Tennessee Nurse - May 2021

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Page 8 Tennessee Nurse May, June, July 2021 Delores Jackson, PhD, MSN, BSN, ASN, RN Dependency and Abuse of Opioids Prescribing opioids is not the problem. Opioids provide highly effective pain management for acute pain originating from injury, surgery, cancer, and palliative or end-of-lifecare. Appropriate prescribing achieves adequate pain control; reduces patient addiction risks, abuse, or toxicity; and Delores Jackson minimizes drug diversion. Nevertheless, abuse and overdose deaths are still problematic, although data indicate US healthcare providers are making headway; since 2012, prescription overdose deaths have been declining. There were 67,367 US drug overdose deaths in 2018, which represented a 4.1% decline from 2017. Seventy percent of US drug overdose cases involved opioids. But deaths from natural and semi-synthetic opioids such as those typically prescribed by primary care practitioners (hydrocodone, oxycodone, or codeine) actually declined 14% from 2017 to 2018. Tennessee deaths from prescribed opioids also declined in 2018. Nursing Roles All RNs contribute to safe care delivery, patient assessment, pain management and education, whether working as an office RN, Advanced Practice Registered Nurse (APRN), or Nurse Practitioner (NP) with advanced practice credentials that include specialized pharmacology education with prescriptive authority. The diversified roles of RNs extend beyond primary care to assorted direct patient care and leadership positions. As skilled educators and patient advocates, nurses help patients and families understand other pain management modalities such as physical therapy, psychological management options, complementary medicine and non-opioid management strategies to ease the burden of pain. The American Nurses Association (ANA) noted that in part, the current US crisis has been created by ineffective medical efforts to manage chronic pain. The ANA applauds nurses as key players for pain management by providing early recognition and pain interventions in primary care settings, including patient-centered, interdisciplinary and self-management strategies. Spotlight on Practice Nursing Contributions for Safe & Effective Opioid Pain Management How Can Nurses Provide Safe Pain Management? Remove Barriers to Effective Pain Management Several barriers exist that can impact effective pain management. Nurses can overcome these barriers by transforming their practice to eliminate key problems that interfere with adequate pain control. 1) At the clinical institution level, interdisciplinary teams can develop best practices for pain management, treatment plans and drug prescriptions. 2) Individually, nurses should expand their education by attending conferences, searching for current evidence-based practices via professional literature, and taking additional coursework (CEUs) on opioid prescription best practices. Best practice should include an interdisciplinary focus that includes mental health, behavioral health, and complementary or alternative pain management approaches. 3) Nurses must remain diligent to avoid cultural or societal stigma for those who report pain. It is our duty and responsibility to treat pain to promote an optimal quality of life and reduce suffering. Likewise, we must be cognizant that patient cultural barriers might exist that could impede the patient’s willingness to discuss pain. 4) Costs of pain management can be a barrier, particularly if we recommend or order treatment plans other than drug management. Some insurances will not pay for alternative or complementary medicine options, mental health services, or other care modalities outside drug regimens. Anti-inflammatory herbals may be useful, but not if the patient cannot afford these expensive nutritional supplements. Even rehabilitation services such as PT may be limited under many insurances and Medicare plans. Know State Regulations for Prescription Drug Monitoring Programs (PDMP) All 50 states have developed PDMPs. Access to PDMPs may determine if the patient has a history of using multiple doctors, frequent ER visits, or demonstrates other evidence of prior drug abuse such as frequent opioid prescriptions. The PDMP also records primary care prescription activity. It is the provider’s responsibility to know all state regulations and required reporting. Unfortunately, inconsistent data collection and nonstandardized regulations have created confusion for providers and thus have not been as effective as hoped. Worse, in some cases, these regulations have thwarted some primary care providers’ desire to order opioids, which have caused fears that some patients’ pain management needs are not effectively met which could lead to patients seeking illicit pain