1. State common pain terminology and describe the difference between addiction, physical dependency and tolerance.
2. Define adequate patient assessment and proper pain assessment, incorporating both subjective and objective findings.
3. Discuss the goals of acute pain management in opioid-dependent patients.
4. Explain the use of opioids vs. adjuvant analgesics for adequate pain control. Summarize nonpharmacologic modalities for pain.
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Pain is the most common reason patients seek healthcare. Yet pain medications are generally underutilized in patients with a history of substance abuse due to associated stigma and misconceptions about both pain and chemical dependency.1-3
When treating this population, one of the most significant challenges is to differentiate between a real need for pain medication and gratuitous drug-seeking. Patients exhibiting substance abuse usually have a lower pain threshold and higher tolerance to usual doses of opioids. Both factors contribute to difficulty in the treatment of these patients when they experience acute pain. Healthcare providers who treat opioid-dependent patients should become competent and confident about caring for this population by increasing their knowledge and confronting longstanding myths and biases.
NPs and PAs provide essential healthcare to patients with a history of drug abuse. They also serve as role models for staff nurses, focus on the provider-patient relationship, and provide education and support for staff. Pain management for patients with substance abuse problems requires the establishment of goals and expectations in addition to the provision of safe and adequate pain relief. Clinicians should expect that a patient with a history of substance abuse might require a higher dose of pain medication. They should be vigilant in monitoring medication dosage because the dose required for analgesia may be close to the dose that induces sedation and respiratory depression.
In clinical practice, terms such as addiction, tolerance and physical dependence are often used interchangeably. Such usage can lead to misconceptions and fuel prejudices. For example, patients who exhibit signs and symptoms of physical dependence and/or tolerance may be labeled inaccurately as addicts.
The American Pain Society, the American Academy of Pain Management and the American Society of Addiction Medicine define addiction as a primary, chronic neurobiologic disease that includes genetic, psychosocial and environmental factors.1 Addiction is characterized by behaviors that include impaired control over drug use, compulsive use, continued use despite harm, and drug craving.1 Addiction differs from physical dependence and tolerance mainly because of its psychological and behavioral components. Table 1 defines terms commonly associated with substance abuse.
Barriers to Adequate Pain Control
Patients with a history of substance abuse are usually aware that some people have negative, judgmental opinions about them. Consequently, they are concerned about unfair treatment in the healthcare setting.2 It is therefore essential that clinicians exhibit a nonjudgmental and positive attitude toward such patients, to encourage a good therapeutic relationship.
For the provider, fear of addiction is another leading barrier to adequate pain management.3 Behaviors and attitudes stemming from this fear may establish an atmosphere of distrust and an adversarial relationship between the healthcare provider and the patient, causing distress and frustration on both sides. For the patient, the possibility of inadequate pain control exists due to inappropriate withholding of pain medications by providers.
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In the outpatient setting, clinicians who assess patients with acute pain should perform a complete patient history review and physical examination. The review should begin with pertinent past medical records and treatment successes and failures. The patient's history should inform the provider about drugs used, along with their frequency and duration of use. It is also important to determine whether other treatments (pharmacologic or nonpharmacologic) have failed in the past. This information will allow clinicians to consider opioids for certain patients only when ample evidence suggests no other modality has worked.1 It is also appropriate for the clinician to contact healthcare providers who have previously treated a patient for substance abuse to determine the patient's adherence to recommendations.
The assessment should identify psychiatric diagnoses such as anxiety, depression, bipolar disorder or eating disorder.2 A psychiatric disorder can impede the initiation and effectiveness of treatment.4 Physical, sexual, socioeconomic and environmental factors that might affect the patient's overall well-being should also be incorporated into the initial assessment. Finally, find out how long the patient has successfully avoided substance abuse and whether the patient currently attends a recovery program.
Providers face major challenges when trying to differentiate the causes of pain in patients with a history of substance abuse. Assume that a patient's report of pain is true unless there is a legitimate reason not to believe it. Believing patients and aggressively managing their pain helps establish a trusting relationship and allows for open communication. If the pain report seems exaggerated given the medical issue, consider a possible low pain threshold or psychiatric comorbidity.1 Incorporating both subjective and objective findings and determining whether they appear appropriate to the patient's pain complaint is crucial to discerning that the patient is truly in pain.
