1. Kennedy, Maureen Shawn MA, RN, FAAN


Will legitimate concerns over opioid safety harm some patients?


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The opioid overdose epidemic (encompassing the use of both prescription opioids and heroin) has been dominating the media in recent months, with good reason. A recent report from the Centers for Disease Control and Prevention (CDC) examining drug overdose deaths between 2000 and 2014 noted that the rate of opioid overdoses tripled during that time. In 2014 alone, opioids accounted for 61% of all drug overdose deaths. The report also notes that, since 1999, prescriptions for opioids have quadrupled. Natural and semisynthetic opioids, which include oxycodone and hydrocodone, are among the most commonly prescribed pain medications; they're also implicated in more deaths than any other type of opioids.

Figure. Maureen Shaw... - Click to enlarge in new window Maureen Shawn Kennedy

In response to all this, state and federal legislators and government agencies have called for sweeping changes in prescribing practices, including how and why these drugs are prescribed, who may prescribe them, and which patients are eligible to receive them. In this issue, authors Risa Denenberg and Carol P. Curtiss, two nurses with substantial experience in treating patients in pain, address many relevant issues ("Appropriate Use of Opioids in Managing Chronic Pain"). They describe how to assess the potential risks versus benefits of opioid use, discuss best prescribing practices when opioids are essential to pain control, and explain how to monitor patients on long-term opioid therapy.


To curtail the current epidemic, several actions must be taken without delay. For one, we must ensure that health care professionals are prescribing the right treatment in the right amount to the right patients for the right reasons-as is true for any intervention. Many professional organizations and many universities that train health care professionals have committed to including content on proper prescribing in their programs. At both state and federal levels, new legislation addressing opioid prescribing practices is being considered.


But some experts are concerned about how legislators are responding. I recently spoke with Renee C. B. Manworren, director of nursing research at the Ann and Robert H. Lurie Children's Hospital of Chicago, and Aaron Gilson, research program manager in the Pain and Policy Studies Group at the Carbone Cancer Center, University of Wisconsin-Madison (and authors of "Nurses' Role in Preventing Prescription Opioid Diversion," August 2015). They say it will take more than just educating prescribers and increasing oversight and restrictions, and they're apprehensive about how such legislation might negatively affect patients who need opioids and take them responsibly.


"For one thing, there's a lack of aggregate information," Gilson told me. "We don't really know to what extent the opioid overdoses involved people who misused opioids that were legitimately prescribed to them, or involved others who obtained the drugs illegally from family or friends or purchased them off the street. We need to be clear about this difference."


Manworren said that focusing on prescribers without also addressing the drug supply system and drug diversion was simplistic. Some states have passed or are considering legislation that isn't supported by research-for example, laws that would deny advanced practice NPs the ability to prescribe opioids, or would set limits on dosages or the number of days a supply should last. She also noted that much of the research on the current epidemic has been conducted among substance abusers. She cited a large, more relevant study by Bohnert and colleagues of patients being treated for noncancer pain, which found that fewer than 1% of those prescribed opioids overdosed. She expressed concern that "insufficient treatment of pain has been the reality for many, and there are patients whose pain is well managed on opioids. Now this all may be taken away." She urged nurses to take advantage of the focus on opioids to get correct information about their proper use, securement, and disposal out to patients and families.


A 2011 report from the CDC that heralded the current epidemic offered this caveat: "Public health interventions to reduce prescription drug overdose must strike a balance between reducing misuse and abuse and safeguarding legitimate access to treatment." We need to make sure that amid the rush to address the overdose epidemic, this message also gets heard.