Michigan: Pain and Symptom Management for Nurses

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As a professional, you will learn that pain is a subjective, complicated symptom that afflicts every human at some point in their lives. Managing pain within healthcare settings is a challenge and must take into consideration patient-centered preferences, treatment goals, as well as guidelines and laws from governing bodies. For many years, opioids were the first line of defense against acute and chronic pain conditions. With the opioid crisis, this mindset has been required to change.  In this Michigan: Pain and Symptom Management course, you will be equipped with a fresh mindset regarding the types of pain, and how to treat them.

Epidemiology of Pain

Pain is a subjective, complicated symptom that afflicts every human at some point in their lives. Managing pain within healthcare settings is a challenge and must take into consideration patient-centered preferences, treatment goals, as well as guidelines and laws from governing bodies. For many years, opioids were the first line of defense against acute and chronic pain conditions. With the opioid crisis, this mindset has been required to change.  

Due to an overabundance of prescribing opioids, the opioid related death toll has continued to rise. Not only has this fatal epidemic resulted in untimely deaths for many, but it is also estimated that "For every 1 prescription opioid death, there are 20 specialty substance abuse treatment admissions, 45 emergency department visits for nonmedical use and adverse events, 156 people with substance use disorder and dependence, and 533 people using the drugs nonmedically overall" (1).  

This public health crisis has resulted in the conviction of pharmaceutical companies that were behind the political stronghold monopoly on pain management in America. As a result, the Federal government has collaborated with The Institute of Medicine (IOM) and the Centers for Disease Control (CDC), among many other experts in the field, to develop a plan that protects the American public from unintended opioid use and promotes a multi-disciplined, multi-modal approach to combating pain in America.  

Michigan: Pain and Symptom Management Statistics

Pain is a widespread public health concern that reaches every corner within America. In a 2011 report titled, Relieving Pain in America: A Blueprint for Transforming, Care, Education, and Research, the IOM revealed that pain affects nearly 100 million Americans and nationally costs upwards of 635 billion each year (2). Of these numbers, over 25 million American adults report that they suffer from pain daily, while 23.4 million state a significant amount of pain (3).  

Researchers gathered data from 8,781 American adult participants regarding individual perceptions of their overall health, underlying illnesses, and pain experiences within the previous three months. This study ranked pain on a scale of categories from one through four, with one being the least amount of pain, and four being the highest level of pain.  

From this data, it is estimated that almost 40 million individuals ranked themselves as living with pain at a category three or four. Individuals in these categories were also found more likely to have an accompanying disability, access healthcare on a more frequent basis, and have an overall worse quality of health and life (4). 

What is Pain and Why Does it Occur? 

Merriam-Webster defines pain as "a localized or generalized unpleasant bodily sensation or complex of sensations that causes mild to severe physical discomfort and emotional distress and typically results from bodily disorder (such as injury or disease) (5)".  

Pain is the body's defense to achieve a response against further damage from a perceived threatening stimulus. The brain perceives pain via specific pathways. Four stages of pain transmission occur: transduction, transmission, perception and modulation (6). 

Receptors within afferent fibers are activated when a potential threatening stimulus occurs. This initiates three stages of pain perception. Initially, pain sensitivity is triggered. From there, signals follow a network of peripheral neural pathways towards the spinal cord. Within the spinal cord is the dorsal horn, which contains neurons that translate and relay information about the painful or irritating peripheral stimulus to the thalamus and cortex to elicit a protective response (6,7). 

Pain can be further distinguished within two frameworks, chronic and acute, and by pain related conditions, such as inflammatory responses, nociceptive, and physiological dysfunctions.  

Michigan: Pain and Symptoms Management for Nurses - Identifying Types of Pain

Pain is classified by three distinct types: nociceptive, inflammatory, and neuropathic. Following are general descriptions of the types of pain; however, it must be noted that these pains can overlay each other and be occurring simultaneously.  

