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Washington Suicide Prevention Training

Introduction   

Defined as a harmful act to end one’s own life, suicide is a mental health emergency (25). In 2021, suicide claimed over 48,000 lives in the United States alone. That is approximately 130 individuals daily, and one life every 11 minutes (8). It is reported that in 2021, 12.3 million American adults considered suicide while 3.5 million made a plan, and 1.7 million made an attempt. Of those that complete suicide, 46% had a known or diagnosed mental disorder (23). In comparing this data to other medical conditions, suicide was the 11th cause of death in the United States as reflected in the chart below (5) [See figure 1]. 

Figure 1: Leading Causes of Death in the U.S. in 2021 (5) 

In the United States, Wyoming, Montana, and Alaska all have the highest rates of suicide, over 30 per 100,000 deaths, while New York and New Jersey have the lowest, 7.9 and 7.1 per 100,000 deaths respectively (7). Washington state ranks 27th on this list with 1,229 deaths or 15.3 in the year 2021 (7). Age wise, those 85 years and older had the highest rate of suicide in 2021 at a rate of 22.4 per 100,000. Chart 2 reflects suicide rates among Americans aged 10 to 85+ (7) [See figure 2]. Race and gender must also be considered when discussing suicide. Chart 3 discusses suicide rates based on race [See figure 3], while Chart 4 discusses rates by gender [See figure 4]. 

Figure 2: Suicide Rates by Age in the U.S. (7) 

Figure 3: Suicide Rates by Race in the U.S. (7) 
 

Figure 4: Suicide Rate by Gender in the U.S. (7) 

Suicide is a leading cause of death on a global level with more deaths than human immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome (AIDS), breast cancer, war, homicide, or malaria. The World Health Organization reports that an estimated 703,000 individuals die from suicide each year, approximately one in every 100 individuals. However, this number could be higher due to the COVID-19 pandemic and risk factors that were exacerbated during the pandemic: isolation, anxiety, loss of job, and financial stress (40).  

Low and middle income countries see higher rates of suicide at approximately 77%. Within the past 45 years, the global suicide rate has increased 60%. For those ages 15 to 29, suicide is the fourth leading cause of death—behind road death, tuberculosis, and interpersonal violence—with it being the third leading cause of death in females and the fourth in males (40).  

Terminology 

Using proper definitions to clearly understand what is being discussed is important when discussing suicide. Providers may use certain words or phrases and mean different things. By having clear definitions that are universally used, providers can understand what other providers are conveying and continue care in an appropriate manner. Below is a list of commonly used terms when referring to suicide.  

Table 1: Commonly Used Terms When Referring to Suicide (11, 21, 29) 

Suicide Assessment 

Healthcare providers perform a variety of assessments on their patients: cardiac assessment, respiratory assessments, neurological assessments, etc. Just as those assessments help providers decide what treatment needs to be done, the suicide assessment is utilized to evaluate a variety of factors that can increase an individual’s risk for suicide.  

The latest guidelines from the American Psychiatric Association have clear goals of the suicide assessment: (17) 

• Identify any psychiatric signs and symptoms 
• Assess past suicidal behavior 
• Review any available past treatment  
• Determine if there is a family history of suicide or mental illness in the family 
• Identify the patient’s current psychosocial situation and the cause of the current crisis 
• Recognize strengths or coping skills and any opportunities for improvement that the patient has 

With the suicide assessment, there are five areas of questions that the American Psychiatric Association discusses with examples as to what is being looked for in each area (17). These areas can be found below:  

Table 2: American Psychiatric Association Suicide Assessment (17) 

The Interview: Gathering Information 

Conducted in a private place, the suicide assessment is an interview of the patient. Providers must ensure that they ask the right questions based on information provided to them by the patient or those that are accompanying the patient. Empathy, compassion, and trust must be integrated in these interviews. Below is a list of questions that can be used during the interview process. It is important to follow your facility’s specific policies and procedures regarding the suicide assessment and use the proper screening tools. Some common screening tools utilized in healthcare will be discussed later.  

Table 3: Suicide Assessment Interview Questions (17)  

It is important to keep in mind that the answers to these questions are self-reported, so patients may not be honest for any reason. Providers should pair answers given during the interview with objective data they collect through observation and past medical records. Family, friends, and partners can be a source of information; however, providers should consider collecting information with these individuals separately.  

Columbia-Suicide Severity Rating Scale: 

Also known as the Columbia Protocol, the Columbia-Suicide Severity Rating Scale was created by Columbia University, University of Pittsburgh, and University of Pennsylvania to be used during a 2007 National Institute of Mental Health study to decrease the suicide risk in adolescents with depression. The Centers for Disease Control and Prevention began using this protocol and recommending it be used in data collection in 2011. The next year, the Food and Drug Administration stated the Columbia Protocol was the standard for measuring and assessing suicidal behaviors and ideation in clinical trials (33).  

The Columbia Protocol is used to assist providers and laypersons in determining if an individual is at risk for suicide. These questions are worded in plain language to ensure this scale can be administered by anyone, regardless of profession. This scale questions individuals about the following information: (33) 

• If and when they have had any suicidal ideation or thoughts 
• Any action they have taken to prepare for suicide and when they have done so 
• If they have attempted suicide or started a suicide attempt that they interrupted or someone else did  

The image below [See figure 5] is the six-question Columbia Protocol that can be used by anyone in assessing suicide risk. The far-right column is color coded based on severity if they answer “yes” to the question. Yellow is low-risk, orange is medium-risk, and red is high-risk. The answers the individual gives will guide the interventions needed. If the individual answers “yes” to questions two or three, behavioral healthcare should be sought out. If the individual answers “yes” to questions four, five, or six immediate help is needed. Those asking the questions should call the suicide and crisis lifeline, 911, or take the individual to the nearest emergency department. The individual should not be left alone until an evaluation has been done (33).   

Figure 5: Columbia-Suicide Severity Rating Scale (Columbia Protocol) (33) 

Suicide Assessment Five-step Evaluation and Triage: 

The Suicide Assessment Five-step Evaluation and Triage consists of five questions that identifies risk and protective factors, risk levels and interventions, suicide inquiry, and documentation of treatment plans. This tool was created by Douglas Jacobs, MD, the physician who assisted in creating the suicide assessment published by the American Psychiatric Association (31). The five questions include: 

1. Identify risk factors with attention to those that can be modified. 
2. Identify protective factors and those that can be enhanced. 
3. Complete a suicide inquiry by asking about thoughts, plans, intent, and behavior. 
4. Determine risk level and any interventions that are appropriate for the risk level and attempt to reduce risk. 
5. Document as appropriate to include risk and rationale, interventions, and any follow-up that is needed. 

The Suicide Assessment Five-step Evaluation and Triage can be combined with the Columbia Suicide-Severity Rating Scale (C-SSRS) to expand on the benefits of both tools (34).  

Questions one through six from the C-SSRS all have an option for “yes” or “no,” If question two is a no, questions three through five can be skipped. After the C-SSRS questions have been asked, further assessment can be directed to precipitating events, clinical status presentation/statements, past treatment history, and any other relevant information. Providers also want to assess for access to lethal means by asking specifically about the presence of firearms in the home or how easy it would be to obtain a firearm (34).  

The next step is to identify protective factors the individual has. These can be internal or external factors that the individual has that can provide support. Internal factors can consist of fear of death, or reasons for living while external factors can consist of responsibility to family or friends, supportive social network, or interacting and engaging at work and/or school (34). 

Step three is the C-SSRS Suicidal Ideation Intensity screening questions that consists of thoughts, plans, and suicidal intent. Questions focus on frequency of thoughts, duration of how long the individual has had these thoughts, controlling the thoughts, if there is anything that the individual can do to deter the thoughts, and the reason for the suicidal ideation (34). 

Ask Suicide-Screening Questions 

The Ask Suicide-Screening Questions consists of the Suicide Risk Screening Tool that can be administered in the emergency department, inpatient medical unit, outpatient, primary care, or specialty provider offices as well as schools and juvenile detention centers. All questions are “yes” or “no” with additional open-ended questions if the individual answers “yes” (24) [See figure 6].  

Figure 6: Ask Suicide-Screening (24)

The answers provided will guide treatment/interventions. If the individual answers “no” to questions one through four, no intervention is needed. If they answer “yes” to any of the questions, question five must be asked since the individual is said to have a positive screen. If question five has a “yes” response, an imminent risk is identified, or they are an acute positive screen. The patient needs a safety or full mental health evaluation before they are able to leave. Immediate interventions that must be considered are keeping the patient in eyesight at all times, removing items that could be used to harm/kill self or others, notify the provider that is responsible for the individual’s care (24). 

You may wonder what to do if the individual answers “yes” to any of questions one through four but does not answer “yes” to question five. This means the individual is a non-acute positive screen and there is a potential risk identified. A brief suicide screen must be done in order to determine if a full mental health evaluation needs to be completed. The individual is not allowed to leave until they have been assessed for safety, and the provider must be notified (24).  

Depending on where the individual is when asking these questions, there are some additional questions that need to be asked regarding safety and safety plans. The links below will take you to the safety screening tools based on the location of the individual being assessed (24).  

Emergency Department Suicide Safety Assessment 

Inpatient Medical Unit 

Outpatient, Primary Care Provider, Specialty Provider Office 

Patient Health Questionnaire 

Since depression is often a risk factor for suicide, the Patient Health Questionnaire (PHQ-9) is used to measure, screen, monitor, and diagnose depression severity. This screening utilizes diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders 4th edition and rates the frequency of the individual’s symptoms. Question nine focuses on the presence and duration of suicidal thoughts while a non-scored question assigns and screens how much depression is affecting the individual’s activities of daily life and function. The minimum score is five while the maximum is 27. Anything greater than 20 has a provisional diagnosis of major/severe depression with a treatment recommendation of antidepressants and psychotherapy (27) [See figure 7] 

Figure 7: Patient Health Questionnaire (PHQ-9) Results Interpretation (27) 

The screening answer options include: not at all = 0, several days = 1, more than half the days = 2, and nearly every day = 3. The questions are as follows: (27) 

• Little pleasure or interest in doing things 
• Feeling hopeless, depressed, or down 
• Difficulty sleeping, staying asleep, or sleeping too much 
• Having too little energy or feeling tired 
• Overeating or a poor appetite 
• Feeling bad about yourself, or that your family sees you as a failure or that you have let them down 
• Having difficulty concentrating on things, like reading a book or watching a movie/television 
• Either being too fidgety or restless or moving/speaking slowly that you and/or others notice 
• Thoughts that you would be better off dead or thoughts of hurting yourself 
• Non-scored question: If you selected any of the above problems, how difficult have those problems made it for you to complete work, get along with family, friends, or manage things at home? (Answers options include: not difficult at all, somewhat difficult, very difficult, extremely difficult). 

Suicide Risk, Protectives Factors, and Warning Signs  

Risk factors for suicide can appear in a variety of ways: individual, relationships, community, society. These are factors that increase an individual’s risk for suicide through different means. For example, stay at home orders and quarantining during the initial phases of the COVID-19 pandemic led to isolation, which is a risk factor of suicide. Combining this with other risk factors increases the chance of an individual taking action to end their life (6).  

Table 4: Criteria for Low and High Suicide Risks (3, 4) 

Gender 

Per research, men are four times as likely to die as a result of suicide as opposed to women. This is regardless of religion, marital status, or race. However, women are three times as likely to have thoughts of suicide and/or attempt suicide than men. Research deducts that this is because the differences in attempt methods between women and men (3). Studies show that 30% of transgender youth in the United States have attempted suicide in their lifetime while 40% of adults who identify as transgender have attempted (15).  

Age 

Suicide rates increase with age. Individuals who have not gone through puberty are very unlikely to attempt or die by suicide as opposed to those that have gone through puberty. Age 45 is when suicide rates are the highest among men while it is highest in women after 55. Those over the age of 65 or who are considered elderly are less likely to attempt suicide, but they are more successful when they make an attempt. As we pointed out earlier, suicide is increasing among the young population: it is the third leading cause of death among individuals aged 15-24 (3).  

Marital Status 

Individuals who are married and have children have a lesser likelihood than their single counterparts. Those that are single or never married have a risk two times higher than those that are married (8). Divorce suicide rates in men are three times more than women. Some individuals may attempt or die by suicide on the anniversary of a loved one’s death (3). 

Sexual Orientation 

Homosexual and heterosexual individuals have differences in suicide rates. Those that identify as homosexual, regardless of marital status, do have higher rates of suicide (3).  

Race/Ethnicity 

Caucasian individuals, regardless of gender, are three times more likely to die by suicide as opposed to African Americans. Young Alaskan Natives or Native Americans have higher than the national average rates of death by suicide (22). Moving on to immigrants, the rates are much higher than citizens of the United States (40).  

Religion 

Many religions have negative views on suicide. Despite that, religious groups such as Protestants and Jews have higher rates of suicide than Muslim and Catholics combined. It is important to note that religion alone is not an accurate indicator of suicide, but the inclusion and societal integration and beliefs are better predictive factors (3).  

Occupation 

Increases in socioeconomic status increase the risk of suicide in any individual. It is noted that being employed is one protective factor, and while true, there are some occupations that increase the risk. Lawyers, healthcare providers, mechanics, artists, and insurance agents are classified as high-risk occupations. On the other hand, unemployment brings an increased risk of suicide in comparison to those that are employed. Providers should be aware that suicide risk increases during economic depressions and decreases during economic booms (3). 

Physical Health 

Good physical health is vital to good mental health and wellbeing as poor physical health contributes to at least half of all suicides. Thirty percent of those who died by suicide saw a provider within the past six months prior. Physical effects that increase risk factors include disfigurement, loss of mobility, and chronic pain. If these effects impact the individual’s relationships and/or work life, that can increase suicide risk even more (3).  

Mental Health 

Almost 95% of those who die by suicide have at least one diagnosed mental health disorder. Depressive disorders like major depressive disorder account for 80% of all suicides, and a diagnosis of delusional depression comes with the highest risk of suicide. Those with schizophrenia have a 10% risk, while those with delirium or dementia have a 5% risk of suicide. Alcohol dependency is found in over one fourth of suicide cases (3).  

Substance Abuse 

As mentioned earlier, alcohol or other substances can play a large factor in suicide. The use of any substance can lead to impairment of judgement, sedation, or manic behavior that can lead to respiratory depression or self-injury (19).  

If there is a suspicion of substance abuse, it is important to consider discussing these concerns with patients in a non-threatening, non-judgmental manner (19). Providers should start with questions regarding socially acceptable habits: exercise or dieting, caffeine, and tobacco can help ease the patient into comfort. This is something that should be done as standard procedure for all patients, and providers can even say that to patients. “We ask these questions to everyone.” Providers need to ask questions such as “how many”, “how much”, “how often” to any “yes” answer the patient provides (37). Below are common substances that are abused: 

• Alcohol: While alcohol is legal to consume for those over the age of 21 in the United States, patients may still be hesitant to answer truthfully. Providers must take patients at their word but make note of any objective data that they gather through their assessment. Appearances of patients who may have a substance abuse disorder will be discussed later. It is important to ask about specific alcoholic beverages as some cultures may not consider beer or wine to be alcohol (37). 
• Over-the-counter medications: These medications can be a source of intentional or unintentional substance abuse, so providers must ensure that they are asking about herbal supplements, cold and cough medications, or diet aids. Prescription medications might be prescribed to the patient or someone else and usually consists of sleeping aids, pain medications, diet medications, or attention deficit (hyperactive) disorder medications (37). 
• Cannabis/Marijuana: Cannabis or marijuana use has various levels of legality in states across the United States, so providers should be aware of their state’s rules and regulations regarding its use. Regardless, it is important to screen for usage during any patient interaction as treatments can be affected (37). 
• Illicit Drugs: Illicit or street drugs consist of cocaine, heroin, methamphetamine, inhalants, hallucinogens, and more. Asking about use of the substances is important, and again should be done in a non-judgmental manner. Methods include saying the name of each substance as opposed to calling them illegal or street drugs are a great way of doing this. Providers need to assess the amount, method of usage, if patients are doing these substances with someone who they consider safe, if they have access to Narcan, if they are buying from the same person, and if they are sharing needles, or using dirty or clean needles (37). 

Knowing the patient’s own view of their substance use can be very helpful. If the patient does not see their usage as a problem or reason for concern, they are less likely to seek out help or accept it. The same goes for consequences (19). Below is a table of tools providers can use to screen for substance abuse in adults and adolescents (32) [See figure 8]. 

Figure 8: List of Substance Abuse Screening Tools for Adults and Adolescents (32) 

As mentioned above, patients may not be completely honest when providing substance use history. Providers need to collect both subjective and objective data to assist them in providing the proper care. 

Patients may vocalize thoughts of continuously thinking about the substance they are using. They might forget things or have a hard time focusing or concentrating. If they are aware or know they are abusing a substance, they may be unable to stop regardless of a physical and/or mental challenge that is a result of the substance (19). 

There may be reports of strong cravings to use the substance. Patients may report a desire to decrease use of the substance, stop using it all together, or they may take actions to obtain the substance that leaves them feeling guilty or remorseful. Depending on the substance used, the patient may report changes in mood or mood swings (19). 

Behaviors may vary from patient to patient, and the type of substance they are using. They may dedicate extensive amounts of time to obtain the substance, neglect important tasks or individuals within their lives, or actively appear intoxicated. They may argue or get in trouble with family, friends, or law enforcement. They may take the substance when it is hazardous to the health and safety of themselves and others. They may also start taking the substance in higher doses for longer than recommended (19). 

The physical appearance of the patient can consist of noticeable changes in weight, bloodshot eyes, increased tolerance for a particular substance, constricted or dilated pupils, or irregular sleep patterns. Patients may also have signs of withdrawal that consist of shakiness, sweating, agitation, headaches, nausea and/or vomiting, fatigue, and possibly seizures (19).  

Stigma 

Stigma is known as negative thoughts that are held towards other individuals, groups, or circumstances (19, 30). Usually stigma stems from differences. Differences can encompass any part of life, ranging from clothing to gender to race to medical or mental health diagnoses. Stigma impacts how society addresses those differences. If most of society sees mental health and suicide as shameful, those that have mental health diagnoses or have attempted/thought of suicide may be less likely to seek help—this is social stigma. Those with mental health diagnoses may have self or perceived stigma. These individuals internalize society’s opinions or their own perception of discrimination (30).  

Traumatic Childhood 

Traumatic childhood events such as sexual abuse are directly linked to increased risks of suicide or suicide attempts. It is vital that healthcare providers assess children and adults for this history to assist with appropriate treatment and support in order to decrease risks and guide the individual to recovery (19).  

Genetics 

Recent studies have discovered a locus in the form of a DNA variation on chromosome seven that can increase an individual’s risk for suicide. Other variations in this region can lead to risk-taking behaviors, smoking, and insomnia. This variation was present even after “conditioning on major depressive disorder.” The locus has been deemed to be independent from psychiatric diagnoses as well, meaning that those without a mental health disorder could still be at risk for suicide attempts or suicide if this variation is present (22).  

General/Other Risk Factors 

There are other general risk factors that can impact an individual and their risk for suicide. The Centers for Disease Control and Prevention rank these risks from individual risk factors to societal risk factors and describes them: (6) 

• Individual Risk Factors: serious or chronic illness such as chronic pain, previous attempts of suicide, criminal and/or legal problems, substance use, history of mental illnesses like depression, feelings of hopelessness, job or financial loss or problems, current and/or prior history of adverse childhood experiences, and victim of violence or perpetration. 
• Relationship Risk Factors: family or loved one having a history of suicide, social isolation, loss of relationship, bullying, and violent or high-conflict relationships. 
• Community Risk Factors: stress of acculturation, historical trauma, violence in the community, discrimination, lack of access to healthcare, and cluster of suicide within the community. 
• Society Risk Factors: stigma regarding seeking help for mental health or mental illness, unsafe/inaccurate medical portrayal of suicide/self-harm, and access to lethal means in populations at risk for suicide. 

Protective factors are those that improve mental health and provide support to the individual. These can range from individual to societal levels of protection. It is important to know that everyone can participate in preventing suicide within their relationships, communities, or society through equal support (6). Below are some protective factors: (6) 

• Individual Protective Factors: strong sense of culture, reasons for living (like friends, family, pets, etc.), effective coping skills, and effective problem-solving skills. 
• Relationship Protective Factors: partner, family, and friend support, and having or feeling a connection to others. 
• Community Protective Factors: feeling a connection to school, work, or community, and having consistent and high-quality mental and physical healthcare. 
• Society Protective Factors: reducing the access and availability of lethal means to those that are at a higher risk of suicide, and religious, moral, or cultural objection to suicide and/or suicide attempts. 

Case Study Reflection 

Below is a case study divided into three parts. This case study will take you through a scenario and ask questions about what should or should not be done with this patient based on the information that has been covered so far (6).  

Case Study Reflection 1 

Noelle has lived in your neighborhood for years and is one of your favorite neighbors. She would sometimes watch your children when they were young and worked as a waitress until she retired recently. She mentioned to you once, shortly after her retirement, that her funds are “not what they used to be” as she is relying on her social security’s fixed income. This forces her to budget more than she ever needed to, and she is contemplating finding a job. However, her knee pain has been getting worse, keeping her from moving around and sleeping. You notice she doesn’t garden like she used to. One day when you stop by, you ask her about her children, who you have not seen visit. She tells you they are busy, but she would like to see them because she is lonely. She appears restless and sullen.  

A few days later, you realize you have not seen Noelle outside of her house, nor have you seen her two dogs. Since you know her children, you call the older son to reach out and see if he has spoken with his mother. The son sounds rushed on the phone and says they only talked for a few minutes the day before. Deciding to call Noelle yourself, you are surprised that she answers the phone. She again reiterates that it is hard for her to move and leave the house because of her knees and age. She says that she is lonely. You state you would like to check on her every day for a few days, but she adamantly declines. “I just get irritable around people,” she tells you.  

The day after your conversation with Noelle, you go to check on her as you are still concerned. When you knock on the door, no one answers, but you know someone is home because of the noises coming from the house. You are able to enter her house through the patio, something she had given you permission to do in the past, and you can now hear her dogs barking continuously. After calling for Noelle and not receiving an answer, you head upstairs to her room. You find Noelle in bed with an empty bottle of prescribed pain medication that she uses for her knees. She seems to be “out of it” but is crying and muttering that she “can’t do this anymore.”  

Non-Suicidal Self-Injury 

As discussed earlier, self-injury can either be non-suicidal or suicidal in nature. Those who perform non-suicidal self-injury are not looking to end their lives, but instead are trying to escape emotions, thoughts, or other feelings that are causing distress (i.e., not being good enough; feeling anguish, despair, desperate, or depressed; needing a way to relieve stress; believing that people do not care). Physical pain is created through a variety of means, including cutting, burning, biting, scratching, pulling out hair, kicking or punching objects to injure self, or snapping rubber bands on their bodies (19).  

To determine if the injury is related to a suicide attempt or not, providers must perform a suicide assessment and discuss actions and behaviors with the patient in a non-judgmental manner. It is important to remember that non-suicidal self-injury is a coping mechanism for individuals, and it may be the last coping mechanism available before an individual makes a suicide attempt. Providers need to refrain from preventing self-injurious behavior until they provide the patient with other coping mechanisms. Always follow facility policy and procedures when addressing non-suicidal self-injury (19). 

Understanding the Risk of Suicide: Using Assessment Information 

As discussed, suicide has many risk factors, one of which is past suicide attempts. Studies have shown this correlation to be more serious than previously thought, with higher rates of a second attempt within the first three months of the first attempt. What does this mean? As providers we should be providing more support during that initial post-attempt phase to ensure patients have better coping skills and resources to decrease the chances of another attempt. 

The provider must look at a variety of factors gained during the suicide assessment interview such as any previous self-harming behaviors, suicide attempts, and/or aborted attempts (stopped by themselves or someone else). If you are not the patient’s regular provider, consider consulting their primary care provider or psychiatric provider to assess past history of suicide (3).  

Previous hospitalizations for suicide attempts and/or past psychiatric treatment provides important information to the provider that they should be aware of. Consulting with the patient, family, or friends can provide valuable insight into the patient’s history and coping skills (3). Patients may have a history of agitation, anxiety, depression, feelings of hopelessness, changes in mood (which can be severe), insomnia, or substance use (19).  

Family history and dynamics can impact a patient and be a factor for suicide, either a risk or preventative. Dysfunctions within the family have a direct link to suicide and self-injurious behaviors. Providers should ask about family history regarding mental health and illnesses as well as family dynamics. Separations, family history of substance abuse, legal or financial trouble, abuse, or domestic violence should be documented and reported as required by law (3).  

Assessing the patient’s presentation at the time of the interview is vital and can provide significant objective data on the patient’s psychological status. Providers should ask questions about current stressors in their lives: financial hardships, interpersonal loss, or changes in their economic status. As already discussed, loss of job or residence, family dynamics, religious beliefs, and cultural customs can impact the patient as well (3).  

Determining strengths and areas for improvement will guide the provider in providing support, treatment, and referrals as care progresses. These traits may include coping skills, support (from family, friends, religion, or community), personality, and methods of thinking or solving problems. It is important that patients are guided to adjust their thought processes, such as mentalities and self-expectations, that can be detrimental to mental health (3). 

