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In 2018, West Virginia had not only the highest opioid-related death rate in the nation, but also the highest synthetic opioid-related death rate (46). In 2019, West Virginia ranked in the top 10 for opioid dispensing rates, with a rate of 59.4 per 100 persons being prescribed an opioid (10), which is well above the national average of 46.7 per 100 (9). While this number has consistently decreased since 2006, the numbers of individuals in West Virginia affected by addiction and overdose remains high (30). 

Introduction   

The opioid crisis in the United States continues to affect millions of individuals, families, and communities (2). In fact, it is estimated that over 16 million globally and 2 million people in the United States experience some sort of addiction to at least one opioid medication, causing several challenges for workplaces, health care facilities, and communities (3). The Centers for Disease Control and Prevention (CDC) identified that in 2021, there were 106,699 drug overdose deaths, an increase from years prior (1). The majority of drug overdose death involved at least one opioid (1).  

The National Institute on Drug Abuse (NIDA) identifies misunderstandings and misconceptions about addiction of prescription opioids, held by pharmaceutical companies and health care providers in the 1990s. These ideologies from the 1990s led to an increase in their use and subsequent rise in misuse and addiction. In 2010, deaths related to heroin began to rise quickly, and in 2013, deaths associated with synthetic opioids, like illicitly manufactured fentanyl, began to increase (4).   

The impact of opioid misuse and addiction is devastating to people and their families. Opioid misuse can lead to job loss, relationship difficulties, inability to care for children, financial challenges, and death. Families and caretakers who have a loved one struggling with opioid addiction may feel at a loss regarding handling or supporting their loved one, putting additional stress on the family unit. Arrest, conviction, hospitalization, and even death of a parent from opioid addiction, often place children in the care of the child welfare, further straining the system. Not only does the use of opioids impact individuals and families, but it puts additional strain on both state and national economies. It is estimated that misuse of prescription opioids costs the United States billions per year (4, 5).  

The West Virginia Office of Drug Control Policy has a state comprehensive response to the substance use disorder crisis (6). Recommendations of the West Virginia statewide response include improved treatment for neonatal abstinence syndrome (NAS), improved access to treatment, improved overdose reporting, improved access to opioid antagonists (like naloxone), improved access to job opportunities and financial resources, and improvement in pain management and prescribing practices (6). It is important to discuss The Opioid Reduction Act of 2018 in this West Virginia Drug Diversion course.  

The Opioid Reduction Act of 2018 requires health care providers to prescribe the lowest effective dose and limits opioid prescriptions to a four-day supply for an emergent or urgent care, a three-day supply for minor surgery or procedure, a three-day supply for dentist or optometrist, or a seven-day supply for patients seen by their primary physician or at discharge from a hospital (7).  

While West Virginia has taken steps to address the opioid crisis, more work is needed to meet the unique needs of patients, families, and health care workers (7). Health care providers who are not specifically trained to treat substance use disorders may struggle when working with patients who suffer from addiction, as there are often knowledge gaps related to these patients’ care. Gaps exist related to fully understanding the broad spectrum of a substance use disorder and in the identification of at-risk populations, such as homeless populations. Additionally, stereotypes about people using opioid medications still exist, which can inhibit health care providers from properly identifying and developing treatment plans for these patients (3, 5, 7). 

Many patients with substance use disorders are often able to hide their addiction from loved ones and providers for a period of time, which further complicates timely identification and intervention. Health care providers prescribing opioids and other medications that are high-risk for abuse should perform not only regular screening of at-risk patients, but they should also explore alternative methods for treating and managing chronic pain (3, 5). In an effort to address these concerns, the West Virginia Board of Nursing requires annual education for nurses who prescribe, administer, or dispense controlled substances (8).  

This course will address issues concerning the opioid crisis, including best practices for prescribing controlled substances, managing patients who divert, behaviors associated with drug seeking and substance use disorders, providing patient education on opioid use, storage, disposal, and reversal agents, as well as use of the West Virginia Controlled Substance Automated Prescription Program (CSAPP) (8). 

Epidemiology of Pain 

Pain is a complex problem (9). Due to the personal nature and the varying pain experiences of the patient, pain is often difficult to adequately treat. When pain goes unrelieved, the potential impact on the patient’s life negatively increases. Untreated pain can result in increased stress on the body, increased healing time after injury or surgery, decreased immune response, increased feelings of anxiety or depression, and increased alterations in performing activities of daily living. The effect of unrelieved pain can be long-reaching as it can result in a decrease in work performance and job loss for some patients (9).  

Acute and Chronic Pain 

For this West Virginia Drug Diversion course, it is necessary to outline that pain can be classified as either acute or chronic (9). Acute pain is often associated with injury, inflammation, ischemia, or surgery and typically only lasts for a short while. Patients experiencing acute pain are often able to easily localize and describe the pain. Acute pain that is not adequately treated can progress to chronic pain. One example of this is seen in musculoskeletal injuries, such as back strain, where repeated injury and inadequate pain management progress to a state of chronic pain. 

Chronic pain usually lasts more than three months. Unlike acute pain, chronic pain often is not as well defined. In addition, the onset of chronic pain is typically gradual, and characteristics of the pain can change over time. While some chronic pain can be tied to a specific cause or disease state, such as arthritis or cancer, other times, the exact cause is not as easy to determine, leading to possible complications for adequate pain management (9).    

Nociceptive and Neuropathic 

Pain can be further categorized into nociceptive and neuropathic pain (10). Nociceptive pain is a result of normal stimuli and is either somatic or visceral pain. Somatic pain is superficial and involves skin, muscles, bone, blood vessels, and connective tissues. An example of acute somatic pain would be a sprained ankle, and an example of chronic somatic pain would be arthritis. Visceral pain refers specifically to pain in the organs. An example of acute visceral pain is when someone is experiencing cardiac ischemia, which is often described as chest pain or left arm and jaw pain in patients experiencing a myocardial infarction (MI). An example of chronic visceral pain would be abdominal pain secondary to stomach cancer (9, 10). 

Neuropathic pain results from damage to either the central or peripheral nervous system. While most cases of neuropathic pain are chronic, acute neuropathic pain can be seen in injuries or infections affecting the nerves. In some cases, acute neuropathic pain, such as in amputations, may come and go with the severity of the pain differing greatly from patient to patient. Acute neuropathic pain may progress to chronic neuropathic pain if not treated effectively. Additionally, other disease states may cause chronic neuropathic pain, such chronic diabetic neuropathy in patients with diabetes. Chronic neuropathic pain is often difficult to treat, and patients may be prescribed several medications before finding something that provides some pain relief (9, 10). 

Pain Assessment 

There are various factors affecting how pain is perceived and managed (9). These factors include the type of pain, how long the pain has been occurring, patient age, cognitive level of the patient, the patient’s personality or temperament, previous experiences with pain, and even cultural beliefs. Understanding how these factors influence the patient’s response can help to inform the assessment and may be helpful in determining appropriate treatments for the pain (9, 10).  

A comprehensive assessment of the pain is also important in determining the type of pain and pain management options. A thorough assessment at the start of treatment will also serve as a baseline and help to determine if interventions have been effective. Additionally, patients who are not adequately assessed for pain are at a higher risk of their pain not being effectively managed. It is important to remember not all patients are capable of describing their pain. As such, completing a pain assessment can help these patients to provide the information necessary for informed diagnosis and treatment. How a pain assessment is obtained may also vary. Traditionally, a pain assessment is completed as part of the general assessment, use of a paper or electronic form completed by the patient prior to evaluation may also be used. For this West Virginia Drug Diversion course, it is vital to thoroughly read through the “Pain Assessment Components” table below (9, 10).  

