What is NP Safe Prescribing of Controlled Substances While Avoiding Drug Diversion?
Chronic pain and the misuse of painkillers like opioids are significant issues in the United States. More than a quarter of Americans suffer from chronic pain, making it one of the most common complaints in outpatient clinics and emergency departments. Mismanaged chronic pain and issues related to opioid dependence can lead to severe health problems, and significant healthcare costs.
Chronic pain is defined as any pain lasting for more than three months. It can come from various sources and is often treated with a combination of medication and non-medication options. A combination approach generally provides better pain relief than a single treatment. Chronic pain patients are often also dealing with depression and anxiety and they are at a higher risk for suicide. As such, it’s important for doctors to understand how to accurately diagnose and manage chronic pain.
Unfortunately, many medical professionals haven’t been adequately trained to manage pain. This has lead to an increase in implementing educational programs focused on prescribing guidelines for chronic pain treatment set by the Centers for Disease Control and Prevention.
Proper opioid prescription involves balancing effective pain control while avoiding addiction, abuse, and misuse. Doctors must adapt their methods to avoid not prescribing enough medication, prescribing too much, or continuing to prescribe when they’re no longer effective.
The American Society of Addiction Medicine perceives addiction as a manageable chronic disease influenced by environmental factors, genetics, an individual’s personal experiences, and brain functions. Often, individuals addicted to opioids or other medications show compulsive behaviors, which can result in harmful consequences.
Regrettably, misinformation about addiction is rampant among healthcare providers, lawmakers, and law enforcement, contributing to the societal difficulty in dealing with addiction issues. Once-revered terms like “addiction,” “substance abuse,” and “substance dependence” have caused confusion and hindered proper pain management in the past. Now, the term “substance use disorder” is used to encompass all these issues, with levels ranging from mild to severe.
There are many challenges in pain management, such as overprescribing and underprescribing of opioids, particularly in patients with chronic pain. This can lead to patients experiencing untreated pain on one hand and opioid abuse and addiction on the other. Providers need additional education and training to provide the best patient care and avoid legal issues related to opioid prescription.
Misunderstanding of opioids has resulted in significant societal problems. The misuse of controlled substances is widespread, leading to serious health problems. Three common types of drugs that are often misused include opioids, depressants, and stimulants. Opioids are frequently relied upon for pain control, given their effectiveness in reducing pain signals to the brain.
However, with misuse and misunderstanding, the prescription of opioids has led to significant social and health challenges. To create substantial change, there needs to be significant education and training on the matter. Furthermore, it’s critical to understand the difference between addiction, dependence, and tolerance when dealing with opioid prescription. Understanding these differences can help in providing effective treatment and preventing harmful outcomes.
What Causes NP Safe Prescribing of Controlled Substances While Avoiding Drug Diversion?
Many people who experience long-term pain often deal with multiple types of discomfort. For instance, someone with chronic back pain might also have fibromyalgia, a condition that causes widespread pain. A large number of these patients also struggle with major depression or general anxiety disorder. In fact, over 67% of people with chronic pain also have a mental health disorder.
Pain can be categorized into various types depending on what causes it. These include:
1. Neuropathic Pain: This kind of pain comes from nerve damage. For example, it’s present in conditions like post-herpetic neuralgia (pain after shingles) or diabetic neuropathy (nerve damage due to high blood sugar).
2. Central Neuropathic Pain: This happens due to a problem in the brain, and can occur after a stroke.
3. Nociceptive Pain: This is pain caused by injury to body tissues. You’ll feel it when you have a burn, bruise, sprain, or break a bone.
4. Musculoskeletal Pain: This includes back pain or myofascial pain, which is discomfort in the muscles and the connective tissues around them.
5. Inflammatory Pain: This occurs when your body’s immune system acts up, as in rheumatoid arthritis, or after an infection.
6. Psychogenic Pain: Sometimes, pain is the result of emotional, psychological or behavioral factors. This type of pain can result in headaches or abdominal pain.
