Building Partnerships to Address Pain Management in Persons with Addictive Illness

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Building Partnerships to Address Pain Management
in Persons with Addictive Illness

• Susan Krupnick, MSN, APRN, BC, CARN Thomas E.
  Quinn, MSN, RN, AOCN, CHPN

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Additional resources

• http//www.massgeneral.org/painrelief/addictive_il
  lness.htm

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Objectives

• Describe the current problematic environment in
  which opioids are prescribed for acute and
  persistent pain
• Describe a systematic approach to addressing the
  complex problem of managing pain with opioid
  analgesics in a patient with addictive illness
• Identify advantages to partnering as a strategic
  component of caring for patients with pain and
  addictive illness

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Case 1

• 19 yo Hispanic male
• Sickle cell crisis
• Focused request for Dilaudid hydration
• Married, one child, employed

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From Kuehn BM. Scientists Probe Ways to Curb
Opioid Abuse Without Hindering Pain Treatment.
JAMA. 2007297(18)1965-1967.
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People who use prescription opioids

• People in pain no drug problems
• Acute
• Chronic, cancer-related
• Chronic, noncancer-related
• People abusing or addicted no pain
• People abusing or addicted w/pain
• Acute
• Chronic, cancer-related
• Chronic, noncancer-related

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Addictive Illness

• In recovery (abstinent)
• Maintenance program (AKA opioid substitution
  therapy)
• methadone
• buprenorphine
• Active problematic use
• recreational use
• frank addiction

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A Problem of Definition

• No consensus definitions for
• Substance abuse
• Inappropriate use/aberrant use
• Substance use disorder
• Problematic use, but without craving or
  dependency

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Consensus definitions

• Tolerance
• a state of adaptation in which exposure to a drug
  induces changes that result in a diminution of
  one or more of the drug's effects over time.
• Physical Dependence
• a state of adaptation that is manifested by a
  drug class specific withdrawal syndrome that can
  be produced by abrupt cessation, rapid dose
  reduction, decreasing blood level of the drug,
  and/or administration of an antagonist.

Savage, et al 2003
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Consensus definitions

• Addiction
  a primary, chronic, neurobiologic disease,
  with genetic, psychosocial, and environmental
  factors influencing its development and
  manifestations. It is characterized by behaviors
  that include one or more of the following
  impaired control over drug use, compulsive use,
  continued use despite harm, and craving.
• At variance with WHO DSM-IV definitions

Savage, et al 2003
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Relationship issues

• Patient
• Psychiatric comorbidity
• Distrustful
• Anger (the difficult patient)
• Sense of helplessness
• Professional caregivers
• Compassionate blockade
• Moral superiority
• Emotional distaste
• Distrust
• Sense of helplessness

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Concerns of the person in recovery

• Relapse
• Justifiable concern
• Craving cascade
• Inadequate pain management
• Tolerance
• Ignorance or prejudice of caregiver

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Acute pain treatment
Chronic pain treatment
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Addictive illness vs pain

• Addiction a chronic neurobiological illness
• It is not illegal, immoral, unethical, or
  unprofessional to provide opioids for medical
  reasons to patient w/ addiction
• The setting of acute pain is inappropriate for
  initiating addiction tx

• Pain is preventable or manageable
• It is unethical and medically inappropriate to
  withhold opioids when they optimize pain
  management
• Recovery from surgery is the primary focus of
  care addiction is secondary

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Opioid-tolerant vs. matched controls

• Higher pain scores
• Used more post-op opioid analgesia (greater than
  a mere replacement dose)
• Fewer side effects (except sedation)
• Required more anxiolytics

Rapp et al, 1995
Opioid tolerant, pain intolerant
Peng et al 2005
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General goals of treatment

• Establish maintain adequate analgesia
• Prevent withdrawal
• For patient with history of addictive illness,
  optimize conditions for preventing relapse

Collaboration with multispecialty colleagues
improves outcome
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Best practices

• Be open forthright with patient
• Provide reassurance to decrease anxiety
• Enlist patient as active part of team
• Be aware of own biases and work to prevent them
  from interfering with careprocess consultation
  helps
• For ambulatory or post-discharge planning, enlist
  clinical/community partners

