@FeliciaJCox. Caring for the person with addiction in the acute pain setting. Felicia Cox FRCN MSc RN

Transcription

1 @FeliciaJCox Caring for the person with addiction in the acute pain setting Felicia Cox FRCN MSc RN

2 Disclosures Editor - British Journal of Pain Associate Editor - Pain Clinical Updates (IASP PAIN Reports) Co-Editor - IASP Acute Pain SIG newsletter Chair - Royal College of Nursing Pain and Palliative Care Forum Honorary Member - British Pain Society I have received honoraria for acting as an advisor and speaker for a number of pharmaceutical companies

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4 Commonalities between groups Addiction Dependence on illicit opioids Chronic pain Dependence on prescribed opioids

5 Opioid induced hyperalgesia Increased pain sensitivity Commonalities between groups Opioid tolerance Reduced opioid effectiveness Risk of opioid withdrawal if unable to take usual drugs Increased sympathetic nervous system activity, increased stress, increased acute pain

6 Undertreatment of pain: Challenging behaviour Increased stress responses Self medication Patients with addiction Overtreatment of pain: Diversion Short acting opioids more reinforcing and more likely to trigger relapse BUT slow acting analgesics not as responsive to acute pain treatment

7 Patients with addiction Other drugs of addiction Withdrawal Psychiatric co-morbidities Anxiety and depression 5-46% Personality disorder 25-90% Not an appropriate time for opioid withdrawal but may provide a teachable moment to engage with chronic pain or addiction services Stromer W, Michaeli K, Sandner-Kiesling A. (2013) Eur J Anaesthesiol. 30(2):55-64.

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11 Patients with addiction There is often no right answer Managing pain and managing risks requires communication with patients & team assessment development of a treatment plan close monitoring reviewing of treatment as needed. An acute pain team to ensure good management of pain Access to addiction team Action on Addiction (2013) The management of pain in people with a past or current history of addiction.

12 Non-opioid substances of misuse Stimulants Amphetamines Khat Cocaine Depressants Alcohol Barbiturates Benzodiazepines Hallucinogens Cannabis Synthetic cannabinoids Mescaline Lysergic acid diethylamide (LSD)

13 Non-opioid substances of misuse Stimulants Amphetamines Khat Cocaine Depressants Alcohol Barbiturates Benzodiazepines Hallucinogens Cannabis Synthetic cannabinoids Mescaline Lysergic acid diethylamide (LSD)

14 Non-opioid substances of misuse Stimulants Amphetamines Khat Cocaine Depressants Alcohol Barbiturates Benzodiazepines Hallucinogens Cannabis Synthetic cannabinoids Mescaline Lysergic acid diethylamide (LSD)

15 OST retention and acute pain Study of 12 month outcomes of patients on opioid substitution therapy (OST) +/- an acute pain episode Acute pain reduced 12 month retention by 40% Greater impact if on buprenorphine rather than methadone Worst outcome if pain was poorly treated: 80% less likely to stay on maintenance plan Bounes V, Palmaro A, Lapeyre-Mestre M et al (2013) Pain Physician 16(6): E739 47

16 Patients on long-term opioids Opioid induced hyperalgesia Increased pain sensitivity Need for optimal multimodal analgesia Ketamine Opioid tolerance Reduced opioid effectiveness Higher opioid dose where needed Gabapentin, pregabalin Risk of opioid withdrawal if unable to take usual drugs Continue baseline opioids Clonidine, gabapentin, pregabalin

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19 Buprenorphine Subutex 8mg buprenorphine hydrochloride Maximum 24mg/day >16 years old Suboxone 2mg naloxone hydrochloride + 0.5mg naloxone dihydrate or 8mg naloxone hydrochloride + 2mg naloxone dihydrate Maximum 32mg/day >15 years old

20 Buprenorphine Partial agonist at mu receptor Strong receptor affinity Low intrinsic activity At high doses for OST (16-32mg), full receptor occupancy Given SL once every 1 or 2 days to suppress symptoms of opioid withdrawal Duration of analgesic effect is much shorter More recent evidence: continue usual buprenorphine as with any other opioid tolerant patient Greenwald MK, Johanson CE, Moody DE et al. (2003) Neuropsychopharmacology 28: Macintyre PE, Russell RA, Usher KA et al (2013) Anaesth Int Care. 2013;41(2):

21 Strong opioid agonist µ receptor Analgesia Methadone Some agonist activity κ and δ receptors Anti-tussive Depression of respiration Nausea and vomiting Constipation

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23 Extra information needed Reliability of methadone dose Additional drug misuse Heroin Benzodiazepines Gapentinoids Alcohol Cannabis Prescription opioids Hepatitis and HIV status Liaison with drug rehab services: Drug collection Useful for discharge planning

