Carolyn Concia, NP, was confronted with the larger implications of the crackdown on opioid prescribing when she learned why her friend's son had died by suicide.
The son could not sleep because he was in significant, chronic pain as a result of injuries from serving in the military in Afghanistan, and he had sought help from a doctor. The provider thought he was a drug seeker and did not prescribe anything that would help relieve his symptoms, and the distraught young man went home and ended his life. At first, Concia thought this case was an outlier, but she soon discovered there were others throughout the country who were encountering similar problems. People with chronic pain conditions who had taken opioids responsibly for years were suddenly being forced to reduce or taper-off their medications. Others who wanted to continue their opioid prescriptions had difficulty finding providers who would accept them as new patients. "These people are suffering from withdrawal symptoms as well as an increase in their pain because they are no longer receiving adequate treatment," said Concia, a private practice geriatric and palliative care nurse practitioner in Oregon. "Patients are confused, scared, and many have lost the ability to function." Concia is not alone in her concern for patients who are suffering both physically and psychologically because insurance companies, providers, and governmental organizations are changing opioid prescribing policies.
The Opioid Prescription Paradox
A 2019 study of primary care clinics in Michigan found 40% of the clinics would not accept new patients receiving opioid therapy for pain. In a study published in Pain Management Nursing, researchers conducted interviews and surveys to understand the experiences of people seeking pain relief who had been taking opioids for six months or longer, and the results were sobering. "We found that many of these patients felt like they were battling a healthcare system that was supposed to be providing help," said study author Crystal Lederhos Smith, PhD, an assistant research professor in the College of Medicine at Washington State University. "They were not only suffering from chronic pain, but also felt demoralized because they were labeled as drug seekers and bad people." The policy changes also are affecting patients in hospitals who are experiencing acute pain, said Maureen Cooney, DNP, FNP-BC, a pain management nurse practitioner at Westchester Medical Center in Valhalla, N.Y. Many states have passed laws limiting opioid prescribing for acute pain at the time of discharge. Some of these laws limit patients who have never taken opioids to a seven-day supply of these medications. As a result, patients who need refills must follow up with a surgeon or primary care provider.
"Getting an appointment is not always easy, and there are many providers who are not comfortable prescribing opioids," said Cooney. "This can leave people struggling with pain once they are discharged."
She has also started seeing an increase in the number of patients who refuse to take opioids because they are afraid of developing opioid use disorder. Cooney often recommends a multimodal analgesia approach to treat pain, which combines analgesics from two or more drug classes. Patients with rib fractures, for example, may benefit from opioids when they are used with a foundation of non-opioid pain medications -- and when risks for developing opioid use disorder are assessed. "Opioids, along with non-opioid medications and non-pharmacological approaches, may be appropriate when pain is high and uncontrolled pain is posing a problem for recovery," said Cooney, president-elect for the American Society for Pain Management Nursing (ASPMN). "If patients are in too much pain to breathe well, cough, and move the risk of pneumonia and other complications increases."
Uncovering Misconceptions About Prescription Opioids
Although nurse practitioners specializing in pain management agree the country is confronting an opioid epidemic, researchers like Cathy Carlson, PhD, APRN, FNP-BC, were concerned the statistics were not accurately portraying the problem. Carlson, an associate professor in Northern Illinois University's School of Nursing, started studying the methods used to calculate statistics such as prescription opioid deaths, and she discovered that many people who die of an overdose have more than one substance in the body. "They may have died from the effects of a drug other than a prescribed opioid, but it is still marked as a prescription opioid death," said Carlson, whose findings were recently published in Pain Management Nursing.
Carlson also investigated the claim that prescription opioid overdose deaths continue to escalate and cause the majority of opioid-related deaths. She found illicit opioids are primarily driving the current rise in opioid-related overdose deaths, whereas prescription opioid overdose deaths declined after 2011, with small rises since 2014.
