The Nurses Role in the Opioid Epidemic Nursing CE Course

C (2024d) estimates that in 2021, the number of people who died from a drug overdose was six times higher than in 1999, with over 75% of the 107,000 deaths involving an opioid. More recent trends have shown that between 2021 and 2022, heroin-related deaths decreased by 36% and overall opioid-related deaths decreased by 12.5%, while synthetic opioid-related deaths increased by 4%.

 

Pathophysiology

Opioids are prescribed to control pain, decrease coughing, or relieve diarrhea. Opioids bind to receptors (delta, kappa, mu) in the central and peripheral nervous systems, leading to a feeling of euphoria. Delta receptors act on the central nervous system, inducing physiological effects (e.g., analgesic, antidepressant, respiratory depression, convulsant, physical dependence). Kappa receptors also act on the central nervous system, inducing physiological effects (e.g., analgesic, anticonvulsant, hallucination, diuresis, dysphoria, miosis [pinpoint pupils], neuroprotection, sedation). Mu receptors induce physiological effects on the central nervous system (e.g., analgesic, physical dependence, respiratory depression, miosis, reduced gastrointestinal motility, euphoria, vasodilation) and peripheral nervous system (e.g., depressed cough reflex, constipation). Opioids can be endogenous (e.g., endorphins), naturally occurring opium alkaloids (e.g., morphine [MS Contin], codeine), semi-synthetic (e.g., heroin, which is made from morphine), and synthetic (e.g., fentanyl [Duragesic] and methadone [Dolophine], which have chemical structures that differ from opium alkaloids but bind to the same receptors; Azadfard et al., 2023; Dydyk et al., 2024; Lyden & Binswanger, 2019).

Chronic opioid use causes alterations in receptor sensitivity, leading to changes in pain perception and medication tolerance. Opioid tolerance, dependence, and OUD are distinct phenomena with markedly different clinical implications. Both opioid tolerance (diminished response to a substance that occurs with frequent use) and opioid dependence (signs or symptoms of withdrawal when the dose is decreased or stopped abruptly) are anticipated physiologic adaptations that occur with repeated doses. However, OUD is not an anticipated or adaptive response to repeated opioid use, unlike tolerance and dependence. Instead, OUD is a maladaptive behavior pattern that results in compulsive drug-seeking despite harmful consequences. Withdrawal symptoms can occur when opioids are discontinued abruptly, resulting in nausea, vomiting, diarrhea, hot/cold flashes, insomnia, anxiety, muscle pain, tachycardia, piloerection, and dehydration (Azadfard et al., 2021; Lyden & Binswanger, 2019; O’Malley & O’Malley, 2022a; Strain, 2022).

Risk Factors 

                OUD is a multifaceted disorder, with biological, environmental, genetic, and psychosocial risk factors that contribute to the opioid crisis. Biologically, patients who have a deficiency in neurotransmitters such as dopamine are more likely to seek external sources of endorphins. Genetically, OUD has a 50% heritability. Environmentally, OUD is more likely to occur when there is exposure or pressure from peer relationships. Psychosocially, patients who have a history of depression, post-traumatic stress disorder (PTSD), or anxiety are more likely to experience OUD. Additionally, risk factors for opioid misuse include initiation at a young age (prescribed or illicit), previous history of illicit drug or alcohol misuse, sexual abuse). Finally, the misuse of prescription opioids is a risk factor for subsequent heroin use, as research has shown that the first opioid misused is most often a prescription opioid (Azadfard et al., 2023; Dydyk et al., 2024; Strain, 2022).

Clinical Manifestations

The clinical manifestations of OUD may vary depending on the duration and intensity of opioid use. Therefore, providers and nurses should obtain a detailed history and physical examination for anyone who has suspected OUD. However, obtaining a thorough history can be challenging since patients may withhold or minimize the details of their opioid use due to fear of stigma (Azadfard et al., 2023; Strain, 2022).

 

History

Obtaining a history regarding drug use from a patient who has suspected opioid misuse or OUD should include identifying the substance/s used, frequency of use, amount consumed, adverse consequences of use, treatment history, and age at first use (Dydyk et al., 2024; Strain, 2022).

