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Asthma Treatment and Monitoring

Introduction   

When hearing the phrase asthma, what comes to mind? If you’re an advanced practice registered nurse (APRN) with prescriptive authority, you’ve definitely heard of asthma before. Even as a nurse or maybe before nursing school, conversations about prescription drug use and respiratory health existed every so often.

Presently, patients seek guidance and information on various health topics from APRNs, including medication management and respiratory health. The information in this course will serve as a valuable resource for APRNs with prescriptive authority of all specialties, education levels, and backgrounds, to learn more about medications that can treat and manage asthma.

Defining Asthma 

What Is Asthma? 

Asthma is a non-communicable chronic health condition that affects the airways of the lungs and affects millions of people nationwide. Asthma is often diagnosed in childhood and can resolve in adulthood or continue for the rest of a patient’s life. Several studies postulate the cause of asthma, but there is no definitive cause.  

Genetics, age, environmental exposures, smoking, and a history of allergies are thought to play a role in asthma severity and development. Clinical presentation of asthma often includes trouble breathing, chronic airway inflammation, and airway hyperresponsiveness. Assessment for asthma often includes patient history, clinical presentation, spirometry testing, and pulmonary function tests (PFTs). 

What Are the Stages of Asthma? 

Since asthma is a chronic condition, several established guidelines can be used to determine the severity of asthma and explore possible medication options. Depending on the stage of asthma and patient response to existing therapy, treatment and management vary.  

The four stages of asthma include intermittent, mild, moderate, and severe. Based on the 2020 National Asthma Education and Prevention Program (NAEPP) guidelines, here is the standard criteria for what constitutes each stage of asthma (2). 

Intermittent asthma is characterized with the following clinical presentation and assessment (2): 

• Patient history of respiratory symptoms, such as cough, trouble breathing, wheezing, or chest tightness <2 times a week 
• Asthmatic flare-ups are short-lived with varying intensity  
• Symptoms at night are <2 a month 
• No asthmatic symptoms between flare-ups 
• Lung function test FEV 1 at >80% above normal values 
• Peak flow has <20% variability am-to-am or am-to-pm, day-to-day 

Mild persistent asthma is characterized with the following clinical presentation and assessment (2): 

• Patient history of respiratory symptoms, such as cough, trouble breathing, wheezing, or chest tightness 3-6 times a week 
• Asthmatic flare-ups may affect activity level and can vary in intensity 
• Symptoms at night are 3-4 times a month 
• Lung function test FEV1 is >80% above normal values 
• Peak flow has less than 20-30% variability 

Moderate persistent asthma is characterized with the following clinical presentation and assessment (2): 

• Patient history of respiratory symptoms, such as cough, trouble breathing, wheezing, or chest tightness daily 
• Asthmatic flare-ups may affect activity level and can vary in intensity 
• Symptoms at night are >5 times a month 
• Lung function test FEV1 is 60%-80% of normal values 
• Peak flow has more than 30% variability 

Severe persistent asthma is characterized with the following clinical presentation and assessment (2): 

• Patient history of respiratory symptoms, such as cough, trouble breathing, wheezing, or chest tightness continuously  
• Asthmatic flare-ups affect activity level and often vary in intensity 
• Asthmatic symptoms at night are constant 
• Lung function test FEV1 is <60% of normal values 
• Peak flow has more than 30% variability 

Based on patient history, clinical presentation, and these criteria, treatment can be administered to decrease the symptoms of the patient. If a patient presents with symptoms that are outside of your scope of work or understanding, you can always refer patients to a pulmonologist or asthma specialist.  

Often times, more severe cases of asthma and asthma emergencies require increased frequency and dosing of asthma-related medications. Health care provider professional discretion and patient condition should guide therapy. Consider reviewing a patient’s medication history, pulmonary function, and health history prior to prescribing asthma medications (1). 

What Are Asthmatic Emergencies? 

Asthmatic emergencies are if a patient has asthma symptoms that are beyond what they typically experience and are unable to function without immediate medical intervention. Asthma emergencies can occur as a result of a patient being unable to access their asthmatic medications, being exposed to a possible allergen, or being under increased stress on the body.  

Asthmatic emergencies often require collaborative medical intervention, increased dosages of medications discussed below, and patient education to prevent future asthmatic emergencies (1).  

What If Asthma Is Left Untreated? 

Depending on the clinical presentation and severity of asthma, asthma can cause several long-term complications if left untreated. If asthma is not properly managed, several complications, such as chronic obstructive pulmonary disease (COPD), decreased lung function, permanent changes to the lungs’ airways, and death can occur (1, 2).  

Defining Asthma Medications 

What Are Commonly Used Medications to Manage Asthma? 

Commonly used medications to manage asthma include inhaled corticosteroids, oral corticosteroids, short-acting beta agonists (SABAs), long-acting beta agonists (LABAs), long-acting muscarinic antagonists (LABAs), adenosine receptor antagonists, leukotriene modifiers, mast cell stabilizers, and monoclonal antibodies. The dosage, frequency, amount of asthma management medications, and medication administration route can all vary depending on clinical presentation, patient health history, and more.  

How and Where are Asthma Medications Used? 

Asthma medications can be used routinely or as needed for management of asthma symptoms depending on the patient. Asthma medications can be used at home, in public, and in health care facilities. Depending on the specific asthma medication and dosage, these medications can be taken by mouth, by an external device, such as an inhaler, via subcutaneous injection, or via intravenous solution (1).  

What Are the Clinical Criteria for Prescribing Asthma Medication? 

Clinical criteria for prescribing asthma medication can depend on the clinical presentation of a patient. Assessment of lung health and patient history are essential to determining the dosage and medications needed for adequate asthmatic symptom control.  

Clinical guidelines from reputable organizations, such as the National Asthma Education and Prevention Program (NAEPP), the National Institutes of Health (NIH), the Global Initiative for Asthma (GINA), and the American Academy of Family Physicians (AAFP) can provide insight into the latest recommendations for asthma management (1, 2). In addition, local laws or health departments might have recommendations for asthma medication guidelines.  

What Is the Average Cost for Asthma Medications? 

Cost for asthma medications can significantly vary depending on the type of medication, insurance, dosage, frequency, medication administration route, and other factors. Cost is among a leading reason why many patients cannot maintain their medication regime (3). If cost is a concern for your patient, consider reaching out to your local pharmacies or patient care teams to find cost effective solutions for your patients.  

Inhaled Corticosteroids Pharmacokinetics 

Health care provider professional discretion and patient condition should guide therapy. Consider reviewing a patient’s medication history and health history prior to prescribing asthma medications.  

Drug Class – Inhaled Corticosteroids  

Commercially available inhaled corticosteroids include: ciclesonide (Alvesco HFA), fluticasone propionate (Flovent Diskus, Flovent HFA, Armon Digihaler), budesonide (Pulmicort Flexhaler), beclomethasone dipropionate (QVAR RediHaler), fluticasone furoate (Arnuity Ellipta), and mometasone furoate (Asmanex HFA, Asmanex Twisthaler).  

Clinical criteria for prescribing an inhaled corticosteroid includes adherence to the latest clinical guidelines, patient medical history, patient clinical presentation, and drug availability (4).  

Inhaled Corticosteroids Method of Action 

Inhaled corticosteroids have an intricate mechanism of action involving several responses to the immune system. Inhaled corticosteroids decrease the existing initial inflammatory response by decreasing the creation and slowing the release of inflammatory mediators. Common inflammatory mediators include histamine, cytokines, eicosanoids, and leukotrienes. Inhaled corticosteroids can also induce vasoconstrictive mechanisms, which, as a result, can lead to less blood flow, resulting in less discomfort and edema (4).  

In addition to anti-inflammatory properties, inhaled corticosteroids can create a localized immunosuppressive state that limits the airways’ hypersensitivity reaction, which is thought to reduce bronchospasms and other asthma-associated symptoms. It is important to note that inhaled corticosteroids often do not produce therapeutic effects immediately, as many patients may not see a change in their asthma symptoms for at least a week after beginning inhaled corticosteroid therapy (4).  

Inhaled Corticosteroids Side Effects 

Every medication has the possibility of side effects, and inhaled corticosteroids are no exception. Common side effects of inhaled corticosteroids include oral candidiasis (thrush), throat irritation, headache, and cough.  

Patient education about rinsing their mouth and oral hygiene after use is essential to avoid the possibility of thrush and other oral infections and irritations. More severe side effects can include prolonged immunosuppression, reduction in bone density, and adrenal dysfunction (4).  

Inhaled Corticosteroids Alternatives 

While there are clinical criteria for asthma medications, everyone can respond to medications differently. Some patients might not report their symptoms alleviating with inhaled corticosteroids, so additional medication, increased dosage, a change in frequency, or a new medication class might need to be considered (4).  

Oral Corticosteroids Pharmacokinetics 

Health care provider professional discretion and patient condition should guide therapy. Consider reviewing a patient’s medication history and health history prior to prescribing asthma medications.  

Drug Class – Oral Corticosteroids  

Commercially available oral corticosteroids include methylprednisolone, prednisolone, and prednisone. Clinical criteria for prescribing an oral corticosteroid includes adherence to the latest clinical guidelines, patient medical history, patient clinical presentation, and drug availability (4).  

Oral Corticosteroids Method of Action 

Methylprednisolone and prednisolone have a method of action as intermediate, long-lasting, synthetic glucocorticoids, have COX-2 inhibitory properties, and inhibit the creation of inflammatory cytokines (5). 

Prednisone is a prodrug to prednisolone and has anti-inflammatory and immunomodulating glucocorticoid properties. Prednisone has a method of decreasing inflammation by reversing increased capillary permeability and suppressing the movement of certain leukocytes (6).  

Oral Corticosteroids Side Effects 

Every medication has the possibility of side effects, and oral corticosteroids are no exception. Methylprednisolone and prednisolone have possible side effects of skin changes, weight gain, increased intraocular pressure, neuropsychiatric events, neutrophilia, immunocompromised state, fluid retention, and GI upset.  

Consider monitoring symptoms and overall health of patients on systemic corticosteroids to assess for long-term side effects (5). Prednisone has possible side effects of changes in blood glucose, changes in sleep habits, changes in appetite, increased bone loss, an immunocompromised state, changes in adrenal function, and changes in blood pressure (6).  

Oral Corticosteroids Alternatives 

While there are clinical criteria for asthma medications, everyone can respond to medications differently. Some patients might not report their symptoms alleviating with oral corticosteroids, so additional medication, increased dosage, a change in frequency, or a new medication class might need to be considered (6).  