While nurse practitioners like Carlson are supportive of policies that encourage providers to exercise caution when prescribing opioids, they are concerned about guidelines that limit the ability to individualize treatment. The CDC's Guideline for Prescribing Opioids for Chronic Pain, which was released in 2016, urged providers to avoid prescribing more than 90 morphine milligram equivalents (MME) per day. This limit was far below what was needed for one 64-year-old woman who reached out to Concia for help. The woman had suffered complications after multiple surgeries to treat colon cancer, and her doctor had prescribed opioids for several years for her chronic abdominal pain. "She was a model patient," Concia said. "She never negotiated for more medication, never doctor-shopped and always used one pharmacy."
Four years ago, her doctor abruptly stopped prescribing opioids, and since then, the woman had been turned away by multiple providers because she was a chronic pain patient. Her pain had become so severe that she stopped working, rarely left her room and lost her ability to function.
Concia carefully evaluated the case and decided to prescribe a combination of oxycodone and morphine. Concia equipped the woman with a certified letter describing that her patient qualified for opioid pain medication to control symptoms and that she was not at risk of diversion, addiction, misuse, or abuse. This letter could be given to a pharmacist if needed. The woman's pain significantly decreased after she began taking the medication and she started resuming her activities of daily living.
Opioid Regulations Affecting Children
The crackdown on opioid prescribing also is impacting the pediatric patient population, said Sharon Wrona, DNP, PNP, FAAN, Director of Comprehensive Pain & Palliative Care Services at Nationwide Children's Hospital in Ohio. She sees patients who benefit from opioids when they are experiencing pain from sickle cell disease, arthritis, muscular dystrophy, or severe accidents, but families are often afraid to let people in the community know about their use of these drugs, said Wrona.
"They also worry that they won't be able to fill their prescriptions because pharmacies and insurance companies vary in what they allow," she said.
In Ohio, pediatric patients can leave the hospital with a five-day opioid prescription to treat acute pain, but exceptions may be allowed if a provider deems this necessary. Wrona wrote an extended prescription -- with an explanation of why this was necessary -- for a patient who had suffered multiple fractures after a car accident, but his pharmacy would not fill the extended prescription. To help educate federal and state organizations about the implications of the new prescribing regulations, Wrona, who is also immediate past president of ASPMN, testified at an FDA Opioid Policy Steering Committee public hearing in 2018. She discussed the importance of individualized pain management, which includes more insurance coverage for opioids as well other forms of pain management, such as acupuncture and non-opioid pain medications. Although it may be tempting to vilify the decision-makers who are creating stricter regulations for opioid prescribing, Pain Management Nurse Advocate Marsha Stanton, PhD, RN, believes that many of these leaders may not understand the consequences of the new rules. "It's a matter of educating them about what led to the crisis and how we have swung to the other extreme," said Marsha Stanton, PhD, RN, a member of the ASPMN who has advocated for more individualized opioid prescribing policies. "Generally, they are pretty receptive and want to hear how things have gone awry."
Take these courses on opioids and pain management:
Responsible Opioid Prescribing, Chronic Pain, and Addiction (1.5 contact hrs) The goal of this continuing education program is to provide nurses with information about best practices in the prescribing of controlled substances, including safe and effective prescribing, administering, and dispensing of controlled substances to the patient with chronic pain. Heroin: The Illegal Opioid (1.5 contact hrs) Characteristics of heroin such as its appearance, chemical structure, administration, metabolism, and mechanism of action are addressed in this continuing education module to elaborate on how the drug elicits such a strong, unique euphoric effect compared to other opioid medications. This includes the identification and treatment of heroin overdose, withdrawal, addiction, and other associated complications of chronic use. Evidence-Based Approaches to Pain Control (2.5 contact hrs) This continuing education module takes a public health approach across the continuum of pain care, which can be accomplished without worsening the opioid crisis. The strategy begins with preventing and effectively treating acute pain while avoiding unnecessary exposure to opioids followed by early identification and effective treatment of chronic pain or opioid use disorder, then preventing morbidity and mortality from "high-impact chronic pain".
