1. Chronic Non-Cancer Pain in the
ED: Assessing Nurse
Perceptions
and Beliefs for Practice
Improvement
Dorothy Moore
California State University: NorCal DNP

2. Prescription drug abuse is America’s
fastest growing drug problem.

3. More people overdose and die
annually from prescription opioids
than heroin or cocaine

4. We are in the middle of a
prescription opioid abuse
epidemic.

5. Pain is the number one complaint
that brings people into the ED
30% of all opioids are prescribed
from EDs

6. Patients with chronic pain are hard to
care for in the ED.
Some require a lot of pain
medication.
Some are frequent visitors….

7. Pain is subjective.
Opioids work best for acute pain.

8. Nurses are often caught in the
middle.

9. They have a duty to assess and
treat.
But they can feel conflicted.

10. Nurses sometimes fall back on labels
to cope.

11. Drug seeking
Addicts
Seekers
Dilaudid Sponges

12. How do RNs assess chronic
pain in the ED?
What do RNs know?
What don’t they know?

13. Pseudo-addiction
Oliogoanalgesia
Hyperalgesia
Opioid Tolerance

14. There are opioid guidelines for
MDs…even pharmacists.
What are best practices for
RNs?

15. Opioid Risk
assessment tools
SBIRT (Screening, Brief
Intervention, Referral)
Case Management

16. Improved pain assessment
Team communication
Understanding of pain
protocols

17. Better RN assessment and
understanding….

18. … mean better, safer patient care.

20. Thank you.

21. That was the Wind-up….
Now, here’s the pitch:
Emergency room nurses meet many
patients in pain. Some of these patients
can be quite challenging. They exhibit
behaviors nurses and doctors come to call
“drug-seeking”
McCaffery, Grimm, Pasero, Ferrell and Ullman, (2005)

22. Drug-Seeking Behaviors
These behaviors include:
Knowing exactly which pain drug they want
Knowing in which vein to start the IV
Wanting the medication to be mixed with
Benadryl
Losing prescriptions
McCaffery, M., Grimm, M. A., Pasero, C., Ferrell, B., &Uman, G. C. (2005)

23. Nurse Attitudes and
Perceptions
Can adversely affect our ability to
humanely care for patients.
Labels create distance: “them” vs. “us.”
Our beliefs affect our ability to manage
pain
Davitz, Davitz and Rubin, (1980)

24. Standardized Screening
What if instead of relying on “nursing sense”
(and prejudice), Nurses used standardized
screening tools for assessment?
What if addiction was seen as a chronic
disease, not a moral failing?
What if we used “universal precautions” with
all chronic pain patients, and ask everyone
about their usage history?

25. SBIRT
SBIRT: Screening, Brief Interview, Referral to Treatment
This is an evidence-proven intervention for alcohol and
chemical dependency (SAMHSA, 2013).
SBIRT is an integrated approach to the delivery of early
intervention and treatment(Babor et al., 2007).
SBIRT encourages healthcare providers to practice
universal screening, much as one would for any chronic
condition, such as diabetes or hypertension

26. How SBIRT Works
The RN uses a simple tool, such as the “Opioid Risk
Tool.” It is four basic questions.
If the patient scores too many points, the nurse initiates a
brief interview using open-ended questions.
The goal is to get the patient to verbalize an intention or
need to change. Referral then can be made to
appropriate interventional services: case management,
pain service, or chemical dependency.

27. It has worked with ETOH
Patients
There are no published studies demonstrating
SBIRT’s efficacy with chronic non-cancer pain
patients and opioid misuse in the ED.
But there are numerous studies that show it works
with other Substance Abuse Disorders. BUT…
SAMHSA recommends investment in developing SBIRT-like models
for most common behavioral health conditions, for use in public health
settings….

28. Now for My Project….
First, I plan to survey the nurses in my department
regarding their perceptions and beliefs about “drug-
seeking” patients.
The Survey will inform my creation of a “Proof-of-
Concept” learning module that teaches nurses how to
use the SBIRT intervention.

29. The Goal
Practice improvement!

30. References
Slide 2: (CDC), Centers for Disease Control and Prevention. (2012). CDC
grand rounds: prescription drug overdoses - a U.S. epidemic. MMWR Morb
Mortal Wkly Rep, 61(1), 10-13.
Slide 3: (CDC), Centers for Disease Control and Prevention. (2012). CDC
grand rounds: prescription drug overdoses - a U.S. epidemic. MMWR Morb
Mortal Wkly Rep, 61(1), 10-13.
Slide 4: (CDC), Centers for Disease Control and Prevention. (2012). CDC
grand rounds: prescription drug overdoses - a U.S. epidemic. MMWR Morb
Mortal Wkly Rep, 61(1), 10-13.
Photo credit:
Baylen, L. (2012, Nov. 11, 2012). Legal drugs, deadly outcomes, Los Angeles
Times. Retrieved from http://www.latimes.com/news/science/prescription/la-
me-prescription-deaths-20121111-html,0,2363903.htmlstory?main=true
Slide 5: Todd, Knox H., Cowan, Penney, Kelly, Nicole, &Homel, Peter. (2010).
Chronic or recurrent pain in the emergency department: National telephone
survey of patient experience. Western Journal of Emergency Medicine, 11(5),
408.

31. Slide 16: Althaus, F., Paroz, S., Hugli, O., Ghali, W. A., Daeppen, J. B.,
Peytremann-Bridevaux, I., &Bodenmann, P. (2011). Effectiveness of
interventions targeting frequent users of emergency departments: a systematic
review Ann Emerg Med (Vol. 58, pp. 41-52 e42). United States: Inc.
Slide 19: Glover, S., Girion, L. (2012, Nov. 11, 2012). Legal drugs, deadly
outcomes, Los Angeles Times. Retrieved from
http://www.latimes.com/news/science/prescription/la-me-prescription-deaths-
20121111-html,0,2363903.htmlstory?main=true
Slide 21: McCaffery, M., Grimm, M. A., Pasero, C., Ferrell, B., &Uman, G. C.
(2005). On the meaning of “drug seeking”. Pain Management Nursing, 6(4),
122-136.

32. Slide 22: McCaffery, M., Grimm, M. A., Pasero, C., Ferrell, B., &Uman, G. C.
(2005). On the meaning of “drug seeking”. Pain Management Nursing, 6(4),
122-136.
Slide 23: Davitz, L. J., Davitz, J. R., & Rubin, C. F. (1980). Nurses' responses to
patients' suffering. New York: Springer Publishing Company.
Slide 25: SAMHSA. (2013). Screening, Brief Intervention, and Referral to
Treatment (SBIRT) Medical Professional Training Program. from
http://www.samhsa.gov/grants/2013/ti-13-002.aspx
Babor, T. F., McRee, B. G., Kassebaum, P. A., Grimaldi, P. L., Ahmed, K., &
Bray, J. (2007). Screening, Brief Intervention, and Referral to Treatment
(SBIRT): toward a public health approach to the management of substance
abuse. SubstAbus, 28(3), 7-30. doi: 10.1300/J465v28n03_03
Slide 26: McCaffery, M., Grimm, M. A., Pasero, C., Ferrell, B., &Uman, G. C.
(2005)
Hamdan-Mansour, A. M., Mahmoud, K. F., Asqalan, S. M., Alhasanat, M. Y.,
&Alshibi, A. N. (2012) These are the only two studies I know of that examine
ED nurse perceptions of this patient population.