Decreasing the Opioid Epidemic: Implications for Advanced Practice Registered Nurses
Bronson Bybee, BSN Student, Jonathan Plaskett, BSN Student
School of Nursing and Health Sciences, Westminster College, Salt Lake City, UT
Abstract
Background: The prescribing rates of opioid analgesics have significantly increased in recent years leading
to increased related adverse conditions (Kolodny et al., 2015, p. 559). This study’s intention is to determine
whether advanced practice registered nurses (APRN) and physicians (MD, DO) have different prescribing
practices and if those differences would be significant in regards to decreasing the U.S. opioid crisis.
Methods: A literature review of 11 articles discussing the opioid crisis and prescribing rates by provider type
was conducted to address the following questions: Is there a difference in opioid prescription rates between
APRNs and physicians? If so, what causes heterogeneity? What are the implications of methods utilized by
APRNs? Can these methods be utilized to decrease rates of prescription opioid use and subsequently lower
rates of opioid related adverse complications?
Results: There were significantly lower opioid prescribing rates in APRN independent practice states than in
states where APRNs cannot prescribe or have prescribing restrictions. Mid-level providers (MLP)(e.g. nurse
practitioner, physician assistant, etc.) were found to be half as likely to prescribe opioids for musculoskeletal
pain in the emergency department (ED) than their physician counterparts. It has been suggested that APRN
education and training may lead nurses to use alternative modalities for pain management before prescribing
opioids. This study found no evidence that APRN patients are undertreated or have lower patient satisfaction
scores, even when compared with physician care.
Conclusions: Prescribers are recommended to use caution when prescribing opioids and utilize alternative
pain management modalities when appropriate. When prescription opioids are favorable, it is recommended
that supplies are limited; specifically ED supplies should be limited to 3 days.
Problem Statement
It is well documented that the rising use of prescription opioids has significantly increased in the last two
decades (CDC, 2012). Since the late 1990’s, consumption of hydrocodone has more than doubled,
consumption of oxycodone has increased nearly 500%, and the rate of opioid-related overdose death has
nearly quadrupled (Kolodny et al., 2015, p. 559). Kochanek, Murphy, Xu, & Tejada-Vera (2016) reported that
opioid overdoses accounted for more than 20,000 deaths in 2015 according to the CDC, ranking it in the top
10 causes of death alongside other common killers such as Parkinson’s disease and pneumonitis. While
problems can arise when comparing data from different years, the magnitude of the problem and the rate at
which it is escalating is apparent and concerning. The increase of opioid prescription rates have lead to
increased rates of opioid-related hospitalization, readmission, addiction, overdose, and death. Methods to
decrease complications related to this problem should be searched out and addressed.
Clinical Questions
1. Are there a differences in opioid prescribing rates between APRNs and physicians? If so, what causes
heterogeneity?
2. What methods are utilized by APRNs when prescribing opioids?
3. Can these methods be utilized to decrease rates of prescription opioid use and subsequently lower rates of
opioid-related adverse complications?
Answering these questions will determine whether there are current prescribing practices easing the opioid
crisis and how these approaches can be more fully utilized.
Methods
This study, Decreasing the Opioid Epidemic: Implications for Advanced Practice Registered Nurses, was
designed using a search in PubMed, EBSCOhost, and ScienceDirect databases conducted in November 2017.
Articles containing the terms ‘opioid prescribing rates’, ‘opioid overdose’, ‘opioid prescribing by provider
type’, and ‘opioid prescribing nurse practitioners’ were searched for with a filter limiting the search to peer
reviewed articles published in the last 5 years. The abstracts of these articles were then assessed to determine
whether they contained information relating to complications of opioid use, opioid prescribing practices by
provider types, and/or methods to decrease opioid prescribing rates. 57 studies were reviewed to determine
applicability, and 11 relevant papers were identified. 3 articles were selected as main support.
Conclusion
The rising use of prescription opioids has lead to epidemic levels of increased opioid-related complications.
Consequently, opioid overdose death rates have reached the CDC’s top 10 causes of death.
States with independent APRNs have shown significantly lower opioid prescribing rates than states where
APRNs have prescribing restrictions. Emergency department physicians are twice as likely to prescribe
opioids for musculoskeletal pain than prescribing mid-level providers (e.g. nurse practitioner, physician
assistant, etc.). It has been suggested that this phenomenon may correspond with APRN training being more
holistic and wellness focused, proposing that nurses are more likely to incorporate nonopioid pharmacologic
and non-pharmacologic alternatives to treat pain. Additionally, many states require APRN controlled
substance education before granting authority to prescribe; which is not always required of physician-
prescribing counterparts. An anticipated concern may regard APRNs having lower levels of patient
satisfaction and their patients being undertreated. On the contrary, data supports that APRNs maintain high
levels of patient satisfaction, even when compared with physician care. This study confirms existing
differences in prescribing rates of physicians and APRNs; specifically lower opioid prescribing rates among
APRNs.
