In less than 20 years, America’s opioid crisis has grown exponentially: As recently as 2017, the number of overdose deaths involving opioids was six times higher than it had been in 1999. Nowadays, on average, 130 Americans die every day from an opioid overdose.
Clinical solutions specialist Linda Robinson joined GetWellNetwork following nearly three decades in nursing at St. Elizabeth Healthcare in Kentucky. Having spent more than two-thirds of her career in the ER, she's seen the effects of the opioid epidemic up close and personal. We recently sat down with her to learn more about her experience as a nurse in one of the regions in the U.S. hit hardest by the opioid epidemic.
Below, Robinson shares her thoughts on a side of the crisis we don't often hear about, including the impact of opioids on workplace violence, the common disconnect for healthcare organizations trying to mitigate misuse and the influence this epidemic often has on staff burnout.
Q: What was your experience like as a nurse in the ER where you witnessed opioid misuse and its effects first-hand?
"Imagine this," she starts. "A young man runs into the emergency department lobby yelling, 'My friend’s not breathing, help!'
Nurses run outside to a car where we find a young adult male motionless in the backseat, not breathing, blue but with a faint pulse. His friend is reluctant to give any information except the man's name. With some coaxing, he admits that the patient may have done heroin.
Time is of the essence. After a struggle to get him out of the car and wheeled by stretcher into the hospital, we bag the patient with oxygen and treat with Narcan as quickly as possible. He awakens and we're all able to stop holding our breath. But he's irritated and wants to go. He refuses counseling and instead leaves with his friend.
Hours later that same day, the same young man returns by ambulance. This time, he's 'dead on arrival.' The same staff that resuscitated him earlier are still on duty and we are now faced with this tragedy. We must contact family and tell yet another parent about the death of their child from an opioid overdose. All that remains is an empty feeling of 'If only we could've done more…'.
Sadly, this kind of 'life-in-your-face moment' is all too common in emergency departments today. Across the U.S., families and communities are destroyed and front-line clinical staff are bereft.
The emergency department is an emotional roller coaster for nurses and physicians. Though we're highly trained to save lives, there's a feeling of powerlessness against this epidemic that's killing thousands every year. Handling the 'compassion fatigue' is exhausting and at times overwhelming."
An epidemic takes shape.
During her practice, Robinson saw opioid misuse grow in three stages over the years:
Healthcare providers started using pain as the fifth vital sign. This led to an increase in opioid administration and prescriptions.
Around this time, laws were passed to tighten the opioid prescription use and track dispensing which decreased the amounts of opioids accessible.
The unaddressed problem, however, was that little-to-no resources were added for patients who were already addicted to prescription opioids. Supply and demand ruled, causing the price of heroin to drop significantly and leading to a rapid increase in heroin sales and overdoses.
The year 2013 brought the rapid rise of overdose deaths related to illicitly manufactured synthetic opioids such as fentanyl alone or mixed with heroin.
Q: In your opinion, where is the disconnect for healthcare organizations when it comes to mitigating opioid misuse?
“Healthcare organizations, along with communities and legislators, have been working hard to close the disconnect with opioid misuse," says Robinson. "Community grassroots measures such as streamlining resources and driving community education in schools and libraries have proven very effective. This is a multi-dimensional problem and coming at it from all angles is pivotal."
“This is a multidimensional problem and coming at it from all angles is pivotal.”
Changing the culture of pain.
Robinson says that much of the struggle is in shifting the perception of pain. "CMS has now eliminated pain management questions from their satisfaction surveys, allowing hospitals to have a more realistic approach to pain management. Healthcare providers no longer feel pressure to prescribe opioids to boost patient satisfaction. The perception that a patient should be pain-free isn’t realistic or safe. The focus is now on healthy pain management practices.
Healthcare organizations and the medical community also have a responsibility to change the culture of pain perception and management. The use of non-opioid and non-drug management treatments for pain is crucial. Alternative methods of relief need to be actively promoted and part of patients’ care plans.
Patients and their families must be educated about pain, the dangers of opioid usage and alternative methods for pain relief. This should be a priority. Patients ‘don’t know what they don’t know,’ and it’s our responsibility as health professionals to involve them in their care.
Many emergency departments don’t have opioid screening processes or counselors present to speak with those who misuse opioids. These are ‘right-time-right-place interventions’ that again engage the patient to participate in their care. They also provide much-needed support and information about outpatient medical and community resources to assist in their recovery journey."
Translating “life in your face” experiences at the top.
