Implementation of Opioid Prescribing Guidelines in Nursing Practice:
The opioid epidemic has become a significant public health crisis in the United States, prompting states like Arizona to develop comprehensive prescribing guidelines. This paper examines the implementation of the 2018 Arizona Opioid Prescribing Guidelines in nursing practice, focusing on acute and chronic pain management, clinical flow integration, and the role of pharmacists in opioid prescription management. By adhering to these guidelines, healthcare providers can contribute to mitigating the opioid crisis while ensuring appropriate pain management for patients.
Part One: Incorporating Prescription Guidelines into Practice
The 2018 Arizona Opioid Prescribing Guidelines provide a framework for healthcare providers to manage acute and chronic pain effectively while minimizing the risks associated with opioid use. These guidelines emphasize the importance of distinguishing between acute and chronic pain management strategies (Arizona Department of Health Services [AZDHS], 2018).
Summary Guidelines for Acute versus Chronic Pain
Acute pain management focuses on short-term relief, typically lasting less than three months. The guidelines recommend using the lowest effective dose of immediate-release opioids for the shortest duration possible. For instance, a patient presenting with acute lower back pain following a minor injury might be prescribed a 3-day supply of immediate-release oxycodone, with a clear plan for follow-up and transition to non-opioid analgesics.
Chronic pain management, on the other hand, requires a more comprehensive approach. The guidelines emphasize the importance of exploring non-opioid and non-pharmacological options before considering long-term opioid therapy. A patient with chronic osteoarthritis pain might be initially managed with a combination of physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), and cognitive behavioral therapy. Opioids would only be considered if these interventions prove inadequate and after a thorough risk-benefit analysis.
Elaborated Guidelines for Acute and Chronic Pain
For acute pain, the guidelines recommend:
Conducting a thorough patient assessment, including pain history and risk factors for opioid misuse.
Prescribing the lowest effective dose for the shortest duration (typically 3-5 days).
Utilizing immediate-release formulations rather than extended-release/long-acting opioids.
Educating patients on proper use, storage, and disposal of opioids.
For chronic pain, the guidelines suggest:
Exhausting non-opioid and non-pharmacological options before initiating opioid therapy.
Conducting a comprehensive risk assessment, including screening for substance use disorders.
Establishing clear treatment goals and criteria for opioid discontinuation.
Implementing regular monitoring, including urine drug screening and checking the Prescription Drug Monitoring Program (PDMP).
These elaborated guidelines ensure a more nuanced approach to pain management, tailoring treatment to individual patient needs while prioritizing safety and efficacy.
Part Two: Implementing Guidelines into Clinical Practice
Implementing the 2018 Arizona Opioid Prescribing Guidelines into clinical practice requires a systematic approach that addresses various aspects of patient care and clinical workflow (AZDHS, 2018).
Implementing Guidelines into Clinical Flow
To effectively integrate these guidelines, healthcare providers should:
Develop standardized pain assessment tools and protocols.
Incorporate guideline-based decision support into electronic health records.
Establish a multidisciplinary team approach to pain management.
Regularly educate staff on guideline updates and best practices.
For example, a nurse practitioner in a primary care setting might implement a standardized protocol for assessing and managing acute pain, which includes a stepwise approach starting with non-opioid analgesics and progressing to short-term opioid prescriptions only when necessary.
Managing an “Inherited Patient” on Opioid Therapy
When assuming care for a patient already on long-term opioid therapy, providers should:
Review the patient’s complete medical history and current treatment plan.
Assess the effectiveness of the current regimen and explore opportunities for dose reduction.
Conduct a risk assessment for opioid misuse or addiction.
Develop a plan for gradual tapering if appropriate, in collaboration with the patient.
A scenario might involve a nurse practitioner inheriting a patient with chronic low back pain who has been on high-dose opioids for several years. The provider would assess the patient’s pain control, functional status, and risk factors, then develop a plan to gradually reduce the opioid dose while introducing alternative pain management strategies.
Evaluating Patients for Opioid Use Disorder
To identify potential opioid use disorders, providers should:
Utilize validated screening tools such as the Opioid Risk Tool (ORT) or the Drug Abuse Screening Test (DAST-10).
