1. Gould, Kathleen Ahern RN, MSN, PhD

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Managing pain in the shadow of the opioid crisis is a significant challenge. All health care professionals share a role as we address drivers of this complex issue. Many new programs exist to provide research and support to reduce opioid-related death and disability. Efforts to combat this epidemic started in 2016, as the Centers for Disease Control and Prevention (CDC) issued new guidelines for prescribing opioids-including recommendations that clinicians avoid prescribing benzodiazepines concurrently with opioids if possible.1 Both classifications of drugs now carry black box warnings to this effect. The CDC has also provided a checklist for prescribing opioids for chronic pain (, as well as a website ( with additional tools to guide clinicians in implementing the recommendations. Prescribing guidelines include 12 critical recommendations, although they are not directed to providers caring for patients during end of life, acute injury, active cancers, or palliative care. Nonetheless, they do provide tremendous guidance as we struggle to create a balance between benefits and harms for our patients. Currently, we are proud to see many professional and political efforts in place to turn the tide of the epidemic as this wave moves toward prevention and recovery.


In the search for balance, we are challenged by the escalating patient needs for sedation and pain management in the intensive care unit (ICU). The overuse of opioids and benzodiazepines in the acute and chronic care settings contributes to the crisis. Patients requiring protective lung ventilation and support such as extracorporeal life support (ECLS) may require high doses of both opioids and benzodiazepines. Titrating these medications is often difficult. Tapering doses and providing support during transitions are advanced skills, often complicated by withdrawal and inadequate pain management.


In the ICU, medications such as propanol offer some alternative for acute care but carry the adverse effects of hypotension and bradycardia in already hemodynamically compromised patients. Nurses in the ICU report that is it common to see patients receiving propofol, dilaudid, or fentanyl. However, alternatives to opioids are used more often, and new uses for old medications are reconsidered. With more education and introduction of alternative treatments, providers are seeing a trend toward alternate medications such as ketamine and dexmedetomidine/precedex for sedation. Blended pain management plans suggest alternatives for pain associated with nerve and muscle injury. Traditional comfort measures such as heat and cold are being reexplored in conjunction with acupuncture, massage, reiki, and other nonpharmaceutical healing modalities.


In every episode of care, we are changing how we manage pain for interventional procedures to chronic pain management. Many patients are receiving enhanced recovery after procedure/surgery (ERAP or ERAS) medication regimens.2 Surgical and procedural areas are working closely with anesthesia to develop comprehensive programs. Preprocedure cocktails may include drugs such as Celebrex, lidocaine patches, and regional blocks. These steps allow a significant reduction in intraprocedure drugs, such as versed (midazolam) and fentanyl and may reduce postprocedure need opioids.


As we work to reeducate ourselves and change the system to lessen the opioid load, our goals are focused on meeting the patients' needs. We would love to hear what you are doing in your practice.[alpha] We invite you to share your ideas, innovations, and experiences in DCCN.


Kathleen Ahern Gould, RN, MSN, PhD


Editor - In Chief - DCCN Wolters Kluwer Health Duxbury, Massachusetts




1. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain - United States, 2016. MMWR Recomm Rep. 2016;65(1):1-49. Accessed Retrieved on January 28, 2019. [Context Link]


2. Jankowski C. Preparing the patient for enhanced recovery after surgery. Int Anesthesiol Clin. 2017;55(4):12-20. doi:10.1097/AIA.0000000000000157. [Context Link]