Controlled Substance Prescribing: The Tennessee Chronic Pain Guidelines (FL INITIAL Autonomous Practice-Pharmacology)

Opioids manage pain but are associated with many risks, including abuse, diversion, and inappropriate use. Tennessee ranks in the top ten per capita for opioid prescriptions, and there has been a recent increase in unintentional overdose deaths (Tennessee Department of Health, 2020). The state of Tennessee created a guideline to help clinicians effectively and safely prescribe opioids. This guideline assists clinicians in prescribing opioids and other controlled substances safely and effectively.

A controlled substance is a drug, compound, preparation, mixture, or substance contained in Schedule I, II, III, IV, or V. This list is updated annually, and substances are classified into their schedules based on the substance's current medical use, abuse potential, and the likelihood of causing dependence.

Controlled substances are laced with risks. Understanding the dangers of controlled substances is critical for proper prescribing. The prescriber who understands the medications and prescribes them appropriately will provide better and safer care for their patients.

Prescription opioid abuse takes a heavy toll on the patient, healthcare provider, and society. Abuse and misuse of controlled substances occur for multiple reasons, including self-medication, use for reward, diversion, and compulsive use. Opioid use has increased in recent times leading to an increase in abuse and opioid overdoses. Proper screening lowers the risk of iatrogenic addiction. Unfortunately, no currently available screening method accurately predicts who is at high risk of abuse or misuse of opiates.

Misuse of prescribed medications describes potentially aberrant drug-taking behaviors. In 2016, 48.5 million individuals in the United States misused prescription drugs or used illicit drugs (Hoots et al., 2018). Sixty-six percent of the 630,000 drug overdose deaths were due to illegal or prescription opioids. The number of opioid overdoses in the emergency department increased by 30 percent from July 2016 to September 2017 (Hoots et al., 2018).

Healthcare providers tend to under-assess patients at risk for opioid-related aberrant behaviors. One study showed that providers assessed the risk of misuse, abuse, or diversion at less than 2% when in reality, 10.4% of patients had prior illicit drug use, 23.4% had abnormal urine drug tests, almost 11% reported crushing or chewing opioids in the past and 60% of patients self-reported abuse, misuse, or diversion (Setnik et al., 2017).

Prescriber lack of training and inexperience can have a profound impact on misuse of medications. One study showed that resident physicians (compared to attending physicians) were more likely to prescribe opioids for more than three months (Strain et al., 2020). In addition, they were more likely to have their patients report that their prescriptions were lost/stolen. They were also more likely to have patients who exhibited substance misuse and were more likely to have their patients get opioids prescribed by a different prescriber in addition to them.

Prescribers receive little training in prescribing scheduled substances, screening for substance abuse, and referring patients who need substance abuse treatment. Proper continuing education is one way to address this problem.

The National Institute of Drug Abuse (NIDA) reports findings on the cost of drug use. Data from NIDA suggests that illicit drug use is very costly to the United States, costing more than $740 billion each year in costs related to crime, lost work productivity, and health care. See Table 1, adapted from the NIDA (National Institute on Drug Abuse, 2017).

Substance abuse issues are a genuine concern in the management of pain. Inappropriate prescriptions of pain medications have the potential to increase patients' chances of medication abuse. Below are some statistics regarding the current state of substance abuse:

• According to the Centers for Disease Control and Prevention (CDC), 41 people die each day in the United States from an overdose of prescription painkillers (Centers for Disease Control, 2020).
• Overdoses from synthetic opioids increased from 3.1 per 100,000 people in 2015 to 6.2 people per 100,000 people in 2016 (Hedegaard et al., 2017).
• Between 1999 and 2015, drug overdose deaths have tripled (Black et al., 2020).
• About 53 percent of people who have ever tried heroin develop heroin abuse or dependence (Strain et al., 2020).

Prescription drug misuse involves using prescription medication in a method or intent inconsistent with how it was prescribed. Misuse includes using medicine to get high, selling or sharing it with others (diversion), overuse, having multiple prescribers, and concurrent use of alcohol or other illicit substances. Misuse is a necessary but not solely a sufficient criterion for a substance use disorder (McKay, 2020).

Susceptible individuals are at risk to misuse medications that stimulate the brain's reward center, including opioid analgesics, stimulants, benzodiazepines, or tranquilizers. Medically or socially inappropriate drug use defines drug abuse. Controlled substances may lead to dependence, either physical or psychological. Physical dependence transpires when withdrawal symptoms include anxiety, tachycardia, hypertension, diaphoresis, a volatile mood, or dysphoria after the substance's rapid discontinuation (McKay, 2020).

Psychological dependence is the perceived need for the substance (McKay, 2020). It makes the person feel as though they cannot function if they do not have the substance. Psychological dependence often kicks in after physical dependence wears off. It typically lasts much longer than physical dependence and often is a substantial contributing factor to relapse.

Addiction is psychological dependence and extreme behavior patterns associated with the drug (McKay, 2020). At this point, there is typically a loss of control regarding drug use and continued drug use despite severe medical and social consequences. Tolerance, increasing doses of the medication needed to produce an equivalent effect, typically occurs when addiction is present. Physical dependence can occur without addiction. Individuals who take chronic pain medication may be dependent on the medication but not addicted (McKay, 2020).