This research recommends prescribers use more caution when prescribing opioids for both acute and chronic
pain management, limit extended-release opioids, limit emergency department prescription supplies to 3 days,
and implement sufficient alternatives for pain management when appropriate. Further research is warranted to
confirm these preliminary conclusions.
Opioid prescriptions per 100 persons in states with independent and non-independent practice for APRNs
Schirle, L., & Mccabe, B. E. (2016). State variation in opioid and benzodiazepine prescriptions between independent and nonindependent
advanced practice registered nurse prescribing states. Nursing Outlook, 64(1), 86-93.
Nursing Implications
The nursing discipline comes from a background of patient advocates with a focus on care and cure rather
than being strictly disease oriented. Today, this background is reflected in the curriculum of the nursing
discipline. APRNs have a unique place in medicine as they have many roles and can be considered anything
from mid-level provider, to primary care provider, to specialist.
This study suggests that, due to curriculum differences between APRNs and physicians, some states mandate
APRNs take controlled substance education courses prior to administering medications. This may be a
contributing factor to their prescribing habits, which implies that APRN education can be supplemented
through more learning prior to prescribing sensitive medications such as opioids. Data from this study shows
that APRNs generally prescribe less opioids than physicians. It can then be surmised that this difference is due
to the additional education required of APRNs.
Thomas et al. (2015) found MLPs prescribe less than half as many opioids in the ED than physician-
prescribing counterparts. However, this study found no correlation between the state requirements of
substance education courses and EDs within the study done by Thomas et al. (2015). It cannot then be
assumed that all ED MLPs underwent the substance education courses; the variances in prescribing practices
among provider types must be attributed to other factors.
Research cites the background of APRNs as being instrumental in their practices and as being “more holistic,
wellness focused, and less disease oriented and cure focused” (Schirle, et al., 2015). This research suggests
that the holistic nature of nurse education is instrumental in decreasing opioid prescribing rates and is
supported by “data evidenc[ing] high levels of patient satisfaction with APRN care, even as compared with
physician care” (Schirle et al., 2015). It should be noted that this high satisfaction was expressed by patients
of APRNs who prescribed less inpatient/outpatient opioids. This is strong evidence supporting strengths
found within nursing as a professional discipline, as well as within clinical nursing practice. Further research
is warranted into utilizing tools found within the nursing discipline in regards to decreasing levels of opioid
related complications.
Literature Review
Three articles were chosen which were published within the last 5 years and which supported elements of our research
including the background and relevance of the problem, current practices for both APRNs and physicians, and
methodologies of APRNs deemed peculiar to the profession. The following paragraphs will detail strengths of each
article chosen as well as clarify the value of each.
Schirle & McCabe (2015) published a journal titled State Variation in Opioid and Benzodiazepine Prescriptions
Between Independent and Non-independent Advanced Practice Registered Nurses. The purpose of this study was, “to
investigate the relationship in opioid- and benzodiazepine-prescribing rates between independent and non-independent
APRN prescribing states” (p. 86). The authors analyzed a 2014 CDC study reporting state variations in prescribing
rates. This represented 259 million prescriptions distributed by pharmacies, which distribute approximately 90% of the
Nation’s opioids. They defined independent states as those in which all APRN types were free of restrictions relating to
prescribing and non-independent states were those with APRN prescribing restrictions. Their findings stated that
independent APRN states had significantly lower opioid and benzodiazepine prescribing rates than those of non-
independent APRN states. Furthermore, their numbers remained significant after controlling for differing state
characteristics (e.g., number of physicians/capita, Medicare rates, race, and socioeconomic status). Included are
suggested explanations for the differences between prescriber type practices explaining that many independent APRN
states mandate controlled substance education before an APRN could obtain independent prescribing status,
but this requirement is not always required of physician-prescriber counterparts (p. 91). Additionally, they
suggest that, “APRN training is more holistic, wellness focused, and less disease oriented and cure focused, so
nurses may be more likely to incorporate nonopioid pharmacologic and non-pharmacologic treatment
modalities to treat pain” (p. 91). One anticipated concern mentioned is that patients of APRNs may be undertreated
due to lower rates of opioid prescribing. However, the authors address this concern explaining that, “data evidences
high levels of patient satisfaction with APRN care, even as compared with physician care” (p.92). The authors
state a limitation of their study is that prescribing statistics were limited to pharmacy distributed prescriptions and do
not account for all prescription sources.