Case Study Reflection 2 

Marc is a new patient at your organization, who recently relocated to Washington from Wisconsin for a new job. He has moved to your city with his wife and young children. While talking with Marc, you can tell that the move has not been easy on him while his family seems to be settling in well. He makes a comment about “feeling inadequate at work” because everyone has expectations for him despite the fact that he is new to the company and role. He reports that he does not feel a sense of community where he lives, saying that the city he came from was much friendlier and warmer.  

You note that Marc does not mention any current coping skills, but you do identify that he used to bike-ride to de-stress after work. The environment is different for him, and he has different work hours with the new position, making it challenging for him to find time or energy to bike. Marc says he thinks that relocating was not the right decision for his family as he has barely any time for them and less time for himself. He says he is a failure.  

Suicide Risk: Documentation 

Documentation of the patient’s suicide assessment is a vital part of the provider’s job. Based on the hospital or facility’s policies, providers might document a suicide risk assessment each time they encounter the patient. Ensure that you are following proper policies and procedures regarding when a suicide risk assessment should be documented. Some best practices include documenting during the first inpatient hospitalization or the initial psychiatric assessment, when there is a significant change, and when there is an occurrence of suicidal ideation or behavior (3). 

Providers should consider documenting the following: (3)  

• Any changes in treatment 
• Risk assessments 
• Prescription medications 
• Previous treatments, especially regarding past suicide attempts  
• Decision making processes 
• Conversations with other providers  
• The patient’s access to firearms  

Actions and Referrals for the Various Levels of Suicide Risk  

Patient statements and actions guide the actions and steps a healthcare provider must take. If a patient has attempted suicide, admission to a hospital to treat any medical injuries is the first step, followed by admission to an inpatient behavioral health unit or hospital. Some facilities may have psychiatrists or clinical psychologists see the patient when they are on the medical floor, so both types of treatments can occur simultaneously. Individuals who may benefit from an inpatient psychiatric admission include those who have acute suicidal ideation with previous attempts, previous suicide attempts with no suicidal ideation (but has other psychiatric concerns), or an exacerbation of a mental illness. Individuals who would benefit from outpatient services include those with suicidal ideation or strong support systems (3).  

Table 5: Suicide Attempt Criteria for Recommended Treatment Services (3) 

While some patients may agree to inpatient treatment after a suicide attempt, others may not. The state of Washington has an Involuntary Treatment Act that manages the psychiatric hold. For additional information, review Title 71.05 of the Revised Code of Washington (39).  

Per Washington legislation, any individual that has firsthand knowledge of an individual they are concerned about can refer them for an evaluation that must be completed by a trained professional such as a psychiatric nurse practitioner or a psychiatrist. The following two points meet the criteria for involuntary admission: (39) 

• The individual must have a diagnosed or diagnosable mental health disorder. This is defined as an organic, emotional, or mental impairment that severely impacts the individual’s volitional or cognitive behavior.  
• They present with harm to others, property, or self, or the patient is classified as gravely disabled (unable to care for themselves safely).  

The trained mental health provider can make a determination if the patient meets the criteria, and if they do, they can initiate a 72-hour involuntary hold. After this hold is initiated, the patient will be transferred to a psychiatric hospital or receiving facility to receive the appropriate treatment. It is important to remember that patients under these holds still maintain their individual rights while in the facility and are presumed competent. This places the patient in a confidential status (39). 

Once the 72 hours have passed, the patient can request legal counsel and be evaluated by the court if they continue to refuse voluntary treatment. Psychologists typically evaluate the patients by performing independent exams to determine if the patient still meets the criteria for involuntary placement. The patient and the legal counsel (who is representing the patient) will meet and discuss the patient’s desires in a Probable Cause Hearing (39).  

In this meeting, the judge will determine if there is probable cause for the patient to continue treatment on an involuntary placement. During the hearing, the following four decisions can be made (39): 

• Involuntary petition is dropped, and the patient is released. 
• The case is dismissed by the judge, resulting in the patient being released. 
• The patient can make the decision to stay voluntarily. 
• The patient can be ordered by the judge to continue involuntarily placement and can stay at the facility for 14 additional days. 

If a patient is ordered to stay at the facility for 14 additional days and the provider believes that additional treatment longer than 14 days is needed, a 90-day petition can be filed. This will lead to another hearing where the judge can agree or disagree with the petition. An agreement of the petition would lead to the patient being transferred to the Western State Hospital for adults or the Fairfax Hospital for children (39).   

Case Study Reflection 3 

Jack is a 19-year-old teenager who has just been admitted to your unit following an overdose of prescription medications. It is unclear from the emergency department notes if his actions were accidental or not, and today is your first day speaking with him. He tells you that he was in a car accident last year and has been having a hard time ever since. Past medical history reports depression and feelings of hopelessness. When you ask him about what brought him to your facility, he admits to you that he was trying to end his life. Jake tells you he has seen a provider in the past but does not feel like they listened to him. 

Management and Treatment 

Within any healthcare setting, the provider and patient must develop a therapeutic rapport or alliance to ensure that the relationship is productive and respectful. Trust should be a key factor in these relationships. If the patient cannot trust the provider, then they may not wish to disclose personal information that could aid the provider in treatments and care. The opposite can be true as well (17). 

Patient safety must be a concern at all times during the provider/patient relationship. If there is concern for the safety of the patient at any time, the proper assessments should be performed, and professional staff should be notified (17).  

Together with the patient, the provider needs to create an effective treatment plan for the patient with a focus on the treatment setting, proper education for the patient and their family or other support, and care coordination with other providers. Treatment should be the most beneficial but least restrictive (17).  

Non-Pharmacological Interventions and Treatments 

Cognitive Behavioral Therapy 

The Department of Veteran Affairs recommends the use of suicide-focused cognitive behavioral therapy (CBT) with patients who have a recent history of self-harm or injury (35). Overall, this type of treatment can be beneficial for patients with diagnoses including anxiety disorders, depression, eating disorders, severe mental illness, alcohol and other substance abuse disorders, and even martial problems. The basis for CBT is built on the following three core principles: (2) 

• Psychological behaviors can be a result of learned patterns of negative behavior  
• Psychological behaviors can be a result of unhelpful ways of thinking 
• Those who have psychological diagnoses can learn and develop better coping mechanisms that may help in being more effective in daily life and relieving the symptoms they are experiencing. 

Changes in thinking patterns can be attained by training individuals to recognize alterations in their thinking that might create problems in their life. Changes can also occur when the training focuses on reframing an individual’s thinking, which may occur through reevaluating the thoughts realistically rather than based on negativity. Patients can look into obtaining a better understanding of how others are motivated or behave. Problem solving skills can be taught or expanded to help patients cope. Providers can promote role play (to prepare for particular situations), teach patients mind and body relaxation techniques, or encourage patients to face fears rather than avoid them. Patients and providers can work together to come up with the best method to implement CBT (2).  

Dialect Behavioral Therapy 

Those with recent self-injury or harm as well as borderline personality disorders can benefit from dialect behavior therapy (DBT) (35). It can also be used for those with depression, anxiety, eating disorders, and post-traumatic stress disorder. A type of talk therapy, DBT helps patients accept the reality of their lives and behaviors with the goal to help change the unhelpful behaviors and ultimately change their lives. This is beneficial in many conditions as it focuses on addressing the negative coping skills used to manage negative emotions. Patients may participate one-on-one with the provider, or they may enter DBT group therapy to advance skills gained in one-on-one sessions (10).  

Other Psychotherapies 

Interpersonal Therapy – helps patients understand interpersonal problems such as conflicts with family or friends, difficulty relating to others, unresolved grief, and changes in work or social roles. This type of therapy assists patients to learn healthier ways to cope and express themselves through effective communication (3). 

Psychodynamic Therapy – used with adults to reflect on childhood and other past experiences in order to bring to light some emotions, feelings, thoughts that may have been suppressed. Patients may have developed patterns that can be deemed unhealthy, and this type of therapy can help change those unhealthy coping strategies. Psychoanalysis is a more in-depth form of psychodynamic therapy that is held several times a week (3). 

Supportive Therapy – used to support patients in developing their own coping strategies and resources. This process can be used to build self-esteem, improve community and social interactions, and reduce anxiety (3). 

Pet, Play, and Creative Art Therapy – can be used in combination with any of the above therapies. 

Case Study Reflection 4 

Sabrina and her mother come to your outpatient facility for a routine medical visit. Sabrina started high school and wants to join the lacrosse team, so she needs a physical in order to participate. During your assessment you notice that she has lost a significant amount of weight. When her mother steps out of the room, you ask her how she is doing. Sabrina reports that she has been in the nurse’s office more often with stomachaches and nausea. She also reports she fainted in class but was able to convince the school to not call her mother. She tells you that she would like to talk to her mother about all of the stress with school she is experiencing though she is not sure how. 

Medical Treatments and Interventions 

Providers need to be aware of medications that can cause or exacerbate depression in patients and increase the risk of suicide. While the list is not all inclusive, some common medications include calcium channel blockers, sedatives, corticosteroids, beta-blockers, H2 blockers, and chemotherapy agents. After a suicide attempt, the provider should assess all medications and diagnoses the patient has. From there, the providers should decide if adjustments should be made (3).  

As discussed previously, depression is a major factor in suicide and is present in many other medical and mental health conditions. Anxiety (includes general phobia, specific phobia, generalized anxiety, obsessive compulsive, social anxiety, agoraphobia without panic, and panic disorder), trauma/stress related disorders, bipolar disorder, psychosis, eating disorders, substance use disorders, and non-suicidal self-injury can all have depression as a symptom (19). Medical conditions that co-exist with or exacerbate depression consist of cancer, heart disease, dementia, diabetes, Parkinson’s Disease, and stroke (3). 

Medication 

The goal of medication administration is to assist the patient to regain balance in their brain’s chemistry and restore it to optimal functioning by controlling the signs and symptoms the patient may have. These medications do not usually result in a cure; instead, they should be taken for extended periods of time, possibly for the patient’s lifetime. These medications can also be combined with other treatment options to give the patient the best possible outcomes (3).   

Controversy exists with patients taking antidepressants. In 2004, the Food and Drug Administration made the decision to require that antidepressants have a black box warning addressing increased risks of suicide in young adults. There was a similar claim regarding antiepileptic medications, but the black box warning was not required due to the scientific advisory committee voting against it. Regardless, providers need to stay up to date on medications and warnings, ensuring that they are administering medications in the best interest of their patients. One medication that may work for one patient may not work for another (13).  

Antidepressants come in several categories that are based on the type of brain chemical (dopamine, norepinephrine, and serotonin). These categories include serotonin modulators, norepinephrine dopamine reuptake inhibitor, monoamine oxidase inhibitor, tricyclic agents, selective serotonin reuptake inhibitors, and serotonin norepinephrine reuptake inhibitors. 

Figure 9: Monoamine Oxidase Inhibitors (28)

Figure 10: Selective Serotonin Reuptake Inhibitors and Serotonin Modulators (9)

Figure 11: Norepinephrine Dopamine Reuptake Inhibitor (16) 

Figure 12: Serotonin and nor-epinephrine reuptake inhibitors (18) 

Figure 13: Tricyclic Antidepressants (20) 

Case Study Reflection 5 

Hope is a 35-year-old who recently moved to your town with her husband, Douglas. She is a teacher at the nearby elementary school while Douglas works in a tech startup, but he was suddenly laid off from his job. After this, Hope brings him to your facility to be evaluated. She tells you that Douglas has become increasingly agitated. He told her that he is a failure and “did not make the right choices in my life.” Douglas admits to drinking heavily with friends since he was laid off.  

Substance Abuse Care 

Research shows that the longer substance abuse goes on, the harder it is to recover from. Early recognition and treatment can decrease the chance of serious medical conditions or death (19). There are multiple treatment options for patients with substance use disorders, but providers must be aware of each patient’s individual circumstances: time, family and friend support, cost/expenses, and willingness.  

All individuals go through the five stages of change when they want to make adjustments in their lives. Those with substance abuse disorders must be willing to make a change for themselves. Even though a person with a substance abuse disorder may want to change for another person or situation (changing for grandchildren, a spouse/romantic partner, children, etc.), they must consider that this person/situation may not remain in their lives. For this reason, they must be willing to make a change for themselves. Sometimes family or friends become too overburdened with the individual’s substance abuse, driving them away. That could inhibit or completely stop the person’s desire to change. The patient may say, “they’re no longer around, what’s the point?” Providers should not deter patients from having support systems as these could be motivation for change. However, patients should also be encouraged to find support within themselves (19). The following are the five stages of change: (19) 

• Stage 1: the pre contemplation phase; they do not believe they have a problem. They are not thinking of making changes in their lives or considering how the substance may be harming them. 
• Stage 2: the individual begins contemplating the need for change. They begin to realize that the substance is affecting them. This is a great time for providers to encourage them to keep contemplating and consider making a change by identifying the pros and cons of using the substance. 
• Stage 3: the preparation phase; the patient has made the decision to change. More encouragement is needed. Healthcare providers should assist patients in planning and providing resources. 
• Stage 4: the patient makes the change. They may start decreasing the use of substances or stop using them completely. The best thing to do for the patient is to be as supportive as possible. Patients should develop strategies on how to say “no” to situations regarding the substance. 
• Stage 5: the patient is maintaining the change. Patients should focus on the positives of not using the substance and their achievements during this process. 

Providers should be honest with patients regarding relapse. Recovery from substance abuse is not a linear path that is 100% successful. Everyone has moments of relapse when it comes to new habits, and it should not be discouraging. Remind patients that there is always help from providers who are non-judgmental. 

Treatment strategies can include managing withdrawal symptoms in the acute phase, remaining in treatment, and preventing relapses. Many psychotherapies such as cognitive behavioral therapy can be very beneficial for recovery from substance abuse. Twelve step facilitation programs are twelve weekly sessions done individually that prepare patients for twelve step mutual support programs such as Alcoholics Anonymous and Narcotic Anonymous. While these support programs are not treatments, they are beneficial as additional support to other treatments.  

Contingency management programs are similar to a rewards program. Patients, families, friends, or providers may offer rewards or privileges for meeting certain requirements of substance abuse recovery. These requirements might be taking medications as prescribed, participating in sessions, or remaining free of the substance. Rewards can be decided upon by the patient in collaboration with family, friends, and providers (26).  

Safety Planning Strategies and Monitoring the Usage of the Safety Plan 

Active suicidal ideation and behaviors are considered a medical emergency and should be treated accordingly. Providers in the emergency department setting should focus on medical emergencies and treatments first before moving on to any mental health treatments or consultations (19). Since suicide can be prevented, it is the duty of healthcare providers to ensure the patient is in a safe environment.  

Ensuring safety can encompass a variety of methods. One example is searching belongings to remove any weapons or items that can be used to harm the individual or others such as lighters, shoelaces, strings from hoodies, and medications. 

Patients may be placed under various observation statuses based on orders made by the physician or a mid-level provider. These observation statuses are also based on facility policies and best practices guided by evidence. Patients withdrawing from substances may need to be closely monitored on a medical floor due to worsening signs and symptoms. Seizures can be life-threatening for these patients.  

Restraints and/or seclusion may be required as a last resort for patients. Per Washington law, patients must be under a one-to-one status, meaning there is one staff member always observing the patient. Observation can be done via audio and video equipment, or in-person. There must be documentation discussing the patient’s behavior and condition, attempts for a least restrictive method of treatment, response to seclusion and/or restraints, and the need to continue seclusion and/or restraints. A face-to-face assessment must be performed by a trained professional within one hour of the patient being placed in restraint or seclusion (38).  

General regulations for restraints and seclusion include: (38) 

• Within one hour of seclusion and/or restraints being initiated, an order from the physician must be entered. 
• The nurse must communicate with the family or patient’s legal caregiver regarding the restraints and or/seclusion and the process that will be followed. 
• The nurse must discuss with the patient the need for seclusion and/or restraints and attempt to get cooperation from the patient.  
• There is to be support from others to assist with the seclusion and/or restraint process. 
• Continuous observation is to be maintained while the patient is in seclusion or restraints. 
• Physical and psychological needs must be addressed at regular intervals. 
• The nurse is responsible for documenting the need for seclusion and/or restraints and patient assessments.  
• The nurse is required to maintain education and competence on restraints. 

Obtaining Support and Engagement from Third Parties 

As reflected in this course, family and friends are vital supportive factors for the individual with suicidal ideation or attempts. If the patient is willing, education should be given to their support system so that everyone understands medications, treatments, follow-up and outpatient treatment, and what to do in another crisis resulting in a suicide attempt or exacerbation of suicidal ideation.  

Case Study Reflection 6 

Courtney is a 25-year-old female patient who is at your facility with her husband. She was discharged from the hospital a few weeks ago for an aborted suicide attempt. Her friend found her overdosed in the bathroom of her house. She was given follow-up with your facility. Now that she is with you, she reports that she would like resources to help her cope better. After being told she has a history of depression and post-traumatic stress disorder, you begin to think of resources and treatment you can offer her. 

Restricting Access to Lethal Means 

Statistics report that 55% of those that attempt suicide use firearms, 26% use suffocation, and 12% use poisoning. The last 8% is classified as “other” (8). Reducing or limiting access to lethal means can be defined as increasing the distance between someone with suicidal ideation and lethal means. An example would be to have the patient give their firearms over to another responsible adult that lives over 30 minutes away (12). 

All providers should discuss this information with their patients and their support systems. By reducing access to lethal means, it is possible to decrease rates of suicide. However, providers must be aware that patients may not tell the full truth when it comes to availability of lethal means, and restricting access is only part of treatment and care (12). 

Transition of Care: Discharge and Referrals for Continuity of Care 

Treatment of the patient who has suicidal ideation or had a suicide attempt does not stop once they leave the hospital setting. Care must be continued outside of the hospital setting through outpatient psychiatric providers such as a psychiatrist or psychiatric nurse practitioner. These providers can prescribe medications, adjust treatments, and provide additional therapy referrals that may be beneficial for the patient. These psychiatric providers should collaborate with the patient’s primary care provider. As discussed previously, certain psychiatric medications can interact with medication for medical diagnoses. 

Veteran Populations 

Data from 2020 reports that there were over six thousand veteran suicides in the United States, an average of 17 veterans dying by suicide each day. Substance use and mental health prevalence among those using the Veterans Health Administration rose from 27.9% to 41.9% from the years 2001 to 2020 (14). These numbers are staggering as veterans have a 1.5 higher risk of suicide than those in the general population and women Veterans have a suicide rate that is 2.5 times higher than civilian women (36). The chart below shows the suicide rates based on gender as classified by male and female [See figure 14].  

Figure 14: Suicide Rates Among Veterans by Gender From 2001 to 2020 (36) 

Rates of suicide were also affected by age. Veterans in the 18- to 34-year age range had a 95.3% increase between 2001 to 2020. Those aged 55 to 74 only rose to 58.2% during that same time period. From 2019 to 2020, older veterans’ suicide rates decreased while those in the 18 to 34 age group increased (14). As with the civilian population, methods of suicide were relatively similar; data was gathered from 2001 to 2020 [See figure 15]. Additionally, rates for suicide are higher among the veteran population in comparison to civilians; the change percentage is based on 2001 data [See figure 16]. 

Figure 15: Methods for Suicide Among Veterans from 2001 to 2020 (36)

Figure 16: Methods for Suicide among Veterans and Non-Veterans (36)

Veterans have similar risk factors that have different causes from their civilian counterparts. They have complex mental health conditions such as post-traumatic stress disorder, anxiety, depression, manic-depressive disorder, and traumatic brain injuries as a result of combat exposure. Others have combat wounds that can lead to severe medical diagnoses and possible prescribing of opioid medications for controlling pain. Veterans may have insomnia which can exacerbate any of their other symptoms or diagnoses. These individuals may turn to substance abuse instead of other forms of treatment due to the ease of accessibility. Studies show that over one in 10 veterans are diagnosed with at least one substance use disorder. There is an increased risk of opioid overdose, but this population is more likely to turn to alcohol (36).  

The Department of Veteran Affairs has taken steps to provide resources for mental health and suicide prevention to all veterans. Veterans and families are given suicide prevention education upon discharge, and suicide assessments are completed during every visit. Each facility has a Suicide Prevention Coordinator that can be contacted at any time. Veterans, and their families and friends can utilize Veterans Chat, a free, anonymous messaging service that gets them in touch with a Veterans Affairs counselor. If needed, the counselor can transfer the individual to the Veterans Crisis Line for further counseling or referral services (35). 

Veteran Resources (All civilian resources are available to veterans): 

https://www.veteranscrisisline.net/ 

https://www.va.gov/health-care/health-needs-conditions/mental-health/suicide-prevention/ 

https://theactionalliance.org/veteran-and-military-suicide-prevention-resources  

Case Study Reflection 7  

Cory is a 45-year-old male patient that presents to your emergency department for severe abdominal pain. During your initial assessment, Cory tells you he also feels dehydrated and has been more tired than usual lately. He says he ran out of his sleep medication, “but the providers at the VA are so hard to see. It takes months for an appointment.” When you ask him the standard questions (if he drinks alcohol or uses any other substances), he becomes angry and snaps at you before immediately apologizing. Cory admits that he has been drinking more than usual for the past few months because his chronic leg pain—an injury from when he was in combat—has been bothering him more than normal. 

Suicide Loss Survivors 

As highlighted throughout this course, suicide can happen to anyone, and they leave behind many people. Friends, families, coworkers, and acquaintances can all be affected by the loss. Those who have lost a loved one to suicide are often referred to as suicide loss survivors. 

If a healthcare provider encounters a suicide loss survivor, they should always assess the risk for suicide. As discussed previously in this course, some individuals may attempt suicide on the anniversary of their loved one’s passing. In addition, they could attempt on a day of significance to the individual that passed or a major holiday that held special meaning. If the suicide loss survivor is at a high risk for suicide, follow your facility’s protocols for additional assessment or treatment (1).  

If there is no significant risk for suicide, provide support and resources. Remember that some individuals have chronic suicidal ideation. Support can be through active listening, having a non-judgmental attitude that is free of bias or criticism. Some individuals may be hesitant to tell their story due to the nature of the loved one’s death. Encourage them to talk to someone they can trust if they do not want to share that information with you. Reassure them that bereavement is not a linear process and that they do not have a time limit to when they should be done grieving. Every person is different, and how they progress through the stages of grieving varies (1).  

Resources that can be provided include any of the above options discussed earlier in this course. Psychiatric providers, therapy, and medications may be indicated for survivors of suicide loss. Offer them resources and referrals per your facility’s protocols, but also let them know they are always able to return to your facility if needed, especially emergency departments. Medical providers may need to be involved as well if the patient has any medical concerns (1).  

Conclusion

Suicide impacts everyone. With the ever-growing need for mental health services and the rise in mental health decline, it is no surprise that suicide rates have increased among all populations. Without proper assessments, knowledge of risk and protective factors, and proper treatment requirements at each level of suicide risk, individuals in need may be missed. It is the job of the healthcare provider to ensure that all individuals are screened and treated appropriately. You may be the last point-of-contact a patient has with a provider prior to taking their own life. Ensure that you ask the questions.  

LGBTQ+ Cultural Competence

LGBTQ+ patients may experience healthcare disparities due to multiple factors, including lack of provider knowledge. In this course we will discuss how to deliver care, with LGBTQ cultural competence.

Introduction   

Lesbian, gay, bisexual, transgender, and questioning (LGBTQ+) individuals represent a rapidly growing segment of the U.S. population [1]. This rapid growth brings with it risk for stigmatization [1]. Implicit healthcare provider biases may result in LGBTQ+ patients receiving a lower standard of care or restricted access to services as compared to the general population [2]. Even when institutions and providers make commitments to equitable care explicit and implicit biases operating outside of conscious awareness may undermine that commitment. There is an urgent need to ensure that healthcare providers are prepared to identify and address their own implicit biases to ensure they do not contribute to the health care disparities experienced by LGBTQ+ and other vulnerable populations. Only by addressing their own implicit biases will health care providers be able to provide patient care in accordance with LGBTQ+ cultural competence.

LGBTQ+ individuals face significant disparities in physical and mental health outcomes [3]. Compared to their heterosexual counterparts, LGBTQ+ patients have higher rates of anal cancer [4], asthma, cardiovascular disease [5,7,8], obesity [6], substance abuse [8,9,10], cigarette smoking [11], and suicide [14]. Sexual minority women report fewer lifetime Pap tests [13,15, 16], transgender youth have less access to health care and LGBTQ+ individuals are more likely to delay or avoid necessary medical care [17] compared to heterosexual individuals. These disparities are due, in part, to lower health care utilization by LGBTQ+ individuals [3]. Perceived discrimination from health care providers and denial of health care altogether are common experiences among LGBTQ patients and have been identified as contributing factors to health disparities [19,20,21,22]. Disparities in health care access and outcomes experienced by LGBTQ+ patients are compounded by vulnerabilities linked to racial identity [23,24,25] and geographic location [6].