Addiction is a primary concern in those taking opioids. When prescribing opioids, it is essential to determine who is likely to participate in aberrant drug-related behaviors. Misuse may occur in those with major depression, psychotropic medication use, younger age, or family or personal history of drug or alcohol misuse. The prescriber and a specialist should co-manage the patient.

Aberrant behaviors may include abuse, misuse, or addiction. Examples of aberrant drug-related behaviors include (McKay, 2020):

• Requests for early refills
• Not taking medications as prescribed
• Failure to keep appointments
• Visits in distress
• Frequent reports of lost medication
• Using multiple prescribers
• Positive urine drug test for illicit substances
• Altering prescriptions
• Resistance to referrals
• Resistance to providing prior medical records
• Resistance to change in therapy
• Increasing the dose without telling the prescriber
• Requests for specific drugs

With chronic pain and opioid use being so prevalent, the Tennessee Board of Nursing (BON) guides in chapters 1000-04 (Tennessee Board of Nursing, 2019). The chapter recognizes that controlled substances are an essential part of the armamentarium of the prescriber to manage a patient's symptoms. Pain is a subjective experience and effective medication and appropriate dose vary between individuals.

No discipline will be sanctioned on the Advanced Practice Registered Nurse (APRN) who treats legitimate pain with controlled substances in professional practice. The appropriate use of controlled substances is legitimate if based on scientific knowledge of the management of pain. The provider must document the history and physical exam before prescribing medications for pain. The history should include previous evaluations, any potential substance abuse history, other comorbidities, a psychological evaluation, and the reason for using the controlled substance (Tennessee Board of Nursing, 2019).

For disciplinary action to be considered on the APRN, the BON will look to ensure that the APRN prescribes consistent with public health and welfare and look for appropriate documentation and the use of a medication that is appropriate (Tennessee Board of Nursing, 2019). The length and quantity of the prescription are based on appropriate diagnosis, medical indication, and appropriate follow-up evaluations.

Tennessee Board of Nursing Chapter 1000-04.11 discusses minimum discipline for opioid prescribing. The board may impose one of many penalties on the APRN who violates the BON or committee's statutes or rules. These include a reprimand, mandating an educational program regarding opioids, restricting the power to prescribe opioids for at least six months, a civil penalty, or proof that the APRN notified all collaborating providers of the discipline (Tennessee Board of Nursing, 2019). APRNs who repeatedly violate rules regarding opioids receive a higher level of discipline.

Probation and a practice monitoring program may be implemented if APRNs violate the BON statutes or rules within one year of having their opioid privileges reinstated. The practice monitoring program may include quarterly reports that detail the APRNs' practice and prescribing habits and could include a restriction to prescribing opiates for at least one year and civil penalties at least twice the amount of the initial sanction (Tennessee Board of Nursing, 2019).

Addiction is a chronic condition that tends to relapse. Traditionally, treatment involved managing withdrawal signs and symptoms and then limited outpatient treatment, with the actual duration of outpatient treatment being less than 30 days (McKay, 2020). Research indicates that between 40 and 60 percent of individuals treated for drug or alcohol dependence go back to regular use within 12 months (McKay, 2020).

Management includes continual assessment of the patient's risk of relapse and treatment intensity is modified based on individual risk. Patients are taught self-management skills, utilize community support services, work with mental health providers, and take prescribed medications to manage drug addiction's physiological effects (Saxon & Strain, 2019).

Addiction leads to functional and structural alterations in the brain. Brain volume loss is seen with cocaine use, opiate use, alcohol dependence, and polysubstance abuse (McKay, 2020). In addition, dopamine and endorphins are changed in those who chronically use drugs and alcohol. Early life addiction may lead to difficulty obtaining practical life skills resulting in chronic functional deficits (McKay, 2020).

Addiction treatment has shifted to a chronic care model working with patients over time instead of short-term interventions during an acute crisis with addiction. Patients are taught skills to encourage self-management of addiction. Treatment involves linking patients to community resources.

Some addicted individuals need more care than others. Individuals who have been in recovery for extended periods may only require brief, sporadic assessments to manage their disease. Those who are at high risk of relapse may need long-term, intensive, structured care.

According to the Joint Commission Statement on Pain: "The hospital assesses and manages the patient's pain." The current Joint Commission standard requires that facilities implement pain assessment policies, treat pain, and carry out staff education to ensure the implementation of proper policies (Joint Commission, 2017).

Regardless of the patient setting, the intensity of pain should be assessed and documented (Joint Commission, 2017):

1. During the initial evaluation of the patient.
2. After any known pain-producing procedure.
3. With each new report of pain.
4. At suitable intervals after pharmacologic (45-60 minutes after an oral intervention; 15-30 minutes after parenteral intervention) or non-pharmacologic intervention to evaluate the current pain treatment plan.

Pain threshold refers to the minimal level at which an individual senses pain as a harmful stimulus. It is the level at which the patient first states that what they are feeling is painful and, as such, varies significantly from patient to patient.

Pain tolerance refers to the degree of pain a person can tolerate before it becomes unbearable for them. Pain tolerance differs from patient to patient and varies for the same individual depending on numerous factors, including time, setting, and stimulus. Healthcare providers must resist the temptation to compare patients' pain threshold and pain tolerance, especially those with similar procedures.