Nociceptive pain is that which is due to nerve impairment or injury and is the most common type of pain that occurs. It is sometimes noted as being central pain that is caused by repeated, potentially or harmful stimuli. The nociceptors activated in this type of pain are spread throughout the body within internal organs, bones, joints, and the integumentary system (6).

Nociceptive pain is generally described as radicular, somatic, or visceral depending on the nerve involvement. Examples of nociceptive pain include the sensation from touching a hot object, a broken arm, or a paper cut at the initial time of injury. It may also describe pain caused by cancer, arthritic changes, and ischemic pain that does not originate from nerve injury. 

Inflammatory pain is part of the cascade of sequelae that makes up the immunological defense to damage caused by heat, toxins, trauma, foreign substances, or infection. Neutrophils, along with prostaglandins, histamine, and other chemical mediators flood the location of injured tissues as a part of the bodies normal, inflammatory response. Classic signs include erythema, edema, and heat at the site of injury (6). Inflammatory pain can be seen in cases of an ankle sprain, cellulitis, and allergic reactions.  

Neuropathic pain is also often associated with a phenomenon called allodynia. Allodynia is the sensation of pain from an activity or event that is typically not associated with causing pain. Rather than being the result of a physiological event, neuropathic pain is pathologic in nature.

According to Yam, Loh, Tan, Adam, Manan, and Basir (2018), “This condition can be described as “pathologic” pain, because neuropathic pain actually serves no purpose in terms of defense system for our body, and the pain could be in the form of continuous sensation or episodic incidents” (6). It is thought to be caused by disorders affecting the peripheral or central nervous system and is linked to diseases that cause nerve damage such as trauma, toxins, diabetes, as well as certain viral infections, such as herpes zoster.

Chronic Pain vs Acute Pain

Acute pain is that which is short-term and self-limiting. The timeframe of acute pain is based on the expected healing process of the injurious event and may be up to six months. Chronic pain lasts beyond the expected period of healing or is recurrent.

Acute pain can usually be attributed by a defined contributing factor or event, such as appendicitis or a broken bone. Chronic pain can be related to a myriad of causes or the etiology may be unknown (6).

In clinical settings, pain lasting more than three months is typically used to define the transition from acute to chronic. As such, chronic pain must be treated and managed differently than acute pain. 

Michigan: Pain and Symptom Management for Nurses -

Risk Factors

Several risk factors have been identified that make it more likely for an individual to experience chronic pain. In general, age influences the prevalence of chronic pain by population, with those age 18 to 39 having an increased prevalence of chronic pain. This may be due to other age groups under-reporting. Those over 80 were found to report acute pain more often but were less likely to acknowledge chronic pain when asked. As well, cognitive decline, dementia and other age-related diseases must be considered as factors when collecting data. Chronic pain after surgery is reported at a higher rate amongst adolescents (7). 

Chronic pain is more likely to be experienced and reported by females over males. However, studies have shown that women experience pain differently than males at a lower threshold. Women have been found to be more likely to seek treatment for pain (7,8). 

Certain co-morbidities have been identified that are linked to an increase of chronic pain. Almost 90% of patients reporting chronic pain have significant co-morbidities. Co-morbidities with the highest link to chronic pain are cardiovascular and respiratory diseases and depression. The link between chronic pain also affects mortality rates. In those reporting severe chronic pain, the 10-year survival rate is decreases significantly. At ten years, those reporting severe chronic pain are twice as likely to have died from ischemic heart disease or respiratory disease than those with little to no pain (7). 

Depression and anxiety are reported at a rate four times higher in individuals with chronic pain than those living without pain (7). Specific conditions that have a higher rate of being linked to mental health disorders include (all from 8): 

• Arthritis 
• Fibromyalgia 
• Back/Neck pain 
• Chronic migraines 
• Menstrual-related pain
  

Other factors that have been found to influence the prevalence of reported chronic pain include (7,8): 

• Poverty 
• Self-identify as minority 
• Obesity 
• Manual labor occupations 
• Unemployed 
• Smoker 
• Alcohol use 
• Lack of physical activity 
• Poor nutrition 
• Low levels of Vitamin D 
• Post-surgical and medical interventions 
• Sleep Disorders

Physical and Psychological Elements of Pain

Pain elicits a response from the sympathetic nervous system (SNS) leading to signs and symptoms affecting all systems of the body. The following are some of the physical effects that pain may cause within each individual system. 