Table 1. Pain Assessment Components (9, 10) 

Substance Use Disorder 

Substance use disorder (SUD) affects over 5 million adults in the United States (11). Addiction costs related to productivity, health care, and legal care for people with substance use disorders are estimated to cost billions annually (4, 5, 11). These statistics are staggering and show why early intervention to identify individuals at risk and prevent severe substance use disorders is necessary. 

There is a drastic difference between substance use and addiction, which is more accurately called substance use disorder (11, 12). Not every patient who uses a controlled substance develops a substance use disorder. However, risk factors may predispose some patients to develop one. There is an increased risk for the development of a substance use disorder in patients who have family members who also suffer from substance use or mental health disorders (11, 12). Additionally, how the drug acts within the body and brain, and stress will increase the risk of developing a substance use disorder, even when the medication is taken as prescribed (11, 12). 

Substance misuse (abuse) is the action of taking medication other than prescribed, either for purpose or dose, taking another person’s prescription, or taking a medication to get high (11, 12). Misuse, by itself, may not necessarily indicate an addiction as other factors need to be considered. Patients may misuse a wide variety of prescription medications without incident; however, when misuse of medication is common, the risk of occurrence with medications that are addictive or controlled is higher. In patients who make a choice to misuse medications regularly, the ability to control their own behavior decreases (11, 12). Addiction is a chronic condition, where patients may have periods of relapse, will compulsively seek out drugs, and continue to use, despite the harmful effects and long-lasting changes it may have on the brain. Substance use disorder is considered a complex physiological and psychological condition (11, 12, 13). 

Diagnosis 

The process of developing a substance use disorder occurs on a continuum. The majority of patients who take a couple of doses of an opioid to treat acute pain, such as seen in post-surgical patients, will not become addicted or develop substance misuse concerns. The risk for addiction increases when the patient is at higher risk because of genetics or psychological factors (12, 13). Exposure to a substance changes how the brain responds, leading to intoxication (11). When a patient repeatedly uses the substance, they build up a tolerance, which then requires the patient to use more of the substance to achieve the same feeling. Over time, even patients who use a substance as prescribed can develop a tolerance. This is often seen in patients who suffer from chronic pain and use opioid medications for pain management. While increased tolerance can be an indicator of addiction, this alone does not equate to a diagnosis of addiction or a substance use disorder (11, 12, 13, 14).  

The Diagnostic and Statistical Manual of Mental Disorders: Version 5 (DSM-5) categorizes substance use disorder symptoms into four categories, impaired control, social problems, risky use, and physical dependence (3). Understanding the DSM-5 categorizations will further help you to identify the following signs and symptoms of substance use disorders in patients (3, 4).  

Impaired Control 

• Unable to control the use of the substance 
• Unable to cut down or stop using 
• Spends time obtaining, using, or withdrawing from substance 
• Reports craving the substance 

Social Problems 

• Unable to meet obligations of work, home, or school 
• Continues use of a substance even though it causes social or interpersonal problems 
• Is no longer as active in social, work, or recreational activities 

Risky Use 

• Uses the substance in dangerous situations, such as when driving 
• Continues using the substance even though it is making a medical or psychological problem worse 

Physical Symptoms 

• Displays evidence of tolerance 
• Has symptoms of withdrawal when the substance is stopped or counteracted 

If a patient has more than two positive symptoms in a 12-month period, they should be diagnosed with a substance use disorder and referred for appropriate treatment and management for this condition (3, 12). The severity of the disorder is further determined by the number of criteria or symptoms present, with mild being 3 to 4, moderate 4 to 5, and severe addiction being greater than six (3, 12). 

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Opioids 

Indications and Action 

Opioid analgesics can be used to manage pain, used as anesthesia adjuncts in surgery, and as a cough suppressant. Opioid analgesics work by binding to specific opiate receptors (mu, delta, and kappa). Opiate receptors can be found in the central nervous system, peripheral tissues, and in the gastrointestinal (GI) tract. Opiate receptors also help to control blood pressure, pupil dilation, GI secretions, respiration, and pain response. When opioids are used to manage pain, opioids act upon these same opiate receptors, resulting in a decrease in pain and affecting the control these receptors have on other systems, resulting in some of the effects experienced by patients when taking opioids (14).  

Some of most prescribed opioids include hydrocodone, oxycodone, oxymorphone, morphine, codeine, fentanyl, hydromorphone, tapentadol, and methadone (4). Administration routes vary based upon the type of opioid prescribed (4). 

In determining which route should be used, consideration should be given to the type of medication, what type of pain is being treated, as well as the age and cognitive level of the patient. Common routes for home use include oral (both tablet and liquid), buccal, sublingual, intranasal, topical, and transdermal. Rectal routes may be used for pediatric patients or for those who are unable to tolerate oral ingestion. Opioid treatment in hospitals or clinics may also include intravenous (IV) injection, subcutaneous (SQ) injection, and intrathecal administration. Patients prescribed opioid medications should receive medication education that includes administration, adverse effects, and general education about safety, storage, and disposal (4, 14). 

Scheduled Substances  

The Controlled Substances Act identifies scheduled medications based upon their current acceptable medical use, abuse potential, and risk of dependence (4). 

• Schedule I: Substances have a high abuse potential and are not currently considered to be acceptable for medical use (i.e., heroin) 
• Schedule II: Substances that can be prescribed but are high risk for abuse (i.e., hydromorphone, oxycodone, morphine, methadone, and fentanyl 
• Schedule III: Acetaminophen with codeine (products that contain less than 90mg of codeine per dose) 
• Schedule IV: Tramadol 
• Schedule V: Antidiarrheal diphenoxylate/atropine and cough suppressants containing less than 200 mg/100 ml of codeine  
• Schedule V drugs have the lowest potential for abuse compared to Schedule I-IV drugs. 

Contraindications and Precautions 

Use of opioid analgesics should be used cautiously in patients with conditions resulting in respiratory insufficiency, morbid obesity, and pregnancy (4, 14). Additional assessment and risk analysis should be performed prior to prescribing or administering opioid analgesics to patients with a diagnosed substance abuse disorder, concurrent psychiatric conditions, and those taking benzodiazepines. Concurrent use of opioids and benzodiazepines should only occur if no other treatment options are available due to the increased risk of respiratory depression. Patients taking tramadol, meperidine, or fentanyl are at an increased risk for the development of serotonin syndrome when these drugs are taken with other medications that affect serotonin, and care should be taken when these medications are prescribed concurrently (4, 14). 

Adverse Effects 

Adverse effects of opioids range from mild to severe, and most patients who are prescribed opioids will experience one or more effects (4, 14). Common adverse effects include (4, 14): 

• Nausea 
• Vomiting 
• Constipation 
• Urinary retention 
• Urticaria 
• Lightheadedness 
• Sedation 

With the exception of constipation, which can be an ongoing effect, many of the common adverse effects such as nausea, vomiting, and urticaria often lessen in severity with continued opioid use. More serious adverse effects, which may occur even with continued opioid use, include hypotension, bradycardia, and respiratory depression. Patients should be prescribed the shortest-acting, lowest effective dose to minimize severe adverse effects (4, 14). 

Toxicity 

Opioid toxicity can occur regardless of the route of administration. Patients presenting with opioid toxicity often have central nervous system (CNS) depression, ranging from confusion and drowsiness to unresponsiveness. Other symptoms of toxicity include respiratory depression and pupil constriction. Patients may initially present with hypotension, but as CNS and respiratory depression worsen, hypertension may be seen as the body attempts to compensate. Patients should be monitored for seizure activity if the overdose is a result of meperidine (4, 14). 