• Consumption: The amount of drug consumed influences the likelihood and severity of withdrawal symptoms if the opioid is stopped. Ask patients about the consumption of prescription opioids, nonmedical use of opioids, and illicit use of synthetic or semisynthetic opioids. Additionally, ask patients about codependency with other drugs or alcohol.
• Route of administration: Prescription opioids and heroin can be consumed through various routes, including intravenous (IV), intranasal, oral, and inhalation. IV administration produces a rapid, high bioavailability of the opioid and is the route by which most overdoses of heroin occur.
• Tolerance: Chronic use of opioids will lead to opioid tolerance, in which larger doses are required to achieve the desired effect. Patients who report increasing the frequency and strength of opioids are at risk for opioid withdrawal if stopped abruptly.
• Last use: The date of last use, dose, frequency, and pattern of use are essential information to obtain during the history-taking.
• Treatment history: Ask the patient about past treatment for OUD (e.g., medically supervised withdrawal; opioid maintenance with medications such as methadone [Dolophine]; inpatient, residential, or outpatient counseling). Additionally, ask about past and present physical and psychiatric conditions and the impact of OUD on employment and relationships.

Screening for OUD is recommended for patients who are at risk for opioid misuse or those who have not had a good response to chronic opioid use (e.g., functional improvement). The Rapid Opioid Dependence Screen (RODS) and the OWLS are two screening tools for OUD. They are readily available, easy to use, and quick to administer, and they have good sensitivity and specificity. The RODS is an 8-item tool that can be used as a stand-alone instrument during a comprehensive history. A trained HCP should administer this screening tool, which has a sensitivity of 97% and specificity of 76% (Strain, 2022). The first question asks the individual if they have ever taken any of the following drugs (heroin, methadone [Dolophine], buprenorphine [Suboxone], morphine [MS Contin], oxycodone [Oxycontin], or other opioid analgesics, including hydrocodone [Vicodin]). If the individual answers yes, proceed to questions 2 through 8. If they answer no to all of the different opioids listed, then they can be coded “no” for opioid dependence. Questions 2 through 8 are (Wickersham et al., 2015):

• Did you ever need to use more opioids to get the same high as when you first started using opioids?
• Did the idea of missing a fix (or dose) ever make you anxious or worried?
• In the morning, did you ever use opioids to keep from feeling “dope sick,” or did you ever feel “dope sick”?
• Did you worry about your use of opioids?
• Did you find it difficult to stop or not use opioids?
• Did you ever need to spend a lot of time/energy on finding opioids or recovering from feeling high?
• Did you ever miss important things like doctor’s appointments, family/friend activities, or other things because of opioids?

The HCP should add up the number of “yes” responses to questions 2 through 8. If the total is greater than three, then the patient should be coded as opioid dependent. If less than three, they should be coded as “no” for opioid dependence (Wickersham et al., 2015). The OWLS screening tool is a 4-item (Overuse, Worrying, Losing interest, and feeling Slowed down) self-administered tool to detect prescription OUD in individuals with long-term prescribed opioid therapy (Picco et al., 2020).

Physical

A physical examination, including a complete head-to-toe assessment, should be performed to evaluate signs of opioid misuse and OUD. Patients who sporadically misuse opioids in small amounts may appear healthy on physical examination. However, patients who chronically use opioids may appear sedated and display miosis and a hyperactive response to pain. Physical examination findings for a patient who has opioid intoxication can include confusion, miosis, hypersomnia, and slurred speech. In addition, patients who have suspected chronic opioid use should be assessed for signs of acute opioid withdrawal (watery eyes, runny nose, yawning, muscle twitching, hyperactive bowel sounds, piloerection, agitation, diaphoresis, vomiting, elevated blood pressure, elevated heart rate). In addition, the nasal septum should be examined for perforation from repeated intranasal opioid use. Finally, for patients who have repeated IV opioid use, physical exam findings may include track marks (callouses and scars along a subcutaneous vein, usually on the dorsal aspect of hands, antecubital fossae, legs, or neck), poor dentition, lack of IV access, abscess, or cellulitis (Azadfard et al., 2023; Dydyk et al., 2024; O’Malley & O’Malley, 2022a; Strain, 2022).

