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Nursing:
doi: 10.1097/01.NURSE.0000383898.65472.8f
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How to manage pain in addicted patients

D'Arcy, Yvonne MS, CRNP, CNS

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Yvonne D'Arcy is pain management and palliative care nurse practitioner at Suburban Hospital-Johns Hopkins Medicine, Bethesda, Md., and a member of the Nursing2010 editorial board.

YOU LEARN IN REPORT that the post-op patient you'll be caring for today has a history of opioid addiction. Do you feel confident that you can adequately manage the patient's post-op pain without exacerbating addiction issues?

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Patients with a history of addiction are often undertreated for acute pain despite reporting high pain intensity levels. Clinicians may label their repeated requests for more medication as "drug seeking" and administer inadequate medication dosages. But the reality is that because of opioid tolerance, these patients may need much more medication to control acute pain than opioid-naïve patients.

Many healthcare practitioners think giving opioids to a patient addicted to opioids is a high-risk practice, but every patient has a right to adequate pain relief. The American Society of Pain Management Nurses has issued a position statement affirming that patients with a history of addiction need to have their pain treated and that they'll need higher doses of medication for pain.1

Patients actively using illicit substances or misusing prescription drugs and patients with a history of addiction can expect to have a difficult time when they have pain unless the healthcare providers understand the issues surrounding addiction and pain relief. This article will dispel misconceptions and provide guidelines for managing pain in these patients. The following case studies help illustrate some common misconceptions about pain control and addiction.

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Sara: A history of chronic pain

Admitted with acute abdominal pain related to a complete small bowel obstruction (SBO), Sara, 28, also has chronic low back pain from a car crash she was involved in as a teenager. She takes prescription opioids daily to control her chronic pain and allow her to teach high school science.

After surgery to relieve the SBO, Sara requests pain medication well before it's due and consistently rates her pain as an 8/10 (8 on a 0-to-10 point numeric pain intensity rating scale).

One evening, a nurse administering two oxycodone with acetaminophen (Percocet) tablets sees Sara take one out of her mouth and hide it under the pillow. When confronted, Sara tells the nurse that no one will answer her call light at night, so she keeps a stock of medications to control her pain until morning. She also states that at home, she's been taking twice the prescribed opioid dosage to relieve her back pain.

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John: A history of illicit drug use

Under treatment for lung cancer, John is admitted with bilateral pleural effusions causing high-intensity chest wall pain he rates as 10/10. When the nurse obtains his history, he says he uses heroin daily and last used it 1 hour before admission. Unsure how to convert his heroin use to standard pain medication doses, the healthcare provider prescribes morphine via patient-controlled analgesia (PCA) at higher-than-normal doses with a continuous basal infusion. Although no longer recommended for opioid-naïve patients on PCA, a basal infusion is necessary to manage pain in a patient who takes opioids regularly. Because he's opioid-tolerant, John needs a basal infusion to compensate for his chronic heroin use.

When PCA is discontinued, John's need for extended-release opioids and breakthrough medication is quite high: 400 mg of MS Contin twice per day with 40 mg of immediate-release morphine as needed for breakthrough pain.

During his hospitalization, John never rates his pain as less than 5/10, but this is significantly lower than his rating before treatment. John tells his healthcare provider that he's satisfied with his pain control and would like to stop using heroin. He's referred to an outpatient clinic.

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Which patient is addicted to opioids?

John is the obvious answer: He admits to heroin use and requires large doses of medication to reduce his pain to a level that could be considered moderate. But what about Sara? Her behavior could easily be interpreted as indicating addiction. She's escalated her home medications without a prescription, has been observed hoarding medications, and seems to be requesting unusually high doses of opioids for her surgical pain.

Her nurses think the medication doses she's using are too high and that she's addicted to opioids. They doubt her consistently high report of pain intensity and can't believe that the high drug doses they give her aren't relieving her pain or oversedating her. They've labeled her a "drug-seeker." For both patients, nurses are reluctant to continue giving consistently high doses of medications. In Sara's case, they're afraid they'd be adding to the potential for addiction. In John's case, they approve of his stated desire to stop using heroin and don't want to undermine his recovery by providing more opioids.

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Does prolonged opioid use cause addiction?

In the United States, many patients with chronic pain take opioid medications regularly. (See Drug use and abuse on the rise.) Are they becoming addicted through routine use of opioids?

Yes and no. A small percentage of patients become addicted, but not nearly as many as healthcare professionals may assume. Many patients who do become addicted had some previous exposure to opioid use.

