By Michael Wong, JD (Founder & Executive Director, Physician-Patient Alliance for Health & Safety)
Our Opioid Dichotomy
Opioids are something we love and hate, all at the same time. On the one hand, they are a great pain reliever and are often used to provide analgesia and supplement sedation during general anesthesia or monitored anesthesia care. On the other hand, opioids can be addictive and too much opioids can lead to opioid overdose and death. Justine Igwe (Nursing Student in Nigeria at the University of Nigeria Enugu Campus) recently wrote about opioids’ pain relief vs. addiction/overdose dichomotomy:
When consumed, opioids activate the release of endorphins (the feel-good neurotransmitters) which suppresses the perception of pain and intensify the feelings of pleasure, creating a temporary yet powerful sense of well-being.
However, when the dose wears off, the patient feels depressed and wants another dose which will make them feel that sense of well-being again. (This is actually the first point toward potential addiction).
Opioids have now become a substance of concern as the world is fighting to strike a balance between their use as pain relievers and euphoriants necessitating abuse. Tragically, the CDC estimates that about one million people have died of drug overdose since 1999, of which 82.3% were opioid-involved overdose deaths involving a synthetic opioid.
As expected, reducing the burden of suffering from pain and reducing opioid addiction and overdose deaths pose a major public health challenge.
#1 – Follow Pain Management Guidelines on Opioids
The American Society for Pain Management recently released guidelines on “Nursing Guidelines on Monitoring for Opioid-Induced Advancing Sedation and Respiratory Depression” (ASPN Nursing Guidelines). In issuing these guidelines, the report underscores the necessity of the importance of managing opioids:
As the complexity of analgesic therapies increases, priorities of care must be established to balance aggressive pain management with measures to prevent or minimize adverse events and to ensure high quality and safe care. Opioid analgesia remains the primary pharmacologic intervention for managing pain in hospitalized patients. Unintended advancing sedation and respiratory depression are two of the most serious opioid-related adverse events.
As the report is about monitoring patients, two commonly used monitoring devices should be noted:
- Pulse Oximetry – Pulse oximeters, which measure oxygen saturation, are commonly used on almost all patients in-hospital. However, the report concludes that it is “difﬁcult to determine the beneﬁts of pulse oximetry monitoring because the numbers of patients studied were small and episodes of hypoxemia were rare.”
- Capnography – Monitoring with capnography, which measures the adequacy of ventilation, is recommended. The report states:
End-tidal CO values obtained via capnography are a surrogate measure of perfusion and ventilation. Capnography is considered to be a more sensitive measure and early indicator of respiratory compromise, including respiratory depression from decreased central respiratory drive and diminished chemoreceptor responsiveness as well as decreased airway tone resulting in obstruction. Research shows that capnography can detect compromised respiratory status before oxygen desaturation or diminished chest excursion is observed.
Although directed towards nurses, these guidelines should be followed by all clinicians who administer opioids to a patient.
#2 – Monitor All Patients Receiving Opioids In-Hospital
All patients receiving opioids in healthcare facilities should be continuously electronically monitored with pulse oximetry for oxygenation and with capnography for adequacy of ventilation. For the Physician-Patient Alliance for Health & Safety statement on Continuous Electronic Monitoring, please click here.
#3 – Identify At-Risk Patients for Opioids Using the PRODIGY Risk Assessment Tool
The ASPN Nursing Guidelines recommend that nurses identify patients at risk for unintended advancing sedation and respiratory depression from opioid therapy. To make that patient assessment, I recently interviewed Ashish K. Khanna, MD, FCCP, FCCM, FASA (Associate Professor and Vice-Chair of Research; Director, Perioperative Outcomes and Informatics Collaborative; Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist).
The PRODIGY risk assessment tool uses five independent variables: age over 60 years of age (in decades), sex, opioid naivety, sleep disorders, and chronic heart failure. All of these variables are easily available in the EMR or can be gathered from a thorough history taking and clinical assessment. Importantly, the tool is easy to use, available and can be configured at the bedside by all levels of providers (not just physicians ), and would also be very easily deployable as an actionable alert in the EMR.
3 Things Clinicians Can Do to Improve Patient Safety and the Quality of Patient Care
Clinicians can do these 3 things to improve patient safety and the quality of patient care:
- Follow Pain Management Guidelines for Opioids
- Monitor All Patients Receiving Opioids In-Hospital
- Identify At-Risk Patients for Opioids Using the PRODIGY Risk Assessment Tool