February Journal Club

[katevaughn]

February’s journal club is presented by Jessica Switzman. She chose a great editorial that explores the current opioid crisis going on in the United States. It outlines the current impact this crisis is having on our healthcare system and offers recommendations and ways that the CRNA can help. This is a hot topic right now and this editorial offers excellent insight. Enjoy!



Here is a link to the article. 

Questions to encompass within your discussion:


1. Describe how the medical community contributed to the opioid crisis; do you believe we are at fault?

2. Point out two ways Nurse Anesthetists can help reduce the use of opioids.

[Ben Waldbaum]

1.) Of course the medical community contributed to and continues to contribute to the opioid crisis. Pain as the 5th vital sign should never have been allowed. The author is absolutely correct that this lead to over treatment of pain with narcotics and under utilization of non-opioid medications or other modalities such as PT, biofeedback, CBT, acupuncture, and many others. Opioids have no role in chronic pain, only acute pain.

2.) First and foremost, increase the use of non-opioids. Also, discuss pain with patient and that it is normal and the goal is control it, not eliminate it and the role of other modalities mentioned above in controlling it.

[BrittneyKeating]

1. Describe how the medical community contributed to the opioid crisis; do you believe we are at fault?

This was a great article to bring attention to the current opioid crisis that our nation is experiencing. I found it interesting how the article detailed the history of the epidemic, particularly how increased attention to pain management was initially altruistically driven beginning in the 1980s, followed by more profit-driven and reimbursement-driven motivations beginning in the early 2000s by efforts of the pharmaceutical industry and insurance regulations. The article describes contributing factors to this epidemic as being 3-pronged: 1.) “Poorly developed published evidence,” 2.) Altruistic factors being a “push from well-meaning healthcare systems” and advocacy groups, 3.) “A strategically directed campaign from profit-driven pharmaceutical companies.”
I find the following two discussion points in the article as having highlighted how the medical community made error: 1.) establishing practice changes based on publications which were poorly developed, filled with conflict of interests and misrepresentations & 2.) Insurance companies (CMS) and TJC creating a system that incentivized practitioners to be overly aggressive in pain management in order to maintain accreditation and reimbursement.

2. Point out two ways Nurse Anesthetists can help reduce the use of opioids.

The main method I can see Nurse Anesthetists reducing the use of opioids is by way of education. That being academic institutions increasing curriculum focus on pharmacologic (opioid and non-opioid) and non-pharmacologic modalities for the treatment of pain, including greater focus on regional and peripheral nerve block education in Nurse Anesthesia programs.
Additionally, Nurse Anesthetists can have an impact on reducing use of opioids by educating patient’s on pharmacologic modalities other than opioids that can be useful for patients in the perioperative period. This patient education may be best achieved in the pre-operative period as post-op and follow-up education services are limited by the CRNA due to time restraints and practice models.

[ashleybroyles]

1. Describe how the medical community contributed to the opioid crisis; do you believe we are at fault?
As a young nurse I was taught to lecture my patients on how they could not get addicted to opioids if they were truly in pain. At that time I believed I was helping them as I encouraged their pain medication consumption. Fast forward to present day and we can see a direct correlation between opioid consumption and addiction. The medical community normalized narcotic use to the point where we thought it was abnormal if our patients did not want them. The over prescription of outpatient narcotics has left medicine cabinets full of unused pills. Furthermore, the lack of non-opioid pain management techniques left patients thinking there were no other options. When hospital reimbursement began being tied to pain management, it left bedside clinicians with little choice than to make sure their patients had as many narcotics as they desired before discharge. This did not leave much room for non-pharmacologic management of pain in the hospital.
2. Point out two ways Nurse Anesthetists can help reduce the use of opioids.
Decreasing the amount of intraoperative opioids, providing realistic education to our patients, and getting the entire surgical team involved are all ways Nurse Anesthetists can reduce the use of opioids. Nurse anesthetists are at the front line of the opioid epidemic because we are often the first to talk to the patients about the medications they will receive and how they will feel in the perioperative period. Furthermore, we will be giving patients their first narcotics and often are prescribing postoperative pain relief. As nurse anesthetists we have the obligation to be involved in enhanced recovery protocols to decrease the amount of narcotics and try to reduce the amount of time the patient is in the hospital at the same time. We are making the decisions on how much narcotic versus non-narcotic pain relief we are providing in the operating room. Communicating with the surgical team for local anesthetic and regional anesthesia is also an extremely vital role for us.