Measuring the severity of pain is often done on scales. Pain scales compare the intensity of the patient's pain at different time points, not to compare one person's pain to another. The use of pain scales assists the healthcare provider in determining the effectiveness of pain treatment.

It is essential to consider which type of scale would work best for the individual patient. The best scales are brief, valid, require minimal training, and use behavioral and descriptive pain measures. Patient education regarding pain assessment is also important; for example, before a surgical procedure, the nurse needs to discuss how their pain will be assessed after the surgery and demonstrate how the Numbering Rating Scale and the Wong-Baker FACES Pain Rating Scale work. After explaining each to the patient, allow the patient to choose which scale will work better.

In recent times, opioid therapy has become more commonly used. In the past, it was only used for severe acute pain and cancer pain (Black et al., 2020). A position paper from the American Academy of Neurology suggested evidence for good short-term pain relief with opioids. However, no good evidence exists showing continued pain relief or improved function with opioids for extended periods without sustaining a severe risk of dependence, overdose, or addiction.

Opioids function by activating opioid receptors that are located in the spinal cord and the brain. Most of the pain relief related to opioids is their actions on the periaqueductal gray (PAG) cells and the descending pain pathways. Opioid receptors are molecules located on the surface of cells; opioid substances attach themselves to them and release their effects.

There are three different opioid receptors found in the brain: Mu, Kappa, and Delta receptors (Strain et al., 2020). Mu and Kappa receptors are also found in the spinal cord and mediate pain transmission from the brain's peripheral nervous system. A primary pain receptor in opioid abuse and treatment is the Mu receptor. When opioids activate Mu receptors, the most significant potential for pain relief and addiction is initiated. However, Kappa and Delta receptors also play a role in opioid addiction.

The Controlled Substance Act divided drugs and other substances into five schedules, updated annually at www.deadiversion.usdoj.gov/schedules/:

• Schedule I controlled substances have no accepted medical use in the United States; they include heroin and lysergic acid diethylamide (LSD).
• Schedule II and IIN substances may potentially be abused and may lead to severe physical or psychological dependence.
• Schedule II narcotics include oxycodone (OxyContin®, Percocet®), hydrocodone (Vicodin®, Zohydro® ER), Fentanyl (Sublimaze®, Duragesic®), methadone (Dolophine®), hydromorphone (Dilaudid®), morphine, opium, and codeine.
• Schedule III or IIIN substances have less abuse potential than those substances that are Schedule I or II. They are at high risk for psychological dependence and low to moderate risk of physical dependence. Examples of medications in this class include buprenorphine (Suboxone®) and products with less than 90 milligrams of codeine per dosage unit, such as Tylenol with codeine. Schedule IIIN includes anabolic steroids such as Depo-Testosterone and ketamine.
• Schedule IV controlled substances have a lower potential for abuse when compared to Schedule III controlled substances. Examples of this class include benzodiazepines, midazolam (Versed®), tramadol (Ultram®), and carisoprodol (Soma®).
• Schedule V controlled substances have a low abuse potential relative to Schedule IV and include cough preparations containing less than 200 milligrams of codeine per 100 milliliters or 100 grams, such as Robitussin AC.

Most controlled substances alter mood, feeling, or thought due to their effect on the central nervous system. Medications likely to produce euphoria are more likely to be abused, but medications may be abused to aid in sleep, reduce pain, reduce anxiety, reduce depression, and improve energy.

The goals of pain management are not necessarily complete pain relief. They may include reducing pain, improved quality of life, improved physical and psychological functioning, improved ability to work, improved ability to function in society, and reduced healthcare utilization (Strain et al., 2020).

A pain management plan is more than just a prescription for pain medication (Strain et al., 2020). In addition to pharmacotherapy, it should include psychological and physical modalities to manage pain. It should be modified when interventions are not effective. Successful treatment of chronic pain requires an interdisciplinary healthcare team's input and a holistic approach to care to improve the patient's overall quality of life. One of our most essential roles is listening to our patients, which is especially important for patients with chronic pain. These patients often live with intense fear, anxiety, uncertainty about the future, and frequently social isolation and loneliness. The opportunity to tell one's story to someone who is consciously listening is therapeutic in itself.

Educate the patient regarding the plan. Education should include medications prescribed, other treatment options, and methods to contact the pain management team.

When developing a treatment plan, there are many considerations. Consider the type of pain and its effect on lifestyle, including psychological, social, and biological components of life.

Many factors affect the success of the treatment plan (Strain et al., 2020). Issues related to the patient, such as their ability to understand and apply the management plan, will help determine its success. The patient's willingness to implement the whole plan can profoundly affect the success of the plan. If a patient is willing to take a pill but is unwilling to work on non-pharmacologic interventions (such as physical therapy or weight loss), the plan will lose its effectiveness.

Referral to a pain management specialist may be indicated for those who have debilitating symptoms, need increased doses of pain medications, are non-responsive to treatments, or have symptoms at multiple sites (Strain et al., 2020). In addition, any APRN who does not provide long-term pain management to patients with intractable pain should refer the patient to a provider whose primary practice is to manage the pain (Tennessee Board of Nursing, 2019).