It is important to note in this West Virginia Drug Diversion course that treatment of opioid toxicity should begin immediately with the administration of naloxone, an opioid overdose withdrawal medication. Repeat dosing may need to be administered as naloxone has a half-life of 30-60 minutes. Pre-hospital treatment with nasal or injectable naloxone should be administered, even if unsure of overdose or toxicity. In-hospital treatment should consider not only the patient’s condition, but also the half-life of the opioid (if known). The naloxone dose should be titrated based upon these factors to limit the potential adverse effects of naloxone (4, 14). One option for treatment is continuous IV infusion as opposed to repeated larger bolus doses. Continuous IV infusion has been shown to decrease the symptoms of opioid withdrawal better than bolus dosing (4,14).  

Pain Management Using Opioids 

Opioid Pain Assessment 

Patient assessment is an important factor in determining the need for opioid therapy. Assessment of all patients should start with a full history and physical, including a complete pain assessment, and any previous episodes of pain and treatments used (9). A thorough social and psychological assessment should also be completed. A social assessment should explore how the patient functions at home, work, and social spaces while including a discussion of how the current pain impacts their ability to function (9). A psychological assessment should include a previous history of substance use disorders and substance use as well as any underlying mental health disorders and medications currently used for treatment (9). 

For patients with a history of substance abuse disorders, the initial assessment should further explore the substance use disorder. The history should include the type and number of opioids used recently, routes of administration, date of last use, any treatment the patient received, and physical, social, or psychological problems experienced as a result of the disorder (4, 9, 11).  

Patients should be screened for infectious diseases, such as hepatitis B and C, human immunodeficiency virus (HIV), and tuberculosis (TB) (4, 5). If the patient has a history of IV drug use, follow-up should include infections related to IV use, such as infective endocarditis, osteomyelitis, and abscesses (4, 7, 9). As opioid misuse and alcohol abuse often occur concurrently, questions related to alcohol use, frequency, and the amount should be addressed (4, 7, 9, 11).  

During the physical assessment, the health care provider should also look specifically for signs and symptoms of opioid intoxication or withdrawal, as well as any physical symptoms related to long term substance abuse. Patients with a history of opioid use may have alterations in hematology, and in patients with chronic use, diet changes may result in anemia or malnutrition. In patients with a history of substance abuse, a baseline laboratory analysis of a complete blood count (CBC) and complete metabolic panel (CMP) are recommended in addition to infection disease screening (4, 9, 11, 12, 14).  

Table 2. Clinical Manifestations of Opioid Intoxication/Overdose, Withdrawal, and Chronic Use (4) 

Addiction Risk Assessment 

In addition to the history and physical exam, the use of an addiction risk assessment tool can be helpful in determining the risk of misuse or addiction in patients prescribed opioids for chronic pain (4). There are several addiction risk assessment tools available, but these tools vary in complexity as well as the specific criteria being measured. 

It is important when using a screening tool to determine the risk of misuse or addiction that healthcare providers recognize a “one size fits all” approach does not work. The type of assessment used may need to vary based upon the patient and their history. For patients with a complex history of a substance use disorder, a more complex and complete assessment should be used. A patient without risk factors may only need a basic risk assessment. Availability, ease of access, and target patient age may also play a part in the type of tool chosen. Having two or three tools available that health care providers have been trained to use and are comfortable using allows for improved assessment and ability to better identify individuals at risk. 

Discovering that a patient is high-risk can be scary for both the healthcare provider and the patient as the goal of treatment is not to create an additional problem. However, the risk assessment does not mean the patient’s pain should not be treated. Evaluating alternative treatment methods is important, and opioids or other controlled substances should not be a first line option. Additional support is needed through referrals to both a pain and behavioral health specialist to ensure the needs of the patient are met and pain is adequately treated (4, 9, 11, 12). 

Treatment Options and Goals 

While acute pain can be treated with opioid medications, considerations should be made regarding the severity of the pain, diagnosis, and the effect of the pain on the ability of the patient to function (4, 9, 13). If the patient can tolerate the pain and there is minimal impact on their ability to function, non-pharmacological and non-opioid medications should be used before determining whether an opioid is necessary. Additionally, steps should be taken to evaluate and treat underlying causes of pain. In cases where the acute pain is severe and impairs patient function, steps should be taken to ensure the patient is prescribed the lowest possible dose of an immediate-release opioid, ideally with only a three-to-five-day supply (14).  

Non-pharmacological Pain Management 

Options for non-pharmacological pain management and their effectiveness will vary based on the patient and the nature of their pain (4). When determining which methods will work for the patient, healthcare providers should discuss options with the patient and provide education about how it can be used and the benefits of using a particular therapy. Healthcare providers, after reading this West Virginia Drug Diversion course, should also evaluate potential costs and the barriers to using these therapies. Follow-up is necessary in determining the effectiveness of therapy and if further treatment is necessary.  

Table 3. Sample of Non-Pharmacological Pain Management Modalities (4, 14) 

Non-Opioid Pain Management 

Non-opioid medications for pain management should be carefully considered before implementation (4, 9). These medications should be evaluated based upon the need for short-term or long-term therapy. For some medications, the risk of complications when taken concurrently with opioids is high. Patient evaluation and screening are key in determining the current use of opioids. The patient should be monitored for therapeutic effectiveness and potential side effects. Additionally, some non-opioid options carry their own risk of addiction and patients should be monitored for related substance use disorders.  

Table 4. Sample of Non-opioid Options for Pain Management (4) 

Evaluation of the type and nature of the pain is important in determining which options would best fit the patient’s needs. Healthcare providers should inform the patient that they may need to try different modalities and medications to find a fit that is right for them. Patient tracking of symptoms, use of relief methods and medications, the effect on the ability to function, and effectiveness of interventions is key in determining which modalities and medications are working. Various mobile apps for tracking and managing pain are available and may be an option for helping some patients to record and track this data.  

In the event the patient and healthcare provider determine non-pharmacological and non-opioid medications are not effectively managing the pain, opioids may be added to the treatment plan (4, 14).  

If opioid therapy is needed, and tramadol is prescribed, consideration should be given to tapering patients off antidepressants used for pain relief to decrease the risk of serotonin syndrome. Opioids should be prescribed at the lowest effective dose, and immediate-acting opioids be prescribed before long-acting opioids. Long-acting or sustained-release formulations remain an option for treating neoplastic-related pain (4, 14). Prior to prescribing opioid therapy and at every visit, the risk versus benefits of opioids should be evaluated and discussed with the patient. If benefits do not outweigh risks of continued therapy, steps should be taken to taper the dose down or taper to discontinue the opioid (14). 

Therapy Goals 

Another important step in therapy is the determination of therapy goals. Goal setting should occur early in the treatment process and should be a collaboration between the patient and the health care provider. When setting goals, both should be realistic about what can be achieved medically according to the patient’s basic functioning. In addition, goals should be specific as to what the patient wants to achieve and include a realistic time frame for achieving these goals (4, 14). Goals should be included in the patient’s plan of care in the electronic health records (EHR) and should be reviewed at each visit. Evaluation of goals should also incorporate data tracked by the patient.  

Compliance with use and appointments should also be encouraged. Patient education about the proper use of opioids and follow-up appointments is key. Other steps include requiring a follow-up visit before the first refill, understanding no additional scripts will be written until after the follow-up, and scheduling future appointments before the patient leaves the office (4, 14). Health care providers should also work with the patient’s other providers to ensure the patient is not receiving multiple prescriptions and to ensure there are not any concurrent prescriptions for benzodiazepines (4, 9, 14). A thorough check in the EHR for previously written prescriptions should be completed. For outside health care providers, the patient should be asked to sign a release of information to allow these records to be obtained. For health care providers living in states with prescription drug monitoring programs (PDMPs), the databases should be checked prior to prescribing and information regarding prescriptions written should be submitted following the regulations set forth by individual states (3, 4, 8, 14). 

