Near the end of my tenure as editor-in-chief of AJN, the American Journal of Nursing in 2009, I asked one of the coordinators of our pain column to write an article on opioid dependence and addiction. The diversion and misuse of drugs such as oxycodone, with a resultant spike in overdose deaths, had been widely reported in the news media. Her surprising response continues to resonate for me as we face the urgent public health problem of opioid abuse.
Diana Mason, PhD, RN
The column’s coordinators, 2 thoughtful nurse leaders in pain management, periodically presented evidence showing that physicians underprescribed and nurses underadministered pain medication, even at the end of life, leaving patients with unrelenting suffering.
The column coordinator said she didn’t want to write about the risk of opioid dependence and addiction because nurses already had “misconceptions” about the risk of addiction and inadequately assessed and managed patients’ pain. This came at a time when the undertreatment of pain was a major concern and pain assessment was promoted as the fifth vital sign.
The success of this effort is evident today. Nurses and physicians now routinely ask patients to rate their pain on a scale of 1 to 10; prescriptions for opioids increased from 116 million in 1999 to 202 million in 2009 and 207 million in 2013; pain management was incorporated into surveys to ascertain patients’ satisfaction with hospital care; and the Veterans Administration even developed a toolkit on using pain as the fifth vital sign.
Still, pain—particularly chronic pain—continues to be poorly managed. Furthermore, there’s abundant evidence of the unintended consequences of improving pain management through the unstinting and singular use of opioids—especially long-term opioid use for chronic, noncancer pain. Last year, the Centers for Disease Control and Prevention (CDC) reported an increase of 6.5% in the rate of deaths from heroin and prescription opioids. The latter account for at least half of opioid deaths and the rate of prescription opioid death persistently increased over the last 15 years. Whole communities have been devastated by a rise in heroin and prescription opioid abuse, and federal and state policy makers are responding.
A 2011 report of the then–Institute of Medicine influenced the US Department of Health and Humans Services’ National Pain Strategy released this year and additional public and private sector efforts. The FDA vowed to examine its role in addressing the crisis, including evaluating the impact of requiring manufacturer’s of long-acting opioids to provide low-cost or free continuing medical education.
In July, Congress passed legislation to address the issue that has been called a landmark policy but may become a “lame duck” policy because its funds have not been appropriated. In July, the House Committee on Appropriations passed the fiscal 2017 spending bill for the departments of Labor, Health and Human Services, and Education, which includes $500 million for programs that address opioid abuse—about a $100 million increase over last year and less than half of what President Obama recommended.
What does the future hold for a federal response to the opioid crisis? Democratic Presidential candidate Hillary Clinton has advocated a medical approach to opioid abuse rather than incarceration, as well as requiring licensed prescribers to have a minimum level of training and consult a prescription drug monitoring program before prescribing controlled substances. The only position listed to date on the website of Republican Presidential candidate Donald Trump is provided in a video produced in conjunction with the New Hampshire primary and suggests that he will address the problem by clamping down on the flow of drugs from Mexico.
A recent Harvard poll found that 34% of respondents hold physicians responsible for the growing crisis of prescription opioid abuse. But physicians and nurses are often following public and private sector policies, policies that are increasingly being viewed as misguided.
There is growing concern that a major factor in the opioid crisis is the requirement that pain be the fifth vital sign, including by one of its early proponents. The Joint Commission recently issued a statement to correct a common misconception that it requires hospitals to use pain assessment as the fifth vital sign. At its 2016 annual meeting, American Medical Association delegates voted to end its use.
Pain-intensity rating scales are inadequate for assessing the experience and perceptions of the importance of pain relief, particularly for people for whom the burden of chronic pain on functionality and quality of life may be more important than intensity. The National Pain Strategy calls for a multidisciplinary approach to pain management that includes comprehensive assessment and advocates the use of nonopioid approaches to pain management. Relying solely on opioids for pain management is costly and harmful to patients with chronic pain, the CDC noted in its recent prescribing guidelines, adding that little evidence exists supporting opioids’ effectiveness in treating pain lasting longer than 3 months.
Instead, clinicians must work with patients to incorporate other interventional, psychological, behavioral, and complementary approaches. Of course, paying for some of the nonmedication approaches to pain management has been a major barrier. The National Pain Strategy calls for this to be addressed and also calls for enabling people to self-manage their pain, necessitating better advisement of patients on the use of opioids.
This was brought home to me when an elderly relative had major surgery and was prescribed oxycodone for over a month during and after hospitalization. No one talked with him about tapering or the dangers of persistent opioid use. I was concerned about his becoming dependent upon the opioid—and for good reason. JAMA Internal Medicine published a study on July 11 showing that Medicare beneficiaries who had not been taking opioids prior to surgery were at increased risk of chronic opioid use.
There has also been growing concern that the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey questions related to pain management have led to overmedicating hospitalized patients because pain management satisfaction scores are tied to hospital payment. There is evidence to support this claim. On July 6, the Centers for Medicare & Medicaid proposed eliminating these scores from the calculation of hospital Medicare payment.
A colleague from my days at AJN asked me whether we as editors were unintentionally complicit in the current opioid crisis. Did we too readily accept the argument that addressing the risks of opioid use would undermine pain management, even as the rate of opioid overdoses was rising? I’m not sure. I do know that we don’t want to go back to the days of undertreated pain, including pain in terminally ill patients. The dual crises of unrelieved pain and opioid dependence, addiction, and overdose require a more thoughtful approach to pain management—one driven by institutional and public policies that support clinicians and patients in developing a comprehensive approach to managing pain that aligns with patients’ goals.
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