24 Support during hospital admission Highly anxious about unplanned drug withdrawals During ED waits Early in admission when OST not prescribed Fear of being stigmatised, not believed Fear of pain Previous poor experiences Need understanding and non-judgemental communication to develop rapport and trust Realistic expectations

25 Support during hospital admission Highly anxious about unplanned drug withdrawals During ED waits Early in admission when OST not prescribed Fear of being stigmatised, not believed Fear of pain Previous poor experiences Need understanding and non-judgemental communication to develop rapport and trust Realistic expectations

26 Consider withdrawal management as separate to analgesia Avoiding withdrawal Continue usual opioids if able Caution with fentanyl patches if: Hypovolaemia and peripheral vasoconstriction absorption Pyrexia absorption Sweating absorption Continue OST Assess withdrawal symptoms with COWS

27 Clinical Opioid Withdrawal Scale (COWS) Resting pulse Sweating Restlessness Pupil size GI upset Bone & joint pain Tremors Goosebumps Yawning Anxiety or irritability Tears and runny nose

28 Withdrawal prevention No oral absorption PCA background provides withdrawal prevention (PCA bolus provides analgesia) Absorbing medication with stable methadone dose Continue usual methadone (check dose with OOH prescriber) Absorbing medication with stable buprenorphine dose Continue usual buprenorphine in divided doses Absorbing medication with no reliable OST dose If COWS <5 no methadone needed If COWS 5-24 give 10mg methadone If COWS >24 give 20mg methadone Reassess with COWS every 3-6 hours Give up to max 40mg methadone per day

29 Treating nociceptive pain in a opioid tolerant patient NSAIDs (Prostaglandins) Tramadol (opioid, 5-HT, α) Clonidine (α) Paracetamol (central action) Local anaesthetics (Na+ channels) Opioids +++ (endogenous opioid receptors) Ketamine (Spinal NMDA receptors)

30 Oral absorption WITHDRAWAL PREVENTION Continue methadone OR Continue buprenorphine in 2 or 3 divided doses OR Give methadone incremental doses based on COWS score Consider alcohol withdrawal prevention PAIN MANAGEMENT Multimodal analgesia Sevredol not oramorph (10% alcohol content) PRN Strong OPIOIDS PCA BACKGROUND NSAIDS PARACETAMOL

31 No oral absorption WITHDRAWAL PREVENTION PCA background infusion Methadone 30mg/day 0.5-1mg/hr background Methadone >30mg/day 1-2mg/hr background PAIN MANAGEMENT Multimodal analgesia PCA bolus PCA BOLUS PCA BACKGROUND NSAIDS PARACETAMOL

32 No oral absorption WITHDRAWAL PREVENTION PCA background infusion Calculate iv hourly rate from usual long acting opioid, then halve it MST 60mg bd po = 120mg/day = 35 mg/day iv = 1.5mg/h iv Reduce by 50% if unwell/ septic = 1mg/h PAIN MANAGEMENT Multimodal analgesia PCA bolus PCA BOLUS PCA BACKGROUND NSAIDS PARACETAMOL

33 Acute pain management adjuvants Clonidine reduces opioid withdrawal symptoms Gabapentinoids attenuate OIH and tolerance + reduce opioid withdrawal symptoms Ketamine improves post-surgical analgesia and may reduce opioid requirements Opioid tolerant patients report Higher pain scores, have slower pain resolution with a longer hospital stay and increased readmissions Also have higher opioid requirements and higher interpatient variation in the doses needed Schug SA et al (2015) Acute pain management: scientific evidence 4 th Edn.

34 Discharge medication for patients with addiction Re-establish usual OST where appropriate Encourage engagement with addiction services Non-opioid analgesia where possible Discuss with community addiction team If facilities available, frequent pain OPD appt in first 2/52 to supervise and adjust short-acting opioid doses Consider witnessed supervision of MST with weaning doses

35 Protecting patients from inadequate analgesia Pre-op visit by APS to plan perioperative care Communicate agreed plan to perioperative teams Anaesthetist, pharmacy, psychiatry Containment plan from the pain service, particularly if poor behaviour and manipulation Good communication with key workers + GP

36 Protecting patients from opioid misuse Clear discharge plan for methadone Community plan with flare-up strategy to avoid hospital attendance ED plan to avoid readmission Collaboration with pain team and addiction services to support problem opioid use patients

37 Excess supply Accidental exposure Misuse 3 rd party access Excess supply

38 Action on Addiction (2013) The management of pain in people with a past or current history of addiction. pain_management_report final_embargoed_1 3_june.pdf Further reading Quinlan J, Cox F (2017) Acute pain management in patients with drug dependence syndrome PAIN Reports 00 e611 Schug SA et al (2015) Acute pain management: scientific evidence 4 th Edn. Canberra, ANZCA Wesson DR, Ling W (2003) The Clinical Opiate Withdrawal Scale (COWS) Journal of Psychoactive Drugs 35(2) 253 9

39 Keep RCN Pain and Palliative Care APSIG IASP