Application of Advanced Practice Nurses Attitudes and Behaviors about Opioid Prescribing for Chronic Pain Survey Pat Bruckenthal, PhD, APRN-BC, ANP Aaron Gilson, MS, MSSW, PhD Conflict of Interest Disclosure Authors Conflicts of Interest; P. Bruckenthal, advisory board Mallincrodt A. Gilson, no conflicts of interest This project is funded by an ASPMN research grant Thank you to RAs Donna Willenbrock, ANP, Kelly Reinhardt, Administrative Assistant Any views or opinions in this presentation are solely those of the author/presenter and do not necessarily represent the views or opinions of the American Society for Pain Management Nursing. Objectives Discuss conceptualization for initiating research project Review research process for this study Discuss results to date Evaluate survey questions for refinement and next steps 1
Nursing Regulatory Pain Policy (n=24) WA OR ID MT ND SD MN WI VT NY ME NH MA CA NV UT WY CO NE KS IA MO IL MI PA OH IN WV VA KY RI CT NJ DE MD AK AZ NM OK AR TN NC SC DC MS AL GA TX LA HI FL Pain CME for Nurses (n=6) WA OR ID MT ND SD MN WI VT NY ME NH MA CA NV UT WY CO NE KS IA MO IL MI PA OH IN WV VA KY RI CT NJ DE MD AK AZ NM OK AR TN NC SC DC MS AL GA TX LA HI FL APN Prescribing Authority 2010, 2012, & 2013 25 20 Number of States 2010 2012 2013 15 10 5 0 No Rx authority MD involvement + limits MD involvement Independent Rx authority PPSG. Achieving balance in state pain policy: A progress report card (CY 2013). 2014. 2
National Council of State Boards of Nursing 2008 Policy: Report of Disciplinary Resources Committee (September, 2008, pp. 114-324) National Council of State Boards of Nursing Unique Situations the Board Encounters A nurse fails to meet the expected standards of nursing pain management, resulting in the risk of harm and suffering for patients An advanced practice registered nurse (APRN) fails to appropriately prescribe medications for pain management A nurse s personal pain or treatment for pain affects his/her ability to practice safely A chemically dependent nurse requires pharmacologic pain management NCSBN. Report of Disciplinary Resources Committee. 2008. National Council of State Boards of Nursing New Standards Pain Management Nursing: Scope & Standards of Practice (2005, ANA/ASPMN) Regulatory implications Lack of knowledge about healthcare standards Regulatory scrutiny Misunderstanding of addiction-related terms Lack of knowledge about regulatory policies Nursing boards as effective educators Team approach to pain care Concept of Balance NCSBN. Report of Disciplinary Resources Committee. 2008. 3
National Council of State Boards of Nursing New Standards Guides licensure decisions about pain issues Determining appropriate action for non-compliance with requirements in law Acknowledges numerous systemic barriers to nurses involvement in pain treatment Supports nurses role in assessment and treatment of pain Emphasizes benefit/risk considerations Supports team approach/integrated care model NCSBN. Report of Disciplinary Resources Committee. 2008. Nursing Pain Management Practice Clinical Considerations Identifying and addressing addiction, other co-morbidities, or other risk factors Changing treatment or treatment strategies Pharmacologic issues Involving patients in treatment decisions Discussing risk mitigation issues with patients Legal or regulatory barriers Nursing Pain Management Practice Potential Policy Barriers Prescribing authority is prohibited Formal physician involvement (??) Additional requirements/limitations Supply limits (e.g., 24 hours, 72 hours, 7 days, 30 days) Not for chronic pain (including cancer pain) Ambiguous language Recent, not widespread, regulatory guidance Regulatory scrutiny PPSG. Achieving balance in federal and state pain policy: A guide to evaluation (CY 2013). 2014. 4
Research Concept What do we know about the relationship between state policies governing APN practice and the impact on safe pain management practices? Impact of Individual State Policies on APN Prescribers Ability to Deliver Effective Pain Management Question: Do APN s in states with full RX and practice authority have different attitudes and behaviors regarding opioids in the treatment of chronic pain than those who do not? Study Phases: 1: initial questionnaire development and face validity determination 2: questionnaire pilot testing and refinement 3. assessment of APN s attitudes and behaviors concerning safe practice when prescribing opioids to treat chronic pain Focus Group In many states, APNs cannot prescribe controlled medicines without entering into a formal collaborative relationship with a physician. To what extent do you believe that this requirement of a formal collaborative relationship inhibits nurses prescribing practices? What would you consider to be barriers, if any, in your state that can hinder APNs role in providing appropriate pain management? Do you believe that the nursing regulatory board in your state provides sufficient guidance about treating chronic pain? 5