 

Evaluation and Treatment

A diagnosis of OUD is primarily based on the findings from the history and physical exam. A urine drug screen can detect metabolites of morphine [MS Contin] and heroin, usually 1 to 3 days after the last use. However, some opioid analgesics are not always detected by this test (e.g., oxycodone [Oxycontin] and methadone [Dolophine]), and there is a potential for false-positive and false-negative tests. In addition, if OUD is suspected, a complete blood count (CBC) and liver function tests (LTFs) may be ordered to screen for infection and liver dysfunction. Patients who have suspected or confirmed IV heroin use should be screened for human immunodeficiency virus (HIV), hepatitis (A, B, and C), syphilis, and tuberculosis. The nurse should monitor vital signs frequently, perform neurological checks, and continually assess for signs and symptoms of opioid withdrawal (Clinical Opiate Withdrawal Scale [COWS] score greater than 10). Patients experiencing opioid withdrawal can be treated with antiemetics, antidiarrheals, and IV hydration. If a patient is unconscious or obtunded, a respiratory assessment (listening to lung sounds) should be performed and they should be monitored for aspiration. If opioid overdose is suspected based on respiratory depression or cardiac arrest, treatment with naloxone [Narcan] should be initiated immediately. Naloxone (Narcan) can be administered intravenously, intranasally, or intramuscularly, usually starting at 0.4 to 0.8 mg. For patients who have taken large amounts of opioids, larger and more frequent doses of naloxone [Narcan] may be indicated. Naloxone [Narcan] rapidly displaces opioids from opioid receptors and prevents opioid activation of these receptors (Azadfard et al., 2023; Dydyk et al., 2024; O’Malley & O’Malley, 2022a; Strain, 2022).

All patients who have OUD should be offered inpatient or outpatient substance use disorder (SUD) treatment. In addition, several medications have shown promising results in the treatment of OUD (e.g., buprenorphine [Suboxone], methadone [Dolophine], naltrexone [Vivitrol]). MAT refers to using the previously described medications combined with counseling and behavioral therapies (e.g., cognitive-behavioral therapy [CBT]). The goal of MAT is to limit opioid use to the minimum level needed to provide pain relief and prevent relapse for patients who are no longer using opioids. PDMPs offer an online database that lists all prescribed controlled substances dispensed to each patient by pharmacies in the region. All states have PDMPs, and prescribers should search the database as per state policies before prescribing controlled substances. OUD or diversion could be suspected when a patient does not disclose an existing or recent controlled substance prescription. Finally, naloxone [Narcan] kits are recommended for individuals who chronically use opioids or those who may witness an opioid overdose (e.g., first responders or substance abuse programs (SAPs); Azadfard et al., 2023; Bart et al., 2020; Becker & Starrels, 2021; Dydyk et al., 2021; O’Malley & O’Malley, 2022b).

 

Alternatives to Opioids for Pain Management

Given the severity of the opioid epidemic, HCPs must utilize effective pain management strategies. The first step in preventing OUD is to avoid prescribing controlled substances when safer, effective alternatives are available (Becker & Starrels, 2023). According to the CDC clinical practice guideline for prescribing opioids for pain, 1 in 5 adults experience daily chronic pain, and millions of Americans are treated with prescription opioids. In addition, providers are often uncomfortable determining when it is appropriate to prescribe opioids. Therefore, the CDC established the Guidelines for Prescribing Opioids for Chronic Pain, seeking to improve communication between patients and providers and reduce the risks associated with long-term opioid therapy. These guidelines are not intended for patients involved in active cancer treatment, palliative care, or end-of-life care and include 12 best practice reminders (Dowell et al., 2022):