Ongoing Monitoring 

Urine screens should not be used solely to determine risk of substance use disorder. When used in combination with other risk assessment strategies, urine screens may be helpful in identifying patients at high risk of overdose particularly. Urine screens can help identify which patients may need additional monitoring or support (4, 5, 14). Urine screens should be used at the start of opioid therapy for chronic pain and can be used throughout therapy to validate what the patient has reported and to identify the use of multiple substances (4, 5, 14). The frequency of testing should be determined by the stability of the patient, type of treatment, and setting in which the treatment is taking place (4). Recommendations vary on the frequency of urine screenings; however, urine screening typically occurs annually for patients on long-term opioid therapy (4, 5, 14). However, in some cases and in some practices, more frequent screening may be mandated for patients undergoing treatment for substance use disorders (4).  

It is important to note that not all urine screens are the same. As such, the healthcare provider, nurses, and staff performing the screen should obtain additional training and education beyond this West Virginia Drug Diversion course regarding the specific screen being used and according to manufacturer recommendations for performance. Some substances may only be present in the urine for up to three days. For this reason, a negative result may not rule out use of a substance (4, 11). Instead, health care providers should use these results in conjunction with assessment findings and subjective patient reporting to determine if further action or monitoring is necessary. 

In addition, pill counts are sometimes used as a method for ongoing monitoring of a patient’s compliance with therapy and as a method for preventing drug diversion. The idea behind pill counts is if the patient presents to the visit with the correct number of pills, then misuse and diversion are not occurring. When used alone, pill counts are not effective in preventing addiction, and the evidence does not support using this method alone to prevent misuse (4, 5, 14). However, pill counts are still sometimes used as part of opioid therapy and are still sometimes included as part of the treatment agreements. When used with other methods, pill counts can provide insight into patient use of the medication and provide an opportunity for ongoing education about safe use and storage of opioid medications.  

Healthcare practitioners choosing to use pill counting as a method of deterring misuse and diversion should recognize pill counts may be “padded” by borrowing, renting, or purchasing additional pills illegally. Care should be taken in counting the pills remaining as well as verifying the pills all have the same appearance (4, 5, 14).  

Referrals

Referrals are an important part of managing a patient with pain, especially in cases of chronic pain. Healthcare providers should be willing to provide referrals to outside providers and specialists to address specific pain concerns. For example, if a patient is identified as having chronic pain in their lower back or hips, a referral to an orthopedic specialist for evaluation is warranted. If a patient has used multiple modalities, including opioids, without success, a referral to an interventionalist may be needed to determine if the patient is a candidate for a nerve block, neuromodulation, or implantation of an intrathecal medication delivery device (9, 13, 14). 

For patients with a history of substance use disorder or other underlying health concerns, a referral to a psychologist, psychiatrist, or mental health therapist should be provided. The healthcare provider should work in conjunction with this specialist to manage the patient. Behavioral health services should also be considered for patients without a personal or family history of addiction or mental health disorders, as chronic pain can cause depression and anxiety. When opioids are used, long-term chemical changes in the brain occur, increasing the risk of substance use disorder, depression, anxiety, paranoia, and hallucinations (4, 5, 9). This West Virginia Drug Diversion course highlights the importance of not only identifying patients who may be suffering from a mental health disorder due to opioid use but ensuring that proper treatment is provided.  

For some patients with chronic pain, referral to a pain specialist may be necessary. While not every patient needs a referral, there are some situations in which a referral becomes necessary (9, 10, 13): 

• The patient requires higher dosages of morphine or another opioid 
• Concurrent use of other CNS depressants (benzodiazepines, muscle relaxers, or anticonvulsants) 
• Requests more opioids, asks for early refills, or has pain-related visits to the emergency department or urgent care 
• Reports use of illicit drugs or urine drug screen is positive for non-prescribed drugs 
• The patient is unable to follow the pre-agreed upon treatment plan 
• The patient refuses to use non-pharmacological or non-opioid pain management strategies  
• The patient refuses to taper dosage when risk outweighs benefits 

Primary healthcare providers should work with pain specialists to determine if the patient should be referred for medication management or if a transfer of care is necessary (9, 12).  

Referrals may also be needed for services, such as physical therapy or occupational therapy. In some states, patients may seek out therapy services on their own. In some states, a referral or prescription is required. Health care providers should determine if a prescription or referral is necessary for insurance purposes before sending the patient for evaluation by a physical or occupational therapist or other specialty healthcare providers. When determining which referrals are needed, the healthcare provider should explore resources available locally as well as any barriers the patient may have for attending appointments (9, 12). 

Treatment Agreements and Informed Consent

Patient-provider agreements have a long history in opioid treatment. Initially, agreements were used to set standards or requirements for patient behavior and often included dismissal as a punishment for not adhering to the agreed-upon treatment regimen (4, 14). When used in this manner, the effect on patients was not always positive. Patients often felt a sense of distrust and stigma related to the use of these agreements, which only served to undermine the therapeutic relationship and threatened the treatment plan (3, 4, 5). Yet, the use of patient-provider agreements continues to be included as part of treatment recommendations. When used correctly, agreements can help support both the patient and healthcare provider (5, 9, 14). 

Due to these recommendations, treatment agreements continue to be used. Healthcare providers should ensure treatment agreements are implemented in a way that is patient-centered and are not punitive in nature. They should provide information about risks and benefits, and steps to ensure compliance (4, 14). Perhaps a better way of looking at treatment agreements is to see them as a method of informed consent, wherein the patient is provided need-to-know information including risks, benefits, and consequences of noncompliance. From then, patients and health care providers work together to determine if undergoing treatment is what they desire (4, 9, 14).  

While patient treatment agreements historically may not have always been effective, they become one part of a patient-centered treatment plan when used correctly. Not only can these agreements serve as a way to document the patient’s informed consent of the treatment, but they can be used to identify clear goals and expectations for patients receiving opioid therapy. Treatment forms may vary from clinic to clinic, but common components include (4, 14):  

• Treatment goals 
• Responsibilities for safe medication use 
• Storage and disposal of opioid medications 
• Requirement for the patient to obtain prescriptions from only one clinician or practice 
• Requirement to only fill prescriptions at one pharmacy 
• Agreement for periodic drug testing 
• Clinician agreement to be available or have coverage 

In addition to treatment agreements, healthcare providers should implement informed consent forms (4, 14). In some cases, these are combined with the treatment agreements, and in other cases, the informed consent may be a separate document. Components of informed consent should include (4, 14):  

• The limited benefit of opioid in chronic pain 
• Risks and benefits of opioids 
• Potential side effects, including sedation and impaired motor skills 
• Risk of tolerance, physical dependence, development of a substance use disorder, overdose, and death 
• Prescribing policies and expectations 
• Reasons why therapy may be changed or discontinued 
• Education that the patient should not expect to be pain free 

Discontinuing Opioid Therapy

Discontinuing opioid therapy may be considered for various reasons, such as risk outweighs the benefit, effective use of non-pharmacological therapies and non-opioid medications, patient desire to stop use, and noncompliance. Understanding why opioid therapy is discontinued and communicating with the patient is important to ensure pain management goals are met. Recommendations for discontinuing opioid therapy included initially just tapering the dose, then extending the time between doses (3, 4, 14). Once a patient has reached the point where they are taking an opioid less than once a day, the opioid can be stopped (14).  

