A few years ago, I was reviewing the clinical record of a patient who had just been discharged from the hospital with a severe GI bleed. While he was hospitalized, a drug screen was run and it was determined that he had no opioids in his system despite the fact that he had Lortab ordered three or four times a day. Going back further, I read that while his wife was present during visits, she was often ‘napping’. I do not know how the physician knew to order the drug screen but it’s not a long leap to figure out why Adult Protective Services were called. As it was discovered, the patient’s wife was substituting two aspirin for the Lortab doses; hence the bleed.
Fast forward to a couple of months ago when I read a chart of a man who had chronic back pain. He had been taking oxycodone for years and had recently underwent surgery which mostly corrected the cause of his pain. He then fell and was admitted for pneumonia. The admitting physician said the patient asked for much more than his prescribed dose of pain medication. When he received it, he was somnolent and showed other signs of overdose.
Then there was a patient whose chart indicated that she had very severe 10/10 pain on each visit. The physician was not called. I called the agency on this during a meeting as multiple clinicians had seen the patient. They told me that what I didn’t see was the five o’clock news when the patient was arrested for selling her prescription medication.
Here are some facts.
- Pain affects approximately 100 million American adults each year, resulting in a national cost of $635 billion annually in medical treatment and loss of productivity.
- Medicare beneficiaries (aged and disabled) have among the highest and fastest-growing rates of diagnosed opioid use disorder at more than 6 of every 1,000 beneficiaries (CMS, January 2017).
- In 2011, on an average day, 80 adults aged 65 and older visited the emergency department for problems with narcotic pain relievers and seven older adults’ visits (on an average day) involved heroin (Mattson et al., 2017)
Obviously, there is more information and statistics about Opioid use in the elderly. Half of the internet could be filled with the complex reasons of how the epidemic began but that is hardly useful information. The most useful intervention that a visiting clinician can employ is common sense which is exceedingly uncommon in healthcare. Consider the following:
- Blind adherence to CDC guidelines is causing some patients who have been on large doses of narcotics for years to have their doses abruptly dropped by a significant level. This Huffington Post Story tells the story of Jay Lawrence who had his pain medication reduced by 25%. Shortly before the next pain management visit, when he expected that his dosage would be reduced again, he committed suicide. If a visiting nurse or therapist had been in the home, they could have tried to intervene by documenting the patient’s history including prior and current abilities. Although awkward, the CDC guidelines should have been reviewed with the physician as he appeared to be following guidelines for patients new to narcotic pain relievers.
- Disabuse yourself of the notion that narcotics given for legitimate pain do not cause addiction. Many of you will be insulted by this tidbit of advice but this information was shared with healthcare providers for years by pharmaceutical sales people. In fact, there is no ICD-10 code for addiction – only for dependence which occurs after taking the medication for a prolonged period of time regardless of the reason.
- Do not hesitate to code an F11 code if you have physician documentation.
Assess the patient completely for pain remembering that assessment is more than interview. For years, we were told by very respectable organizations that the patient’s pain was what the patient said it was. That’s not always true. A full assessment includes observation of the patient’s ability to participate in daily activities, assessing sleep patterns, appetite and nonverbal behaviors such as grimacing, inability to focus on what you are saying and guarding the area the area where the pain is. Ask family members when present during assessments if the patient shows signs of pain during the evening or in the mornings when getting out of bed.
- The blind adherence to CDC guidelines has physicians focusing on the amount of opioids ordered but they seem to be oblivious to the recommendation that they find treatment and/or support for patients who may have a serious problem. The physician is more likely to refer a patient for help if you have suggestions handy. Waiting for an order takes much longer than asking for an order for a referral to specific providers.
- If your patient has been abruptly cut off or has had a sharp reduction in pain medication, be aware that suicides increase dramatically after the cessation of opioids. Depression is part of the withdrawal process and can be intolerable for patients who have an existing diagnosis of depression.
- Include both long term and short term effects of opioid pain relief. This is especially valuable for patients who do not take opioids on a regular basis but are undergoing a procedure that will leave them with pain. Help them set realistic pain goals. Teach your patient that pain medications should reduce the pain to where it is tolerable but can cause falls, confusion and impaired judgement. Long term, speak to the idea of tolerance to the medication and dependence. Reassure them that problems do not occur if they take pain meds infrequently for a short period of time and return to tylenol or NSAIDs as soon as their physician allows. Teach caregivers to wait until the patient asks for the medication instead of giving it routinely.
- Visiting clinicians probably see diversion more than most other healthcare providers. If there is any suspicion of diversion, ask the pharmacy to dispense only a week at a time so that missing medications will become obvious sooner if that is allowed in your state. Alternatively, ask for two pill bottles and keep only seven days worth and (with the patient’s or trusted caregiver’s knowledge) hide the remainder. If you know with reasonable certainty that medications are being taken from a patient, call elderly protective services and allow them to investigate. If there is doubt about why pills are missing, call in the social worker.
The extremists on either side of the opioid crisis are costing money and in some cases, lives. Complications from opioid use have resulted in opportunities to create new laxatives specific to Opioid induced constipation that are priced upwards of 350.00 per month. The sexual performance pharmaceuticals are also benefiting as patients suffering Opioid induced sexual dysfunction need a little boost. Falls in the elderly taking opioids are common and should a hip be broken, there is a 25 percent chance that they will not be alive in six months.
And yet, there is no feeling more powerful than shooting some morphine into the veins of a patient suffering from kidney stones. Hospice patients have a better quality of life with opioids and they are very useful for fracture and burn patients. Make no mistake. Opioids have their place as do antihypertensives, diabetic medications, etc. but they need to stay in their place. Patients should be cautioned about taking opioids for chronic pain unless all other avenues of pain relief have been explored and nurses and therapists need to be honest and unreserved in their teaching of medication safety.