With the sensation of pain, the cardiovascular system anticipates an event that is threatening. The SNS produces a rush of adrenaline and cortisol that results in tachycardia, hypertension, and increased oxygen demand. The respiratory response includes elevated breathing that is shallow. The cortisol levels affect the endocrine system, resulting in a surge of glucose by triggering a release of glucagon from the liver that will keep up with the demands needed for the fight or flight response.

In contrast, with chronic pain, continued elevated cortisol levels may lead chronic hyperglycemia. The gastrointestinal system slows gastric motility which may lead to nausea, vomiting, and constipation. Chronic pain may lead to an increase in gastrointestinal discomfort, including irritable bowel syndrome. The urinary tract reacts to stress with oversensitivity leading to an increased urgency to urinate and, in some cases, incontinence (7).  

Physical indications of pain from the musculoskeletal system are displayed via piloerection, tremors, and muscle tension and rigidity. The nervous system reconfigures with the processing of pain and attempts to adapt to the additional stresses. Repeated episodes of acute pain can increase the risk of an individual developing chronic pain.

Cumulatively, the stresses and changes that occur on these systems have a negative effect on the immune system. The immune system is unable to keep up with the demands and becomes desensitized to repeated inflammation culminating in a lowered immune response. The lowered immune response then poses an increased risk of infection for the individual (5).

Pain Management

As guidelines have changed due to the opioid crisis, new evidence published by the CDC suggests that opioid dependency can occur in as little as a ten-day course of treatment. In addition, the American Pain Society and the American Society of Anesthesiologists have released guidelines that stress a multi-modal approach to pain management in the operative and recovery setting. Of the recommendations, the following were released as having high-quality evidence and strongly recommended (as cited in 8): 

“. . . that clinicians offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in children and adults” 

“. . . that clinicians provide adults and children with acetaminophen and/or non-steroidal anti-inflammatory drugs (NSAIDs) as part of multimodal analgesia for management of postoperative pain in patients without contraindications” 

“. . . that clinicians offer neuraxial analgesia for major thoracic and abdominal procedures, particularly in patients at risk for cardiac complications, pulmonary complications, or prolonged ileus” 

“. . . that clinicians consider surgical site-specific peripheral regional anesthetic techniques in adults and children for procedures with evidence indicating efficacy”. 

The shift has moved from starting patients on opioids after surgeries or other pain inducing procedures, to treating pain using the multi-modal approach which stresses using alternatives to opioids as the first line of defense. After the information detailed in this Michigan: Pain and Symptom Management course, we can defer to the CDC as your source of information regarding main management medications. The CDC further recommends and advises (8): 

“Nonopioid medications are not generally associated with development of substance use disorder. The number of fatal overdoses associated with nonopioid medications is a fraction of those associated with opioid medications. Nonopioid medications are also associated with certain risks, particularly in older patients, pregnant patients, and patients. With certain comorbidities such as cardiovascular, renal, gastrointestinal, and liver disease.

Nonpharmacological treatments can reduce pain and improve function in patients with chronic pain. These treatments can also encourage active patient participation in the care plan, address the effects of pain in the patient’s life, and can result in sustained improvement in pain and function with minimal risks. If opioids are used, they should be combined with nonopioid medication and nonpharmacological treatments, as appropriate.”

Pharmacological Pain Treatments

Opioids may be used for moderate to severe acute or chronic lower back pain, osteoarthritis, and neuropathic pain. Studies showing long-term efficacy are extremely limited. Opioids are suggested only after other non-opioid and non-pharmacological therapies have failed to provide relief. This class should be used with caution as may induce sedation, respiratory depression, nausea and vomiting, and constipation.  