7. Mechanical Pain: This is pain caused by cancer growth.
There’s also the role of various opioid manufacturers. These companies, like Purdue Pharma, have been sued by individuals and various levels of government for encouraging the use of these highly addictive drugs, especially the long-lasting form of oxycodone.
Risk Factors and Frequency for NP Safe Prescribing of Controlled Substances While Avoiding Drug Diversion
Chronic pain is a considerable issue in the United States, with over 100 million people meeting the criteria for a chronic pain syndrome. Around 50 million Americans have debilitating chronic pain, and for over 20 million, it impacts their daily lives. Out of chronic pain sufferers, 11.1% report chronic regional pain, 10.1% back pain, 7.1% leg and foot pain, 4.1% arm and hand pain, and 3.5% suffer from headaches. Widespread pain is reported by 3.6% of chronic pain sufferers.
The elderly often receive fewer pain medications than the average person, up to 25% less. The financial impact of chronic pain is immense, costing over $600 billion each year in lost productivity and medical treatment. In their lifetimes, over 50% of adults are likely to experience chronic pain, with more than 40% reporting that their pain isn’t under control, and over 10% suffering from long-term disabling chronic pain.
Unfortunately, there is a significant association between chronic pain and suicidal tendencies, with between 5% and 14% of chronic pain sufferers attempting suicide at least once in their lives. Around 20% experience suicidal thoughts; of those who commit suicide, 53.6% die from gun-related injuries, and 16.2% from an overdose of opioids.
The number of people with chronic pain is growing because of various factors. These include the rise in pain related to obesity, more people surviving traumas and surgical procedures, an aging population, and a heightened awareness that pain can be treated.
Opioids are the most frequently used medication for chronic pain. These drugs are synthetically produced from generally unrelated compounds. Opiates, on the other hand, come from the sap of the opium poppy. Both opioids and opiates work on three major classes of opioid receptors: mu, kappa, delta, and other less known classes like nociceptin and zeta. In layman’s terms, the mu receptors manage pain, suppress breathing, slow heart rate, can lead to physical dependence, cause issues with digestion, and create a sense of happiness. The kappa receptors can cause hallucinations and feelings of dysphoria. Finally, the delta receptor likely helps control pain and mood.
A few decades ago, healthcare providers in the U.S. seldom prescribed opioids, except for chronic cancer pain. However, this changed in the 1990s. A push to recognize and treat pain as the “fifth vital sign” led to a significant increase in opioid prescriptions for various chronic pain conditions. As a result, opioid sales soared, making the US the largest consumer of opioids in the world, accounting for more than 80% of global use. With such high usage rates, problems such as abuse of opioid painkillers have also surged.
Signs and Symptoms of NP Safe Prescribing of Controlled Substances While Avoiding Drug Diversion
When discussing your pain with a healthcare provider, they’ll want to understand various things. These include when the pain started, how it feels, its location, whether it spreads or stays localized, and how intense it is. They’ll also want to know anything that worsens or relieves the pain, how often you feel it, and if it’s consistent or if there are periods where the pain is more intense. To help measure how severe your pain is, they might use a verbal numeric rating scale (VNRS), which scales your pain from 0 (no pain) to 10 (severe pain).
Additionally, they will ask about any associated symptoms such as muscle aches, changes in skin or hair, temperature changes, feeling stiff when you wake up, weakness, changes in how strong your muscles feel, limitations in your movement, and changes in your sense of touch. They’ll also want to understand how this pain affects your daily life including activities like dressing, eating, bathing, and walking, and whether it’s causing depression or changing your relationships, hobbies, sleep patterns, or ability to exercise or work.
For older adults, expressing pain can sometimes be challenging, and pain might be described as soreness or discomfort rather than using the term “pain”. To understand the history of your pain, healthcare providers might use acronyms like “COLDERAS” or “OLDCARTS”, which stand for character of the pain, onset, location, duration, exacerbating symptoms, relieving symptoms, radiation of pain, and severity.
