The Problem

The big challenge with fentanyl is its very effectiveness against pain. Long-term treatment of fentanyl dependence relies on pharmacologic management and behavioral therapy. The objective of treatment is to reduce dependence and addiction on opioid drugs, with the goal to decrease fentanyl-related deaths and mortality. Clinical studies show behavioral modification isn’t effective on its own because the body has physical dependence that must be addressed. Fentanyl abuse is not just an ethical or moral addiction, but rather a physiological response to the need for opioid receptor activation.

Physical withdrawal is painful and difficult and those with opioid addiction will do anything to avoid it. With careful management, a person can successfully overcome the physical withdrawal; however, the psychological withdrawal is often more difficult than morphine withdrawal and requires continuous emotional support. Programs such as Alcoholics Anonymous can help guide the person through a series of steps toward independence from opioids and from pain.

Pain clinics are a newly developed specialty that allow patients suffering from chronic pain to work with a pain specialist for more effective management using a variety of modalities. It is estimated that at least 100 million Americans live with chronic pain. Pain clinics are adept at focusing on procedures that deal with specific pain, such as neck and lower back. They can also approach pain through an interdisciplinary approach involving psychologists, physical therapists, nutritionists, and occupational and vocational therapists, in addition to physicians and nurses.

Other modalities such as acupuncture, biofeedback, cognitive behavioral therapy, water therapy, massage, and meditation can be options for chronic pain in lieu of relying solely on opioids. Both patient and prescriber education need to include these alternative treatment strategies.

Recognition of opioid use among healthcare professionals has been addressed by the National Council of State Boards of Nursing. A free educational webinar for understanding substance use disorder in nursing is available to nurses and managers to help identify signs of opioid use and abuse. It also outlines the system of helping professionals into therapy and recovery. It can be accessed here: https://www.ncsbn.org/5127.htm

The Solutions

It is estimated that the high incidence of illicitly manufactured fentanyl is due to mixtures of drugs from multiple illegal sources. Solutions include better access to evidence-based treatments for fentanyl abuse, which may help the fentanyl-related overdoses (Peterson, 2016). Such treatment programs have not seen great success because compliance from the users is generally low, and cost, supplies, and training for the healthcare professionals is high. Because the problem is multifactorial in that physical and emotional stressors lead to the use of fentanyl, the solutions must also be multifactorial.

Early identification of those who may have addictive behaviors, or even a genetic predisposition to addiction, should be identified early. Ideally, a prescriber could identify a patient who may be prone to an opioid addiction and prescribe them non-opioid medications instead. A variant of the mu opioid receptor has been identified and patients with this gene experience higher pain levels, which may require higher doses of opioid and resultant tolerance and addiction. Testing for the gene (A118G) is now possible through several companies, which may give providers valuable information to know who may not experience adequate pain relief from opioids and who may be at an increased risk for addiction (Mistry et al., 2014). Knowing that a patient may have a higher probability of addiction to opioids than the average patient may help provider seek alternatives for pain management.

Alternative strategies for both acute and chronic pain relief include physical therapy; distraction; nonpharmacologic comfort measures such as temperature manipulation, massage therapy acupressure, and acupuncture; and even nutrition therapy. A standard for pain control based on research demonstrating its effectiveness for both acute and chronic pain includes electrical stimulation such as a TENS unit (transcutaneous electrical nerve stimulation) that attaches to the skin and produces small electrical signals to distract the deeper pain receptors. A spinal cord stimulator (SCS) is also an electrode implanted near the spinal cord that sends mild and safe electrical signals to the skin and can help relax nerves blocking pain messages.

Additional nonpharmacologic techniques for pain control include aromatherapy, deep breathing, exercise and meditation, guided imagery, music, biofeedback, self-hypnosis, and yoga. Unfortunately, human nature is such that people would rather take a pill for quick pain relief than try an alternative modality. Healthcare professionals need to be better educated on these modalities so they can offer them to patients. Guided imagery by a tranquil nurse does take longer than a quick injection of morphine by a busy nurse. The lack of evidence-based research on nonpharmacologic modalities is an issue because much pain relief research is provided by pharmaceutical companies who have a profit motive. Until credible research is produced on the value of nonpharmacologic modalities, healthcare professionals and users will continue to reach for the pills.

Some states and federal agencies have begun to offer state-sponsored heroin, cocaine or fentanyl delivery programs. The high rate of fatalities is often due to tainted products wherein heroin has been laced with unknown amounts of fentanyl, which can be lethal. Regardless of the public awareness programs against use of opioids, addicts will continue to use them because they are physically unable to stop by themselves.

Programs that invite users to obtain “clean” drugs end up costing the state less by keeping users out of emergency rooms, the criminal justice system, and even morgues (Ostroff, 2017). Controversy arises, however because taxpayers don’t like to know their hard-earned tax dollars are being spent on narcotics for addicts. The challenge continues to find financially responsible and morally ethical solutions.

Answer: D