Biases among health care students and providers toward LGBTQ+ patients are common [27,28] despite commitments to patient care equality. These biases, also known as negative stereotypes, may be either explicit or implicit [29]. These biases contribute to a lack of LGBTQ+ cultural competence in patient care. A large study of heterosexual, first-year medical students demonstrated that about half of students reported having negative attitudes, explicit bias, towards lesbian and gay people and over 80% exhibited increased negative evaluations of lesbian and gay people compared to heterosexual people  (implicit bias) [27]. Research in social-cognitive psychology on intergroup processes defines explicit biases as attitudes and beliefs that are consciously-accessible and controlled; these characteristics are typically assessed via self-report measures and are limited by an individual’s awareness of their attitudes, motivation to reveal these attitudes, and ability to accurately report these attitudes [30,31]. In contrast, the term implicit bias refers to attitudes and beliefs that are unconscious (i.e., outside of conscious awareness) and automatic [32,33]. Implicit bias can be assessed with the Implicit Association Test (IAT) [34], which aims to define the relationships between concepts (ex. race, sex, idea), and positive or negative associations and/or stereotypes. Idenitfied biases are then delegated as slight, moderate, or strong [35].

Healthcare provider biases are correlated with poorer access to services, quality of care, and health outcomes [29, 36, 37, 38]. Explicit biases held by health professionals towards racial/ethnic minorities, women, and older adults are known to affect clinical assessments, medical treatment, and quality of care [39]. Importantly, implicit bias measures are more strongly associated with real-world behaviors than explicit bias measures [40] and are linked to intergroup discrimination [43]. Health care provider’s implicit biases towards vulnerable patient groups may persist despite an absence of negative explicit attitudes [36], resulting in preconceived notions about patient adherence, poor doctor-patient communication, and micro-aggressions, all of which can interfere with optimal care. With less time and limited information processing capacity, provider’s decisions are increasingly governed by stereotypes and implicit biases [42]. Medical student and provider biases may contribute to health disparities in vulnerable populations by negatively impacting communication with patients and decisions about patient care [29, 33]. Taken together, these findings suggest that medical students and healthcare providers are likely to underestimate or to be unaware of their implicit biases towards LGBTQ+ patients, particularly when they are rushed or fatigued, which could impact their behavior and judgments in ways that contribute to health disparities experienced by LGBTQ+ populations. By learning about and addressing their implicit biases, health care providers can work towards demonstrating LGBTQ+ cultural competence and providing optimal care(Introduction section courtesy of Morris, M., Cooper, R. L., Ramesh, A., Tabatabai, M., Arcury, T. A., Shinn, M., Im, W., Juarez, P., & Matthews-Juarez, P.-  reference 2).

Terminology

Understanding the standard terminology utilized is pivotal to treating and interacting with LGBTQ+ patients. Below are listed some of the common terms and how they should be referenced.

Ally– A person not identifying as LGBTQ+, but whom promotes equality and support of LGBTQ+ peoples in a variety of ways.

Androgynous– Identifying as neither masculine nor feminine.

Bisexual – A person who is emotionally, romantically, or sexually attracted to more than one sex, gender, or gender identity.

Cisgender – A person whom identifies with their gender which as assigned at birth. For example, a person assigned female gender at birth who identifies as female.

Gay – A person who is emotionally, romantically and/or sexually attracted to those of the same gender.

Gender-fluid – A person who identifies as a fluid or unfixed gender identity.

Lesbian – A woman who is emotionally, sexually, and/or romantically attracted to other women.

LGBTQ+ – Acronym for “lesbian, gay, bisexual, transgender, and queer.”. The plus sign stands for the innumerable other identities.

Non-binary – Adjective describing person(s) who do not identify exclusively as man nor woman.

Pansexual – A person who has the potential for romantic, emotional, and/or sexual attraction to people of any gender.

Queer – Often used interchangeably with “LGBTQ+”, or to express fluid identities or orientations.

Sexual orientation – An inherent or enduring emotional, romantic, or sexual attraction to other people.

Transgender –Umbrella term for people whose gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth. It does not imply any specific sexual orientation and transgender persons may identify as straight, gay, lesbian, bisexual, etc.

*Definitions largely derived from (44, 45).

Best Practices

Below we will list and discuss the best practices for ensuring a positive, equitable healthcare experience for LGBTQ+ persons, according to the Joint Commission (this is not a comprehensive list, nor inviolable, but rather highlights).

Create a welcoming environment that is inclusive of LGBT patients and demonstrates LGBTQ+ cultural competence.

• Prominently display the hospital nondiscrimination policy and/or patient bill of rights.
• Waiting rooms and common areas should be inclusive of LGBTQ+ patients and families.
• Unisex or single-stall restrooms should be available.
• Ensure that visitation policies are fair and do not discriminate (even inadvertently) against LGBTQ+ patients and families.
• Foster an environment that supports and nurtures all patients and families.

Avoid assumptions about sexual orientation and gender identity.

• Refrain from making assumptions about a person’s sexual orientation and/or gender identity.
• Be cognizant of bias, stereotypes, and other communication barriers.
• Recognize that self-identification and behaviors do not always align.

Facilitate disclosure of sexual orientation and gender identity, but be aware that disclosure is an individual process.

• Honor and respect patient’s decisions to provide or not provide sexual and/or gender information.
• All forms should contain inclusive, gender-neutral language that allows patients to self-identify.
• Use neutral and inclusive language when communicating with patients.
• Listen to and respect patients’ choice of language when they describe their own sexual orientation.
• Conduct confidential patient satisfaction surveys that include questions regarding sexual orientation and gender identity

*Information largely derived from Joint Commission field guide, reference 45.

For more information on best-practices in the workforce, visit the Joint Commission website by clicking here.

Establishing Relationships with LGBTQ+ Patients

When interacting with patients, one should not assume gender or sexuality. Addressing a patient whom identifies as a female as a male can cause grave harm to the relationship. Instead, nurses should use open-ended questions. For example, rather than saying “Hi sir, what brings you to the hospital,” a nurse might say, “Welcome, what brings you to the hospital today (45)?”

If a nurse uses the incorrect pronoun, the best practice is to apologize and ask the patient what pronoun and name they prefer. For example, a nurse may say, “I apologize for assuming your gender. How would you like to be addressed? (45).

In conversation, the nurse should use the name and/or pronoun the patient prefers without drawing special attention to the subject (45). For example, if a patient prefers to be identified as their partner’s wife, you should follow suit.

The core of relationship-building with LGBTQ+ patients is no different than any other patient, fundamentally. If nurses have a basic understanding of best practices and a healthy dose of respect and compassion for LGBTQ+ patients, a positive relationship is likely to develop.

Health Disparities of LGBTQ+ Patients

LGBTQ+ Americans are at higher risk of substance use, sexually transmitted diseases, cancer, cardiovascular disease, obesity, bullying, isolation, anxiety, depression, and suicide when compared to the general population (49). LGBTQ+ youth are frequently bullied at schools (46). In fact, early victimization and subsequent emotional distress accounted for 50% of the disparities between LGBTQ+ youth (46).  In other words, LGBTQ+ Americans are discriminated against and disadvantaged from a very young age.

When home life also reflects a lack of LGBTQ+ cultural competence, more problems arise.  A major cause of LGBTQ+ distress is family rejection. Disclosure of gender identity or sexuality can cause very significant interpersonal conflicts among family and friends of LGBTQ+ persons (46). This explains some hesitancy and should help nurses understand the importance of respecting privacy, while giving options to patients about disclosing sexuality and gender.

Providing an Inclusive and Accepting Care Environment

LGBTQ+ patients often experience difficulty in finding healthcare environments in which they feel accepted and understood (45). Past negative experiences, lack of knowledge among healthcare providers, and limited access to healthcare in general may become major barriers for LGBTQ+ persons when seeking care (45).

The core tenant of providing an inclusive environment is understanding the needs of LGBTQ+ patients, and working diligently to create an environment which does not disadvantage or discourage them from seeking care.

Policies and procedures at institutions should be designed to reflect a non-discriminatory environment. For example, many hospital policies dictate that only legal family spouses or partners can visit in specific circumstances. Policies such as this are inherently discriminatory toward LGBTQ+ patients, as they may not have legal spousal status due to social, legal, or personal reasons.

Laws Specific to Washington D.C.

1973: Title 34 is passed, which prohibits discrimination based on sexual orientation.

2006: The D.C. Human Rights Act is updated to ensure residents of the district are protected regarding employment, house, and public accommodations.

2016: The Armstrong Amendment is repealed in D.C., which allows religious schools exemptions from complying with anti-discrimination laws.

2016: LGBTQ Cultural Competency CE Act is passed. This requires that all licensed healthcare providers take a 2-credit hour course to increase competency (such as the one you are currently taking!).

Exercises on LGBTQ+ Cultural Competence

To help solidify your learning, please complete the following exercises at your own pace. The answers/guidance for each are provided below.

Scenario 1

A patient enters your emergency department and you assume the patient identifies as a female. You introduce yourself and say, “Ma’am, how can we help you? What brings you in today?”

The patient appears dismayed but answers the question. The nurse is confused and does not understand why the patient appears distressed. What is the best course of action?

Answer: The nurse should apologize to the patient and ask the patient how they would like to be addressed. Then, the nurse should update the patient’s records to reflect such, to reduce further confusion.

If the nurse does not address the issue, the patient may feel uncomfortable and develop a negative association with healthcare, which can lead to disparities in the future.

Scenario 2

A patient in your ICU has had a deterioration while his husband was in the room. After a family meeting, a member of the healthcare team makes a derogatory remark about the patient’s sexuality. What is the next best action for the nurse?

Answer: Pre-conceived phobias and stigmatizations can cause significant distress to LGBTQ+ patients, even if not stated directly to them. These type of remarks are abusive and should not be tolerated. The nurse should confront the co-worker (if safe) and consider reporting the comments to the Human Resources department.

Scenario 3

A LGBTQ+ patient is being admitted and prefers not to disclose their sexuality. However, the nurse is unable to proceed with the admission process without this information. What could be done to rectify this system-level issue?

Answer: The nurse should work with administration to ensure that all charting and paperwork allows individuals to self-report sexuality and/or gender if they want. However, healthcare systems should not force patients to “come out” unless it is absolutely medically necessary.

Conclusion

LGBTQ+ cultural competence must be ingrained in our healthcare systems in order to foster excellent relationships between members of the LGBTQ+ community and medical staff.  Hospitals and healthcare systems have a great deal of work to do in becoming LGBTQ+ friendly.  The efforts must continue until LGBTQ+ patients and families do not feel disadvantaged, anxious, or frustrated when interacting with healthcare systems.  As the patient’s ultimate advocate, nurses are at the front-line and should advocate for patients both individually and from a policy perspective. Nurses should work with and spearhead efforts to ensure that healthcare policies reflect best-practice and do not discriminate against LGBTQ+ patients in any way.

Washington State Healthcare Professional Telemedicine Training

Introduction   

Telehealth has become more popular and widespread across the United States. With its widespread use and popularity, more nurses and health care practitioners are required to complete courses like this Washington Telehealth Training. The earliest encounter with telehealth involved Alexander Graham Bell in 1876 when he used his telephone as a means of getting help from his assistant after he had an accident involving spilled acid on his trousers (1). The origin of telehealth officially began in 1959, with clinicians at the University of Nebraska utilizing video communication for medical purposes. These clinicians established a two-way television setup to transmit information to medical students across campus. Five years later, the setup was linked with a state hospital to perform video consultations. Telemedicine first became popular in rural areas, where populations with limited healthcare access could now reach specialists from afar. In the 1960s and 70s, the Public Health Department, NASA, the Department of Defense, and the U.S. Health and Human Services Department all invested time and money into telemedicine research.

In this Washington Telehealth Training course, the following outcomes and objectives will be reviewed:

• Discuss the background, origin, and scope of telehealth practice.
• Explain policies and regulations related to telehealth.
• Describe ways to determine if an organization is ready and prepared for telehealth and the process for the actual telehealth visit.

Telehealth Background

Definition

This Washington Telehealth Training course defines telehealth as the delivery of healthcare services using digital technology and can include services in the behavioral health field, such as substance use disorder treatment, serious mental illness treatment (SMI), and counseling. The clinic is considered the originating site (where the patient is located during the telehealth visit) and the specialist at the other location is the distant site.

In organizations that serve individuals with intellectual and developmental disabilities (IDD), telehealth is the practice of healthcare within a professionally designated scope of practice using electronic communication, information technology, or other means between a licensee in one location and a client in another location with or without an interviewing healthcare provider.

Telehealth allows patients to have better access to a variety of specialists which, in turn, increases the number of people receiving appropriate care. Overall, it can provide cost savings to the patient and increase the quality of care.

Telehealth and its Scope of Practice

The practice of nurses using telehealth is within the legal scope of practice for licensed nurses, registered nurses, licensed practical nurses, and advanced practice registered nurses (2). It can be used among these professionals as needed or when a patient is unable to make an in-person visit.

Telehealth Policy and Regulations

In-State/Out-of-State Requirements

Most providers are only allowed to see patients located in states where the provider is licensed or certified. However, many states temporarily changed this policy during COVID-19. These in-state restrictions are often due to the nature of the services a clinic provides.

Organizations can choose if they want to provide telehealth services. However, if the topic is suggested, the organization must have team members in place to discuss the options, pros, cons, and feasibility of telehealth within its practice.

Additional Credentialing and Protocols

There are no additional credentialing or privilege protocols in place for those located out-of-state as those individuals are required to seek services within their area and state. The credentialing requirements must abide by the specific guidelines set forth by each organization and these can vary from one place to another.

It is imperative that the right billing codes are used in order for the insurance company to reimburse for services rendered. Typically, there are codes known as the Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS). It is important to pay attention to any changes, as these codes do change from time to time. If ever in doubt, always double-check to ensure that the codes being entered are the correct ones for proper billing and reimbursement.

Reimbursement of In-Person Visits

Telehealth visits are typically reimbursed at an equal rate to in-person visits, but the reimbursement for those with intellectual and developmental disabilities (IDD) relies mostly on Medicaid Home and Community Based Services (HCBS) waivers. The overwhelming majority of waivers permit the temporary use of telehealth services for those individuals with IDD; however, only a small percentage include the use of telehealth on a permanent basis for this population. The limitations that were noted involved those individuals that were not a part of the following services: employment, day, and prevocational services, and in-home residential supports. Controlled substances are also not allowed to be prescribed by using telehealth until an in-person visit takes place.

Ryan Haight Act of 2008

The Ryan Haight Act summarizes that no controlled substance may be delivered, distributed, or dispensed by an electronic method such as the Internet without a valid prescription and requires at least one in-person medical evaluation (3).

This Washington Telehealth Training course asks nurses to consider the following example: if a patient undergoing a telehealth visit needs to be prescribed a controlled substance, the person issuing the prescription must have a doctor-patient relationship with the patient. This may seem reasonable, but the narrow definition in the law indicates that a telehealth visit may be inadequate due to the law specifically requiring an “in-person evaluation”.

Telehealth Readiness

When an organization begins to consider whether or not telehealth service is right for them, there are four critical factors that must be considered. These four factors include 1) workflow, 2) practitioner availability and acceptance, 3) infrastructure and cost, and 4) sustainability. All of these factors must be considered when attempting to decide if telehealth services would prove beneficial to an organization. An organization must meet as a team to discuss these components in order to assure that these factors can or cannot be met successfully.

Standards of care must be implemented and followed at any given practice and specialty area. The same is true for practices utilizing telehealth. The following serve as standards of care (4):

• Training of staff – staff must be trained in the use of the technology used and must be competent.
• Evaluations and Examinations – diagnosis should be established by establishing the patient’s history, mental evaluation, physical examination, and appropriate laboratory and diagnostic testing.
• Licensee-Patient Relationship – proper identification must be made prior to any telehealth encounter. Failure to verify the patient’s identity may lead to fraudulent activity or disclosure of patient information that is confidential. The location and identity of the patient must be verified. The licensee’s name, professional credentials, and location should be provided to the patient. Appropriate follow-up care and a complete medical record must be available to the patient and other health care providers involved in the treatment plan.
• Prescribing – the concept of “Contact with Patients before Prescribing” must be practiced – other providers must be involved in ongoing care and evaluations of the patient. All federal and state laws must be followed and are expected to participate in the Controlled Substances Reporting System.
• Medical Records – complete records must be maintained and must be consistent with prevailing medical record standards. HIPAA and security related documents must be present and signed appropriately. Confidentiality must be maintained and a copy of the medical records consistent with state and federal laws must be in place.
• Disclaimers – a statement that includes any unique limitations of the electronic model being used should be present, if applicable.
• Licensure – the practice of medicine is deemed to occur in the state in which the patient is located. If the licensee intends to practice telehealth outside of their current state must first check with other state’s licensing board to ensure if this is allowed.

Protocols for the necessity of visits

Typically, most patients can receive an appointment for a telehealth visit without any difficulty as long as the following are not present: conditions causing severe pain or those requiring a detailed in-person examination, prescription and refill of controlled substances, any condition that requires in-person drug administration, highly complex medical conditions, and psychiatric emergencies.

There are certain protocols regarding the type of visit that is appropriate for telehealth and when one should be referred to an in-person visit. The following are some common types of visits that meet the standards of telehealth:

• Lab tests or x-ray results
• Recurring conditions such as migraines or urinary tract infections
• Skin conditions
• Mental health treatment, online therapy, counseling, and medication management
• Prescription management
• Urgent care issues such as colds, coughs, and stomach aches

A patient should be referred to an in-person visit when they require highly specialized care, such as cancer treatments or complex specialty care.

How to Receive a Telehealth Appointment

With most telehealth appointments, it is best and easier if the patient will download the app and initially set up an account. There is also a 1-800 number that can typically be called as well if the patient needs additional help. Each patient will need to complete a brief medical history just as one would at the doctor’s office and once submitted, the telehealth specialist will connect the patient with the right medical professional – doctor, therapist, or a specialist. The telehealth specialist will assist the patient with setting up a date/time for the appointment and the appointment can be completed by phone, video, or app.

General Overview of Telehealth Software

This Washington Telehealth Training course recommends following five things should be considered when looking to choose a platform to implement telehealth services: integration using the same interface which allows everything to be accessed; user-friendly design – all patients should feel comfortable using the platform and not frustrated; specialty care solution – look for a platform that caters to providers that provide specialty services; configuration and customization – the platform needs to be customizable to meet each patient’s unique preferences along with the preferences of the healthcare facility; data analytics – it is important to gain new insights by recoding and logging each patient interaction, which allows the organization to better manage the practice and the experiences of the patients. The collected data assists with identifying issues early and creating resolutions in a timely manner.

In general, the practice of telehealth requires a good source of internet access by all parties, supported by broadband internet connection and mobile communication. The following list includes hardware requirements:

• Desktop
• Computer
• Laptop
• Smartphone with a camera
• Tablet with a camera and microphone
• Telemedicine care

Guide on Approved Software

It is important to ensure that the software platforms used are HIPAA compliant. The list below includes vendors that represent HIPAA-compliant video communication products that are recommended by this Washington Telehealth Training course:

• Skype/Microsoft Teams
• Updox
• VSee
• Zoom for Healthcare
• me
• Google G Suite Hangouts Meet
• Cisco Webex Meetings/Webex Teams
• Amazon Chime

Obtaining Patient Consent for Telehealth

Once the patient has decided to use telehealth for an appointment, official informed consent may be required. It is important to keep in mind that specific informed consent laws vary by state, but this Washington Telehealth Training course recommends the following actions that are always a good idea to follow (5):

• Explain to the patient what they can expect from the telehealth visit and what their rights consist of.
• Check in with the patient about their responsibilities during online counseling or telehealth visits such as wearing headphones and finding a place to be alone to ensure privacy.
• Inform the patient to get anyone’s consent from the start that may be observing the patient.
• Instruct patients to complete required forms ahead of time and bring them to the telehealth visit.
• Ensure the informed consent form and any other documentation has been done during the check-in process, including verbal consent.

It is important to have your medical intake forms reviewed by the legal team. Obtaining informed consent from each patient is important to have completed before the first appointment.

Verbal consent is where a patient gives their consent to a procedure in a verbal manner and does not sign any written form. This Washington Telehealth Training course provides the following example:

My name is ________________________________ and I am verbally consenting to participate in the study. By signing above, I give permission to be a part of the study and to allow the data collected to be used for the resulting process.

IT Support Services

In order for telehealth to be productive, IT support services must be in place to ensure that all areas are fully functioning and if a problem occurs, the IT department must be available and ready to intervene 24/7/365. If a patient is experiencing problems making an appointment or with any connectivity issues, IT can be notified to assist in these areas.

Practice First

Telehealth is a relatively new technology and as it gains widespread usage it is important for each organization using telehealth to do a practice run first to ensure that all of the elements are working properly. Every platform is used differently, and it is important to understand the requirements for each one. Also, the patient may need to have an app downloaded beforehand to make the entire process smoother.

Emergency Outage Plan

Planning can go a long way to prepare for an emergency situation during a telehealth appointment. If an emergency outage situation occurs, answer the following questions with the patient before or at the beginning of their first appointment:

• What is your current location?
  • Confirm the patient’s exact location and obtain their full address.
• What is the information for your emergency contact?
  • There should always be more than one number given in case disconnection occurs.
• Do you have an alternate way of contacting the clinic if disconnection occurs?
  • If not, this needs to be made known at the beginning of the call.
• Do you have an alternate video platform to use if disconnection occurs?
  • If so, this needs to be communicated with the provider at the start of the call.

Patient Information Security/HIPAA Protocols

This Washington Telehealth Training course recommends that all telehealth services provided by insured health-care providers and health plans must comply with the established HIPAA rules according to the Health Insurance Portability and Accountability Act of 1996. The HIPAA rules are in place to ensure that both paper and digital medical histories remain private. During the actual call, the health care provider is required to call the patient from a private setting such as their office or an appointment room. The patient should also be in a private, safe location in which they can freely discuss their health.

There are four important ways to stay compliant with the telehealth HIPAA regulations, 1) check one’s remote communications, 2) double-check the tracking of data, 3) keep all vendor agreements in writing, and 4) protect any and all stored communications.

Connecting Interpreter Services to Telehealth

Many virtual meeting platforms offer an option to connect an interpreter if requested by the patient. Once conencted, a Language Line can be added to the address book that enables the interpreter to be accessed. The service assists in building trust, reducing misunderstandings, and improving the overall patient experience. The patient will be connected to experienced professionals who will securely and patiently assist those with language barriers to make important healthcare decisions. The patient can also access telehealth resources translated from English on the platform that allows the patient to view the information in their own preferred language.

Billing and Documentation Protocols

When submitting documentation for a telehealth visit, the following elements must be included: date of visit; consent for visit from the patient or patient representative (either verbal or written consent); category of office visit, real-time audio with audio/telephone or video only.

In order to ensure that medical records are accurate and supported by telehealth services, the following must be documented in the health record (6):

• Method of telehealth (video connection, phone call, etc.)
• Location of provider (name of clinic, city, home, other)
• Listing of all clinical participants, roles, and actions
• Member location (name of clinic, city, home, other)
• Time actually spent in medical discussion – start/stop times.
• Patient consent – documented confirmation or verbal consent must be documented

Telehealth Visit

Guidelines

Just as bedside manner encompasses much more superficial appearance, web-side manner transcends how an individual looks on camera, including empathy and understanding for patients regardless of physical distance. The same standards apply for in-person visits, but a patient is likely to observe and evaluate how the telehealth visit goes based on the visual manners given during the visit. The medical professional should be dressed in an appropriate and professional manner. The lighting, angle of the camera, and background are all important factors to consider when doing a telehealth visit. This Washington Telehealth Training course provides the following fundamentals for each telehealth visit:

• Ensure that all professional identification is within clear view for the patient.
• Place yourself in the center of the video frame. You are the focal point – not the background.
• Ask the patient for a contact phone number or alternative communication in case a disconnection occurs.
• If this is the first telehealth visit with the patient, consent must be obtained.
• Ensure that you are HIPAA-compliant by confirming that anyone else in the room and is approved by the patient and that the patient is comfortable performing the visit.
• Position lighting to reduce any glare or spotlights. Uniform lighting is the best and allows the patient to see your face.
• Eliminate background items which may distract the patient.
• Confirm the patient’s location to ensure you have the proper licensure.
• Ask the patient to make any rearrangements regarding furniture, lighting, or body position in order to give you a better view of the patient and a more accurate exam.

Telehealth is not for everyone or for every medical condition. It is important for an individual to discuss the risks, advantages, and disadvantages with one’s healthcare provider.

How to Start a Telehealth Visit

This Washington Telehealth Training course recommends the following four steps will help you successfully conduct a telehealth visit from start to finish:

1. Ensure the patient has the resources to schedule a telehealth appointment– patients need to be aware of how to schedule an appointment and how to contact a customer service representative if any problems arise.
2. Prepare for the telehealth visit – send the patient a reminder a day before the appointment reminding them to connect 10 minutes prior to the appointment for registration and check-in. The co-payment can also be collected at this time.
3. Conduct the telehealth visit – the provider should carefully review the patient’s chart and medical history just as they would for an in-person appointment. Additionally, any messages or information in the patient portal should be reviewed and imported beforehand. The provider should start the visit note, use the appropriate telehealth template, and begin the visit. A proper web-side manner should be implemented the entire time with intentional listening and clear communication. During the evaluation, the provider will document any complaints and symptoms reported by the patient. Note any assessments or treatment plans including the proper diagnosis codes, orders, mediations, and relevant instructions. After ending the telehealth visit, the provider should complete any documentation and sign the note.
4. Follow up and complete the telehealth coding and billing – the practice should send a follow-up text message or email the day after the appointment offering contact information for any questions or concerns with a link to a patient survey. The patient can log into the patient portal to review a summary or the visit, education resources, pay a balance, and communicate with the practice if needed.