Caregiver or healthcare provider issues often affect the pain management plan (Strain et al., 2020). Many caregivers and healthcare providers do not accurately comprehend the patient's pain and may hold false beliefs regarding pain management. Caregivers and healthcare providers may be inhibited by fear of side effects from medications or drug addiction concerns; therefore, they may withhold medication from pain patients. Also, caregivers, healthcare providers, and patients may have conflicting goals.

Prescribe controlled substances for a legitimate medical purpose while carefully considering the patient's safety, therapy goals, and efficacy. Not only should pain treatment include pharmacotherapy, but physical and psychological therapies should also be used. Many caregivers lack knowledge and understanding of non-pharmacological pain treatments and cannot provide patients with the full scope of available pain therapies.

The state of Tennessee developed clinical practice guidelines for outpatient management of chronic non-malignant pain, which discuss how to treat chronic pain to improve function and quality of life (Tennessee Department of Health, 2020). The guidelines specifically discuss the use of opioid medications.

Numerous non-pharmacologic therapies manage pain. These may include a combination of physical and psychological techniques. Some methods used other than medications include physical therapy, exercise, massage, ultrasound therapy, heat/cold application, chiropractic manipulation, psychotherapy, biofeedback, relaxation therapy, acupuncture, transcutaneous electrical nerve stimulation (TENS), music therapy, injections, neuromodulation, spinal cord stimulation, deep brain stimulation, and radiofrequency ablation of nerve tissue (National Institute of Health [NIH], 2018).

For those with pain, a physical or occupational therapy trial can be helpful. With the help of a physical therapist, exercises targeting a specific type of pathology can help manage pain. Occupational therapists can help recommend devices that can assist in enhancing activities of daily living.

There is a tendency not to move with chronic pain, which leads to deconditioning and further incapacity—deconditioning results in more significant pain with any form of movement. Maintaining muscle mass prevents this downward spiral. The more an individual participates in exercise, the less probability there is of developing back pain. Physical activity improves overall health significantly for those with lower back pain. Exercise, especially in water, is beneficial for patients with arthritis pain and aerobic exercise has effectively decreased pain connected with fibromyalgia (NIH, 2018).

Yoga and Pilates have also become popular alternative treatments, especially for back pain (NIH, 2018). Tai Chi, a Chinese practice involving slow, gentle movements, deep breathing, and relaxation, has positive effects on pain relief for several conditions, including fibromyalgia, arthritis, and lower back pain. However, some yoga poses can be a potential cause of injury, especially those that involve overstretching of the neck.

Massage is soothing and relaxing, both physically and mentally. Massage may decrease pain by relaxing muscle tension and increasing capillary circulation, thereby improving general circulation.

A vibration is a form of electric massage. When vibration is applied lightly, it may have a soothing effect similar to massage. Vibration used with moderate pressure may relieve pain by causing numbness, paresthesia, and anesthesia of the area stimulated.
Heat and cold therapies can assist in the management of pain (NIH, 2018). Heat reduces inflammation and promotes relaxation. It can be in the form of hot tub baths, heating pads, or heat packs. Cold is often more effective in relieving pain than heat. The application of cold reduces muscle spasms secondary to underlying skeletal muscle spasms, joint pathology, or nerve root irritation. Cold application methods include ice massage, ice bags, and gel packs. Alternating heat and cold may be more effective than using either one alone.

Multiple psychological techniques can aid in reducing pain. The basis for using these methods is that thought influences feelings, and if thought (and behaviors) can be changed, so can feelings and even sensations, such as pain. Cognitive-behavioral methods require the patient's active participation.

Cognitive-behavioral therapy (CBT) is an effective coping skill for those with chronic pain (NIH, 2018). CBT emphasizes the present moment, where the individual becomes aware of their thoughts, feelings, and behaviors, and may include journaling these perceptions. CBT helps decrease the emotional distress associated with chronic pain by focusing on perceiving pain and adjusting to it. CBT decreases pain in chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and back pain. It also helps prevent headaches.

Relaxation is a state of relative freedom from anxiety and skeletal muscle tension, quieting or calming the mind and muscles. Relaxation is a learned technique but can be learned quickly in a motivated patient.

Imagery/visualization involves mentally creating a picture by using one's imagination. This mental picture may focus on a person, a place of enjoyment, a past event, or anything that brings pleasure. An occupied mind does not focus on the pain.

Distraction from pain is the focusing of attention on stimuli other than the pain sensation (NIH, 2018). The stimuli focused upon can be auditory, visual, or tactile-kinesthetic (hearing, seeing, touching, and moving). By concentrating on stimuli other than pain, the pain moves to the periphery of awareness. Distraction does not make the pain go away, nor does the effectiveness of distraction indicate the absence of pain. Music and humor are good means of distraction.

Transcutaneous Electrical Nerve Stimulation (TENS) provides low-voltage electricity to the body via electrodes placed on the skin. TENS may help with acute or chronic pain. Electrical stimulation of sensory nerves helps block pain signals going to the brain. TENS is contraindicated in patients with pacemakers, electrical implants, cardiac arrhythmias, circulation problems, and pregnancy.

Biofeedback is a technique to harness the mind's power to make the patient more aware of the body's sensations. Its exact mechanism is unclear, but it promotes relaxation and helps reduce pain (NIH, 2018).