• Opioids should not be a first-line or routine treatment for acute pain; nonpharmacologic and non-opioid pharmacologic therapy are preferred and are at least as effective for many types of acute pain. HCPs should discuss the benefits and known risks with the patient before prescribing an opioid.
• Opioids should not be a first-line or routine treatment for subacute and chronic pain; nonpharmacologic and non-opioid pharmacologic therapy are preferred. HCPs should discuss the benefits and known risks with the patient before prescribing an opioid. They should establish treatment goals for pain and function and discuss how opioid therapy will be discontinued if the benefits do not outweigh the risks.
• When starting opioids for acute, subacute, or chronic pain, HCPs should prescribe immediate-release instead of extended-release opioids.
• When opioids are initiated for opioid-naïve patients, HCPs should prescribe the lowest effective dosage.
• For patients already receiving opioid therapy, HCPs should weigh the benefits and risks and exercise caution when changing the opioid dosage. HCPs should work with patients to optimize non-opioid therapies while continuing opioid therapy. When discontinuing opioids, HCPs should taper to lower doses over time.
• For patients who have acute pain, HCPs should prescribe opioids in no greater quantity than needed for the expected duration of pain.
• HCPs should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy and reduce or taper the medication if needed.
• Before starting and routinely during opioid therapy, HCPs should implement strategies to mitigate opioid risks (e.g., monitoring OUD and providing the patient with naloxone [Narcan]).
• HCPs should check PDMPs for undisclosed opioid prescriptions.
• HCPs should consider the risks and benefits of toxicology testing to assess for prescribed medication and nonprescribed controlled substances when prescribing opioids for subacute or chronic pain.
• HCPs should avoid prescribing opioids and benzodiazepines concurrently.
• Clinicians should arrange for evidence-based treatment (MAT with buprenorphine [Suboxone] or methadone [Dolophine] combined with behavioral therapies) for patients with OUD.

Although opioid prescriptions will be necessary to treat many patients who have chronic pain, evidence suggests that non-opioid treatments (e.g., medications and nonpharmacological therapies) can be effective and safer. Practical approaches to chronic pain should include the following measures (CDC, 2024c; Tauben & Stacey, 2024):

• Prioritize the utilization of non-opioid therapies as often as possible.
• Identify and address co-existing mental health conditions (e.g., anxiety, depression, PTSD).
• Focus on functional goals by actively engaging patients in their pain management.
• Use disease-specific treatments when available (e.g., triptans for migraines and anticonvulsants [e.g., gabapentin (Neurontin), pregabalin (Lyrica)] or antidepressants [e.g., duloxetine (Cymbalta)] for neuropathic pain).
• Use first-line medication options.
• Consider interventional therapies (e.g., corticosteroid injections) for patients who do not respond well to standard non-invasive treatments.
• Use multimodal approaches (e.g., interdisciplinary rehabilitation for patients who have failed traditional treatments, have severe functional deficits, or psychosocial risk factors).

Non-opioid medications can be beneficial for chronic and disease-specific pain. See Table 1 for non-opioid medication options and indications.

 

Table 1

Non-Opioid Medication Options for Chronic and Disease-Specific Pain

Medication	Indications
Acetaminophen (Tylenol)	First-line analgesic Less effective than nonsteroidal anti-inflammatory drugs (NSAIDs)
NSAIDs	First-line analgesic
Gabapentin (Neurontin)/pregabalin (Lyrica)	First-line agent for neuropathic pain Pregabalin (Lyrica) approved for fibromyalgia
Tricyclic antidepressants (TCAs) and serotonin/norepinephrine reuptake inhibitors (SNRIs)	First-line treatment for neuropathic pain TCAs and SNRIs approved for fibromyalgia TCAs approved for headaches
Topical agents (lidocaine, capsaicin, NSAIDs)	Safer than systemic medications Lidocaine for neuropathic pain Topical NSAIDs for localized arthritis Topical capsaicin for musculoskeletal and neuropathic pain

                                                                                                (CDC, 2024c; Tauben & Stacey, 2024)

Nonpharmacologic therapies include an array of treatments that can be beneficial for treating chronic pain, including exercise therapy, psychoeducational interventions (e.g., CBT, family therapy, psychotherapy, patient education), mind-body therapies (e.g., mindfulness-based stress reduction [MBSR]), and physical interventions (e.g., physical therapy, acupuncture, chiropractic manipulation, massage). These therapies can be done alone or in combination with other nonpharmacologic treatments or non-opioid medications. In addition, individuals may choose a treatment based on personal preference, type of pain, access to care, and costs (Tauben & Stacey, 2024).

