Taking Precautions When Furnishing Pain Medication Can Help Curb Abuse and Addiction

By Kristin Rhodes, NP
CANP Orange County Chapter

When I started out as an oncology nurse over 20 years ago, the initiative to assess and treat patients for pain as a fifth vital sign was started.  Pain secondary to cancer metastases was regarded as the worst pain a patient could experience.  Opioids were the treatment of choice, and later their use in combination with ibuprofen or acetaminophen was developed to respond to peripheral as well as central pain.

But at what point did opioids become the solution for non-cancer related bone pain?  When did they become the “go to” for any level of discomfort for some patients?

One of my first jobs as a nurse practitioner was in a drug and alcohol recovery home.  I quickly learned how easy it was for someone to get controlled substances and the street was not their primary source.  As clinicians we may have used the PQRST technique for evaluating pain, but as addicts, they could answer appropriately.  As caregivers with the belief that we shall do no harm and no one should suffer in pain, we may have been inclined to prescribe.  And those with opioid addiction would repeat the process with a variety of providers, knowing who in the community was easy with whom to get prescriptions.

Their pattern repeated monthly, quarterly as they did the rounds.  Today, the primary source for opioids abused by adolescents is a family member’s medicine cabinet.  Today, the number one killer of young adults is drug overdose from prescription analgesics, more than cocaine and heroin combined; and instances have increased more than 300 percent since 1990.

So I ask, are you contributing to or preventing the problem of opioid abuse?

A few years back a veteran who had been working in the Middle East got a rib fracture incurred saving a neighborhood goat.  Coming to the states only the night before, he needed a refill of Vicodin.  He lacked medical records but the exam confirmed tenderness over the rib cage.  I ordered an x-ray and gave ten pills.  He never got the x-ray but I later learned he went downstairs to urgent care with the same story to get more opioids.  I had been duped, but by furnishing a small amount of the drug, he learned I wasn’t a prescriber he could utilize again to fix his habit.

Getting my DEA certificate was a privilege and professional responsibility as a nurse practitioner.  Getting on CURES became a tool to assure that my patients were not using me inappropriately as their health care provider.  But it also made sure that I wasn’t going to add more harm.

It is not possible to screen all patients with every visit, but a random review can reveal more of a patient’s history than what they tell you.  A new patient with anxiety came to the office and was on benzodiazepines and in recovery from alcohol and heroin.  He had only expressed the history of clonazepam.  CURES revealed he was on Suboxone and hydrocodone/APAP.  When asked if he wanted to tell me more, he became more honest.  I was able to direct him to more appropriate care with an addiction specialist and psychiatrist.  He didn’t follow through with my recommendation but we are building a relationship without my enabling former addictions.

I see many patients that are using hydrocodone/APAP on a regular basis for such things as chronic back or neck pain, arthritis, or migraines.  The odd thing about analgesics is patients can develop hyperalgesia – rebound pain related to opioid use.   So rather than helping the patient, we may make them worse.  I don’t furnish these substances on a continued basis, as my education and experience know there are alternatives to manage their pain.  If they choose to decline my treatment plan, I refer them to pain specialists or their primary care physician.

Take care to educate and, when appropriate, refer the patient on alternative or adjunctive pain management, such as exercise, stretching, trigger management, complementary medicine, or acupuncture, to name a few.  In some cases, you may look to treat their anxiety and depression, which magnifies the perception of “worse pain”.  Often I get patients who weren’t aware of how their “took as prescribed” medication was an extension of a provider who didn’t know how to refer to someone who could manage their pain more appropriately and instead aggravated the patient’s opioid dependence.

So in summary, to be a safe prescriber and avoid enabling patients and possibly save their life, I do the following:

1. Take a thorough history and exam of where the pain is.  The number one way undercover detectives find unsafe providers is prescriptions written without a documented exam.
2. Consider alternatives for the type of pain the patient is experiencing – NSAIDs, acetaminophen, anti-epileptics, SSRIs, or complementary medicine.
3. If you furnish a controlled substance, make sure your standardized procedures address management of acute and chronic pain; give only an adequate amount for the amount of time typical for severe pain.
4. Use the VIS app with your EMR to send a prescription directly to the pharmacy directly to avoid giving the patient the opportunity to alter your prescription.  Also make sure the patient is using one pharmacy to fill controlled substances.
5. Run a CURES report (make sure you register before July 1, 2016).  Be aware that a person with addiction will vary their name, address or other identifying information in an effort to circumvent the system.
6. If you suspect controlled substance abuse, express your concerns, be prepared for the patient to be defensive and, since many have personality disorders, stay firm in your treatment plan.  If the patient wants help, refer to Pills Anonymous meetings or the National Recovery Hotline for treatment centers -1-800-662-HELP (4357) or http://www.samhsa.gov/find-help/national-helpline.  Know your addictions specialists in your community.
7. Learn more by attending the CANP Annual Conference or a free on-line course from American Society for Addiction Medicine