Acupuncture is a neurostimulation technique that treats pain by inserting small, solid needles into the skin at varying depths. Various theories exist to explain how acupuncture works. The Chinese acupuncture theory states that it allows the release of blocked energy into the body. In Chinese medicine, this energy source is known as Qi, and its ability to flow freely through the body is related to overall well-being (NIH, 2018).

Music therapy treats pain. Music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a credentialed professional's therapeutic relationship. This individual has to complete an approved music therapy program. Research in music therapy supports its effectiveness in a wide variety of healthcare and educational settings (NIH, 2018).

Music therapists use music to facilitate changes that are non-musical. Individuals doing music therapy listen to music created under the guidance of a specially educated and certified professional in music therapy.

The theory of music therapy's effect on chronic pain deals with how pain signals travel through the body. When the brain senses injury to the body, pain signals begin in the somatosensory cortex and the hypothalamus and work their way through the "pain pathway," ultimately sending signals that provide pain relief. Some signals stimulate the release of neurotransmitters such as endorphins, dynorphins, and enkephalins. Music helps in pain reduction by activating these sensory pathways. Like relaxation and guided imagery, music can strengthen the brain's right side, which controls the body's healing processes.

Different surgical interventions or procedures assist in the pain management plan. Procedures include injections, spinal cord stimulation, deep brain stimulation, neural ablative techniques, and surgical interventions. These are potential options for those in whom other methods have not controlled the pain (NIH, 2018).

Pain has two parts; first of all, there is the perception of pain, which is related to the strength and characteristics of the pain, and secondly, there is the effect the pain has on the individual.

What is its emotional impact, and how is it impacting their quality of life? In a pain assessment, healthcare providers measure the strength or intensity of the pain, which may not reflect how the pain affects their lives. How pain affects an individual is intimately associated with the patient's ability to cope with the pain.

Coping can be defined as what an individual thinks and does in a situation that causes them stress. It is greatly affected by the resources that are available to the person to manage the event. Coping is a crucial part of pain management, especially for those with chronic pain. Healthcare providers need to be aware of the necessity to assess the patients coping patterns as they relate to pain and to be able to discuss necessary coping skills with them.

Catastrophizing is the opposite of coping and is the belief that a situation will continue to worsen. It is an essential predictor of pain and adjustment, especially in chronic pain. However, recent research has shown an important link between acute pain and pain catastrophizing (Block et al., 2017). The individual experiences heightened levels of worry and fear that have intensified the person's amount of pain. Instead of problem-solving, the individual tends to turn away and feel hopeless about their situation. Catastrophizing needs to be something that nurses are watchful for when assessing a patient's pain by listening carefully to how the patient describes their pain and how they perceive its effect on their life now and in the future.

Undertreatment of chronic pain remains a persistent problem, with an estimate of approximately 30% of those who suffer from chronic pain receiving less than adequate treatment (American Chronic Pain Association [ACPA], 2020).

Pain medication may be administered on an as-needed basis for episodic pain or given routinely for chronic pain. The use of routine, around-the-clock medication sustains a steady state in the blood and offers better pain relief for those with persistent pain (ACPA, 2020). Consider side effects when deciding which medication to use.

Medication classes include non-opioid analgesic agents, antidepressants, muscle relaxants, antiepileptic medications, topical agents, and opioids. Some get adequate relief from one medication, but some get better pain relief from a combination of medications that work on different pathways. Unfortunately, research is sparse on combination medication in the management of pain (ACPA, 2020).

Considering all co-morbidities is an essential step in the management of pain (ACPA, 2020). For example, when a patient suffers from chronic pain and depression, some medications may help effectively manage both conditions (for example, duloxetine treats chronic musculoskeletal pain, including discomfort from osteoarthritis and chronic lower back pain in addition to depression). It is also essential to establish the pain syndrome's pathophysiology, evaluate the medication list, and consider the medications' side effects (ACPA, 2020).

The clinician should distinguish between neuropathic pain and nociceptive pain (ACPA, 2020). Establish the etiology of neuropathic pain and, if the etiology is reversible, manage the underlying problem. For example, if a medication (e. g., metronidazole, nitrofurantoin, isoniazid, or many cancer agents) is the cause of the neuropathy, stop that medication (if possible).

Medications used in treating neuropathic pain include gabapentinoids (gabapentin and pregabalin), tricyclic antidepressants, serotonin-norepinephrine uptake inhibitors (SNRIs), the lidocaine patch, and narcotic analgesics (ACPA, 2020).

Nociceptive pain is treated with non-narcotic and opioid analgesia (ACPA, 2020). Common causes of nociceptive pain include arthritis and chronic low back pain.

When prescribing opioids for acute pain, the prescription should be no longer than the expected length of pain. The typical duration is three days or less, and if more than seven days are needed, good documentation must outline the reason for this course. Treat acute pain with immediate-release opioids and not extended-release medications. Start opioids at low doses in the opioid naïve patient and titrate to effectiveness.

Avoid benzodiazepines in those receiving opioids. If the patient is receiving 120 mg MME and the patient is on benzodiazepines for mental health reasons, the mental health provider should assess the need for the benzodiazepine. Any patient on more than 120 MME a day should be referred to a pain management specialist (Tennessee Department of Health, 2020).