 

Diversion

Drug diversion occurs when prescription medications are obtained or used for illegal purposes. Drug diversion is a complex issue involving multiple parties, including patients, providers, nurses, and pharmacists. Investigations of opioid drug diversion are on the rise because people who use drugs prefer prescription opioids to street drugs, and drug diverting is lucrative. For example, a bottle of 30 OxyContin 30 mg dose pills can be trafficked for $1,100-$2,400, which is 12 times the price of the prescription. The trafficking prices for these medications have also increased since the COVID-19 pandemic. Opioid diversion has been carried out by people seeking drugs who utilize fake names to obtain repeat prescriptions from various providers. Providers have been investigated for opioid diversion due to writing illegal or medically unnecessary prescriptions. In addition, pharmacists and pharmacy owners have stocked or re-labeled expired or counterfeit medications, selling them illegally and billing insurance companies (Mutter et al., 2022; HHS, 2016; U.S. Department of Justice, n.d.).

Nurses have also been part of drug diversion, primarily in the hospital setting. When health care providers divert controlled substances, they put patients at risk of harm (substandard care delivered by an impaired health care provider, denial of pain medication, medication errors, risk of infection). The CDC and state and local health departments have investigated outbreaks of infection stemming from drug diversion or tampering with injectable drugs (e.g., hepatitis C virus and bacterial pathogens; CDC, 2024a). The U.S. SAMHSA and the American Nurses Association (ANA) have documented that 10% of health care workers misuse drugs (TJC, 2019). Due to the availability of opioid medications in health care organizations, drug diversion can be difficult to detect and prevent. Health care organizations that dispense opioids should have a comprehensive controlled substances diversion prevention program (CSDPP) and an organizational culture that empowers staff to speak up when something seems abnormal or unsafe.

According to TJC (2019), health care organizations should focus on three critical components for drug diversion:

• Prevention – Prevention is the priority. Health care systems must have safeguards such as CSDPPs and must educate staff on these programs and protocols.
• Detection – Health care facilities must have systems to facilitate early detection (e.g., video monitoring in high-risk areas, active monitoring of both pharmacy and dispensing record data, fostering staff awareness of and reporting signs of potential diversion).
• Response – Facilities should create a patient-safety culture and empower health care workers to report any unusual or suspicious behavior (e.g., "see something, say something"). Health care workers should watch for unexpected behaviors, altered physical appearance, and poor job performance of coworkers. In addition, drug diversion should be suspected when controlled substances are removed with no order, product containers are compromised, medication is documented as given but not administered, excessive medication pulls are noted (e.g., one nurse administering significantly more opioid medications compared to colleagues), waste is not appropriately witnessed, and/or patients continue to report excessive pain despite documented administration of pain medication.

 

A Nurse's Role in Prevention and Advocacy

While efforts have successfully decreased the number of opioid prescriptions, synthetic and semi-synthetic agents remain high. In 2022, 107,00 people died from drug overdoses, making it a leading cause of injury-related death in the U.S. In addition, the rate of overdose deaths involving synthetic opioids was 11 times higher in 2019 compared to 2013 and increased by another 4% in 2022. Many national organizations have created strategies to combat this opioid epidemic (CDC, 2024d). The CDC has outlined five key strategies to guide its mission to prevent opioid misuse, overdose, and death. These strategies include the following:

• Conducting surveillance and research (providing high-quality, timely data to track opioid deaths)
• Building state, local, and tribal capacity (providing support for PDMPs, regulating controlled substances, licensing health care providers, responding to drug overdose outbreaks, and running public insurance programs)
• Supporting providers, health systems, and payers through guidelines for prescribing opioids for chronic pain
• Partnering with public safety entities to reduce drug overdoses
• Empowering consumers to make safe choices by raising awareness about the risk of opioid misuse (CDC, 2024d)

The ANA (2018) recognizes the central role that nurses play in addressing the opioid epidemic. Nurses are frontline care workers who are pivotal in advocating for effective pain management while preventing opioid overuse and dependence. In addition, as educators and patient advocates, nurses can assist patients with holistic approaches to pain management, including nonpharmacologic treatments and non-opioid medications. The ANA stresses the importance of a comprehensive approach that focuses on:

• Eliminating barriers to effective pain management (e.g., system, clinician, patient, insurance)
• Viewing prescribers as gatekeepers for prescription opioids (e.g., improving clinician education and enhancing PDMPs)
• Using naloxone [Narcan] for prescription and illicit opioid overdose
• Expanding access to MAT for OUD
• Promoting the safe storage of prescription opioids and disposal of unused opioids
• Addressing the stigma associated with OUD (ANA, 2018)

References

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