Short Acting 

• Codeine 
• Hydrocodone/acetaminophen or ibuprofen 
• Oxycodone/acetaminophen or ibuprofen 
• Hydromorphone 
• Morphine 
• tramadol

Long Acting 

• Fentanyl 
• Hydrocodone 
• Methadone 
• Morphine 
• Oxycodone 
• Oxymorphone 
• Tapentadol
  

Anticonvulsants may be used for fibromyalgia, diabetic and other neuropathies, and neuralgias. Use with caution as significant drug-drug reactions have occurred. Dosing should be adjusted for renal impairment. May cause sedation, dizziness, dry mouth, weight gain, and edema. 

• Gabapentin 
• Pregabalin 
• Carbamazepine 
• Valproic acid
  

Antidepressants are commonly prescribed for fibromyalgia, low back pain with radiculopathy, migraines, neuropathies and neuralgias, and chronic musculoskeletal pain. Patient must be monitored for mood changes and is at an increased risk for suicide. Other side effects may include sedation, urinary retention, dry mouth, weight gain, and blurry vision. Cardiac patients must be monitored for arrythmias and blood pressure changes. 

Tricyclic Antidepressants 

• Amitriptyline 
• Desipramine 
• Nortriptyline
  

Serotonin-Norepinephrine Reuptake Inhibitors 

• Duloxetine 
• Milnacipran 
• Venlafaxine
  

Muscle Relaxers are effective for acute lower back pain and fibromyalgia. These may cause sedation and dizziness. Caution must be used when operating a car or machinery. Common muscle relaxers that may be prescribed include:

• Carisoprodol 
• Cyclobenzaprine 
• Metaxalone 
• Methocarbamol 
• Tizanidine
  

Topical agents are particularly helpful for osteoarthritic and rheumatoid arthritic pain as well as neuropathies. May be used for relief of sprains, strains, and back pain. The following are topical agents that may be found over-the-counter:

• Capsaicin 
• Diclofenac Topical Gel 
• Lidocaine 5% patches 
• Menthol/Salicylate
  

Non-Steroidal Anti-Inflammatory Drugs(NSAID)  may be used to treat backache, joint pain and inflammation, headache, arthritic pain, muscle aches and strains, and menstrual cramps. Caution to be used in patients with liver or kidney disease and alcohol misuse. NSAIDs may cause gastrointestinal discomfort or bleeding. Use with caution if patient in on anticoagulation therapy. Prescription and non-prescription NSAIDs include:

• Ibuprofen 
• Diclofenac 
• Indomethacin 
• Meloxicam 
• Naproxen 
• Celecoxib 
• Aspirin
  

Acetaminophen remains one of the most prescribed pain relievers for headache, backache, muscle ache, and joint pain. Caution must be used with liver disease and alcohol misuse. Dosage must not exceed 3,000 – 4,000 mg/day. 

Interventional Treatments include epidural or intraarticular glucocorticoid injections and arthrocentesis. Michigan: Pain and Symptom Management for nurses students should always defer to the CDC for up-to-date information on interventional treatments.  The CDC recommends these for short-term treatment of inflammatory diseases such as rheumatoid arthritis, osteoarthritis, rotator cuff disease and other radiculopathies.  

Adapted from (8).

Non-Pharmacological Treatment 

The CDC provides many strategies for healthcare providers to manage the challenges of patient pain control in a manner that lessens the need for opioid use and provides alternative options. Primarily, a patient-centered approach to treatment is now the gold standard and should include patient engagement.  