"Nurses and physicians are experiencing the opioid epidemic on the frontlines," Robinson continues. "They face the 'life-in-your-face' moment I described earlier on a daily basis. Healthcare executive leadership needs to actively round on emergency department staff to gain real knowledge and insight into what they’re seeing and the toll that it can take. They should also be transparent with their support. It is only then that they can become fully aware of the magnitude of the opioid crisis and its effects on not only patients and their families but their staff as well."
Q: That's a perfect transition to our next question. We hear a lot about staffing ratio challenges and clinician burnout, do these things impact how opioid misuse is treated or managed? Or vice-versa, how does the epidemic impact staff burnout and/or satisfaction?
"Debriefings and huddles should occur immediately after tragic events in the emergency department," Robinson states. "Staff should have a forum in which to talk about their feelings, and executives should be regular attendees to these activities. They need to be aware of what their staff face on a daily basis. Reading about it and seeing the emotional effects are drastically different.
The opioid crisis is very challenging and can cause nurses to suffer compassion fatigue. Witnessing these traumas can cause secondary post-traumatic stress disorder (SPTSD). SPTSD can be seen with both compassion fatigue and burnout. The main symptoms are depression, flashbacks and difficulty in functioning.
I've talked to nurses who are afraid to return to work, tearful and sad — nurses who 'just don’t think they can do it anymore.' This is also a tragedy. We must advocate for our nurses as we do for our patients!"
Q: Talk about the influence opioid misuse has on workplace violence. What is the connection?
The connection is strong, she says. "Emergency departments are a microcosm of the community they serve. The opioid epidemic has brought an increase in violence to both the ER and hospitals. Patients’ increasing quest to obtain opioids and the legitimate denial of opiate prescriptions by providers places all healthcare workers at increased risk of workplace violence. In fact, nearly 75% of the 25,000 workplace assaults reported annually are in the healthcare industry. Research also shows that at least half of hospital violence stems from patients and/or family members who are intoxicated or on drugs. Hospitals once seen as safe havens are no longer safe.
I've dealt with workplace violence first hand. I’ve seen the effects of the violence on the faces of our patients, their loved ones and our own staff. I’ve talked to staff who were fearful about coming back to work. These are dedicated individuals who love what they do…delivering care. It is our responsibility to keep those seeking care, their loved ones and healthcare workers safe. A hospital should be a safe place for everyone in it.
We've seen a rise in violence in our hospitals over the past 10 years. It's spiked again in the last five years with the opioid crisis. Many of you reading this right now have likely been exposed to it. The sobering fact is that 80% of emergency medical workers experience physical violence at some point during their careers.
A nurse’s job is to take care of patients and their families and to provide a healing environment. This includes keeping our patients safe, but in order to do that, healthcare staff must feel safe as well. It's their right to have a safe environment in which to work. Again, it is vital to advocate for nurses. Even back in 1893, Florence Nightingale's intent was to allow nurses the autonomy of purpose to advocate for patients and for the nursing profession. Her intent is an old one but it still rings true today."
Q: In your opinion, what needs to be done to initiate change?
Robinson's thoughts are clear: "Effectively integrating prevention, treatment and recovery services is key to addressing opioid misuse. As I mentioned earlier, the healthcare community must take responsibility for improving patient and family education about prescription opioid use and misuse."
Filling the gaps in pain management.
"Communication gaps between providers and patients can have unintended consequences. Patients receiving long-term opioid therapy need to be educated on the risks, their options and opioid safety. Many are unaware of proper disposal options which in turn creates an opportunity for access: family, friends or children get their hands on medication that isn't stored or disposed of correctly and misuse it. We also need to better promote healthy pain management practices to counter the perception that painkillers should and will eliminate pain entirely. Finally, providing a support network of resources and information to guide patients and families toward recovery is critical," she says.
Learn how GetWellNetwork is supporting the healthcare community's efforts to combat the opioid epidemic in our upcoming webinar.
How can we better engage and support patients before they leave the hospital to make sure they don’t become a statistic in the opioid epidemic?
Join GetWellNetwork's Dr. Karen Drenkard, chief clinical & nursing officer for a discussion with Dean Robin Newhouse of Indiana University School of Nursing about her work in partnership with the state and major health care systems to reduce the number and impact of substance use disorders.
Dr. Drenkard will also introduce the Opioid Pathways Collection™ for GetWell Inpatient™ which provide critical education and resources designed to interrupt the prescription-addiction pathway and support patients and families struggling with opioid use disorder.