Short-Acting Beta Agonists (SABAs)  

Health care provider professional discretion and patient condition should guide therapy. Consider reviewing a patient’s medication history and health history prior to prescribing asthma medications.  

Drug Class – SABAs 

Common commercially available SABAs include albuterol sulfate (ProAir HFA, Proventil HFA, Ventolin HFA), albuterol sulfate inhalation powder (ProAir RespiClick, ProAir Digihaler), levalbuterol tartrate (Xopenex HFA), and levalbuterol hydrochloride (Xopenex) (4). 

SABAs Method of Action 

Short-acting beta-agonists (SABAs) have a rapid onset as broncho-dilating medications. SABAs, especially albuterol in emergent situations, are used often to quickly relax bronchial smooth muscle from the trachea to the bronchioles through action on the β2-receptors.  

While SABAs are effective bronchodilators in the short term for asthma symptoms, SABAs do not affect the underlying mechanism of inflammation. As a result, SABAs are often used for short-acting intervals, such as few hours, and have limited capabilities to prevent asthma exacerbations alone (4). SABAs can be administered via meter-dosed inhalers, intravenous, dry powder inhalers, orally, subcutaneously, or via nebulizer.  

SABAs Side Effects 

Every medication has the possibility of side effects, and SABAs are no exception. Because of the beta receptor agonisms, possible SABA side effects include increased heart rate, chest pain, chest palpitations, body tremors, and nervousness (4). Because of the short half-life of SABAs, chronic side effects are not typically observed.  

SABAs Alternatives 

While there are clinical criteria for asthma medications, everyone can respond to medications differently. Some patients might not report their symptoms alleviating with SABAs, so additional medication, increased dosage, a change in frequency, or an additional medication class might need to be considered (4).  

Long-Acting Beta Agonists (LABAs) 

Health care provider professional discretion and patient condition should guide therapy. Consider reviewing a patient’s medication history and health history prior to prescribing asthma medications.  

Drug Class – LABAs 

Common commercially available LABAs are salmeterol and formoterol (7).  

LABAs Method of Action 

Long-acting beta-agonists (LABAs) have a rapid onset like SABAs, but also have a longer half-life. LABAs are used often as asthma maintenance medications to relax bronchial smooth muscle from the trachea to the bronchioles through action on the β2-receptors. While SABAs are effective bronchodilators in the short term for asthma symptoms, LABAs are effective bronchodilators in the long term for asthma symptoms.  

Like SABAs, LABAs do not affect the underlying mechanism of inflammation. LABAs can be administered via meter-dosed inhalers, intravenous, dry powder inhalers, orally, subcutaneously, or via nebulizer. LABAs are often effective for 12-hour durations (7). 

LABAs Side Effects 

Every medication has the possibility of side effects, and LABAs are no exception. Like SABAs, because of the beta receptor agonisms, possible LABA side effects include increased heart rate, chest pain, chest palpitations, body tremors, and nervousness (7). Other more prolonged side effects can include changes in blood glucose levels and changes in potassium levels with prolonged LABA use (7).  

LABAs Alternatives 

While there are clinical criteria for asthma medications, everyone can respond to medications differently. Some patients might not report their symptoms alleviating with LABAs, so additional medication, increased dosage, a change in frequency, or an additional medication class might need to be considered (4).  

In addition, there are combination inhaled corticosteroid/LABA medications that can be considered, such as fluticasone propionate and salmeterol (Advair Diskus, Advair HFA, AirDuo Digihaler, AirDuo RespiClick, Wixela Inhub), fluticasone furoate and vilanterol (Breo Ellipta), mometasone furoate and formoterol fumarate dihydrate (Dulera), and budesonide and formoterol fumarate dihydrate (Symbicort) (4). 

Long-Acting Muscarinic Antagonists (LAMAs) 

Health care provider professional discretion and patient condition should guide therapy. Consider reviewing a patient’s medication history and health history prior to prescribing asthma medications.  

Drug Class – LAMAs 

Common commercially available LAMAs include two inhalation powders via inhalers known as tiotropium bromide (Spiriva Respimat) and fluticasone furoate, umeclidinium, and vilanterol (Trelegy Ellipta) (4).  

LAMAs Method of Action 

Both drugs mentioned above are long-acting muscarinic antagonists (LAMAs). LAMAs work to alleviate asthmatic symptoms by antagonizing the type 3 muscarinic receptors in bronchial smooth muscles, resulting in relaxation of muscles in the airway (4). Because LAMAs are long-acting, they are not recommended for cases of acute asthma exacerbations or asthmatic emergencies (4). 

LAMAs Side Effects 

Possible LAMA side effects include urinary retention, dry mouth, constipation, and glaucoma (4).  

LAMAs Alternatives 

While there are clinical criteria for asthma medications, everyone can respond to medications differently. Some patients might not report their symptoms alleviating with LAMAs, so additional medication, increased dosage, a change in frequency, or an additional medication class might need to be considered (4). 

Adenosine Receptor Antagonists Pharmacokinetics 

Health care provider professional discretion and patient condition should guide therapy. Consider reviewing a patient’s medication history and health history prior to prescribing asthma medications.  

Drug Class – Adenosine Receptor Antagonists 

The commercially available adenosine receptor antagonist for asthma management is theophylline as a pill or intravenous (8). 

Adenosine Receptor Antagonists Method of Action 

The method of action for theophylline is acting as a nonselective adenosine receptor antagonist, acting as a competitive, nonselective phosphodiesterase inhibitor, and reducing airway responsiveness to histamine, allergens, and methacholine (8).  

Adenosine Receptor Antagonists Side Effects  

Common side effects of theophylline include GI upset, headache, dizziness, irritability, and arrythmias (8).  

Adenosine Receptor Antagonists Alternatives 

While there are clinical criteria for asthma medications, everyone can respond to medications differently. Some patients might not report their symptoms alleviating with theophylline, so additional medication, increased dosage, a change in frequency, or an additional medication class might need to be considered (4). 

Leukotriene Modifiers Pharmacokinetics 

Health care provider professional discretion and patient condition should guide therapy. Consider reviewing a patient’s medication history and health history prior to prescribing asthma medications.  

Drug Class – Leukotriene Modifiers 

Commercially available leukotriene modifiers include montelukast (Singular) and zafirlukast (Accolate) as oral pills taken once a day. Zileuton (Zyflo CR) is a 5-lipoxygenase inhibitor that also modifies leukotriene activity (4).  

Leukotriene Modifiers Method of Action 

Montelukast and zafirlukast work to control asthma-related symptoms by targeting leukotrienes, which are eicosanoid inflammatory markers. Montelukast works in particular by blocking leukotriene D4 receptors in the lungs, thus allowing decreased inflammation in the lungs and increased relaxation of lung smooth muscle (9).  

Zafirlukast works by being a competitive antagonist at the cysteinyl leukotriene-1 receptor (CYSLTR1) (10). Zileuton is a 5-lipoxygenase inhibitor, in which 5-lipoxygenase is needed for leukotriene creation. Blocking 5-lipoxygenase decreases the formation of leukotrienes at several receptors. As a result of decreased leukotriene production, there is decreased inflammation, decreased mucus secretion, decreased bronchoconstriction (11). 

Leukotriene Modifiers Side Effects 

Possible side effects of montelukast include headaches, GI upset, and upset. Neuropsychiatric events, such as nightmares, changes in sleep, depression, and suicidal ideation are more severe side effects associated with montelukast.  

Possible side effects of zafirlukast include headache, GI upset, and hepatic dysfunction (9).  

Possible side effects of zileuton include hepatic dysfunction, changes in sleep, changes in mood, headaches, and GI upset. When the leukotriene modifiers, neuropsychiatric side effects are to be monitored for in particular, especially for suicidal ideation (9,10,11).  

Leukotriene Modifiers Alternatives 

Some patients might not report their symptoms alleviating with leukotriene modifiers, so additional medication, increased dosage, a change in frequency, or an additional medication class might need to be considered (4). 

Mast Cell Stabilizer Pharmacokinetics 

Health care provider professional discretion and patient condition should guide therapy. Consider reviewing a patient’s medication history and health history prior to prescribing asthma medications.  

Drug Class – Mast Cell Stabilizer 

A commercially available mast cell stabilizer is cromolyn available via metered-dose inhaler and nebulizer solution (12).  

Mast Cell Stabilizer Method of Action 

Cromolyn has a method of action in which it inhibits the release of inflammatory mediators from cells, such as the release of histamine and leukotrienes (12).  

Mast Cell Stabilizer Side Effects 

Every medication has the possibility of side effects, and cromolyn is no exception. Common side effects of cromolyn include dry throat, throat irritation, drowsiness, dizziness, cough, headache, and GI upset (12).  

Mast Cell Stabilizer Alternatives 

While there are clinical criteria for asthma medications, everyone can respond to medications differently. Some patients might not report their symptoms alleviating with mast cell stabilizers, so additional medication, increased dosage, a change in frequency, or an additional medication class might need to be considered (4). 

Monoclonal Antibody Pharmacokinetics 

Health care provider professional discretion and patient condition should guide therapy. Consider reviewing a patient’s medication history and health history prior to prescribing asthma medications.  

Drug Class – Monoclonal Antibody 

Commercially available monoclonal antibodies include Omalizumab (Xolair), mepolizumab (Nucala), reslizumab (Cinqair), benralizumab (Fasenra), dupilumab (Dupixent), and tezepelumab-ekko (Tezspire). Omalizumab, mepolizumab, benralizumab, dupilumab, and texepelumab-ekko are available via subcutaneous injection. Reslizumab is available via intravenous solution (4). 

Monoclonal Antibody Method of Action 

Omalizumab is an anti-IgE monoclonal antibody that works by inhibiting the binding of IgE to mast cells and basophils. As a result of decreased bound IgE, activation and release of mediators, such as histamine, in the allergic response are decreased (13).  

Mepolizumab, reslizumab, and benralizumab are interleukin (IL)-5 antagonists. These IL-5 antagonists inhibit IL-5 signaling, allowing for a decrease in the creation and survival of eosinophils. However, the full method of action for IL-5 antagonists is still unknown, as more evidence-based research is needed (4, 15).  

Dupilumab is an IgG4 antibody that inhibits IL-4 and IL-13 signaling by binding to the IL-4Rα subunit. This inhibition of the IL-4Rα subunit allows for the decrease of IL-4 and IL-13 cytokine-induced inflammatory responses (14). 

