PODCAST week 12 FINAL

Nicholas Popp, a registered nurse, is working on his Doctor of Nursing Practice degree and is focused on prescription opioid abuse. In this podcast episode, he discusses pain management and the prescribing of opioids with a colleague from a rural urgent care clinic. They also talk about non-opiate interventions for pain management, opioid dispensing data in Minnesota and the US, and the nation's efforts to address the opioid epidemic. They define opioids, highlight the opioid epidemic in the US, and discuss the prescribing of opioids for pain management in central Minnesota. They also mention the relevance of this topic to primary care providers and interview a nurse practitioner from an urgent care clinic who shares her experience with prescribing opioids. They discuss concerns about multiple pain medications being prescribed and the use of a tool called a prescription drug monitoring program to monitor opioid prescriptions. They also touch on opioid addiction and withdrawal symptoms. Hey, everyone. My name is Nicholas Popp and I am a registered nurse who has been working in rural Minnesota healthcare systems for nearly six years. I'm currently in the first year of obtaining my Doctor of Nursing Practice degree. I'm more than excited to dive into the topic of prescription opioid abuse as this will be the epicenter of my doctoral project. This podcast is for anyone in the healthcare field who is curious about the unintentional consequences that come with prescribing opioids for pain management. In this episode, we will be speaking with a colleague of mine who works as a nurse practitioner in an urgent care clinic here in rural Minnesota. We will be discussing pain management and the subsequent prescribing of opioids and we will discuss what non-opiate interventions clinicians can offer their patients for pain management. We will also go over some epidemiologic data regarding prescription opioid dispensing in Minnesota and throughout the United States. Lastly, we will discuss how the nation is currently addressing the opioid epidemic. With that, let's get into the meat and potatoes of the issue that is opioid use and misuse. First of all, well, what is an opioid? According to the University of Michigan Medical School, an opioid is a class of drug that binds to opioid receptors in your brain and throughout your body. These receptors are responsible for controlling someone's pain. Opioids are prescribed in the primary care setting to help patients manage severe pain, especially after major surgical procedures or injuries. Believe it or not, we already have opioids circulating throughout our bodies. These are called endorphins, which have been coined as feel-good chemicals. The federal government and state government bodies have been fighting what is known as the opioid epidemic in the United States. According to the Robert Wood Johnson Foundation, 50 Americans die each day from overdosing on prescription opioid pain medications. Another harrowing statistic is that the prescription opioid overdose deaths have quadrupled to 16,000 per year since 1999. Now, let's look at how central Minnesota handles the prescribing of opioids for pain management. The following data was accessed through the Center for Disease Control and Prevention's opioid dispensing map. In the tri-county area that involves Morrison, Stearns, and Crow Wing counties, on average 30.63 opioid prescriptions per 100 people are ordered. Minnesota performs relatively well, on average with less than 36.1 opioid prescriptions per 100 people. The southern states, however, for example, Louisiana, Arkansas, Missouri, Alabama, and others prescribe over 52.8 opioids for pain management per 100 people. There is some speculation on why this is the case, but the Centers for Disease Control and Prevention believe this is mostly in relation to cultural expectations for pain management. Before we get into our scheduled interview, we need to discuss the relevance of this topic to primary care providers. The American Medical Student Association has stated that nearly half of all prescription opioids are prescribed in the primary care setting, and the act of writing out opioid prescriptions has nearly quadrupled since 1999 to 2014. With that being said, a formal introduction is in order for my colleague and good friend Sarah, who is a nurse practitioner in an urgent care clinic. Hello, Sarah. I'm so glad to hear from you, and thank you for taking some time away from your busy schedule to answer a few questions about chronic pain management and opioid use in the primary care setting. So, Sarah, if you don't mind, please fill the audience in on who you are, what it is that you do, and how long you've been in the nursing profession. Thank you, Nick. I'm so happy to be able to help. Hi, everyone. I'm Sarah Turbo. I graduated with a master's degree as a family nurse practitioner in 2020. I have been working in the urgent care setting in a small rural community for the past two years. Prior to this, I had experience as a registered nurse in both long-term care and in the hospital setting as a med-surg nurse and ICU nurse. Fantastic. So, the first question I have for you as an urgent care provider is, how often are you seeing patients in the urgent care setting that are seeking opioid pain medications for pain management? Well, being in a rural community and in the urgent care setting, we are not actually seeing that as often as you'd think. When we do prescribe opioid medication for certain cases, such as kidney stones or rib fractures, that can be pretty painful. We usually only prescribe two to three days' worth of pain medications and then have them follow up with their primary for further management. We do get patients that come in frequently who want