Emergency discontinuation of therapy or rapid tapering of opioid dosing may occur when a patient overdoses on their current dose (4, 14). In these cases, patients should be closely monitored in a controlled setting, and supportive therapy to manage withdrawal symptoms should be employed. Urine screens should be completed to rule out the presence of other drugs. Baseline blood work labs, such as a CBC and CMP, should be obtained. The clinical opiate withdrawal scale (COWS) should be utilized to monitor for signs and symptoms of withdrawal (4, 11). 

The COWS is an 11-criterion scale that looks at physical symptoms of withdrawal. Each criterion is scored based upon what is being evaluated or observed in the patient. A score of 5 to 12 indicates mild withdrawal, 13 to 24 is moderate, 25 to 36 is moderately severe, and patients scoring above 36 are in severe withdrawal. The criterion evaluated includes: 

• Resting pulse rate 

• Sweating 
• Restlessness 
• Pupil size 
• Joint pain 
• Runny nose or tearing of the eyes 
• GI upset 
• Tremors 
• Yawning 
• Reported anxiety or irritability 
• Piloerection (raising of skin hair or goose bumps) 

Proper use of COWS is important, and staff who will be using the scale to evaluate patients should be properly trained in its use. Treatment of acute withdrawal symptoms should be based on the patient’s COWS score and the symptoms they are presenting. In addition to the symptoms evaluated using the COWs, blood pressure should be monitored, and hypertension should be managed. Medications used to manage symptoms of acute withdrawal include anti-emetics, non-opioid antidiarrheals, clonidine, or lofexidine. Care should also be taken to provide a low stimuli environment, such as dimmed lights, limiting excess noise, and keeping the room at a comfortable temperature (4, 11, 14). 

Managed withdrawal can also occur more slowly and is commonly seen in patients who are heroin-dependent or if the patient and healthcare provider identify a detoxification program is needed. In some cases, methadone or buprenorphine may be used to lessen the symptoms of withdrawal. Patients prescribed methadone should also be provided referral to a methadone clinic for monitoring and medication distribution. Patients undergoing methadone or buprenorphine treatment should also be referred for behavioral therapy to help manage psychological effects, and for ongoing treatment and support of a substance use disorder (4, 11). 

Patient Education 

Educating patients at the point of prescribing and at every visit thereafter is important to ensure patients are actively involved in their own care and are taking steps to manage their care at home. However, educational practices may not be inconsistent between clinics and facilities, and between health care practitioners. In some cases, education is missing (4, 5, 14). For patients who are prescribed opioids, education is a key component towards ensuring patient safety.  

Both patients and family members should be taught the risks and benefits of opioid use, the effectiveness of opioids, and the appropriate use of opioid medications. Patients and families should be taught the signs and symptoms of an overdose and how to appropriately intervene in case of an overdose. Additionally, patients should be taught about diversion’s risk and steps to prevent it (4, 5, 14). 

Prior to engaging in patient education about opioids or addiction, the nurse should first self-evaluate or reflect on their own feelings related to these topics. Efforts should be made to approach each patient as an individual and to avoid stereotyping patients based upon their type of pain, use of opioids, or history of a substance use disorder. Patients should be approached in a nonjudgmental manner, and nurses should employ therapeutic communication techniques, allowing the patient to express their concerns and to encourage questions (4, 5, 14).  

When starting an educational session, it is important to identify the specific learning needs of the patient. This may range from identifying the patient’s type of learning, the level of education or reading level, and even includes identifying specific questions or concerns the patient has related to using an opioid (4, 5, 14). 

Time should also be committed to evaluating what the patient’s current knowledge about opioid use is and to dispel misconceptions the patient may have about opioids.  

Misconceptions that may be held by patients about opioids, addiction, or the prescribing process might include (4, 5, 14): 

• Misconception 1: Opioids are the only thing that will help the pain. 
• Misconception 2: When taken as prescribed, addiction will not occur. 
• Misconception 3: Not being prescribed an opioid means the health care provider thinks the patient is an addict. 
• Misconception 4: Addiction only happens to certain types of people. 

Nurses should take care to provide facts and evidence (at the patient’s level) to dispel misconceptions. When addressing misconceptions, it is also important to be aware of tone and forms of non-verbal communication to not inadvertently pass judgment on what the patient believes (5, 14).  

While teaching should be specific to meet the patient’s individual needs and prescribed opioid, information about safe use, storage and disposal, and use of opioid antagonist medications should be provided to every patient. The information provided in this West Virginia Drug Diversion course offers great opportunities and points to share with patients. Standardized educational materials should be around a 6th grade reading level to ensure that most patients easily understand the material. The use of videos through a patient education platform can be useful for educating patients who are unable to read the material or those who are auditory learners. If these are not available, clinic-made videos or videos available online from reputable sources may be used (5, 14).  

Safe Use of Opioids 

One aspect of patient education that is essential to highlight in this West Virginia Drug Diversion course is the safe use of opioids. Since opioids are used in both acute and chronic pain management, education about safe use is an important step in helping patients take an active role in their treatment plan and ensuring their safety outside of the clinical setting. When a patient is treated for acute pain, instructions should include guidelines on how the opioid should be taken and for how long it should be taken. Nurses’ common education for a patient with acute pain is to take their opioid pain medication to “stay ahead” of the pain. This instruction does not go far enough to address safe use. Patients should be instructed to take their opioid medication as prescribed and not increase the frequency or dosage if the pain worsens, but instead to notify their health care provider.  

Patients may believe that if it is prescribed, they must take the medication. The nurse should also educate that opioids are an as-needed medication and should not be taken if not needed. In most cases of acute pain, opioids may only be needed for the first few days. Teaching patients to self-evaluate their pain is important in determining if the opioid is necessary or if an alternative medication, such as a NSAID, would be more appropriate (4, 11, 14).  

In the case of a patient being treated for chronic pain, instructions should still include guidelines for how it should be taken, but additional guidance should be provided about safety related to toxicity and withdrawal. Opioids for chronic pain management may be either immediate-acting or long-acting, and education differs based on what is prescribed. Patients prescribed immediate-acting medications should be instructed not to change the frequency or dosage prescribed because of the risk of toxicity (4, 5, 14). 

If the patient finds their pain is not being managed, further evaluation is necessary, and patients should be instructed to notify their healthcare provider. These patients should also be aware of how many doses have been prescribed and be taught to manage the use of their medications. Patients who are unable to manage their medications effectively may find they have finished the supply and are not able to refill the prescription for several days, leading to withdrawal. For patients prescribed long-acting opioids, they should be provided education on how these medications differ from immediate-acting and to not take extra for breakthrough pain. Taking long-acting opioids as prescribed is important to prevent withdrawal. Since these medications stay in the system longer, there is also a risk of toxicity if the patient takes an extra dose or additionally medicates with a short-acting opioid (4, 11, 14).  

With any patient-prescribed opioids, additional education related to misuse and diversion should be provided. Most people who reported misusing prescription opioids identified they got the drugs from a friend or family member (4, 5). Patients should be taught to count their medications and to keep track of their use. If patients identify pills are missing, patients should be informed to notify authorities and their healthcare provider. Education should include that the prescriptions are only for personal use and should not be shared with a relative or friend. Education about safe use also needs to include concurrent use of opioids with other medications or alcohol. The patient should be instructed to avoid alcohol because of the additive CNS depressant effects, which increase the risks associated with respiratory depression. A thorough review of all patient medications, prescribed, over the counter, and herbal, should be completed. Education regarding potential reactions should be provided (4, 14).  

