The United States (US) is in the midst of an opioid epidemic. Frontline providers, such as emergency department (ED) nurses, are pivotal in providing care to individuals with pain-related complaints. ED visits related to opioid use have increased across the country, and evidence is mounting that the initial opioid prescription is associated with continued, long-term use (Barnett, Olenski, & Jena, 2017). It has been estimated that nearly 20% of persons taking opioids will misuse their prescription, and four out of five new heroin users began abusing drugs by misusing prescription pain medication (Centers for Disease Control and Prevention [CDC], 2017). The number of opioid overdoses is now five times higher than in 1999, with an average of 115 Americans dying every day from opioids (CDC, 2017). To combat the epidemic many initiatives have been inaugurated. Although the CDC has instituted guidelines for prescribing opioids for chronic pain, there is still ambiguity regarding acute pain prescribing practices. Based upon the extent of opioid misuse in the US, it is clear that the problem requires additional action at many levels.
'Helping to End Addiction Long-Term' (HEAL) is a new, interdisciplinary initiative by The National Institutes of Health (NIH) aimed at improving treatments for opioid misuse addiction and improving pain management (Collins, Koroshetz, & Volkow, 2018; NIH, 2018). While the HEAL initiative has successfully contributed to the strategies for responding to the opioid epidemic, it is not an upstream defense approach to address the treatment of acute pain.
Similarly, the evidence-based, Screening, Brief Intervention and Referral to Treatment (SBIRT) tool, which has been recommended to identify individuals for risky behavior related to current substance use, provides guidance and provision for a brief verbal intervention and referral to treatment, but does not provide guidelines for treating acute pain (Substance Abuse and Mental Health Services Administration [SAMHSA], 2011). SBIRT’s aim is to identify non-dependent substance users for early intervention, thus preempting opioid misuse or abuse (SAMHSA, 2011). However, the opioid naïve individual, who may be at a high risk for a substance use disorder (SUD), potentially falls through the cracks when receiving care in a setting such as the ED.
The use of a predictive model to assess for opioid abuse potential is an approach to mitigate the risk of SUD and addiction. Unfortunately for ED providers, no guidelines for acute pain management exist. In the chronic pain guideline, assessment tools to assess potential for opioid-related harm are discussed. Risk assessment tools that have been evaluated for risk stratification in chronic pain instances include: the opioid risk tool (ORT), screener and opioid assessment for patients with pain, revised (SOAPP-R), and brief risk interview (BRI). Results were inconsistent, and no study evaluated the effectiveness of these mitigation strategies (CDC, 2016).
Assessing an individual’s risk factors for SUD or misuse prior to receiving the first opioid prescription will heighten specific awareness of potential psychiatric and biopsychosocial variables that may predict long-term opioid use and have the potential to impact the opioid crisis long-term (Jones, Schmidt & Moore, 2015). Preventing the transition from initial opioid use to non-prescribed opioid use is key for prescribers. An individual factor that has been found to increase the risk of long-term opioid use is that of diagnosed psychiatric disorders, such as attention deficit and hyperactivity disorders (Mason, 2018). Individuals with mental health diagnoses and a history of non-medical use of prescription drugs have a strong propensity for SUD (McCabe, 2008). Routine screening to assess for misuse or a risk of SUD should be the initial step in prescribing opioids for acute pain. Integrating a screening tool into an electronic medical record may be a feasible approach for conducting an opioid abuse risk assessment (Weiner, Horton, Green, & Butler, 2015a).
Although the CDC guidelines for chronic pain management recommend the use of screening tools, no screening tools have been validated in the ED setting (CDC, 2016). As a result of the opioid epidemic, research has been conducted to evaluate tools regarding patients’ self- report of drug use, and the incidence of persistent drug use post-discharge following an opioid prescription from the ED. However, these are downstream findings and not preventive approaches. The ED setting is a key area in which to implement an opioid misuse or abuse screening tool, though few tools have been studied explicitly for emergency department use (Weiner, Horton, Green, & Butler, 2015b).
Studies are being conducted to evaluate a screening tool for trauma patients so as to identify opioid risk for victims of traumatic injury. Opioid prescribing practices for trauma patients may be modified as a result of this study (Brown et al., 2017). Researchers are evaluating the many independent variables which are included in 18 questionnaires, scales and/or assessment tools. The study is multifactorial with a goal of compiling a tool that will predict opioid misuse or abuse. One screening tool, the Screener for Opioid Assessment for Patients with Pain Revised (SOAPP-R), has been validated in specialty pain clinic practices, but to date has not been adequately studied in the ED. The SOAPP-R was found to perform sub-optimally in the ED, although it may be a feasible tool until further research validates a potential, ED-specific risk potential tool.
Currently, there is no validated tool available for nurses to identify patients who are at risk for misuse and abuse in the ED setting. We are missing an opportunity both for identifying potentially high-risk individuals, such as the opioid naïve patient, and the opportunity for prevention. Guidelines for acute pain management are critical for the provision of appropriate ED care. Organizations that focus on the promotion of safe care and practice must partner to support and conduct research that will ensure the ED is not the gateway to opioid misuse and SUD.
Jeannie Burnie, MS, APRN, AGCNS-BC, CEN, FAEN
Angela Clark, PhD, RN