Documentation

Nurses have an important role to play in keeping medical records complete and accurate. Patient medical records should remain current and be accessible for review, and should include the following:

• Medical history and physical examination
• Diagnostic, therapeutic, and laboratory results
• Evaluations and consultations
• Treatment objectives
• Discussion of risks and benefits
• Informed consent
• Treatments
• Medications, including date, type, dosage, and quantity prescribed
• Instructions and agreements
• Periodic review (MSD, 2013)

Referral to Pain Management Specialists

Clinicians should be willing to refer patients to pain management specialists if they are uncertain about the pain diagnosis or the prescribing, monitoring, or discontinuing of opioid analgesics for patient pain.

Pain specialty professional organizations and primary care professional associations should work together to support the collaboration of pain specialists with primary care practitioners and teams when primary care providers have exhausted their expertise and the patient’s pain persists (IOM, 2011).

Discontinuation of Opioids

Discontinuing opioid therapy is appropriate if there is a lack of therapeutic effectiveness or if risk increases. Also, if the patient reports continued severe pain despite a trial of several different opioids, discontinuing the opioid therapy by careful, safe tapering is indicated.

Another reason to taper is if the patient is experiencing unmanageable adverse side effects, complications such as depressed mood, sleep apnea, sedation, or is displaying aberrant drug-related behavior or signs of addiction despite a reasonable dose.

Clinicians must exercise the following precautions in tapering opioids:

• Tapering decisions must be made on an individual basis.
• Clear, written and verbal instructions should be given to patients and their families to educate them about tapering and to minimize withdrawal symptoms.
• Be prepared to provide supportive counseling and frequent (weekly) follow-up visits. Ask about pain, withdrawal symptoms, and any beneficial effects of the tapering, such as improved mood, energy level and alertness and decreased pain.
• Prepare a detailed tapering plan, including type of opioid, scheduled doses, and a frequent dispensing schedule.
• Switch to morphine if the patient is dependent on hydromorphone or oxycodone.
• Use slow tapering for patients who have cardio-respiratory conditions.
• Adjust dose up or down as necessary to relieve withdrawal symptoms without inducing sedation.
• Refer patients with complicated withdrawal symptoms to a pain specialist or a medical center that specializes in treating withdrawal.
• Refer patients with opioid addiction for substance abuse disorder treatment. Addiction is best managed by opioid agonist treatment such as methadone or buprenorphine. (VA/DoD, 2013)