Prescribing Opioids to Addicted Populations

Between 2006 and 2012, more than 32 million prescription pain pills circulated through Berkshire County, Massachusetts, a rural area of about 130,000 people.

Patients recovering from opioid addiction are seen at the local emergency department every day, according to Martha Roberts, a critical care Nurse Practitioner (NP) and Georgetown University School of Nursing & Health Studies alumna. Roberts works in Berkshire’s emergency department, which sees 50,000 patients per year — more than a third of the county’s population.

“It’s challenging,” she said. “It’s also an opportunity to help those patients in a way that may improve their outcomes.”

Patients in addiction recovery aren’t exempt from the need for pain relief in the case of acute injuries, surgical operations, or chronic pain. Providers like Roberts are tasked with finding and offering alternatives to opioids.

How can clinicians balance the weight of ethical responsibility with a patient’s need for immediate relief?

About 21% to 29% of individuals who are prescribed opioids misuse them, and 8% to 12% of them develop an addiction, according to the National Institutes of Health. Though only a small percentage of patients are likely to develop an addiction, there is still a chance of dependence, which is characterized by a physical reliance on the medication that, if unaddressed, can lead to addiction.

Even if the patient is not demonstrating symptoms of addiction, providers look for specific signs of dependence, according to Dr. Jill Ogg-Gress, assistant Family Nurse Practitioner (FNP) program director at Georgetown University.

“Opiate medications have side effects of dependence,” said Ogg-Gress, who works as a board-certified emergency NP in several Iowa and Nebraska emergency rooms. “If a provider recognizes that a patient is experiencing dependence, or if a patient demonstrates behaviors of dependence, it should be recommended to the patient they should talk to their primary care provider or the prescriber of the opioids.”

Signs of opioid dependence

• Taking painkillers more frequently than prescribed
• Taking higher doses than prescribed
• Seeking a euphoric effect to counter physical pain
• Experiencing excessive sleepiness or irritability

Taking these signs into account, providers can evaluate patients’ needs on an individual level to assess the magnitude of pain. If the patient is likely to develop a dependence, the providers may need to help them find an alternative treatment plan that is effective and sustainable.

Ruling out opioids altogether isn’t a realistic approach, Roberts said.

“There are still some painful injuries that will benefit from short-term opioid use,” she said.

Her key to implementing an effective treatment plan is working with the patient to assess their needs and openness to non-opioid pain medication.

Opioids are a class of drugs that can be prescribed for pain relief but are highly addictive and illegal for consumption when not prescribed by a health care provider.

Individuals recovering from drug addiction might encounter injuries or surgical operations that require management of immediate acute pain or chronic pain in the long term. Providers can evaluate a patient’s needs when creating a treatment plan to manage that pain.

Analgesics: Some of the most common painkillers can be obtained over the counter in small doses or prescribed in high doses by a health care provider. Roberts and Ogg-Gress agreed that these are the most common alternatives to opioid prescriptions.

Gabapentinoids: This class of drugs includes gabapentin and pregabalin and has been historically used for seizure prevention. It is available by prescription to address pain but only in circumstances set by the Food and Drug Administration. While these painkillers can be an alternative to opioids, Roberts said they are not her intervention of choice because studies show there are other, more effective alternatives.

When medication isn’t appropriate or preferable, many non-pharmacological options exist to relieve pain and suffering.

“There are a lot of other nonpharmacological therapies that are available, if people are willing to try it,” Ogg-Gress said. “Providers need to educate patients regarding these therapies instead of the common thought of, ‘Here, take a pill, swallow it, and you’ll feel better.'”

Non-pharmacological alternatives to opioids

• Localized numbing
• Ice
• Massage
• Exercise
• Physical therapy
• Acupuncture
• Relaxation

Every patient deserves time and attention to explain their case and their needs to a provider who is listening thoughtfully.

Providers treating addicted populations must keep a constant eye out for identifying drug seeking behaviors, without stereotyping or wrongly assuming a patient’s motives. A 2016 report published by the National Institutes of Health described several types of drug-seeking behaviors.

Common Drug-Seeking Behaviors

Requests and complaints

• Describing a need for a controlled substance
• Asking for specific opioids by brand name
• Requesting to have a dose increased
• Citing multiple allergies to alternative therapies

Inappropriate self-medicating

• Taking more doses than recommended by the provider
• Hoarding a controlled substance
• Using a medication despite not being in pain
• Injecting an oral formula instead of consuming orally

Inappropriate use of general practice

• Visiting multiple providers for controlled substances
• Calling clinics when providers who prescribe controlled substances are on call
• Frequent unscheduled visits, especially for early refills
• Consistently disruptive behavior

Patterns of resistance

• Hesitancy to consider alternative treatments
• Declining to sign controlled substances agreement
• Resisting diagnostic workup or consultation
• Being more interested in the medication than solving the medical problem

Illegal activity

• Obtaining controlled drugs from family members or illicit sources
• Using aliases or forging prescriptions
• Pattern of lost or stolen prescriptions

Clinicians who have identified these behaviors can use electronic medical records and crossover notes from other providers to see how many times a patient has sought medication for the same problem.

“People are here for assistance, but they’re not taking personal responsibility,” Roberts said. Engaging with patients to help them understand treatment plans can build a sense of agency over their own care.

Roberts said providers can help patients identify ways to care for themselves before writing a prescription for opioids. She recommended a gradual approach to trying different types of treatment:

A Step-Wise Approach for Pain Management

Get to know the patient

Use analgesics to address pain symptoms

Use non-pharmacological treatments as intervention for side effects

Encourage patient to stop smoking and drinking alcohol

Eliminate foods that irritate the stomach or digestive system

Reflect on previous steps: Did you really exhaust everything?

Consider opioids as a last resort, and only enough to support immediate pain relief

Nurse Practitioners who work with a multidisciplinary team are uniquely positioned to provide holistic care. Clinicians serving communities with large addicted populations have to be familiar with law enforcement, social work organizations and, in the case of making a referral outside the clinic or emergency department, recovery programs and child protective services.

Roberts also acknowledged that providers working in communities fraught with addiction are at a high risk for fatigue. “If you have three back pain patients in a row, you’re going to be pretty burned out within two hours of working your shift, so you really, truly have to look at each case individually,” she said.

Taking time to self-reflect on personal motivations for treating patients can help remind providers of why caring for others is important to them.

“It’s hard to walk in and do a good job if you’re upset about the work you’re doing,” Roberts said. “Make sure you can do this without letting your own bias get in the way.”

Please note that this article is for informational purposes only. Individuals should consult their health care professionals before following any of the information provided.

Citation for this content: Nursing@Georgetown, the online DNP program from the School of Nursing & Health Studies