Significant withdrawal symptoms occur when abruptly stopping opiates including (FDA, 2020; Tennessee Department of Health, 2020; Saxon & Strain, 2019):

• Sweating
• Nausea
• Vomiting
• Headache
• Abdominal pain
• Myalgia

Abruptly stopping benzodiazepines and alcohol can be fatal, but opiate withdrawal is rarely fatal.

Opiate withdrawal could be managed using multiple protocols. One method uses a ten percent reduction per week, and a more aggressive wean would include a 25% reduction every four days.

The Tennessee Department of Health (2020) does not recommend any specific weaning plan. The use of clonidine can be considered to help manage symptoms of opiate withdrawal. If an individual diverts opiates, which a negative urine drug screen may suggest, weaning is unnecessary.

To prevent prescription drug abuse, the clinician needs to assure:

• Patients are assessed and reassessed
• Treatment agreements are used
• Prescription monitoring occurs
• Safe prescription methods are practiced

Patients' risks should be assessed, and contraindications should be immediately identified. Contraindications to opioid treatment include those who have an erratic follow-up, suffer from current untreated addiction, or have poorly controlled mental illness.

When taking a patient history, document the opioid currently prescribed, its dose, the frequency of use, and duration. It is essential to query the state prescription drug monitoring program (PDMP) to confirm the patient’s medication use (Strain et al., 2020). Also, it is essential to contact past providers to obtain medical records.

Before prescribing controlled substances, assessment should be done for a history of illegal substance use, alcohol use, tobacco use, prescription drug use, family history of substance abuse and psychiatric disorders, history of sexual abuse, legal history, behavioral problems, employment history, marital history, social network, and cultural background. A history of substance abuse does not prohibit treatment with opioids but may necessitate more intensive monitoring or referral to an addiction specialist.

Multiple tools are available to evaluate opioid risk (Strain et al., 2020).

The Opioid Risk Tool (ORT) is used in primary care to screen adults for the risk of aberrant behaviors when prescribed opioids for chronic pain. It is a copyrighted tool, encompasses five questions, and takes about one minute to use. It classifies a patient as low, moderate, or high risk to abuse opioids. Those who are high risk have a high likelihood of aberrant drug-related behavior. It is not validated in individuals without pain. The five questions include asking about (Strain et al., 2020):

1. Family history
2. Personal history of substance abuse (alcohol, prescription drugs, or illegal drugs)
3. Age (risk is 16-45 years old)
4. Psychological disease
5. Preadolescence sexual abuse history

The questions are scored with different points assigned for each question, variable between men and women, and the total score is tallied. The patient is placed into low, moderate, or high risk.

Regular follow-up is important and should occur at a minimum of every three months. When assessing the pain patient, the “Five A’s” should be assessed (Strain et al., 2020):

1. Analgesia
2. Addiction
3. Activities of daily living (ADLs)
4. Adherence
5. Adverse effects

A follow-up should include urine drug testing, which can detect medication adherence and illicit and non-prescription drug use. It is critical that the clinician adequately document any interactions with patients, assessments, and results of testing and treatment plans.

Use written treatment agreements between prescribers and patients when controlled substances are used. This helps guide the conversation between the patient and the prescriber. It discusses expectations, the risks, and the monitoring of the controlled substances (See Table 5).

In addition, obtain informed consent when starting opioid therapy. Informed consent discusses benefits versus risks, including the risk of addiction, physical dependence, sedation, reduced motor skills, and death. An example of a treatment agreement and informed consent is the Tennessee Chronic Pain Guidelines (2020): Visit Source.

Prescription monitoring programs are available in the majority of states, including Tennessee. They provide an online database that lists all prescriptions of controlled substances dispensed for each patient by pharmacy. The prescriber should check the database before prescribing controlled substances. If a patient has an undisclosed prescription for a controlled substance, it is prescription drug misuse.

When abuse/misuse is detected, how should the clinician respond? If it is a single, minor deviation, then provide counseling and more intensive monitoring. Tapering controlled substances to reduce the risk of withdrawal is appropriate in more severe or persistent misuse cases. When diversion is the cause of misuse, immediate removal of the prescription is likely the best course. If a substance abuse disorder is suspected, a referral to an addiction specialist is recommended.

An important role of the practitioner is prescribing controlled substances. Controlled substances have inherent risks, so the prescriber needs to realize that the primary goal of prescribing opioids should be to maintain patient safety. A responsible prescriber should follow multiple steps to ensure safe and effective care of the patient.

Steps a prescriber can take include:

