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Not Addicted - Nurses Taking Meds For Chronic Pain

Monday October 9, 2006
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A nurse has chronic pain from a back or hip injury or arthritis or another chronic condition. After trying other meds such as non-steroidal anti-inflammatory drugs, his or her primary care provider prescribes low doses of long-acting medication containing morphine sulphate.
Should the nurse return to work while taking this medication? Should the nurse tell a supervisor? What if the nurse commits some sort of error while using the medication? Will his or her license be in jeopardy?
Pain experts, ethics experts, representatives of boards of nursing, and nurse executives respond almost always the same way:
First, they say: Those are good questions. Then they say: It depends on the nurse, the employer, and even the state where the nurse practices.
"It all comes back to the individual situation, and every one of them is going to be different," says Laurie Badzek, RN, MS, JD, LLM, director of the American Nurses Association Center for Ethics and Human Rights and a professor at West Virginia University School of Nursing in Morgantown, W.Va.
The need for pain medication
A report by Peter D. Hart Research Associates that was commissioned by AFT Healthcare, states that nearly 40% of the 509 randomly-selected hospital nurses surveyed in February reported they regularly work with chronic pain. One-third said they have struggled with chronic pain for at least two years, and one in 10 said they have worked while taking prescription pain medication.
Many types of pain medication are available for chronic conditions, from non-steroidal anti-inflammatory drugs to opioid analgesics such as morphine and oxycodone. But while most people wouldn't question a nurse taking ibuprofen to relieve a backache, many mistakenly associate opioids with impairment, addiction, or diverting medications.
As nurses age and increase their risk for conditions that cause chronic pain, and as hospitals offer incentives to keep them working after retirement age, the number of those who use chronic pain medication at work will probably increase.
Pain management experts say any medication for chronic pain, when prescribed and used correctly, should not impair anyone's ability to work. "It actually allows them to function better," says Irene Zamora, RN, MSN, CNS, a certified pain management nurse at the University of New Mexico Hospital in Albuquerque. "Would we expect someone with diabetes to function without their medication?"
It's very rare - a less than 1 % risk, she says, that taking opioid medication will lead to addiction. "Just having opiates in your system doesn't make you an impaired person," says Rhonda Nichols, RN, MS, CNS, a private consultant in pain management in San Francisco, "but not every institution is going to recognize that."
This doesn't mean that nurses taking a newly prescribed pain medication should immediately return to work, pain experts add. Anyone starting any medication, whether for diabetes, heart disease or acute pain after a procedure such as dental surgery, should allow for a few days to adjust and watch for side effects such as dizziness or drowsiness before doing tasks that require clear thinking, such as driving or working. They should also have clear instructions from their providers about when it is safe to return to work.
Anyone using medication for a chronic condition should do the same when changing the dosage of the medication, and should check in with his or her provider at regular intervals, pain experts say. More worrisome than sustained-release, low-dose pain medication, pain experts say, are short-acting analgesics, which are usually taken in higher doses and build tolerance more quickly. This increases the likelihood that a nurse will experience side effects when the medication peaks, followed by increased pain as blood levels drop rapidly, Nichols says. Another potentially troublesome situation is under-medicating, which may cause nurses in pain to be distracted and less able to focus on their work, pain experts say.
"They work in pain, and their patient care will suffer," Nichols says. But taking a lot of short-acting medications to get through the shift is not a good idea either, she says. Side effects and development of tolerance to medication are more prevalent "when you do the on-off, on-off."
But many physicians prefer to prescribe the short-acting medications, she adds. A 15 mg. dose of sustained-release morphine sulphate (MSContin) every eight hours is probably safer than a prescription for two hydrocodone (Vicodin) every 4-6 hours, she says. "But people feel more comfortable writing for Vicodin, or Tylenol with codeine. It doesn't make sense to manage chronic conditions with that type of medication."
Nurses with chronic pain should discuss the benefits of long-acting analgesics with their providers, rather than continuing to rely on short-acting medications, she says, or make arrangements to work without duties such as heavy lifting that might require more pain medication.
Nurses should make the decision with their health care providers about when to return to work, pain experts say, and much depends on whether the nurses feel they can practice safely.
Nurses are not legally required to disclose to their employers whether they are taking any medication, say boards of nursing and others. But if nurses work in places that have specific disclosure policies or random urine sampling or other forms of drug testing, they should explain that they are taking prescription medication as part of an approved treatment plan, and offer backup documentation from their providers, say pain experts and others.
American Hospital spokesperson Amy Lee†says there are no national guidelines about nurses returning to work while taking prescribed medications. "That is really a local hospital decision," she says. Some hospitals require nurses to disclose if they are taking prescribed medicines containing opiods. Haase-Herrick says about half of 15 nurse executives in Washington and Oregon told her in response to an e-mail query that their facilities had some sort of disclosure policy.
The policies vary in their language and specific requirements, she says, but most require nurses to report that they were using prescription pain medications containing opioids; to be evaluated or provide a statement from a health care provider saying they were able to work; and to understand that they had a responsibility to be aware of any potential impairment the medications might cause and to not work if they felt they were impaired in any way. The policies "were written to be very supportive" of nurses taking the medications, she says, as well as to protect patient safety.
