Sunday, June 5, 2016


Narcotic pain medication is big news these days. Thousands of people are reportedly addicted to opioid pain medication, like Percocet or Vicodin. Many more are using heroin--these days it's a lot cheaper than a $40 Norco pill bought on the street, and less fuss than trying to get legitimate oral medication from a doctor's office. Some doctors have managed to turn their offices into "pill mills", complete with an armed guard at the door. Overdose deaths have risen. Musician Prince, we learned this week, seems to have died of an overdose of the prescription drug fentanyl, a drug roughly 200 times more potent than heroin. 

The result: laws passed giving police and EMS personnel the authority to carry and administer the drug naloxone, which blocks opioid receptors in the nervous system, and can reverse an overdose before death occurs; increases in training for physicians and nurses on how to prescribe and use narcotic pain medication; and new guidelines from national organizations on when to use--and when not to use--such medicines.

Last time, I said I'd share some bits about what today's nurse wants to know more about and what it says about health care in America. Today we'll start with the "Opioid Crisis". 

RNs fulfill a variety of roles here. Yes, they administer pain meds in the hospital, but they also manage panels of outpatients in clinics that need to treat pain, like orthopedics or pain management. They survey what patients are using during medication reviews and help fill pillboxes in those who have difficulty managing their meds, like some elders or folks with mental health problems. They teach patients how to use their meds safely, and because of their more regular, closer contact with patients are often the first to see that a person is showing signs of a drug problem. They advocate for patients, too, and are often the ones requesting that pain meds be increased, decreased, or adjusted based on changes in a patient's condition.

So when today's news describes growing numbers of overdoses, patients causally prescribed opioids for all sorts of ills, and the emergence of cheaper heroin, nurses want to know how to deal with all that. In the mini-mester course I just taught, the syllabus is broadly written enough to allow us to be topical with our lessons, so I polled the incoming class, 14 nurses from local hospitals and agencies, working on their bachelor's degrees, and asked what they wanted to learn about. Several of them said they wanted to learn more about these changes in how we prescribe and monitor opioids.

They know the history: that in the mid-20th century it was hard to get doctors to take pain seriously and prescribe adequately. They know that in the late 1960s nurse Margo McCaffrey was advocating for more humane pain treatment, having written that pain is, “whatever the experiencing person says it is, existing whenever the experiencing person says it does” (McCaffrey, 1968, p. 5).

She wasn't trying to create an epidemic of overdoses. She just wanted people to suffer less.

If I ask the question, "what is pain?" to these seasoned nurses, they all reply with essentially this quote from McCaffrey. Mission accomplished. 

There's also a lot of suspicion. Nurses and doctors routinely suspect patients of "drug seeking", and sometimes they are right. Sometimes they aren't seeing the bigger picture. As the largest consumers of prescription and non-prescription drugs in the world, Americans seem more prone to medicate than other societies. We often think of drug use as something people do to "party", but as Hanson, Venturelli, and Fleckenstein (2014) note, a lot of drug use and abuse is for "illegal instrumental" purposes. That is, people are self-medicating, not just getting high for fun.

In short, understanding why a society uses drugs the way we do, understanding how medical professionals see their role in managing problems humanely, and building a coherent educational program around those issues is a real challenge. For the course I just taught, I included the Centers for Disease Control's new Guideline for Controlling Chronic Pain.

Bear in mind, this is a reaction to the sudden wave of overdose deaths and the growing problem of people addicted to prescribed pain meds. One thing that struck me was the following passage, "Benefits and Harms of Opioid Therapy":

This screenshot is just a bit of the section, but I read it and not a single "benefit" was stated. The entire section is about "harms". Why is this a concern to me? Because too often our health care system is less about science and more about culture. I know what will happen: doctors will go from generously (and carelessly) prescribing opioids to refusing to use them at all.

My working nurses, these students I taught in May, reported routine prescriptions for post-surgical patients for 30, 60, even 90 tablets of opioids. If the prescription is for "1 to 2 tablets every 4 hours as needed"--which by the way is a perfectly correct prescribing of, say, Vicodin--that means a few patients could end up using as many as 12 tabs per day, or upwards of 36 in 3 days. If one doesn't want calls in the middle of the night for more meds, then you write for 30-60 tabs. That'll cover the worst case scenario.

And what happens in most cases? People take a few, maybe one or even none. What happens to the unused meds? They end up in the toilet...or in some enterprising person's hands, to be distributed, sometimes for money, for other people's pain--or fun. By the way, the ones we flush? They end up in your water supply because treatment systems aren't equipped to remove drugs from the wastewater stream.

In our class discussions we concluded that we need a more complex, nuanced national discussion that encompasses more realistic goals for the use of these drugs. Health care workers often operate with fear running in the background: fear of being sued, fear of delicensure, fear of criticism from colleagues, fear of hospital administrators. When leading organizations like the CDC assemble unbalanced, sloppy "guidelines" like the one depicted above, it contributes to this culture of fear that drives health care workers to the lowest common form of practice. Hysteria, driven by salacious news (overdoses, "pill mills") ends up creating a new culture to displace the old one.

I expect that new culture will bring some genuine innovations--and I did highlight several of these in the class, like the use of regional pain blocks for certain routine surgeries. But I expect the new culture will bring on more suspicion, and the undertreatment of pain, too. 


Hanson, G.R., Venturelli, P.J., & Fleceknstein, A.E. (2104). Drugs and Society (12th Ed.). Burlington MA: Jones & Bartlett.

McCaffery, M. (1968). Nursing practice theories related to cognition, bodily pain, and man-environment interactions. Los Angeles: University of California at Los Angeles Students’ Store.

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