Proper Storage and Disposal 

Proper storage of opioids can deter theft, loss, and misuse of medications. Patients should be taught to keep opioids in the original packaging and not to store them in pillboxes. Many patients often keep medications in the kitchen or bathroom near the sink or on a shelf. Patients should be taught to keep opioids in a locked drawer or cabinet that is not easily visible or accessible to others. Additional patient education should include the dangers of accidental ingestion by children, other household members, or pets. Patients should also be cautious with whom they tell about their opioid prescription and should be educated that this information should only be shared with direct caregivers (3, 4, 5, 11, 14).  

Patients also need to be taught about the proper disposal of opioids. Many patients will often save leftover prescription medications, “just in case.” In addition, many patients may have multiple old prescriptions in their home, increasing the likelihood they are unaware of what is there or if it may have gone missing. It is estimated less than 20% of patients properly dispose of opioid medications. Educating patients on proper disposal can help to prevent problems related to the diversion of opioids by people the patient knows. The Food and Drug Administration (FDA) identifies the preferred disposal method of opioids or other controlled substances is to take the medication to a disposal location (3, 4, 5, 11, 14). Many pharmacies offer take-back services that will allow patients to dispose of old or unused prescriptions. Locations for take-back services can also be found by completing a search through the Department of Justice website at https://apps2.deadiversion.usdoj.gov/pubdispsearch (20). 

In some cases, a patient may not be able get to a drop off location. In these cases, the FDA has also identified both a flush and no-flush list for medications that can either be disposed of by flushing down the toilet or by discarding into the trash (21). Most medications containing opioids can be flushed to prevent misuse or diversion (21). 

For other controlled substances that cannot be flushed, it is recommended patients be taught to mix the medications in something most people wouldn’t dig through or ingest, such as cat litter, to place the mixture in a sealed plastic bag, and to throw it in with regular household trash. Patients should also be taught to blacken with a permanent marker or to scratch out any personal information on the prescription bottles before putting them in the trash. Education on disposal should include where a local drop-off site is located, which prescribed medications can be flushed, and which ones need to be put in the trash. Patients concerned about the environmental impact of flushing medications should be informed that the FDA has found the flushable medications “present negligible risk to the environment” (3, 4, 5, 11, 14). 

Opioid Antagonists 

There are two commonly used opioid antagonists in use in the United States, naloxone and naltrexone. Both medications bind to opiate receptor sites, blocking the ability of the opioid to bind to the site. Patient education should include why a specific opioid antagonist is being used, appropriate administration, and potential side effects (4, 14). 

Naloxone 

Naloxone is used as a reversal agent for acute overdose or accidental ingestion. Patients taking opioids or who have family members who take opioids can either obtain naloxone either by prescription or directly from their pharmacist without a prescription. Naloxone can be used by patients or their loved ones in the home to prevent death or permanent disability as the result of opioid use. Family members should be taught to call for emergency assistance (911) if they administer naloxone to a loved one. Additionally, they should be taught to look for signs and symptoms of respiratory depression in the event a second dose needs to be administered. Patients and families should also be taught naloxone is only effective for the treatment of opioid overdose and will not treat overdose related to other substances. The FDA recommends healthcare providers discuss and consider prescribing naloxone for patients who meet the following criteria (4, 14):  

• High risk for overdose 
• Take other central nervous system (CNS) depressants 
• History of substance abuse  
• History of overdose 
• Have children who may accidentally ingest opioids 

Currently, naloxone has been approved for administration via the following three methods (4, 14): 

• Injectable naloxone – This is available in a 2mg/2ml syringe and is mostly used by healthcare workers in hospitals and by paramedics. For patients who receive this type of naloxone, training should be provided on the appropriate use of a syringe, dosing, and administration.  
• Autoinjectable Naloxone – Teach patients each autoinjector only contains one dose. If an additional dose is necessary, a second autoinjector will need to be used. If using an auto-injectable form, patients should be taught specifically how to open and activate the device and inject into the outer thigh.  
• Nasal Spray – A prepackaged nasal spray is often easiest for patients to use and can be obtained without a prescription from a pharmacy. With the nasal spray, patients and families should be instructed to ensure the patient is laying on their back, place the device’s tip into one nostril, and press firmly on the activator. Each package of spray contains one dose. Additional doses can be administered but a new device will be needed. Patients and families should be instructed to alternate nostrils if repeat doses are necessary. 

Naloxone adverse effects are often related to the reversal of the opioid and may include nausea, vomiting, diaphoresis, tachycardia, blood pressure irregularities, and tremors (4, 14). When administered to a patient who regularly takes opioids or in an overdose, withdrawal symptoms may become present within minutes. Severe adverse effects include seizures, dysrhythmias, pulmonary edema, and cardiac arrest (4, 14). 

Naltrexone 

Naltrexone is an opioid antagonist used for longer-term treatment and management of opioid addiction. Naltrexone requires a prescription and can be taken as a daily oral medication or as a monthly injectable. It should not be prescribed to patients who currently take opioids or who have recently used opioids or alcohol, as withdrawal symptoms will occur. Patients prescribed naltrexone should be instructed to avoid any opioids (prescribed or non-prescribed), alcohol, and cough or cold medications containing alcohol. Prior to naltrexone being prescribed, patients should have a thorough medication review done to avoid potential interactions with other prescribed medications, specifically those used to treat depression. Education regarding adverse effects should also be provided.  

Common adverse effects of naltrexone include nausea, vomiting, decreased appetite, drowsiness, and problems sleeping. Instruct patients to notify their health care provider if they experience severe adverse effects such as difficulty breathing, skin changes at the injection site, right upper abdominal pain, or suicidal thoughts (4, 14). 

Drug-Seeking and Diversion Among Patients 

The term ‘drug-seeking’ can have a negative connotation. It is often used by healthcare providers and nurses to refer to patients who behave in a certain way, seek out treatment for certain types of pain, or their explanation of events is viewed as unbelievable or untrustworthy. Unfortunately, because the term drug-seeking has come to be used as a kind of a catch-all, legitimate patients sometimes get identified as being “drug seekers,” and their pain goes untreated. The use of the term ‘drug-seeking behavior’ specifically refers to behaviors displayed by patients who are struggling with substance use disorders. In caring for patients who display drug-seeking behaviors, nurses need to be aware of their own feelings and biases as they relate to opioid use and addiction. They should approach each situation with a patient in a non-judgmental manner and objectively evaluate the patient so proper intervention can be given (4, 5, 7, 9, 11, 12, 14).  

Patients who are misusing prescription opioids may not recognize they have a problem and may feel their pain is being ignored. They will often lie about symptoms or exaggerate the amount of pain they are experiencing. This can be especially difficult to assess as nurses are taught pain is whatever the patient says it is. Since each patient’s pain experience is different and their responses vary, making objective pain assessments can be difficult. Physical changes which may be seen in instances of acute pain, such as elevated blood pressure, tachycardia, or diaphoresis, are often not present in chronic pain, further complicating the assessment (4, 5, 7, 9, 11, 12, 14). 

Patients may visit multiple clinics, urgent care, and emergency departments, which is often called ‘doctor shopping.’ This practice allows the patient to potentially receive multiple opioid prescriptions from different healthcare providers. Depending upon what is available in the area where the patient lives, the patient may also travel to other towns or neighboring states to obtain prescriptions. Often, in these cases, the patient will only give a partial or vague history. Patients may deny a request to obtain recent health records or provide false information about either themselves or where they have been treated. In addition to ‘doctor shopping,’ patients may also use multiple pharmacies to have prescriptions filled. Following the completion of this West Virginia Drug Diversion course, it is vital for healthcare providers to pick up on these signs of ‘doctor shopping’ (4, 5, 7, 9, 11, 12, 14). 