Subjective data should include routine information such as that captured in the acronym OLD CHARTS: Onset, Location, Duration, CHaracter (sharp, dull, etc), Alleviating/Aggravating factors, Radiation, Temporal pattern (every morning, all day, etc.), Symptoms associated). Particular attention should be paid to the onset of pain, its intensity and duration, and whether this pain is different from the patient's chronic pain. It is important to correlate the reports of pain with physical findings such as vital signs in order to distinguish which patients are gratuitously seeking drugs.
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It is also crucial to distinguish among patients who are actively abusing substances, who are in methadone maintenance programs, and who have a history of chemical dependence. Many screening tools are available to identify patients who regularly use alcohol or drugs. One tool is a brief questionnaire known as the CAGE-AID (Table 2),5 which scores responses 0 for No and 1 for Yes. A score of 2 or greater is considered significant. In patients who currently use substances, the typical pattern should be determined.
A written contract that sets boundaries and establishes expectations for the patient and the clinician is vital in the care of patients with substance abuse problems. The proper use of medications, refills, appointments and other issues of adherence to the treatment plan should be clearly spelled out and agreed on. The agreement should establish ground rules that will be used to monitor behavior throughout treatment. The agreement should also clarify the respective roles of the clinician and the patient, limit the potential for misinterpretation, and help everyone involved quickly identify problems that might suggest addiction.6-8
Whether a patient is currently undergoing opioid therapy or has a history of substance abuse, it is critical to determine whether a physical reason for the pain exists. Conditions such as renal calculi, fractures, surgical procedures and soft tissue injuries are painful regardless of substance use history.7 Uncontrolled pain from such physical causes may harm patients by impairing cardiac, pulmonary and endocrine functions.9 Physiologic changes caused by uncontrolled pain result from activation of the peripheral and central nervous systems. Table 39 lists effects of undertreated severe acute pain.
Management of Acute Pain
Table 410 outlines the goals of acute pain management in opioid-dependent patients. These goals are important regardless of setting (inpatient or outpatient). The goal of acute pain management is effective pain relief, with elimination of suffering as an ideal goal. Maintenance of the patient's physical, social and cerebral functions is generally a secondary concern. Any treatment plan, including its goals, should be jointly developed with, and agreed to, by the patient. Patient cooperation develops trust, respect and a sense of control, and thus improves outcomes. Proper pain management in patients who abuse opioids should adopt a multimodal approach, using a combination of pharmacologic and nonpharmacologic techniques.11
Before starting treatment, it is essential to determine as accurately as possible the patient's current daily consumption of drugs. Doses of prescribed drugs should be verified, either from the dispensing label on the bottle or by contacting the prescribing practitioner, dispensing pharmacy or drug treatment facility.12 Patients who are dependent on "street drugs" are incapable of quantifying their drug consumption and unable to identify the composition of the drugs they are using. To avoid the risk of opioid withdrawal, the approximate daily dosage can be given in two to four divided doses. Patient response, level of sedation and respiratory rate must be closely monitored.12
Structured access to medication can decrease the likelihood of relapse.2 Such access can be controlled through the use of long-acting or controlled-release agents for a short term, such as 1 week at a time, and arranging distribution of the medication by someone other than the patient. However, inadequate pain relief may encourage addicts to seek pain relief through self-medication, thereby increasing the chance for relapse.11 The plan for an adequate pain regimen should consider but not be limited to patient preferences, past experiences and the long-term management plan. Reassurance to the patient that his or her acute pain is a priority plays a key role in gaining trust.13
Not all patients with acute pain complaints should be treated with opioids right away. The literature suggests that most can be treated successfully with nonopioid analgesics such as aspirin, acetaminophen, nonsteroidal anti-inflammatories (NSAIDs), cyclooxygenase-2 inhibitors or muscle relaxants.14 Clinicians may also use adjunctive analgesics such as anti-epileptic agents or low-dose antidepressants, which can alleviate neuropathic pain. Physical therapy, ice, heat and other nonpharmacologic measures may also be helpful. For mild to moderate pain, NSAIDs such as ketorolac might be a useful alternative.
If conservative measures are ineffective and opioids are deemed necessary for patients with a history of addiction, it is important to choose the correct agent. Immediate-release (IR) opioids are available with or without aspirin or acetaminophen.