Providers also have a few different tools to evaluate the severity of your pain and its impact on your life. One such tool is the Pain, Enjoyment, General Activity (PEG) tool, which uses a score of 0 to 10 in each category, with higher scores indicating worse pain and worse impact on function. They might use a Four-item Patient Health Questionnaire or PHQ-4 to screen for symptoms of depression or anxiety, and the Defense and Veterans Pain Rating Scale (DVRPS) to measure pain and its impact on sleep, mood, stress, and activity.
For children, healthcare providers often use observation and visual analogs like pictures of faces expressing different levels of pain. Along with self-reporting, provider might use the Pediatric Pain Questionnaire or the Adolescent and Pediatric Pain Tool, asking children to draw on a body map where they’re experiencing pain.
For individuals unable to verbally express their pain, providers use observational assessment tools. These look at facial expressions, fussiness, ability to be consoled, responsiveness, and motor activity. They could use the Revised Face, Legs, Activity, Cry, Consolability (r-FLACC) tool or a number of other validated tools.
Caregivers may need to help nonverbal children with neurologic impairments report their pain. Some signs of pain in this group include grimacing, crying, increased muscle tone, unusual behaviours, and arching. The Brief Pain Inventory (BPI) can assess your beliefs about pain and its impact on your life, and the Neuropathic Pain Scale can monitor how well treatment is managing nerve pain.
Along with this history, a healthcare provider will complete a physical exam, which will focus on the musculoskeletal, neurologic, and psychiatric systems and the area where you’re experiencing pain.
Testing for NP Safe Prescribing of Controlled Substances While Avoiding Drug Diversion
Health professionals are strongly encouraged to follow guidelines when prescribing pain medications, especially since these medications can often be misused. To ensure safe prescribing of these controlled substances, several steps should be taken.
Firstly, a comprehensive history should be taken including the patient’s chief complaint, current and past medical conditions, a list of current and past medications and dosages, any relevant family and social histories, and an opioid abuse risk assessment. In addition to this, a thorough physical examination is recommended. Lastly, obtaining a urine drug test might be necessary.
When it comes to chronic pain assessment, standard blood work and imaging tests aren’t usually required unless a specific cause of pain is suspected. Sometimes, urine toxicology is used to monitor compliance and rule out the use of nonprescribed drugs. Patients with chronic pain could also have underlying psychiatric disorders like major depressive disorder and generalized anxiety disorder, which could worsen the pain symptoms. It’s important to note that patients with chronic pain have an increased risk for suicide and suicidal thoughts.
Assessing the risk of addiction is also crucial when prescribing controlled substances. The risk can be assessed into three levels: low, moderate, and high. Each risk level requires a different degree of monitoring.
Before prescribing opioids, a detailed patient history should be taken. This includes information about the pain, prior pain treatments, comorbid conditions, and the impact of pain. It’s also essential to take into account other factors such as family support, employment, housing, and previous history of substance abuse.
The decision to prescribe opioids should always be weighed against the risks of abuse, addiction, reactions, overdose, and physical dependence. If a patient has a history of substance abuse, it is advisable to consult with a psychiatrist or addiction specialist before prescribing opioids.
There are various screening tools available to help determine the risk level and desired degree of monitoring and structure in a treatment plan. These tools can aid in identifying signs of opioid addiction or abuse, the likelihood of current substance abuse, compliance with long-term opioid therapy, and more. However, their validity is not yet fully supported by scientific literature.
Urine drug tests are also used to check if the prescribed medication is being used and detect any unsanctioned drug use. Based on the risk level, monitoring frequency could vary. Discuss positively with the patient if urine test results suggest aberrant opioid use and make sure the discussion is well documented.
Treatment Options for NP Safe Prescribing of Controlled Substances While Avoiding Drug Diversion
If you’re experiencing pain, your healthcare provider will first consider using a non-controlled substance to help ease your discomfort. If this isn’t successful, they may decide to prescribe a controlled substance. Before this, though, you’ll need to provide informed consent and sign a patient-provider agreement. Informed consent lets your provider know that you understand what drug you’re being prescribed, what risks are involved, how it will benefit you, how long you’ll take it, and what your follow-up care will look like. The patient-provider agreement outlines the responsibilities of both you and your provider, the goals of using the controlled substance, and what happens if you don’t comply with your treatment plan.