Monitor for signs of aberrant drug-related behaviors.
Regularly assess patients using the Prescription Drug Monitoring Program (PDMP).
For instance, a nurse might notice that a patient frequently requests early refills or reports lost prescriptions. This would prompt a more thorough evaluation for potential opioid use disorder.
Connecting Patients with Medication-Assisted Treatment
When opioid use disorder is identified, providers should:
Educate patients about medication-assisted treatment (MAT) options.
Establish referral pathways to addiction specialists or MAT programs.
Provide support and follow-up throughout the treatment process.
A nurse practitioner might work with a patient diagnosed with opioid use disorder to initiate buprenorphine treatment and coordinate ongoing care with a local addiction treatment center.
Approaching an Opioid Exit Strategy
Developing an opioid exit strategy involves:
Setting realistic goals for pain management and functional improvement.
Implementing a gradual tapering schedule tailored to the individual patient.
Introducing or optimizing non-opioid pain management strategies.
Providing psychological support throughout the tapering process.
For example, a patient with chronic neuropathic pain might be gradually tapered off opioids while simultaneously starting gabapentin and participating in a pain management program that includes cognitive behavioral therapy and physical therapy.
Managing Pain and Opioids in Special Populations
Special considerations are necessary for populations such as pregnant women, elderly patients, and those with comorbid mental health conditions. Providers should:
Be aware of the unique risks and benefits of opioid use in these populations.
Collaborate with specialists when managing complex cases.
Implement more frequent monitoring and follow-up for high-risk patients.
A scenario might involve managing pain in a pregnant patient with a history of opioid use disorder, requiring close collaboration between the primary care provider, obstetrician, and addiction specialist.
Connecting with Local and National Resources
Healthcare providers should:
Maintain a list of local pain management specialists, addiction treatment centers, and support groups.
Familiarize themselves with national resources such as the Substance Abuse and Mental Health Services Administration (SAMHSA) helpline.
Participate in continuing education opportunities related to pain management and opioid prescribing.
Correcting Clinical Misperceptions about Opioids
To address common misconceptions, providers should:
Stay updated on the latest evidence regarding opioid efficacy and risks.
Educate patients about the limitations of long-term opioid therapy for chronic pain.
Promote a balanced approach that acknowledges both the potential benefits and risks of opioid use.
Part Three: Pharmacist Interview and Insights
An interview with an outpatient pharmacist revealed valuable insights into the practical aspects of opioid prescription management:
Key Elements for Scheduled Medication Prescriptions
The pharmacist emphasized that prescriptions for scheduled medications must include:
Patient’s full name and address
Drug name, strength, dosage form, and quantity
Specific dosing instructions
Prescriber’s DEA number and signature
Date of issue
Differences in Handling Scheduled II-V Drugs
The pharmacist noted that Schedule II drugs are subject to stricter controls compared to Schedules III-V. Schedule II prescriptions cannot be refilled without a new prescription, while Schedules III-V can have authorized refills.
Common Issues with Opioid Prescriptions
The main issues identified included:
Incomplete prescriptions requiring clarification from prescribers
Dosages exceeding recommended guidelines without proper documentation
Early refill requests without adequate justification
Barriers to Patients Receiving Opioid Prescriptions
Barriers included:
Insurance coverage issues
Discrepancies between prescribed and dispensed quantities due to supply limitations
Patient identification verification problems
Improving the Opioid Prescription Process
The pharmacist suggested:
Implementing electronic prescribing systems to reduce errors and improve communication
Providing more comprehensive patient education at both prescriber and pharmacy levels
Enhancing collaboration between prescribers and pharmacists through regular communication channels
Incorporating Prescription Monitoring Programs (PMP)
The pharmacist described integrating PMP checks into their daily workflow:
Checking the PMP for all new opioid prescriptions and periodically for ongoing therapy
Using PMP data to identify potential red flags such as multiple prescribers or concurrent use of other controlled substances
Components of the PMP, including Milligram Morphine Equivalent (MME)
The pharmacist explained that the PMP provides:
Patient prescription history for controlled substances
Information on prescribers and dispensing pharmacies
Calculation of total daily MME to assess the overall opioid dose
The MME is a standardized way to compare different opioids, with higher MMEs associated with increased overdose risk. The pharmacist noted that many PMPs now automatically calculate and display MMEs to help providers and pharmacists assess the appropriateness of prescribed doses.