[amandaeggert]

1. Describe how the medical community contributed to the opioid crisis; do you believe we are at fault?

I believe the medical community along with other factors contributed to the opioid epidemic. Although there were good intentions from the medical community and healthcare systems along with advocacy from pain groups, there was poorly developed published evidence, and profit-driven pharmaceutical companies contributing to increased opioid use. In addition, the Joint commission and the Centers for Medicare and Medicaid Services linked pain control to accreditation and reimbursement, incentivizing overly aggressive pain management.


2. Point out two ways Nurse Anesthetists can help reduce the use of opioids.

CRNAs can help reduce the use of opioids by decreasing the use of opioids and increasing the use the use of non-opioid analgesics when appropriate. We can also educate not only the patient but their family members of proper pain management. It was addressed in grand rounds that many times patients with opioid addiction are obtaining them from someone else with a prescription. Working in collaboration with the surgical team to provide education on post-op pain control and opioid use as well as prescribing the minimum amount of post-op opioids and educating patients on proper disposal of unused opioids will help to decrease their use.

[Faresha Sims]

1. The medical community contributed to the opioid crisis when our community was discouraged from using discernment if a patient displayed drug-seeking behaviors and/or opioid abuse. Anther way the medical community contributed is by opioid overprescribing.

2. Nurse Anesthetists can help reduce the use of opioids by advocating for responsible prescribing practices and support legislative efforts to mitigate the opioid crisis epidemic. 

[LarSharVeA Bennett]

Had the war on drugs in the 1970s evolved more valiantly, we would have a stronger blueprint on fighting the war on opioids. Anyway, I digress. The medical community has contributed to the opioid crisis in enumerable ways. It seems as though history had been ignored as we began to see an increase of opioid prescription and use in the 80s; largely, propelled by the gains of pharmaceutical companies as well as an evolving culture that sought to please patients rather than do what was right by them.

As CRNAs, we can increase the use of adjuncts. We should also tailor pain management such that we are cognizant of those patients with a history of opioid and drug abuse to mitigate contributing to relapse or even aiding and abetting the abuse. I was perturbed to read that JCAHO essentially rewarded over aggressive pain management with accreditation. The AANA needs to be on the front lines fighting against such legislation, we need to pay our dues to support those efforts, and with our pens, paper, and/or presence, we should all stand up against laws, rules, or standards that we know will harm our communities and our patients.

[Kristen Praesel]

1. Describe how the medical community contributed to the opioid crisis; do you believe we are at fault?

In the late 90's, there was a push for routine pain assessment making pain the fifth vital sign. Drug companies also pushed for pain management to be the standard of care and the Joint Commission added standards of care to improve pain management in the 2000's. In 2011, the Joint Commission added non-pharmacologic methods to support pain control to pharmacologic methods. This push has produced an expectation to be pain free among patients (and often times providers) rather than the goal of pain control. As members of the medical community, we should take some responsibility in this crisis as we are the ones prescribing medications and administering the medications to relieve pain.

2. Point out two ways Nurse Anesthetists can help reduce the use of opioids.

Nurse Anesthetists can help to reduce the use of opioids by delivering an opioid sparing anesthetic that involves the use of multi-modal pain treatment options (including non-opioids) in addition to minimum effective dose opioid treatment. Nurse Anesthetists can also educate their patients regarding pain management and pain control (rather than pain free) in order to set realistic expectations of pain management in the postoperative period.

