Combating the opioid crisis: What physicians, nurses and pharmacists are doing at St. Joseph’s/Candler

The opioid epidemic is one that has the attention of everyone – from the White House to neighborhood cops. Hospitals are certainly no exception, and St. Joseph’s/Candler is actively changing to address this epidemic.

Pain management has changed over the last five or so years, says Dr. Kit Melton, hospitalist with Chatham Hospitalists at St. Joseph’s/Candler. Physicians are not prescribing opioids like they used to. Therefore, patients should not come to the hospital or emergency room expecting their pain will be treated with an opioid.

“Historically, pain was treated as the fifth vital sign and treated in the manner it was perceived,” Dr. Melton says. “Now, we are in an epidemic and pain is looked at differently. It is no longer a vital sign. We have an ethical obligation to treat pain. We look at their diagnosis, and we know what hurts or should hurt, and we write for pain medication or an alternative.”

Opioids are a class of drugs that include legal, illegal and synthetic drugs. These drugs act on opioid receptors on nerve cells in the body and brain to relieve pain.

Examples of legal, prescribed opioids include morphine, hydromorphone (better known by the brand name Dilaudid), oxycodone (Percocet or OxyContin) and hydrocodone (Vicodin). Fentanyl is a common synthetic opioid. Examples of illegal opioids include heroin and illicitly manufactured fentanyl. 

Opioids are top of the line for pain control, says Erica Merritt, PharmD, BCPS, Clinical Pharmacy Specialist of Emergency Medicine in the Candler Hospital Emergency Department. When used properly, they can be helpful to control chronic and severe pain. However, they also are highly addictive.

“The longer you are on an opioid, the more you need to get the same effect because more receptors develop in the body,” Merritt says. “Especially with patients with a chronic pain issue, they need higher and higher doses and more and more and more to get the same relief. If somebody is on chronic pain medication, or even someone who was on it temporarily, and they like the way it made them feel, you get addicted to it.”

Because opioids are easily addictive, there’s been a steep rise in opioid overdoses within the last several years. So much so that the United States is in the midst of an opioid overdose epidemic. It has grabbed the attention of many including physicians, nurses, pharmacists and others at St. Joseph’s/Candler.

“From a medical standpoint, there are people with a true medical disorder and they need these pain medications but it also can breed this problem of addiction,” Merritt says. “Then, there are people that abuse them and don’t have a reason to be taking these medications, especially for the long term.”

According to the latest numbers from the Centers for Disease Control and Prevention, opioids killed more than 42,000 people in 2016, more than any year on record. That’s an average of approximately 115 Americans dying every day from an opioid overdose.

The CDC also reports 40 percent of all opioid overdose deaths involve a prescription opioid. Emergency departments are seeing the epidemic first hand. According to another CDC report, ED visits for suspected opioid overdoses increased 30 percent in the United States from July 2016 through September 2017.

St. Joseph’s/Candler policies and practices

St. Joseph’s/Candler has set policies on pain management and drug administration. The patient care policy on pain management states:

“It shall be the policy of St. Joseph’s/Candler Health System, Inc. to require an initial assessment and ongoing reassessment of pain to ensure optimal patient comfort, which is established with the patient, family and interdisciplinary healthcare team.”

“Our goal is for every patient to always be comfortable,” says Marianne Fields, MSN, RN, NE-BC, Director of Patient Care Services at St. Joseph’s/Candler. “We want to make sure we are informing patients, communicating well and giving them the information in a way they can understand.”

St. Joseph’s/Candler staff uses a pain scale of 0 to 10 when discussing pain with a patient. The numeric pain intensity scale is a 10-point scale on which the patient rates the intensity of their pain by choosing a number from 0 (no pain) to 10 (pain as bad as it could be). Staff also may use the Wong-Baker Faces. This description pain rating scale is represented by faces with expressions. Zero is represented by a smiley face, while 10 is represented as a distraught, crying face. For patients that are unable to communicate their pain level effectively, nurses look for objective measurements such as crying, increased vital signs and expressions.

Once pain is identified, the patient’s care team will set management goals, determine what is best to alleviate pain and try to determine what is causing the pain.