• Assessment and documentation of a comprehensive history including medical history, substance abuse history, current medications taken including dosages, route, and time (including opioids), psychiatric, and psychosocial history.
• Establish a physical and psychological diagnosis and establish medical necessity before starting or maintaining opioid therapy. Those with mental illness are at higher risk of abusing medications.
• Screen for a substance abuse history because substance abusers are at increased risk to misuse controlled substances.
• Establish goals in therapy regarding pain control and functional goals.
• Use prescription monitoring programs to help determine patterns of prescription use. These are state-run databases that track controlled substance prescriptions and help find issues with overprescribing and misuse patterns.
• Urine drug testing can be used to identify non-compliance or aberrant drug use.
• Consider contraindications before prescribing opioids, such as acute psychiatric instability, uncontrolled suicide risk, opioid allergy, respiratory instability, history or current abuse of substances or alcohol, current use of benzodiazepines, current use of heavy doses of other central nervous system depressants, current use of other medications that have severe drug interactions or those who practice diversion of controlled substances.
• Judicious utilization of imaging tests and other evaluations as some testing may increase fear, foster activity restriction, encourage maladaptive behaviors, and encourage requests for more opioids.
• A written agreement between prescriber and patient when opioids are used reduces the risk of abuse, diversion, misuse, and overuse.
• Discuss the risks and benefits of the medications.
• Obtain informed consent before prescribing controlled substances.
• In general, start opioid therapy at low doses with short-acting medications.
• Use long-acting opioids in high doses only for severe, intractable pain that cannot be adequately managed with short-acting opioids or moderate doses of long-acting opioids.
• Use caution when titrating long-acting opioids and consider the potential for overdose and misuse.
• Consider consultation for those who require high-dose opioid therapy.
• Be the only prescriber of all opioids for a given patient.
• Monitor for and manage constipation.
• Prescribe the lowest effective dose and the smallest quantity needed based on the expected length of the pain.
• Periodically review the treatment plan, including any new information about the patient, their condition, and their pain and progress toward their goals.
• Keep accurate records.
• Be compliant with all laws and regulations related to controlled substances.
• Individualize treatment based on the patient’s prior exposure to opioids, response to treatment, and adverse events.
• Monitor for aberrant drug-related behaviors.
• Discontinue chronic opioid therapy in those who repeatedly engage in aberrant drug-related behaviors, do not progress toward established goals, or experience significant side effects. Patients who have been taking the opioid for an extended time should have the medication tapered slowly.

• Have an upper dosing threshold. The risk of accidental overdose increases with higher doses of opioids. Prescribers should generally avoid doses of morphine or morphine equivalents more than 90 - 200 mg/day.
• Use caution with certain medications. For example, methadone should only be used by a prescriber who is extremely comfortable with the medication. Fentanyl is another medication that requires extreme caution as there is unpredictable absorption.
• With opioid use, respiratory depression is more likely in the older population and cachectic or debilitated. Patients at high risk should be monitored more closely, and opioids should not be given in combination with other respiratory depressants. The dose of opioids should be started at one-third to one-half the typical starting dose in at-risk patients. Titration should be done carefully. Constipation is more likely, and a bowel regime should be prescribed when opioids are used.
• When starting chronic opioid therapy should be started as a therapeutic trial that may last from several weeks to several months. The decision to continue the therapy must be carefully considered based on the trial's outcomes, such as progress toward meeting goals, side effects, changes in the underlying condition causing pain, and any concern for medication misuse or addiction.
• The greatest risk of opioid use is respiratory arrest and death, which is most significant when therapy is started or increased. Opioid-induced respiratory depression is manifested by the reduced desire to breathe and reduced respiratory rates. The patient will be breathing shallowly, and CO2 retention can exacerbate the sedating effects of opioids. If this is noted, the family should call 911.
• Opioids should not be used in those with respiratory depression. Titration must be done slowly, and when changing formulations, do not overestimate the converting dosage.
• Opioid rotation – changing from one opioid regime to another to reduce adverse events and improve therapeutic outcomes – may be considered. Tolerance to one opioid can lessen the analgesic effects, and the use of a different opioid may result in an improved analgesic effect and fewer adverse effects.
• When opioid rotation is done, it requires the prescriber to determine the approximate equianalgesic dose. This is the ratio used to get about the equivalent analgesic effect. When switching from one opioid to another, the dose should be reduced by 25 – 50% to prevent adverse effects. Multiple computer programs or applications for mobile devices are available to help with this conversion.
• Avoid combinations of opioids and benzodiazepines. When these two classes are combined, particularly if more than 100 mg of morphine or morphine equivalents per day are used, the risk of accidental overdose is high.
• Pay attention to drug-to-drug and drug-to-disease interactions.

The state of Tennessee developed clinical practice guidelines for outpatient management of chronic non-malignant pain, which discuss how to treat chronic pain to improve function and quality of life but also provide guidelines for other controlled substances, including benzodiazepines, barbiturates, and carisoprodol (Tennessee Department of Health, 2020).

John is a 38-year-old male with chronic back pain due to three herniated discs and spinal stenosis, first diagnosed three years ago after a motor vehicle accident. He currently rates the severity of his back pain as a 9/10 and has been unable to work as a plumber due to his pain.

The pain can be described as dull and constant, with occasional sharp exacerbation in the lower back, with the pain increasing with bending, prolonged standing, and walking. The patient denies any loss or change of bowel/bladder control, history of IV drug use, recent infection, progressive neurological complaints, night pain, night sweats, weight loss, or fever. The pain occasionally radiates into the right buttock. The patient can do all his daily living activities but reports poor sleep at night.

He has a past medical history of hypertension and recently has developed stage II chronic kidney disease secondary to hypertension and excessive use of ibuprofen. His only current medication is lisinopril to control his blood pressure.

He has had multiple treatment modalities, including four rounds of physical therapy, chiropractic treatment, and numerous medications. He tried to control his back pain with acetaminophen, naproxen, ibuprofen, the lidocaine patch, and topical non-steroidal anti-inflammatory agents without relief. The patient experienced significant tremors and an increase in blood pressure while on tramadol. A series of epidural injections did not help. Surgery was discussed, but the patient refused this option.