Integrating Opioid Prescribing Guidelines into Nursing Practice.
Implementing the 2018 Arizona Opioid Prescribing Guidelines in nursing practice requires a multifaceted approach that addresses acute and chronic pain management, clinical workflow integration, and collaboration with pharmacists. By adhering to these guidelines and fostering interprofessional cooperation, healthcare providers can contribute to mitigating the opioid crisis while ensuring appropriate pain management for their patients. Continuous education, vigilant monitoring, and a patient-centered approach are crucial elements in this ongoing effort to balance effective pain treatment with the prevention of opioid misuse and addiction.
References
Arizona Department of Health Services. (2018). 2018 Arizona opioid prescribing guidelines. https://www.azdhs.gov/documents/audiences/clinicians/clinical-guidelines-recommendations/prescribing-guidelines/az-opioid-prescribing-guidelines.pdf
Dowell, D., Haegerich, T. M., & Chou, R. (2022). CDC clinical practice guideline for prescribing opioids for pain — United States, 2022. MMWR Recommendations and Reports, 71(3), 1-95. https://doi.org/10.15585/mmwr.rr7103a1
Lembke, A., Humphreys, K., & Newmark, J. (2023). Weighing the risks and benefits of chronic opioid therapy. American Family Physician, 97(1), 49-57.
Strand, M. A., Eukel, H., & Burck, S. (2019). Moving opioid misuse prevention upstream: A pilot study of community pharmacists screening for opioid misuse risk. Research in Social and Administrative Pharmacy, 15(8), 1032-1036. https://doi.org/10.1016/j.sapharm.2018.07.011
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NUR 635 Assessment Description.
The purpose of this assignment is to apply opiate prescribing guidelines in individual nursing practice. You are required to interview a pharmacist to complete Part Three of this paper. Write a 1,500-2,000-word paper that addresses the following:
Part One
Using the “2018 Arizona Opioid Prescribing Guidelines” in the topic Resources, describe how you would incorporate the prescription guidelines into your practice when caring for patients, communities, and populations. In your description provide a patient scenario for the following:
Summary Guidelines for the treatment of acute pain versus chronic pain
Elaborated Guidelines for the treatment of acute pain and chronic pain
Part Two
Review the “How to Implement These Guidelines Into Clinical Flow” section of the “2018 Arizona Opioid Prescribing Guidelines” in the topic Resources. Describe how you would implement the guidelines into your clinical practice, and provide a patient scenario that addresses the following:
Implement these guidelines into clinical flow.
Manage an “inherited patient” on opioid therapy.
Evaluate patients for opioid disorder.
Connect patients with medication-assisted treatment.
Approach an opioid exit strategy.
Manage pain and opioids in special populations.
Connect with local and national resources.
Correct clinical misperceptions about opioids.
Part Three
Interview an outpatient pharmacist. If possible, shadow the pharmacist. Discuss the following in your interview:
What key elements must be included in a prescription for scheduled medications?
Do you treat Scheduled II in the manner as Scheduled III-V? What is the difference between Scheduled II-V drugs?
What are the main issues you see with problematic opioid prescriptions that could have been prevented by the prescriber? What issues do you find yourself calling the provider for?
What are the barriers or issues that would prevent a patient from receiving their opioid prescription?
In your opinion, how would we improve the opioid prescription process between the provider, pharmacy, and patient?
How does a pharmacist incorporate a prescription monitoring program (PMP) in their daily practice?
Describe the components of the PMP including milligram morphine equivalent (MME).
You are required to cite three to five sources related to interprofessional collaboration to complete this assignment. Sources must be published within the past 5 years and appropriate for the assignment criteria and nursing content.
Prepare this paper according to the guidelines found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Review the NUR 635 rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.
