What All Nurses Must Know What you will Learn The current dilemma pain management vs risk of substance misuseabuse Best practices for rational transparent and risk managed opioid prescribing ID: 728148
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Slide1
Best Practices Prescribing & Preventing Drug Diversion
What All Nurses Must Know.Slide2
What you will Learn
The current dilemma: pain management vs. risk of substance misuse/abuseBest practices for rational, transparent and risk managed opioid prescribing.How to Recognize aberrant drug taking behaviors that may indicate misuse/abuse.
Requirements for compliance with current legislative mandates.Slide3
Nursing Roles & Responsibilites
Nurses Care for more patients than any other healthcare providers.Nurses are the eyes and ears of healthcare.
Nurses are in the best position to help reduce this public health epidemic. Education is a key factor in shifting this culture of misuse and abuse of prescription drugs.Slide4
Prescription Drug AbuseA Public Health Crisis
Between 1998 & 2008, the rate of opioid misuse increased 400
%More than 6 million Americans are abusing prescription drugs. Prescription drug abuse is the fastest growing drug problem in Ameerica
Between 1999-2007 the number of deaths related to prescription opioid analgesics quadrupled
.
Opioid overdose is now the second-leading cause of accidental death in America, exceeded only by car crashes. In 17 states it is the leading cause of accidental death
.Slide5
West Virginia
Between 1999-2004, there was a 550% increase in unintentional poisoning mortality in WV, with more than 90% of the deaths due to prescription drug overdoses.
In 2008, WV had the highest rate of prescription drug overdose deaths in the U.S., surpassing both Motor vehicle crashes and falls as the leading cause of accidental death
.
Polling Question 1Slide6
WV Overdose Deaths by Year
6Slide7
Illicit drug use among our Youth
Did
you know?Children
who start to use drugs/alcohol or use drugs during adolescence are 4X
more likely to become
substance involved
as
adults.Slide8
National Legislation
Action Plan to Address National Prescription drug abuse EpidemicIntroduced in 2011
Provided support to states to Expand state based prescription drug monitoring programs (PDMP’s)Education for patients and healthcare providersEnforcement efforts aimed at eliminating “pill mills”Slide9
State Legislation (WV)
SB 365 – Online access to controlled substance databaseSB 81 – WV Official Prescription Program Act
SB 362 – Clariifies “Doctor Shopping”
SB
514
– Clarifies language in Controlled
Substances
Monitoring Act Slide10
More Legislation / WV
Controlled Substance Monitoring Program (CSMP) - Established in WV Code Chapter 60A; Article 9
SB 437 – established a requirement for Substance abuse education for all providers who dispense, prescribe or administer controlled substances.
Polling Question
2Slide11
Pain Control LadderSlide12
Has the pendulum swung too far? Slide13
Best Practices for Prescribing & Preventing Diversion
The Federation of State Medical Boards (FSMB) “Model Policy for the Use of Controlled Substances for the Treatment of Pain”
The American Pain Society (APS) and American Academy of pain Medicine (AAPM) “
Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic non-cancer
pain”.Slide14
The DilemmaCan we Treat pain effectively without
addiction?
IOM Report 2011
A
2011 study mandated by IOM reported that 100 million American suffer from chronic pain, costing up to 635 billion annually in treatment and lost productivity.
The number of patients with chronic pain exceeds diabetes, heart disease and cancer combined.
World Health Report
World Health Organization reports that substance abuse is the #1 most preventable health problem. It is costing our nation billions of dollars per year and contributing to the death of hundreds of people.
By Taking Simple Steps to ensure that opioids are prescribed safely and transparently, clinicians can help their patients achieve better outcomes and prevent misuse/abuse.Slide15
Pain / Addiction
Polling Question
3Slide16
Two Faces of Pain
What is Pain?An unpleasant sensory and emotional experience associated with actual or potential tissue damage.
Categories of PainAcute Pain – results from disease, inflammation or injury to tissues; generally comes on suddenly and may be accompanied by anxiety or emotional distress.Chronic Pain – widely believed to represent disease itself and can be made much worse by environmental and psychological factors; persists over a long period of time and is resistant to most medical treatments.Slide17
Types of Pain
Nociceptive Pain (sprains, bone fractures, burns, bruises)Neuropathic Pain (shingles, neuralgia, phantom limb pain, CTS, peripheral neuropathy)
Mixed category Pain (migraine headaches)Slide18
Undertreated Pain vs Over-Prescribing
Contributing Factors
Lack of knowledge among prescribers about current pain management guidelines, risk management practices, and research in pain medicine.Lack of knowledge among prescribers about addiction, dependence and misuse.Slide19
Periodic Review and Monitoring
Pt. Evaluation & Selection
Treatment
Plans
Fundamental Tenets of Responsible
Opiod
PrescribingSlide20
Patient EvaluationPain Assessment
The best way to begin assessing a patients pain is to ask about and listen.