This article was chosen to support our study as it provided extensive evidence regarding the differences in opioid
prescription rates of physicians and APRNs in independent versus non-independent states. The data provided by this
article included information gathered from pharmacies across the Unites States with distinction of practice by state. As
the inclusive sample included pharmacies throughout the Nation grouped by state with factors such as Medicare rates,
race, socioeconomic status, and number of physicians/capita being considered and controlled for (Schirle, et al., 2015),
this study had strong external validity.
The article by Thomas et al. (2015), titled Variation Between Physicians and Mid-Level Providers in Opioid Treatment
For Musculoskeletal Pain in the Emergency Department, “assessed for possible association between practitioner status
(physician [MD] vs. mid-level provider [MLP]) and use of opioids for in-ED treatment of musculoskeletal pain
(MSP)” (p. 415). The design was a secondary sub-analysis of 688 prospectively studied subjects with MSP who
received pain treatment in the ED. Data was collected from September 2012 to February 2014 from 12 EDs at
academic centers throughout the U.S. Of the 688 participants physicians saw 58% of the sample while MLPs saw 42%.
Findings showed that physicians prescribed over twice the amount of opioids as MLPs. While this seems
significant, the authors make note that this study was intended to serve as an analysis to determine heterogeneity of
practice and not as a conclusive basis regarding MD/MLP prescribing practices (Thomas et al., 2015); this study is
limited due to this fact. The authors emphasize that further studies are warranted to confirm their preliminary
conclusions. This article supported our research questions by providing additional data suggesting that heterogeneity
exists between the prescribing practices of physicians and mid-level providers.
The article was selected due to its sample being collected over multiple academic centers throughout the U.S.,
increasing the variability and scope of the sample and thus the validity.
Kolodny et al. (2015) indicates in their literature review, The Prescription Opioid and Heroin Crisis: A Public Health
Approach to an Epidemic of Addiction, that their purpose is to address the rising opioid crisis and recommend
interventions by taking an epidemiological approach through focusing on preventing opioid addiction (primary
prevention), assessing early signs and symptoms of addiction (secondary prevention), and providing access to
addiction treatment (tertiary prevention) (p. 565). Regarding primary prevention, it is recommended that health care
professionals prescribe opioids more cautiously for both acute and chronic pain, limit extended-release opioids,
utilize substituted nonopioid analgesics and nonpharmacological approaches for pain relief, and limit
emergency room prescription supplies to 3 days (p. 566). Secondary prevention methods include assessing signs and
symptoms of addiction in chronic pain management patients and using prescription drug monitoring programs to
prevent patients from receiving prescriptions from multiple prescribers (p. 567). Tertiary prevention involves addicts
receiving pharmacotherapy treatment and rehabilitation efforts (p. 567).
This study was selected as an example of interventions that may be utilized by APRNs to decrease opioid prescription
rates. It is a strong article as it is a literature review covering the history of opioid addiction from the 19th to the 21st
century, as well as implications and interventions with extensive literature references. The article is peer-reviewed,
reviewed and approved by Johns Hopkins University and cleared of conflicts of interest. However, the article lacks in
explanation with regards to methods of their data collection.
References
CDC (2012). CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic. Morbidity and Mortality Weekly Report, 61(1), 10-13.
CDC (2011). Vital signs: overdose of prescription opioid pain relievers-United States, 1999-2008. Morbidity and Mortality Weekly Report, 60, 1487-1492.
Kochanek, K. D., Murphy, S. L., Xu, J. Q., & Tejada-Vera, B. (2016). Deaths: Final data for 2014. National vital statistics reports, 65(4), 1-122.
Kolodny, A., Courtwright, D. T., Hwang, C. S., Kreiner, P., Eadie, J. L., Clark, T. W., & Alexander, G. C. (2015). The Prescription Opioid and Heroin Crisis: A
Public Health Approach to an Epidemic of Addiction. Annual Review of Public Health, 36(1), 559-574.
Schirle, L., & Mccabe, B. E. (2016). State variation in opioid and benzodiazepine prescriptions between independent and nonindependent advanced practice
registered nurse prescribing states. Nursing Outlook, 64(1), 86-93.
Thomas, S. H., Mumma, S., Satterwhite, A., Haas, T., Arthur, A. O., Todd, K. H., . . . Pollack, C. V. (2015). Variation Between Physicians and Mid-level
Providers in Opioid Treatment for Musculoskeletal Pain in the Emergency Department. The Journal of Emergency Medicine, 49(4), 415-423.