Tezepelumab-ekko is an IgG antibody that binds to the thymic stromal lymphopoietin (TSLP) and prevents TSLP from interacting with the TSLP receptor. Blocking TSLP decreases biomarkers and cytokines associated with inflammation. Knowing this, the full method of action for Tezepelumab-ekko is still unknown, as more evidence-based research is needed4,15.  

Monoclonal Antibody Side Effects 

Possible side effects of omalizumab include injection site reactions, fracture, anaphylaxis, headache, and sore throat (13). Possible side effects of mepolizumab, reslizumab, and benralizumab include injection site reactions, headache, and hypersensitivity reactions (4). Possible side effects of dupilumab include joint aches, injection site reactions, and headache (14). Possible side effects of tezepelumab-ekko include injection site reactions and headache (14). 

Monoclonal Antibody Alternatives 

While there are clinical criteria for asthma medications, everyone can respond to medications differently. Some patients might not report their symptoms alleviating with monoclonal antibodies, so additional medication, increased dosage, a change in frequency, or an additional medication class might need to be considered (4). 

Nursing Considerations 

Nurses remain the most trusted profession for a reason, and APRNs are often pillars of patient care in several health care settings. Patients turn to nurses for guidance, education, and support. While there is no specific guideline for the nurses’ role in asthma education and management, here are some suggestions to provide quality care for patients currently taking medications to manage asthma or concerned about possibly having asthma. 

• Take a detailed health history. Often times, respiratory symptoms, such as a cough or trouble breathing, are often dismissed in health care settings, or seen as “common symptoms with everyone.” If a patient is complaining of symptoms that could be related to asthma, inquire more about that complaint.  

Ask about how long the symptoms have lasted, what treatments have been tried, if these symptoms interfere with their quality of life, and if anything alleviates any of these symptoms. If you feel like a patient’s complaint is not being taken seriously by other health care professionals, advocate for that patient to the best of your abilities.  

• Review medication history at every encounter. Often times, in busy clinical settings, reviewing health records can be overwhelming. Millions of people take asthma medications at varying dosages, frequencies, and times of day. Many people with asthma take more than one medication to manage their symptoms.  

Ask patients how they are feeling on the medication, if their symptoms are improving, and if there are any changes to medication history.  

• Be willing to answer questions about asthma, respiratory health, and medication options. Society stigmatizes open discussions of prescription medication and can minimize symptoms of asthma, such as a chronic cough.  

There are many people who do not know about medication options or the long-term effects of undiagnosed or poorly managed asthma. Be willing to be honest with yourself about your comfort level discussing topics and providing education on asthma medications and asthma clinical assessment options.  

• Inquire about a patient’s life outside of medications, such as their occupation, living situation, and smoking habits. Household exposures, such as carpets or pets, can trigger asthma. Occupations with high exposure to smoke can also trigger asthmatic symptoms. Smoking, living with someone who smokes, or residing in an area with high levels of pollution can also influence asthma symptoms.  

Discuss possible solutions to help with symptoms, such as improving ventilation, increasing air quality, and mask wearing when possible.  

• Communicate the care plan to other staff involved for continuity of care. For several patients, especially for patients with severe asthma, care often involves a team of nurses, specialists, pharmacies, and more. Ensure that patients’ records are up to date for ease in record sharing and continuity of care. 

• Stay up to date on continuing education related to asthma medications, as evidence-based information is always evolving and changing. You can then present your new learnings and findings to other health care professionals and educate your patients with the latest information. You can learn more about the latest research on asthma and asthma-related medications by following updates from evidence-based organizations.  

How can nurses identify if someone has asthma?  

Unfortunately, it is not always possible to look at someone with the naked eye and determine if they have asthma. While some people might have visible asthmatic symptoms, such as wheezing or trouble breathing, asthmatic clinical presentation can significantly vary from person to person.  

APRNs can identify and diagnose if someone has asthma by taking a complete health history, listening to patient’s concerns, and offering pulmonary function testing. 

What should patients know about asthma medications?  

Patients should know that anyone has the possibility of experiencing side effects medications for asthma management, just like any other medication. Patients should be aware that if they notice any changes in their mood, experience any sharp headaches, or feel like something is a concern, they should seek medical care.  

Nurses should also teach patients to advocate for their own health in order to avoid untreated or undetected asthma and possible chronic complications from asthma or asthma-related medications.  

Here are important tips for patient education in the inpatient or outpatient setting: 

• Tell the health care provider of any existing medical conditions or concerns (need to identify risk factors). 
• Tell the health care provider of any existing lifestyle concerns, such as tobacco use, other drug use, sleeping habits, occupation, diet, menstrual cycle changes (need to identify lifestyle factors that can influence asthmatic medication use, asthma severity, and asthma management). 
• Tell the health care provider if you have any changes in your breathing, such as pain with deep breathing or persistent coughing (potential asthma exacerbation symptoms or possibility of asthma medications not being as effective for treatment). 
• Tell the nurse of health care provider if you experience any pain that increasingly becomes more severe or interferes with your quality of life. 
• Keep track of your health, medication use, and health concerns via an app, diary, or journal (self-monitoring for any changes). 
• Tell the health care provider right away if you are having thoughts of hurting yourself or others (possible increased risk of suicidality is a possible side effect for montelukast use). 
• Take all prescribed medications as indicated and ask questions about medications and possible other treatment options, such as non-pharmacological options or surgeries. 
• Tell the health care provider if you notice any changes while taking medications or on other treatments to manage asthma (potential worsening or improving health situation). 

Research Findings 

What Research on Asthma Medication Exists Presently? 

There is extensive publicly available literature on asthma and asthma-related medications via the National Institutes of Health and other evidence-based journals (1,2,4).  

What are some ways for people who take asthma medications to become a part of research? 

If a patient is interested in participating in clinical trial research, they can seek more information on clinical trials from local universities and health care organizations. 

Conclusion

Asthma is a chronic condition that affects many people from their childhood to their aging years. As more medications for asthma come onto the market and more evidence-based approaches to asthma and lung care emerge, APRNs will be at the forefront of primary care and asthma care across the lifespan.  

Case Study #1 

Susie is a mom to a 15-year-old named Jill. She arrives at the pediatric asthma and allergy specialist practice for a new patient visit. Susie reports that she notices Jill is having trouble sleeping at night and coughing more during the day for the past month. Jill plays soccer with her school, but her mom is concerned about coughing and trouble sleeping interfering with her sports.  

Susie knows that her dad has asthma, and Jill spends a lot of time with her aunt who smokes cigarettes. Jill has a history of generalized anxiety disorder and reports no smoking, no drinking, and no recreational drugs. Jill also wants to learn more about her lung health, as she wants to play soccer professionally one day.  

• What are some specific questions you’d want to ask about Jill’s coughing and respiratory health? 
• What are health history questions you would want to highlight? 
• What are some tests or lab work would you suggest performing?  

Case Study #2 (Continued) 

Susie also shares that she is dating a new partner who vapes in the home, and they recently got a pet puppy in the home. She states that Jill had trouble sleeping at night and coughing a lot when she was younger, but Susie thought Jill grew out of it. Susie wants to learn more about if Jill has asthma like her grandfather, if there are any ways to manage this cough, and if there are any tests that can determine Jill’s lung health in the office today. 

• What sort of tests can be done in-office to assess pulmonary function? 
• What sort of environmental exposures can trigger respiratory conditions?  

Susie agrees to have Jill do allergy testing and to do an in-office pulmonary function test for teenagers. Jill also wants to learn more about spirometry that you mentioned earlier and how to monitor her health outside of the office since she’s busy with school and soccer and doesn’t want to come to the office every time there’s a problem.  

Susie is open to medication options for Jill but doesn’t want anything that will interfere too much with Jill’s social time with her friends. Susie and Jill also want to know if this is a health condition that Jill will have forever or if Jill will grow out of this.  

• Knowing Susie’s concerns and Jill’s age, what are some talking points about reducing possible asthma triggers? 
• How would you explain asthma as a chronic health condition to an adolescent patient?  
• Given Jill and Susie’s concerns about medications, what would be some possible medication options to consider after reviewing Jill’s pulmonary function test results and patient history? 

SSRI Use in Major Depressive Disorder

Introduction   

When hearing the phrase selective serotonin reuptake inhibitors, what comes to mind? If you’re an advanced practice registered nurse (APRN) with prescriptive authority, you’ve heard of SSRIs before. Even as a nurse or maybe before nursing school, conversations about prescription drug use and mental health existed every so often.

Presently, patients seek guidance and information on various health topics from APRNs, including medication management, women’s health, and mental health. The information in this course will serve as a valuable resource for APRNs with prescriptive authority of all specialties, education levels, and backgrounds to learn more about SSRIs and major depressive disorder (MDD).  

Defining SSRIs 

What Are SSRIs? 

Selective serotonin reuptake inhibitors, known as SSRIs, are a type of pharmacological drug class. SSRIs have existed for the past several decades as a class of prescription medications that can manage major depressive disorder (MDD) and other mental health conditions (1).

While this course focuses explicitly on SSRI use in MDD management, SSRIs are also Food and Drug Administration (FDA) approved to manage obsessive-compulsive disorder (OCD), panic disorder (PD), post-traumatic stress disorder (PTSD), and social anxiety disorder (SAD). In addition, several off-label uses for SSRI include management for binge eating disorder and menopausal vasomotor symptoms.  

How and Where Are SSRIs Used? 

SSRIs are commonly prescribed to manage MDD and other mood disorders in the U.S. and around the world in pediatric, adult, and geriatric populations (1, 2). SSRIs can be taken by mouth as a pill, capsule, or liquid oral solution. Presently, SSRIs cannot be offered via intravenous, rectal, buccal, or injection routes.  

What Is the Clinical Criteria for Prescribing SSRIs? 

Clinical criteria for prescribing SSRIs can vary depending on the intention for the SSRI. In the case of MDD, several factors can play a role in the clinical criteria for prescribing SSRIs. A patient’s adherence to swallowing a pill daily, dosage given the patient’s weight, medical history, and MDD concerns, and prior experience with other medications can influence prescribing SSRIs. When considering prescribing SSRIs for MDD management, consider assessing the patient for MDD first, taking a detailed health history, and discussing the risk versus benefits of starting SSRIs for this patient (1, 3).  

What Is the Average Cost for SSRIs? 

Cost for SSRIs can significantly vary depending on the type of SSRI, insurance, dosage, frequency, and other factors. Cost is among leading reasons why many patients cannot maintain their medication regime (4). If cost is a concern for your patient, consider reaching out to your local pharmacies or patient care teams to find cost-effective solutions for your patients.  