Suggestions and strategies to incorporate patient cooperation and engagement with their pain management plan include (all from 9): 

• Use reflective listening by maintaining eye contact, empathizing, and confirming understanding 
• Set agreed upon, reasonable and achievable goals 
• Discuss treatment options using a multi-modal treatment plan
  

As part of a multimodal therapy in treating pain, the CDC highly recommends incorporating exercise along with other psychologically based approaches into care. These may include: 

• Physical and occupational therapy and exercise such as swimming, yoga, walking, free weights, and other strength training. This can improve strength and posture, which may provide relief from lower back, hip, and osteoarthritic pain, improve fibromyalgia symptoms, and has been shown effective in preventing migraines (9).
• Cognitive behavior therapy (CBT) is a psychosocial training technique that addresses modifiable situation factors and cognitive processes that may affect the experience of pain. CBT aims to provide coping techniques, relaxation methods, and may include self-help instruction, professional counseling, or support group attendance (9).
• Heat Therapy
• Cryotherapy
• Massage
• Ultrasound
• Transcutaneous Electric Nerve Stimulation (TENS) units
• Acupuncture
• Hypnosis
• Stress Management
• Chiropractic Manipulation
• Herbal Preparations
• Aromatherapy

Federal and Michigan Laws on Opioid Prescribing and Use 

In 2016, the CDC reported that over 40 Americans were dying each day due to prescription opioid overdoses. The opioid crisis has been attributed to the over prescribing of opioids for pain and non-pain conditions with a lack of oversight leading to a 400% increase in opioid prescribing and sales since 1999 (10).

In response, the federal government implemented an initiative to combat the issue with improved education, guidelines, and treatment management. In October of 2018, the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, a 660-page bill was signed into law.

This comprehensive, bi-partisan legislation aimed to provide funding and expand access to increase treatment availability through Medicaid and Medicare, expand alternative non-opioid pain management treatment, set guidelines for improved patient education, and identify best practices.  

Prescription-drug monitoring program and the use of electronic prescribing for Schedule II and III medications is supported by the Federal government and allows individual states to have primary control over authorization and enforcement. The following are the regulatory practices specific to Michigan (10,11).

Drug Classification and Schedule in Michigan

Under the Public Health Code, Act 368, state and federal agencies monitor certain drugs based on their risk of addiction, dependance, and abuse characteristics. These controlled substances are categorized based on a system of Schedules I through V. There are three criteria that determines the drugs category: acceptable medical use, potential for abuse, and the predictive value of dependance if it is abused (14). The schedules are as follows: 

Schedule I drugs are considered to have no appropriate medical use and have an extremely high potential for abuse. Examples of Schedule I drugs include: 

• LSD 
• Heroin 
• Bath Salts 
• Quaaludes
  

Schedule II drugs have a high potential for abuse and may lead to psychological or physical dependance. Examples of Schedule II drugs include: 

• Fentanyl 
• Demerol 
• OxyContin 
• Morphine 
• Codeine 
• Marijuana
  

Schedule III drugs have a high potential for abuse and may lead to psychological or physical dependence. Examples of Schedule III drugs include: 

• Acetaminophen with Codeine 
• Vicodin 
• Suboxone 
• Ketamine 
• Anabolic Steroids
  

Schedule IV drugs have a low to moderate potential for psychological or physical dependence but have a lower risk for abuse. Examples of Schedule IV drugs include: 

• Ativan 
• Xanax 
• Valium 
• Soma 
• Klonopin
  

Schedule V drugs are a low potential for physical or psychological dependence or abuse. Examples of Schedule V drugs include: 

• Gabapentin 
• Robitussin 
• Ezogabine 
• Phenergan with Codeine
  

Michigan Laws

In 2016, Michigan, along with 32 other states, recognized the dramatic increase in deaths caused by overdoses in the United States. Overdose had become one of the leading causes of accidental death in the nation. The Good Samaritan Laws were introduced to encourage quick response to potentially fatal overdoses with a decrease in the fear for legal repercussion. 

Michigan’s Good Samaritan Law

As stated by Michigan Department of Health and Human Services: 

During a drug overdose, a quick response can save a life. However, people illegally using drugs sometimes fail to seek medical attention during an overdose for fear of alerting the police to their illegal drug use. In order to prioritize saving lives, Michigan passed a Good Samaritan law in 2016. 