For mild pain, you’ll likely be given acetaminophen or a non-steroidal anti-inflammatory drug. But for moderate pain, you might need something a bit stronger, like codeine or tramadol. Severe pain may require powerful opioids like hydrocodone, hydromorphone, oxycodone, or morphine.
Chronic pain sufferers are usually put on a trial of therapy. The CDC has issued guidelines on how to properly prescribe opioids for chronic pain.
In cases where the pain is debilitating, a pain management referral may be necessary. They can help mitigate pain through various methods, such as medications and therapeutic interventions.
The list of medications for chronic pain is extensive. They range from nonopioid analgesics like aspirin to stronger drugs like opioids. Antiepileptic drugs, antidepressants, muscle relaxers, and other types of medications may also be used.
Different types of pain require different treatments. For instance, chronic musculoskeletal pain is usually treated with a combination of nonopioid analgesics, opioids, and nonpharmaceutical therapies. Neuropathic pain, on the other hand, may be initially treated with drugs like gabapentin or pregabalin.
Botulinum toxin, cannabis, and topical treatments like lidocaine or capsaicin cream can also be helpful for certain types of pain.
Finally, there are numerous nonpharmaceutical options for alleviating chronic pain, including heat and cold therapy, biofeedback, chiropractic adjustments, physical therapy, exercise, and many others. If other options have been exhausted, interventional techniques, like spinal cord stimulators, may be considered.
What else can NP Safe Prescribing of Controlled Substances While Avoiding Drug Diversion be?
Pain is a feeling we experience, not a specific disease or condition. When a patient feels chronic pain, doctors’ aim to figure out the possible root causes of the discomfort. It’s crucial for them to understand the actual issue causing this pain, so they can choose the best way to treat it. As an example, doctors need to know if a patient’s nerve pain is coming from the peripheral nerves (those outside the brain and spinal cord) or the central nervous system. Or, if someone has severe knee pain, it’s vital to figure out if it’s due to serious osteoarthritis, as this could mean the patient might need a knee injection or even a knee replacement. However, if the knee pain is due to another problem like rheumatoid arthritis, infection, gout, pseudogout, or an injury to the knee’s cartilage (meniscal injury), the needed treatments would be quite different.
For cases of chronic pain that affects the entire body, the list of possible causes can include certain side effects from long-term use of painkillers (allodynia), major depression, other mental health or sleep disorders like insomnia, and autoimmune diseases such as lupus or psoriatic arthritis. Doctors also consider conditions like fibromyalgia and central pain syndromes, which could cause widespread, persistent pain. There are four primary types of pain: nerve pain (neuropathic), muscle or bone pain (musculoskeletal), pain from wear and tear or injury (mechanical), and pain from inflammation (inflammatory). When pain goes untreated for a long time, it can turn into chronic pain. So, while chronic pain might start off as a symptom of one or multiple conditions, it can also become a condition of its own as it persists and changes our body’s chemistry. It’s, therefore, very important to treat acute (short-term) and subacute (somewhat long-term) pain before it develops into chronic pain.
What to expect with NP Safe Prescribing of Controlled Substances While Avoiding Drug Diversion
Present treatments for chronic pain can lead to roughly a 30% reduction in a patient’s pain levels. This decrease can considerably enhance a patient’s functioning and quality of life. However, patients with long-term chronic pain may still experience reduced functioning and life quality. Encouragingly, their outcomes can be improved by treating any psychiatric illnesses they might be suffering from. Chronic pain not only increases patient illness and death rates but also ups the prevalence of chronic disease and obesity. Additionally, patients with chronic pain have a notably higher risk of suicide compared to the general population.
For half of the patients, spinal cord stimulation doesn’t provide adequate pain relief. Moreover, up to 20 to 40 percent of patients can develop a tolerance to this treatment, decreasing its effectiveness over time. Similarly, patients dealing with chronic pain and relying on opioids frequently build tolerance over time, leading to increased illness and death rates as the opioid dosage goes up.