What Is Major Depressive Disorder (MDD)? 

Major depressive disorder (MDD) is a mental health condition in which a person has consistent appetite changes, sleep changes, psychomotor changes, decreased interest in activities, negative thoughts, suicidal thoughts, and depressed mood that interfere with a person’s quality of life (5). According to the Diagnostic and Statistical Manual of Mental Health Disorders, a patient must have at least five persistent mood related symptoms, including depression or anhedonia (loss of interest in activities once enjoyed), that interferes with a person’s quality of life to be formally diagnosed with MDD. Note that MDD does not include a history of manic episodes, and pediatric populations can present with more variable MDD symptoms (5). As an APRN, you can assess for MDD by doing a detailed patient health history or having a patient complete the Patient Health Questionnaire-9 (PHQ-9) – a depression assessment tool (5). 

SSRI Pharmacokinetics  

Drug Class SSRIs 

Selective serotonin reuptake inhibitors, known as SSRIs, are a type of pharmacological drug class part of the antidepressant drug class. They can be prescribed at various dosages depending on the patient history, severity of major depressive disorder (MDD), other medication use, and other factors based on patient-centered decision making. Currently, SSRIs that are FDA approved for MDD management include paroxetine, sertraline, citalopram, escitalopram, vilazodone, and fluoxetine. SSRIs can be prescribed for the oral route and are available via capsule, tablet, or liquid suspension/solution. SSRIs can be taken at any time of day. They can be taken with or without food, though vilazodone in particular is recommended with food. SSRIs are often prescribed to be taken once a day, sometimes twice a day, depending on the severity of MDD. Health care provider professional discretion and patient condition should guide therapy (1).  

SSRIs are metabolized by and known to affect the cytochrome P450 system. CYP2D6 inhibitors include escitalopram, citalopram, sertraline, paroxetine, and fluoxetine. Fluoxetine and fluvoxamine are inhibitors of CYP2C19. Fluvoxamine is an inhibitor of CYP1A2. Consider reviewing a patient’s medication history and health history prior to prescribing SSRIs (1).   

SSRIs Method of Action 

SSRI method of action has been subject to several studies, especially in the last few years. Serotonin is a neurotransmitter that plays a role in mood and other bodily functions. It can be measured in plasma, blood, urine, and CSF (6). It is important to note that serotonin is rapidly metabolized to 5-hydroxyindoleacetic acid (5-HIAA) (6). SSRIs work by inhibiting the reuptake of serotonin at certain chemical receptors, thereby increasing serotonin activity and concentration (1). SSRIs inhibit the serotonin transporter (SERT) at the presynaptic axon terminal.  

By obstructing the SERT, a higher amount of serotonin (5-hydroxytryptamine or 5HT) remains in synaptic clefts. This higher amount of serotonin can then stimulate postsynaptic receptors for a more extended period (1). While SSRIs can increase serotonin activity, there is some evidence that suggests the possibility of long-term SSRI use reducing serotonin concentration (6). In addition, the clinical response to SSRIs in patients with MDD can take anywhere from a few to several weeks to emerge (7). While some research suggests that there are initial improvements in mood, evidence remains inconclusive as to the exact time SSRIs can take to provide a therapeutic response for patients (7). Also, while research suggests that SSRIs can increase serotonin levels, there is still mixed evidence on the exact method of action for SSRIs (7).  

As a result, it is important to counsel patients that SSRIs can take a few weeks to provide a therapeutic response and to monitor mood and symptoms while taking SSRIs.  

SSRI Side Effects 

Every medication has the possibility of side effects, and SSRIs are no exception. Fortunately, SSRIs are known to have less side effects than other drug classes of antidepressants, such as monoamine oxidase inhibitors (MAOIs) or tricyclic antidepressants (TCAs). The most commonly known side effects of SSRIs include weight gain, sleep changes, headache, gastrointestinal issues, drowsiness, orthostatic hypotension, and sexual function changes (1).  

Sleep changes can include an increased desire to sleep, increase in the amount of time sleeping, or insomnia. Gastrointestinal issues can include an upset stomach, nausea, or dry mouth. Mood changes, such as anxiety, are possible side effects as well. Sexual function changes can include erectile dysfunction, libido changes, impaired orgasmic response, and vaginal dryness (1, 8).  

There are more serious possible side effects of SSRIs as well. For instance, SSRIs have the possible side effect of QT prolongation, which if left untreated or undiagnosed, can lead to fatal cardiac arrythmias (1, 8). In particular, the SSRI citalopram has been shown to have more of a risk for QT prolongation compared to other SSRIs. Also, like any other medication that can possibly increase levels of serotonin in the body, there is a possibility of serotonin syndrome as a complication of SSRI use. Possible serotonin syndrome clinical manifestations include increased blood pressure, increased sweating, increased reflex ability, and increased dry eyes (8). Due to the wide varied range of side effects, patient counseling, monitoring, and education is essential when prescribing SSRIs. 

SSRI Black Box Warning  

In 2004, the FDA issued a black box warning for SSRIs and other antidepressant medications due to the possible increased risk of suicidality in pediatric and young adult populations (up to age 25). When considering SSRI use in patients under 25 and knowing MDD is a risk factor for suicidality, having a conversation with the patient about risks versus benefits must be considered. However, in the past several years since the FDA’s warning, there is no clear evidence showing a correlation between SSRIs and the increased risk of suicidality (1, 8). Health care provider professional discretion and patient condition should guide therapy. 

SSRI Alternatives 

MDD can be a complex, chronic condition to manage with varying clinical presentation and influence on a patient’s quality of life. There are several alternatives to SSRI use, such as: (1, 9) 

• Other prescription drugs 
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs). Commonly known SNRIs include milnacipran, venlafaxine, desvenlafaxine, duloxetine, and levomilnacipran. 
  • Atypical antidepressants. Commonly known atypical antidepressants include bupropion and mirtazapine. 
  • Tricyclic antidepressants (TCAs). Commonly known TCAs include amitriptyline, desipramine, imipramine, clomipramine, doxepin, and nortriptyline. 
  • Monoamine oxidase inhibitors (MAOIs). Commonly known MAOIs include phenelzine, tranylcypromine, isocarboxazid, and selegiline. 
• Psychotherapy, such as cognitive behavioral therapy (CBT) or interpersonal therapy 
• Electroconvulsive therapy (ECT) 
• Vagus Nerve Stimulation (VNS) 
• Transcranial Magnetic Stimulation (TMS) 

Nursing Considerations 

Nurse’s Role 

What Is the Nurses’ Role in SSRI Patient Education and Management? 

Nurses remain the most trusted profession for a reason, and APRNs are often pillars of patient care in several health care settings. Patients turn to nurses for guidance, education, and support. While there is no specific guideline for the nurses’ role in SSRI education and management, here are some suggestions to provide quality care for patients interested in or currently taking SSRIs to manage current or suspected major depressive disorder (MDD). 

1. Take a detailed health history. Often times, mental health symptoms, such as depressive thoughts or anxiety, are often dismissed in health care settings, even in mental health settings. If a patient is complaining of symptoms that could be related to major depressive disorder, inquire more about that complaint. Ask about how long the symptoms have lasted, what treatments have been tried, if these symptoms interfere with their quality of life, and if anything alleviates any of these symptoms. If you feel like a patient’s complaint is not being taken seriously by other health care professionals, advocate for that patient to the best of your abilities.  
2. Review medication history at every encounter. Often times, in busy clinical settings, reviewing health records can be overwhelming. While a vast number of people take SSRIs, many are no longer benefiting from the medication. Ask patients how they are feeling on the medication, if their symptoms are improving, and if there are any changes to medication history.  
3. Ask about family history. If someone is complaining of symptoms that could be related to MDD, ask if anyone in their immediate family, such as their parent or sibling, experienced similar conditions.   
4. Be willing to answer questions about mental health and SSRIs. Society can often stigmatize open discussions of prescription medication and mental health. SSRIs are no exception. There are many people who do not know about the benefits and risks of SSRIs, the long-term effects of unmanaged MDD, or possible treatment options. Be willing to be honest with yourself about your comfort level discussing topics and providing education on SSRIs and MDD.  
5. Communicate the care plan to other staff involved for continuity of care. For several patients, MDD management often involves a team of mental health professionals, nurses, primary care specialists, pharmacies, and more. Ensure that patients’ records are up to date for ease in record sharing and continuity of care. 
6. Stay up to date on continuing education related to SSRIs and mental health conditions, as evidence-based information is always evolving and changing. You can then present your new findings to other health care professionals and educate your patients with the latest information. You can learn more about the latest research on SSRIs and mental health by following updates from evidence-based organizations.  

Identifying Major Depressive Disorder 

How can nurses identify if someone has major depressive disorder?  

Unfortunately, it is not possible to look at someone with the naked eye and determine if they have MDD. APRNs can identify and diagnose if someone has MDD by taking a complete health history, listening to patient’s concerns, having patients complete the PHQ-9 questionnaire and communicating any concerns to other health care professionals (9). 

Patient Education 

What should patients know about SSRIs?  

Patients should know that anyone has the possibility of experiencing side effects of SSRIs, just like any other medication. Patients should be aware that if they notice any changes in their mood, experience any sharp headaches, or feel like something is a concern, they should seek medical care. Due to social stigma associated with mental health and SSRI use, people may be hesitant to seek medical care for fear of being dismissed by health care professionals (1, 6). In addition, side effects (that interfere with the quality of life) are often normalized (1, 6). However, as more research and social movements discuss mental health and SSRI use more openly, there is more space and awareness for SSRI use and mental health.  

Nurses should also teach patients to advocate for their own health in order to avoid progression of MDD and possible unwanted side effects of SSRIs. Here are important tips for patient education in the inpatient or outpatient setting.  