When there is no hospital policy, pain experts and others say, the decision to disclose is very personal and depends on the attitudes of employers and colleagues, as well as nurses' own concerns. Many nurses say they would prefer to disclose because they fear the consequences if something went wrong while they were taking medication, whether or not the medication had anything to do with the error.
"Your medical history is your own business, and you have no obligation to disclose it," says Vicki Bermudez, RN, regulatory policy specialist for the California Nurses Association. "But if your assessment is wrong and your actions suggest you may be impaired, your employer may insist you be evaluated to be sure you can provide competent care." Such evaluations may include tests for narcotics, she says.
The nursing code of ethics states that nurses are accountable for their practice, Badzek says, and that colleagues must respond to signs of impairment in their co-workers, and report them if necessary. As a precaution, nurses returning to work while taking medication may at least want to confide in a trusted peer or supervisor who could watch for any signs of unsafe behavior, such as sluggishness, that they may not notice themselves, she says.
Staff at the Texas Board of Nurse Examiners and others suggest informing a nurse manager who can help monitor the nurse taking the medication. If necessary, the manager may be able to reassign the nurse to temporary non-patient care duties, especially when he or she first returns to work, or anytime changes in the drugs or doses occur.
Suspicions and fears
But if administrators and colleagues don't understand chronic pain management, pain management nurses and others say, nurses might be better off keeping the information to themselves, or telling a supervisor they are taking "pain medication" without describing what kind.
Nurses can feel judged if colleagues know they are taking opioid pain medicine, Zamora says. She knows of one case of a nursing supervisor who took morphine sulphate while recovering from a chronic pain condition. "She got looks when people found out." When she was eventually prescribed liquid morphine for her pain, she decided not to tell anyone, Zamora says. "[The nursing supervisor] felt terrible that she was sneaking around, but if people knew, she'd get these looks that made her feel horrible."
Such fears cause many nurses to not take pain medication at work, especially not opioids, pain specialists say. Instead they make do with aspirin or ibuprofen, or distract themselves with work. The pain builds up, Nichols says, and when they go home from work, they can't function in other roles, such as caring for children or maintaining a household. "Their lives really are controlled by the pain," she says.
If chronic pain is not treated, studies show that the threshold for pain decreases and eventually even pain a person would have previously tolerated becomes incapacitating, she says. "It's not a good idea for anyone in chronic pain to let themselves be in pain for eight hours a day, and in health care, it's more typical to be in pain for 12 or 13 hours."
Patient safety is paramount
Documentation, such as a provider's release to go back to work, is extremely important, say boards of nursing representatives and others, and should provide some protection if a nurse who is taking pain medication makes an error or is the subject of a complaint. But they warn that such documentation is not a guarantee against an investigation or disciplinary action. "The boards have to focus on the public's protection," says Vickie Sheets, RN, JD, CAE, director of practice and regulations at the National Council State Boards of Nursing. If it comes down to a nurse's right to practice and patient safety, she says, "boards put protecting the patient first."
Representatives of various state boards say they look at each case individually, and if a complaint were filed against a nurse who was taking opioids, prescribed or not, they would investigate carefully. "The process would be quite similar in any case that involves the use of drugs," says Elliot Hochberg, enforcement program manager for the California Board of Registered Nursing. "The bottom line is, are they safe to practice?"
Cases of complaints against nurses taking prescribed pain medications are extremely rare. Most cases of impairment related to opioid use involve nurses with chemical dependency problems, Hochberg says.
Addiction vs. pain control
The difference between a nurse who is taking medication to control pain and one who is addicted can sometimes be a fine line, pain management nurses say. But the deciding factor is almost always the nurse's ability to function. "Addiction is when there's a problem," when behavior is inappropriate, Zamora says. Both the provider and the nurse taking the medication need to constantly watch for red flags, such as whether the medication is being taken to ease anxiety, to cope, to sleep better - for any reason other than for pain.
Some behaviors, such as taking more than a prescribed dose, could be signs of either addiction or under-treatment of pain, she says. But if the medication is not controlling the pain, the nurse should talk with the provider and work out an adjustment rather than just taking more medicine.
More education about pain management would help nurses better understand their patients' need for relief, as well as their colleagues' needs, pain experts say. Improved education about pain may also help foster a more open, less fearful workplace, where nurses would not have to worry about whispers or strange looks, or work in pain because they were afraid to take prescribed medication that could help them.
Chronic pain "needs to be looked at like any other illness," Zamora says. "There's always a potential for abuse [with pain medications], but more than that, we want to give people back their lives. They shouldn't feel guilty. They should just be able to manage their pain as best they can."
Cathryn Domrose is a staff writer for NurseWeek. To comment on this story, send
e-mail to editorca@nurseweek.com.
This information is for educational purposes only and is not intended as legal or any other advice. The reader is encouraged to seek the advice of an attorney or other professional when an opinion is needed. For more information, visit the American Society for Pain Management Nursing at www.aspmn.org.