Michigan’s Good Samaritan law prevents drug possession charges against those that seek medical assistance for an overdose in certain circumstances. This law makes saving lives the priority during a drug overdose, not criminal prosecutions of illegal drug users (11). 

The following are pertinent Public Acts and Laws enacted starting in 2017 that were put into effect to support the efforts of tackling the opioid crisis. This also gives structure to primary care providers ability to prescribe opioids and decreases the accessibility of opioids through (all from 13): 

Public Act 246 of 2017

Disclosure of prescription opioid information with the risks to minors and patients is required, beginning 6/1/18. This act also includes the use of the Start Talking form. The form includes the patient’s information, type of controlled substance containing an opioid, signature of patient or guardian, and number of refills allowed. The form required that the provider shares the following information to the patient regarding the substance having potential for abuse (MDHHS-5730, Rev. 3-20): 

1. The risks of substance use disorder and overdose associated with the controlled substance containing an opioid.
2. Individuals with mental illness and substance use disorder may have an increased risk of addictions to a controlled substance. (Required only for minors.)
3. Mixing opioids with benzodiazepines, alcohol, muscle relaxers, or any other drug that may depress the central nervous system can cause serious health risks, including death or disability. (Required only for minors.)
4. For a female who is pregnant or is of reproductive age, the heightened risk of short and long-term effects of opioids, including by not limited to neonatal abstinence syndrome.
5. Any other information necessary for patients to use the drug safely and effective as found in the patient counseling information section of the labeling for the controlled substance.
6. Safe disposal of opioids has shown to reduce injury and death in family members. Proper disposal of expired, unused, or unwanted controlled substances may be done through community take-back programs, local pharmacies, or local law enforcement agencies. Information on where to return you prescription drugs can be found at http://www.michigan.gov/EGLEDrugDisposal.
7. It is a felony to illegally deliver, distribute or share a controlled substance without a prescription properly issued by a licensed health care prescriber.

Public Act 247 of 2017

Requires prescribers to be in a bona fide prescriber-patient relationship prior to prescribing Schedules 2-5 controlled substances. These provisions were due to take effect on 3/31/18, however the implementation date has been pushed back by Public Act 101 of 2018. 

Public Act 248 of 2017

Requires the review of MAPS prior to prescribing or dispensing to a patient a controlled substance in a quantity that exceeds a 3-day supply, beginning 6/1/18. Further, the act requires that a licensed prescriber be registered with MAPS prior to prescribing or dispensing a controlled substance to a patient, beginning 6/1/18. 

Public Act 249 of 2017

Provides sanction for failing to comply with the new MAPS usage mandates, failure to establish bona fide prescriber-patient relationships, and failure to inform patients regarding the risks associated with the prescription of opioid drugs. 

Public Act 250 of 2017

Requires health professionals that treat patients for opioid-related overdoses to provide such patients with information regarding Substance Use Disorder Services, beginning 3/27/18. 

Public Act 251 or 2017

Requires prescribers treating for acute pain to not prescribe such patients with more than a 7-day supply of an opioid within a 7-day period, beginning 7/1/18. 

Public Act 252 of 2017

Provides that before dispensing or prescribing buprenorphine or a drug containing buprenorphine and methadone to a patient in a substance use disorder program, the prescriber shall review a MAPS report on the patient, beginning 3/27/18. 

Public Act 253 of 2017

Codifies Medicaid coverage for detox programs, beginning 3/27/18. 

Public Act 254 of 2017

Requires the Prescription Drug and Opioid Abuse Commission (PDOAC) to develop for Michigan’s Department of Education (MDE) recommendations for the instruction of pupils on the dangers of prescription opioid drug abuse, by 7/1/18. 

Public Act 255 of 2017

Requires MDE to make available to school districts a model program of instruction on the dangers of prescription opioid abuse, developed or adopted by the PDOAC, by 7/1/19. Further, beginning in the 2019-2020 school year, MDE shall ensure that the state include within its health education standards, instruction on prescription opioid drug abuse. 