• Tell the health care provider of any existing medical conditions or concerns (need to identify risk factors) 
• Tell the health care provider of any existing lifestyle concerns, such as alcohol use, other drug use, sleeping habits, diet, menstrual cycle changes (need to identify lifestyle factors that can influence SSRI use and MDD) 
• Tell the health care provider if you notice any changes in your mood, behavior, sleep, sexual health (including vaginal dryness or erectile dysfunction), or weight (possible changes that could hint at more chronic side effects of SSRIs) 
• Tell the health care provider if you have any changes in urinary or bowel habits, such as increased or decreased urination or defecation (potential risk for SSRI malabsorption or possible unwanted side effects) 
• Tell the nurse of health care provider if you experience any pain that increasingly becomes more severe or interferes with your quality of life 
• Keep track of your mental health, medication use, and health concerns via an app, diary, or journal (self-monitoring for any changes) 
• Tell the health care provider right away if you are having thoughts of hurting yourself or others (possible increased risk of suicidality is a possible side effect for SSRI use) 
• Take all prescribed medications as indicated and ask questions about medications and possible other treatment options, such as non-pharmacological options or surgeries 
• Tell the health care provider if you notice any changes while taking medications or on other treatments to manage your MDD (potential worsening or improving mental health situation) 

Research Findings 

What Research on SSRIs exists presently? 

There is extensive publicly available literature on SSRIs via the National Institutes of Health and other evidence-based journals.  

What are some ways for people who take SSRIs to become a part of research? 

If a patient is interested in participating in clinical trial research, they can seek more information on clinical trials from local universities and health care organizations. 

Case Study 

Case Study Part 1 

Susan is a 22-year-old Black woman working as a teacher. She arrives for her annual exam at the local health department next to her place of work. She reports nothing new in her health, but she says she’s been feeling more tired over the past few months. Susan reports having some trouble sleeping and trouble eating but doesn’t feel too stressed overall. She heard one of her friends talking about SSRIs and wants to try them, but she’s never taken prescription medications long-term before. She also thinks she might have some depression because she looked at some forums online and resonated with a lot of people’s comments.  

Case Study Part 2 

Susan agrees to complete bloodwork later this week and thinks she might have a family history of depression. She said that no one in her family talks about mental health, but she heard about depression from her friends recently and family a long time ago. She’s back in the office a few weeks later, and her labs are within normal limits. Susan states she’s still feeling fatigued and feeling a bit more hopeless these days. She denies thinking about hurting herself or others. 

Case Study Part 3 

Susan completed the PHQ-9 questionnaire and had a high score. After discussing her responses with her, you diagnose her with MDD. Susan admits that she is open to trying SSRIs. She is also open to seeing a therapist, as she states that she’s never been to therapy. She would like resources on any therapy services, medication options, and non-pharmacological options to help her manage her condition.  

Conclusion

Major depressive disorder is a complex chronic health condition that affects many people nationwide. SSRIs are often a first-line pharmacological option for MDD management. However, clinical presentation and symptom management with SSRIs can vary widely. While some patients would prefer a low-dose SSRI, others will need a higher dose and possible extra medication management. Education and awareness of SSRIs can influence the lives of many people.  

Safe Prescribing of Opioids 

Introduction   

For centuries, humans have been using, developing, and synthesizing opioid compounds for pain relief. Opioids are essential for treating patients who are experiencing severe and sometimes even moderate pain. Chronic pain can negatively affect our lives. In 2011, the cost of chronic pain ranged from $560 to $635 billion in direct medical expenses, lost productivity, and disability. An estimated one in five U.S. adults had chronic pain (11).

Introduction of opioid drug class, indications for use, most prescribed opioids, and their effects.

Opioids usually bind to mu-opioid receptor sites, where they have agonist effects, providing pain relief, sedation, and sometimes feelings of euphoria. Opiates refer only to natural opioids derived from the poppy plant. The term "opioids" includes all-natural, semi-synthetic, and synthetic opioids.

Opioids are classified into several categories based on their origin and chemical structure:

1. Natural Opioids (Opiates): These come from the opium poppy plant. Examples include morphine and codeine.
2. Semi-Synthetic Opioids: These are natural opioids that are chemically modified. Examples include drugs like oxycodone, hydrocodone, oxymorphone, and hydromorphone.
3. Synthetic Opioids: These opioids are entirely synthesized in a laboratory and do not have a natural source. Examples include fentanyl, tramadol, and methadone (4).

Providers must always caution patients about the benefits and risks. The main advantage of opioid medication is that it will reduce pain and improve physical function. A provider may use a 3-item Pain, Enjoyment of Life, and General Activity (PEG) Assessment Scale:

1. What number best describes your pain on average in the past week?
2. What number best describes how, during the past week, pain has interfered with your enjoyment of life?
3. What number best describes how, during the past week, pain has interfered with your general activity?

The desired goal is a 30% improvement overall with opioid treatment. (Centers for Disease and Control)

Providers must also go over potential side effects and warnings. Side effects include sedation, dizziness, confusion, nausea, vomiting, constipation, itching, pupillary constriction, and respiratory depression. Providers should discuss the importance of taking medication as prescribed. Taking opioids in larger than prescribed dosage, or in addition to alcohol, other illicit substances, or prescription drugs, can lead to severe respiratory depression and death. Individuals should not drive when taking opioids due to the sedating effects and decreased reaction times.

There are now thousands of different Food and Drug Administration (FDA) approved opioids available for providers to prescribe. They can be administered via other routes and come in various potencies. The strength of morphine is the "gold standard" used when comparing opioids. A morphine milligram equivalent (MME) is the degree of µ-receptor agonist activity. The following is a sample of some of the most prescribed opioids and their MME:

To utilize this information, multiply the dose for each opioid by the conversion factor to determine the quantity in MMEs. For example, tablets containing hydrocodone 5 mg and acetaminophen 325 mg taken four times a day would include a total of 20 mg of hydrocodone daily, equivalent to 20 MME (11).

A history of opioids leading to the current epidemic

While the current opioid epidemic has caused devastating effects in recent years, destruction from opioids has been going on for centuries. In the early 1800s, physicians and scientists became aware of the addictive qualities of opium. This finding encouraged research to develop safer ways to deliver opioids for pain relief and cough suppression, which led to the development of morphine. By the mid-1800s, with commercial production and the invention of the hypodermic needle, morphine became easier to administer.  

During the Civil War (1861 to 1865), injured soldiers were sometimes treated with morphine, and some developed lifelong addictions after the war. Without other options for pain relief, physicians kept giving patients morphine as treatment. Early indicators that morphine should be used cautiously were largely ignored. Between 1870 and 1880, the use of morphine tripled. Even with the problems associated with opioids, they continued to serve a vital part in the pain treatment of patients, and their use and development continued (6).  

Opioid prescribing increased fourfold during 1999–2010. Along with the increase in opioid prescriptions during this time, how they were prescribed also changed; opioids were increasingly prescribed at higher dosages and for longer durations. The number of people who reported using OxyContin for non-medical purposes increased from 400,000 in 1999 to 1.9 million in 2002 and to 2.8 million in 2003. This was accompanied by an approximately fourfold increase in overdose deaths involving prescription opioids (8).  

In 2020, approximately 1.4 million people were diagnosed with opioid use disorder (OUD), of those associated with opioid painkillers, as opposed to 438,000 who have heroin-related OUD (1, 4). Over 100,000 people died of a drug overdose, with 85% involved in an opioid (1, 4).  

Widespread efforts were made to combat this growing issue. The prescribing rate peaked and leveled off from 2010-2012 and has been declining since 2012. In 2021, an estimated 2.5 million adults had been diagnosed with OUD. However, the amount of MME of opioids prescribed per person is still around three times higher than in 1999 (5). 

 Controlled Substances

On July 1, 1973, the Drug Enforcement Administration (DEA) was established in the United States. The Diversion Control Division oversees pharmaceuticals. Within this Division are five levels of controlled substances, which classify illicit and medicinal drugs (7).  

Schedule I Controlled Substances

No medical use, lack of accepted safety for use under medical supervision, and high abuse potential.

Examples of Schedule I substances are heroin, lysergic acid diethylamide (LSD), and marijuana (cannabis).

Schedule II/IIN Controlled Substances (2/2N)

High potential for abuse, which can lead to severe dependence.

Examples include hydromorphone, methadone, meperidine, oxycodone, and fentanyl. Other narcotics in this class include morphine, opium, codeine, and hydrocodone.

Some examples of Schedule IIN stimulants include amphetamine, methamphetamine, and methylphenidate.

Other substances include amobarbital, glutethimide, and pentobarbital.

Schedule III/IIIN Controlled Substances (3/3N)

Less potential for abuse than substances in Schedules I or II, and abuse may lead to moderate or low physical dependence or high psychological dependence.

Include drugs containing not more than 90 milligrams of codeine per dosage unit like Acetaminophen with Codeine and buprenorphine.

Schedule IN non-narcotics includes benzphetamine, phendimetrazine, ketamine, and anabolic steroids such as Depo®-Testosterone.

Schedule IV Controlled Substances

Have a low potential for abuse relative to substances in Schedule III.

Examples include alprazolam, carisoprodol, clonazepam, clorazepate, diazepam, lorazepam, midazolam, temazepam, and triazolam, Tramadol.

Schedule V Controlled Substances

Low potential for abuse relative to Schedule IV and primarily consist of medications that have small quantities of narcotics.

Examples include cough preparations containing not more than 200 milligrams of codeine per 100 milliliters or per 100 grams and ezogabine (10).

Explore behaviors that indicate opioid seeking, misuse, or addiction in patients.

Opioid use disorder (OUD) causes significant impairment or distress. Diagnosis is based on the following criteria: unsuccessful efforts to reduce or control use or use that leads to social problems and a failure to fulfill obligations at work, school, or home. The term Opioid Use Disorder is the preferred term; "opioid abuse or dependence" or "opioid addiction" have negative connotations and should be avoided. (3).

OUD occurs after a person has developed tolerance and dependence, resulting in a physical challenge to stop opioid use and increasing the risk of withdrawal. Tolerance happens over time when a person experiences a reduced response to medication, requiring a larger amount to experience the same effect. Opioid dependence occurs when the body adjusts to regular opioid use. Unpleasant physical symptoms of withdrawal occur when medication is stopped. Symptoms of withdrawal include anxiety, insomnia, abdominal pain, vomiting, diarrhea, etc. (5).

Patients who have OUD may or may not have practiced drug misuse. Drug misuse, the preferred term for "substance abuse," is the use of illegal drugs and the use of prescribed drugs other than as directed by a doctor, such as using more amounts, more often, or longer than recommended or using someone else's prescription (3).

Some indications that a patient may be starting to have unintended consequences with their opioid prescription may include the following symptoms: craving, wanting to take opioids in higher quantities or more frequently, difficulty controlling use, or work, social, or family issues. If providers suspect OUD, they should discuss their concerns with their patients nonjudgmentally and allow the patient to disclose related concerns or issues. Providers should assess the presence of OUD using the DSM-5 criteria.

