Pain Management in Persons with Substance Abuse

Transcription

1 Pain Resource Nurse Program Pain Management in Persons with Substance Abuse Joseph R. Ineck, Pharm.D.,CPE Clinical Pain Lead Resource Oral Chemotherapy Nurse Program Program Mountain States Tumor Institute Module 8 St. Luke s Health System 4/11/2015 Copyright Scope of the Problem Misuse, Abuse, Addiction in the United States 10-1

2 Prevalence Rates are Plagued by Terminology Problems No uniform definition of substance abuse DSM-IV-TR definition of substance dependence includes common effects of opioids taken by patients in pain Tolerance and withdrawal Large amounts over a period of time Unsuccessful effort to cut down amount Use of DSM criteria could lead to an apparent increased incidence of substance dependence in persons treated with opioids for pain Critical that nurses know the definitions of terms 8-3 DSM-IV Addiction Definition Substance dependence, or addiction, as defined by the DSM-IV,is indicated by the presence of three or more of the criteria listed below in the last 12 months. Note that all but the first two criteria reflect some form of loss of control over the use of or effects of the drug. Tolerance:Does the patient tend to need more of the drug over time to get the same effect? Withdrawalsymptoms:Does the patient experience withdrawal symptoms when he or she does not use the drug? Continued use of drug despite harm:is the patient experiencing physical or psychological harm from the drug? Loss of control:does the patient take the drug in larger amounts, or for longer than planned? Attempts to cut down:has the patient made a conscious, but unsuccessful, effort to reduce his or her drug use? Salience:Does the patient spend significant time obtaining or thinking about the drug, or recovering from its effects? Reduced involvement:has the patient given up or reduced his or her involvement in social, occupational or recreational activities due to the drug?

3 True Or False If a person goes into withdrawal, they must be addicted. FALSE 8-5 Physical Dependence Definition Physical dependence is 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 Normal predictable, physiological response Characterized by drug class specific physical withdrawal syndrome Can develop to opioids within a week Taper the dose to prevent withdrawal Opioid withdrawal symptoms can persist for weeks to months in some persons

4 Tolerance Definition Tolerance is a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug s effects over time Normal physiological adaptation Tolerance is less predictable than physical dependence and develops more rapidly than analgesia 8-7 Addiction 1,2 A primary, chronic, neurobiologicdisease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry 5 Cs Chronic Compulsive abuse Control is lost Craving Continued abuse despite harm 1 Adapted from: American Academy of Pain Medicine, American pain Society, and American Society of Addiction Medicine. Consensus document Available at: Accessed Savage SR. Assessment for addiction in pain-treatment setting. Clin J Pain. 2002;18:S28-S

5 Addiction A Neurobiological Disease The neurobiology of addiction encompasses more than the neurochemistry of reward There is altered impulse control, altered judgment, and the dysfunctional pursuit of rewards Susceptible individuals may have an alteration of the limbic or related system that causes sensitization to the reinforcing effects of drugs 8-9 Rate Effect PAIN & ANALGESIA CENTER PAG Nucleus Accumbens PLEASURE CENTER Locus Ceruleus Raphe Nucleus Mesolimbic System PAG = periaqueductal gray Nelson RA, et al., Effect of rate of administration on subjective physiological effects of intravenous cocaine in humans. Drug and Alcohol Dependence 82 (2006) McCaffery and Pasero Pain: Clinical Manual p Mosby Inc

6 Addiction: A Multi-factorial Disease State Psychology Environment Availability & Milieu Biology Innate Acquired * Drug Reinforcement * Manifestation of the disease of addiction 8-11 The Pathways of Addiction Persistent Use Addiction Intermittent relapse Abstinence

7 Addiction Behavioral Manifestations A Inability to consistently Abstain B Impairment in Behavioral control C Craving; or increased hunger for drugs or rewarding experiences D Diminished recognition of significant problems with one s behaviors and interpersonal relationships, and E A dysfunctional Emotional response 8-13 Not Addiction! Physical dependence Tolerance Pseudoaddiction