Preventing chronic pain is key. If acute and subacute pain are properly treated, the progression to chronic pain can be avoided, sparing the patient from significant impacts on their quality of life.
Possible Complications When Diagnosed with NP Safe Prescribing of Controlled Substances While Avoiding Drug Diversion
Chronic pain can significantly impact the quality of life, causing issues like reduced productivity, wage loss, worsening of chronic diseases, and mental health disorders like depression and anxiety. Moreover, it increases the risk of suicide and suicidal thoughts.
The medications often used to treat chronic pain can have potential risks, side effects, and complications.
Acetaminophen, a common drug used for chronic pain, can cause liver damage if consumed more than four grams per day. Especially, people with chronic liver disease can face this risk even at the prescribed doses.
Frequently used medications such as gabapentin or pregabalin can cause side effects like drowsiness, swelling, mood changes, confusion, and difficulty breathing in older adults in need of additional pain relief. These drugs also increase the mortality rate when used in combination with opioid pain relievers.
Duloxetine, another medication for chronic pain, can cause mood changes, headaches, and nausea. It’s best to avoid it in patients with a history of kidney or liver disease.
Opioids, while effective for pain relief, can cause addiction and risk of overdose leading to respiratory problems. Patients also might become more sensitive to pain due to long-term use of opioids. Other side effects include constipation, tolerance, dependence, nausea, stomach discomfort, arrhythmia, and hormone imbalance. The risk of an opioid overdose increases with the daily dosage.
Patients using spinal cord stimulators face a high complication rate, such as migratory leads causing inadequate pain relief, fractures, swelling, infections, and direct spinal cord trauma. There is a spike in post-procedure headaches and in extreme cases, there can be a spinal epidural hematoma requiring instant neurosurgical decompression.
Regrettably, some individuals may seek prescribed opioids for illegal gain, either due to addiction or financial reasons. They may resort to aggressive demands for more drugs, doctor-shopping, forging prescriptions, consuming higher doses without approval, injecting oral medications, or obtaining them through non-medical means. Prescription mishaps like losing or stealing prescriptions, selling them, or increasing doses on their own are also red flags.
Medical professionals can prevent drug diversion by communicating between providers and pharmacies, educating patients about the dangers of sharing opioids, and prescribing fewer quantity of opioids. Doctors also advocate that patients should store opioid medications privately and not disclose their consumption publically. In case a patient is suspected of drug-seeking or diversion, urine drug screening, thorough examination, and pill counting can be performed. If there’s a violation of treatment agreement, the doctor may decide to terminate the patient-doctor relationship legally, ensuring the patient can find alternative care.
If a patient has a substance abuse problem or addiction, they should be referred to a specialized pain clinic. Any theft or loss of controlled substances should be reported to the governing drug enforcement administration. All incidences of drug diversion should be documented and reported to law enforcement, if occurred.
Preventing NP Safe Prescribing of Controlled Substances While Avoiding Drug Diversion
Patients and their families can play a crucial role in making informed decisions about continuing or stopping opioid therapy. Families can often tell if a patient is feeling down and not functioning as usual. Some questions to ask the family members could be: Does the patient’s day seem to revolve around taking opioid pain medication? How often is the pain medication taken? Has the patient struggled with other drug or alcohol problems? Does the patient avoid activity? Is the patient feeling depressed? Can the patient function normally?
Patients who are taking opioids should be aware of the following: They should avoid driving or operating heavy machinery. They should not suddenly stop taking opioids. They must steer clear of other drugs that can slow breathing, like alcohol, sedatives, and anxiety medication. If the pain medication is not providing enough relief, they should reach out to their doctor. They should dispose of opioids according to specific product instructions, which often recommend flushing them down the toilet or mixing them with cat litter or coffee grounds. They should avoid chewing tablets, and never share opioids with others. They need to follow the prescribed dosage regimen closely, and they should only take opioids as prescribed by their doctor.