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Case 2

• 25 yo M
• cellulitis
• Hx heroin use

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Preoperative1

• A clear strategy for pain management should be
  established before surgery. May et al, 2001
• Thorough history
• Opioid (and other medication) history
• Dose Schedule

The practice of abrupt discontinuation of
methadone or other opioids before surgery is
unjustifiable.
Peng, et al 2005
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Preoperative2

• Consult/coordinate/plan for postop
  post-discharge
• PCP or other prescriber of opioids
• MMT program
• Patients community pharmacy
• Pain specialist, addiction specialist or both
• Support system
• Therapist
• AA/NA sponsor
• Family
• Patientreassurance inclusion in planning
• Anesthesiology, PATA, PACU, inpatient unit

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Postoperative

• Opioid-sparing regimen
• Regional blockage
• Ketamine
• Scheduled, not PRN, analgesics
• If PCA, use basal to replace baseline
• Anticipate higher pain score, greater frequency,
  and greater opioid use than usual for this
  surgery
• Consider anxiolytic
• Document function as well as pain score

• Alpha2 agonists
• COX-2 inhibitors

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Case PresentationTrauma patient in ED with
polysubstance dependence and multiple fractures

• Mr. K is a 59 year old Caucasian male brought to
  the ED via Life Flight from an outside hospital.
  Patient fell forward onto concrete walk onto his
  face, his wheelchair fell on top of him. Patient
  had CT of head, chest and demonstrated parietal
  lobe subdural hematoma, pneumonia, multiple
  facial fractures, rt. wrist fracture and blow out
  injury of rt. eye. Pt BAL was 3318 and urine
  toxicology opiates, marijuana. Patient also has
  history of major depression and chronic low back
  pain. Patient reports 8 pain of wrist and face
  is killing me. Physicians are reluctant to
  treat patient with opioids. What to do for? What
  to do for alcohol dependence? What else do we
  need to know?

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Formulaic Prescribing

• Weight-based dosing
• The procedure is the determinant of the amount
  duration of pain
• The patient should follow the pattern typical
  of the procedure
• The goal of rapid turnover of beds overshadows
  goal of patient comfort
• Patient progresses or is weaned from IV to
  predetermined dose of oral analgesic
• Should give as little as possible (drug seeker,
  addict)

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Needs-based Prescribing

• Individualized systematic
• Patient defines amount and duration of pain
• Begin at safe starting dose and titrate to effect
  (comfort side effects function)
• Switching from IV to oral is based on
  equianalgesic value

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• The immediate perioperative period is not the
  optimal time to attempt detoxification or
  rehabilitation management for any patient abusing
  opioids.

Mitra Sinatra 2004
Think post-discharge consultation
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Relapse

• Of concern to both patient caregivers
• Risk factors
• Drug exposure
• Unrelieved pain
• Anxiety
• Interactions with professionals that negatively
  impact self-image
• Lack of a support system that can adjust to
  increased need
• Emerging evidence that we need pay attention to
  this concern

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Case 3

• 56 yo F
• S/P mastectomy post-mastectomy pain syndrome
• Hx alcohol dependence 10 yr sobriety
• Overused opioids for pain, then resumed alcohol
  to supplement Neurontin

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Treating chronic pain is a complicated and
sensitive art. The physician is required to
balance the physical and psychological needs of
the patient against often shifting regulatory
requirements.
Michael Clark, MD, MPH. Safe and Effective Use
of Long-Acting Opioids While Navigating the
Changing Regulatory Environment. Special Report
(CME program sponsored by Johns Hopkins
University School of Medicine.)
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Questions in Search of Answers

• Are opioids efficacious for persistent pain?
• Is physiologic tolerance to opioids a clinically
  significant problem?
• Do opioid side effects or toxicities play a
  clinically significant role?
• How do opioids fit into a multimodal treatment
  approach to persistent pain?
• What is the relationship between prescription
  opioids and addictive illness in patients with
  persistent pain?
• Do prescription opioids contribute to the
  societal problem of drug abuse?

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Potential Long-term Effects
Opioids
Pain

• Pronociception
• Immunosuppression
• Hormonal insufficiency
• CNS changes
• Addiction(?)