“Pain management is a sticky thing,” Dr. Melton says. “We have to get a feel for the pain level and see if it’s consistent with the injury or condition.”

Physicians have guidelines to follow and an ethical obligation when it comes to pain management. If it’s new chest pain with sweating and signs of a heart attack, then physicians know pain is present and often prescribe morphine. If it’s abdominal pain or a headache, Dr. Melton says pain can be more subjective. He’ll look at a patient’s vital signs, such as blood pressure and heart rate, to help determine the level of pain and most likely will prescribe acetaminophen.

Physicians also consider side effects of certain medications. Some opioids can cause abdominal pain in some patients; therefore, physicians may look for an alternative to treat stomach pain.

“People have strong opinions about pain management,” Dr. Melton says. “We talk to them and explain what we are prescribing and why we are not prescribing something. We try to educate our patients on why or why not we are giving them certain things.”

St. Joseph’s/Candler also has policies on how often and the amount of a certain medicine that can be given over time.

For example, for patients who haven’t had a lot of opioids in the past, a physician may prescribe Dilaudid (a brand of hydromorphone) through IV. Physicians take into account a patient’s history and tolerance to opioids as well as severity of pain to determine the amount and frequency of Dilaudid.

Such policies are in place partly due to the side effects of opioids, among which is respiratory failure.

“These drugs do have side effects, which is part of why we are worried about this epidemic,” Merritt says. “A main side effect is respiratory depression, which could be a risk to your health and life. Some people have the expectation that they want more, more, more, but we also have to balance side effects and keep you safe.”

Keeping patients comfortable and other opioid alternatives

Physicians look at all treatment options to treat pain, not just medication. For example, Dr. Melton says he may recommend physical therapy if he believes that will help a condition therefore alleviating the pain.

Even pharmacists look at alternatives to pain management before recommending opioids. Examples include heat and ice, massage, yoga, acupuncture, elevation for joint pain, rest, steroids for inflammation and maybe even surgery.

“Opioids aren’t necessarily going to fix the cause of what is causing the pain,” Merritt says. “A lot of times when you see a doctor, that physician is going to ask a lot of what may seem like annoying questions. When you are in pain, you just want something to make it better, but that doctor is trying to get to the root of what is causing that pain and what would be best to treat it.”

Another alternative to pain medication or a compliment to it is comfort.

Keeping patients comfortable is a big focus of the nursing staff. In addition to accessing a patient’s pain every shift, nurses also address their comfort levels, Fields says. Examples of things nurses can do to improve comfort levels are:

• Repositioning a patient in bed
• Adding a fan to the room
• Putting the patient in a warm bath
• Turning out the lights
• Talking in soft tones
• Having a dietitian review a patient’s diet and make suggestions
• Asking pastoral care to talk to a patient
• Listening to light music through The Care Channel
• Adding a pillow or a blanket to the bed

“Our goal is to keep them safe yet comfortable,” Fields says. “We feel really solid that improving a patient’s comfort level is a compliment to what the physician has ordered.”

Preventing addiction and overdoses

If you are prescribed an opioid, it is important to follow the doctor’s orders precisely. It’s also very important to never take a medication that was not prescribed to you.

“Typically the people we see that are overdosing are the people taking the medications incorrectly, specifically those that are purposely abusing them,” Merritt says. “If you are taking it as prescribed and taking it appropriately, you shouldn’t have any issues.”

Physicians and hospital staff are doing what they can to try to combat the opioid crisis.

One such example that many states are doing, including Georgia, is creating prescription drug monitoring programs (PDMPs). This electronic database tracks a person’s controlled substance prescriptions prescribed within the state. Providers register with the PDMP to document what’s been prescribed and consult a patient’s prescription history.

Merritt, who is registered with the program in Georgia, believes the database is helping some. Unfortunately, so much of the epidemic comes from either people selling it illegally or obtaining it illegally.

“We can’t just take opioids off the face of the planet because they do have a very important place in therapy,” Merritt says. “When used appropriately, when used safely, they can be very helpful. Unfortunately, people find all kinds of creative ways to abuse things that were meant to help.”