Determining the rates of addiction with long-term opioid use in the healthcare setting is difficult. In a study of 800 primary care patients taking opioids, the rate of addiction was roughly 4%.2 In another review study involving patients with various pain complaints, the rate of addiction was found to be less than 1% for patients who'd never used opioids previously and about 4% for patients who'd been exposed to opioids previously.3 Even in pain clinic patients who were taking opioids regularly for pain relief, research indicates that 40% will exhibit aberrant behaviors, 20% will abuse or misuse their medications, and 2% to 5% will become addicted.4

These statistics highlight the number of patients using opioids who don't become addicted but use their medications responsibly to manage pain. The low incidence of addiction in patients taking opioids consistently shows that regular opioid use for pain control isn't an indicator of addiction. A patient who becomes addicted is a patient with different needs who comes to the experience of opioid use in a completely different way.

Addiction, dependency, and tolerance are different states that are still widely misunderstood by healthcare professionals. See Is it dependence, tolerance, or addiction? to review the crucial differences.

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Understanding aberrant behaviors

Patients using opioids to manage chronic pain may engage in certain aberrant behaviors ranging from hoarding prescription drugs (as in Sara's case) to buying illicit drugs on the street.5 Some of these behaviors are more predictive of addiction than others.

Aberrant behaviors that are probably less predictive of addiction in patients with pain include hoarding medications, taking someone else's medication, requesting a specific drug or dose, raising drug doses without a prescription, drinking more alcohol when in pain, smoking cigarettes to relieve pain, and using opioids to treat other symptoms. Behaviors that are more predictive of addiction include concurrent use of illicit drugs, stealing or selling prescription drugs, and deterioration in family and work relationships related to drug use.5

Healthcare providers need to assess aberrant drug-related behaviors to determine whether they reflect undertreated pain or a need for closer observation and tracking to determine whether the patient is having increasing difficulty managing opioid use. It's not easy to ask difficult questions about aberrant drug taking behaviors, but it must be done to ascertain the potential for opioid abuse.

In Sara's case, the nurse would address Sara's hoarding and tell her she can't continue that practice. To address the reason behind the hoarding, the nurse might ask Sara whether she wants to be awakened at night to take her pain medication. If so, the nurse should ask the night nurse to wake up Sara and offer the medication when it's due to reassure Sara that she'll get her medications.

To address the increased dosage Sara has been taking at home, the nurse should ask her how long she's been doing it, how many tablets she really takes a day, and whether she's discussed this with the healthcare provider who prescribes her medications. If she hasn't informed the provider, the nurse will have to take appropriate action. This includes telling Sara honestly that she'll have to inform her current provider, who should also discuss the medication increases with Sara.

For patients who use alcohol with opioids, a nurse might ask questions to determine how much, what type, for how long, and why—because the pain medication isn't adequately treating the pain, or because they like the way it makes them feel?

Nurses are in an ideal situation to observe patients and discuss the meaning of new behaviors. If the pain is being undertreated, the patient may need a new treatment plan that includes increased medication doses or the addition of co-analgesics or complementary methods to decrease aberrant behaviors.

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How addiction issues affect the care plan

Opioids trigger the reward centers in the limbic system related to the rapid release of large amounts of dopamine. Because smoking, injecting, or snorting these substances can result in a more rapid onset of effect, oral preparations are less attractive to a patient with a history of addiction.6

Using long-acting medications is considered the best approach for controlling pain in patients with addictive disease. Short-acting opioids tend to produce a roller coaster effect and aren't recommended at all.1

Adequately treating these patients for pain requires a high investment of time, practices, and procedures to ensure that opioid medications are used solely for pain relief and not for other purposes, such as recreational use or diversion for profit. Complete and full documentation and follow-up is a must.1,7

The American Academy of Pain Medicine and the American Pain Society have affirmed that using opioids to treat pain in patients with addiction is appropriate and provide recommendations about the types of monitoring, documentation, and use of counselors, psychologists, and others who specialize in addiction treatment.7,8 This multidisciplinary treatment approach can help facilitate the best pain management for the patient with addiction.

For addicted patients being treated for pain in the acute care setting, make your priority relieving pain. Asking questions about the amount of drugs the patient uses daily will give a baseline for the patient's medication use; additional medication is needed to control the new pain. For scheduled physical therapy or a procedure, provide adequate premedication as prescribed. General recommendations for treating pain in hospitalized patients with addictive disease include the following.1,9,10

* Avoid medication with a quick peaking action, if possible, and short-acting medications such as Percocet or Vicodin. As discussed previously, PCA may be a tool to provide dosage estimates for conversion to long-acting opioids that avoid blood level fluctuations.

* If a patient is on methadone therapy, continue methadone, even though it's being used to treat addiction, not pain, because the medication is a part of the patient's daily regimen. The patient may not know the dose, so the nurse or healthcare provider may need to call the clinic providing the methadone to get the exact dose and provide that dose of medication along with additional medication to treat the new pain.

* Set realistic expectations with the patient about what to expect regarding medication doses, administration times, and requests for dose increases. Setting expectations early on in the hospitalization helps head off future confrontations.

* Only one practitioner should prescribe opioids for the patient.