relief strategies. Other state or federal guidelines. To curb abuses, states mandate physical assessments prior to prescribing an opioid drug. To protect the public, prosecution immunity is enacted for citizens who attempt to assist a person who may have overdosed. Drug disposal, community education, and expanded naloxone distribution are other safety mechanisms set forth by legislation. Create Treatment Plans that Include Addiction Risk Assessments Nurses obtain thorough patient histories and should verify injury by usual diagnostic assessments. Assessments should include level and intensity of pain; pain relief measures; how pain interferes with quality of life, such as its impacts on physical and psychological function; household support systems; and if pain is interfering with work, home relationships, mood, sleep, exercise, leisure activities, or food consumption. Information from family members, the patient interview, and a thorough assessment include screening tools to define the patient’s addiction risks. Low-risk patients would receive the usual amount of monitoring and follow-up. As the risk increases, the level of monitoring and frequency of follow-up visits increase. Monitoring could include pill counts and urine drug screens. Higher risk patients should be referred to pain management clinics and always receive short acting opioid formulas. Based on the patient’s history and family member accounts, the nurse determines if the patient demonstrates or verbalizes behaviors that might suggest high risk for drug addiction or abuse. Behaviors that might suggest a problematic return to normal daily activities include daytime sleeping instead of night; lack of usual family involvement and interactions; decreased appetite; poor hygiene and appearance, mood swings or volatility; and impaired functioning due to potential effects of drug use. The decision to continue, alter, or stop opioid drug regimens is based on the patient’s progress in
May, June, July 2021 Tennessee Nurse Page 9 meeting treatment plan objectives while avoiding adverse behaviors suggestive of overdose or diversion. Satisfactory plan of care outcomes are improving pain levels, function, and quality of life. Opioid Prescription Patient Education by Nurses 1) Take opioid as prescribed, noting the importance of sticking with the dose regimen. Patients should know what to do if they miss a dose or if pain is not managed by the recommended doses. 2) Remind patients that the medication should not be crushed or chewed. 3) Warn patients of the dangers of using CNS depressants, including sedatives, alcohol, or illicit drugs. 4) Reinforce the fact that due to the addictive nature of the drugs, discontinuation should be accomplished by tapering the drug’s dosing with primary care provider assistance. 5) Drugs should never be shared. To avoid diversion, opioids should be locked up in a secure location. 6) Potential side effects include death due to respiratory depression. 7) The drug could impact one’s ability to drive, operate machines, or affect balance that could cause falls. 8) Instruct the patient on safe disposal of unused opioids. Many senior centers or primary care offices are depositories for unused drugs. Community awareness. Nurses are often instrumental in providing community education. These educational sessions might be in schools, at hospitals, senior centers, or at other community locations. All aspects of opioid safety should be taught to interested key community members to heighten awareness. Naloxone. Release of Naloxone (Narcan) toolkits to the general public, families of those who use opioids, and patients themselves has increased in the US over the last few years. These life-saving kits do not treat overdoses of benzodiazepines, stimulants, or barbiturates but do reverse the effects of opioids, including heroin and fentanyl, when the first symptoms of respiratory arrest or coma occur. Since 2019, Narcan can be dispensed for Tennessee individuals at risk of opiate-related overdose. Conclusion The ANA advocates for all RNs, APRNs and NPs to practice in the fullest extent of their education and practice authority for the implementation of patient treatment plans and access to care to combat pain and the opioid crisis. The ANA promotes care delivery instead of litigation or legal actions against those who have fallen victim to this national epidemic. I Am TNA continued from page 1 Cynthia (Cindy) Borum, DNP, APRN, FNP-C, NE-BC TNA District 3 Member of the TNF Board of Trust My nursing career has enriched my knowledge and the ability to fulfill my ongoing commitment to confidently serve the healthcare needs of my patients and my community. I believe that nursing is admired and respected by professionals both inside and outside the medical community. As nursing