[krechti1]

1. Describe how the medical community contributed to the opioid crisis; do you believe we are at fault?

The medical community contributed to the opioid crisis in part by overprescribing opioids for pain management. Before this turned into an epidemic, many providers thought it was easier to prescribe a large amount of opioids for their postoperative patients to avoid calls and pages regarding refills and/ or pain control issues. For example, even though it may be reasonable to prescribe 15 pills of oxycodone for a postop tonsil, a surgeon may prescribe 60 pills to make a patient happy, and ensure they do not call back. The remaining pills may either be taken by the patient, leading to addiction, or given to a family member or friend, leading to addiction.

2. Point out two ways Nurse Anesthetists can help reduce the use of opioids.

CRNA's can 1) do a thorough preop assessment and identify any existing or potential risk of opioid addiction and 2)minimize the use of opioids by using multimodal pharmacolologic agents and regional anesthesia when appropriate.

[klinden2]

Its easy to blame JHCHO for the 5th vital sign campaign, but drug abuse has been around for centuries. None of us like our patients to have pain, so we give increasing amounts of narcotics. Our surgeons and general practitioners have also fallen into this rut, let's not forget our dental colleagues. The amount of medication prescribed far exceeds the amount of pain a patient should have. Whatever happened to preemptive narcotics, front loading of narcotics? Few patients had much pain with these techniques.

CRNA's can help reduce the use of opioids by using the multimodal techniques, opioid sparing techniques - the use of precedex, gabapentin, Tylenol, NSAIDS. Education is always a great answer, however, I think this has to come from the prescriber. We need to focus on educating the surgeons, general practitioners, dentists etc, who are likely to prescribe incredible amounts of postop pain meds, instead of using non-opioid options.

[nanci]

1. Describe how the medical community contributed to the opioid crisis; do you believe we are at fault?
Pharmaceutical companies peddled their opioids and campaigned for their use to help relieve pain (and made so much money from this). CMS linked reimbursement to pain management satisfaction (so Hospitals encouraged and demanded increased pain management satisfaction so they could get reimbursed/money). Joint Commission to improve pain management initiated standards of care which medical community follows so they can get reimbursement and not be shut down or pay fines. So yes, the medical community contributes to follow the direction that policy and procedures take them.
All linked together to help create and sustain an opioid use/misuse system that expands and has gotten out of control bringing it into the news and making more people aware of what has happened.


2. Point out two ways Nurse Anesthetists can help reduce the use of opioids.
a)Use non-opioid analgesics and assess our own practices. Our ERAS procedures have helped to develop protocols to decrease use of opioids and still manage patient's pain.
b)Education and patient advocacy, referrals to expert social work and addiction experts when working up patients with pain management issues to better assist them. Educate to realistic pain management parameters (not to have no pain but find out what pain score is tolerable for them and work from there). Maintain our own education and refresher on opioids, non-opioid analgesics and stay current on best use of what is available to us.

[mdougla5]

1. Describe how the medical community contributed to the opioid crisis; do you believe we are at fault?

As a person of color, the "opioid/drug" problems is a multigenerational problem that has effected the "urban" communities, and those communities comprised predominantly by people of color. In the 1990s, I was a drug and alcohol counselor and witnessed first hand the separation of families, homelessness, and unemployment due to untreated drug addictions. Unlike today, this population has been viewed as having inherent flaws and labeled as lazy and irresponsible, unlike the "opioid epidemic" population of today. However, I cannot recall a client who wanted to lose their children to this disease or who did not want to better their lives for themselves and their families. Our country has historically viewed addiction as a crime and not a disease. The Violent Crime Control and Law Enforcement Act of 1994 mandated life sentences to those who were convicted of two or more drug crimes. Sadly enough, many of the perpetrators of these drug crimes were addicts attempting to medicate themselves and to lessen their own physical suffering.

As the article states, the 1980s reflected a boost in opioid prescribed in an attempt to treat patients experiencing pain. For this reason, I feel that the medical community contributed to the past and present drug epidemic. People will find a way to treat their pain. If they cannot receive relief from their providers, they will turn to illicit drug use to manage their symptoms.

