opioid epidemic

Situation of Focus
The opioid epidemic in America has arisen in part as a result of over-prescription of drugs to patients (Brummett et al., 2017). While patients have a right to expect pain relief, the tendency among health care providers to prescribe opioid therapy to opioid naïve patients at an unnecessarily high dosage can have detrimental effects and risks, such as long-term addiction of the patient (Harbaugh et al., 2018), sleep apnea and even depression (Rowsell et al., 2016). Nurses and doctors should be careful, therefore, to use opioid therapy at the lowest doses for effective pain relief, with the goal being pain management at a tolerable level rather than for opioids like oxycodone to be prescribed at high levels so that the patient can experience zero pain.
Problem Statement
The problem is that some patients may expect to be given a strong prescription that will effectively take all their pain away following surgery. The nurse’s job is complicated by the fact that the nurse should seek to provide quality care in every way and assist the patient in the patient’s needs, whatever they may be; but at the same time the nurse has a duty to practice preventive care and to promote the patient’s health literacy by explaining the risks of high-dosage drugs like oxycodone and the potential for long-term habit-formation and addiction, the onset of sleep apnea or depression.
To assist nurses in explaining these risks and encouraging patients to see that pain tolerance (i.e., the lowest effective dosage of opioid therapy) is preferable to total pain relief (i.e., a high dosage), two nursing theories can be applied to this case: the mid-range theory of unpleasant symptoms developed by Lenz, Supee, Gift, Pugh and Milligan (1995) and utilitarian ethical theory, developed by Mill and used to promote nursing ethical principles of beneficence and non-maleficence (Wagner & Dahnke, 2015). The theory of unpleasant symptoms calls for treatment of the whole person and aligns with the holistic care approach by looking at the combination of symptoms for the underlying issue rather than attempting to treat each symptom individually as a separate and unique issue disconnected from what is going on with the whole person. Utilitarian ethical theory focuses on determining what is good for the patient by looking at the outcomes of various options and seeing which one would have the best impact on the patient and everyone else. A third theory could also be applied in terms of a recommending an intervention—the midrange theory of transcultural nursing developed by Leininger (2008). It explains that a nurse should have develop cultural competence so as to be able to address patients’ needs in a culturally sensitive manner that enables the nurse to increase the patient’s understanding of health risks and benefits of types of treatment.
Literature Review
Theory
The mid-range theory of unpleasant symptoms can be useful in this situation because it can allow the nurse to focus on the underlying issue regarding the patient’s pain tolerance. A patient may not realize the risks associated with opioid usage, but the nurse should and therefore it is important for the nurse to explain to the patient why pain tolerance is the most appropriate goal in opioid therapy rather than complete pain elimination. The theory of unpleasant symptoms helps the nurse to see that the pain following surgery may not be the biggest issue (Lenz et al., 1997): other factors in the patient’s life may also be contributing to the patient’s desire for a higher dosage. The patient may fear a lack of support from family at home, or the patient may have problems resting or sleeping in general. The nurse can probe the patient’s feelings by asking questions that will help the nurse to have a better understanding of the patient’s needs so as to provide alternative care solutions that holistically treat the patient instead of simply upping the dosage of opioid therapy and risking a long-term habit formation.
In order to appropriately treat the patient, the nurse must understand the whole, complex, interacting aspects of the patients’s symptoms and more deeply understand the meaning of the patient’s complaint. A patient who may have a low pain tolerance may also lack sufficient ways to distract attention from the pain. This is something that can be discussed in more detail with the patient when the nurse applies this theory. Lenz et al. (1997) explained that nurses have to provide adequate scope and understanding to the patient’s issues in order to treat them effectively.
The utilitarian ethical theory provides additional light on the problem of how to treat a patient that wants something that might neither be the patient’s best long-term interest or in society’s interest (as every opioid addiction effectively places a new burden on society). The basis of this theory is in the idea that the good or right action is determined by the effect of the action. The better the effect is for all, the more one can say that it is good (Wagner & Dahnke, 2015).
Leininger’s (2008) theory of transcultural nursing focuses on the nurse’s need to be culturally competent so as to identify cultural cues that patients signal and to administer nursing care in a way that is culturally appropriate to the patient. The theory is helpful in administering care because it highlights the value of providing personalized care at an individualized level based upon the nurse’s ability to understand cultural differences and how health literacy might be increased through the usage of cultural understanding.