Providers can use validated screening tools such as:

• Urine and oral fluid toxicology testing
• Drug Abuse Screening Test (DAST)
• Tobacco, Alcohol, and/or other Substance use Tools (TAPS)
• A three-question version of the Alcohol Use Disorders Identification Test (AUDIT-C)

The following patients are at higher risk for OUD or overdose:

• History of depression or other mental health conditions
• History of a substance use disorder
• History of overdose
• Taking 50 or greater MME/day or taking other central nervous system depressants with opioids

The 12 components of the CDC’s recent guidelines for opioid prescribing.

In 2022, the CDC updated the 2016 guidelines to help prescribers navigate prescribing opioids amid an epidemic. These guidelines are directed toward prescribing medications to adults to be taken in the outpatient setting, for example, primary care clinics, surgery centers, urgent cares, and dental offices. These do not apply to providers caring for individuals with sickle-cell disease, cancer, those receiving inpatient care, or end-of-life or palliative care. They are also intended to serve as a guideline, and each treatment plan should be specific to the unique patient and circumstances.

Some of the Goals of the guidelines are to:

• Improve communication between providers and patients about treatment options and discuss the benefits and risks before initiating opioid therapy.
• Improve the effectiveness and safety of treatment to improve quality of life.
• Reduce risks associated with opioid treatment, including opioid use disorder (OUD), overdose, and death.

Recommendation #1: Determining when it is appropriate to initiate opioids for pain.

An essential part of the prescribing process is determining the anticipated pain severity and duration based on the patient’s diagnosis. Pain severity can be classified into three categories when measured using the standard 1-10 numeric scale. Pain scores 1-4 are considered mild, 5-6 are moderate, and 7-10 severe. Opioids are typically used for moderate to severe pain.

The patient’s diagnosis will allow the provider to determine if pain initially falls into one of the following three categories of anticipated duration: acute, subacute, and chronic. Acute pain is expected to last for one month or less. Acute pain often is caused by injury, trauma, or medical treatments such as surgery. Unresolved acute pain may develop into subacute pain if not resolved in 1 month. If pain exceeds three months, it is classified as chronic. Pain persisting longer than three months is chronic. It can result from underlying medical conditions, injury, medical treatment, inflammation, or unknown cause.

The CDC guidelines state that non-pharmacologic and non-invasive methods are the preferred first-line method of analgesia, such as heat/cold therapy, physical therapy, massage, rest, or exercises, etc. Despite evidence supporting their use, these therapies are only sometimes covered by insurance, and access and cost can be barriers, particularly for uninsured persons who have limited resources, no reliable transportation, or live in rural areas where treatments are not available.

When this is insufficient, non-opioid medications, such as Gabapentin, acetaminophen, or nonsteroidal anti-inflammatory drugs (NSAID), should be considered next. Selective antidepressants and anticonvulsant medications may also be effective. Some examples of when these drugs may be appropriate include neuropathic pain, lower back pain, musculoskeletal injuries (including minor pain related to fractures, sprains, strains, tendonitis, and bursitis), dental pain, postoperative pain, and kidney stone pain.

Providers, however, must also consider the risks and benefits of long-term NSAID use because it may also negatively affect a patient’s gastrointestinal and cardiovascular system. Depending on the diagnosis, a patient may also require an invasive or surgical intervention to treat the underlying cause to alleviate pain.

If the patient has pain that does not sufficiently improve with these initial therapy regimens, at that point, opioids will be the next option to be considered.

It does not mean that patients should be required to sequentially “fail” nonpharmacologic and non-opioid pharmacologic therapy or use any specific treatment before proceeding to opioid therapy. Example: A patient for whom NSAIDs are contraindicated has recently sustained a rotator cuff injury and is experiencing moderate pain to the point at which it is disturbing their sleep, and it will be several weeks before they can have surgery.

Recommendation #2: Discuss with the patient realistic treatment goals for pain and overall function.

Ideally, goals include improving quality of life and function, including social, emotional, and physical dimensions. The provider should help guide these patients to realistic expectations based on their diagnosis. This may mean that the patient may anticipate reduced pain levels but not complete elimination of pain. The provider should discuss the expected or typical timeframe where they may need medications.

If medications are anticipated for acute or subacute pain, a discussion about the expected timeframe for pain should be highlighted in the debate. The patient may then better understand if their recovery is progressing. For chronic conditions, the conversation will focus on or may emphasize the overall risks of beginning long-term medication therapy. They may also advise patients, particularly those with irreversible impairment injuries, that they may experience reduced pain but will not regain function. A withdrawal plan will be discussed if opioid therapy is unsuccessful or the risk vs. benefit ratio is no longer balanced.

The second section of recommendations covers the selection of opioids and dosages.

Recommendation #3: Prescribe immediate-release (I.R.) opioids instead of extended-release and long-acting (ER/LA) opioids when starting opioid therapy.

Immediate-release opioids have faster-acting medication with a shorter duration of pain-relieving action. ER/LA opioids should only be used in patients who have received specific dosages of immediate-release opioids daily for at least one week. Providers should reserve ER/LA opioids for severe, continuous pain, for example, individuals with cancer. ER/LA opioids should not be for PRN use. The reason for this recommendation is to reduce the risk of overdose. A patient who does not feel adequate relief or relief fast enough from the ER/LA dose may be more inclined to take additional amounts sooner than recommended, leading to a potential overdose.

Recommendation #4: Prescribe the lowest effective dose.

Dosing strategies include prescribing low doses and increasing doses in small increments. Prescribe the lowest dose for opioid patients. Carefully consider risk vs. benefits when increasing amounts for individuals with subacute and chronic pain who have developed tolerance. Providers should continue to optimize non-opioid therapies while continuing opioid therapy. It may include recommendations for taking non-opioid medications in addition to opioids and non-pharmacologic methods.

Providers should use caution and increase the dosage by the smallest practical amount, especially before increasing the total opioid dosage to 50 or greater morphine milligram equivalent (MME) daily. Increases beyond 50 MME/day are less likely to provide additional pain relief benefits. The greater the dosage increases, the tendency for risk also increases. Some states require providers to implement clinical protocols at specific dosage levels.

Recommendation #5: Tapering opioids includes weighing the benefits and risks when changing the opioid dosage.

Providers should consider tapering to a reduced dosage or tapering and discontinuing therapy and discuss these approaches before initiating changes when:

• The patient requests dosage reduction or discontinuation,
• Pain improves and might indicate the resolution of an underlying cause,
• Therapy has not reduced pain or improved function,
• Treated with opioids for a long time (e.g., years), and the benefit-risk balance is not clear.
• Receiving higher opioid dosages without evidence of improvement.
• Side effects that diminish the quality of life or cause impairment.
• Opioid misuse
• The patient experiences an overdose or severe event.
• Receiving medications or having a condition that may increase the risk of an adverse event.

Opioid therapy should not be discontinued abruptly unless there is a threat of a severe event, and providers should not rapidly reduce opioid dosages from higher dosages.

Patient agreement and interest in tapering will be key components of successful tapers. Integrating behavioral and non-opioid treatment and interventions for comorbid mental health conditions before/during a taper can help manage pain, strengthen the therapeutic relationship between the provider and patient, and improve the likelihood of positive tapering outcomes. When dosages are reduced or discontinued, a taper slow enough to reduce symptoms and withdrawal should be used. Patients should receive education on possible withdrawal symptoms and when to contact the provider.

For those taking opioids for a shorter duration, a 10% decrease of the original dose per week or slower until close to 30% of the initial amount is reached, followed by a weekly reduction of roughly 10% of the remaining dose) is less likely to trigger withdrawal. Tapers of 10% per month or less are better tolerated than rapidly tapering off when patients have been taking opioids for a longer duration (e.g., for a year or longer). Significant opioid withdrawal symptoms can indicate the need to slow the taper rate further. Short-term medications might also help manage withdrawal symptoms. Providers should follow up frequently (at least monthly) with patients engaging in opioid tapering.

Close monitoring is required for patients who cannot taper and who continue on high doses or otherwise high-risk opioid regimens and should collaborate with patients to mitigate overdose risk. Some patients with unanticipated challenges to tapering may need to be evaluated for OUD.

The third section focuses on the duration of opioid therapy and routine patient follow-up.

Recommendation #6: Prescribing no greater quantity than needed for the expected duration of severe pain requiring opioids.

A few days or less is often enough when opioids are used for common causes of nonsurgical acute pain. Many states have passed legislation that limits initial opioid prescriptions for acute pain to less than seven days. Many insurers and pharmacies have enacted similar policies. Providers should avoid prescribing additional opioids to patients if pain continues longer than expected.

Providers should prescribe and advise opioid use only as needed rather than on a scheduled basis (e.g., one tablet every 4 hours). Limiting the duration of therapy can decrease the need to taper. However, tapering may need to be considered if patients take these medications around the clock for more than a few days.

Longer durations of therapy may be needed when the injury is expected to result in prolonged severe pain (e.g., greater than seven days for severe traumatic injuries). Patients should be evaluated at least every two weeks if they are receiving opioids for acute pain. Suppose opioids are continued for a month or longer. In that case, providers should address potentially reversible causes of chronic pain so that the length of therapy does not continue to extend.

Recommendation #7: Evaluate the benefits and harms of opioid therapy regularly.

The benefits and risks for Evaluating benefits and risks within 1-4 weeks of starting long-term opioid therapy for subacute and chronic pain should be evaluated within 1-4 weeks of initiating therapy and after dosage increases.

The evaluation should include patient perspectives on progress and challenges in moving toward treatment goals, including sustained improvement in pain and function. The Three-item Pain, Enjoyment of Life, and General Activity (PEG) assessment scale could be utilized to help determine patient progress.

Providers should also ask patients about common adverse effects, such as constipation and drowsiness, and assess for outcomes that might be early warning signs for more serious problems such as overdose or OUD.

Patient re-evaluation should occur after therapy begins (about two weeks) when ER/LA opioids are prescribed if the total daily opioid dosage is greater than or equal to 50 MME/day or if there is a concurrent benzodiazepine prescription. These individuals are at a higher risk for overdose. Follow-up for individuals starting or increasing the dosage of methadone is recommended every 2-3 days for the first week. Providers should reassess all patients receiving long-term opioid therapy at least every three months.

The last section of recommendations covers patients at risk for OUD and overdose.

Recommendation #8: Use strategies to mitigate risk by evaluating risk for opioid-related harms, discussing risk with patients, and incorporating risk reduction strategies into the treatment plan.