• Pronociception
• Immunosuppression
• CNS changes
• Hormonal (androgen) changes
• Suffering

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Anchoring treatment

• Systematic approach to assessment, treatment,
  follow-up
• Collaborating/partnering
• Primary treatment
• Rehabilitation
• Supportfor both patient clinician

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Why to partner

• High rate of co-occurring conditions
• Anxiety
• Depression
• Sleeplessness
• Physical deconditioning
• Psychiatric disorders
• Number breadth of treatments for pain
• Time consuming
• Emotionally burdensome

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Partners

• Patient
• Colleagues in own practice
• Primary care clinician
• Multidisciplinary/Multispecialty
• Pain (anesthesia neurology oncology)
• Psychiatry/mental health
• Pharmacy
• Physiatry PT/OT
• Addiction specialist MMT program
• Complementary
• Community
• Family spiritual advisor
• 12-step program employer

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How to partner

• Principles
• Communicate
• Communicate
• Communicate
• Capacities limitations of partners
• Negotiate what info to share how
• Negotiate division of labor
• Support promote each other
• Negotiate consistent approach, especially with
  difficult patients

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Partner network
Primary treatment Rehabilitation Maintenance Suppo
rt Practice management

• Primary care
• Specialists
• Pain
• Psychological
• Addiction
• Physical medicine
• Community pharmacy
• Complementary therapists
• Patient family social network
• Billing/coding consultant
• Legal/regulatory consultant

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Case Presentation Patient requesting
detoxification from alcohol in the ED setting

• Patient is a 49 year old Caucasian male patient
  who presents to the ED frequently for referral
  and medical clearance for inpt detoxification. Pt
  presented with spitting up blood and labs
  indicated a drop in hemoglobin and hematocrit
  urine toxicology also reported cocaine and
  opiates and BAL 1876. Patient reports taking
  heroin for back pain, states physician will no
  longer prescribe pain medications for low back
  pain. Addiction consultant in the ED called.
  What else does the consultant need to know? Who
  else does the consultant need to speak to?
  Patient was admitted for GI bleed. Who else needs
  to be consulted once pt is admitted?

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Consultations for patient with GI Bleed and
Addictive Illness

• Pain management CNS
• Clinical nurse specialist in the unit pt was
  assigned to for inpt care
• Discussion with attending physician in the
  hospital
• Discussion with PCP
• Addiction social worker (inpt)
• Psychiatric consultation liaison nurse specialist
  (inpt)

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Partnering

• Dont go it alone
• Dont reinvent the wheel
• Who you partner with depends on your patients
  characteristics needs
• Referred by . . .
• Referred to . . .
• Intent of referral
• Expected ongoing relationship between partners

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Methadone buprenorphine

• Special attention is required for patients on
  maintenance/substitution therapy
• MMT dose prevents withdrawal, but does not
  provide significant analgesia
• Buprenorphine may provide some analgesia, but may
  block effect of other opioid analgesics at low
  doses

Coordination and frequent communication with
maintenance program is essential!
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Methadone (pain or MMT)

• Post-op pain management
• MMT
• prevents withdrawal
• does not provide analgesia
• May lower pain threshold
• Continue usual methadone dose schedule
• Use a different opioid for analgesia via PCA with
  basal dose
• Use opioid-sparing techniques

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Best practices with opioid substitution

• Carefully assess patient history current
  substance use
• Continue methadone or buprenorphine schedule
  dose
• Anticipate need for higher than average doses
  and shorter dose interval
• Multimodality opioid-sparing pain tx

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Case 4

• 53 yo male
• old back injury, s/p 3 surgeries, failed back
  surgery
• Hx 3 surgeries for renal stones, sent to ED by
  PCP for excruciating left flank pain

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Partnership

• PCP referral w/ request for addictions consultant
  in ED
• ED attending
• Pain team recommendations
• ED nurse pain champion
• Psych/addictions NP in ED
• Pain CNS
• Pain Team NP
• Inpt Psychiatric Consultation Liaison Nurse
• Ambulatory satellite clinic SW liaison

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Partnerships in Providing the Best Care Possible

• Remember, complex situations require complex
  solutions that are best crafted by a team of
  experts in their field. You should never worry
  alone seek out consultation for you and your
  patients

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Additional resources

• http//www.massgeneral.org/painrelief/addictive_il
  lness.htm