According to the Centers for Disease Control and Prevention, prescribers should evaluate risk factors related to opioid use prior to initiation of opioid medication. The practice problem in this DNP project was that providers failed to consistently assess patients with complaints of pain for risk of opioid misuse and/or abuse prior to initiating opioid medication. An opioid risk-assessment screening tool (ORAST) has the potential to identify patients at high risk for opioid misuse and/or abuse. The purpose of this Doctor of Nursing Practice project was to identify and introduce an ORAST and then develop a policy to guide providers in its use in an ambulatory care clinic. Rosswurm and Larrabee's model for evidence-based practice served as the framework that helped guide project development. Evidence in the literature review supported The Opioid Risk Tool (ORT) as the most appropriate tool for the clinic. An 11-member project team voted unanimously for the ORT and to develop a policy to guide the use of the tool in the clinic. The ORT and its policy were evaluated by the team using the AGREE II Instrument. The team agreed that the ORT and its policy should be implemented into their practice setting (64% strongly agreed and 36% moderately agreed). A summative evaluation supported the Doctor of Nursing Practice student leadership of the project. Use of an ORAST has the potential to create positive social change by reducing the number of prescribed opioid by assisting providers in determining a patient's plan of care based on the patient's level of risk for prescription opioid misuse and/or abuse. Patient outcomes may be improved through reduction in opioid misuse and/or abuse.

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This document only includes an excerpt of the corresponding thesis or dissertation. To request a digital scan of the full text, please contact the Ruth Lilly Medical Library's Interlibrary Loan Department (rlmlill@iu.edu).

This document only includes an excerpt of the corresponding thesis or dissertation. To request a digital scan of the full text, please contact the Ruth Lilly Medical Library's Interlibrary Loan Department (rlmlill@iu.edu).

Yes

The current opioid epidemic is devastating our communities. The American Medical Association’s Task Force on opioid addiction has identified stigma as a primary target of intervention for mitigating this epidemic. Stigma is a mark of disgrace or being objectionable. Experiences of stigma and resulting shame serve only to fuel health inequities experienced by people with opioid addiction. Emergency Medical Services (EMS) have an important role to play in mitigating this epidemic as entry-level providers in the healthcare system. The quality of that patient-provider encounter had the potential to shift intrinsic motivation to seek and maintain addiction treatment. Patient-centered care is identified as supporting therapeutic communication and is well-suited for rural EMS operations in Maine. The purpose of this research was to examine predictors of intention to provide patient-centered care to people experiencing opioid addiction and overdose (OAO) among EMS providers in the state of Maine. A cross-sectional online survey of currently licensed EMS providers offered a direct measure of intention to give patient-centered care to people experiencing OAO. Multiple regression analysis identified four predictor variables for intention: job satisfaction, exploring patient perspective, sharing information and power, and dealing with communicative challenges. The fitted model resulted in a significant R2 = .529, (F (4, 734) = 226.381, p < .001) exceeding the critical F statistic (F (4,739) = 2.384, p = .05), thus confirming the predictive value of the coefficients. Results suggested that EMS providers at all license levels will benefit from interventions that expand their knowledge of the medical definition of addiction and patient-centered care. EMS providers will also benefit from adopting approaches that support exploring the patient perspective and sharing information and power such as Motivational Interviewing and human performance strategies to develop awareness of socially conditioned biases that moderate provider attitudes. These evidence-based interventions could elevate the standard of care provided by EMS and reduce experiences of stigma in the patient-provider encounter. Reductions in stigma increase self-worth and prime motivation to seek and maintain treatment, thereby closing the treatment gap that exists for those experiencing opioid addiction in the state of Maine.