The patient’s habits (including alcohol and illicit drug use) and behavioral and mental health must be considered. Patients with a history of substance use disorders, depression, and/or mental health disorders have a higher risk of overdose and OUD. Even though the dangers of opioid therapy are higher with these patients, they may still require opioid treatment for pain management.

Psychological distress can interfere with the improvement of pain and/or function in patients experiencing chronic pain; using tools like the Generalized Anxiety Disorder (GAD)-7 and the Patient Health Questionnaire (PHQ-9 or PHQ-4) to assess for anxiety, post-traumatic stress disorder (PTSD), and depression might help providers improve overall pain treatment outcomes. They should also ensure that treatment for depression and other mental health conditions is effective, consulting with behavioral health specialists when needed.

Additionally, providers should:

• Educate on the risks of overdose when opioids are combined with other drugs or alcohol.
• Use caution when prescribing opioids for people with sleep-disordered breathing due to their increased risk for respiratory depression. The provider may ascertain if a patient is compliant with prescribed CPAP.
• Use caution and increased monitoring for patients with renal or hepatic insufficiency.
• Use caution and increased monitoring for patients aged 65 years or older.
• Offering naloxone when prescribing opioids, particularly to patients at increased risk for overdose.

If patients experience a nonfatal opioid overdose, providers should evaluate for OUD. Providers should reduce opioid dosage, discontinue opioids when indicated, continue monitoring, and support for patients prescribed or not prescribed opioids.

Recommendation #9: Reviewing prescription drug monitoring program (PDMP) data.

Providers should review PDMP data specifically for prescription opioids, benzodiazepines, and other controlled medications patients have received from additional prescribers to determine all the opioids the patient could potentially receive. Patients with multiple prescriptions and from various providers are at an increased risk for overdose or OUD. PDMP data should be reviewed before initial drugs for subacute or chronic pain and at least every three months during long-term opioid therapy.

Recommendation # 10: Considering the benefits and risks of [urine] toxicology testing.

Toxicology testing should be used to inform and improve patient care. Providers, practices, and health systems should minimize bias in testing and not test based on assumptions about different patients.

Recommendation # 11: Use caution when prescribing opioid pain medication and other medications concurrently.

Benzodiazepines and opioids can cause CNS depression and potentiate opioid-induced decreases in respiratory drive. Because other CNS depressants can potentiate respiratory depression associated with opioids, benefits vs. risks should be considered.

Recommendation # 12: Offering or arranging treatment for OUD if needed.

Includes referring a patient to a specific treatment center where behavior therapy and medications may be prescribed.

Prescription Drug Monitoring Programs (PDMP) and Electronic Prescribing.

Prescription Drug Monitoring Programs (PDMP) is a database that keeps track of controlled substance prescriptions. It helps to improve opioid prescribing, inform clinical practice, and protect at-risk patients. A pharmacist must enter controlled substances into the state PDMP when dispensing them. When the pharmacist enters this data, it may occur at various intervals, from one month, daily, or even "real-time." However, a PDMP is only helpful if providers check the system before prescribing (10).  

Some states have implemented legislation that requires providers to check a state PDMP before prescribing certain controlled substances and in certain circumstances. Most current mandates require that all prescribers query PDMPs when prescribing any opioid. Some states require prescribers to query PDMPs every time a controlled substance is prescribed, while others require a query only for the initial prescription. Subsequent checks of PDMPs also vary from every time a drug is issued to specific intervals (e.g., every 90 days, twice a year, annually) should prescribing continue.  

Some mandates have categorical requirements; e.g., a query must be made if the prescription is over a three-day or seven-day supply or if a certain prescribed level of MME is exceeded. Other states' mandates are based on subjective criteria, e.g., a prescriber's judgment of possible inappropriate use or the prescriber's discretion regarding whether to query the PDMP. Finally, some states mandate that only prescribers in opioid treatment programs, workers' compensation programs, or pain clinics must query PDMPs (10, 11).  

In addition to PDMPs, there has been an increase in requirements for providers to utilize Electronic Prescribing for Controlled Substances (ECPS). Electronic prescribing programs for both providers and pharmacies must meet DEA requirements. The DEA's March 31, 2010, conditions were updated on July 27, 2023 (12).  

On January 1, 2023, the Centers for Medicare and Medicaid Services (CMS) implemented additional requirements for controlled substances for recipients of Medicare Part D. There are over 51 million U.S. people enrolled in Medicare Part D (Center for Medicare Advocacy, 2023). In addition to state laws, these rules require that prescribers e-prescribe at least 70 percent of controlled substances for patients that have Medicare Part D. A waiver may be approved if the prescriber cannot conduct electronic prescribing due to circumstances beyond the provider's control (12).  

Starting June 27, 2023, the 'Consolidated Appropriations Act of 2023' requires new or renewing Drug Enforcement Administration (DEA) registrants, to have at least one of the following: 

• A total of eight hours of training from specific organizations on opioid or other substance use disorders 
• Board certification in addiction medicine or addiction psychiatry from the American Board of Medical Specialties, American Board of Addiction Medicine, or the American Osteopathic Association 
• Graduation within five years and status in good standing from medical, advanced practice nursing, or physician assistant school in the U.S. that included an opioid or other substance use disorder curriculum of at least eight hours (11, 12).  

Providers must follow either state law or DEA/CMS regulations, whichever is more stringent. The following map indicates various rules in each state, which will continue to change when new legislation is enacted (11, 12).  

Important teaching points about opioid storage and disposal.

Safe Storage 

Patients should understand that prescription opioids need to be stored securely (i.e., keeping them in a locked area). This is especially true if children, teens, and other visitors in the house may be aware of their presence. Teens and young adults are the biggest misusers of prescription pain medication. In 2018, over 695,000 youths ages 12–17 and 1.9 million young adults ages 18–25 reported misusing prescription pain medication in the past year. Young people may misuse prescription opioids for many reasons, including curiosity, peer pressure, and wanting to fit in. Another reason teens and young adults may decide to take prescription opioids is because they can be easier to get than other drugs. Studies show that 53% percent of people over 12 who obtained prescription pain medication for non-medical use received them from a friend or relative (13).  

Safe Disposal 

Patients should be advised on how to get rid of unused or expired medications. The best option is to immediately take them to a drug take-back site, location, or program. These sites or programs can be found online, or the pharmacist may have information. If it is not feasible for the patient to get rid of the drug using a take-back program, the patient should be advised to check if it is on the FDA flush list. If it is, the medication should be flushed down the toilet. Again, the list of drugs is available on the FDA website. If it is not on that list, it should be discarded in the trash at home.  

Patients should follow these disposal instructions: Mix medicines (liquid or pills; do not crush tablets or capsules) with an unappealing substance such as dirt, cat litter, or used coffee grounds. Next, place the mixture in a container such as a sealed plastic bag; then throw away the container in your trash at home. Last, the patient should remove or permanently cover all personal information on the prescription label of empty medicine bottles or packaging, then trash or recycle the open container (14).  

OUD treatment, including medications.

Treatment for OUD is multi-faceted and typically includes both mental health components and FDA-approved OUD treatment medications. Mental health components may consist of counseling or a structured treatment program. Cognitive behavioral therapy (CBT) may also be beneficial. A potential barrier to OUD treatment, on the provider's and patient's behalf, is the perception that patients must engage in counseling to start or continue receiving OUD treatment medication. While the mental health components are essential, there may be barriers for patients to begin mental health treatment programs, which include expense, travel, and available openings within the programs. Medication therapy may be a helpful start for these patients (9). 

FDA-approved medications indicated for the treatment of OUD include methadone, buprenorphine, and naltrexone. Suboxone is a combination drug composed of buprenorphine and naltrexone.  

Medication has several advantages as part of the OUD treatment plan.  

• Help the individual to remain safe and comfortable during detox. 
• Reduce or eliminate cravings for opioids 
• Minimize relapse since the individual is not experiencing uncomfortable withdrawal symptoms 
• Allow the individual to focus on therapy without being distracted by withdrawal symptoms and cravings 
• Increase safety in cases of overdose 

Methadone 

Methadone is a full agonist opioid and is a Schedule II controlled medication. Methadone can be prescribed purely for the treatment of pain, as well as for OUD. Methadone treatment for OUD can only be provided through a Substance Abuse and Mental Health Services (SAMHSA)-certified opioid treatment program. Patients taking methadone to treat OUD must receive the medication under the supervision of a clinician. After consistent compliance, patients may take methadone at home between program visits. The length of methadone treatment should be a minimum of 12 months. Methadone doses are often adjusted and readjusted. Methadone is slowly excreted, and there is overdose potential if not taken as prescribed (9).  

Buprenorphine 

Buprenorphine is a partial agonist opioid. Buprenorphine can be prescribed by any provider with a current, standard DEA registration as a Schedule III Controlled Substance. Like opioids, it produces effects such as euphoria or respiratory depression. With buprenorphine, however, these effects are weaker than those of full opioids such as heroin and methadone. It also has unique pharmacological properties that help lower the potential for misuse and diminish the effects of physical dependency opioids, such as withdrawal symptoms and cravings (9). Subutex was a brand-name version of buprenorphine, discontinued in 2011 after new formulations that were less likely to be misused were developed.  

Naltrexone 

Naltrexone is an opioid antagonist, not addictive, and does not cause withdrawal symptoms. It blocks the euphoric and sedative effects of opioids by binding and blocking opioid receptors and reduces and suppresses opioid cravings. There is no potential for misuse and diversion. Naltrexone can be prescribed in any setting and can be taken as a pill or once monthly extended-release intramuscular injection (9).  

It was estimated 2021 that of the 2.5 million people with OUD, only 36% received any treatment, and only 22% received medications. A part of the July 27, 2023, Consolidated Appropriations Act amended the Controlled Substances Act to eliminate the requirement that providers obtain a specific waiver (a DATA waiver) to prescribe buprenorphine (including Suboxone) to treat opioid use disorder, known as the X-waiver. Additionally, there are no longer any caps on the number of patients a practitioner can treat. This, however, does not change the requirements for methadone treatment (15).  

Case Study #1

Patient Name: John Henderson,

Gender: Male

Age: 60

Height: 6' 1"

Weight: 190 lbs.

He is employed as a grocery store manager. Reports not using tobacco; drinks alcohol occasionally and has no illicit drug use. He has hypertension and high cholesterol and takes Losartan 50mg daily and Atorvastatin 20 mg daily.

