CDC Opioid-Prescribing Guideline for Chronic Pain: Concerns and Contexts

by frankieleon/ via flickr by frankieleon/ via flickr

By Jacob Molyneux, senior editor

The CDC’s new Guideline for Prescribing Opioids for Chronic Pain was released this week. The context for this comprehensive new guideline is widespread concern about opioid-related overdose deaths and substance abuse in the U.S.

The guidelines make 12 main recommendations, among them the following:

  • nonpharmacologic or nonopioid pharmacologic treatments should be considered “preferable” first-line therapy for those with chronic pain.
  • a daily opioid dosage limit of morphine milligram equivalents should be imposed.
  • immediate-release opioids should be prescribed before moving to extended-release formulations.
  • urine testing should precede new opioid prescriptions for chronic pain and treatment goals should be set.
  • clinicians should prescribe the lowest possible number of days’ worth of medication for acute pain (often three days or less).
  • prescription drug monitoring program (PDMP) databases should be consulted to determine patients’ past histories of opioid prescriptions.

Some of the recommendations would seem to be no-brainers, such as consulting PDMPs when writing new prescriptions. Others, such as a “one-size-fits-all” daily dosage limit and restrictions on the use of extended release formulations, have raised alarms among pain management experts. See, for example, “I’m Worried About People in Pain,” a recent AJN Viewpoint essay by Carol Curtiss, a nurse and pain management expert, who notes the increased stigmatization experienced by pain patients and the chilling effects of new restrictions on doctors’ prescribing, to […]

Ethical Practice with Patients in Pain

Photo @ AJ Photo / Hop Americain / Science Photo Library Photo @ AJ Photo / Hop Americain / Science Photo Library

Pain is difficult to define and hard to convey. The way both patients and clinicians respond to it can be influenced by a multitude of possible biases. This month’s Ethical Issues column in AJN is by Doug Olsen, PhD, RN, an associate professor at Michigan State University College of Nursing. In “Ethical Practice with Patients in Pain,” Olsen summarizes the challenge nurses and other clinicians face in treating patients’ pain:

Responding to a patient’s pain is a fundamental ethical obligation in nursing. However, nurses caring for patients in pain can run into ethical conflicts from both over- and undertreatment of pain. Undertreatment of pain represents a failure to fulfill the core nursing obligation to alleviate suffering—but overtreatment may ultimately harm the patient, contradicting a core nursing value, nonmaleficence. The complex nature of pain complicates efforts to provide treatment that is ‘just right.’ Nurses must understand that complexity if they are to make ethical decisions in the care of patients who experience pain.

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Managing the All-Too-Real Symptoms of Fibromyalgia Syndrome

By Sylvia Foley, AJN senior editor

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Fibromyalgia syndrome (FMS) is one of the most common rheumatic disorders, affecting as many as 15 million people in this country, the vast majority of them women. People with FMS typically experience chronic widespread pain, as well as various concurrent symptoms that can include fatigue, cognitive disturbances (such as memory problems, confusion, and difficulty concentrating), distressed mood (especially anxiety and depression), nonrestorative sleep, and muscular stiffness. One study found that up to 65% of patients experienced lost workdays as a result.

Yet as author Victoria Menzies reports in one of our January CE features, “Fibromyalgia Syndrome: Current Considerations in Symptom Management,” many health care providers “doubt the syndrome’s validity.” Diagnosis is often delayed for years.

Menzies provides a concise overview of the illness, which has no known cure, and then focuses on what can be done to alleviate symptoms and improve patients’ quality of life. Here’s a brief overview of the article:

Symptom management appears to be best addressed using a multimodal approach, with treatment strategies tailored to the individual. While medication may provide adequate symptom relief for some patients, experts generally recommend integrating both pharmacologic and nonpharmacologic approaches. Some patients may benefit from the adjunctive use of complementary and alternative medicine (CAM) modalities. Because symptom remission is rare and medication adverse effects can complicate symptom management, well-informed nursing […]

‘I’m Worried About People in Pain’: A Nurse’s Take on Opioid-Prescribing Regulation Changes

by frankieleon/ via flickr by frankieleon/ via flickr

Many patients and clinicians have strong feelings about opioids: they’ve seen a loved one denied adequate pain control, or they’ve seen a family member or friend’s son or daughter lost to prescription pill and/or heroin addiction, or they’ve worked in an ED with too many drug-seeking patients, or they’ve seen a patient in terrible pain waiting for a new analgesic order from an unavailable or uncompassionate physician.

But feelings don’t solve complex problems, and an excessively punitive or permissive approach can do more damage than good. Recently, there have been almost daily headlines and policy recommendations about the importance of restricting opioid-prescribing practices. The trend is alarming a number of clinicians with expertise in working with patients in pain. Clinical nurse specialist and pain management consultant Carol Curtiss addresses what’s at stake in “I’m Worried About People in Pain,” the Viewpoint essay in the January issue of AJN:

According to a 2011 Institute of Medicine report, chronic pain is a public health crisis . . . Well-intended efforts to address prescription drug abuse—another public health crisis—may place heavy burdens on people with pain who benefit from opioids and use them responsibly as part of a comprehensive treatment plan. . . . Gains made in pain treatment are at risk. New regulations threaten access to opioids for people with […]

A Nursing Perspective on a Recent NEJM Palliative Care Article

Pam MolloyBy Pam Malloy, RN, MN, FPCN, director and co-investigator of the ELNEC Project, American Association of Colleges of Nursing (AACN), Washington, DC.

I just read a New England Journal of Medicine article by Drs. Craig D. Blinderman and the late J. Andrew Billings that came out on Christmas Eve, 2015. “Comfort Care for Patients Dying in the Hospital” was a thoughtful, informative article and I am grateful that it appeared in a journal that wasn’t focused solely on hospice/palliative care.

2016_ELNECLogoWhile the information in the article is essential for all health care professionals, I would like to take this opportunity to remind my nursing colleagues that we have a tremendous opportunity and privilege to plan, provide, and orchestrate the care that was described in this article—and we have been doing so for some time.

Nurses spend more time at the bedside and out in the community assessing and managing patients with serious, complex illness than any other health care professional. Our interdisciplinary colleagues depend on our assessments and we play a major role in developing plans of care with our diverse team. We are there having difficult conversations with patients—many times in the middle of the night when they cannot sleep.  We are entrusted […]