8 Pseudoaddiction Results from the undertreatment of pain Manifested by behaviors similar to addiction Clock watching Focus on obtaining drug Aberrant behaviors Behaviors resolve when the pain is effectively managed 8-15 Definitions 1 Abuse Taking a substance or medicine for non-medical reasons like getting high Experimentation Episodic substance abuse Addiction a neurobiological disease 1 Diversion taken out of legal chain of custody Selling or trading medicines for profit or favors 1 American Pain Society. Definitions related to the use of opioids for the treatment of pain. Available at: Accessed

9 Prevalence of Addiction/Substance Abuse In the General Population In 2013, 21.6 million persons (8.2% of those 12 years or older) were classified with substance dependence or abuse (DSM-IV criteria) Drugs with highest level of abuse were: Marijuana 19.8 million users: 7.5% Pain relievers 4.5 million users: 1.7% Cocaine 1.5 million users: 0.6% Hallucinogens 1.3 million users: 0.5% Inhalants ~500,000 users: 0.2% Heroin ~300,000 users: 0.1% Substance Abuse and Mental Health Services Administration. (2013). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. Retrieved October 1,2014, from Addiction A Serious Public Health Problem In treatment United States Population ~ Million Million (11%) Abusers/Addicts needing treatment (alcohol, drugs) 22.7 Million (8%) 1 Orford J. Conceptualizing addiction: addiction as excessive appetite. Addiction. 2001;96: Substance Abuse and Mental Health Services Administration (SAMSHA) National Survey on Drug Use and Health 8-18 Highlights. US Dept of Health & Human Services. Available at: Accessed

10 Prevalence of Addiction/Substance Abuse In Persons Treated with Opioids Reported rates vary depending on definition used and population studied Prevalence does not appear greater than in the general population except in patients with a current or past history of substance abuse or psychiatric co-morbidities 8-19 Recognition Identifying Medication and Substance Abuse 10-10

11 Broaching the Subject 1 1. Biggest initial obstacle to helpful discussion is how to broach the subject and initiate some form of constructive dialogue. 2. General approach is to ask open-ended questions that allow exploration of the person s motivational state without generating significant resistance. Closed questions, likely to evoke resistance: You drink quite a bit, don t you? It seems like you have a problem with marijuana; don t you agree? Don t you think that your cocaine habit is a big cause of this problem? Open-ended questions, to open discussion: Tell me about your drinking in a typical week? What do you enjoy about smoking pot? How does cocaine fit in here? 1 Borrelli B. Using motivational interviewing to promote patient behavior change and enhance health Medscape Available at: Accessed Substance use and abuse Part of the general medical history Non-judgmental, matter-of-fact attitude 1 Start general, get specific How often do you drink alcohol these days? Exaggerating range offers tacit permission to acknowledge heavy use 1 e.g., Do you drink a case or two on a Friday night? How often do you use marijuana or other drugs? Attitudes Why do you drink/use drugs? Do you have health concerns about your alcohol/drug use? 1 Savage SR. Assessment for addiction in pain-treatment settings. Clin J Pain. 2002; 18 (4Suppl):S28-S

12 Assessment: Interview Tips **Be nonjudgmental** Explain importance of information Feelings of impending withdrawal does drug use helps relieve pain or other problems Be aware of stages of change problems or side effects Use established assessment tools 8-23 Track marks and skin-popping scars Skin-popping scar Track marks