The Opioid Problem
The opioid epidemic can be traced back in part to opioid therapy and the over-prescription of high-dosage opioids to opioid naïve patients (Brummett et al., 2017; Harbaugh et al., 2018). There are detrimental effects of too-high opioid dosage for patients that can include addiction, sleep apnea, and depression (Rowsell et al., 2016). In order to reduce the risk of these negative effects it is important to nurses to educate patients on the benefits of using the prescription only for pain tolerance rather than to achieve zero pain (Volkow & McLellan, 2016). To better assist patients recovering from surgery, nurses should recommend and prescribe lower-dosage opioid relief so that the risk of addiction, sleep apnea or depression does not become too great. Otherwise the worst-case scenario could unfold—i.e., the patient becomes addicted to opioids and becomes another statistic and victim of the ever-widening opioid epidemic.
Tenets, Rationale for Selection and Application
The tenets of the three theories are: 1) utilitarian ethical theory holds that the nurse should pursue the greatest common good based on the likely outcome of the proposed range of options; 2) theory of unpleasant symptoms holds that the nurse should seek to identify the underlying issue that brings the symptoms together to explain what the patient is going through in a deeper and more helpful way so that more effective holistic care can be provided; and 3) transcultural nursing theory holds that the nurse should develop a high cultural competence so that the nurse can understand the patient’s cultural background, needs, health beliefs, and thereby identify sensitive pathways to getting the patient to see what is in the patient’s best interests in terms of proper health care.
Each theory has been implemented in the past and has been recommended by researchers as appropriate for caring for patients in a variety of settings (Leininger, 2008; Lenz et al., 1995; Wagner & Dahnke, 2015). Each can likewise be applied to the case to help the nurse provide higher quality care for the patient by emphasizing the need to limit opioid prescription risk, to identify possible ulterior causes for patient anxiety, and to find alternative sources of comfort through cultural awareness. The manner in which the theories can be applied in this case are described below.
The Situation
The situation in this case is a middle-aged patient who is recovering from surgery and is looking for medication that will take all the pain away. Zero pain is what the patient seeks, but he nurse is aware of the risks of prescribing a high dosage of opioid therapy, so there is a need to explain to the patient why zero pain is not advisable. The patient does not understand and says that she thought doctors were supposed to help the patient feel better. The patient feels that the hospital is trying to be stingy and that the nurse does not actually care about the patient’s pain.
The nurse learns from the patient that she is Jewish, lives with her son, who is divorced and has no children. The son works from home but is very considerate towards her and has been with her in the hospital throughout. The patient is very comforted by her son. She also has a fond love of music and she is looking forward to getting home and playing some old records while she recuperates. The nurse encourages this as well as the physical therapy that the patient is to do in order to restore health. All that remains is the issue of pain management.
Discussion
Intervention
From a theoretical perspective, the nurse knows a number of things from the discussion with patient and from her own background as a nurse practitioner. First, the nurse knows that from the utilitarian ethical position, a high dosage opioid therapy is not recommended in spite of the patient’s low pain tolerance claim. There is risk of opioid addiction setting in, as well as sleep apnea and depression—so the nurse understands that from the utilitarian ethical perspective, there is a need to provide a lower dosage opioid therapy; otherwise, too many negative consequences can emerge.
The theory of unpleasant symptoms can also be applied by the nurse in this situation: first, the nurse is aware that the patient does not live alone but has her adult son there to provide her with assistance. She has a love for music and she has not been able to have access to her records since being in the hospital, which is probably adding to her anxiety, since music is one of the things in her life that calms her. Likewise, she has not been able to get to the Jewish synagogue to see her friends. All of these combined effects are likely impacting her current sense of having a low pain threshold and the theory of unpleasant symptoms can be used to see how they are all related. Instead of simply taking the complaint at face value, the nurse can see how other factors are impacting the patient’s whole experience and how once those other factors are addressed, the patient will likely be in a much better place mentally, emotionally and physically. The nurse can use this theory to comfort the patient and provide a holistic approach to care, explaining to the patient that at home she will have access to her records, her friends at the synagogue and her son to help provide her with assistance.