Other options include long-acting opioids such as methadone or a controlled-release (CR) opioid. Although all opioids may create physical dependence and tolerance, research suggests that a long-acting or CR opioid is less likely to induce tolerance and abuse than an IR opioid.15 For this reason, using a CR or long-acting opioid would be appropriate for moderate to severe pain in patients with a history of addiction. Both opioids maintain steady-state blood levels, which prevents the fluctuating opioid blood levels that induce euphoria alternating with craving.2
Drug users or substance abusers should receive the level of opioid treatment required to control their pain, at least until unwanted adverse effects occur.2 Although patients may be tolerant to opioids and respiratory depression is unlikely when large doses are given, patients should be monitored continuously. Patients who are currently taking opioids for chronic underlying conditions should continue their home regimen, and short-acting opioids should be added as a first step for acute pain treatment.
Undertreating acute pain may lead to decreased responsiveness to opioid analgesics, thus making subsequent pain control more difficult.1 For this reason, clinicians should begin treatment by dosing aggressively with scheduled doses instead of only as-needed (PRN) doses. Initially, intravenous (IV) doses are more effective than oral doses because they provide fast relief and are easily titrated.11 If oral long-acting agents are administered, several opioid therapies should be provided with parenteral increments of morphine or fentanyl titrated in addition to the baseline opioids.10 Mixed agonist and antagonist opioid analgesics such as pentazocine (Talwin), nalbuphine (Nubain) and butorphanol (Stadol) should be avoided due to their ability to precipitate acute opioid withdrawal in opioid-dependent patients. Tramadol can also be an analegesic option for some opioid-tolerant patient due to its lower abuse potential. But tramadol alone cannot prevent withdrawal or provide adequate analgesia.12
As discussed, use of a combination of long-acting and short-acting oral agents is recommended. Relying solely on PRN medications is not advisable for such patients because these may not be given promptly, and withholding them can make patients feel as if they are "begging" for pain medication.11
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Methadone should be used to prevent opioid withdrawal symptoms.2 Methadone has been used successfully in place of morphine when the latter failed to provide adequate analgesia in opioid-dependent patients because methadone acts on receptors that have not developed tolerance.10 For patients whose opioid consumption can't be quantified, the literature suggests starting patients on 15 mg to 20 mg of methadone orally. Patients should be closely monitored for signs of withdrawal or narcotic overdose, and the regimen should be adjusted accordingly. If withdrawal begins, an additional 10 mg of methadone should be added every 6 hours until a stable regimen is achieved. At that point, daily doses should be administered.1 Due to methadone's long half-life, clinicians should monitor for toxicities such as respiratory depression or symptomatic cardiac arrhythmias such as prolonged QT interval or torsades de pointes.16 Table 5 provides a summary of the appropriate treatment of acute pain in patients receiving opioid agonist therapy.1,11
Other Adjuvant Analgesics
Nonopioid systemic analgesics play an important role for patients receiving long-term opioid therapy. Several drug classes have been studied, particularly ketamine, NSAIDs, acetaminophen, dextromethorphan, dexmedetomidine and gabapentin.
Ketamine, an N-methyl-D-aspartate (NMDA) antagonist, is especially useful for these patients when combined with opioids.17 Evidence shows that NMDA receptors play a major role in the development of drug tolerance to opioids. Ketamine may alleviate the pain not only by its direct analgesic effects or by preventing sensitization of nociceptive pathways within the central nervous system, but also by reducing or reversing opioid tolerance and opioid-induced hyperalgesia.17 Several studies found that initiation of ketamine intraoperatively reduces by 30% to 40% the amount of narcotics required in opioid-naïve patients. One study showed a similar opioid-sparing effect in patients receiving long-term opioid therapy.18 Further study about the role of ketamine in managing acute pain in these patients is needed.
Nonpharmacologic modalities such as transcutaneous electrical nerve stimulation, deep rhythmic breathing, relaxation, heat and cold, massage, imagery and behavioral therapy can help minimize the amount of psychoactive medication required. Neuraxial opioids (dosed with or without local anesthetics) and regional nerve blocks are other options to consider.
Discharge and Follow-Up
Patients should be educated about realistic goals for acute pain treatment - in particular that they will never be pain free. The goal of treatment should be to get to a point at which they can achieve functional goals and maintain an acceptable level of pain relief. If a patient requires opioid analgesics for pain upon discharge, several guidelines should be followed. Of priority is a contract specifying the pain medication prescription, number of pills, dosing interval and actions if the prescription is lost.14 Clinicians must emphasize that only a single provider will prescribe and monitor medication use, and that frequent follow-up visits are necessary.