professionals, we have an ethical and social responsibility to utilize our intellectual capabilities to promote the health of our patients, our communities as well as the healthcare system. I have been a nurse for 35 years, and nursing is a part of my DNA. In fact, my career choice in the nursing profession was greatly influenced because of the connection to helping others. I have always wanted to be a nurse, and as a young girl, I volunteered as a candy striper in the hospital, where I fed patients and helped the nursing staff. After high school, I started working on my baccalaureate nursing degree at the same time I worked during the summer as a nursing assistant. Both TNA and ANA proudly remind us that noble characteristics of nursing are honesty and trust. Nursing continues to be recognized as the most trusted profession for 18 years consecutively (ANA, 2020, Gallup, 2020). My values, beliefs, and faith are my compass that guides me both personally and professionally. My passion comes from my values and beliefs of doing the right things and doing things right for others. I am dedicated to lead by example through my actions and behaviors. After receiving my baccalaureate nursing degree, I worked with critically ill patients. I quickly discovered my niche in nursing and my desire to care for chronically ill cardiovascular patients to ‘mend the broken hearts.’ During this time in my career, I took advantage of every opportunity to expand my education and apply my knowledge as an expert cardiovascular nurse. My ministry is bringing awareness of the unhealthy lifestyle behaviors that contribute to cardiovascular disease. These behavioral factors are established by social and cultural norms within many Tennessee communities. I actively participate in community activities like the annual Heart Walk, ‘Go Red for Women’ Heart campaign and provide CPR classes to organizations within my community. As a faith community nurse, I provide health promotion activities such as blood pressure checks for people of all faiths. I learned about faith community nursing through TNA. Furthermore, I lead by example and role-model a healthy lifestyle that includes physical activity, healthy eating, and not smoking. Every nurse is a leader with developed leadership competencies. The diverse collection of leadership knowledge and clinical skills that I have ascertained throughout my career constantly opens doors for new opportunities. Utilizing leadership competencies like coaching, mentoring, emotional intelligence, change management, systems thinking, active listening, adaptability, self-awareness, and relationship management allow me to work with multi-professional teams both inside and outside of healthcare. The ANA webinars and online courses are a marvelous approach for ongoing learning and the attainment of continuing education credits. As a nurse practitioner, I recognize the contributions of advanced practice registered nurses to address policy issues that improve access to care and population health across Tennessee. Because of my TNA membership, I am involved in and advocate for advanced practice registered nurses. Through TNA, I network with Tennessee nurse leaders to discuss real-life issues. Together, we address problems such as quality of care and access to healthcare for Middle Tennesseans. Establishing lifelong relationships and working collaboratively with key stakeholders is a benefit of TNA membership. Nurses play a critical role in the new era of healthcare, and I have a responsibility to positively influence the patient experience, improve population health, and make healthcare affordable. There is so much to do in health care, and I am poised to lead healthcare transformation and promote good health. In the words of Florence Nightingale, “Let us be anxious to do well, not for selfish praise but to honour and advance the cause, the work we have taken up.” I take pride in being a member of ‘our’ professional organization, TNA, to honor and advance nursing’s cause. References American Nurses Association. (2020). ANA president proud of nurses for maintaining #1 spot in Gallup’s most honest and ethical professions poll. Retrieved from https:// www.nursingworld.org/news/news-releases/2020/ american-nurses-association-president-proud-of-nursesfor-maintaining-1-spot--in-gallups-2019-most-honestand-ethical-professions-poll/ Gallup. (2020). Nurses again outpace other professions for honesty, ethics. Retrieved from https://news.gallup. com/poll/274673/nurses-continue-rate-highest-honestyethics.aspx Vicinus, M. & Nergaard, B. (Eds.). (1990). Ever yours, Florence Nightingale: selected letters. Cambridge, MA: Harvard University Press.
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Tennessee Nurse - May 2021

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