The following can three diagnostic errors that may create issues during telehealth visits: 1) inadequate history taking due to poor or inadequate communication, 2) limited physical examinations such as the omission of auscultation and accessibility of private areas of the body, and 3 )reliance on patients and their families to accurately measure vital signs, report them, and describe physical findings.

Spinal Cord Injury: Bowel and Bladder Management

Introduction   

Imagine one day you are able to walk and take care of your own needs. Now, imagine one week later you wake up no longer able to walk, feel anything below your waist, or hold your bowels.  

This is a reality for many people who sustain spinal cord injuries. Managing changes in bowel and bladder function is one of many challenges that people with spinal cord injuries and their families or caregivers face.  

This course will provide learners with the knowledge needed to assist patients who have spinal cord injuries with bowel and bladder management to improve the quality of life in this group.

Spinal Cord Injuries: The Basics

Spinal Cord Function 

Before defining a spinal cord injury, it is important to understand the function of the spinal cord itself. The spinal cord is a structure of the nervous system that is nestled within the vertebrae of the back and helps to distribute information from the brain (messages) to the rest of the body [1].  

These messages result in sensation and other neurological functions. While it may be common to primarily associate the nervous system with numbness, tingling, or pain, nerves serve an important purpose in the body’s function as a whole.

Spinal Cord Injury Definition 

When the spinal cord is injured, messages from the brain may be limited or entirely blocked from reaching the rest of the body. Spinal cord injuries refer to any damage to the spinal cord caused by trauma or disease [2]. Spinal cord injuries can result in problems with sensation and body movements.  

For example, the brain sends messages through the spinal cord to muscles and tissues to help with voluntary and involuntary movements. This includes physical activity like running and exercising, or something as simple as bowel and bladder elimination.  

Spinal Cord Injury Causes 

Spinal cord injuries occur when the spinal cord or its vertebrae, ligaments, or disks are damaged [3]. While trauma is the most common cause of spinal cord injuries in the U.S., medical conditions are the primary causes in low-income countries [4] [2]. 

Trauma 

• Vehicle accidents: Accounts for 40% of all cases [2] 
• Falls: Accounts for 32% of all cases [2] 
• Violence: Includes gun violence and assaults; accounts for 13% of all cases [2] [5] 
• Sport-related accidents: Accounts for 8% of all cases [2] 

Medical Conditions 

• Multiple Sclerosis (MS): Damage to the myelin (or insulating cover) of the nerve fibers [1] 
• Amyotrophic Lateral Sclerosis (ALS): Lou Gehrig’s disease, damage to the nerve cells that control voluntary muscle movements [1] 
• Post-Polio: Damage to the central nervous system caused by a virus [1] 
• Spina Bifida: Congenital defect of the neural tube (structure in utero that eventually forms the central nervous system) [1] 
• Transverse Myelitis (TM): Inflammation of the spinal cord caused by viruses and bacteria [1] 
• Syringomyelia: Cysts within the spinal cord often caused by a congenital brain abnormality [1] 
• Brown-Sequard Syndrome (BSS): Lesions in the spinal cord that causes weakness or paralysis on one side of the body and loss of sensation on the other [1] 
• Cauda Equina Syndrome: Compression of the nerves in the lower spinal region [1] 

Spinal Cord Injury Statistics 

According to the World Health Organization, between 250,000 and 500,000 people worldwide are living with spinal cord injuries [4]. In the U.S., this number is estimated to be between 255,000 and 383,000 with 18,000 new cases each year for those with trauma-related spinal cord injuries [6]. 

Age/Gender 

Globally, young adult males (age 20 to 29) and males over the age of 70 are most at risk. In the U.S., males are also at highest risk, and of this group, 43 is the average age [2].  

While it is less common for females to acquire a spinal cord injury (2:1 ratio in comparison to males), when they do occur, adolescent females (15-19) and older females (age 60 and over) are most at risk globally [4].  

Race/Ethnicity 

In the U.S. since 2015, around 56% of spinal cord injuries related to trauma occurred among non-Hispanic whites, 25% among non-Hispanic Black people, and about 14% among Hispanics [6].  

Mortality 

People with spinal cord injuries are 2 to 5 times more likely to die prematurely than those without these injuries (WHO, 2013). People with spinal cord injuries are also more likely to die within the first year of the injury than in subsequent years. In the U.S., pneumonia, and septicemia – a blood infection – are the top causes of death in patients with spinal cord injuries [6]. 

Financial Impact 

Spinal cord injuries cost the U.S. healthcare system billions each year [6]. Depending on the type, spinal cord injuries can cost from around $430,000 to $1,300,000 in the first year and between $52,000 and $228,000 each subsequent year [6].  

These numbers do not account for the extra costs associated with loss of wages and productivity which can reach approximately $89,000 each year [6]. 

Spinal Cord Injuries: Types and Complications

Four Levels of the Spinal Cord 

• Cervical (vertebrae C1 – C8): Neck; controls the back of the head down to the arms, hands, and diaphragm 
• Thoracic (vertebrae T1 – T12): Upper mid-back; controls the chest muscles, many organs, some back muscles, and parts of the abdomen 
• Lumbar (vertebrae L1 – L5): Lower back; controls parts of the lower abdomen, lower back, parts of the leg, buttocks, and some of the external genital organs 
• Sacral (vertebrae S1 – S5): Lower back; controls the thighs down to the feet, anus, and most of the external genital organs 

Types of Spinal Cord Injuries 

Spinal cord injuries may be classified by level and degree of impairment. There are four types of spinal cord injuries [5]. 

Injury Level 

• Tetraplegia or Quadriplegia: Injury at the cervical level; loss of feeling or movement to the head, neck, and down. People with this type of spinal cord injury have the most impairment. 
• Paraplegia: Injury at the thoracic level or below; limited or complete loss of feeling or movement to the lower part of the body.  

Impairment 

• Incomplete spinal cord injury: Some sensation and mobility below the level of injury as the spinal cord can still transmit some messages from the brain. 
• Complete spinal cord injury: Total loss of all sensation and mobility below the level of injury. Spinal cord injuries of this type have the greatest functional loss. 

Spinal Cord Injury Complications 

Complications from spinal cord injuries can be physical, mental, or social, and can impact overall quality of life. There are six common complications of spinal cord injuries [2]. 

Depression 

Studies show that 32.9% of adults with disabilities experience frequent mental distress [7]. Mental distress may be related to functional limitations, chronic disease, and the increased need for healthcare services.  Up to 37% of people with spinal cord injuries develop depression [2]. 

Pressure injuries 

People with spinal cord injuries may have problems with circulation and skin sensation– both risk factors for pressure injuries. Some may be bedridden or wheelchair-bound which also places them at risk for pressure injuries. Up to 80% of people with spinal cord injuries will have a pressure injury during their lifetime and 30% will have more than one [2].  

Spasticity 

Around 65% - 78% of people with spinal cord injuries have spasticity [2]. Spasticity is uncontrolled muscle tightening or contraction. The damage from spinal cord injuries causes misfires in the nervous system leading to twitching, jerking, or stiffening of muscles. 

Autonomic dysreflexia 

In some people with spinal cord injuries, a full bladder or bowel distention can cause a potentially dangerous condition called autonomic dysreflexia. The full bladder or bowel triggers a sudden exaggerated reflex that causes an increase in blood pressure. This condition is also associated with a severe headache, low heart rate, cold skin, and sweating in the lower body [8]. 

Respiratory problems 

If the diaphragm function is affected, as with cervical spinal cord injuries, there may be breathing difficulties. People with lumbar spinal cord injuries can even have respiratory problems as the abdominal muscles are used to breathe. 

Sexual problems 

Due to changes in muscle function and depending on the degree of damage, people with spinal cord injuries may have problems with arousal and climax due to altered sensations and changes in sexual reflexes.  

Changes in bowel and bladder function 

Many people with spinal cord injuries lose bowel control. Bowel problems can include constipation, impaction, and incontinence. They may also have problems with urination, for example, urinary retention. 

Bowel and Bladder Dysfunction in Spinal Cord Injuries 

This section will cover the normal function of the bowel and bladder, and the types of bowel and bladder dysfunction that occurs in patients with spinal cord injuries.

Normal Bowel and Bladder Function 

In normal bowel and bladder function, when the rectum or bladder fills with stool/urine and presses on area nerves (stimulation), the message is sent to the spinal cord which sends it to the brain. The brain gives the person the “urge” feeling, allowing an option to control the elimination or not.  

Whatever decision the person makes, the brain sends the message back to the spinal cord, which in turn sends a message to the elimination muscles (anal and bladder sphincters) to either relax or stay closed until the person is ready. In people with spinal cord injuries, the messages are limited or blocked, leading to problems with bowel and bladder control [9] [10].  

Bowel Dysfunction with Spinal Cord Injuries 

Reflex hypertonic neurogenic bowel occurs when a rectum full of stool presses against area nerves sending a message to the spinal cord, but it stops there. The message never makes it to the brain, so the person never gets the urge.  

As a result, a reflex is set off, prompting the spinal cord to send a message to the anal muscle (sphincter) instead, causing it to relax and release the stool. This condition leads to bowel incontinence and usually occurs in spinal injuries at the cervical and thoracic levels [9] [10]. 

Flaccid hypotonic bowel occurs when area nerves are also stimulated by a full rectum, but the message does not even reach the spinal cord, so there is no reflex. The anal sphincter is always in a relaxed state.  

As a result, the bowels simply empty when they are full, and this can occur at any time without the person having the ability to control it. This condition results in bowel incontinence and can lead to constipation as the patient does not have the urge and may not have the ability to push. This condition usually occurs in spinal injuries at the lumbar level [9] [10]. 

Bladder Dysfunction with Spinal Cord Injuries 

Reflex neurogenic bladder occurs when the bladder automatically starts to contract after filling with a certain amount of urine. The person has no urge to go as the messages are either limited or blocked from reaching the brain, therefore leading to loss of bladder control. Similar to reflex hypertonic neurogenic bowel, the full bladder triggers are nerves that set off a reflex, prompting the spinal cord to send messages to the bladder releasing urine outside of the person’s control [9] [10]. 

Acontractile bladder occurs when the bladder loses muscle tone after a spinal cord injury, lessening its ability to contract, leading to bladder distention, and dribbling of urine. People with this condition need to use urinary catheters to help empty the bladder [9]. 

The Nurse’s Role in Bowel and Bladder Management 

This section will cover how nurses can assess, intervene, and teach when caring for patients with spinal cord injuries who have bowel and bladder dysfunction.

Nurse Assessments 

When caring for patients with spinal cord injuries, nurses should obtain a detailed bowel and bladder history including diet, fluid intake, medications, and elimination patterns/habits [11]. Many of these patients may already manage their own bowel and bladder care at home.  

If so, the nurse should obtain the patient’s current regimen and communicate the information to the physician. The physician may choose to continue the regimen or adjust as needed based on the patient’s current illness/condition.  

Questions the nurse can ask the patient: 

• What does your typical diet consist of? 
• How much fluid do you drink on a daily basis? 
• How often do you have a bowel movement or urinate? 
• Do you schedule your bowel movements with assistance from medications? 
• Are there certain body positions or things you do to help you pass stool more easily?
• How often do you use an intermittent urinary catheter for bladder relief? 
• How much time do you spend on your bowel and bladder regimens? 
• Do you care for all of your elimination needs or does someone help you? 
• How does your bowel and bladder dysfunction affect your quality of life? 

Some assessments may be observed. For example, nurses may notice that the patient has a surgically placed permanent suprapubic urinary catheter or colostomy (when the bowel is cut somewhere above the level of the rectum and diverted to the outside of the abdomen). 

Nurse Interventions 

Since many patients with spinal cord injuries have problems with bowel and bladder function, elimination must be scheduled. Nurses can help by implementing bowel and bladder programs and providing education and support to patients, families, or caregivers.  

Regimens 

Follow the patient’s home bowel and bladder regimen (as ordered). This may include maintaining intermittent catheterization every few hours or administering suppositories daily.  

For patients who do not have a regimen already or wish to modify their current one, encourage them to pay attention to how often they urinate and pass stools, elimination problems, foods that alleviate or worsen the problem, and medications or other things that help. This can be done through a diary. 

Dietary Considerations 

Educate patients on the importance of a fiber-rich diet to avoid constipation. Patients should also be made aware that high-fat foods, spicy foods, and caffeine can alter gut dynamics and lead to bowel incontinence episodes [12]. 

Fluid Intake 

Some patients may avoid drinking enough water to avoid bladder complications (e.g., frequent incontinent episodes) [12]. However, nurses should educate patients on the importance of adequate fluid intake to prevent constipation. Patients should be made aware that bladder and bowel elimination regimens go hand in hand. 

Bladder Elimination 

For bladder dysfunction, help patients perform intermittent urinary catheterization as needed or place a temporary urinary catheter (as ordered). 

Bowel Elimination 

For bowel dysfunction, administer ordered suppositories and laxatives to help the bowels move (use suppositories in conjunction with the level of sensation the patient has near the anus/rectum) [9]. Changes in body position may help as well.  

While many of these interventions may not work in some patients with spinal cord injuries, bowel irrigation (water enemas) may be helpful [11]. Surgical placement of a colostomy may be indicated if all other measures have failed [11]. 

Emotional Support 

Ensure privacy and sensitivity during all elimination care as patients may experience embarrassment or frustration. 

Education for Families or Caregivers 

Provide education to families or caregivers on the importance of helping patients stay consistent with their elimination regimen, follow diet and fluid intake recommendations, and comply with medication orders.  

Referrals 

Inform the physician if interventions are not effective or if the patient, family, or caregiver has a special need (e.g., counselor or dietician). Refer patients and families or caregivers to support groups as needed.

Support Groups and Resources 

Christopher and Dana Reeve Foundation 

Christopher Reeve – an actor who was left paralyzed after an equestrian accident – and his wife Dana’s legacy lives on through their foundation, an organization that advocates for people living with paralysis [13].  

Miami Project to Cure Paralysis 

In response to his son, who acquired a spinal cord injury during college football, NFL Hall of Famer Nick Buoniconti and world-renowned neurosurgeon Barth A. Green, M.D. started a research program aimed at finding a cure for paralysis and discovering new treatments for many other neurological injuries and disorders [14]. 

National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) 

The National Institute on Disability, Independent Living, and Rehabilitation Research, a part of the U.S. Department of Health and Human Services’ Administration for Community Living, helps people with disabilities integrate into society, employment, and independent living [15].  

Paralyzed Veterans of America (PVA)  

A group of World War II veterans who returned home with spinal cord injuries, started this organization to support those with spinal cord injuries and dysfunction. Today, the organization focuses on quality health care, research and education, benefits, and civil rights to affected veterans [16].  

United Spinal Association 

The United Spinal Association supports people with spinal cord injuries and those in wheelchairs. The organization advocates for disability rights like access to healthcare, mobility equipment, public transportation, and community support. Support groups can be found on their website [17).  

Conclusion

Spinal cord injuries can have devastating effects on patients and their families. Management of basic bodily functions like bowel and bladder elimination should be made as easy as possible for these patients.

When nurses learn how to effectively help patients with spinal cord injuries better manage their own bowel and bladder regimens, quality of life and health outcomes may be improved for this group.

Pressure Injury Prevention, Staging and Treatment

Introduction   

When hearing the term HAPI, what comes to mind? The fact is, HAPI may not necessarily generate happy thoughts. Hospital-acquired pressure injuries (HAPIs) are a significant problem in the U.S. today. In fact, pressure injuries in general – whether acquired in a hospital or not – are a global problem.

Many articles have noted that staging and differentiating pressure injuries can be overwhelming for nurses [9]. The purpose of this course is to equip learners with the knowledge needed to reduce pressure injuries, resulting complications, financial risk, and associated death. The information in this course will serve as a valuable resource to nurses from all specialties and backgrounds.

What is a pressure injury?

The National Pressure Injury Advisory Panel (NPIAH) defines pressure injuries as “localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device” [17]. Pressure injuries can present as intact or opened skin and can be shallow or deep. Pressure injuries can be quite painful for patients and may require extensive treatment.

Prior to 2016, pressure injuries were termed “pressure ulcers.” However, since ulcer implies “open skin,” the NPIAH changed it to “pressure injury” as the skin is not always open with some of these injuries [22][25].

What causes a pressure injury to develop?

Pressure 

Intense and/or prolonged pressure on the patient’s skin and/or tissue can cause compromised blood flow and decreased sensation [7]. This can occur when patients lay or sit on a bony prominence for an extended period of time [16].  

Bony prominences are areas where you can easily feel a bone underneath the skin or tissue when palpating. These can include the heels, hips, elbows, and tailbone. Approximately two-thirds of all pressure injuries occur on the hip and buttocks area [7]. 

Friction and Shear 

Friction and shear often happen when patients slide down in bed, for example, when the head of the bed is raised. Although “friction and shear” are often used together, there is actually a difference between the two.  

While friction occurs when skin is dragged across a coarse surface (leading to surface-level injuries), shearing occurs when internal bodily structures and skin tissue move in opposite directions (leading to deep-level injuries) [10]. Shearing is often associated with a type of pressure injury called deep tissue injury (occurring in the deeper tissue layers rather than on the skin’s surface) [10].

[24] 

What are risk factors for developing a pressure injury? 

There are numerous risk factors for pressure injuries – some of which may not be directly related to the skin. These risk factors can be categorized as either intrinsic factors (occurring from within the body) or extrinsic (occurring from outside of the body) [2][13]. 

Intrinsic Risk Factors 

- Poor skin perfusion (e.g., peripheral vascular disease or smoking) 

- Sensation deficits (e.g., diabetic neuropathy or spinal cord injuries) 

- Moist skin (e.g., urinary incontinence or excessive sweating) 

- Inadequate nutrition (particularly poor protein intake) 

- Poor skin elasticity (e.g., normal age-related skin changes) 

- End of life/palliative (leads to organ failure including the skin) 

- Limited mobility (i.e., bedridden, or wheelchair-bound) 

Extrinsic Risk Factors 

- Physical and chemical restraints (leads to limited mobility) 

- Undergoing a procedure (laying down for extended periods of time) 

- Length of hospital stay (for HAPIs) 

- Medical devices (can lead to medical device-related pressure injuries)

Statistical Evidence 

This section will cover pressure injury statistics both globally and nationally. This section will also cover the impact pressure injuries have on healthcare.

What is happening on a global scale? 

In a global study, researchers found that the prevalence (all cases) and incidence (new cases) of pressure injuries in 2019 were 0.85 million and 3.17 million, respectively – numbers that have decreased over time [23][25]. Numbers were disproportionately high in high-income North America, Central Latin America, and Tropic Latin America [25]. Numbers were lowest in Central Asia and Southeast Asia. The report revealed that although numbers are high overall, they are much lower than what they were predicted to be, which may be attributed to better prevention and treatment initiatives.

What is happening nationally? 

In the U.S., 2.5 million people develop pressure injuries each year [1]. This number does not account for the many people trying to manage pressure injuries on their own at home (i.e., when family acts as the caregiver).  

HAPIs in particular are a growing problem. The most recent data on hospital-acquired conditions in the U.S. shows that from 2014 to 2017, HAPIs increased by 6% (647,000 cases in 2014 to 683,000 in 2017) [6]. Each year 60,000 patients in the U.S. die as a direct result of pressure injuries [1]. 

How do pressure injuries impact healthcare? 

Pressure injuries can be quite costly to the healthcare system. These injuries can lead to persistent pain, prolonged infections, long-term disability, increased healthcare costs, and increased mortality [1].  

In the U.S., pressure injuries cost between $9.1 - $11.6 billion per year [1]. These injuries are complex and can be difficult to treat [7]. Often requiring an interdisciplinary approach to care, the costs of one pressure injury admission can be substantial. Individual care for patients with pressure injuries ranges from $20,900 to $151,700 per injury [1]. Not to mention, more than 17,000 lawsuits are related to pressure injuries every year [1].  

Due to the significant impact that these injuries have on healthcare, prevention and accurate diagnosis is imperative.

Staging and Diagnosis 

The section will cover the staging, varying types, and diagnosis of pressure injuries.  

What is the difference between wound assessment and staging? 

Pressure injury staging is more than a basic wound assessment. Wound assessment includes visualizing the wound, measuring the size of the wound, paying attention to odors coming from the wound, and lightly palpating the area on and/or around the wound for abnormalities. Pressure injury staging, however, involves determining the specific cause of injury, depth of skin or tissue damage, and progression of the disease.  

What are the six stages of pressure injuries? 

According to NPIAP guidelines, there are six types of pressure injuries – four of which are stageable [14]. 

[16] 

Stage 1 

In Stage 1 pressure injuries, there is intact skin with a localized area of non-blanchable erythema (pink or red in color), which may appear differently in darkly pigmented skin. Before visual changes are noted, there may be the presence of blanchable erythema or changes in sensation, temperature, or firmness. Stage 1 pressure injuries do not have a purple or maroon discoloration (this can indicate a deep tissue pressure injury). 

Stage 2 

In Stage 2 pressure injuries, there is partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may represent an intact or opened serum-filled blister. Fat (adipose) and deeper tissues are not visible. Granulation tissue, slough (soft moist material, typically yellow or white), and eschar (hard necrotic tissue, typically black in color) are not present. Stage 2 injuries cannot be used to describe wounds associated with moisture-only, skin chaffing, medical adhesives, or trauma. 

Stage 3 

In Stage 3 pressure injuries, there is full-thickness loss of skin, in which fat is visible in the injury, and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be noted. The depth of tissue damage is dependent on the area of the wound. Areas with a significant amount of fat can develop deep wounds.  

Undermining (burrowing in one or more directions, may be wide) and tunneling (burrowing in one direction) may be present. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar covers the extent of tissue loss, this would be considered an unstageable pressure injury, not a Stage 3. 

Stage 4 

In Stage 4 pressure injuries, there is full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the wound. Slough and/or eschar may be visible. Rolled wound edges, undermining, and/or tunneling are often present. The area where the wound is present will determine the depth. As with stage 3 pressure injuries, if slough or eschar covers the extent of tissue loss, this would be considered an unstageable pressure injury. 

Unstageable 

In unstageable pressure injuries, there is full-thickness skin and tissue loss in which the extent of tissue damage within the wound cannot be confirmed because it is covered by slough or eschar. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed.  

Deep Tissue Injury 

In deep tissue pressure injuries (also termed: deep tissue injuries or DTIs), there is intact or non-intact skin with localized area or persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister.  

Pain and temperature changes often precede skin color changes. Discoloration may appear differently in darker-pigmented skin. The injury may resolve without tissue loss or may worsen quickly and open up, revealing the actual extent of tissue injury. Deep tissue pressure injuries should not be used to describe vascular, traumatic, neuropathic, or dermatologic conditions.  

What are other types of pressure injuries? 

Mucosal Membrane Pressure Injury 

Mucosal membrane pressure injuries are found on mucous membranes with a history of a medical device in use at the location of the injury. For example, a wound on the inside of a nostril from a nasogastric tube would be considered a mucosal membrane pressure injury. Due to the anatomy of the tissue, mucosal membrane pressure injuries cannot be staged [18]. 

Medical Device-Related Pressure Injury 

Medical device-related pressure injuries, often associated with healthcare facilities, resulting from the use of devices designed and applied for diagnostic or therapeutic purposes [15]. The resulting pressure injury typically conforms to the pattern or shape of the device which makes identification easier. The injury should be staged using the staging system.  

Hospital Acquired Pressure Injury (HAPI) 

While the general hospital setting places patients at a 5% to 15% increased risk of developing a pressure injury (HAPI), patients in the intensive (or critical) care unit in particular have an even higher risk [17]. Critical care patients typically have serious illnesses and conditions that may cause temporary or permanent functional decline. There is also evidence that pressure injuries in this setting can actually be unavoidable.  

The NPIAP defines “unavoidable” pressure injuries as those that still develop after several measures by the health provider have been taken. These measures include when the provider has (a) evaluated the patient’s condition and pressure injury risk factors, (b) defined and implemented interventions consistent with standards of practice and the patient’s needs and goals, and (c) monitored and evaluated the impact of interventions [20]. There are certain situations in which a critical care patient may have a higher risk of developing unavoidable pressure injuries.  

In one study of 154 critical care patients, researchers found that 41% of HAPIs were unavoidable and those who had a pressure injury in the past were five times more likely to develop an unavoidable pressure injury during their stay [20]. The study also found that the chance of developing an unavoidable HAPI increased the longer patients stayed in the hospital – a 4% risk increase each day.  

How are pressure injuries diagnosed? 

Diagnosing a pressure injury is done by simply staging the injury. The health provider may stage the injury or rely on the nurse’s staging assessment before giving the final diagnosis and initiating treatment. There are tests that may be ordered to help identify the early stages of a developing injury.  

For example, subepidermal moisture assessment (SEM) scanners may help to identify tissue changes early on in patients with darker skin tones [8]. Tests may also be ordered to determine the extent of the damage, disease, or infection caused by a pressure injury. A magnetic resonance imaging test (MRI) can be used to determine if the infection in a stage 4 pressure injury has spread to the bone. 

Prevention and Treatment 

This section will cover various strategies that can be used to prevent and treat pressure injuries. 

What are some ways to prevent pressure injuries? 

Preventing pressure injuries takes more than just one nurse repositioning a patient every two hours. It involves a combination of strategies, protocols, and guidelines that facilities can implement across various departments, specialties, and care team members. The NIAPH recommends the following prevention strategies [19]. 