Initiation of any type of treatment, with or without opioids, should include a pretreatment agreement between the patient and the provider for random, witnessed drug screens at 1-month, 3-month and 6-month intervals.19 The same regimen should be adhered to after therapy has been discontinued.19 Chemical dependency treatment is also recommended, including community-based Alcoholics Anonymous or Narcotics Anonymous, as a prerequisite to receiving opioids. Principles for formulating effective pain management are presented in Table 6.20
The discharge plan should involve the patient's family or significant others. Referral to a pain specialist may be necessary if patients are on high doses of medication in the hospital and need assistance being weaned from the medication after discharge. A close relationship with an addiction counselor, support group leader and others in recovery may provide the social support necessary for enhancing coping strategies for remaining drug-free.14 In addition, evaluation by a psychologist and regular follow-up with a social worker should be incorporated into the treatment plan. Finally, clinicians should consider referring the patient to a detoxification center or at least to a methadone maintenance program.
Complicated and Challenging
Treating acute pain in patients with a history of substance abuse is complicated and challenging.
Fears that opioid analgesia will cause addiction relapse or respiratory or central nervous system depression are unfounded. Clinicians should not allow concerns about this or about being manipulated to cloud their clinical judgment. Viewing these patients as having a chronic medical condition, rather than a moral shortcoming, will assist in effectively and compassionately providing healthcare.11 Working with opioid-dependent patients can cause frustration, and clinicians can minimize this by gaining each patient's trust and by successfully providing adequate pain relief when necessary.
1. Alford DP, et al. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006;144(2):127-134.
2. Wintle D. Pain management for the opioid-dependent patient. Br J Nurs. 2008;17(1):47-51.
3. Morgan BD. Knowing how to play the game: hospitalized substance abusers' strategies for obtaining pain relief. Pain Manag Nurs. 2006;7(1):31-41.
4. Chuck B. The long-term use of opiates for pain control. Laputa revisited? AANA J. 2005;73:62-69.
5. Iocolano CF. Perioperative pain management in the chemically dependent patient. J Perianesth Nurs. 2000;15(5):329-347.
6. Collen M. Opioid contracts and random drug testing for people with chronic pain-think twice. J Law Med Ethics. 2009;37(4):841-845.
7. Cone EJ, Caplan YH. Urine toxicology testing in chronic pain management. Postgrad Med. 2009;121(4):91-102.
8. Arnold R, et al. Opioid contracts in chronic nonmalignant pain management: objectives and uncertainties. Am J Med. 2006;119(4):292-296.
9. Layzell M. Current interventions and approaches to postoperative pain management. Br J Nurs. 2008;17(7):414-419.
10. Mehta V, Langford RM. Acute pain management for opioid dependent patients. Anaesthesia. 2006;61(3):269-276.
11. Grant MS, et al. Acute pain management in hospitalized patients with current opioid abuse. http://www.medscape.com/viewarticle/557043
12. Huxtable CA, et al. Acute pain management in opioid-tolerant patients. A growing challenge. Anaesth Intensive Care. 2011;39(5):804-23.
13. Habor PS, et al. Management of injecting drug users admitted to the hospital. Lancet. 2009;374(9697):1284-1293.
14. Ziegler PP. Safe treatment of pain in the patient with a substance use disorder. Psychiatric Times. http://www.psychiatrictimes.com/articles/safe-treatment-pain-patient-substance-use-disorder
15. D'Arcy YM. Meeting the challenges of acute pain management: Pain assessment for acute pain. http://www.medscape.org/viewarticle/574105_2
16. Brown R, et al. Methadone: applied pharmacology and use as adjunctive treatment in chronic pain. Postgrad Med J. 2004;80(949):654-659.
17. Carroll IR, et al. Management of perioperative pain in patients chronically consuming opioids. Reg Anesth Pain Med. 2004;29(6):576-591.
18. Angst MS, Clark JD. Ketamine for managing perioperative pain in opioid-dependent patients with chronic pain: a unique indication? Anesthesiology. 2010;113(3):514-515.
19. Stanley AH, Safford MM. Treating chronic pain in the presence of substance abuse. J Natl Med Assoc. 2004;96(8):1102-1104.
20. Prater CD, et al. Successful pain management for the recovering addicted patient. Prim Care Companion J Clin Psychiatry. 2002;4(4):125-131.
Tatyana Shuster is a nurse practitioner specializing in acute pain management and anesthesia at the Cleveland Clinic in Cleveland. She has completed a disclosure form and reports no relationships related to this article.