CDC expert: Nephrology nurses must build trust with patients to reduce opioid-related harm
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By developing relationships based on trust and open communication, nephrology nurses have a unique opportunity to help patients with kidney disease safely manage chronic pain, according to a speaker from the CDC.
“Thirty-eight people die every day from overdose involving prescription opioids,” Lorretta Jackson Brown, PhD, RN, CNN, team lead for the division of overdose prevention at the CDC, said during her virtual presentation at the American Nephrology Nurses Association National Symposium. “This is something that is, for the most part, preventable.”
Brown emphasized that patients with kidney disease are at higher risk for opioid-related harm (including mortality) than the general population due to impaired renal function and comorbidities. Risk-increasing comorbidities include cardiovascular disease and pulmonary issues, the latter of which can contribute to respiratory depression when opioids are added to the equation.
Citing a study that found 40% to 50% of patients on hemodialysis experienced chronic pain — with 80% of these reporting moderate to severe pain — Brown said this patient population is likely to be prescribed opioids and it is necessary to remain vigilant about the risks.
“If you are going to start opioids in your patients for management of chronic pain and want immediate relief, not extended, the lowest effective dose of 50 mg of morphine equivalent or less should be prescribed in short durations for acute pain (ideally 3 days),” Jackson Brown recommended. “Evaluate the benefits and harms frequently. If benefits do not outweigh harms, you want to begin to taper or discontinue.”
Trust-based relationships
The nephrology nurse, according to Brown, plays an important role in addressing the harms and risks of opioid therapy because patients may be more comfortable talking to nurses than other health care providers.
“Particularly for dialysis treatments, you [as the nurse] spend a number of hours with your patients,” she said. “They may feel comfortable disclosing sensitive information with you ... Nephrology nurses are well poised to support patients.”
According to Brown, trust is a critical component toward opening communication with patients and the act of listening is necessary to building a trust-based relationship.
“To build that rapport of trust is essential,” Brown said. “Express genuine interest that you’re there and want to help your patients and listen. Above all else, listen. When you’re listening, you will confer that you understand, while helping them to move toward a more realistic expectation of what can happen with their pain.”
She also suggests practicing empathy and genuinely trying to understand the patient’s position.
“Oftentimes, we as health care professionals are more set on the things that we have to get done without taking into consciousness what the patients may be experiencing,” she said, stressing that nephrology nurses should ask patients about their quality of life and how their current treatments are working, while also being mindful that patients may find the questioning intrusive.
“They may not want to disclose everything that’s going on with them, but I think if you work to build that trust, they will respect you. If you ask them in a way that’s not demanding, they’re more likely to open up to you. Reassure them you’re asking questions out of concern for their health and your commitment to enhancing their quality of life, [not out of judgement].”
The trust-based relationship is important past the goal-setting and education on risks phase, Brown added, and can be particularly useful for patients who have to undergo drug testing; patients may be more likely to accept the testing as out of concern for their safety and not because they are suspected of any wrong-doing if a relationship is already in place.
Leadership and advocacy
According to Brown, the nurse’s role in increasing opioid safety is not limited to the relationship with the patient. Other actions nephrology nurses can take involve utilizing state prescription drug monitoring programs, keeping the electronic health record up to date with accurate and detailed information, and helping to implement quality improvement measures.
“Nephrology nurses play both a leadership role and an advocacy role,” Brown said. "Advocate for your patients’ safety, your patients’ education and [lead] prevention efforts.”
Brown also suggests spearheading efforts to develop training programs on stigma and health equity language, or programs that are aimed at increasing understanding and respect for each patient’s unique circumstances.
“[How we perceive our patients] is going to influence the care choices we make,” she said. “The perception we have about our patients rolls into how we care for them.”
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Jackson Brown L. The nephrology nurse's role in safe opioid prescription/practices. Presented at: American Nephrology Nurses Association National Symposium (virtual meeting); May 2-5, 2021.
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