Today, however, the epidemic has now spread to "small-town communities" and the financial implications have been devastating on the economy. These reasons appear to have served as a catalyst for the renewed societal drive to support those suffering from drug addiction and to prevent the spread of the epidemic.

2. Point out two ways Nurse Anesthetists can help reduce the use of opioids.

One way that CRNAs can help to reduce the use of opioids is to conduct a careful preoperative patient evaluation to identify existing or potential drug addiction. A second way to help reduce the use of opioids is to use a Multi-modal approach to pain management. Never the less, our job is to serve as an advocate for our patients and meet them where they are. Some patients have a higher tolerance for narcotics. And, because addiction cannot be created nor treated in one day, it would never be in our patients best interest to undertreat their pain in the perioperative area for fear of worsening their opioid requirements.

[Angie Brooks]

1. Describe how the medical community contributed to the opioid crisis; do you believe we are at fault?
For years pain has been rated and opioids distributed based on the patients pain score. "Pain is what the patient says it is. Make sure you get the patients pain score down to their acceptable rating." We as a healthcare system have encouraged patients to take pain medications until they are pain free. I witnessed a nurse trying to "push" pain medications on a patient that clearly stated they did not want the medication. She continued to insist that the patient needed to take the medicine because they would be in pain even thought he clearly stated numerous times that he did not want narcotics.
Doctors continue to fill prescriptions for pain medications well beyond the acceptable time frame instead of giving alternative methods for pain management. Also after surgery, doctors are writing presciptions for increasing numbers of tablets for post op pain control that are not necessary. These left over pills are available to the patient and their family, friends, etc. This allows for medications in circulation that are unregulated.

2. Point out two ways Nurse Anesthetists can help reduce the use of opioids.
As Nurse Anesthetists we are able to find other modalities of pain control. The ERAS protocol allows for decreasing amounts of opioid use by performing blocks, and utilizing anti-inflammatory medications when able.
We are also in a position to help educate other nursing professionals in the use of alternative methods of pain control. We do need to treat pain however, we should also be attempting to equip our patients with many ways to relieve their discomfort.

[Jocelyn Datud]

1. Describe how the medical community contributed to the opioid crisis; do you believe we are at fault?
There are several factors such as social, educational, and economic factors that can contribute to opioid crisis. Specifically, our medical system has a great impact on it as well. Working in the Emergency Room for a while, I witnessed how certain patients will try to manipulate their symptoms to be able to request for narcotics. Some would even jump from one hospital to the other just to have the opportunity to have access to pain medications. Since pain is a very subjective data and because of the drive for higher patient satisfaction, oftentimes providers are obliged to "treat" the pain and prescribe narcotics. But recently, physicians now have a system where they can pull the patient's name and track the prescriptions that they received which I believe is very essential in monitoring and controlling prescribed drugs.

2. Point out two ways Nurse Anesthetists can help reduce the use of opioids.
As Nurse Anesthetist, we can greatly help reduce the use of opioids. First, by listening to our patients- assess their pain history, know what medications work and doesn't work for them. Have a discussion with them with regards to the pain level that they will be having and how you are going to treat them. Next is incorporating multi-modal analgesia in our practice. As nurse anesthetist, we have a huge access to different medications- take advantage of it and continue to read/research about these drugs.

[Chuck Eder]

1. The medical community can shoulder some of the blame for the opioid crisis. Over prescribing opioids post op have led to the over use and misuse of prescription pain meds. This has impacted many patients and even their loved ones. The years of simply writing pain med scripts from "recipe" formula instead of tailoring it to actual patient needs has greatly impacted the opioid crisis.

2. CRNAs need to help educate patients and providers about better ways to treat pain using non opioid methods. Other meds such as acetaminophen and NSAIDS can be effective. Physical therapy and acupuncture can be possible other ways of finding relief. Also, CRNAS can change their practice a bit by advocating for preop meds (acetaminophen, gabapentin, celebrex) and possibly regional techniques if applicable. The medical community has helped to create the opioid crisis, now they need to be a major player in finding solutions.