Escalation of use is often seen and occurs when patients take a higher dose, a dose more frequently, or both, outside of how the opioid has been prescribed by their provider. Patients may also take measures to obtain additional prescriptions from their regular healthcare provider. Patients who call the office to ask for a prescription right before the weekend or a holiday may require further investigation, especially if this is a common occurrence. One occurrence of a patient doing this does not meet the criteria of drug-seeking behavior; however, when there are repeated incidents or a pattern of behavior, it should be addressed (4, 5, 7, 9, 11, 12, 14). 

Patients may request a specific opioid or have a long list of allergies to other pain medications. Many of these patients may also report they are currently taking multiple opioids or other controlled substances. When asked about the use of opioids, other controlled substances, or even illicit drug use, patients may become angry. Aggression may also be seen when adjusting a plan of care, where the opioid medication will be changed, or the healthcare provider identifies it is time to start tapering the medication due to risks outweighing the benefits of treatment (4, 5, 7, 9, 11, 12, 14). 

In urgent care, emergency department settings, and even with the general hospital setting, changes in behavior from the waiting room to the treatment room are sometimes observed. When this occurs, patients may be calm, at a distance appear to be comfortable, or may be seen doing other activities (talking on the phone, conversing with other people, walking around); however, once placed in a treatment room, the patient may hold the area that hurts, moan, or even begin crying. If receiving IV medications, patients may ask the nurse to “push it fast” or may request oral medications be changed to IV (4, 5, 7, 9, 11, 12, 14). 

Drug diversion is an illegal act occurring when a prescribed controlled substance is obtained illegally. In some cases, diversion is done as a method of obtaining prescription opioids in order to sell them. However, diversion also occurs when a patient obtains a prescription, under false pretenses, for their own use. Identifying the end goal allows the health care provider to take appropriate steps to help the patient. Healthcare providers have a duty to report opioid diversion to law enforcement; however, criminal action against a patient will vary based upon the state, intent of diversion, and if there is an intent to sell or distribute. When a patient is diverting drugs for their own use, treatment of the substance use disorder is a priority and, depending upon the situation; legal action may not be taken if the patient undergoes treatment (4, 5, 7, 9, 11, 12, 14). 

Drug Diversion Among Nurses 

Estimates of practicing nurses who are abusing one or more substances significantly vary; however, research indicates that the COVID-19 pandemic increased the number of nurses who used substances. Nurses with substance use disorders often go unidentified and it can be easy for co-workers to ignore the signs and symptoms or to dismiss them as being stress related. Yet, failing to identify nurses who are struggling with substance use puts not only patients, but co-workers and health care systems at risk (22, 23). It is necessary to address this prevalence in this West Viriginia Drug Diversion course.  

Since nurses often have readily available access to controlled substances, their methods of diversion differ from those of patients and often are not as easily detected until a pattern is identified (22, 23).  

Nurses may remove a full dose but only give a partial dose to the patient, may substitute the patient’s injectable opioid for saline, or may “forget” to waste excess opioids. Additionally, the nurse may be overly helpful, such as coming in early or staying late, offering to give medications for another nurse, or picking up extra shifts as it gives them greater access. If not identified, the nurse may divert for a period of time undetected, in some cases, years. For some nurses, it is not until their behavior or physical appearance starts to change for co-workers and managers to identify a problem.  

Physical changes may include changes in appearance, hygiene, disheveled clothing, and in their cognitive ability (memory or concentration). Behaviors commonly seen include changes in their schedule (coming in early, leaving late, or frequent sick days), multiple breaks off the unit, and frequent bathroom breaks. As the drug starts to have a greater impact on the nurse, there may be an increase in the documentation or medication errors, or narcotic counts will consistently be off when that nurse works (22, 23).  

When a nurse is suspected of diversion, reporting the incident helps the individual and helps to keep patients safe. Depending upon the environment and area where the nurse works may determine to whom or where the suspicions should be reported (22, 23).  

Many facilities have policies related to what should be reported, who it should be reported to, and what documentation will be required. In most cases, the incident would be reported to the direct supervisor or employer. Once it has been reported, the employer is responsible for investigating the incident, which included looking at pharmacy logs, reviewing documentation, and interviewing involved parties. In some cases, law enforcement may also be contacted if the amount missing may indicate theft. The nurse will also be reported to their state board of nursing. In some cases, the nurse may be given the opportunity to self-report the incident. It is also important to note best practice supports the nurse not being terminated when impairment or diversion is confirmed, as this often prevents the nurse from accessing treatment (22, 23).  

The act of drug diversion by a nurse does not immediately mean their license will be revoked. An investigation by the West Virginia licensing board will occur and depending upon the circumstances, the nurse’s license may be suspended, and they may be required to undergo substance abuse treatment, or, in some states, may enter an alternative-to-discipline program. This program entails evaluation, treatment, and ongoing monitoring as a condition of being allowed to return to work (8, 22, 23). The nurse who has had their license suspended may request their license to be reinstated if they meet the requirements by the board of nursing disciplinary board. In some cases, restrictions may be placed limiting the administration of controlled substances to patients.  

Once the nurse returns to the workforce, employers should take steps to support the nurse and their recovery. Best practice supports the use of employer-employee contracts that outline conditions (22, 23). Suggested components of the contract include (22, 23): 

• Providing the nurse with a mentor who has been successful in recovery 
• Assigning to a day shift 
• Information regarding facility liability insurance and relevant guidelines and policy from the state board of nursing 
• Practice restrictions placed by either the board of nursing or the facility 
• Accommodations made to support in recovery (time off to attend meetings) 
• Facility policies on random drug testing 
• Evaluation criteria and timeline for evaluations 
• Expectations related to ongoing treatment 
• Consequences if the nurse relapses 
• Length of time the contract will be valid 

Nurses who are undergoing treatment and returning to work should be encouraged to ask questions to ensure expectations are clear. There remains a lot of stigma related to substance use disorders in nurses, and employers should take steps to ensure the nurse is placed will be a supportive environment. Steps should also be taken to protect the nurse’s right to privacy from co-workers as it relates to ongoing treatment (22, 23).  

Prescription Drug Monitoring Programs 

While tracking and monitoring controlled substances ultimately falls under the DEA purview, in reality, the DEA’s ability to accurately track this data on a state or local level is difficult. In response to the need for improved data collection and access to data, multiple states have prescription drug monitoring programs (PDMP) (3).  

These programs are used to track prescribers and pharmacies, and patients who receive these prescriptions as well. PDMPs improve patient safety by allowing practitioners and pharmacists to quickly identify patients who have obtained prescriptions from multiple providers, identify the total number of prescribed opioids, and identify high-risk patients who have been prescribed other controlled substances (3, 7). Through careful tracking and data collection, states can also use the data to determine if other statewide measures to combat opioid addiction and overdose are having any impact. The biggest drawback to these programs is the interoperability of systems between states, which limits data sharing and integration with electronic health records (3, 7).  

In 1995, West Virginia introduced their first controlled substance monitoring program. Since its initial introduction, the program has evolved to an internet-based program capable of exchanging information with several other states. Once fully integrated, providers can search for patients through the system without logging into the PMDP separately and help providers identify patient risk scores, prescription data, and patient safety alerts (3, 6, 7). 

