Theoretical Framework Schlossberg’s Transition Theory is the mid-range theory which defines transitions as an occurrences that build into life changes of relationships, roles, or routines. Melies further theorized that there can be an incorporation of situation specific events that are limited to specific populations resulting in a clinical practice defined by an equally specific nursing phenomena, which is referred to as Melies Situation Specific transition theory. The combining of both theories gives the framework upon which to base this multifaceted issue of how the use of opioids started as treatment routine and continued to morph into a specific population issue, that in turn continues to change and encompass larger populations because each specific population involved in the process had different occurrences impacting their roles. A descriptive theoretical framework with basis in historical data that outlines the knowledge gaps that existed concerning medication potential for addiction combined with FDA approval in addition to aggressive marketing campaigns by pharmaceutical companies, were instrumental in the current state of opioid addiction crisis in America. Additional knowledge gaps related to addiction and polysubstance abuse related to opioid usage on a genetic and neurochemical level contributed to the rate of substance abuse. Governing organizations’ attempts at improving quality of care through the use of patient satisfaction scoring tools that included pain-specific quality identifiers influenced opioid prescribing rates and contributed to the opioid crisis. Drug Enforcement Agency (DEA) monitoring systems currently serve to limit the amount and number of opioids that are prescribed in an attempt to reduce the instances of over-prescribing or unethical abuses of prescribing privileges. Implications for mid-level providers include job opportunity and liability issues related to obtaining a DEA prescriber license number. Key Concepts/KeywordsKnowledge gaps, HCHAPS pushing for pain treatment, DEA limits on prescriptions, Scope of conditions to prescribe opioids for, Joint commission’s part in opioid epidemic, Condition leading to opioid addiction, CDC opioid related deaths with comorbidities DatabasePeer-reviewed research and systematic reviews between the years of 2005–2018 found on the CINAHL, Medline, PubMed, ScienceDirect, Simmons proxy, and google were used. Inclusion criteria were based on search words and included government data sitesLiterature searchA Critical Review: Ethical Dimensions of the Prescription Opioid Abuse CrisisThe purpose of this review is to provide a critique of the article, “Ethical Dimensions of the Prescription Opioid Abuse Crisis”, written by Stratton, Palombi, Blue, & Schneiderhan. It shall provide a look at the purpose and objectives in addition to a view of the research design with its limitations and strengths. There will be an evaluation of the samplings methods that will include size, determination, type, and techniques to obtain the data, along with a discussion of the rigor and validity of the obtained data. To understand what exactly is being discussed in this article, a question to answer PICO should be presented. How has the progression of concerns of government agencies verses primary care providers toward addressing pain added to the current opioid crisis. The article presented stated that the National academy of medicine, in 1987, instituted a pain grading system to be used that measured pain quantitatively. They further reported that The Joint Commission built on this measure and in 2001 instituted the “fifth vital sign” for use in emergency departments relative to the belief that current patient reported pain was not being accurately reported and therefore needed standardizing. Over years, this “fifth vital sign has been modified, deleted, re-added and then replaced with different wording to represent a non opioid approach to pain. Throughout the remainder of the article, three case studies by the authors were done by participants affected by the opioid crisis. The authors then provided the ethical, legal, clinical, and social considerations that arose for the opioid usage. There was not any information that was provided statistically to support the choices of participants or the questions. The interviews were done informally and only to gain information to relate a clinical case story. There was a beginning of a research purpose but it appeared to be very narrow with the use of only 3 participants which limited the study’s scope. The purposive sampling for this study was limited to who the authors interacted with and included no specific exclusionary factors. The article was written as a presentation, but leaves open the beginnings of a much larger study that could be started to benefit both the medical community and those needing their services. Validity and reliability were unable to be addressed in the case studies but factual information from the historical perspective were considered both valid and reliable. Based on the John Hopkins scale for level of evidence, this would be rated at a level 5 with a grade evaluation of D (“Johns Hopkins LOE scale,” 2018). However, since many studies begin with small pieces of pertinent evidence, it was included in this review.A Critical Review: The purpose of this review is to provide a critique of the review article, “Clinical solutions to chronic pain and the opiate epidemic”, written by Murray, Stone, Pearson, and Treisman. It shall provide a look at the purpose and objectives in addition to a view of the research design with its limitations and strengths. There will be an evaluation of the samplings methods that will include size, determination, type, and techniques to obtain the data, along with a discussion of the rigor and validity of the obtained data. A question this review was answering was: In the treatment of chronic pain patients, who are considered an element of the opioid crisis, what alternative systems are available to empower clinicians to use judgement in the providing of high-quality care. The review provided reliable historical data based on valid sources such as the CDC. The information was presented with some bias which came through in such statements as “ The Joint Commission denies playing a role in the opiate epidemic on their website despite requiring pain assessment tools and protocols for pain treatment since 2001” ( ,2018). However, the amount of supporting evidence and validity of the sources provided the counterpoint to many of the personalized statements. The article provided a well rounded presentation of the problem, a supporting historical trail of changes, and myriad of plausible factors that should be addressed to make a comprehensive change to the existing crisis. This article would also be rated at a level 5 with a grade evaluation of D (“Johns Hopkins LOE scale,” 2018). Provider roles: “Opioid pharmacovigilance: A clinical-social history of the changes in opioid prescribing for patients with co-occurring chronic non-cancer pain and substance use” is an article published in 2017 by Social Science and Medicine. The writing studies provider implementation of opioids in practices based upon training received during their residencies and formal medical education in the mid 1990s. Sampling for these semi-structured surveys consisted of 23 clinicians comprised of 18 physicians, 4 nurse practitioners and 1 physician’s assistant, all of whom worked in primary care settings in the San Francisco bay area. The method was 1-2 hour audio recorded interviews of participants followed by verbatim transcription. Data was synthesized by a coding system and utilization of Atlas, a qualitative data analytical tool to tabulate results. Although a small and narrow sampling for this study is a limitation, the results serve to illustrate the inclusion of pain as a vital sign by the Joint Commision in the 1990s escalated the use of narcotics for the treatment of pain by providers. A Critical Review: “Pharmacogenetics and Human Molecular Genetics of Opiate and Cocaine Addictions and Their Treatments”. The purpose of this article is to demonstrate studies that were conducted as early as 2005 with patients suffering from opioid addiction not responding to behavioral treatment methods in reaction to the opioid crisis. The findings that addiction has basis in genetic coding and mutations, and that opioid usage can permanently alter brain chemistry, sheds light on the need for additional research as well as treatments targeting behavioral therapies aligning with new evidence. Evidence in this article establishes a timeline of knowledge surrounding addiction, and offers a better explanation of human addictive behaviors and the progression from addictions to multiple substances. Opioids were still prescribed despite what was known at that time about addictive properties of the substances.A Critical Review: “Genetic addiction risk score (GARS) ™, a predictor of vulnerability to opioid dependence”, written by Kenneth Blum sourced from multiple contributors, encompasses numerous genetic and neuroscience studies focused on the genetic predisposition of individuals to addictive behaviors. In light of the behavioral component of addiction, the genetic predisposition of individuals coupled with opioid usage potential for genetic mutation and alteration of individuals, this study demonstrates a framework of addictive patterns, and the evolution of addicts from a personality trait genetic change perspective. Evidence will show that addiction creates social and behavioral changes in the addicted person and that those behaviors are driven to manipulate healthcare providers to feed their addiction. Multiple treatment methods are addressed as well as the need for further research.
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