their pain meds refilled, but we actually don't refill medications as a service either. In the urgent care, we do see and treat a lot of acute and chronic pain, but we don't have a lot of medications in the urgent care such as morphine or Oxycontin that we can treat with. The only medications we really have in the urgent care to give patients is Tylenol, Ibuprofen, Toradol. So, if a patient comes in with severe pain, we usually have to send them to the emergency room for a higher level of care. Wow. It sounds like you got a pretty good handle on that, I'd say. So my next question, have you ever felt concerned about how many pain medications a patient is being prescribed through their primary care provider? For example, this could be related to the quantity of pills for the opioid prescription or the patient is being prescribed multiple different opioids for pain management. So, I do feel concerned when I'm seeing patients on multiple pain medications, especially if they have a lot of pain medications along with psych medications. When I do usually have a concern about these patients, I utilize our chain of command and bring it to our clinic manager for further evaluation. So, in the urgent care setting, we use like a, it's called a PDMP tool, a prescription drug monitoring program. It's an easily accessible tool through our charting system. This gives us detailed report of a patient's recent and current opioid prescription medications and then along with a 30-day average of their MME report, which is a morphine milligram equivalent. And this is used for patients who are on more than one opioid prescription. This gives us like their overdose risk score. We actually are prompted to review this PDMP score prior to prescribing any opioid medication. So, this works really well to be able to assess how much pain medication they are on along with, you know, if other people are prescribing it as well. So, it's a good tool to use for providers in urgent care and in a primary care setting to make sure that we aren't overdosing our patients on pain medications. That's all I've really got for questions, Sarah. Thank you so much for your time. I really appreciate it. You are welcome. Sarah brought up a great point, which is the morphine milligram equivalent and or MME, which is defined by the Centers for Disease Control and Prevention as a tool to gauge overdose potential in certain patients. This source of information is a level one resource based on Winona State University's evidence-based practice toolkit. The MME is based off of evidence from a systematic review or meta-analysis of all relevant randomized controlled trials. So far in the podcast, we have identified what an opioid is and why it is prescribed in primary care settings. Now, let's address the real elephant in the room here, which is opioid addiction. Kostin and George state that opioid dependence occurs because the brain's opioid receptors become less responsive to the supplemental opioid stimulation. Therefore, someone who has become dependent on opioids is going to need more opioids or stronger concentrations of opioids to obtain a satisfactory level of pain relief or to continue to obtain the high they are chasing. The manifestations of opioid withdrawal symptoms like increased pain, agitation, malaise, nausea, and anxiety are very common. Kostin and Baxter state that these symptoms can last anywhere from 5 to 14 days, and in a study that included patients with chronic pain, over 50% of these patients who were prescribed opioids for pain relief didn't want to quit taking them because of the withdrawal symptoms. Kostin and Baxter conducted a systematic review of several studies pertaining to opioid withdrawal symptoms and their subsequent management to reach these conclusions, making this a Level 5 resource based on Winona State University's Evidence-Based Practice Toolkit. The evidence-based hierarchy ranges from Level 1, which refers to having the lowest risk for possible bias, to Level 7, which has the highest risk for potential bias. All of this begs the question, what are we doing today to combat the opioid crisis and how did we get here? In the early 1970s to 1990s, opioids were touted as safe and effective for acute and chronic pain management. In the late 90s, pain was recognized as the fifth vital sign by Dr. James Campbell during a meeting with the American Pain Society, which led to an increased prescribing rate of opioids for pain management. Now in the 2020s, President Joe Biden awarded $1.5 billion for all states to address the current and future opioid crisis. This means that this money will be used to provide resources to those who struggle with substance use disorder, like 24-7 medication-assisted treatment centers, access to naloxone to prevent opioid overdoses, and this money can also be used to invest in opioid education. The American Medical Association did issue a report in 2021 showing that there has been a 44.4% decrease in opioid prescribing over the last decade. However, drug-related overdose and death have increased. According to Dr. Gerald Harmon, the president of the American Medical Association, a few reasons for continued opioid overdose and death is a result of insurance companies continuing to require prior authorization for medicinal therapies to treat opioid use disorder and not having naloxone readily available to disparaged communities. This is a Level 6 citation based on Winona State University's level of evidence hierarchy because the cited evidence is from a single quality improvement and or evidence-based practice study. I am hopeful that in my future practice as a nurse practitioner, these options to treat and combat the opioid epidemic will be made available to me. Thank you for listening to my podcast and God bless.