the opioid crisis daily. Determining who really needs opioids is especially important given state rules and regulations aimed at limiting the narcotics, or opioids, ED providers can prescribe, said Mike Hastings, MSN, RN, CEN, 2020 president of the Emergency Nurses Association. "We have patients that come into our emergency departments that are truly in acute pain and truly need pain medication to treat whatever is going on with them," said Hastings, clinical manager the emergency department at Swedish Edmonds Hospital, Edmonds, Wash. It's also no secret people who have abused opioids and try to feed their addictions via the ED. "That's where the struggle comes in," Hastings said. "This is something that we all face. It doesn't matter if you're working in a small emergency department in a rural area or work at a big urban trauma center.

Careful not to label pain patients

Labeling ED pain patients as drug seekers isn't a new thing, but it's problematic, according to Cathlyn Robinson, MSN, RN, CEN, emergency department clinical education specialist, St. Joseph's Health. "One of the predominant reasons patients seek care in the emergency setting is because they're having pain," she said. "It's a very legitimate and real reason to come see us. There's no question." To better understand which patients should and shouldn't receive narcotic pain medications, ED nurses need to put aside judgments and biases. They should listen and treat each patient holistically, according to Hastings.

"From a nursing standpoint, we really do have to make sure we are not becoming biased. It can be extremely difficult to do," Hastings said.

By conducting a full assessment and asking about potential injuries, type of employment, medical history, prior pain treatments and more, nurses better understand the root cause of what's going on with the person and can treat the patient holistically. This is opposed to looking only at the patient's chief complaint and labeling them as another overdose patient or addict. Something to keep in mind is even legitimate pain patients can overdose. The incidence of opioid-related ED visits by cancer patients increased about two-fold between 2006 and 2015, according to a study published Dec. 17, 2019 in the Journal of the National Cancer Institute.

"The problem is the stigma around overdosing," Hastings said. "You can legitimately have somebody that accidentally took one of their prescribed medications and overdosed."

Today's goals

The goal when treating pain patients in the ED is to carefully assess, listen and try to treat with options other than opioids as a first line, according to Robinson. "It doesn't mean that patients never receive opioids," Robinson said. "For example in our hospitals, they will receive opioids if it's necessary." [caption id="attachment_76178" align="alignright" width="256"]pain patients - Cathlyn Robinson, RN Cathlyn Robinson, RN[/caption] Patients who might be candidates for opioids include those with cancer and sickle cell anemia. "Sickle cell is so incredibly painful," Robinson said. "These are patients that we need to make sure we listen to, and if they need opiates, those are generally the patients that are going to receive them. Another example is the person that comes into the trauma bay with a fractured pelvis. They are going to need opiates as well. I think what's important is to use them when it's really necessary and to not use them when we have other choices." Many think opioids fix everything and they don't. For example, they're generally not the best pain relief option for inflammatory pain, according to Robinson. Nurses should communicate with pain patients that they're getting a non-opioid drug to treat their pain because it's a better option for their specific pain.

"What we're trying to do is say, 'Let's treat your pain comprehensively, but let's make sure we're giving you the best choice of drug and that best choice may not be an opiate," Robinson said. "'If you need an opiate, yes, we're going to give it to you.'"

Remember the fundamentals Nurses should care for all patients as individuals, regardless of what brought them to the ED, according to Hastings. "It doesn't matter if it's an overdose or a behavioral health patient that's coming in," he said. "We have to step back and make sure we're treating everybody as an individual person and providing the best care that we can for them." Nurses can be important bedside and "stretcher-side" advocates for pain patients by presenting options for better patient pain control to hospital or health system leadership, Robinson said. Still, there are times when nurses can't put aside how they feel or what they think. Hastings stresses to his team that if they feel they can't overcome a bias or are judging a patient, they should consider removing themselves from that patient's care and asking a colleague to take over. "Take a moment to reflect about why you're here, why you became a nurse," Hastings said. "You became a nurse to help other people, to do the best possible job and get the patient the best possible care. So, take that moment and reflect on that before you enter into that situation."

Take these courses to learn more about opioid use:

Responsible Opioid Prescribing, Chronic Pain, and Addiction (1.5 contact hrs) The goal of this continuing education program is to provide information about best practices in the prescribing of controlled substances. This includes safe and effective prescribing, administering, and dispensing to the patient with chronic pain. Patient Counseling: Preventing and Combating Opioid Misuse (1 contact hr) Learn how to assess the nature of patient's opioid use and provide education and/or counseling for opioid use. Also, learn how to refer persons to applicable resources for substance misuse or abuse. Heroin: The Illegal Opioid (1.5 contact hrs) The history of diacetylmorphine (heroin) along with current epidemiological data and overdose statistics together illustrate the dangers associated with heroin. Characteristics of heroin such as its appearance, chemical structure, administration, metabolism, and mechanism of action are addressed. Additionally, various treatment approaches for the management of acute and chronic heroin use are discussed.