This patient presents to a primary care office with pain and stiffness in the shoulder joint, which has progressively worsened for six months following rotator cuff surgery. He states his pain is unchanged, and he has a limited range of motion. It has been interfering with his ability to do his job. He said he went to physical therapy for a few weeks after his surgery but admitted he did not often complete the home exercise program regimen. An MRI was obtained and showed he had adhesive capsulitis. What are treatment options to consider for "frozen shoulder"?

Given the patient's diagnosis, non-opioid therapy options include nonsteroidal anti-inflammatory drugs, intraarticular glucocorticoid injections, steroid injections into the shoulder joint, range of motion exercises, physical therapy, and consulting with an orthopedic specialist who may recommend a joint manipulation under anesthesia. Each of these should be considered before opioid therapy.

Nursing Considerations 

Nurses remain the most trusted profession for a reason, and advanced practice registered nurses (APRNs) are often pillars of patient care in several health care settings. Patients turn to nurses for guidance, education, and support. While there are no specific guidelines for the nurse’s role in opioid education and management, here are some suggestions to provide quality care for patients currently taking opioid medications. 

Obtain a Detailed Health History 

Often times, pain and mental health can be dismissed and overlooked in health care settings. If a patient is complaining of symptoms that could be related to pain, inquire more about that complaint. Ask about how long the symptoms have lasted, what treatments have been tried, if these symptoms interfere with their quality of life, and if anything alleviates any of these symptoms. If you feel like a patient's complaint is not being taken seriously by other health care professionals, advocate for that patient to the best of your abilities. A detailed pain assessment and history can provide context for opioid pain management and a patient's plan of care. When taking a health history, ask about any prior surgeries, major life stressors in the past year, or any prior opioid usage.  

Review the Medication History 

Often times, in busy clinical settings, reviewing health records can be overwhelming. Many people take pain medications, including opioids, for various reasons. Ask patients how they are feeling on the medication, if their symptoms are improving, if there are any changes to medication history, and if they use any other substances other than prescribed medications, such as alcohol, tobacco, or other drugs. Remember, prescription medications are not the only medications people take. Confirm medication route, dosage, frequency, and all the details to make sure you and the patient are on the same page and to avoid medication errors and complications. Medication history should be reviewed at every encounter. 

Avoid Making Judgements 

Society often stigmatizes open discussions of prescription medication and pain. Patients may avoid asking for pain medication for fear of being perceived as a "drug seeker." Other times, patients may have OUD and continuously ask for an increased number of opioid medications. Be willing to be honest with yourself about your comfort level discussing topics and providing education on opioid medications, drug interactions, and pain management. Be willing to address any questions/concerns the patients may have without making judgements. 

Communicate the Plan of Care 

Communicate the plan of care to other staff involved for continuity of care. For several patients, especially for patients with chronic pain or who use opioids long-term, care often involves a team of mental health professionals, physical therapists, nurses, specialists, pharmacies, and more. Ensure that patients' records are up to date for ease in record sharing and continuity of care and to reduce the incidence of opioid medication errors. 

Engage in Self Learning 

Stay up to date on continuing education related to opioid medications, pain management, and prescribing regulations. Evidence-based information and scope of practice is always evolving and changing. You can then present your new learning and findings to other health care professionals and educate your patients with the latest information. You can learn more about the latest research on pain management medications, non-pharmacological pain management options, and opioids by following updates from evidence-based organizations, such as the CDC or your local health department.  

Perform Pain Assessments  

As we know, it is not possible to look at someone with the naked eye and determine if they are in pain. Sometimes, it may be obvious when a patient is in pain (e.g., visible lacerations) and need pain management options, such as opioids. Other times, pain management is addressed as a result of taking a complete health history, listening to patient's concerns, completing a pain assessment, and offering testing to determine the cause of pain. 

Assess for Opioid Use Disorder 

While it is not possible to look at someone and determine if they have OUD, APRNs should pay attention to certain behaviors, for example, when a patient continually asks for more opioid medications or mentions that they are experiencing many symptoms common to those of OUD. OUD may be diagnosed as a result of completing a health history, listening to patient's concerns, and offering testing to determine the cause of pain. Remember, anyone can have OUD, and no two OUD patients appear the same.  

Provide Patient Teaching 

Patients should know that anyone has the possibility of experiencing side effects of opioid medications, just like with any medication. Patients should be aware that if they notice any changes in their breathing, changes in their heart rate, or feel like something is a concern, they should seek medical care. Because of social stigma associated with opioids and pain management, people may be hesitant to seek medical care because of fear, shame, and embarrassment. However, as more research and social movements discuss opioid use, there is more space and awareness for opioid education and opioid overdose prevention.  

Nurses should also teach patients to advocate for their own health in order to avoid possible opioid complications and poor pain management.  

Here are important tips for patient education in the inpatient or outpatient setting.  

• Tell the health care provider of any existing medical conditions or concerns (need to identify risk factors) 
• Tell the health care provider of any existing lifestyle concerns, such as alcohol use, other drug use, sleeping habits, diet, menstrual cycle changes (need to identify lifestyle factors that can influence opioid use and pain management) 
• Tell the health care provider of any prior experiences with opioid medication (if applicable) and any medication reactions or side effects (need to identify risk factors, address pain management appropriately, identify any allergies, and avoid possible opioid overdose symptoms) 
• Tell the health care provider if you have any changes in your breathing, bodily functions, or heart rate (potential opioid overdose symptoms) 
• Tell the nurse or health care provider if you experience any pain that increasingly becomes more severe or interferes with your quality of life 
• Keep track of your pain, overall health, medication use, and health concerns via an app, diary, or journal (self-monitoring for any changes) 
• Tell the health care provider right away if you are having thoughts of hurting yourself or others (possible increased risk of suicidality and public safety concerns) 
• Take all prescribed medications as indicated and ask questions about medications and possible other treatment options, such as non-pharmacological options or surgeries 
• Tell the health care provider if you notice any changes while taking medications or other treatments to manage your pain (potential worsening or improving health situation) 

Research

There is extensive publicly available literature on opioids medications. These can be found via the National Institutes of Health website and other evidence-based journals. As research is dependent upon the available of study participants, there are several ways people who take opioids can become part of research. If a patient is interested in participating in clinical trial research, APRNs can encourage them to seek more information on clinical trials from local universities and health care organizations. 

Case Study #2

• Patient: Pilar 
• Age: 40 
• Height: 5' 1" 
• Weight: 135 lbs. 

Pilar presents to the urgent care clinic today complaining of a severe migraine, which started yesterday. Her history includes a hip injury following a car accident three years ago in which she developed chronic post-traumatic arthritis in the hip. After a total hip arthroplasty, she was diagnosed with heterotopic ossification (bone grows in tissue where it shouldn’t). For the past year, she has been taking 20 mg of oxycodone twice daily to manage chronic hip pain after unsuccessful non-opioid therapies. She has three children with no known pregnancy or postpartum complications. She previously worked part-time as an administrative assistant but has been off work since the car accident. She has post-traumatic stress disorder (PTSD) related to the accident. She has been prescribed Xanax 0.5mg up to three times daily for anxiety. She does not smoke, drink alcohol, or take illicit substances. 

• What are some specific questions you'd want to ask about the hip arthritis? 
• What are some health history questions you'd want to highlight? 
• What lab work or testing would you suggest to perform?  

For her migraine, Pilar stated she needed to take more of her oxycodone to deal with the pain and because she could not sleep last night. She is concerned because she is running out of pills. She said her primary care doctor's office was closed, so she came to the urgent care.  

• What are some non-pharmacological interventions you can do for Pilar's pain? 
• What are some questions you'd want to ask about her migraine? 
• What are side effects of opioids would you discuss with her? 

Here are some things to consider for Case Study #2.  

• Discuss concerns with the patient. This includes taking the opioid more often than prescribed, potential problems with respiratory depression, and overdose.  
• Recommend trying eletriptan or dihydroergotamine nasal spray first rather than additional opioids. 
• Review the PDMP to see the prescription history for this patient. Attempt to contact the primary care provider to develop a plan of care. 
• Consider conducting toxicology testing 
• Consider offering naloxone  
• Use the DSM-5 criteria to assess the presence (and severity) of OUD or arrange an assessment with a substance use disorder specialist. Offer treatment for OUD if it is confirmed. 

Case Study #3 

Sabrina is a 16-year-old Black high school student working as a waitress at a local restaurant. She arrives to the local pediatric emergency room after her shift with her mom because she thinks she is experiencing a sickle cell crisis. Sabrina reports that she has these crises every few months, and this is probably the third time she's been in this much pain. She reports being at this same ER last year for something similar. Her mother is completing paperwork and would like Sabrina to get some pain medication as well.  

• What are some specific questions you'd want to ask about her health? 
• What are some health history questions you'd want to highlight? 
• What lab work or testing would you suggest to perform?  
• What pain assessments would you perform on Sabrina? 

Sabrina agrees to provide bloodwork, complete imaging, and be admitted. She said that no health care provider talked to her about how painful sickle cell crises can be, and she doesn't routinely take pain medication because she "doesn't want to be addicted." Sabrina and her mom heard about pain management options for these extremely painful episodes from social media and the internet and would like Sabrina to get her pain controlled. Sabrina said that she had some opioids last time she was in the ER, but she doesn't remember the name. Her mom doesn't remember the name either, but she remembers it was in an IV medication.  

• How would you discuss Sabrina's pain management concerns? 
• Given Sabrina's age, medical history, and prior history of opioid use, what medication options would be appropriate for a sickle cell crisis in an adolescent?  

Sabrina has been in the pediatric ER for over a day receiving IV hydromorphone. She reports some relief, but Sabrina and her mom are concerned. Sabrina wants to live her life like a normal teenager without being in the hospital every few months for pain. Her mom asks if there is a way to have pain medication at home. Both Sabrina and her mom would like to know if there is anything that can be done to help with the pain outside of medications as well. Sabrina doesn't want to use pain medications daily but wants to have them at home just in case she can't get to the hospital.  

• Knowing Sabrina's concerns, what are some possible non-pharmacological pain management options? 
• Knowing Sabrina's health history, what would be some patient education talking points about at-home opioid medications and possible side effects?   
• What are some possible consequences of leaving pain improperly managed?  

Conclusion

Even providers who do not prescribe opioids should be familiar with the effects of opioids and OUD due to its high prevalence in the United States. Understanding the types of pain, how pain occurs, and how it impacts a person's quality of life is especially important. There is still an associated stigma among patients who use Opioids to treat chronic pain conditions. It is essential to recognize that there are times when opioid use is appropriate, as long as the provider practices the recommended guidelines and sound clinical judgment.

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