Focus Group Are you aware of any resources that are available to provide information about current state pain or policy issues? What are some ways that the DEA recommends to safeguard controlled substance prescriptions? To what extent do APNs prescribing practices contribute to abuse and diversion of controlled medicines? Can you name some Federal and state responses to controlled substances abuse and diversion? Steps of Instrument Development Advanced Practice Nurses Attitudes and Behaviors about Safe Practice of Opioid Prescribing for Chronic Pain Survey (Bruckenthal, Gilson, 2013, in development) Core Competencies for Pain Management: Results of an Interprofessional Consensus Summit (Fishman, S. et al, 2013) Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain (FSMB, July 2013) Advanced Practice Nurses Attitudes and Behaviors about Safe Practice of Opioid Prescribing for Chronic Pain Survey 32 item, 5-point Likert Scale Domain 1: Multidimensional Nature of Pain Domain 2: Pain assessment and Measurement Domain 3: Management of Pain Domain 4: Clinical Conditions Domain 5: Regulatory Considerations 6
Content Validity Index (Polit & Beck, 2006) Round 1: I-CVI =.83 S-CVI/AVE=.83 S-CVI/UA=.54 Rater proportion relevant rating: Rater 1=.83 Rater 2=.91 Rater 3 =.94 Rater 4=.71 Rater 5 =.80 Round 2: S-CVI/UA=.80 Survey Challenges Contacted all category II State NPA s (n=16) Responses: No n=1 No response n=11 Can use unsecured facebook page n=1 Yes; purchase mailing list ($50-$300) n=3 Yes; join organization ($100) n=1 What are driving these challenges? Phase II: Questionnaire Pilot Testing and Refinement Survey Monkey Design Category II state (requires some formal level of physician involvement and may impact prescriptive authority) 26 respondents Data analysis Descriptive statistics Internal consistency (theta coefficient) Inter-item correlations 7
Demographics (n=27) Age range: 27-68 (50 mean) Gender: 92.3% female Years is practice: 1-19 Type of outpatient practice: Private practice: 46.2% Non-academic hospital based: 30.8% Academic hospital based: 7.7% Field of practice Primary/internal medicine: 15.4% Family Medicine: 53.8% % cancer pain patients None 1-10% 11-30% >30% % cancer pain patients 53.8 34.6 7.7 3.8 % cancer pain patients Rx d opioids 46.2 15.4 15.4 23.1 % cancer pain patients Rx d C-II opioids 61.5 15.4 3.8 19.6 % non-cancer pain patients None 1-10% 11-30% >30% % non-cancer pain patients 15.4 46.2 19.2 19.2 % non-cancer pain patients Rx d opioids 19.2 50.0 19.2 11.5 % non-cancer pain patients Rx d C-II opioids 30.8 50.0 7.7 11.5 8
Demographics Ability to manage chronic pain Good/excellent: 61.5% Training to co-manage chronic pain and SUD Good/excellent: 38.5% Data Analysis 38% of item total correlations >.3 Some negative inter-item correlations (Domain 4)?? Alpha coefficient range initial =.306-.675 With suggested item removal =.374-.745 Theta Coefficient (Ercan, et al, 2007, J of Modern Applied Statistical Methods) 30 items subjected to PCA (SPSS v.22) PCA: revealed 10 components with eigenvalues >1explaining 88.15% of variance Scree plot: break after 5 th component explaining 59.46% of variance (16.7%,12.6%,12.3%, 9.6%, 8.1% respectively) Theta Coefficient =.83 9
Interesting Findings I am confident in my ability to identify patients who are using prescribed opioids for other than therapeutic purposes Prior to starting opioid therapy an opioid risk tool is used to assess risk I know how to assess patients for alcohol and drug abuse UDS should be performed at every visit for patients on opioid therapy PMP should be utilized on a routine basis for all patients on opioid therapy 92.3% agree 50.0% disagree/ 7.7% agree 80.8% agree 38.5% disagree/ 34.6% agree 65.4% agree Evaluation of Survey Items Re-assess ambiguous questions Add/delete additional questions To What Extent are the Survey Domains Relevant in Practice? Domain 1: Multidimensional Nature of Pain Domain 2: Pain assessment and Measurement Domain 3: Management of Pain Domain 4: Clinical Conditions Domain 5: Regulatory Considerations 10