Public Act 101 of 2018

Pushes back the effective date for the bona fide prescriber-patient relationship requirement to 3/31/19, on the date on which rules are promulgated.

CDC Guidelines and Recommendations on Prescribing and Use

The CDC continues to promote guidelines initiated in 2016 to support the U.S. government’s initiative to curb the increasingly troubling deaths related to opioid overdose. These guidelines were aimed at assisting primary healthcare providers in effectively managing and treating patient’s pain while addressing health and safety concerns. In relation to opioid use, the guidelines revolved around three main principles (all from 8):  

1. Nonopioid therapy is preferred for chronic pain outside of active cancer, palliative, and end-of-life care. 
2. When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose. 
3. Providers should always exercise caution when prescribing opioids and monitor all patients closely. 

Drug Diversion Within the Healthcare System

According to the Drug Enforcement Administration, the most commonly abused drugs are among five classes and are frequently used in the treatment of pain. These include opioids, depressants, stimulants, hallucinogenic, and anabolic steroids. Of these, the opioid fentanyl is the number one drug that is found to be involved in drug diversion cases (14).  

When used outside of medical purposes, fentanyl has a very high rate of fatality. Far from being just a public problem, the diversion of drugs is a significant problem for healthcare organizations and abusers can be found at all levels, from the C-suite to frontline staff. There are several signs of drug diversion, including poor appearance, failing job performance, uncharacteristic behaviors for the individual, and accessing medication that is not required for their job (14).  

The Joint Commission offers these guidelines for monitoring to identify potential trends and patterns that may indicate the occurrence of drug diversion in the clinical setting (all from 15):

Schedule II – V
Substances Are Removed

• Without provider orders 
• Under patients not assigned to the nurse 
• Under patients that have been discharged or transferred 
• Excessively by one individual 
• Actions involved:

1. Substitute drug is removed and administered while controlled substance is diverted
2. Verbal order for controlled substances is created but not verified by prescriber 
3. Prescription pads are diverted and used to forge prescriptions for controlled substances 
4. Provider self-prescribes controlled substances 
5. Patient alters written prescription 
6. Unadministered medication that is documented as given to patient  
7. Wastes are not completed according to policy and procedures 
8. Multiple discrepancies or overrides are noted  
9. Patient’s report unrelieved pain, despite increasing documented pain medication administration 
10. Assistance is frequently offered to administer medications for other nursing staff 
11. Expired controlled substances go missing or are diverted from medication dispensing systems
    

Individual policy and procedure should be followed when drug diversion is recognized in a clinical setting with consideration to the safety of the patients and offender both addressed. The drug diversion should be reported to an immediate supervisor or manager. Nursing management should contact Quality Control and initiate a thorough root-cause analysis.  

Risks of drug diversion include transmission of blood-borne pathogens, patient safety compromised due to impaired healthcare provider, uncontrolled patient pain, and potential for healthcare provider overdose. 

The Joint Commission advocates for a “see something, say something” approach to combatting healthcare provider drug diversion. A plan to prevent drug diversion within the health care organizations should include three approaches: prevention, detection, and response. Additionally, they state “Detection of drug diversion is challenging, and even the best efforts have not yet achieved complete eradication of diversion. Patient and workplace safety require effective reliable safeguards to maintain the integrity of safe medication practices protecting against diversion. Diversion prevention requires continuous prioritization and active management to guard against complacency” (15). 

Risks of Opioid Use and Misuse

Opioids target mu receptors in the brain and spinal cord. Through inhibition of GABA, dopamine is released. Opioid’s increased risk for addiction is due to the increase of circulating dopamine which is associated with increased pleasure responses. Opioid use has been clinically linked to an increase in addiction as well as substance use disorder. Substance use disorder has been defined by the American Psychiatric Association (APA) as “. . . a problematic pattern of use of an intoxicating substance, leading to clinically significant impairment or distress” (16). Per the APA, this is calculated by at least two of the following characteristics (all from 16): 