Acknowledge the patient’s painAnd treat it in a manner that Provides the most effective pain control
w
ith the least
amount of risk.
Tools for Evaluation of Pain
Tools for Assessing Addiction Risk
Polling Question
4Slide21
Pain Assessment Tools
Free Pain Assessment Tools and Addiction Risk Tools.Federation State Medical Boardshttp
://www.fsmb.org/pain-resources.htmlSlide22
Tools for Assessing Pain
Pain Measurement Scales0-10 scale / faces pain rating scaleMcGill Pain Questionnaire Slide23
Tools for Assessing Addiction Risk
Opioid Risk Tool – Clinician Form
Family History of Substance AbusePersonal History of Substance AbuseHistory of preadolescent sexual abusePsychological disorders
(
ADD,OCD,Bipolar,depression
)
SOAPP 14 Q - Screener and Opioid Assessment ToolSlide24
Patient Evaluation
What to Documentmedical history and physical examination
Document nature and intensity of painDocument current and past treatments for painDocument underlying or coexisting diseases or conditionsDocument effect of pain on physical and psychological functionDocument History of substance abuse.
Document the presence of one or more recognized medical indications for the use of controlled substances.Slide25
Informed Consent
Minimum Risk PatientsRisks / Benefits must be discussedPrescriptions to be obtained from one physician only
Prescriptions to be obtained from one pharmacy whenever possibleHigh Risk patients Written agreement (outlining pt. responsibility)
Drug Screening / Pill counts
Polling Question
5Slide26
Treatment Plan Guidelines
Functional Goals
Progress in physical therapyBetter sleeping patternsIncreased activities of daily livingReturn to workIncreased social
Activities
Regular exercise
Treatment Plans
Patient EvaluationSlide27
Treatment PlanDocumentation
Must
Document Objectives that will be used to determineTreatment success (eg. Pain relief and improved physical and psychosocial function).If other diagnostic evaluations or treatments are planned.Slide28
Opioid Care Plan
A written Plan of Care for Pain Mgt. with Opioids should include … DiagnosisGoals (maximize quality of life & level of
fx)Ways to help patient reach goalsYour specific plan of care for the patient Follow – up instructionsSlide29
Periodic ReviewGuidelines
Never Continue long term treatment if there is inadequate progress toward functional goalsConsult with Specialists when problem exceeds your expertise
Exercise Compassion but always VERIFYPDMP’s, urine screening
Periodic ReviewSlide30
Monitoring & Documentation
Benefit to Harm EvaluationHistory & physicalAppropriate diagnostic testing
ToolsOpioid Risk toolScreener and assessment toolVerify Urine Drug Screening / PDMP’s
Polling Question
6Slide31
Patient Education
Safe Use of Opioid medicationStorage and disposal of medicationAccountability through PDMP’s, drug screening & pill counts.
Termination strategies for chronic therapy.** Opiod Treatment Fact Sheet **Slide32
Prescription Drug Monitoring Programs (PDMP’s)
Statewide programs that collect data on various controlled substance prescriptions
48 states and one US territory have enacted PDMP legislationHelp Identify patients engaged in prescription drug abuse and diversion
PDMP’s are to prescribers what radar is to the policeSlide33
Pt
. Education & disclosureUrine Screen
Patients should be taughtThe purpose for testingWhat will be screened for
Actions that may be taken based on results of screen
Possibility of cost to patient
Patients should disclose
What results the patient expects
Prescriptions or any other drugs the patient has taken
Time and dose of last opioidsSlide34
Opiod MisuseBehaviors to Watch for
More Suggestive of
Abuse/Addiction
Selling Prescription drugs
Stealing drugs from others.
Repeated dose escalation
Repeated visits to the E.R.
Repeated loss of medication or request for early refill
Less Suggestive of
Abuse
/
Addiction
Openly acquiring pain meds from other doctors
Drug hoarding during periods of reduced symptoms.
Aggressive complaining about need for more pain meds.
Reluctance to try alternative treatments.Slide35
Key Universal Precautions in Prescribing Controlled Substances
Select Patients who are appropriate Candidates for opioid management of chronic pain.Follow an evidence-based protocol for initiating, titrating and concluding opioid therapy.
Recognize & Intervene when aberrant drug taking behaviors are identified.Polling Question 7Slide36
Take Home Messages
Prescription drug abuse is the fastest growing drug problem in America. Nurses are in the best position to help prevent prescription drug abuse and diversion
Lack of knowledge about addiction, appropriate pain management & risk are key contributing factors to prescription drug abuse & diversion.Slide37
Thank You
Questions
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