Use of CSAPP 

Practitioners in West Virginia, who prescribe schedule II, III, IV, and V controlled substances, products containing gabapentin, and opioid antagonists, are required to report to the CSAPP, a web-based application monitoring the prescribing of these medications in West Virginia (8, 24). Reports should be submitted every 24 hours (7, 8, 24).  

The information to be reported includes (7, 8, 24): 

• Name, address, pharmacy, and DEA number of the pharmacy 
• Full legal name, address, and date of birth for the patient 
• Name, address and DEA number of the prescriber 
• Name and national drug code number of the substance being prescribed 
• Quantity and dosage of substance being prescribed 
• Date prescription was written and filled 
• Number of refills authorized by the prescriber 
• Government-issued ID of the individual picking up the prescription if not done so by the patient 
• Payment source 

Additionally, in the event a provider treats a patient for an overdose, the provider should report the full legal name, address, and date of birth of the patient being treated as well as any data collected as evidence of the overdose (7, 24). 

Case Study 

1. S. is a 40-year-old male. He denies any chronic illnesses. He is being evaluated at a local urgent care for lower back pain. He reports the pain started after helping a friend move some heavy boxes. C. S. denies any other injuries to his back and states, “other than what is going on right now, I am healthy.”

After evaluation by the health care provider, no acute injuries were identified, and he was diagnosed with back strain. He received instructions to ice his back, was provided exercises to strengthen his back muscles, was prescribed hydrocodone/acetaminophen 5/500mg for the pain and instructed to follow up with his primary health care provider.  

• Based upon what has been learned, what should have been done differently on this urgent care visit regarding prescriptions provided to C. S.? 

It has now been one year since C. S.’s initial diagnosis of back strain. Since then, he has had repeated visits for back pain and has progressed to needing daily opioid medication to manage the pain. He reports the pain got to the point where he struggled to complete tasks at his job and frequently had to call in sick. Recently, he lost his job as a construction worker, a job he had for 17 years. C. S. is being evaluated at his primary health care provider’s office because of his reports of chronic back pain.  

• What priority assessments should be obtained regarding C. S.’s pain and current opioid use?  
• What diagnostic tests should be performed and why are these tests important? 

After meeting with his health care provider, C. S. has agreed to the use of non-pharmacological and non-opioid therapy for his chronic back pain. He reports he is willing to try anything that will make him feel better and get back to work.  

• What non-pharmacological modalities or non-opioid medications might he benefit from receiving?  
• As part of the treatment plan for C. S. what referrals might need to be made?  
• What considerations need to be taken into account when prescribing treatments and making referrals? 

During the visit with the healthcare provider, C. S.’s frequent visits to the urgent care and emergency department are addressed. C. S. admits to often taking more of the hydrocodone than he should have because the pain was so bad.  

• Based upon what is known about C. S., what type of ongoing monitoring should be used? 
• Why is this monitoring the best choice for C. S.?

S. has agreed to the proposed treatment plan, but he also expresses he is worried his family and friends will only see him as a drug addict. He expresses concern that because of his opioid use he won’t be able to go back to work. 

• What should the nurse include in the teaching plan for C. S?  

Case Study 

S. is a 40-year-old male. He denies any chronic illnesses. He is being evaluated at a local urgent care for lower back pain. He reports the pain started after helping a friend move some heavy boxes. C. S. denies any other injuries to his back and states, “other than what is going on right now, I am healthy.”

After evaluation by the health care provider, no acute injuries were identified, and he was diagnosed with back strain. He received instructions to ice his back, was provided exercises to strengthen his back muscles, was prescribed hydrocodone/APAP 5/500mg for the pain, and instructed to follow up with his primary health care provider.  

Based upon what has been learned, what should have been done differently at this urgent care visit regarding prescriptions provided to C. S.?

It has now been one year since C. S.’s initial diagnosis of back strain. Since then, he has had repeated visits for back pain and has progressed to needing daily opioid medication to manage the pain. He reports the pain got to the point where he struggled to complete tasks at his job, and frequently had to call in sick. Recently, he lost his job as a construction worker, a job he had for 17 years. C. S. is being evaluated at his primary health care provider’s office due to his reports of chronic back pain.  

What priority assessments should be obtained regarding C. S.’s pain and current opioid use? 

What diagnostic tests should be performed and why are these tests important?

After meeting with his health care provider, C. S. has agreed to the use of non-pharmacological and non-opioid therapy for his chronic back pain. He reports he is willing to try anything that will make him feel better and get back to work.  

What non-pharmacological modalities or non-opioid medications might he benefit from receiving? 

As part of the treatment plan for C. S. what referrals might need to be made? 

What considerations need to be taken into account when prescribing treatments and making referrals?

During the visit with the health care provider, C. S.’s frequent visits to the urgent care and emergency department are addressed. C. S. admits to often taking more of the hydrocodone than he should have because the pain was so bad.  

Based upon what is known about C. S., what type of ongoing monitoring should be used?

Why is this monitoring the best choice for C. S.?

S. has agreed to the proposed treatment plan but he also expresses he is worried his family and friends will only see him a drug addict. He expresses concern that because of his opioid use he won’t be able to go back to work. 

What should the nurse include in the teaching plan for C. S? 

Conclusion

Pain is a complex process that differs for each patient and is not always easily treated. A thorough assessment is necessary to determine the type of pain present. This assessment also serves to aid in diagnosis and as a baseline for determining the effectiveness of prescribed interventions. For patients with pain who are using opioids, there is a risk of developing tolerance and dependence upon the drug resulting in the development of a substance use disorder, previously known as an addiction. Substance use disorders are now recognized by the DMS-5 and in several health care facilities. This important step has helped to further awareness of the problem among health care providers and provide clear guidelines for the diagnosis of the disorder.  

Best practice guidelines to prescribing opioid therapy include (4, 14): 

• Implement non-pharmacological and non-opioid medications before using opioids for pain 
• Identify realistic goals addressing both pain and level of function 
• Educate patients on both the risks and benefits of opioid therapy 
• Prescribe immediate-release and the lowest effective dose for patients who need opioid therapy 
• When prescribing opioids for acute pain, only prescribe what the patient will need for three days 
• Regularly evaluate risk versus benefit and taper dosage or discontinue if benefits do not outweigh the risks 
• Evaluate risk factors for misuse and addiction 
• Use PDMP data to inform decision-making and identify patients at high risk for overdose. 
• Implement urine drug screening at initiation of therapy and annually 
• Avoid prescribing both opioids and benzodiazepines 
• Offer treatment for patients with substance use disorder 

When non-pharmacological and non-opioid options have been attempted without success, opioid therapy remains an option for pain management. Patient education related to opioid use should focus on the medication being prescribed and address both administration and adverse effects. Additional education related to the safe use of opioids, storage and disposal, and the use of opioid antagonists should also be provided (9).  

The incidence of substance use disorder is the United States remains high, even in light of steps taken by federal and states governments to address the problem (11). The cost of addressing opioid misuse takes a heavy toll on the healthcare system and both state and federal budgets. These costs pale in comparison to the impact on patients and families who are suffering under the heavy burden of substance use disorders (5, 11).  

Everyday patients and their families are affected by opioids and may feel the impact of joblessness, broken families, and death from overdose as result of the opioid epidemic. Measures taken by the state of West Virginia have raised awareness of the problem and helped address concerns related to prescribing and access (5, 7).  

This West Virginia Drug Diversion course is just one step in the right direction. Continuing education about prescribing, administering, and dispensing controlled substances is essential to help curb over-prescribing and to help identify patients at risk of substance use disorders, so early intervention can be provided. Likewise, patient education is needed to ensure patients are taught the skills to safely use opioids to manage their pain and to be prepared to take an active role in their treatment plans.  ​

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