Suicide attempts and opioid dependence are important clinical issues, as both are associated with a high degree of psychiatric morbidity and elevated risk of mortality. Research has identified a number of risk factors for suicide attempts among the general population, and to a lesser extent, among heroin users. Due to a lack of case-control studies, however, it is still not known to what extent opioid dependence per se is a risk factor for suicide attempts. This thesis comprised the first study to directly examine whether opioid dependence is a unique risk factor of suicide attempts. This thesis examined suicide attempts, associated risk factors, and related comorbidity among an opioid-dependent case group and a non-opioid-dependent control group. A structured interview was used to collect data from 726 opioid-dependent cases and 399 non-opioid-dependent controls. This thesis identified a number of important findings. Firstly, although opioid-dependent individuals were more likely to report lifetime suicide attempts compared to controls, the risk factors were largely the same for both groups. It appeared that opioid-dependent individuals were characterised by a higher likelihood of the same risk factors for suicide attempts, rather than having different risks. Cases appeared to be at increased risk of suicide attempts because of increased levels of multiple risk factors. Secondly, borderline personality disorder (BPD) and impulsivity were identified as important risk markers for suicidal behaviour, especially among opioid-dependent individuals. The study concluded that the treatment of BPD should be prioritised among this group. Third, self-mutilation was identified as a clinically significant problem in its own right, however, when combined with a history of attempted suicide, the psychological dysfunction observed was found to be very high. Fourth, non-fatal opioid overdose and suicide attempts were found to be distinct behaviours. The risk factors for each were completely different. While drug-related risks were associated with non-fatal overdose, the risk markers for suicide attempts were related to the presence of psychological disorders. This thesis has highlighted important areas of concern for clinical interventions as well as for future research to explore. Considering this is the first study of its kind, future research should focus on its replication.

Graduation date: 1996

After two decades of liberal prescribing of opioids, there has been an increasing recognition of problems connected to the prolonged use of opioids for chronic pain. The aim of my thesis was to explore some consequences of long-term opioid treatment for chronic pain such as problematic opioid use, endocrine disorders, tolerance and genetic variations in pain and opioid response. Sixty patients with severe pain and problematic opioid use were treated with a structured methadone programme. Risk factors were musculoskeletal pain, psychiatric co-morbidity and previous addiction. Treatment resulted in good pain relief and improved quality of life, but function was impaired by side effects indicating endocrine dysregulation. The possibility of opioid-induced endocrine dysfunction was explored in the second paper, where 40 pain patients treated with strong opioids and 20 pain patients without treatment of strong opioids were investigated. The opioid-treated patients had significantly higher incidence of endocrine disturbance affecting gonadal and adrenal function and prolactin levels. The functionality of the μ-receptor after long-term treatment with morphine, saline and naloxone was explored in a cell-line expressing the μ-receptor. After one and four weeks of treatment the binding was tested with morphine, methadone, fentanyl and DAMGO and function measured by GTP γ-assay. The binding of DAMGO was significantly diminished after 4 weeks in cells treated with morphine compared with saline and naloxone. Genetic variation in three genes with functional impact on opioid response and pain sensitivity was investigated in 80 patients with chronic low-back pain and differential opioid sensitivity and in 56 healthy controls. The results indicated a higher incidence of opioid-related side effects and gender differences in patients with the minor allele of the ABCB1 gene, a correlation between increased opioid sensitivity and the major CACNA2D2 allele and a possible relationship between intrinsic protection against chronic pain and the minor allele of OPRM1.

Suicide attempts and opioid dependence are important clinical issues, as both are associated with a high degree of psychiatric morbidity and elevated risk of mortality. Research has identified a number of risk factors for suicide attempts among the general population, and to a lesser extent, among heroin users. Due to a lack of case-control studies, however, it is still not known to what extent opioid dependence per se is a risk factor for suicide attempts. This thesis comprised the first study to directly examine whether opioid dependence is a unique risk factor of suicide attempts. This thesis examined suicide attempts, associated risk factors, and related comorbidity among an opioid-dependent case group and a non-opioid-dependent control group. A structured interview was used to collect data from 726 opioid-dependent cases and 399 non-opioid-dependent controls. This thesis identified a number of important findings. Firstly, although opioid-dependent individuals were more likely to report lifetime suicide attempts compared to controls, the risk factors were largely the same for both groups. It appeared that opioid-dependent individuals were characterised by a higher likelihood of the same risk factors for suicide attempts, rather than having different risks. Cases appeared to be at increased risk of suicide attempts because of increased levels of multiple risk factors. Secondly, borderline personality disorder (BPD) and impulsivity were identified as important risk markers for suicidal behaviour, especially among opioid-dependent individuals. The study concluded that the treatment of BPD should be prioritised among this group. Third, self-mutilation was identified as a clinically significant problem in its own right, however, when combined with a history of attempted suicide, the psychological dysfunction observed was found to be very high. Fourth, non-fatal opioid overdose and suicide attempts were found to be distinct behaviours. The risk factors for each were completely different. While drug-related risks were associated with non-fatal overdose, the risk markers for suicide attempts were related to the presence of psychological disorders. This thesis has highlighted important areas of concern for clinical interventions as well as for future research to explore. Considering this is the first study of its kind, future research should focus on its replication.