Finally, the theory of transcultural care can be applied so that the patient understands the concerns of health risks. For instance, the nurse can explain that medication is primarily for the purposes of tolerating pain not for taking it away completely. The nurse can emphasize the woman’s cultural beliefs as she is Jewish and find ways to link the need to tolerate pain with the woman’s background and how she has likely had to tolerate pain in the past and how the nurse believes in her and her ability to do it again.
Implementation
Remedy gaps can occur, for instance, if the patient is insistent that the medication will not be enough. Here there is an obstacle between the patient’s understanding and the nurse’s explanation of risks and the usages of medicine. The nurse should emphasize that it is for the patient’s own health and safety that she says as much and that if the patient gets home and finds that the medication strength is still not sufficient even after having the music, her friends and her son there to help, she can always call and have the dosage upped. Care should always be emphasized in a culturally sensitive way to help the patient to see where the nurse is coming from with recommendations.
Inefficiencies may also arise due to the nurse’s need to see other patients as well. The nurse may be stressed by a heavy patient load because of other short-handed staff. The nurse may not feel that there is enough time to negotiate the issues required in this case. The nurse may think that the patient needs to just accept whatever dosage is provided. However, the nurse should be mindful that part of providing quality care is engaging in preventive care and in boosting patients’ health literacy. The more that the nurse can explain to the patient so as to get the patient to better understand the issues that are at stake, the higher quality care the nurse will be able to provide overall. It does neither the nurse nor the patient any good to only devote the minimum amount of time to each patient just so that all patients are seen. In any shift, the nurse is likely to find that some patients require more time than others, and that is to be expected and accepted as part of the job.
Evaluation
The survey method is likely to be the most effective way of evaluating the intervention’s effectiveness overall. First, however, it is important to identify the goals of the intervention in order to see what to measure. The overall goal of this intervention is to reduce the risk of adverse effects of opioid therapy by keeping dosages at the lowest but still effective levels possible for pain management. A decline in opioid addiction rates stemming from prescription addiction across the country could be evidence that the intervention was working were the intervention to be implemented on a nationwide scale. For the purposes of this case, however, the intervention is being measured in a singular instance and so the survey method would be most satisfactory for determining whether the nurse’s intervention achieved the desired outcome of raising the patient’s health literacy (regarding understanding of the need to use opioids to tolerate pain rather than to reduce pain to zero), whether the patient was indeed able to effectively manage pain using the nurse’s recommendations (i.e., whether music therapy helped, whether friends assisted and whether the son was of any comfort), and whether the pain diminished in time without the patient needing to apply for a new dosage. The survey could be personally designed to assess the outcome of this intervention and give the nurse a sense of how effective the intervention was overall. A Likert scale could be used to allow the questions to be answered quantitatively, or the survey could be a simple yes/no survey—so long as the appropriate questions are asked to provide an appropriate measurement of the intervention’s success, the survey may be designed any which way. The instrument could be evaluated by taking the Likert scale scores or the yes/no responses and conducting statistical analysis to find the mean and determining whether the patient’s responses show an average level of effectiveness, below-average or higher-than-average level. Or the survey could be evaluated qualitatively with the nursing staff examining the content of the survey consisting of open-ended responses to find what worked for the patient and what did not and deriving meaning from there.
Conclusion
The opioid crisis is one that needs to be addressed in the U.S. as it has grown into an epidemic. Nurses must be cognizant of the risks associated with over-prescribing opioids in pain management. They must also be able to convey the risks associated with opioid therapy to patients. Some of the ways in which this can be achieved are through the use of utilitarian ethical theory, the theory of unpleasant symptoms, and transcultural theory. Each theory provides a perspective on how the nurse can approach the issue of raising the patient’s health literacy regarding opioids and how the nurse can move the patient to appreciate that pain tolerance when using opioids is a preferable approach to total eradication of pain, which raises the risk of addiction, sleep apnea and depression. Each of these theoretical approaches to nursing can be used effectively in this case and the outcomes can be measured and evaluated using the survey method and statistical or content analysis.





















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