Risk assessment 

Facilities should use a standardized risk assessment tool to help identify patients at risk for pressure injuries (i.e., the Braden or Norton Scale). Rather than using the tool as the only risk assessment strategy, risk factors should be identified by other means (for example, by gathering a detailed patient history).  

Risk assessments should be performed on a regular basis and updated as needed based on changes in the patient’s condition. Care plans should include risk assessment findings to address needs. 

Skin Care 

Monitoring and protecting the patient’s skin is vital for pressure injury prevention. Stage 1 pressure injuries should be identified early to prevent the progress of disease. These include looking at pressure points, temperature, and the skin beneath medical devices.  

The frequency of assessments may change depending on the department. Ideally, assessments should be performed upon admission and at least once daily. Skin should also be cleaned promptly after incontinence episodes. 

Nutritional Care 

Tools should be used that help to identify patients at risk for malnutrition. Patients at risk should be referred to a registered dietician or nutritionist. Patients at risk should be weighed daily and monitored for any barriers to adequate nutritional intake. These may include swallowing difficulties, clogged feeding tubes, or delays in intravenous nutrition infusions. 

Positioning and mobilization 

Immobility can be related to age, general poor health, sedation, and more. Using offloading pressure activities and keeping patients mobile overall can prevent pressure injuries. Patients at risk should be assisted in turning and repositioning on a schedule. Pressure-relieving devices may be used as well. Patients should not be positioned on an area of previous pressure injury. 

Monitoring, training, and leadership 

Current and new cases of pressure injuries should be documented appropriately and reported. All care team members should be educated on pressure injury prevention and the importance of up-to-date care plans and documentation.  

All care team members should be provided with appropriate resources to carry out all strategies outlined. Leadership should be available to all care team members for support (this may include a specialized wound care nurse or wound care provider). 

How are pressure injuries treated? 

There is no one way to treat a pressure injury. Management of pressure injuries involves a specialized team of care providers and a combination of therapies that aim to target underlying factors and prevent complications [7]. Depending on the stage of the wound and skin risk factors, providers may order specific types of treatments.  

Some pressure injury treatments may include the following [7]. 

- Wound debridement – a procedure in which necrotic tissue is removed from a wound bed to prevent the growth of pathogens in the wound, allowing for healing 

- Antibiotic therapy (topical or systemic) 

- Medicated ointments applied to the wound bed (e.g., hydrogels, hydrocolloids, or saline-moistened gauze to enable granulation tissue to grow and the wound to heal) 

- Nutritional therapies (e.g., referrals to dieticians) 

- Disease management (e.g., controlling blood sugar in diabetes) 

- Pain medications 

- Physical therapy (to keep the patient active) 

The Nurse’s Role 

The section will cover the nurse’s role in preventing pressure injuries and the progression of disease.  

What is the nurse’s role in pressure injury prevention? 

Based on NPIAH guidelines, the Agency for Healthcare Research and Quality (AHRQ) – an agency that monitors pressure injury data for the U.S. – breaks down quality initiatives for preventing pressure injuries in a three-component care bundle [2].  

A care bundle is a combination of best practices that when used together, can lead to better patient outcomes [2]. The care bundle includes skin assessments, risk assessments, and care planning. Nurses should follow the guidelines listed under each component. 

Standardized pressure injury risk assessment 

- Use risk assessment tools and processes to identify patients at risk 

- Do not rely on tools only, use your own judgment as well (tools are meant to guide the assessment) 

- Update risk scores at least once daily and if patient’s condition changes 

- Document findings in the medical record 

- Communicate findings to other staff involved for continuity of care (e.g., informing another nurse during patient handoff reporting) 

Comprehensive skin assessment 

- Identify any pressure injuries that may be present 

- Determine whether there are other areas of skin breakdown or factors that may predispose the patient to develop a pressure injury (e.g., moist skin) 

- Identify other skin issues 

- Perform assessments at regular intervals 

- Document findings in the medical record 

- Communicate findings to other staff involved in care so that appropriate changes can be reported (e.g., informing the nursing assistant) 

- Ask colleague to confirm findings for accuracy (i.e., two-nurse skin checks) 

Care planning and implementation to address areas of risk 

- Create care plans that include each skin risk factor (e.g., nutrition, mobility, and moisture) 

- Update care plans as often as needed if there are any changes in the patient’s condition 

- Evaluate whether care plan was effective by assessing patient response to interventions 

-  Individualize care plans for each patient based on risk assessment scores and other observed risks 

- Identify patient learning needs and implement teaching as needed 

- Document care plan in the medical record 

- Communicate care plan to other staff involved for continuity of care (e.g., informing another nurse during patient handoff reporting) 

How can nurses prevent medical device-related pressure injuries?

The NPIAP outlined best practices to prevent medical device-related pressure injuries in various settings including general care, long-term care, critical care, and pediatric care [20]. The following strategies apply across all settings. 

- Choose the correct size of medical device for the individual. 

- Cushion and protect the skin with dressings in high-risk areas (e.g., nasal bridge). 

- Inspect the skin under and around the device at least daily (if not medically contraindicated).  

- Rotate sites of oximetry probes.  

- Rotate between O2 mask and prongs (if feasible).  

- Reposition devices (if feasible).  

- Avoid placement of device over sites of prior or existing pressure injury OR directly under the patient.  

- Be aware of edema under the device and the potential for skin breakdown. 

- Change rigid C-collar to softer collar when medically cleared (for critical care settings).

How can nurses identify pressure injuries in patients with darker skin tones? 

Research suggests that it may be difficult to note early changes that can lead to the development of a pressure injury in patients with darker skin tones – for one, blanching may not be as visible [8]. This places the patient at a greater risk for the advancement of disease as early identification may be challenging.  

In order to appropriately identify pressure injuries in patients with darker skin tones, nurses should use unique strategies. The NIPAH offers these recommendations for nurses to help accurately identify pressure injuries in this group [8]. 

Identification tips 

- Clean the suspected area beforehand 

- Compare the area to surrounding unaffected areas 

- Compare the area to the opposite laterality if possible (i.e., right versus left elbow) 

- Compare the area to unaffected areas in a different location (i.e., upper back versus chest) 

- Look for differences in skin tautness 

- Look for shining skin changes 

- Palpate for changes in skin temperature 

How can nurses quickly differentiate between pressure injury stages? 

Correct staging of pressure injuries is vital as treatment is determined by the extent of damage, disease, or infection. First and foremost, wounds should be gently cleaned prior to staging as drainage or debris can be mistaken for fat or bone within the wound bed [14].  

Nurses can quickly differentiate between stages by asking these simple easy-to-understand starter questions. A more detailed assessment should follow. 

- Stage 1 versus Stage 2: Is the skin intact? 

Rationale: The skin is always intact in Stage 1. The skin is always open in Stage 2 (or there may be an intact blister present). 

- Stage 2 versus Stage 3: Is the wound bed pink or beefy red? 

Rationale: The wound bed is pink or beefy red in Stage 2. In Stage 3, the wound bed has structures within that may be discolored. 

- Stage 3 versus Stage 4: Does the wound bed contain soft or firm structures? 

Rationale: The wound bed contains softer structures in Stage 3. The wound bed contains firmer structures in Stage 4.* 

- Unstageable versus Stageable: Is any part of the wound bed hidden? 

Rationale: The wound bed is not entirely exposed in an unstageable. The wound bed is exposed in a stageable that is open. 

- Intact DTI versus Stage 1: Is the discoloration light or dark? 

Rationale: The discoloration is dark in a DTI. The discoloration is much lighter in Stage 1. 

- Open DTI versus Stage 2: Is the discoloration in or around the wound bed dark? 

Rationale: There is dark discoloration in or around the wound bed in an open DTI. In stage 2, the discoloration is much lighter (if even present). 

*Nurses should familiarize themselves with the appearance of the various structures that may be present in a wound like fat, fascia, bone, tendon, ligament, etc. Most importantly, nurses should consult the wound care team or health provider if a stage cannot be determined. 

What should patients know? 

Facilities can use the NIAPH prevention strategies to devise teaching plans for patients [19]. Nurses should educate patients and families/caregivers on risk factors, signs and symptoms, prevention tips, and the importance of following through with treatment.  

Nurses should also teach patients to advocate for their own health in order to avoid progression of disease. Here are important tips to teach at any point during the patient’s stay. These tips can apply to nurses working in a variety of settings. 

- Tell the nurse or provider of your medical conditions (needed to identify risk factors) 

- Tell the nurse or provider if you notice any numbness or tingling in your body (potential risk for sensory deficits) 

- Tell the nurse or provider if you have a loss of appetite or trouble eating (potential risk for malnutrition) 

- Clean yourself well after using the restroom (maintains skin integrity) 

- Tell the nurse or provider if you need to use the restroom or need help with cleaning yourself (maintains skin integrity) 

- Tell the nurse right away if you have an incontinence episode (maintains skin integrity) 

- Take all prescribed medications (may include necessary antibiotics or wound-healing medications) 

- Reposition yourself in bed often or tell the nurse if you need help doing so (reduces immobility risk) 

- Tell the nurse or provider if you notice a new discolored area on your skin, or an open area (potential new or worsening pressure injury) 

- Tell the nurse or provider if you notice any changes to your wound (potential worsening pressure injury) 

Quality Improvement 

This section will cover the quality improvement measures in place to reduce pressure injuries. 

What is a pressure injury quality improvement initiative? 

Quality improvement involves setting goals (or initiatives) and standards of care. The goal of quality improvement is to improve patient outcomes at a systematic level where everyone involved is on the same page.  

Although possibly unaware, all care team members are involved in quality improvement. Nursing leaders design, manage, and evaluate program initiatives. Staff nurses and other care team members follow protocols that are often developed from these initiatives.  

The Pressure Injury Prevention Program is a guide designed by the AHRQ to help health facilities implement a structured pressure injury prevention initiative based on quality improvement [12]. Facilities can use the guide as a training toolkit to implement a new quality improvement program [5].  

Initiative Goals: 

- Reduced pressure injury rates 

- Reduced adverse events related to pressure injuries 

- Reduced costs associated with pressure injuries 

- Reduced lawsuits related to pressure injuries 

Ways facilities can implement a prevention program: 

- Address the overall objectives of the prevention program 

- Identify the needs for change and how to redesign practice 

- Develop goals and plans for change 

- Use the NIAPH pressure injury prevention recommended practices 

- Establish comprehensive skin assessment protocols 

- Standardize assessments of pressure injury risk factors 

- Incorporate risk factors into individualized care planning 

- Establish clear staff and leadership roles 

What are some pressure injury quality measures? 

Quality measures are tools that measure a system’s healthcare goals and/or ability to provide high-quality care [11]. In simple terms, quality measures are specific ways that systems (governments, states, organizations, etc.) can show how they are making progress in meeting goals. The AHRQ highlights the following three ways the U.S. measures its progress.  

Number of HAPIs 

The AHRQ measures the number of HAPIs per year. The most recent data is from 2014 to 2017 [6].

Rate of HAPIs per admission 

The AHRQ measures the number of HAPIs per admission related to age groups. The number is measured as a “rate,” meaning the number of HAPIs per 1,000 hospital admissions. The most recent evidence is from 2017 [4]. 

Costs of HAPIs 

Another quality measure is HAPI costs. While the AHRQ does not measure costs of HAPIs every single year, the most recent data is from 2017 [3].  

Deaths related to HAPIs 

Patient mortality rates related to HAPIs are a quality measure (calculated per 1,000 pressure injury cases). The most recent data is from 2017 [6]. 

Conclusion

 Pressure injuries are complex conditions that can lead to poor patient outcomes and a burdened healthcare system. The best strategy in the care of patients with pressure injuries or those at risk is prevention.  

However, preventing these injuries involves more than individual nurses taking specific steps. Prevention of pressure injuries involves a team effort from all members of the care team and a systemic plan for improvement.

Controlled Substances

Introduction   

Pain is complex and subjective. The experience of pain can significantly impact an individual’s quality of life. According to the National Institute of Health (NIH) (40), pain is the most common complaint in a primary care office, with 20% of all patients reporting pain. Chronic pain is the leading cause of disability, and effective pain management is crucial to health and well-being, particularly when it improves functional ability. Effective pain treatment starts with a comprehensive, empathic assessment and a desire to listen and understand. Nurse Practitioners are well-positioned to fill a vital role in providing comprehensive and empathic patient care, including pain management (23).

While the incidence of chronic pain has remained a significant problem, how clinicians manage pain has significantly changed in the last decade, primarily due to the opioid epidemic. This education aims to discuss pain and the assessment of pain, federal guidelines for prescribing, the opioid epidemic, addiction and diversion, and recommendations for managing pain.

Definition of Pain

Understanding the definition of pain, differentiating between various types of pain, and recognizing the descriptors patients use to communicate their pain experiences are essential for Nurse practitioners involved in pain management. By understanding the medical definition of pain and how individuals may communicate it, nurse practitioners can differentiate varying types of pain to target assessment.

According to the International Association for the Study of Pain (27), pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or terms of described such in damage.” The IASP, in July 2020, expanded its definition of pain to include context further.

Their expansion is summarized below:

• Pain is a personal experience influenced by biological, psychological, and social factors.
• Pain cannot be inferred solely from activity in sensory neurons.
• Individuals learn the concept of pain through their life experiences.
• A person’s report of an experience in pain should be respected.
• Pain usually serves an adaptive role but may adversely affect function and social and psychological well-being.
• The inability to communicate does not negate the possibility of the experience of pain.

Types of Pain

Pain originates from different mechanisms, causes, and areas of the body. As a nurse practitioner, understanding the type of pain a patient is experiencing is essential for several reasons (23).

• Determining an accurate diagnosis. This kind of pain can provide valuable clues to the underlying cause or condition.
• Creating a treatment plan. Different types of pain respond better to specific treatments or interventions.
• Developing patient education. A nurse practitioner can provide targeted education to patients about their condition, why they may experience the pain as they do, its causes, and treatment options. Improving the patient's knowledge and control over their condition improves outcomes.

Acute Pain

Acute pain is typically short-lived and is a protective response to an injury or illness. Patients are usually able to identify the cause. This type of pain resolves as the underlying condition improves or heals (12).

Chronic Pain

Chronic pain is diagnosed when it continues beyond the expected healing time. Pain is defined as chronic when it persists for longer than three months. It may result from an underlying disease or injury or develop without a clear cause. Chronic pain often significantly impacts a person's physical and emotional well-being, requiring long-term management strategies. The prolonged experience of chronic pain usually indicates a central nervous system component of pain that may require additional treatment. Patients with centralized pain often experience allodynia or hyperalgesia (12).

Allodynia is pain evoked by a stimulus that usually does not cause pain, such as a light touch. Hyperalgesia is the effect of a heightened pain response to a stimulus that usually evokes pain (12).

Nociceptive Pain

Nociceptive pain arises from activating peripheral nociceptors, specialized nerve endings that respond to noxious stimuli. This type of pain is typically associated with tissue damage or inflammation and is further classified into somatic and visceral pain subtypes.

Somatic pain is most common and occurs in muscles, skin, or bones; patients may describe it as sharp, aching, stiffness, or throbbing.

Visceral pain occurs in the internal organs, such as indigestion or bowel spasms. It is more vague than somatic pain; patients may describe it as deep, gnawing, twisting, or dull (12).

Neuropathic pain

Neuropathic pain is a lesion or disease of the somatosensory nervous system. Examples include trigeminal neuralgia, painful polyneuropathy, postherpetic neuralgia, and central poststroke pain (10).

Neuropathic pain may be ongoing, intermittent, or spontaneous pain. Patients often describe neuropathic pain as burning, prickling, or squeezing quality. Neuropathic pain is a common chronic pain. Patients commonly describe allodynia and hyperalgesia as part of their chronic pain experience (10).

Affective pain

Affective descriptors reflect the emotional aspects of pain and include terms like distressing, unbearable, depressing, or frightening. These descriptors provide insights into the emotional impact of pain on an individual's well-being (12).

Case Study

Mary Adams is a licensed practical nurse who has just relocated to town. Mary will be the utilization review nurse at a local long-term care facility. Mary was diagnosed with Postherpetic Neuralgia last year, and she is happy that her new job will have her mostly doing desk work and not providing direct patient care as she had been before the relocation. Mary was having difficulty at work at her previous employer due to pain. She called into work several times, and before leaving, Mary's supervisor had counseled her because of her absences.

Mary wants to establish primary care immediately because she needs ongoing pain treatment. She is hopeful that, with her new job and pain under control, she will be able to continue a successful career in nursing. When Mary called the primary care office, she specifically requested a nurse practitioner as her primary care provider because she believes that nurse practitioners tend to spend more time with their patients.

Assessment

The assessment effectively determines the type of treatment needed, the options for treatment, and whether the patient may be at risk for opioid dependence. Since we know that chronic pain can lead to disability and pain has a high potential to negatively affect the patient's ability to work or otherwise, be productive, perform self-care, and potentially impact family or caregivers, it is imperative to approach the assessment with curiosity and empathy. This approach will ensure a thorough review of pain and research on pain management options. Compassion and support alone can improve patient outcomes related to pain management (23).

Record Review

Regardless of familiarity with the patient, reviewing the patient's treatment records is essential, as the ability to recall details is unreliable. Reviewing the records can help identify subtle changes in pain description and site, the patient's story around pain, failed modalities, side effects, and the need for education, all impacting further treatment (23).

Research beforehand the patient's current prescription and whether or not the patient has achieved the maximum dosage of the medication. Analysis of the patient's past prescription could reveal a documented failed therapy even though the patient did not receive the maximum dose (23).

A review of documented allergens may indicate an allergy to pain medication. Discuss with the patient the specific response to the drug to determine if it is a true allergy, such as hives or anaphylaxis, or if the response may have been a side effect, such as nausea and vomiting.

Research whether the patient tried any non-medication modalities for pain, such as physical therapy (PT), occupational therapy (OT), or Cognitive Behavioral Therapy (CBT). Note any non-medication modalities documented as failed therapies. The presence of any failed therapies should prompt further discussion with the patient, family, or caregiver about the experience. The incompletion of therapy should not be considered failed therapy. Explore further if the patient abandoned appointments.

Case Study

You review the schedule for the week, and there are three new patient appointments. One is Mary Adams. The interdisciplinary team requested and received Mary's treatment records from her previous primary care provider. You make 15 minutes available to review Mary's records and the questionnaire Mary filled out for her upcoming appointment. You see that Mary has been diagnosed with Postherpetic Neuralgia and note her current treatment regimen, which she stated was ineffective. You write down questions you will want to ask Mary. You do not see evidence of non-medication modalities or allergies to pain medication.

Pain Assessment

To physically assess pain, several acronyms help explore all the aspects of the patient's experience. Acronyms commonly used to assess pain are SOCRATES, OLDCARTS, and COLDERAS. These pain assessment acronyms are also helpful in determining treatment since they include a character and duration of pain assessment (23).

Inquire where the patient is feeling pain. The patient may have multiple areas and types of pain. Each type and location must be explored and assessed. Unless the pain is from a localized injury, a body diagram map, as seen below, is helpful to document, inform, and communicate locations and types of pain. In cases of Fibromyalgia, rheumatoid arthritis, or other centralized or widespread pain, it is vital to inquire about radiating pain. The patient with chronic pain could be experiencing acute pain or a new pain site, such as osteoarthritis, that may need further evaluation and treatment (23).

Inquire with the patient how long their pain has been present and any associated or known causative factors. Pain experienced longer than three months defines chronic versus acute pain. Chronic pain means that the pain is centralized or a function of the Central Nervous system, which should guide treatment decisions.

To help guide treatment, ask the patient to describe their pain. The description helps identify what type of pain the patient is experiencing: Allodynia and hyperalgesia indicate centralized pain; sharp, shooting pain could indicate neuropathic pain. Have the patient rate their pain. There are various tools, as shown below, for pain rating depending on the patient's ability to communicate. Not using the pain rating number alone is imperative. Ask the patient to compare the severity of pain to a previous experience. For example, a 1/10 may be experienced as a bumped knee or bruise, whereas a 10/10 is experienced on the level of a kidney stone or childbirth (23).

Besides the 0-10 rating scale and depending on the patient's needs, several pain rating scales are appropriate. They are listed below.

The 0-5 and Faces scales may be used for all adult patients and are especially effective for patients experiencing confusion.

The Defense and Veterans Pain Rating Scale (DVPRS) is a five-item tool that assesses the impact of pain on sleep, mood, stress, and activity levels (20).

For patients unable to self-report pain, such as those intubated in the ICU or late-stage neurological diseases, the FLACC scale is practical. The FLACC scale was initially created to assess pain in infants. Note: The patient need not cry to be rated 10/10.

(21).

Assess contributors to pain such as insomnia, stress, exercise, diet, and any comorbid conditions. Limited access to care, socioeconomic status, and local culture also contribute to the patient's experience of pain (23). Most patients have limited opportunity to discuss these issues, and though challenging to bring up, it is compassionate and supportive care. A referral to social work or another agency may be helpful if you cannot explore it fully.

Assess for substance abuse disorders, especially among male, younger, less educated, or unemployed adults. Substance abuse disorders increase the likelihood of misuse disorder and include alcohol, tobacco, cannabis, cocaine, and heroin (29).

Inquire as to what changes in function the pain has caused. One question to ask is, "Were it not for pain, what would you be doing?" As seen below, a Pain, Enjoyment, and General Activity (PEG) three-question scale, which focuses on function and quality of life, may help determine the severity of pain and the effect of treatment over time.

(21).

Assess family history, mental health disorders, chronic pain, or substance abuse disorders. Each familial aspect puts patients at higher risk for developing chronic pain (23).

Evaluate for mental health disorders the patient may be experiencing, particularly anxiety and depression. The Patient Health Questionnaire (PHQ4) is a four-question tool for assessing depression and anxiety.

In some cases, functional MRI or imaging studies effectively determine the cause of pain and the treatment. If further assessment is needed to diagnose and treat pain, consult Neurology, Orthopedics, Palliative care, and pain specialists (23).

Case Study

You used OLDCARTS to evaluate Mary's pain and completed a body diagram. Mary is experiencing allodynia in her back and shoulders, described as burning and tingling. It is exacerbated when she lifts, such as moving patients at the long-term care facility and, more recently, boxes from her move to the new house. Mary has also been experiencing anxiety due to fear of losing her job, the move, and her new role. She has moved closer to her family to help care for her children since she often experiences fatigue. Mary has experienced a tumultuous divorce in the last five years and feels she is still undergoing some trauma.

You saw in the chart that Mary had tried Gabapentin 300 mg BID for her pain and inquired what happened. Mary explained that her pain improved from 8/10 to 7/10 and had no side effects. Her previous care provider discontinued the medication and documented it as a failed therapy. You reviewed the minimum and maximum dosages of Gabapentin and know Mary can take up to 1800mg/day.

During the assessment, Mary also described stiffness and aching in her left knee. She gets a sharp pain when she walks more than 500 steps, and her knee is throbbing by the end of the day. Mary rated the pain a 10/10, but when she compared 10/10 to childbirth, Mary said her pain was closer to 6/10. Her moderate knee pain has reduced Mary's ability to exercise. She used to like to take walks. Mary stated she has had knee pain for six months and has been taking Ibuprofen 3 – 4 times daily.

Since Mary's pain is moderate, you evaluate your options of drugs for moderate to severe pain.

Opioid Classifications and Drug Schedules

A comprehensive understanding of drug schedules and opioid classifications is essential for nurse practitioners to ensure patient safety, prevent drug misuse, and adhere to legal and regulatory requirements. Nurse practitioners with a comprehensive understanding of drug schedules and opioid classifications can effectively communicate with colleagues, ensuring accurate medication reconciliation and facilitating interdisciplinary care. Nurse practitioners’ knowledge in facilitating discussions with pharmacists regarding opioid dosing, potential interactions, and patient education is essential (49).

Drug scheduling became mandated under the Controlled Substance Act. The Drug Enforcement Agency (DEA) Schedule of Controlled Drugs and the criteria and common drugs are listed below.

(Pain Physician, 2008)

Listed below are drugs classified by their schedule and mechanism of action. "Agonist" indicates a drug that binds to the opioid receptor, causing pain relief and also euphoria. An agonist-antagonist indicates the drug binds to some opioid receptors but blocks others. Mixed antagonist-agonist drugs control pain but have a lower potential for abuse and dependence than agonists (7).

(41).

Commonly Prescribed Opioids, Indications for Use, and Typical Side Effects

Opioid medications are widely used for managing moderate to severe pain. Referencing NIDA (2023), this section aims to give healthcare professionals an overview of the indications and typical side effects of commonly prescribed Schedule II opioid medications, including hydrocodone, oxycodone, morphine, Fentanyl, and hydromorphone.

Opioids are derived and manufactured in several ways. Naturally occurring opioids come directly from the opium poppy plant. Synthetic opioids are manufactured by chemically synthesizing compounds that mimic the effects of a natural opioid. Semi-synthetic is a mix of naturally occurring and man-made (35).

Understanding the variations in how an opioid is derived and manufactured is crucial in deciding the type of opioid prescribed, as potency and analgesic effects differ. Synthetic opioids are often more potent than naturally occurring opioids. Synthetic opioids have a longer half-life and slower elimination, affecting the duration of action and timing for dose adjustments. They are also associated with a higher risk of abuse and addiction (38).