13 Intermediate Skin Popping Scar Intermediate scar 8-25 Skin Abscess on Neck Abscess

14 Perforated Septum (View into Left Nostril) Right turbinates Left turbinates Ulceration 8-27 Constricted Pupil

15 Screening Assessment Tools CAGE-AID Two-Item Conjoint Screening (TICS) for Alcohol & Other Drug Problems Drug Abuse Screen Test (DAST): 28 or 10 items Screener and Opioid Assessment for Patients in Pain (SOAPP) The Opioid Risk Tool (ORT) 8-29 Pain Management Guidelines for Patients with the Disease of Addiction Team approach with case conferences Set realistic goals Treat depression and comorbid psychiatric problems If possible, treat the cause of the pain Try nondrug methods of pain control Maximize nonopioids and adjuvants Choose long-acting opioids when possible Minimize short-acting PRN doses if possible Consider tolerance - patients with abuse history usually require higher doses

16 A Multidisciplinary Team Physician Nurse Addiction Specialist Patient Psychologist/ Counselor Sponsor Social Worker Pharmacist 8-31 Pharmacist Role Collaborate with other health care team members Assess for the presence of pain/addiction and related symptoms such as anxiety and depression Assess, document, and report aberrant behaviors Advocate for effective pain management Provide ongoing communication with the family

17 Challenges to Pharmacist Behaviors that seem manipulative Favoring one provider over another Complimenting specific persons who respond to requests Exhibiting anger when needs are unmet Requesting IV medications be given fast CONSISTENCY is the key to working with this population..be CAREFUL about making exceptions 8-33 Assess and Document Outcomes of Opioid Therapy Analgesia Pain relief Activities of Daily Living Physical, social and emotional function Adverse Events Side effects or other adverse events Aberrant Drug-Related Behaviors Behaviors suggestive of addiction

18 Analgesia Goal is to provide pain relief Increased comfort should improve the patient s quality of life Perform and document routine pain assessments: Average pain during the past week (0-10) Worst pain during the past week (0-10) % of pain relief in the past week 8-35 Activities of Daily Living Goal is to increase activities of daily living Pain relief should improve function Conduct a routine functional assessment: Physical functioning Mood Sleep Relationships Family and Social Networks Overall

19 Adverse Events Goal is to minimize adverse events Adverse events could affect adherence Conduct a routine assessment of side effects: GI: Constipation, nausea, vomiting CNS: Mental clouding, drowsiness, fatigue Other: Itching 8-37 Aberrant Drug-Related Behaviors Goal is to detect aberrant drug-related behaviors early on to prevent abuse, diversion and protect the practice of pain management Consider Cultural norms Less predictive behaviors More predictive behaviors

20 Aberrant Behaviors: Cultural Norms? Borrowing drugs from family and friends Hoarding drugs With improvement of symptoms With resolution of the problem 8-39 Less Predictive Aberrant Behaviors Drug hoarding when symptoms are improved Acquiring drugs from multiple medical sources Aggressive demands for a higher dose Unapproved use of a drug to treat a symptom, e.g., use of an opioid to treat anxiety Unsanctioned dose escalation (1-2x) Reporting psychic effects Requesting specific drugs

21 More Predictive Aberrant Behaviors Selling prescription drugs Forgery of prescriptions Concurrent illicit drug use Multiple prescription/medication losses Ongoing unsanctioned dose escalations Stealing and borrowing drugs Obtaining prescription drugs from nonmedical sources Non-sanctioned route of administration Repeated resistance to change inflexibility 8-41 Causes of Aberrant Behaviors Addiction or pseudoaddiction? Psychiatric disease Personality disorder Depression, anxiety Organic encephalopathy Situational stressors Chemical coping Criminal intent

22 Risk Factors for Addiction/Substance Abuse Family history of substance abuse Legal problems Personal drug or alcohol abuse Mental health problems Multiple motor vehicle accidents Cigarette smoking Reporting fewer side effects High opioid dose 8-43 Opioid Agreements Written documents signed by both clinician and patient Spell out expected behaviors and consequences of these behaviors Purpose is to promote safe and effective use of controlled substances Provide informed consent on risks and benefits of long-term opioid therapy

