The Overuse of Opioids By Julia Anderson

Famous Prescription Medication Deaths Brittany Murphy (Vicoprofen and cold medicine) Heath Ledger (Unspecified painkillers, sleeping pills, anti-anxiety medication and other prescription drugs) Anna Nicole Smith (Methadone and sleeping pills) Prince? (Percocet?)

My patient 31 years old, history of IVDU, diagnosis of Osteomyelitis, wound vac Inpatient for 2 months (on IV Vancomycin) Routine pain medication: Oxycontin Q8H PRNs: Morphine 6mg for wound vac dressing changes, Oxycodone 20mg Q4H, Acetaminophen

So what? The number of unintentional overdose deaths from prescription pain relievers is more than 4x higher than it was in 1999. The number of prescriptions for opioids have grown from around 76 million in 1991 to nearly 207 million in 2013, with the United States their biggest consumer globally, accounting for almost 100 percent of the world total for hydrocodone and 81 percent for oxycodone. By 2002, death certificates listed opioid analgesic poisoning as a cause of death more commonly than heroin or cocaine. America's Addiction to Opioids: Heroin and Prescription Drug Abuse. 2014. https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse.

Alternatives to Opioids Ice Non-Opioid Analgesics Rest/Activity Anti-anxiety Medications Distraction Music/TV

Are non-Opioids Effective on Pain? Research study title: Strong opioids for noncancer pain due to musculoskeletal diseases: Not more effective than acetaminophen or NSAIDs. 2 Double-blind emergency room trials showed similar levels of pain relief with IV acetaminophen as with IV morphine in patients with renal colic, low back pain or acute limb pain. In lower doses and for mild to moderate pain, acetaminophen and NSAIDs have proven to be just as effective as opioids. Exception: Cancer pain, where opioid doses are higher and provide notably more relief than non-opioids Berthelot JM, Darrieutort-Lafitte C, Le Goff B, Maugars Y. Strong opioids for noncancer pain due to musculoskeletal diseases: Not more effective than acetaminophen or NSAIDs. Joint Bone Spine. 2015 Dec;82(6):397-401. doi: 10.1016/j.jbspin.2015.08.003.

The PRN Problem Patients who need their PRNs routinely aren’t being properly medicated with their scheduled medications.

Why do we overuse opioids? Stigma of being more effective If you have to have another nurse present to waste it, it must be good. Patients have been trained to ask for it If it’s ordered, we think it’s fine to give freely It’s quicker and easier to toss them an Oxy and get them off their call light We (patients and nurses) think that if you use it at home or can buy it at Target, it won’t work in the hospital. Who uses Tylenol and ice packs anymore? Amateurs. This is the HOSPITAL, we have the GOOD STUFF.

Appropriate Opioid Use The T’s Titration (trial) Determine the type of pain Use the lowest dose possible Tweaking (tailoring) Goal is 30% pain reduction with no side effects Transition (tapering) Taper slowly to avoid withdrawal Adjuvant therapy while tapering Coluzzi F, Taylor R Jr, Pergolizzi JV Jr, Mattia C, Raffa RB. Good clinical practice guide for opioids in pain management: the three Ts - titration (trial), tweaking (tailoring), transition (tapering). Braz J Anesthesiol. 2016 May-Jun;66(3):310-7. doi: 10.1016/j.bjane.2014.09.005

Appropriate Starting Doses

What you can do as an RN Read your patient Ask the MD Pain is subjective (kind of) Anxiety? Attention seeking? Ask the MD Different scheduled pain medications? Higher dose? More frequently? Educate your patient Risks of prolonged opioid use Alternative analgesics

What could we have done for my patient? Talked to the MD as soon as the oxycodone use became routine, not the day before discharge. Maybe could’ve added in routine acetaminophen or ibuprofen or reduced time in between pain med doses Offer the patient acetaminophen or ibuprofen PRN instead of going straight to oxycodone Explain to him why we want to taper off of the oxycodone and asked him to try non-opioids first

Take-Aways Opiates are overprescribed and can be incredibly addicting, even fatal. Pain is subjective, But that doesn’t mean that every patient who reports pain needs Oxycodone or Morphine. “My fingernail hurts” –Here’s your Dilaudid Find out more about the pain and offer alternatives. Opiates may seem the easiest choice to treat pain quickly, but NSAIDS, Acetaminophen, and non-medicinal interventions are often just as (if not more) effective.