Hydrocodone

Mechanism of Action and Metabolism

Hydrocodone is a Schedule II medication. It is an opioid agonist and works as an analgesic by activating mu and kappa opioid receptors located in the central nervous system and the enteric plexus of the bowel. Agonist stimulation of the opioid receptors inhibits nociceptive neurotransmitters' release and reduces neuronal excitability (17).

• Produces analgesia.
• Suppresses the cough reflex at the medulla.
• Causes respiratory depression at higher doses.

Hydrocodone is indicated for treating severe pain after nonopioid therapy has failed. It is also indicated as an antitussive for nonproductive cough in adults over 18.

Available Forms

Hydrocodone immediate release (IR) reaches maximum serum concentrations in one hour with a half-life of 4 hours.  Extended-release (ER) Hydrocodone reaches peak concentration at 14-16 hours and a half-life of 7 to 9 hours. Hydrocodone is metabolized to an inactive metabolite in the liver by cytochrome P450 enzymes CYP2D6 and CYP3A4. Hydrocodone is converted to hydromorphone and is excreted renally. Plasma concentrations of hydromorphone are correlated with analgesic effects rather than hydrocodone.

Hydrocodone is formulated for oral administration into tablets, capsules, and oral solutions. Capsules and tablets should never be crushed, chewed, or dissolved. These actions convert the extended-release dose into immediate release, resulting in uncontrolled and rapid release of opioids and possible overdose.

Dosing and Monitoring

Hydrocodone IR is combined with acetaminophen or ibuprofen. The dosage range is 2.5mg to 10mg every 4 to 6 hours. If formulated with acetaminophen, the dosage is limited to 4gm/day.

Hydrocodone ER is available as tablets and capsules. Depending on the product, the dose of hydrocodone ER formulations in opioid-naïve patients is 10 to 20 mg every 12 to 24 hours.

Nurse practitioners should ensure patients discontinue all other opioids when starting the extended-release formula.

Side Effects and Contraindications

Because mu and kappa opioid receptors are in the central nervous system and enteric plexus of the bowel, the most common side effects of hydrocodone are constipation and nausea (>10%).

Other adverse effects of hydrocodone include:

• Respiratory: severe respiratory depression, shortness of breath
• Cardiovascular: hypotension, bradycardia, peripheral edema
• Neurologic: Headache, chills, anxiety, sedation, insomnia, dizziness, drowsiness, fatigue
• Dermatologic: Pruritus, diaphoresis, rash
• Gastrointestinal: Vomiting, dyspepsia, gastroenteritis, abdominal pain
• Genitourinary: Urinary tract infection, urinary retention
• Otic: Tinnitus, sensorineural hearing loss
• Endocrine: Secondary adrenal insufficiency (17)

Hydrocodone, being an agonist, must not be taken with other central nervous system depressants as sedation and respiratory depression can result. In formulations combined with acetaminophen, hydrocodone can increase the international normalized ratio (INR) and cause bleeding.  Medications that induce or inhibit cytochrome enzymes can lead to wide variations in absorption.

The most common drug interactions are listed below:

• Alcohol
• Benzodiazepines
• Barbiturates
• other opioids
• rifampin
• phenytoin
• carbamazepine
• cimetidine,
• fluoxetine
• ritonavir
• erythromycin
• diltiazem
• ketoconazole
• verapamil
• Phenytoin
• John’s Wort
• Glucocorticoids

Considerations

Use with caution in the following:

• Patients with Hepatic Impairment: Initiate 50% of the usual dose
• Patients with Renal Impairment: Initiate 50% of the usual dose
• Pregnancy: While not contraindicated, the FDA issued a black-boxed warning since opioids cross the placenta, and prolonged use during pregnancy may cause neonatal opioid withdrawal syndrome (NOWS).
• Breastfeeding: Infants are susceptible to low dosages of opioids. Non-opioid analgesics are preferred.

Pharmacogenomic: Genetic variants in hydrocodone metabolism include ultra-rapid, extensive, and poor metabolizer phenotypes. After administration of hydrocodone, hydromorphone levels in rapid metabolizers are significantly higher than in poor metabolizers.

Oxycodone

Mechanism of Action and Metabolism

Oxycodone has been in use since 1917 and is derived from Thebaine. It is a semi-synthetic opioid analgesic that works by binding to mu-opioid receptors in the central nervous system. It primarily acts as an agonist, producing analgesic effects by inhibiting the transmission of pain signals (Altman, Clark, Huddart, & Klein, 2018).

Oxycodone is primarily metabolized in the liver by CYP3A4/5. It is metabolized in the liver to noroxycodone and oxymorphone.  The metabolite oxymorphone also has an analgesic effect and does not inhibit CYP3A4/5. Because of this metabolite, oxycodone is more potent than morphine, with fewer side effects and less drug interactions. Approximately 72% of oxycodone is excreted in urine (Altman, Clark, Huddart, & Klein, 2018).

Available Forms

Oxycodone can be administered orally, rectally, intravenously, and as an epidural. For this sake, we will focus on immediate-release and extended-release oral formulations.

• Immediate-release (IR) tablets
• IR capsules
• IR oral solutions
• Extended-release (ER) tablets

Dosing and Monitoring

The dosing of oxycodone should be individualized based on the patient's pain severity, previous opioid exposure, and response. Initial dosages for opioid naïve patients range from 5-15 mg for immediate-release formulations, while extended-release formulations are usually initiated at 10-20 mg. Dosage adjustments may be necessary based on the patient's response, but caution should be exercised. IR and ER formulations reach a steady state at 24 hours and titrating before 24 hours may lead to overdose.

Regular monitoring is essential to assess the patient's response to treatment, including pain relief, side effects, and signs of opioid misuse or addiction. Monitoring should include periodic reassessment of pain intensity, functional status, and adverse effects (Altman, Clark, Huddart, & Klein, 2018).

Side Effects and Contraindications

Common side effects of oxycodone include:

• constipation
• nausea
• sedation
• dizziness
• respiratory depression
• respiratory arrest
• hypotension
• fatal overdose

Oxycodone is contraindicated in patients with known hypersensitivity to opioids, severe respiratory depression, paralytic ileus, or acute or severe bronchial asthma. It should be used cautiously in patients with a history of substance abuse, respiratory conditions, liver or kidney impairment, and those taking other medications that may interact with opioids, such as alcohol (4).

It is also contraindicated with the following medications and classes:

• Antifungal agents
• Antibiotics
• Rifampin
• Carbamazepine
• Fluoxetine
• Paroxetine

Considerations

• Nurse practitioners should consider the variations in the mechanism of action for the following:
• Metabolism differs between males and females: females have been shown to have less concentration of oxymorphone and more CYP3A4/5 metabolites.
• Infants have reduced clearance of oxycodone, increasing side effects.
• Pediatrics have 20-40% increased clearance over adults.
• Reduced clearance with age increases the half-life of oxycodone.
• Pregnant women have a greater clearance and reduced half-life.
• Impairment of the liver reduces clearance.
• Cancer patients with cachexia have increased exposure to oxycodone and its metabolite.
• Maternal and neonate concentrations are similar, indicating placenta crossing (4)

Morphine

Mechanism of Action and Metabolism

Morphine is a naturally occurring opioid alkaloid extracted from the opium poppy. It was isolated in 1805 and is the opioid against which all others are compared. Morphine binds to mu-opioid receptors in the brain and spinal cord, inhibiting the transmission of pain signals and producing analgesia. It is a first-line choice of opioid for moderate to severe acute, postoperative, and cancer-related pain (8).

Morphine undergoes first-pass metabolism in the liver and gut. It is well absorbed and distributed throughout the body. Its main metabolites are morphine-3-glucuronide and morphine-6-glucuronide. Its mean plasma elimination half-life after intravenous administration is about 2 hours. Approximately 90% of morphine is excreted in the urine within 24 hours (8).

Available Forms

Morphine is available in various forms, including.

• immediate-release tablets
• extended release tablets
• oral IR solutions
• injectable solutions
• transdermal patches

Dosing and Monitoring

Morphine is hydrophilic and, as such, has a slow onset time. The advantage of this is that it is unlikely to cause acute respiratory depression even when injected. However, because of the slow onset time, there is more likelihood of morphine overdose due to the ability to “stack” doses in patients experiencing severe pain (Bistas, Lopez-Ojeda, & Ramos-Matos, 2023).

The dosing of morphine depends on the patient's pain severity, previous opioid exposure, and other factors. It is usually initiated at a low dose and titrated upwards as needed. Monitoring pain relief, adverse effects, and signs of opioid toxicity is crucial. Reevaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy or of dose escalation. General recommendations for initiating morphine (Bistas, Lopez-Ojeda, & Ramos-Matos, 2023).

Prescribe IR opioids instead of ER opioids.

Prescribe the lowest effective dosage, below 50 Morphine Milligram Equivalents (MME) /day.

Side Effects and Contraindications

Because morphine binds to opioid receptors in the brain and spinal cord, is metabolized in the liver and gut, and has a slow onset, the following side effects are common:

• Constipation
• Nausea
• Vomiting
• Sedation
• Dizziness
• Respiratory depression
• Pruritis
• Sweating
• Dysphoria/Euphoria
• Dry mouth
• Anorexia
• Spasms of urinary and biliary tract

Contraindications of morphine are:

• Known hypersensitivity or allergy to morphine.
• Bronchial asthma or upper airway obstruction
• Respiratory depression in the absence of resuscitative equipment
• Paralytic ileus
• Risk of choking in patients with dysphagia, including infants, children, and the elderly (8)

Concurrent use with other sedating medications: Amitriptyline, diazepam, haloperidol, chlorpromazine

Morphine interacts with the following medications:

• Ciprofloxacin
• Metoclopramide
• Ritonavir

Considerations for Nurse Practitioners

Assess for medical conditions that may pose serious and life-threatening risks with opioid use, such as the following:

• Sleep-disordered breathing, such as sleep apnea.
• Pregnancy
• Renal or hepatic insufficiency
• Age >= 65
• Certain mental health conditions
• Substance use disorder
• Previous nonfatal overdose

Fentanyl

Mechanism of Action and Metabolism

Fentanyl is a synthetic opioid more potent than morphine and was approved in 1968. Fentanyl is an agonist that works by binding to the mu-opioid receptors in the central nervous system. This binding inhibits the transmission of pain signals, resulting in analgesia. Fentanyl is often used for severe pain management, particularly in the perioperative and palliative care settings, or for severe pain in patients with Hepatic failure (8).

It is a mu-selective opioid agonist. However, it can activate other opioid receptors in the body, such as the delta and kappa receptors, producing analgesia. It also activates the Dopamine center of the brain, stimulating relaxation and exhilaration, which is responsible for its high potential for addiction (8).

Indications for fentanyl are as follows:

• Preoperative analgesia
• Anesthesia adjunct
• Regional anesthesia adjunct
• General anesthesia
• Postoperative pain control
• Moderate to severe acute pain (off-label)

Available Forms

• Fentanyl is available in various forms, including:
• transdermal patches
• injectable solutions
• lozenges
• nasal sprays
• oral tablets (8)

Dosing and Monitoring

Fentanyl is metabolized via the CYP3A4 enzyme in the liver. It has a half-life of 3 to 7 hours, and 75% of Fentanyl is excreted in the urine and 9% in feces.

The dosing of fentanyl depends on the route of administration and the patient's needs. For example, transdermal patches are typically applied every 72 hours, while injectable solutions are titrated to achieve the desired analgesic effect. Monitoring should include assessing pain levels, respiratory rate, blood pressure, and sedation scores (8).

Fentanyl is most dosed as follows:

• Post-operative pain control
• 50 to 100 mcg IV/IM every 1 to 2 hours as needed; alternately 0.5 to 1.5 mcg/kg/hour IV as needed. Consider lower dosing in patients 65 and older.

PCA (patient-controlled analgesia): 10 to 20 mcg IV every 6 to 20 minutes as needed; start at the lowest effective dose for the shortest effective duration - refer to institutional protocols (8).

Moderate to severe acute pain (off-label) 1 to 2 mcg/kg/dose intranasally each hour as needed; the maximum dose is 100 mcg. Use the lowest effective dose for the shortest effective duration (8).

Side Effects and Contraindications

Common side effects of fentanyl include:

• respiratory depression
• sedation
• constipation
• nausea
• vomiting
• euphoria
• confusion
• respiratory depression/arrest
• visual disturbances
• dyskinesia
• hallucinations
• delirium
• narcotic ileus
• muscle rigidity
• addiction
• loss of consciousness
• hypotension
• coma
• death (8).

The use of fentanyl is contraindicated in patients in the following situations:

• After operative interventions in the biliary tract, these may slow hepatic elimination of the drug.
• With respiratory depression or obstructive airway diseases (i.e., asthma, COPD, obstructive sleep apnea, obesity hyperventilation, also known as Pickwickian syndrome)
• With liver failure
• With known intolerance to fentanyl or other morphine-like drugs, including codeine or any components in the formulation.
• With known hypersensitivity (i.e., anaphylaxis) or any common drug delivery excipients (i.e., sodium chloride, sodium hydroxide) (8).

Considerations for Nurse Practitioners

Nurse practitioners prescribing fentanyl should thoroughly assess the patient's pain, medical history, and potential risk factors for opioid misuse. They should also educate patients about the proper use, storage, and disposal of fentanyl. It should be used cautiously in patients with respiratory disorders, liver or kidney impairment, or a history of substance abuse. Fentanyl is contraindicated in patients with known hypersensitivity to opioids and those without exposure to opioids.

Alcohol and other drugs, legal or illegal, can exacerbate fentanyl's side effects, creating multi-layered clinical scenarios that can be complex to manage. These substances, taken together, generate undesirable conditions that complicate the patient's prognosis (8).

Hydromorphone

Mechanism of Action and Metabolism

Hydromorphone is a semi-synthetic opioid derived from morphine. It binds to the mu-opioid receptors in the central nervous system. It primarily exerts its analgesic effects by inhibiting the release of neurotransmitters involved in pain transmission, thereby reducing pain perception. Hydromorphone also exerts its effects centrally at the medulla level, leading to respiratory depression and cough suppression (1).

Hydromorphone is indicated for:

• moderate to severe acute pain
• severe chronic pain
• refractory cough suppression (off-label) (1)

Available Forms

Hydromorphone is available in various forms, depending on the patient’s needs and severity of pain.

• immediate-release tablet
• extended release tablets
• oral liquid
• injectable solution
• rectal suppositories

Dosing and Monitoring

The immediate-release oral formulations of hydromorphone have an onset of action within 15 to 30 minutes. Peak levels are typically between 30 and 60 minutes with a half-life of 2 to 3 hours. Hydromorphone is primarily excreted through the urine.

The dosing of hydromorphone should be individualized based on the patient's pain intensity, initiated at the lowest effective dose, and adjusted gradually as needed. Close monitoring of pain relief, adverse effects, and signs of opioid toxicity is essential. Patients should be assessed regularly to ensure they receive adequate pain control without experiencing excessive sedation or respiratory depression.

The following are standard dosages that should only be administered when other opioid and non-opioid options fail.

• Immediate-release oral solutions dosage: 1 mg/1 mLoral tablets are available in 2 mg, 4 mg, and 8 mg.
• Extended-release oral tablets are available in dosages of 8 mg, 12 mg, 16 mg, and 32 mg.
• Injection solutions are available in concentrations of 1 mg/mL, 2 mg/mL, 4 mg/mL, and 10 mg/mL.
• Intravenous solutions are available in strengths of 2 mg/1 mL, 2500 mg/250 mL, ten mg/1 mL, and 500 mg/50 mL.
• Suppositories are formulated at a strength of 3 mg (1).

Side Effects and Contraindications

Hydromorphone has potential adverse effects on several organ systems, including the integumentary, gastrointestinal, neurologic, cardiovascular, endocrine, and respiratory.

Common side effects of hydromorphone include:

• Constipation
• Nausea
• Vomiting
• Dizziness
• Sedation
• respiratory depression
• pruritus
• headache
• Somnolence
• Severe adverse effects of hydromorphone include:
• Hypotension
• Syncope
• adrenal insufficiency
• coma
• raised intracranial pressure.
• seizure
• suicidal thoughts
• apnea
• respiratory depression or arrest
• drug dependence or withdrawal
• neonatal drug withdrawal syndrome
• Hydromorphone is contraindicated in patients with:
• known allergies to the drug, sulfites, or other components of the formulation.
• known hypersensitivity to opioids.
• severe respiratory depression
• paralytic ileus
• acute or severe bronchial asthma (1).

Caution should be exercised in patients with:

• respiratory insufficiency
• head injuries
• increased intracranial pressure.
• liver or kidney impairment.

Considerations for Nurse Practitioners

As nurse practitioners, it is crucial to assess the patient's pain intensity and overall health status before initiating Hydromorphone. Start with the lowest effective dose and titrate carefully for optimal pain control. Regular monitoring for adverse effects, signs of opioid toxicity, and therapeutic response is essential. Educate patients about the potential side effects, proper dosing, and the importance of not exceeding prescribed doses. Additionally, nurse practitioners should be familiar with local regulations and guidelines regarding opioid prescribing and follow appropriate documentation and monitoring practices.

Additional Considerations

In terminal cancer patients, clinicians should not restrain opioid therapy even if signs of respiratory depression become apparent.

Hydromorphone requires careful administration in cases of concurrent psychiatric illness.

Specific Patient Considerations:

• Hepatic impairment and Renal Impairment: Initiate hydromorphone treatment at one-fourth to one-half of the standard starting dosage, depending on the degree of impairment.
• Pregnancy considerations: Hydromorphone can traverse the placental barrier and induce NOWS.
• Breastfeeding considerations: Nonopioid analgesic agents are preferable for breastfeeding women.
• Older patients: hydromorphone is categorized as a potentially inappropriate medication for older adults (1).

Tramadol

Mechanism of Action and Metabolism

Tramadol is a Schedule IV opioid medication with a higher potential for dependency and misuse than non-opioid medications. It binds to opioid receptors in the central nervous system, inhibiting the reuptake of norepinephrine and serotonin. It also has weak mu-opioid receptor agonist activity.

The liver metabolizes tramadol mediated by the cytochrome P450 pathways (particularly CYP2D6) and is mainly excreted through the kidneys.

Tramadol is used for moderate to severe pain.

Available Forms of Tramadol include:

• Immediate-release-typically used for acute pain management.
• Extended-release-used for chronic pain.

Dosing and Monitoring

Tramadol has an oral bioavailability of 68% after a single dose and 90–100% after multiple doses and reaches peak concentrations within 2 hours. Approximately 75% of an oral dose is absorbed, and the half-life of tramadol is 9 hours (18).

Tramadol dosing should be individualized based on the patient's pain severity and response.

The initial dose for adults is usually 50-100 mg orally every 4-6 hours for pain relief. The maximum daily dose is 400 mg for immediate-release formulations and 300 mg for extended-release formulations (18).

It is essential to monitor the patient's pain intensity, response to treatment, and any adverse effects. Regular reassessment and adjustment of the dosage may be necessary.

Side Effects and Contraindications

Tramadol is responsible for severe intoxications leading to consciousness disorder (30%), seizures (15%), agitation (10%), and respiratory depression (5%). The reactions to Tramadol suggest that the decision to prescribe should be carefully considered.

Common Side Effects of Tramadol Include:

• Nausea
• Vomiting
• Dizziness
• Constipation
• Sedation
• Headache
• CNS depression
• Seizure
• Agitation
• Tachycardia
• Hypertension
• reduced appetite
• pruritus and rash
• gastric irritation

Serious side effects include:

• respiratory depression
• serotonin syndrome
• seizures

Contraindications

Tramadol is contraindicated in patients with:

• history of hypersensitivity to opioids
• acute intoxication with alcohol
• opioids, or other psychoactive substances
• Patients who have recently received monoamine oxidase inhibitors (MAOIs)

Additionally, the following can be observed in tramadol intoxication:

• miosis
• respiratory depression
• decreased level of consciousness
• hypertension
• tremor
• irritability
• increased deep tendon reflexes

Poisoning leads to:

• multiple organ failure
• coma
• cardiopulmonary arrest
• death

Considerations for Nurse Practitioners

Tramadol has been increasingly misused with intentional overdoses or intoxications. Suicide attempts were the most common cause of intoxication (52–80%), followed by abuse (18–31%), and unintentional intoxication (1–11%). Chronic tramadol or opioid abuse was reported in 20% of tramadol poisoning cases. Fatal tramadol intoxications are uncommon except when ingested concurrent with depressants, most commonly benzodiazepines and alcohol (18).

Tramadol poisoning can affect multiple organ systems:

• gastrointestinal
• central nervous system: seizure, CNS depression, low-grade coma, anxiety, and over time anoxic brain damage
• Cardiovascular system: palpitation, mild hypertension to life-threatening complications such as cardiopulmonary arrest
• respiratory system
• renal system: renal failure with higher doses of tramadol intoxication
• musculoskeletal system: rhabdomyolysis
• endocrine system: hypoglycemia, serotonin syndrome (18)

Cannabis

Mechanism of Action and Metabolism

Cannabis is classified as a Schedule I status. It contains various cannabinoids, with delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) being the most studied. THC primarily acts on cannabinoid receptors in the brain, producing psychoactive effects, while CBD has more diverse effects on the nervous system. These cannabinoids interact with the endocannabinoid system, modulating neurotransmitter release and influencing various physiological processes (32).

Similar to opioids, cannabinoids are synthesized and released in the body by synapses that act on the cannabinoid receptors present in presynaptic endings (32). They perform the following actions related to analgesia:

• Decrease the release of neurotransmitters.
• Activate descending inhibitory pain pathways.
• Reduce postsynaptic sensitivity and alleviate neural inflammation.
• Modulate CB1 receptors within central nociception processing areas and the spinal cord, resulting in analgesic effects.
• Attenuate inflammation by activating CB2 receptors (32).
• Emerging research shows cannabis is indicated for:
• Migraines
• chronic pain
• back pain
• arthritic pain
• pain associated with cancer and surgery.
• neuropathic pain
• diabetic neuropathic pain when administered early in the disease progression.
• sickle cell disease
• cancer
• inflammatory bowel disease (32)

Available Forms

Cannabis refers to products sourced from the Cannabis sativa plant. There are differences between cannabis, cannabinoids, and cannabidiol (CBD). Cannabinoids are extracted from the cannabis plants. Cannabinoid-based treatments, such as dronabinol and CBD, are typically approved medical interventions for specific indications. THC (9-tetrahydrocannabinol) is the psychoactive component of the cannabis plant. CBD is a non-psychoactive component (32).

Cannabis can be consumed in different forms, each with a different onset and duration. Patients may have individual preferences, including:

• smoking/vaporizing dried flowers.
• consuming edibles
• tinctures or oils
• applying topicals (32)

Dosing and Monitoring

Inhaling marijuana via the lungs by smoking or vaping causes maximum plasma concentration within minutes. Psychiatric effects begin within seconds to a few minutes after inhalation and peak after 15 to 30 minutes. The effect diminishes throughout 2 to 3 hours (32).

Oral ingestion of marijuana causes psychiatric effects that typically occur between 30 and 90 minutes and reach maximum effect after 2 to 3 hours. Ingested marijuana effects last about 4 to 12 hours (32).

Dosing cannabis is challenging due to variations in potency and individual responses. Start with low doses and titrate slowly to achieve the desired effect while minimizing side effects. Regular monitoring is crucial, including assessing symptom relief, adverse effects, and potential drug interactions. Encourage patients to keep a diary to track their cannabis use and its effects (32).

Side Effects and Contraindications

Cannabis can exacerbate mental health conditions such as anxiety and psychosis. Common side effects of cannabis include (32):

• Dizziness
• dry mouth
• increased heart rate
• impaired memory
• psychoactive effects

Contraindications include:

• Pregnancy
• Breastfeeding
• heart disease
• respiratory conditions
• history of substance abuse
• mental health disorders

Case Study

Mary is agreeable to trying an increased dose of Gabapentin. Mary would also like to see a counselor to discuss her past and get help with her anxiety. You made an appointment for Mary to see a Licensed Clinical Social Worker in your clinic.

You read the side effects and warnings for Gabapentin, and it is unsafe to use Gabapentin and Tramadol together since they are both depressants. You order a non-steroidal drug for Mary's somatic knee pain and make a consult for imaging studies on her left knee. You also make a referral to Orthopedics.

You educated Mary about the side effects of Gabapentin and scheduled a follow-up appointment. The day after Mary began her treatment with the increased Gabapentin, you called Mary to follow up on its effect. Mary still has pain, but she is not having any untoward side effects. Gabapentin may not work immediately so you will schedule a follow-up call in 3 days.

Opioid Use, the Opioid Epidemic, and Statistics

The use and misuse of opioids has become a pressing public health concern, leading to a global epidemic. The history of opioid use, the opioid epidemic, and associated statistics provide essential context for healthcare professionals in addressing this public health crisis. More importantly, it is estimated that 1 in 4 patients receiving prescription opioids in primary care settings will misuse them. In addition, 50% of opioid prescriptions are written by primary care providers, including nurse practitioners (22). Understanding the factors contributing to the epidemic and the magnitude of its impact is crucial for effective prevention, intervention, and treatment strategies.

History of Opioid Use

Opioids have a long history of medicinal use, dating back to ancient civilizations. They have been a drug of choice for pain relief for thousands of years. The introduction of synthetic opioids in the 19^th century, such as morphine and later heroin, revolutionized pain management. However, their potential for addiction and misuse soon became apparent (16).