23 Dispensing Issues One provider One pharmacy Limit the amount of medication given at any one time Weekly or 2-3 day prescriptions Utilize pill counts Assess for independent dose escalation and shortages 8-45 Urine Drug Screens Purposes Screen for illicit drugs Screen for controlled substances not prescribed Verification that patient is taking and not diverting prescribed drug Understand the limitations False positives Detection limits vary Ongoing testing needed for verification

24 12 Step Programs Programs Alcoholics Anonymous Narcotics Anonymous Can assist in the pain management plan Curtail drug abuse Minimize aberrant behaviors Attendance should be documented Difference in goals may preclude participation Drug-free versus using opioids for pain 8-47 Opioid Treatment of Patients with the Disease of Addiction Understand tolerance may be present Clear communications between staff and patient and family Avoid parenteral opioids if possible Avoid short-acting PRN formulations When possible, use long-acting opioids Combine opioids with nonopioids and use other multimodal therapies

25 Long-term Care and Follow-up Low risk patient Minimally monitored therapy Psychiatric diagnosis/altered coping Structure and psychiatric input Addiction Highest structure Urine toxicology Recovery programs Nursing role in long-term follow-up Telephone triage Patient follow-up visits 8-49 Addiction Maintenance Therapy Methadone and buprenorphine are used in addiction maintenance programs to prevent craving Methadone maintenance therapy can only be provided by Opioid Treatment Programs certified by the federal government Buprenorphine is approved for in-office treatment of opioid dependence

26 Barriers to Pain Relief Related to Addiction Healthcare professionals may underprescribe Lack of knowledge about addiction, tolerance, and physical dependence Fear of scrutiny by regulatory agencies Patients and Families Patients may be reluctant to take opioids because of fears and confusion about addiction Families may withhold analgesics from patients Healthcare Systems 8-51 Principles of Pain Management in Patients with Substance Abuse Inadequate knowledge and fear of addiction hinder pain management in all patient populations Diagnosis requires ongoing assessment of aberrant behaviors along a continuum Goals of pain management include improving analgesia and activities of daily living, and controlling adverse events and aberrant behaviors Pain management requires effective communication and a multimodal approach including drug and nondrug strategies Patients with an addictive disease present unique challenges but deserve appropriate pain management

27 Case Study Mr. Schmidt is a 28-year old man who is admitted to the ICU following a motor vehicle accident. Injuries include a broken mandible, a crushed pelvis, and fractured ribs. His blood level on admission to the ED was Urine toxicology revealed the presence of cannabinoids. He has a history of polysubstance abuse; he started drinking alcohol heavily in high school and also experimented with amphetamines. His mother and sister report that he straightened out after graduation and has been working at an auto repair shop Pain Management in the ICU Case Continued Pain is managed with a morphine drip in the ICU Pain consistently rated high 10/10 in the pelvis 8/10 ribs Staff reports that patient is on the light every hour requesting a bolus of IV morphine Patient is sleeping a lot and does not appear to be in pain Patient requests morphine be given faster for better efficacy

28 Addiction Issues Case Continued How to assess and treat pain in patients with a current or past history of abuse Consideration of tolerance issues Risk of withdrawal from a variety of substances Behavioral assessment and management (? active addiction or pseudoaddiction) 8-55 Pain Management in Rehab Case Continued Out of ICU admitted to orthopedic trauma unit Pain management regimen Morphine ER 30 mg every 8 hours Morphine sulfate short-acting mg every 3 hours as needed for pain flares Celecoxib 200 mg per day Gabapentin 3600 mg per day Pain rating 7 on a 0-10 scale Requests PRN morphine every 3 hours Friends visit frequently his behavior changes Nursing staff requests a collaborative team meeting

29 Discharge to Home Case Conclusion Patient is discharged from the hospital Continues to be on opioids for pain control Referrals Counseling Alcoholics Anonymous Chronic pain support group Outpatient rehabilitation Counseled to keep his medications in a secure location