Hospice-Appropriate Universal Precautions for Opioid Safety

Catherine Covington-East, MA, RN, BSN, CHPN


Journal of Hospice and Palliative Nursing. 2017;19(3):256-260. 

In This Article

Abstract and Introduction


Universal precautions for opioid safety, analogous to universal precautions for infection control, is one approach to managing the epidemic of prescription pain medication misuse that has been used in pain clinics, primary care practices, and in some hospices. In this project, a set of hospice-appropriate universal precautions was designed, drawing on hospice nursing strengths, and implemented in a midsize hospice agency.


Over the past few decades, misuse of prescription drugs has become a major American public health problem. The Centers for Disease Control and Prevention report that sales of opioid prescriptions drugs, and overdose deaths associated with them, have quadrupled from 1999 to 2015. Misuse of prescription opioids has also led to more than 1000 emergency department visits daily and burgeoning problems with addiction and dependence among Americans.[1]

Various efforts to address the problem of prescription drug misuse include requirements for pharmaceutical companies to produce risk evaluation and mitigation strategies, state drug-monitoring programs, additional barriers to prescribing opioids, abuse-resistant drug formulations,[2,3] and recommendations for wider use of pain management agreements or contracts and urine toxicology screening.[4,5]

One comprehensive, provider-centered strategy for preventing and managing abuse problems with opioids has been called "universal precautions," analogous to universal precautions for infection control. Universal precautions for pain management were proposed in 2005 as a unified approach for assessment and management of chronic pain patients by primary care doctors.[6] This strategy was proposed because it was recognized that physicians are unable to recognize which patients are at risk for drug abuse and diversion. Universal precautions are implemented with all chronic pain patients and include assessment of opioid abuse risk, a pain medication agreement and/or contract that the patient is required to sign, and required compliance with urine toxicology screening tests if requested. Further interventions, such as pill counts and restrictions of amounts of medication ordered at a time, may be undertaken according to an algorithm based on the assessed risk.[2] Since first proposed, universal precautions have been recommended for use in primary care practices and pain management clinics.[2,7]

Research on use of pain medication agreements as the basis of universal precautions in primary care practices and pain clinics has shown some benefits. The benefits may include reduction in opioid misuse and doctor shopping and improved preparation among internists to discuss and manage potential problems with patients.[8–12] Risks of pain management agreements include reluctance of clinicians to treat patients with chronic pain and possibly pushing patients to turn to illegal drugs.[13]

Opioid medications are a mainstay in hospice nursing for their role in achieving optimum quality of life and comfortable dying for patients. Hospice agencies' use of opioid medications for their patients has largely been exempt from the fears of addiction and dependence associated with use of opioid pain medications in nonhospice settings. Less than half of Virginia hospices had written policies and training regarding substance abuse and diversion in 2013,[14] whereas a nationwide survey of palliative clinics showed concern regarding opioid abuse but no standard practices for its prevention.[15] Hospice patients and their providers have also been exempt from some of the barriers to prescribing and obtaining these medications that apply in nonhospice, chronic pain settings. Hospice clinicians seek to preserve ease of access to needed medications for their patients without allowing these medications to become a source of harm to their communities. Moreover, hospice clinicians acknowledge that some of their patients may have comorbid substance abuse disorders, which may contribute to end-of-life suffering.[16]

Universal precautions have been developed and implemented by some hospices. The Virginia Association for Hospice and Palliative Care has made "Risk Evaluation & Mitigation: Strategies to Promote the Safe Use of Opioids" toolkit available online.[17] Clinicians of an Ohio hospice presented the case for universal precautions at the 2015 American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association Annual Assembly.[18] Use of opioid risk assessment tools, an algorithm for interventions based on assessed risk, and pain management agreements for all patients are common to both.

Can universal precautions as an approach to opioid safety benefit home hospice patients? The purpose of this project was to develop universal precautions rooted in nursing theory and practice and tailored for use with hospice patients and their families. This program of universal precautions, designed to make use of hospice strengths and needs, was implemented for home patients in a medium-sized hospital-based hospice agency. The agency's previous policy included interdisciplinary team discussion of any concerns raised by the nurse or social worker in their patient and family assessments. If the hospice team suspected diversion or misuse, the patient or family was asked, at that time, to sign a notice that warned that the patient would be discharged for cause if the problem continued. In the 2 years before institution of universal precautions, 3 patients were discharged because of opioid misuse.