The role of nurse practitioner (NP) was first established within the United States by the mid-1960s in an effort to alleviate a shortage of primary care physicians in both urban and rural under-served populations. NP’s are advanced-practice registered nurses who generally work collaboratively with a physician to provide direct patient care, taking on many clinical duties traditionally performed by their physician counterpart. Since NP’s are qualified to diagnose, order diagnostic tests such as chemistry labs/imaging reports/other, and write prescriptions, if appropriately credentialed, they are especially well suited for the emerging field of pain management. Patients with chronic non-cancer pain require careful evaluation, potential opioid risk stratification for various medication therapies, appropriate monitoring, and ongoing risk assessment/follow-up. Pain management therefore is clearly a specialty environment that warrants provider collaboration and is well within the scope of an advanced practice NP. In the usual course of daily practice, all clinicians need some expertise in pain management. This of course is evident because pain is the most frequent reason for a visit to the primary care provider nationwide.
Although NPs have had the ability to write medication prescriptions since at least 1969, some controversy still exists, depending on the state of practice, especially with regard to opioid medications. Dealing with the complex issues surrounding the assessment and treatment of chronic pain requires specialized education and skills. When controlled substances are involved, prescribers must be familiar with the effects of these drugs and especially vigilant to assess the potential for abuse and addiction proactively. At the same time, the caregiver must remain sensitive to the needs and preferences of patients who are suffering from chronic cancer and non-cancer pain.
Many primary care physicians are reluctant to treat patients with opioids for long-term non-cancer pain due to a lack of knowledge and experience, the perceived risk of opioid abuse and fear of regulatory scrutiny. They may also be unwilling to turn this responsibility over to an NP with extensive pain management experience, especially if there is a collaborative care contract in place that might extend liability to the physician. Instead, internists and family physicians frequently refer patients with chronic pain to pain management specialists, if available. These specialty practices often rely on NP’s for ongoing medication management and in some cases to assist with interventional procedures. NPs with a strong foundation in pain education are ideally suited for the time-consuming job of medication management for long-term chronic cancer and non-cancer pain; NP’s can play a critical role in practices that focus on pain management.
Due to a renewed national focus on the abuse of opioid medications, NPs who prescribe them are often placed in a professionally vulnerable position. They must be on the lookout for individuals who visit multiple prescribers in order to obtain opioids for diversion or to feed their own addiction. Without extensive training, any clinician may fail to recognize the signs of drug abuse, diversion, and/or addiction in their patients. It is not uncommon for clinicians to face criminal charges or professional culpability if a patient overdoses on a pain medication(s). In fact, there is no data that suggests NP’s are any more or less vulnerable to these issues compared to their physician counterparts. President Obama and federal drug enforcement officials though the National Drug Control Strategy (2012), have called for increased substance-abuse education for prescribers. Intervention by a physician or NP can help mitigate prescription drug misuse or abuse among individuals that may be predisposed to an addictive disorder or that crave medication due to inadequately treated pain, sometimes termed “pseudo-addition”.
As the population increases and ages over the coming decades, demands for effective pain management is expected to grow. At the same time, the Association of American Medical Colleges reports that the overall shortage of physicians is expected to worsen. Greater numbers of NPs with experience in pain management will be needed to help serve the large patient loads of primary care physicians as well as pain specialists. Because the pain management field is relatively new, physicians, nurses, nurse practitioners, physician assistants, and pharmacists alike will likely seek education opportunities in the area of pain medicine. Monitoring patient responses to medication, setting appropriate boundaries and recognizing potential for drug diversion and abuse require special skills and knowledge that are best learned from health care professionals well-trained in this specialty. The demand for nursing programs that address these issues is already present and will continue to grow.
Palliative Care and acute pain management are also areas with unmet needs that often include NP’s in collaboration with other healthcare clinicians. For example, just last year a New York Hospital team of 9 clinical pharmacists and a single NP received statewide honors for their unique team approach to pain management. The acute care team handles over 600 physician consult requests yearly, resulting in twice as many patient visits. In this particular model, the team is run by a clinical pharmacist. #RebrandPharmacy
One thing is clear; it takes a team of healthcare providers to adequately and appropriately manage complex pain patients. This may include team members mentioned above in addition to behavior health clinicians and specialists in anesthesiology, neurology, and physical & rehabilitation medicine.
The first step for registered nurses who want a focused practice area in pain management is to earn a masters in nursing degree from schools like Georgetown University. Graduates of MSN programs are eligible to apply for NP certification from the American Nurses Credentialing Center or the American Association of Critical Care Nurses. A growing number of NPs who work in the pain management area are enhancing their professional reputation by becoming certified in pain management through the American Society for Pain Management Nursing.
Written by Guest Blogger, Erica Moss
Note from Dr. Fudin: As good fortune would have it, I was introduced to Ms. Erica Moss by a VERY close colleague. Ms. Moss jumped on an opportunity to write this guest blog. She is the Community Manager for the online midwifery program and others at Georgetown University. Outside of work, she enjoys dabbling in photography and connecting with new people.