On behalf of the 72,000 clinical nurse specialists in the country, the National Association of Clinical Nurse Specialists (NACNS) is pleased to provide comments on the on the CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016.
Clinical Nurse Specialists (CNSs) are one of the four advanced practice registered nurse roles (APRN). CNSs are licensed registered nurses who have graduate preparation (master’s or doctorate) in nursing as a clinical nurse specialist. They have unique and advanced level competencies that can meet the increased needs of improving quality and reducing costs in our healthcare system. They are leaders of change in health organizations, developers of evidence-based programs to prevent avoidable complications, coaches and direct care providers of those with chronic diseases to prevent hospital readmissions, facilitators of teams in acute care and other facilities to improve the quality and safety of care, including preventing hospital acquired infections and reducing length of stays. In addition, growing numbers of CNSs provide Medicare Part B services to beneficiaries and have prescriptive privileges in most states.
The NACNS is pleased that CDC has proposed guidelines that will improve the prescribing and management of patients with chronic pain, and specifically prescribing for primary care providers that are managing patients without active cancer treatment, palliative care, and end-of-life care. NACNS is pleased that time was given in this document to express the challenges of pain management, including the wide variety of pain experiences individuals have, which can lead to less than ideal pain treatment for some populations, including those with racial and ethnic minorities, women, the elderly, persons with cognitive impairment and those with cancer and approaching their end of life.
The guideline appropriately recognizes that it is challenging to estimate the number of individuals that could benefit from opioid pain management, and therefore we would like to highlight the importance of pursuing further research into the use of opioids for pain management both for short-term and longterm management of pain. Nurses, who daily care for patients experiencing pain – both acute and chronic – are important partners in this research.
NACNS would like to clarify the scope and audience of this guideline. The document states, “This guideline is intended for primary care providers (e.g., family physicians and internists) who are treating patients with chronic pain (i.e., pain lasting >3 months or past the time of normal tissue healing) in outpatient settings….” The use of the term primary care provider, because of the choices of examples that follow the term, imply that this guideline and by inference the prescribing of pain medication is solely in the domain of physicians. Prescriptive authority, including prescriptive authority for controlled substances, is within the scope of practice of many advanced practice registered nurses (APRNs). The APRN category includes: clinical nurse specialists, nurse practitioners, nurse midwives and certified nurse anesthetists. Based on a 2015 review of state laws, the CNS has the authority to prescribe drugs and durable medical equipment with the collaboration of a physician in a total to 39 states (76%).
It is also important to consider that APRN’s by virtue of their foundation in nursing and nursing science generally approach pain management from a holistic perspective and include considerations such as, response to medications, life style, support systems, the individual’s view of illness and wellness, and alternative pain relieving interventions in the care of their patients. For these guidelines to comprehensively meet the need of the management of patients that seek primary care services for their pain; your definition of primary care providers must more obviously include the full range of primary care providers in the guideline.
NACNS would like to highlight one topic that is mentioned in the guideline and encourage CDC and the other federal partners to further explore the provider and patient values and preferences related to opioids and medication risks, benefits, and use. With the important attention that the increased use and abuse of opioids has received in the media, it is very possible that providers and patients may develop attitudes that vilify the use of opioids or those patients that are therapeutically managed on opioids for chronic pain. It is important that provider and patient attitudes do not lead to a stigma that in the effort to right-size opioid use does not penalize patients that must rely on these medications in order to gain a degree of wellness.
Thank you for the opportunity to provide these comments for your careful consideration. If you have any questions or require additional information, please feel free to contact Melinda Mercer Ray, NACNS Executive Director, at 703-929-8995.
Peggy Barksdale, MSN, RN, OCNS-C, CNS-BC President