The Opioid Epidemic

The opioid epidemic refers to the surge in opioid misuse, addiction, and overdose deaths. The epidemic gained momentum in the late 1990s with increased prescribing of opioids for chronic pain (43).

No doubt, increased prescribing put opioids in the hands of consumers, but increased prescribing resulted from a multifactorial influence. One of the main influences was aggressive marketing by pharmaceutical companies, which has been well publicized. However, due to the long history of underprescribing pain medications for fear of misuse and addiction, the medical community was primed to expand its opioid prescribing practices (31).

A historical event that increased comfort with prescribing opioids, in the writer's opinion, was the introduction of the Medicare Hospice Benefit in 1986. Medical directors must be contracted or employed by hospices, and these medical directors had or soon gained pain management expertise. To further promote hospice and effective pain management, the hospice medical directors, with newly acquired skills, provided education throughout medical communities about pain management and specifically to decrease the fear of using opioids. Pharmacies and attending physicians grew accustomed to giving opioids for home use. Hospice care is for terminally ill patients, defined as a life expectancy of 6 months or less. Still, the reality is that hospice discharges 12 to 40% of patients for ineligibility and other reasons.

A more prominent factor in increasing opioid prescribing was the 1996 American Pain Society's introduction of pain as "the 5^th Vital sign." Soon after, The Joint Commission promoted pain as "the 5^th Vital Sign" and began compliance surveys in healthcare organizations requiring pain assessment details to be as prominent as blood pressure and heart rate. The Joint Commission cited a quote from 1968 by a nurse from the University of California Los Angeles, Margo McCaffrey, who defined pain as "…Whatever the experiencing person says it is, existing whenever s/he says it does." The Joint Commission accreditation programs pursued pain management as part of the accreditation process throughout its healthcare accreditation programs, including hospice accreditation by 1989 per TJC Timeline (48).

The National Institute of Health published an article about the Joint Commission's role in the opioid epidemic, particularly regarding the definition of pain, "This definition emphasizes that pain is a subjective experience with no objective measures. It also stresses that the patient, not the clinician, is the authority on the pain and that their self-report is the most reliable indicator of pain. This set the tone for clinicians: Patients are always to be trusted to report pain accurately” (45).

Statistics on the Opioid Epidemic

In the United States alone, over 500,000 people died from opioid overdoses between 1999 and 2017. The number of opioid-related overdose deaths continues to increase, with synthetic opioids, mainly illicitly manufactured Fentanyl, playing a significant role in recent years (46). Fentanyl-laced drugs, such as marijuana, are increasingly sold knowing and unknowingly to introduce medications with a high addiction rate, thus creating new consumers. This practice can potentially increase deaths due to the imprecise nature of manufacturing (16).

Opioid-related hospitalizations have also risen substantially. In 2014, there were approximately 1.27 million hospitalizations related to opioids in the United States. These hospitalizations not only place a burden on healthcare systems but also reflect the severe consequences of opioid misuse (3).

Federal Regulations on Opioid Prescribing

The history of substance use disorder prevention that promotes opioid recovery and treatment for patients and communities can be traced back to the early 20^th century. However, the current approach to addressing opioid addiction and promoting healing has evolved significantly in recent times (36).

In the early 1900s, health professionals treated opioid addiction with punitive measures, including incarceration and moralistic approaches. The focus was on punishing individuals rather than providing effective treatment. This approach persisted for several decades until the mid-20^th century when the medical community started recognizing addiction as a medical condition rather than a moral failing (36).

The Controlled Substances Act (CSA), introduced in 1970, was a response to increasing drug abuse and illicit drug trafficking in the United States. The CSA is a federal law regulating the manufacture, possession, distribution, and use of certain substances, including drugs and medications, that can potentially cause abuse and dependence. Its primary purpose is to combat drug abuse, reduce drug-related crimes, and protect public health and safety. The Drug Enforcement Agency (DEA) plays a crucial role in enforcing the CSA by monitoring and controlling controlled substance production, distribution, and use (31).

In the 1990s, the significant increase in opioid prescribing, leading to a surge in opioid addiction and overdose deaths, prompted a shift in focus toward prevention. Efforts were made to educate healthcare providers about the risks of overprescribing opioids and to implement prescription drug monitoring programs to track and prevent abuse (36).

The Comprehensive Addiction and Recovery Act (CARA) was signed into law in 2016 to expand access to treatment and recovery services for opioid addiction. This legislation allocated funding for prevention, treatment, recovery, and support services while promoting evidence-based practices and programs (36).

The Centers for Disease Control and Prevention (CDC) published guidelines in 2016 for prescribing opioids for chronic pain, which was updated in 2022. These guidelines emphasize the importance of non-opioid alternatives, using the lowest effective dose for the shortest duration, and assessing the benefits and risks of continued opioid therapy (13).

Furthermore, the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT) was signed into law in 2018, providing additional resources to address the opioid crisis. This legislation expanded access to medication-assisted treatment (MAT), increased the availability of naloxone, a medication used to reverse opioid overdose, and enhanced support for recovery housing (36).

In recent years, there has been a growing recognition of the importance of a comprehensive approach to opioid addiction, including harm reduction strategies, increased access to naloxone, and the integration of mental health services. Communities and organizations have been working together to address the underlying issues contributing to addiction, such as poverty, trauma, and social determinants of health (50).

Overall, the history of substance use disorder prevention that promotes opioid recovery and treatment has evolved from a punitive approach to a more compassionate and evidence-based model. Efforts are now focused on prevention, early intervention, and expanding access to comprehensive treatment and support services for individuals and communities affected by opioid addiction (36).

The most current federal regulations on opioid prescribing for healthcare providers are the amendments to the CSA in 2018, which added new rules to limit the quantity and duration of opioid prescriptions for acute pain to seven days. In 2022, the CDC updated recommendations to the Clinical Practice Guidelines for Prescribing Opioids for Pain.

The 2022 CDC guidelines are summarized below (13):

1. Non-opioid therapies should be considered the first-line treatment for chronic pain.
2. Establish clear treatment goals with patients, including realistic pain management and functional improvement expectations.
3. Conduct a thorough risk assessment for potential harms before initiating opioid therapy.
4. When opioids are used, start with the lowest effective dose and consider immediate-release opioids instead of extended-release or long-acting opioids.
5. Prescribe the lowest effective dose for the shortest duration possible, typically three days or less and rarely exceeding seven days.
6. Reassess benefits and risks within one day after prescribing opioids, including checking the prescription drug monitoring database.
7. Avoid prescribing opioids and benzodiazepines concurrently whenever possible due to the increased risk of overdose and death.
8. Offer naloxone to patients at increased risk of opioid overdose, including those with a history of overdose, substance use disorder, or concurrent benzodiazepine use.
9. When opioids are no longer needed, taper the dose gradually to minimize withdrawal symptoms.
10. Arrange an evidence-based treatment for patients with opioid use disorder, including medication-assisted treatment (Naltrexone, Buprenorphine, or Methadone).

Safe Prescribing and Prescription Monitoring Program

Prescription Drug Monitoring Programs (PDMP) are state-run electronic databases that track.

the prescribing and dispensing of controlled substances. PDMPs are designed to improve patients.

care and safety by giving clinicians access to patients' prescription histories, allowing them to make informed decisions when prescribing controlled substances. PDMPs help identify patients at risk of substance misuse or prescription drug overdose. They also enable clinicians to identify potential drug interactions and prevent opioid diversion (14).

PDMPs collect and store data from pharmacies and prescribers in a centralized database. Clinicians can access this database to review a patient's prescription history, including the types of medications prescribed, the prescribers involved, and the dispensing pharmacies (14).

In many states, PDMP use is mandated by law, and nurse practitioners may be required to register and use the system. It is essential to understand state-specific laws and regulations regarding PDMP use.

PDMPs have some limitations, such as incomplete data or delays in reporting. The CDC emphasizes that clinicians should use PDMP data for their clinical assessment and other relevant information to make informed decisions about prescribing controlled substances. Still, PDMP cannot be used as the sole basis for denying or providing treatment (14).

Case Study

After five days on Gabapentin, Mary was doing well, and her neuropathic pain had decreased to 3/10. However, Mary suffered a fall after her knee "gave out" and injured her knee and back. She was in severe pain, and her family drove her to the ER. The ER doctors saw Mary, and orthopedics were consulted. Mary has surgery scheduled for a knee replacement a week from now.

Mary was prescribed Vicodin because she was in excruciating pain, but her prescription only allowed enough medication for two days. Mary has made an appointment with you to renew her prescription.

You evaluate Mary because you know that concomitant use of Gabapentin and opioids puts Mary at risk for respiratory depression and possible side effects, including accidental overdose.

Mary stated she has been more alert the past 24 hours and is afraid her functional status will continue to decline if she does not have more Vicodin because the pain in her back and knee makes it difficult to stand. You assess Mary. Mary stated she occasionally drinks alcohol but has not had a drink since she moved. She has no familial history of substance abuse or mental health disorders.

Mary's mother stayed at her house to help her for the first 24 hours after Mary's return from the ER, but Mary is providing her care now.

You check the PDMP database and see that Mary was prescribed eight pills she has taken over the last 48 hours.

Since the Vicodin has been effective without untoward side effects, and Mary's function is improving, you decide to refill the prescription of Vicodin. You will taper the dose to three Vicodin daily for two days and two for one day. Mary will be near her appointment for a knee replacement as well.

Preventing Opioid Use Disorder

As previously discussed, opioid addiction is a growing concern worldwide, affecting individuals from all walks of life. According to the CDC, "Anyone who takes prescription opioids can become addicted to them" (14).

As frontline healthcare professionals, nurse practitioners must recognize the signs of opioid addiction to provide timely intervention and support. This section will outline the key indicators of opioid addiction.

Physical Symptoms

Physical symptoms are often the first noticeable signs of opioid addiction. These symptoms may include constricted pupils, drowsiness, slurred speech, impaired coordination, and increased sensitivity to pain. Additionally, individuals struggling with opioid addiction may exhibit frequent flu-like symptoms, such as a runny nose, sweating, itching, or gastrointestinal issues.

Behavioral Changes

Opioid addiction can significantly impact an individual's behavior. These may include increased secrecy, frequent requests for early prescription refills, doctor shopping (seeking prescriptions from multiple healthcare providers), neglecting personal hygiene, and experiencing financial difficulties due to excessive spending on opioids (37).

Social Isolation

Opioid addiction often leads to social withdrawal and isolation. Individuals struggling with opioid addiction may distance themselves from family, friends, and social activities they once enjoyed. They may exhibit erratic mood swings, become defensive or hostile when confronted about their drug use, and display a general lack of interest in previously important activities (30).

Psychological Changes

The psychological impact of opioid addiction is significant. Individuals with opioid addiction may exhibit increased anxiety, depression, irritability, and restlessness. They may also experience cognitive impairments, memory lapses, and difficulties in decision-making. Healthcare professionals should be attentive to these changes, as they can indicate opioid addiction (51).

Tolerance and Withdrawal Symptoms

The development of tolerance and withdrawal symptoms are critical signs of opioid addiction. Individuals may require increased dosages of opioids to achieve the desired effect, indicating a growing tolerance. Furthermore, withdrawal symptoms such as muscle aches, nausea, vomiting, insomnia, and intense cravings for opioids may occur when the drug is discontinued or reduced abruptly (51).

Opioid Overdose

The management of opioid overdose, withdrawal, and addiction requires a comprehensive approach that combines pharmacological interventions with psychosocial support. Naloxone remains a vital tool for reversing opioid overdose, while medications such as Methadone, buprenorphine, and naltrexone play crucial roles in withdrawal and addiction treatment (National Institute of Health, 2023). Nurse practitioners must stay vigilant and informed about the evolving landscape of medications. This section aims to provide a comprehensive review of medications and treatment strategies for opioid overdose, withdrawal, and addiction and is excerpted from the NIH (40).

Naloxone

Mechanism of Action and Metabolism

Naloxone is an opioid receptor antagonist. It works by binding to opioid receptors and displacing any opioids present, thereby reversing the effects of opioid overdose. It has a higher affinity for opioid receptors than most opioids, effectively blocking their action.

Naloxone is indicated for emergency intervention of opioid overdose. It effectively reverses respiratory depression and other life-threatening effects. Studies suggest the potential benefits of combining naloxone with other medications, such as buprenorphine (see below), to improve outcomes. Initiatives promoting community-based naloxone distribution programs have shown promising results in reducing opioid-related deaths.

Available Forms

Naloxone is available in various formulations:

• Intranasal
• Intramuscular
• Intravenous
• auto-injectors.

The most used form is the intranasal spray, which is easy to administer and requires no specialized training. Intranasal naloxone formulations have gained popularity due to their ease of use and increased availability. A recent study showed that the non-FDA-approved compound spray was far less effective than either FDA compound (15).

Dosing and Monitoring

The recommended initial dose of naloxone for opioid overdose is 2mg intranasally or 0.4mg to 2mg intramuscularly or intravenously. If the patient does not respond within 23- minutes, additional doses may be administered every 2-3 minutes. Continuous monitoring of the patient's respiratory status is essential, as repeat doses may be required due to the short half-life of naloxone.

Side Effects and Contraindications

Naloxone has been shown not to affect individuals without opioids in their system.

Common side effects of naloxone include

• Withdrawal symptoms: increased heart rate, sweating, and agitation
• nausea
• vomiting
• headache

Contraindications include known hypersensitivity to naloxone and situations where the use of naloxone may be unsafe or not feasible.

Considerations for Nurse Practitioners

Fentanyl and other opioids have a rapid onset, and the need to act quickly is paramount. As mentioned previously, the ease of use and higher plasma concentrations using the FDA-approved 4-mg FDANxSpray device compared with the locally compounded nasal sprays should be considered when ordering Naloxone (15).

Fentanyl and other potent synthetic opioids may require multiple administrations of naloxone to achieve reversal of an overdose (Chiang, Gyaw, & Krieter, 2019). As a nurse practitioner prescribing naloxone, it is crucial to assess the patient's risk factors for opioid overdose, such as a history of substance use disorder or chronic pain management. Education regarding the proper administration of naloxone should be provided to the patients and their caregivers. Additionally, it is essential to provide resources for follow-up care, including addiction treatment and ongoing support.

Methadone

Mechanism of Action and Metabolism

Methadone is a long-acting opioid agonist that effectively suppresses withdrawal symptoms and reduces cravings. It binds to the same opioid receptors in the brain as other opioids. It relieves withdrawal symptoms and reduces cravings by blocking the euphoric effects of opioids, thus helping individuals with opioid dependence to achieve stability (33).

Available Forms

Methadone is available in oral tablets and liquid formulations. The oral tablet is the most used form and is typically administered once daily (33).

Dosing and Monitoring

Methadone dosing is individualized based on the patient's response and needs. Initially, the dose often started low and gradually increased until the patient reached a stable dose. Dosing may need to be adjusted based on the patient's response, adherence, and any changes in their overall health. Regularly monitoring the patient's vital signs, urine drug screens, and assessment of their withdrawal symptoms and cravings is essential.

Side Effects and Contraindications

Common side effects of methadone include:

• Constipation
• dry mouth
• drowsiness
• sweating
• weight gain
• respiratory depression

Contraindications include:

• known hypersensitivity to methadone
• severe asthma
• respiratory depression
• certain heart conditions (33).

Considerations for Nurse Practitioners

As a nurse practitioner prescribing methadone, conducting a comprehensive assessment of the patient's medical history, current medications, and substance use history is crucial. Opioid treatment programs or specialized clinics are often involved in methadone treatment, so collaboration and coordination of care with these programs are essential. Regularly monitoring the patient's progress, adherence, and potential side effects or drug interactions is essential. Additionally, providing education on the risks and benefits of methadone and the importance of adherence to the prescribed regimen is crucial for successful treatment outcomes.

Buprenorphine

Mechanism of Action and Metabolism

Buprenorphine is a partial opioid agonist with a ceiling effect that minimizes the risk of overdose while reducing withdrawal symptoms. Buprenorphine is a partial opioid agonist that binds to the same receptors as other opioids but produces a weaker response. It has a high affinity for the mu-opioid receptors, which helps reduce cravings and withdrawal symptoms in individuals with opioid dependence.

Available Forms

Buprenorphine is available in different formulations, including sublingual tablets, buccal films, and extended-release injections. The sublingual tablets have different strengths, such as 2mg, 4mg, 8mg, and 12mg. Buprenorphine is taken as a daily tablet or weekly or monthly injection.

Dosing and Monitoring

The dosing of buprenorphine varies depending on the individual's opioid dependence severity and treatment phase. Initially, a low dose (e.g., 2-4mg) is given, and it may gradually increase to a maintenance dose of 8-24 mg daily. Regular monitoring is essential to assess the patient's response, adherence, and potential side effects.

Side Effects and Contraindications

Common side effects of buprenorphine include:

• Constipation
• Nausea
• Headache
• Insomnia
• Sweating

Serious side effects are rare but can include:

• Respiratory depression
• Allergic reactions

Buprenorphine is contraindicated in individuals with:

• Severe respiratory insufficiency
• Acute intoxication with opioids
• Known hypersensitivity

Considerations for Nurse Practitioners

Nurse practitioners can prescribe buprenorphine for opioid dependence treatment under the Drug Addiction Treatment Act (DATA). To become eligible, they must complete specific training requirements and obtain a waiver from the Substance Abuse and Mental Health Services Administration (SAMHSA). Nurse practitioners should assess patients thoroughly, including their opioid use history, comorbidities, and medication compatibility, while ensuring appropriate counseling and referral for comprehensive treatment (40).

Clonidine + Lofexidine

Mechanism of Action and Metabolism:

Both Clonidine and Lofexidine are alpha-2 adrenergic agonists. They work by stimulating alpha-2 receptors in the brain, which reduces sympathetic outflow and norepinephrine release. This results in decreased sympathetic activity, leading to various effects such as reduced blood pressure, decreased heart rate, and alleviated withdrawal symptoms (28).

Available Forms

Clonidine is available in oral tablets and patches. Lofexidine is available in oral tablets and is taken as needed (40).

Dosing and Monitoring

For opioid withdrawal, the Clonidine dose ranges from 0.1-0.3 mg every 4-6 hours. Lofexidine is usually initiated at 0.53 mg three times daily, and the dose can be increased to 2.88 mg daily. Monitoring blood pressure and heart rate is essential during treatment (40).

Side Effects and Contraindications:

Common side effects of both medications include:

• dry mouth
• sedation
• dizziness
• constipation
• orthostatic hypotension (40).

Both medications are contraindicated in patients with:

• Hypotension
• Bradycardia
• heart block
• history of hypersensitivity to the drugs (40).

Considerations for Nurse Practitioners:

An early study of lofexidine vs. clonidine for withdrawal symptoms showed that treatment with lofexidine resulted in lower withdrawal symptoms, fewer mood problems, less sedation, and hypotension. There were no significant differences in craving levels, morphine metabolites in urine, or dropout rates when both were compared.

Lofexidine can be a safe option for outpatient treatment as it does not lead to hypotension. However, nurse practitioners must closely monitor patients' blood pressure and heart rate during treatment and educate them about possible side effects. If patients experience any concerning symptoms, they should inform their nurse practitioner immediately.

Gradual dose reduction of Clonidine is crucial to prevent rebound hypertension. Before prescribing either medication, nurse practitioners should assess for any contraindications or potential drug interactions (19).

Emerging Therapies for Withdrawal

Extended-release naltrexone: Naltrexone is an opioid receptor antagonist that blocks the effects of opioids, reducing the risk of relapse. It is taken as a monthly injection.

Alpha-2 adrenergic agonists: Emerging evidence suggests the potential use of dexmedetomidine and guanfacine for managing opioid withdrawal symptoms.

Medication-Assisted Treatment (MAT):

Methadone was introduced in the 1960s and marked a significant turning point in opioid addiction treatment or MAT. Along with counseling and behavioral therapies, MAT became the cornerstone of opioid addiction recovery.

Examples of medications used:

• Methadone
• Buprenorphine:
• Naltrexone:

Adjunctive Pharmacotherapies:

Antidepressants: Selective serotonin reuptake inhibitors and tricyclic antidepressants may help manage co-occurring depression and anxiety.

Anticonvulsants:

Medications like Gabapentin and pregabalin show promise in reducing opioid cravings and improving treatment outcomes.

Other Substance Use Disorders

Patients in pain may struggle with Substance Use Disorders other than Opioid Use Disorder. Substance use disorders may often occur with mental health conditions such as anxiety, depression, and bipolar disorder. In addition, many individuals engage in polydrug use. Understanding the most common Substance Use Disorders aids in a comprehensive assessment of the patient and the development of appropriate treatment plans (28).

Alcohol Use Disorder (AUD):

The prevalence of AUD worldwide was estimated to be 9.8% in men and 5.5% in women in 2016 (28).

Cannabis Use Disorder (CUD):

the prevalence of CUD in the United States increased from 2.18% in 2001-2002 to 2.89% in 2012-2013. (28).

Cocaine Use Disorder:

According to the National Survey on Drug Use and Health (NSDUH), in 2019, approximately 1.9 million Americans aged 12 or older had cocaine use disorder in the past year (44).

Methamphetamine Use Disorder:

A study published in Drug and Alcohol Dependence reported that the prevalence of methamphetamine use disorder in the United States was estimated to be 0.2% in 2015-2016 (6).

Drug Diversion and Illegal opioids

Misuse of opioids is facilitated by diversion and is defined as "the transfer of drugs from lawful to unlawful use" (24). Most commonly, this occurs when family and friends share prescribed opioids with other family and friends. Opioids and other controlled drugs are also diverted from healthcare facilities. Statistics show that healthcare facility diversion has increased since 2015 (24)

Diversion affects patients, healthcare workers, healthcare facilities, and public health. Patients experience substandard care due to ineffective pain management and impaired healthcare workers. In addition, affected patients are at risk of infections from compromised syringes (24).

Healthcare employees who divert are at risk of overdose and death. If caught, they face criminal prosecution and malpractice suits. Healthcare facilities also bear the cost of diverted drugs via internal investigations, follow-up care for affected patients, regulatory fines for inadequate safeguards, and declining public trust (24).

Despite the enormous consequences of drug diversion, healthcare facilities have implemented few processes to detect and deter the diversion of controlled substances (24).

Patient Teachings and Considerations

Opioids have significant side effects and carry a risk of addiction and overdose. Nurse practitioners can decrease the risks of misuse and addiction by educating patients on appropriate disposal, safe storage, and potential signs of addiction. Taking additional time to provide teaching nurse practitioners can promote patient safety, informed decision-making, and responsible opioid use.

Safe Storage and Disposal:

• Teach patients to store opioids securely, out of reach of children, pets, visitors, and non-caregiver family members, to prevent accidental ingestion or misuse (13). Only the caregiver, if applicable, or the patient should have access to pain medications.
• Instruct patients on proper disposal methods, such as using drug take-back programs or mixing opioids with undesirable substances (e.g., coffee grounds) before throwing them away (11) (13).

Medication Adherence:

• Emphasize the importance of taking opioids as prescribed, at the correct dose and frequency, to achieve optimal pain relief.
• Encourage patients to notify their healthcare provider if they experience inadequate pain control or side effects (35).

Potential Side Effects:

• Educate patients about common side effects of opioids, including constipation, nausea, sedation, and respiratory depression.
• Discuss strategies to manage side effects, such as maintaining adequate hydration, consuming a fiber-rich diet, and using over-the-counter laxatives as needed (11).

Risk of Dependence and Addiction:

• Explain the potential for opioid dependence and addiction, especially with long-term use or a history of substance abuse.
• Encourage patients to promptly report signs of opioid misuse, such as craving, loss of control, or continued use despite negative consequences (51).

Avoiding Alcohol and Other Central Nervous System Depressants:

• Instruct patients to avoid consuming alcohol or other medications that can enhance the sedative effects of opioids, increasing the risk of respiratory depression.
• Advise patients to contact the Nurse Practitioner before starting new medications, including over-the-counter drugs or herbal supplements (2).

Driving and Operating Machinery:

• Inform patients about the potential impairment caused by opioids, including reduced alertness, reaction time, and coordination.
• Advise patients to avoid driving or operating heavy machinery while taking opioids until they know how the medication affects them (14).

Case Study

You take some extra time with Mary to educate her on the taper dose of Vicodin, the potential for harm, and the risk of opioids, especially when used concomitantly with Gabapentin. You let Mary know it is unsafe to use alcohol, not only with Vicodin but also with Gabapentin. You let Mary know that Vicodin has a risk of dependency and misuse and, therefore, she will be monitored carefully. You also educate that Mary should store the Vicodin away from visibility by anyone but herself since she can self-administer her medication. You let Mary know that Vicodin can cause constipation and that she should increase her water intake and take a stool softener.

You ask Mary to call you if her pain is not adequately relieved or if her medications run out before the three days.  

You let Mary know that if she does stop taking the Vicodin before she has completed all the medication, she should dispose of it by mixing the pills with liquid and coffee grounds to make them unpalatable to animals and others.

Mary complied with your education, completed her course of Vicodin, and was scheduled for surgery. Mary's social worker helped her communicate with her new employer and delayed her start date until after her recovery.

During her recovery, Mary received physical therapy and a short course of pain medication managed by her orthopedist.

