Don't overlook prescription drug abuse
Have a high index of suspicion
Is your patient presenting with vague complaints of abdominal pain, flank pain or a history of renal stones, recurrent dislocations, or intentional trauma? Consider the possibility of pain medication abuse. (See story, below, on new CDC report on ED visits for non-medical use of pain medications.)
"The abuse of prescription pain medications plagues northeast Tennessee and southwest Virginia," says Robert Rutherford, BSN, RN, CEN, CPEN, a shift leader in the ED and Trauma Center at Bristol (TN) Regional Medical Center. "The number of patients addicted to prescription analgesics such as oxycodone, methadone, and others has been increasing in our area for the past several years."
Bristol Regional's ED nurses are seeing more patients with a history of narcotic abuse, Rutherford reports. He says to remember that any patient who presents with an acute altered level of consciousness could be exhibiting signs of prescription drug overdose.
"That possibility should be considered until the etiology is determined," he says. Rutherford says to do the following:
Observe for physical signs of intoxication.
These include slurred speech, strange behavior, lack of coordination, constricted pupils, and impairment of attention or memory, says Rutherford.
Obtain an accurate history of the events preceding that patient's arrival to the ED.
Rutherford says to ask, "When was the onset of symptoms?" and "Where was the patient when symptoms began?"
For noncommunicative patients who arrive via emergency medical services (EMS), determine who activated EMS and why.
"These are important questions to ask, especially if overdose is suspected," says Rutherford. "Someone was concerned enough about this individual to call 911. That person should be able to provide some history and even a little context is better than none."
Carefully monitor vital signs.
"This is a priority in patients where overdose is suspected," says Rutherford. "Patients who exhibit altered levels of consciousness should have continuous cardiac monitoring, blood pressure monitoring and pulse oximetry. Capnography can be useful in the early detection of respiratory depression in these patients."
Look for withdrawal
Does your patient have a history of using opioid pain medications? If so, be observant for symptoms of withdrawal, including nausea, vomiting, diarrhea, rhinorrhea, lacrimation, diaphoresis, or piloerection, says Rutherford. Patients experiencing withdrawal can be febrile and/or tachycardic, he adds.
"While the effects of overdose are generally calming or dulling, patients exhibiting withdrawal symptoms can be agitated or aggressive," notes Rutherford. "Patients who have experienced withdrawal before are likely terrified that they are going to suffer it again."
To avoid behavior escalation, Rutherford says to be reassuring and show empathy. "Develop a rapport with these patients simply by treating them normally and nonjudgmentally," he says.
Identify, but don't judge
Diane Collins, RN, an ED nurse at California Pacific Medical Center St. Luke's Campus in San Francisco, has treated many patients who are addicted to legal pain medications.
"Much of the discussion surrounding treatment of patients abusing pain medications tends to revolve around the identification of drug-seeking behavior," she says. "While many outside the profession speak of the perceived immorality of drug-seeking behavior, morality or condemnation of said behaviors have no place in my practice."
The ED nurse's first concern is to treat the stated symptoms, says Collins. "That said, while I cannot judge or condemn painkiller abuse, it is my job to identify it," she says.
Look for these two signs
Collins says to suspect abuse of pain medication if you see:
- "pinpoint pupils," drowsiness, slurred speech, and poor equilibrium;
- low blood pressure, slowed heart rate, and respiratory depression.
"If the patient tells me that they suffer from chronic pain, I ask the patient whether they have an existing relationship with a physician," says Collins. "Many patients mention lost prescriptions, and many patients speak of histories with a litany of physicians and/or pain specialists."
The biggest reason to identify drug-seeking behavior is to assess whether the patient already has legal or illegal narcotics in their system, she says. "Since an emergency physician may eventually treat the patient's pain with certain powerful medications, it is of critical importance that the physician not administer medications that will adversely react with substances already in the patient's system," Collins says.
New info on ED visits for pain med abuse For the first time, ED nurses are caring for as many patients for non-medical use of over-the-counter and prescription pain medications as for illegal drugs, according to a new report from the Centers for Disease Control and Prevention.1 Also, according to the Food and Drug Administration (FDA), inappropriate use of dextromethorphan, an ingredient found in more than 100 over-the-counter medications, was linked to nearly 8,000 emergency department visits in 2008, which is a 70% increase from 2004. Are there more patients coming to the ED that are "drug seeking"? "This is the age-old question, and the fear of emergency nurses and physicians nationally," says Paula Tanabe, PhD, RN, MPH, an emergency department nurse at Northwestern Memorial Hospital and research associate professor in the Department of Emergency Medicine at Northwestern University, both in Chicago. "However, there has been a lack of strong data to support this claim." According to Tanabe, the belief held by many ED nurses and physicians that many ED patients are drug seeking is "truly the bigger problem and helps contribute to poor pain management in the ED." Tanabe says ED nurses should fully understand the CDC report before applying the findings to clinical practice. She notes that the non-medical use of opioids increased from 144,600 patients in 2004 to 305,000 in 2008. "Placed in context, there were 117 million ED visits in 2007,2 One must ask, is the ED really contributing to this 'epidemic?'" asks Tanabe. There is no screening tool that can accurately predict which patients are at risk of becoming addicted, she says. "In the context of a brief ED visit, it is impossible to identify who may and may not be at risk," Tanabe says. She makes these recommendations: Keep in mind that a past history of drug or alcohol abuse is a predictor of abuse. "However, even individuals addicted to opioids who have severe pain are entitled to receive analgesics," says Tanabe. "Nurses must remain the patients' advocate." Identify whether an individual patient has been filling opioid prescriptions from multiple different providers. "If a nurse is suspicious for whatever reason, most states have prescription drug monitoring programs," says Tanabe. "ED physicians can access these web-based programs and identify all prescriptions filled including dates, locations, and agents." Give a referral if you believe a patient has a substance abuse problem. "If you have a patient whom you are very confident may have an addiction problem, you are obligated to make a referral for addiction treatment," says Tanabe. References
Resource A June 2009 joint position statement on pain management is available from the Emergency Nurses Association, the American College of Emergency Physicians, the American Society of Pain Management Nurses, and the American Pain Society. To access the statement, go to www.acep.org. Under "Practice Resources," click on "Policy Statements." Scroll down to "Optimizing the Treatment of Pain in Patients with Acute Presentations." |
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