* The prescriber should know about and communicate with other healthcare providers involved in the patient's care so everyone knows who will be managing the pain medications and the goals of care.

* Urine screens done on admission may reveal whether additional illicit substances are being used; this may affect the types of medications being provided on this admission. Be aware that withdrawal may occur before the information is received.

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Build a trusting relationship

The key to treating pain in a patient with a history of addiction is to develop a trusting relationship so the patient is comfortable sharing accurate information about past and current drug use. Many patients who abuse drugs have had negative experiences with healthcare providers, so don't be surprised if your patient resists suggestions about pain relief. Maintain a nonjudgmental attitude and try to persuade the patient that you want to help. In turn, the patient may respond more positively to you.

Consider asking a pain specialist for advice about interacting with the patient. Setting boundaries for providing pain medications and requests for dose increases should be clearly identified and discussed with the patient. For example, the patient may request the medications when they're scheduled, but the patient should understand that medications won't be given at other than the specified time except for a clinical reason, such as a change in the patient's condition. If the patient reports a sudden increase in pain, the healthcare provider should assess the reason.

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Make pain relief top priority

No one, including a patient who's addicted to drugs or has a history of substance abuse, should suffer from unrelieved pain. By providing ongoing pain assessments and working with the patient, you can help deliver the best level of pain relief possible. If you can establish a therapeutic relationship with the patient and follow the established plan of care with treatment goals, the patient should progress through hospitalization with the fewest possible problems.

Caring for a patient with drug abuse problems can be time-consuming, but easing the suffering of a challenging patient is extremely rewarding.

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Drug use and abuse on the rise6,10

* As of 2002, an estimated 4 to 6 million patients in the United States were using opioids for pain relief.

* From 1992 to 2002, admissions to substance abuse centers for opioid abuse increased by 155%.

* From 1994 to 2002, ED visits for opioid abuse increased by 117%.

* From 1992 to 2002, new opioid users increased by 542%.

* From 1993 to 2005, the number of college students who reported opioid use in the past month increased by 343%.

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Is it dependence, tolerance, or addiction?8

These terms have distinct meanings. Make sure you know how they differ.

Dependence is a normal physiologic response to chronic opioid use. If an opioid is abruptly withdrawn from a patient on long-term opioid therapy, the patient will experience a withdrawal syndrome with signs and symptoms such as nausea/vomiting, chills, changes in vital signs, and diarrhea.6 Nurses and other healthcare providers should be very careful not to label an opioid-dependent patient as addicted.

Tolerance occurs as the body adapts to chronic opioid use. Because of tolerance, the opioid's effects—both positive and negative—tend to lessen over time. Most adverse reactions such as nausea and sedation diminish, but so does pain relief. (Constipation is the only opioid effect not mitigated by tolerance.) The patient who's becoming tolerant to an opioid will report more pain despite receiving the usual drug dosage. Tolerance is also a normal physiologic response and not a sign of addiction.

Addiction is a chronic, neurobiologic disease with physiologic, psychological, genetic, and environmental components. It's characterized by four C's:

* craving for the substance

* lack of control over the substance

* compulsive use

* continued use despite harm.6

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REFERENCES

1. ASPMN position statement: pain management in the patient with addictive disease. American Society of Pain Management Nurses. http://www.aspmn.org/Organization/documents/addictions_9pt.pdf.

2. Flemming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain. 2007;8(7):573–582.

3. Fishbain DA, Cole B, Lewis J, Rosomoff HL, Rosomoff RS. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction, and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Med. 2008;9(4):444–459.

4. Webster LR, Dove B. Avoiding Opioid Abuse While Managing Pain. North Branch River, MN: Sunrise River Press; 2007.

5. Fine PG, Portnoy RK. A Clinical Guide to Opioid Analgesia. Vendome Group Healthcare Division LLC; 2007.

6. Stanos SP, Fishbain DA, Fishman SM. Pain management with opioid analgesics: balancing risk & benefit. Am J Phys Med Rehabil. 2009; 88(3):S69-S99.

7. Public policy statement on the rights and responsibilities of healthcare professionals in the use of opioids in the treatment of pain: a consensus document from the American Academy of Pain Medicine, The American Pain Society, and The American Society of Addiction medicine. http://www.ampainsoc.org/advocacy/rights.htm.

8. Definitions related to the use of opioids for the treatment of pain: a consensus document from the American Academy of Pain Medicine, The American Pain Society, and The American Society of Addiction medicine. http://www.ampainsoc.org/advocacy/opioids2.htm.

9. Prater CD, Zylstra RG, Miller KE. Successful pain management for the recovering addicted patient. Prim Care Companion J Clin Psychiatry. 2002;4(4):125–131.

10. Wilson Fisher J. Strategies to stop abuse of prescribed opioid drugs. Ann Intern Med. 2007;146(12):897–900.

© 2010 Lippincott Williams & Wilkins, Inc.

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