John is married and has one daughter who lives over 500 miles away from her biological mother. He has limited financial means, lives paycheck to paycheck, and has a prior history of alcohol abuse but has not had a drink in five years. He is currently a smoker. He denies any history of substance abuse, and there is no family history of alcohol or substance abuse.

A physical exam showed a patient with a slow, deliberate gait, a limited range of motion in the spine, and no obvious deformity, swelling, or erythema. There is mild tenderness on the right side of the spine from L4 to S1 and tenderness in the right sacroiliac joint. Normal reflexes, sensation, strength, and no atrophy are noted in the lower extremities. The straight leg raise test is normal.

An MRI showed a herniated disc at the L5/S1 level and mild spinal stenosis one year ago.

The Opioid Risk Tool was administered, and it was determined that the patient was at moderate risk for opioid abuse. He signs a written opioid treatment agreement that outlines the conditions of opioid therapy. His past medical records were verified, suggesting he is not lying.

The patient is prescribed hydrocodone/acetaminophen 5 mg/500 mg, two tablets every six hours as needed (56 tablets) for one week.

Five days later, he calls for an early refill and reports that the medication is not helping his pain, and he lies around all day.

He comes back into the office for a re-evaluation. He reports he needed to take more pain medication than prescribed. His wife confirms that he has been lying around all day, and she believes it is because he is having so much pain. It was reviewed with the patient that he violated the opioid agreement. A urine sample was obtained that showed no illicit substances or medications that would not be expected in the urine.

While the patient is at moderate risk of abusing the medication, his past medical history was confirmed. He was referred to a psychiatrist and a pain specialist. He was agreeable to both. The patient saw the psychiatrist, was diagnosed with depression, and he was started on sertraline. He could get into the psychiatrist within one week, but the pain specialist appointment was four weeks out. The psychiatrist was unable to make an assessment related to opioid abuse.

With the help of the pain specialist, oxycodone ER 10 mg was ordered every 12 hours. The patient was told to follow up in one week to assess effectiveness. After one week, the patient reports he is more functional but still in a lot of pain. The dose of oxymorphone ER was increased to 15 mg every 12 hours. After one more week, he was given oxycodone IR 5 mg one hour before exercise. This allowed the patient not only to function well but also to begin participating in an exercise program. The patient was ordered a bowel stimulant (Senna) with a stool softener (Colace®) to prevent constipation.

The patient is prescribed fourteen pills of oxycodone ER 10 mg (to be taken twice a day) and seven pills of oxycodone IR 5 mg (to be taken once a day before exercise) once a week. Part of the agreement was that the medications were to be given by the patient’s wife to reduce the risk of misuse.

Ms. L is a 49-year-old female with a history of bilateral knee pain. She currently rates the pain as an 8/10 in her right knee and 5/10 in her left knee.

She takes MS Contin® 60 mg every 12 hours with an immediate-release tablet of morphine dosed 15 mg every 8 hours as needed (she averages one dose a day) and has been using this regime for the past six months. Still, over the last month, she has not been getting adequate relief from her pain and has been progressively disabled and has, therefore, stopped exercising.

The pain is attributed to osteoarthritis and has been progressively worsening over the last 1-2 years. She has a past medical history of anxiety and depression but does not take any medication for these conditions. She has a past surgical history of a hysterectomy approximately three years ago. She takes no other medications and has no known allergies.

She has no history of alcohol, drug, or substance abuse. She has a strong family network, including a supportive husband of 25 years and two sons who live nearby.

The physical exam is significant for obesity (BMI of 34). Due to pain, she has crepitus in both of her knees and cannot fully extend the right knee. An x-ray demonstrates moderate arthritic changes in both knees. The patient is unwilling to consider surgery on her knees.

After the state’s prescription monitoring program database was accessed, it was determined that she had not gotten any controlled substances other than morphine for the last two years. A urine drug screen was positive for morphine but no other substances.

The nurse practitioner offers meloxicam and a knee injection in her right knee. On the follow-up appointment, she reports she has not used any breakthrough morphine dosing. The nurse practitioner increases the dose of meloxicam and gives her an injection in her left knee, and has a conversation about weaning the morphine dosing. The patient is agreeable to weaning the dose of morphine by 10 mg every 1-2 weeks with frequent follow-up to assess pain control. She is agreeable to a follow-up in two weeks, which, at that point, there is a notable improvement in her pain level and the amount of enjoyment she gets out of life. Over the next year, she can wean off morphine while continuing on the meloxicam. In addition to the meloxicam, she lost 20 pounds which she attributes to her improved quality of life and enhanced ability to function.

Pain is a disagreeable sensory and emotional experience connected with actual or potential tissue damage. Many conditions can cause pain. Understanding these conditions, assessing them, and treating them is a vital part of adequately managing pain.

The nurse practitioner's role is to perform a good initial pain assessment and an ongoing assessment of pain. Many options are available for pain management, including non-pharmacological options, non-opioid medications, opioid medications, and adjunctive medications. Opioid analgesics, while very good at managing pain, have led to many social and legal problems, including overuse and diversion.

This course discussed pain management and methods to assess patients at risk for opiate abuse and provided safe and effective prescribing tips.

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