• The substance is often taken in larger amounts or over a longer period than it was intended 
• There is persistent desire or unsuccessful effort to cut down or control use of the substance 
• A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects 
• Craving or a strong desire or urge to use the substance 
• Recurrent use of the substance, resulting in a failure to fulfill major role obligations at work, school, or home 
• Continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use 
• Important social, occupational, or recreation activities are given up or reduced because of use of the substance 
• Recurrent use of the substance in situations in which it is physically hazardous 
• Use of the substance is continued despite having knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance 
• Tolerance: a need for markedly increased amounts of the substance to achieve intoxication or desired effect OR a markedly diminished effect with continued use of the same amount of the substance 
• Withdrawal: characteristic withdrawal syndrome for that substance OR the substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms
  

A comparison study was performed based on information garnered in a 2016-2017 study group that focused on the use and misuse of opioids among individuals medicating with opioids inappropriately. This group was split into four categories and compared medical prescription opioid users AND prescriptions with the following: misusers without prescriptions, misusers of own prescriptions, and misusers with both types of misuse (14). 

Individual misusers without a prescription were typically younger, male, and unmarried versus misusers with prescriptions, whether using medically or misusing. It was found that misusers also had an alcohol disorder, used marijuana, and misused benzos and stimulants. As well, noted was that misusers were more likely to be nicotine dependent and to use cocaine and/or heroin (14). 

Prescription users were more likely to concurrently use prescribed benzodiazepines and stimulants. Depression among all misusers was higher compared with the medical users. The misuser also more commonly had received treatment from an inpatient mental health treatment center as well as had been prescribed a medication for a mental health condition. Overall, this group was not more likely to have a physical health condition (14). 

Perceived Barriers to Pain Management

As another consequence of the opioid crisis, a stigma has been cast upon individuals with chronic pain whether they are taking opioids or not. Healthcare professionals should be cautioned against projecting biases onto sufferers of pain as seeking pain medications for misuse reasons. As previously detailed, many patients experiencing pain have co-morbidities and are at a higher risk of having mental health issues in addition to pain.  

Barriers to non-opioid and non-pharmacological pain control may include insufficient medication regimen ordered to address patient’s pain, inadequate training, nursing workload, and a lack of collaborative approach by the healthcare team (17). Barriers to the use of non-pharmacological pain relief methods have been cited as (all from 17): 

• Inadequate training of personnel in how to examine pain and non-pharmacological control methods 
• Patients’ lack of cooperation in the use of non-pharmacological methods to relieve pain 
• Insufficient knowledge about non-pharmaceutical pain relief methods 
• Time-consuming methods of non-pharmaceutical pain relief 
• Nurse’s reluctance to use non-pharmaceutical pain relief methods 
• Failure to use non-pharmacological methods by the physician
  

The study found that with improved education, communication, and collaboration, improved pain management can be achieved by patients.  

Considerations and Interventions

Nursing care plans focused on pain management may be categorized by acute or chronic pain; however, the management and interventions are very similar for each. The outcomes should be specific to the patient presentation, disease process, and preferences (18).  

Pain Assessment and Screening Tools

Screening tools are one of the easiest and most effective ways to evaluate for pain. Some of the most commonly used tools in clinical care include (6, 18, 19): 

• Wong-Baker FACES Scale – may be used for children over the age of 3 and adults 
• FLACC and CRIES – used for infants 
• COMFORT Scale – May be used in children and cognitively impaired or sedated adults 
• Visual Analog Scale 
• Numerical Rating Scale
  

Pain should be also assessed by the patient reported characteristics using pain standardization scales such the McGill Pain Questionnaire. Some verbiage used to describe pain include (6): 

• Aching 
• Burning 
• Shooting 
• Stabbing 
• Throbbing 
• Tender
  

In addition to screening tools, the nursing assessment should include visualization of signs of pain that can include guarding or protecting certain areas of the body, facial changes such as grimacing or furrowing of brows, and other manifestations of pain such as restlessness, moaning, or crying (5).

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