1. The Overuse of Opioids
By Julia Anderson

3. 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?)

4. 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

5. 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

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

8. 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 Dec;82(6): doi: /j.jbspin

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

10. 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.

11. 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 May-Jun;66(3): doi: /j.bjane

12. Appropriate Starting Doses

13. 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

14. 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

15. 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.