CRNAs Seeking New Best Practices in Pain Management

CRNAs Seeking New Best Practices in Pain Management

Many people across the United States rely on certified registered nurse anesthetists (CRNAs) for pain management, and the anesthesia and analgesic specialists are moving to a multimodal approach to address pain issues and the country’s opioid crisis.

“Patient safety is our priority, and we care for patients across the continuum of life, whether it’s a neonate addicted to cocaine or opioids at birth clear through taking care of patients in surgery or the emergency room to resuscitate,” said Lynn Reede, DNP, MBA, CRNA, FNAP, chief clinical officer at the American Association of Nurse Anesthetists (AANA), outlining the organization’s interest in addressing the opioid crisis.

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The role of nurse anesthetists in pain management 

CRNA jobs may include placing epidurals or regional nerve blocks with ultrasound guidance. Military CRNAs place blocks in wounded soldiers before they are transported to a tertiary hospital for definitive care.

Bruce Schoneboom, PhD, CRNA, FAAN, chief learning officer of the AANA, is the organization’s appointee to the U.S. Health and Human Services Pain Management Best Practices Inter-Agency Task Force, which will identify gaps in pain management protocols and make recommendations to address those gaps, propose best practices, and develop a strategy for sharing that information with the public and federal agencies.

Schoneboom is the only nurse appointed to the task force. He has explained the role CRNAs play in pain management and access to care. He indicated that AANA “believes that moving from a unimodal approach of using opioid drugs to manage chronic and acute pain to a more patient-centered, multidisciplinary, multimodal opioid-sparing treatment approach optimizes patient engagement in their own pain care.” That will reduce the risk of substance use disorder.

Reede explained that engaging the patient prior to surgery and educating the patient that he or she will have some pain but the patient will be able to manage it helps with reducing opioid use.

“If we can prevent pain sensations from getting to the brain, the [patient] can be more comfortable,” Reede said. Without opioids, which only work in the brain, the patient will be less sleepy, and not suffer other side effects associated with opioids.

“The real management is the partnership between the provider and the patient,” Reede said.

Managing pain with and without opioids

Every year, millions of Americans experience acute or chronic pain, according to the American Academy of Pain Medicine. An estimated 100 million suffer with chronic pain. There are no easy solutions.

Many patients rely on certified registered nurse anesthetists as their primary pain specialist.

An estimated 6 to 12 percent of patients treated with opioids develop addiction, said Michael D. McGee, MD, chief medical officer at The Haven at Pismo in Grover Beach, California, and author of The Joy of Recovery: The New 12-Step Guide to Recovery from Addiction.

Therefore, he said, it is “important to avoid opioids if at all possible and use multimodal interventions for pain management.”

The Centers for Disease Control and Prevention has issued guidelines for managing chronic pain. It recommends non-pharmacologic therapy for chronic pain and use of opioids only with other methods of relieving pain. Patients receiving opioids must be monitored.

McGee advised in treating chronic pain that clinicians work to improve functioning, reduce pain and reduce psychological suffering.

“Integrate the treatment of pain and other comorbidities, including addictions and other psychiatric illnesses,” McGee said. “Combine nonopioid pharmacological and nonpharmacological therapies, collaborating as part of a team with other caregivers.”

Removing barriers to CRNA practice 

Despite CRNAs administering more than 43 million anesthetics to patients annually, artificial barriers and restrictions exist, limiting access to care.

CRNA jobs are plentiful, and the U.S. Bureau of Labor Statistics predicts job growth will far exceed the average of other occupations from 2016 to 2026.

Recruiters at Staff Care report that nurse practitioner and CRNA jobs are the most in-demand advanced practice specialties for locum tenens assignments.

Seventeen states do not require physician supervision for Medicare A reimbursement. Maryland recently eliminated the requirement that CRNAs have a written collaborative agreement with a physician.

The marketplace is driving change to supervision, because one-on-one supervision is not cost effective, Reede said.

“Employers are looking to provide optimal anesthesia and pain-management services at a reasonable cost,” Reede added. “When a CRNA salary is a half or sometimes a third of the cost of an anesthesiologist, and we are expected to deliver the same care, which we do, it is expensive model when you have an anesthesiologist staffing a CRNA."

AANA continues to push to remove barriers to practice.

“The goal is for all healthcare professionals, in particular the advanced practice providers, to practice to the full scope of education and licensure,” Reede said.

Related: 
CRNA Scope of Practice: Advancing Anesthesia Safety 
Nurse Practitioner and CRNA Scope of Practice: 2018 Updates  

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