How Clear are the Items in Each Domain? How relevant is the item to the domain? Does the item impact how you should practice? How would you change the wording of the item? What would add to make the item more meaningful? What questions come to mind when you think about each item in a domain? Multidimensional Nature of Pain 1. I can recognize behaviors considered aberrant in terms of opioid management 2. I am confident in my ability to identify patients who are using their prescribed opioid analgesic medication for other than therapeutic purposes 3. One of the benefits of opioids as on option for managing pain is that they do not result in end organ damage, so are safe in this respect 4. If a patient is well managed on opioid analgesic medication for 6 months and now complains of increased pain, a reasonable 1st step would be to titrate opioid up by 10 to 20 % of current dose Multidimensional Nature of Pain (continued) 5. If a patient with a chronic pain condition can actively engage in meaningful work, they do not need to be maintained on analgesic therapy 6. Basically, addiction to opioid analgesic medications is the same thing as physical dependence on an opioid analgesic medication 7. It is contraindicated to add an opioid analgesic for patients with chronic pain who are also on antidepressant medication 8. I usually ask patients to bring in their significant other to participate in the early discussions regarding impact of patients pain on family functioning 11
Pain assessment and Measurement 9. As a APRN, I can independently initiate an initial assessment on a patient new to my practice or medical service 10. Prior to starting a patient on opioid therapy, I use an informed consent/treatment agreement document as a tool to initiate a discussion regarding safety and risk for these medications 11. Prior to starting opioid therapy, an opioid risk stratification tool (e.g., the ORT or SOAPP) is used to assess patient risk for misuse 12. I know how to assess patients for alcohol and drug abuse Management of Pain 13. I always discuss safe medication storage with patients who are prescribed an opioid analgesic 14. Treatment plans and goals should be established as early as possible with the patients on opioid therapy 15. Urine Drug Testing should be performed at every visit for patients maintained on opioid therapy 16. State Prescription Drug Monitoring Programs should be utilized on a routine basis for all patients who are on opioid therapy 17. Both short and long acting opioid analgesics may be prescribed concurrently on some patients when needed to treat chronic pain Management of Pain 18. If a trial of opioid therapy is determined to be appropriate treatment, a discussion with significant others should not be offered since this is a private matter for the patient 19. I advise my patients on how to dispose of unused/expired opioid medication 20. Once patients on opioid therapy have successfully met their pain relief and function goals, they should be weaned off of their opioid medication 21. If a patient has not demonstrated improved pain and function goals after a reasonable trial on opioid therapy, I have an opioid exit strategy plan to put in place 22. If a patient on opioid therapy for chronic pain management is found to be obtaining scheduled medications from another health care practitioner, they would be terminated from our practice 12
Clinical Conditions 23. Patients with a diagnosed active substance abuse disorder should not concurrently be prescribed opioid analgesics to manage chronic pain conditions 24. APNs should provide opioid medication management and education to only those patients for whom they initiated the prescription 25. Increasing opioid-related mortality has influenced my opioid analgesic prescribing habits 26. Patients with chronic neuropathic pain or pain resulting form damage to the nervous system will not benefit from opioid analgesics Regulatory Considerations 27. Fear of DEA scrutiny inhibits me from managing patients with chronic pain on Schedule II opioid analgesics 28. Increased regulatory requirements inhibit me from managing patients with chronic pain on Schedule II opioids 29. Laws and regulations governing nursing practice in my state can impede APN prescribers treatment of pain 30. Patients are legally required to report all medications they are on to their health care practitioner 31. Policies adopted by boards of nursing to recognize pain management as an important part of APN practice are useful in improving pain management 32. It is important for a state board of nursing to have a regulation, guideline, or policy statement for APN prescribers regarding pain management and/or the use of opioids for pain Next Steps Implications for Practice Phase 3: Assessment of APN s attitudes and behaviors concerning safe practice when prescribing opioids to treat chronic pain Provide evidence for future policy development surrounding safe and effective pain management 13