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Sessions 1C & 2C

Quality Pain Management Nursing in the “New Normal” of Opioid Prescribing:

Barriers & Opportunities

Jason Sawyer

Wade Delk

Session 1C

• The presenters will provide an overview of recent documents evaluating the role of opioids in chronic non-malignant pain.

• Information from this session will contribute to the development of an ASPMN® nursing strategy for quality pain management in the “new normal” of opioid use for chronic non-malignant pain

Session 2C-Breakout Groups

• Attendees will break out into two moderated groups and discuss opportunities and barriers for nurses to improve the quality of care for patients with chronic non malignant pain

1) pain management in the hospital setting

2) pain management in the community

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� Pain is whatever the person says it is, occurring wherever they say it does (McCaffery, 1968)

� Pain is a complex phenomenon that combines information from the nervous system with thoughts, emotions, and social context (Henry 2008)

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� “To gain a full understanding of a patients’ pain experience and its effect on that person, insight into the individuals history and social circumstances is highly consequential and fundamental to pain assessment” (Hadjistavropoulos et al ppS2)

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1992The Current Pain Management Journey Begins

AHCPR Clinical Practice Guidelines, No. 1.Acute Pain Management

Guideline Panel.

Rockville (MD): Agency for Health Care Policy and Research

(AHCPR); 1992 Feb.

� 4 major goals:

� Reduce the incidence and severity of patients' acute postoperative or posttraumatic pain.

� Educate patients about the need to communicate unrelieved pain so

they can receive prompt evaluation and effective treatment.

� Enhance patient comfort and satisfaction.

� Contribute to fewer postoperative complications and, in some cases,

shorter stays after surgical procedures

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With Emphasis On

� A collaborative, interdisciplinary approach to pain control, including all members of the health care team and input from the patient and the patient's family, when appropriate;

� An individualized proactive pain control plan developed preoperatively by patients and practitioners (since pain is easier to prevent than to bring under control, once it has begun);

� Assessment and frequent reassessment of the patient's pain;

� Use of both drug and nondrug therapies to control and/or prevent pain;

� A formal, institutional approach to management of acute pain, with clear lines of responsibility

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• Appropriate assessment (routine screening, comprehensive initial assessment, and frequent reassessments)

• Interprofessional, collaborative care planning that includes patient input

• Appropriate treatment that is efficacious, cost conscious, culturally and developmentally appropriate and safe

• Access to specialty care as needed

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2015

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� 2012

� 259 million prescriptions for opioids written in the US (1 for every living American adult)

� Prescription opioid sales increased by 300% since 1999

� 2013

� 2 million Americans 12 yrs or older were addicted to opioids

� > 16 000 opioid related deaths (48/day)

� 2014

� 28 647 opioid related deaths (78/day)

http://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdfAccessed March 14 2016

http://www.cdc.gov/mmwr/pdf/wk/mm6450.pdfAccessed March 27 2016

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0-14 15-24 25-34 35-4 45-54 55-64 ≥ 65

Op

ioid

Re

late

d D

ea

ths

(%

)

Age

Proportion Of All Deaths That Were Opioid Related

1992

2001

2010

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Any Pain Slight Pain Moderate Pain Severe Pain Extreme Pain

Pe

rce

nta

ge

of

Pa

tie

nts

Pain Intensity

Proportion of Discharged Patients Reporting Various Post Surgical Pain Levels

Gan et al. 2014

Apfelbaum, et al. 2003

Warfield and Kahn 1995

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� What are the BENEFITS of long-term opioid therapy versus placebo or no opioid therapy for long term (>1year) outcomes?

�There are no studies!

� Studies of ≤ 12 weeks were found to be moderately effective for pain relief and small benefits for functional outcomes

�All studies of relatively poor quality

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� What are the RISKS of long-term opioid use versus placebo

� ↑ risk of opioid abuse, addiction, non-fatal/fatal overdose

�No universally safe dose of opioid

�Risk is dose dependent

�All 12 studies of relatively poor quality

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� Risk assessment and mitigation:� Poor evidence regarding accuracy or risk assessment tools

� Insufficient evidence of effectiveness of risk assessment tools and risk mitigation strategies

� Effectiveness of opioid therapy in acute pain on long term use� Opioid therapy for acute pain increases likelihood of chronic opioid use

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� 12 Recommendations:� There are gaps – nursing can fill the void� RCT’s QI advocacy� Fundamental shift in thinking

� Professions without prescribing privileges need to be heard� PT- education of patients

� Explain Pain book

� Exercise, CBT

� Better links from hospital to community- reduce incidence of postop/traumatic pain patients becoming chronic pain patients

� Access federal research

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� Increase the quality and quantity of data for chronic pain in the US

� Emphasis on prevention

� Address disparities in access to evidence based care

� Appropriate reimbursement and incentives for applying evidence based pain care

� Professional education and training

� Broader education of the public

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• RNs are excellent at capturing data, not so excellent at interpreting and utilizing that data.

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Would you try to limit how much strong pain

killers like morphine you use because you worried about becoming addicted?

1. Yes

2. No

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If you were given a strong pain killer like

morphine after surgery, how worried would you be about becoming addicted?

1. Not worried at all

2. A little bit worried

3. More than a little bit worried

4. Very worried

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• Risk Factors for CPSP

• Preoperative chronic pain

• Orthopedic surgery

• % time spent in severe pain postoperative day 1

• A 10% increase in time spent in severe pain associated with 30% increase in incidence of CPSP at 12 months

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Prospective observational study of 889

patients at 12 months

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http://riktr.com/wordpress/what-are-your-dimentions-of-pain-nicola-lmt-riktr-pro-deep-tissue-swedish-massage-805-637-7482/rates Accessed: March 4 2015

Language of Quality Pain Management

Reframing Incentives and Consequences

A well informed nurse = well informed patient

A poorly informed RN reinforces a poorly informed patient

Favorite Patient Quotes

• “I never take pills”

• “I don’t have pain, so I want to stop the pain medications”

• “I don’t want to become addicted”

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“Not So Favorite” Staff Quotes

• “Complaining” of pain

• “She is watching the clock”

• “She doesn’t look like she is in any pain”

• “She was sleeping, and as soon as she woke up, she said she had severe pain”

Opportunities

• Within the nursing profession

• With the public

• Research

• Advocacy

• Link to recommendations in CDC and NIH

• What are barriers and enablers

An Analogy….

• How would people with diabetes, Afib, ESRD cope without assessing blood glucose, Warfarin levels and weights, short and long term?

– What if it was suggested to NOT assess and measure these parameters?

• Measuring function provides measureable goals beyond pain intensity that are objective & meaningful

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What Is The Problem?

• Pain assessment tools exist for a wide variety of pain and patient presentations and languages

– acute/chronic,

– nociceptive, neuropathic

– dementia

– Pain assessment and documentation are engrained in accreditation standards

What Else Is Happening?

• Massachusett’s – Is Illegal Use Behind the Epidemic?

• Oregon – Will You Definitely Become an Addict

• Media Stories of Chronic Pain

• Will Quebec Follow Ontario on Coverage of Certain Painkillers?

• Effects of Hydrocodone Reclassification

• Advocating for Education

• Comprehensive Addiction and Recovery Act (CARA)

• Stricter Limits on Opioids

What Else Is Happening?

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• Nurses Need to Determine Real Concrete Solutions

• That will be our Next Session

• Time for Specifics

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Thank You

“We cannot do everything at once, but we can do

something at once”(Calvin Coolidge)

“Playing small does not serve the world” (Marianne Williamson)