Mary returned to the clinic for a follow-up visit after completing her therapy and before starting work. Mary's pain level in her knee is 3/10, and she already feels like she can walk further than pre-surgery. Gabapentin has continued to help Mary's neuropathic pain in her back, and she reports 2/10. Mary looks forward to beginning her new job and is optimistic about the future.

Conclusion

Pain management is the leading cause of primary care appointments and chronic pain is the leading cause of disability. Yet, prescribing opioids for primary care patients is also a factor in drug misuse and the opioid epidemic. Nurse practitioners are challenged to appropriately treat pain and effectively control diversion, addiction, and death from overdose.

It is imperative that nurse practitioners use evidence-based practices to assess, appropriately intervene, and educate about the benefits and potential harm caused by treatment with opioids. Nurse practitioners must stay up to date with the current federal regulations regarding PDMPs, clinical prescribing guidelines, and emerging treatments for pain and opioid abuse disorders.

Tirzepatide for Type 2 Diabetes and Weight Management

Introduction   

The emergence of the drug tirzepatide is becoming more popular and widespread and is being utilized among those with diabetes and also those who desire to lose weight. It is one of the newest diabetic drugs given by injection that also triggers dramatic weight loss in those who use the injections.

The U.S. Food and Drug Administration (FDA) approved tirzepatide in 2022 for individuals with diabetes, particularly Type 2 Diabetes. The FDA officials have not approved tirzepatide yet for weight loss, but they are currently tracking the medication and may have a recommendation for its approval by the end of this year. Clinical trials have shown that individuals with an elevated body mass index (BMI) and who did not have diabetes lost a considerable amount of weight when they received tirzepatide (1).

Advanced Practice Registered Nurses (APRNs) need to understand how to safely prescribe tirzepatide and the reasoning as to why it causes weight loss for specific individuals.

Drug Classification

Tirzepatide is part of a class of medications called glucose-dependent insulin tropic polypeptide (GIP) receptor and glucagon-like peptide-1 (GLP-1) receptor agonists. It comprises a 39 amino acid linear synthetic peptide conjugate to selective receptor agonists in preclinical and clinical trials.

Tirzepatide is used for treating Type II diabetes in adults as an adjunct to diet and exercise. It is also used for weight loss in some individuals and has gained increased attention as a new therapeutic agent for glycemic and weight control.

Social media has had a significant influence and increased the desire to use tirzepatide, and while individual results vary, the weight loss in adults ranged from 12 – 25 pounds.

Online pharmacies, diet clinics, and medical spas are implementing thousands of ads on social media to capitalize on a surge of interest in the drug.

Indications of Usage

The use of tirzepatide is being used for both Type II diabetes and weight control in certain patients. It has been a game changer for people living with Type II diabetes. The drug’s primary use is as an adjunct to diet and exercise to improve glycemic control in adults with diabetes.

The drug has also proven beneficial for weight loss in patients experiencing obesity, and those who are taking the highest dosage have shared a body weight reduction of 15.7% (2). Tirzepatide is an injectable prescription medication used together with diet and exercise, and it is not yet known if it can be used safely with patients who have had pancreatitis.

It is important to remember that it is not to be used for patients with Type I diabetes, but it is safe for Type II diabetic patients. Also, the safety of tirzepatide has yet to be discovered for children and those under 18; therefore, the medication should not be used for this age group.

In studies conducted with or without diabetic medicines, 75% – 90% of patients taking tirzepatide reached an overall A1C of less than 7% with an average starting A1C of 7.9 – 8.6% across the following dosages – 5mg, 10mg, and 15mg. The study results were measured at weeks 40 and 52 (3).

Use of Tirzepatide with Diabetic Patients

Tirzepatide can be used for patients with Type II diabetes in combination with a diabetic-friendly diet and exercise. The drug works by lowering the patient’s overall blood sugar and also improves the A1C results of patients over some time. The injection has been approved by the FDA to treat Type II diabetes and is administered once weekly (4).

It is considered the first in a new class of medications – a dual glucose-dependent insulin tropic polypeptide (GIP) and glucagon-like-peptide-1 (GLP-1) receptor antagonist. The mechanism of how it works mimics two gut hormones (GIP and GLP-1). These hormones are essential in how patients digest food and regulate blood glucose after meals. The hormones also play a role in making individuals feel fuller and curb specific food cravings.

The provider can prescribe tirzepatide before attempting other diabetic medications if a patient has a BMI of 30 or greater or 27 or greater with weight-related conditions and if the drug is combined with a personalized weight loss plan that addresses physical activity, nutrition, and lifestyle changes.

However, due to the cost and some insurance companies not covering the injection unless the patient has both diabetes and obesity, the provider must carefully consider prescribing this medication.

Case Study

The patient states this ‘miracle drug’ is worth paying for out of pocket!

Jeff Capron, a 53-year-old Boonville, New York, web developer, started taking tirzepatide in December 2022. His friend had reported good results with the medication, so Jeff looked into the research studies behind it and then spoke with his primary physician.

The physician said, “Yeah, let’s give it a shot,” even though he did not have much experience with it. The physician did not have an opinion one way or the other than looking at the data set and seeing no reason why they could not try it.

Jeff’s hemoglobin A1C went from 10.1% to 6% in 3 months, which was very promising. “I never had that kind of experience with any medication for diabetes.” There is a range in how much A1C reduction people experience with tirzepatide, but many people taking it can get their A1C under 7% — an ideal goal for people with Type 2 diabetes.

Jeff experienced constipation and a little trouble sleeping early, but both issues disappeared quickly. He says, “I wake up in the morning, and my fasting blood sugars are normal.”

The medication took effect, he says, within 12 hours. He compared the feeling to having a gastric bypass.

“You cannot overeat food. As soon as you overeat, you almost feel ill.” While it generally takes a few months to notice effects like A1C reduction and significant weight loss, side effects such as lower appetite may be felt immediately.

Weight loss was not his primary goal, but he lost about 35 pounds on the medication in the first five months. He also lost his sweet tooth. “I can maybe count three sweet things I have eaten since December.”

Jeff found that his appetite slowly recovered days after taking tirzepatide. “You take the shot every Sunday, and by Saturday, you start to get a lot of appetite,” he says. “It does not seem to affect your weight. If I eat a little bit more on Saturday night, on Sunday, the scale will not move one way or the other.”

Jeff is allergic to hornets, so he already carries an auto-injector. He was not worried about using another drug delivered through a needle. “It’s just a push button,” he says. It also helped that his wife is a nurse. “So, I had her with me the first time to ensure I was doing it right. I didn’t even feel it.”

When Jeff was first prescribed tirzepatide, his insurance covered it. The company has since removed that benefit. He has filed an appeal but pays about $1,000 monthly out of pocket for his weekly injections. He plans to keep paying as long as necessary.

He considers the financial burden well worth it. “I have never had a medication that worked as well before for chronic conditions,” Jeff says. “I’ve been blown away by it. For me, it’s a miracle drug. It got rid of my diabetes” (4).

Use of Tirzepatide for Weight Loss Management

As mentioned, this medication is indicated for patients with a BMI of >30 or a BMI of >27 with qualifying comorbidities. Obesity can become a chronic lifetime disease, and for conditions such as these, the patient needs to implement therapy for the lifetime of the disease.

In a study conducted for tirzepatide, there was a dramatic increase in effectiveness compared to traditional nonsurgical interventions such as diet, exercise, and lifestyle changes. However, it has been noted that taking tirzepatide on an ongoing basis is recommended and necessary to maintain any weight loss achieved from the medication.

If a patient stops taking the drug, likely, it will no longer work (5).

Public health officials have expressed concerns about using the drug long-term. Still, data is currently lacking regarding long-term effectiveness, treatment duration, and maintaining weight reduction once the therapy is discontinued.

A recent trial consisted of 783 participants with a BMI greater than 30, and these participants agreed to take either a 10mg or 15mg dose of tirzepatide over 36 weeks. The injection is given once weekly, so this would equal a total of 36 injections.

By the end of 36 weeks, participants lost more than 21% of their body weight. After 36 weeks, participants continued on tirzepatide or received placebo treatment for the following year. The patients needed to be made aware of which treatment they were receiving.

Those still taking tirzepatide injections weekly after 88 weeks lost an additional 7% of their body weight, and those taking the placebo regained 15% at the end of 88 weeks (5).

Common Side Effects and Contraindications

Side Effects

Patients vary immensely with different experiences and side effects related to tirzepatide; however, the following are the most common side effects experienced by those taking the medication:

• Nausea
• Decreased appetite
• Vomiting
• Diarrhea
• Indigestion
• Constipation
• Stomach Pain

Tirzepatide usually does not cause fatigue, leaving one feeling weak, tired, and low energy. However, fatigue can be a common side effect of Type II diabetes.

It is important to note that most individuals who experience nausea, vomiting, and diarrhea episodes do so while the dosage increases, and typically, the symptoms decrease over time. G.I. effects were more prominent in those taking tirzepatide than those taking the placebo. The individuals not in the placebo group were more likely to stop treatment due to the unpleasant side effects (3).

Contraindications

Tirzepatide may cause thyroid tumors, including thyroid cancer, and it is essential to watch for possible symptoms, such as swelling or a lump in the neck, hoarseness, shortness of breath, or trouble swallowing.

Tirzepatide should also not be prescribed to any patient with Type 1 Diabetes.

One of the main ways that tirzepatide works is by stimulating the release of insulin from the pancreas, and due to this fact, there have not been many studies and clinical trials that include those with Type I diabetes.

However, this is not to say that prescribers have never ordered tirzepatide for those with Type I diabetes. Still, it is essential to note that if prescribed, it would be in addition to traditional insulin therapy.

• Personal or family history of a type of thyroid cancer known as medullary thyroid carcinoma (MTC).
• Any history of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
• Patients who are allergic to the actual medication or any of its ingredients.
• Younger than 18 years of age

Safe Prescribing Practices, Guidelines, and Considerations for Providers

Safe Prescribing Practices

As with all prescribed medications, safe standards of care must be implemented and followed to ensure patient safety is maintained. The same applies to providers considering prescribing tirzepatide, and specific criteria must be met beforehand. The following information discusses guidelines involving exclusion and inclusion criteria for providers to prescribe tirzepatide (6) accurately.

Guidelines

Exclusion Criteria – If present, the following indicates that the patient should not receive tirzepatide:

• Diagnosis of Type I diabetes
• Personal or family history of medullary thyroid carcinoma or with Multiple Endocrine Neoplasia syndrome type 2
• Severe gastrointestinal dysmotility
• History of pancreatitis
• Pregnancy
• Proliferative Diabetic Retinopathy (PDR), severe Nonproliferative Diabetic Retinopathy (NDR), clinically significant myalgic encephalomyelitis (M.E.), or diabetic macular edema (DME) unless the risks/benefits have been discussed with the patient and are documented in the patient's health record along with monitoring plans and follow-up with an eye specialist who is informed at the time of initiation.

Inclusion Criteria – All of the following must be met for tirzepatide to be prescribed:

• Diagnosis of Type II diabetes
• A BMI of 25 or greater
• Inadequate glycemic control on at least 1mg of semaglutide injection plus two or more glucose-lowering drugs
• Change needed to achieve goal A1C is less than 1%.
• Goal A1C should be based on those recommended in the Diabetic Guidelines.
• Adherence to current diabetic medications as evidenced by a review of the prescription refill history during the six months.

Additional Inclusion Criteria – All of the following must be met for tirzepatide to be prescribed:

• Patients with atherosclerotic cardiovascular disease or chronic kidney disease
• Patients of childbearing potential who are using oral contraceptives

Inclusion Criteria for Weight Loss

• BMI of >30 or >27 with patient weight conditions.

Considerations for Providers

There are specific considerations that prescribers must be aware of when contemplating if a patient should receive the medication tirzepatide. The following is imperative and must be considered each time the medication is prescribed to a patient:

• Clinical Indications – indicated for treating adults with insufficiently controlled diabetes mellitus as an add-on therapy to diet and exercise; as monotherapy when metformin is considered inappropriate due to contraindications or intolerance; and other medicinal products for treating Type II diabetes.
• Monitoring of medication – routine monitoring of serum calcitonin or thyroid ultrasound is of uncertain value but is recommended for early detection of Medullary Thyroid Cancer (MTC).
• Cost – the average price for tirzepatide ranges from $1,071-$1,351 without any coupons or insurance. Savings Card – manufacturer provided; patients can pay as little as $25 monthly for up to 12 injections. Savings Card – manufacturer provided; patients can pay as little as $25 monthly for up to 12 injections.
• Benefits and Risks – One must evaluate the effectiveness of diabetes and the weight loss experienced. Some of the risks must be evaluated, such as increased cost of medication, unpleasant gastrointestinal side effects, poor insurance coverage, and drug shortages. The FDA has warned that the medicine can cause thyroid C-cell tumors in rats, and it is not sure whether tirzepatide causes similar tumors.

How long does it take for tirzepatide to begin working?

Tirzepatide will start to lower one's blood sugar levels immediately, but it can take 8 to 12 weeks to reach one's target A1C goal.

Compared to other diabetic treatments, studies have shown that it can take eight weeks to reach an A1C target of less than or equal to 7% and 12 weeks to get an A1C of less than or equal to 6.5%. Significant weight loss can occur as early as 28 weeks.

Safe Administration

It is essential to follow the correct steps for safe administration of tirzepatide as listed below:

• The recommended starting dosage is 2.5mg, injected subcutaneously once weekly. The 2.5mg dosage is for treatment initiation and not for glycemic control.
• After four weeks, increase the dosage to 5mg, injected subcutaneously once weekly.
• If additional glycemic control is needed, increase the dosage in 2.5mg increments after at least four weeks on the current dose.
• The maximum dosage is 15mg, injected subcutaneously once weekly.
• If a dose is missed, instruct patients to administer it as soon as possible, within four days (96 hours) after the missed dose. If more than four days have passed, skip the missed dose, and administer the next dose on the regularly scheduled day. In each case, patients can then resume their regular once-weekly dosing schedule.
• The day of weekly Administration can be changed, if necessary, as long as the time between the two doses is at least three days (72 hours).
• Before initiation, train patients and caregivers on proper injection techniques.
• Instruct patients using the single-dose vial to use a syringe appropriate for dose administration (e.g., a 1ml syringe capable of measuring a 0.5 mL dose).
• Administer the medication once weekly, any time of day.
• Inject the medication subcutaneously in the abdomen, thigh, or upper arm.
• Rotate injection sites with each dose.
• Inspect the medication visually before use. It should appear clear and colorless to slightly yellow. Do not use the medicine if particulate matter or discoloration is seen.
• When using the medication with insulin, administer it as separate injections and never mix. It is acceptable to inject tirzepatide and insulin in the same body region, but the injections should not be adjacent.

Does the tirzepatide injection hurt when administered?

Pain from the injection site has not been reported as a common side effect, but it may occur.

Due to the injection being given subcutaneously, slight pain or discomfort can occur.

Alternatives to Tirzepatide for Weight Loss Management

In some instances, patients need to be aware of alternatives to tirzepatide in case they cannot take the actual injection for whatever reason. In cases such as these, there are alternative supplements that can be purchased over the counter, and they include the following (7):

• PhenQ – top OTC choice – comprehensive weight loss solution that targets specific body regions, facilitates prompt fat loss, and expedites the weight loss journey.
• PhenGold – the most potent OTC weight loss alternative – one of the top weight loss supplements that boost metabolism, making one less hungry, less tired, and an overall improved feeling.
• Capsiplex BURN – the best choice for men – helps to burn fat faster and keep blood sugar levels in check. It helps to keep one's muscles, curbs hunger, gives one more energy, and torches stubborn fats.
• Trimtone – the best choice for women – helps women to lose weight, eat less, increase metabolism, burn extra calories, and boost energy.
• Prime Shred – best fat burner for men – boosts metabolism, keeps muscles intact, increases energy, and helps maintain focus.

The advanced practicing nurse or prescriber needs to inform patients about alternative options such as these in an effort for individuals to understand that other choices are available and can be used. Many individuals need to be more knowledgeable about alternatives besides tirzepatide due to the extra hype from social media sources that promote advertisements related to tirzepatide only but do not mention the other options.

Why does social media influence and encourage patients to take tirzepatide?

Social media trends can be helpful but can also become harmful by setting unrealistic expectations and promoting a diet culture mentality. They can create an unhealthy obsession with "clean" eating, especially in the younger populations.

Due to this, many individuals take the medication despite any occurrence or history of Type II diabetes, and the drug can ultimately become misused.

It has been noted that there is an influx of patients requesting this medication for weight loss instead of the intended purpose, which is to help control Type II diabetes.

Tirzepatide represents one of the most recent non-medical treatments aimed at managing the symptoms of Type II diabetes. While it is not indicated for weight management, diabetic patients who receive it frequently report a significant reduction in body weight.

 Empirical evidence suggests the efficacy of tirzepatide in weight management, and certain physicians currently endorse the Administration of the medication as a therapeutic and effective means to overcome obesity.

What are some severe side effects of tirzepatide that can impact patient safety?

The Administration of tirzepatide can benefit many individuals, but some severe side effects must be mentioned.

These include thyroid tumors, thyroid cancer, pancreatitis, hypoglycemia, serious allergic reactions, kidney issues, severe stomach problems, vision changes, and gallbladder issues. All these side effects must be taken seriously and reported, as they can lead to life-threatening

Conclusion

Medications like tirzepatide are game changers for those patients with type 2 diabetes that have failed other medications. Unfortunately, several companies seek to profit from its weight-loss benefits through aggressive marketing campaigns that limit the available supply and increase the costs for those who need it. As healthcare providers, we need to use sound clinical judgment and follow the exclusion/inclusion criteria and other guidelines before prescribing this medication, so we do not unintentionally cause harm while looking to appease our patients who request this.

Semaglutide and Type 2 Diabetes

Introduction   

In 2017, the FDA approved the semaglutide injectable (Ozempic) for treating type 2 diabetes. The drug has experienced widespread acceptance due to its positive effects on weight loss and lowering of chronic health risks. The drug has risen in popularity over the past few years, as many well-known actors/actresses/songwriters, and more came forward, publicly sharing their weight loss journey.

This rise in popularity has also resulted in significant shortages of this medication, negatively impacting the lives of the diabetic community, local pharmacies, and healthcare providers. The goal of this continuing education course is to educate and empower the healthcare provider in all aspects of this drug regimen: clinical indications, patient education, cost options, and benefit/risk analysis.

Diabetes Overview

Diabetes is a chronic medical condition. Despite advances in diet, medications, and monitoring devices, diabetes diagnoses continue to grow at staggering rates. The Institute for Health Metrics and Evaluation (IHME) reports that over 529 million people worldwide are currently living with diabetes, and that number is expected to grow to 1.3 billion in only 30 years. While the risk factors for diabetes are vast in number (poor diet, inadequate activity, obesity, sedentary lifestyles, daily stressors, and more), the sad reality is that this chronic medical condition will most likely linger on for generations to come despite our efforts to contain this health epidemic (1).

According to the latest research on diabetes, there are over 37 million people in the United States alone with diabetes as of 2022. Statistically, approximately 28 million of them have a confirmed diagnosis, while another estimated 8 million are experiencing symptoms, without an official diagnosis. Diabetes currently ranks as the 7^th leading cause of death in the United States (2).

Types of Diabetes

In basic terms, diabetes is an impairment in one’s ability to either adequately produce or utilize insulin, which results in elevated levels of circulating glucose. Chronically elevated glucose levels affect blood vessels at every level, causing chronic inflammation and raising the risk of heart disease, stroke, blindness, and atraumatic amputations.

There are three main types of diabetes:

Type 1 diabetes is thought to be an autoimmune disease. Approximately 5-10 percent of people with diabetes are diagnosed with type 1 diabetes. The diagnosis usually occurs in early childhood, and results in a lifetime use of insulin to regulate blood glucose levels.

Type 2 diabetes is thought to be related to dietary and lifestyle choices. It accounts for nearly 90-95 percent of diabetes diagnoses. Usually occurring later in life (adult-elderly population), it is believed to be related to factors such as diet, activity, weight gain, and related factors. Type 2 diabetes is usually controlled by diet and exercise, in addition to oral medications, although injectable insulin may be included in the treatment plan.

Gestational diabetes refers to elevated glucose levels occurring during pregnancy for patients who are not diabetic at the onset of pregnancy. This version of diabetes usually resolves itself post-partum, although a woman may develop type 2 diabetes later in life, unrelated to pregnancy.

Type 2 diabetes in children: no longer a “later in life diagnosis”

Children are now being diagnosed with type 2 diabetes at an alarming rate. Despite widespread education and an increased awareness of diabetes, our up-and-coming generation is unhealthier than ever. Many families lack access to healthy food for their families, due to both general socioeconomic challenges and an increased rate of food insecurity. (19)

The CDC recommends care providers have resources for diabetic patients and their families, such as food and nutrition programs, budget-friendly diabetes meal plans, how to save money on diabetes care, and coping strategies for diabetes. (19)

Diabetes Signs and Symptoms, Diagnostic Testing

There are various ways to test for diabetes. The fasting blood sugar (FBS)/ fasting glucose level is a simple way to test for diabetes.

The normal fasting glucose level is below 100mg/dl. The fasting glucose result of 100-125mg/dl indicates prediabetes and results above 126mg/dl indicate diabetes.

The hemoglobin A1C blood test is another test used to confirm the diagnosis of diabetes. The patient does not need to be fasting for this test; thus, it is easier to order this test regardless of the time of day. This blood test reflects the average glucose level over the period of 2-3 months.

The normal A1C level is below 5.7%. Test results between 5.7%- 6.4% indicate prediabetes. Test results above 6.5% indicate diabetes.

A random glucose reading above 200mg/dl, done at any time of day, indicates diabetes.

The diagnosis of diabetes is by blood tests, and for improved accuracy, should be based on two separate readings, done (at least) a day apart. In the case of fasting and random blood tests, dietary intake (large amounts of carbohydrates in a single meal) may adversely affect test results. This is not the case when using A1C testing for a confirmation diagnosis, as the results are the average of a 2–3-month span.

Target blood levels for a person with diabetes (3).

Target blood glucose levels for people with diabetes are as follows:

• Fasting glucose 80-130mg/dl.
• Postprandial blood glucose level- less than 180mg/dl
• A1C level 7-8%.

These target ranges are general guidelines. Patient-specific ranges will be dependent on a variety of factors, including preexisting comorbidities, overall health status, age, and activity levels.

The hallmark signs/symptoms of diabetes

1. Polyuria- increased urination
2. Polydipsia- increased thirst
3. Polyphagia-increased hunger/appetite

The truth is, as healthcare providers, you will have patients who have no hallmark signs and symptoms of diabetes; the diagnosis will be found during annual preventive examinations often unrelated to any chronic disease. For this reason, many insurance companies now cover numerous preventive screenings, including diabetes screenings, as part of their wellness and prevention initiatives. These tests are often approved based on a patient's age, or preexisting conditions, rather than outright signs and symptoms.

Lifestyle Interventions and the Diabetes Prevention Program

The initial diagnosis of diabetes can be managed in a variety of ways, depending on the severity of the illness at the time of diagnosis. Lifestyle interventions (behavior modification education) are of utmost importance in the care and management of people with diabetes. Research over the past few decades has consistently shown that such interventions have immense positive effects on the successful long-term management of diabetes.

The official Diabetes Prevention Program was created in 2010 (4) and confirmed the effects of lifestyle interventions in the management of diabetes:  Lifestyle interventions decreased the incidence of type 2 diabetes by 58% compared with 31% in the metformin-treated group. Thus, these findings now serve as the blueprint, if you will, for all-inclusive, patient-specific disease management guidelines. These lifestyle interventions will be discussed in detail later in the program.

Additional Resources on Diabetes Prevention

• Detailed History of the Diabetes Prevention Program
• Detailed on the National DPP Lifestyle Change Program

Semaglutide

Semaglutide is an injectable drug used in the treatment of type 2 diabetes. It was approved by the FDA in May of 2017.

It is a once-a-week injectable and belongs to the drug class known as glucagon-like peptide-1 receptor agonists (GLP-1RAs) (5). It has been referred to as a “miracle weight loss drug” among those who are living with obesity, despite frequent side effects, unusually high out-of-pocket costs, drug shortages, and weight regain when attempting to stop using the medication.

GLP-1 receptor agonist: Hormone Review

GLP-1 RAs are a class of medications used to treat Type 2 diabetes, and in some cases, obesity treatment. They are also known as GLP-1 receptor agonists, incretin mimetics, and GLP-1 analogs.

Ghrelin and Leptin (6)

Ghrelin and Leptin are two hormones that greatly influence appetite and the sensation of fullness. Often referred to as the “hunger hormone.” Ghrelin is responsible for many functions, including playing a key role in metabolism through glucose and insulin regulation.

Ghrelin, produced in your stomach, signals your brain when you are hungry, and results in increased food intake.

Leptin, conversely, is produced in your fat cells, and signals to the brain when you have eaten enough (by a decrease in appetite).

Glucagon-like peptide-1 receptors

Known as GLP1 receptors, Glucagon-like peptide-1 receptor proteins are located in the beta cells of the pancreas as well as in the neurons in the brain. GLP-1 receptors are involved in the regulation of blood glucose levels and affect the secretion of insulin. These cells encourage the release of insulin from the pancreas, increase the volume of beta cells, and reduce the release of glucagon. In doing so, they increase the feeling of fullness during and between meals, suppressing the appetite and slowing gastric emptying.