Substance Abuse and Pain Management

1. Substance Abuse and Pain Management BY Linda York, RN, PhD, PMHCNS-BC

2. DRUG ADDICTION IS A COMPLEX ILLNESS www.drugabuse.gov

3. DRUG ADDICTION IS A COMPLEX ILLNESS www.drugabuse.gov

4. www.drugabuse.gov

6. Narcotic Drug such as cocaine, heroin, or marijuana that affects the brain and that is usually dangerous and illegal Drug that is given to people in small amounts to make them sleep or feel less pain Merriam-Webster Dictionary

7. Opiates/Opioids • Opiate—containing opium or one or more of its natural derivatives. Ex—morphine and codeine • Opioids—semi-synthetic or synthetic that resembles naturally occurring opiates. Ex—heroin, fentanyl, oxycodone, hydrocodone

9. Controlled Substance Act1970 • Schedule I—no currently accepted medical use in US. Ex—heroin, MJ, LSD • Schedule II—high potential for abuse. Ex-methadone, oxycodone, methylphenidate, amphetamine • Schedule III –less potential for abuse than Schedule II. Ex—hydrocodone, codeine combination products

10. Schedule IV—benzodiazapines • Schedule V—cough meds with not more than 200mg codeine

11. Why Do People Use Alcohol and Drugs? • To feel good—substances produce intense feelings of pleasure • To feel better—especially from anxiety, stress, depression • To do better—improve performance • Curiosity—to see what it is like, others are doing it

12. DEFINITION OF ADDICTION • Chronic, relapsing, treatable disease of the brain. • Characterized by craving, dysfunctional behaviors, & inability to control impulses regarding consumption of substance with compulsive use despite harmful consequences. (ASPMN, 2012)

13. TOLERANCE • State of adaptation in which exposure to drug result in changes which diminish drug’s effects over time. • Usually manifested after 2-3 weeks of use • Tolerance to alcohol creates tolerance to opioids

14. Physical Dependence • State of adaptation which results in withdrawal symptoms when there is abrupt cessation, rapid dose reduction, and/or administration of antagonist. • Predictable with prolonged use • Other meds produce dependence such as beta blockers, corticosteroids • Physical dependence does not equal addiction

15. Pseudoaddiction • An iatrogenic syndrome created by undertreatment of pain. Many of the same behaviors are exhibited as in addiction. These behaviors resolve once pain is adequately treated.

16. Behaviors Commonly Associated with Addiction

17. Compulsive Use • Pattern of behavior in which person focuses on obtaining, using and recovering from effects of use. • Daily activities revolve around use.

18. Impaired Control • Person takes larger amounts and/or for longer periods of time than intended. • Unable to cut back or quit using substance. • Attempts to restrict use (time of day, certain days/events)

19. Cravings • Pre-occupation with substance—”gotta have it” • Difficult to stop thinking about the substance • Major factor in use and relapse

20. Behaviors Commonly Associated with Pain Relief Seeking (drug seeking) What has patient done to cause us to believe they are drug seeking (addicted)? Are there other ways to explain the behavior?

21. Could the patient be seeking pain relief rather than drugs for non-medical use? • Are we blaming the patient rather than treatment plan (McCaffery, 1999)

22. Requesting an Increase in Dose • There is no set dose of opioids which is safe and effective for all patients. • Look at the patient, not the dose • Patient history • Tolerance

23. Requesting Specific Drugs • If the patient was requesting specific meds for other conditions such as diabetes, high blood pressure, skin rash etc, what would you think?

24. Some Aberrant Behaviors Associated with Substance Use • Injecting oral or transdermal formulations • Concurrent use of ETOH or illicit drugs • Multiple dose escalations or other non-compliance despite warnings • Selling prescription drugs • Prescription forgery • Stealing or “borrowing” drugs from others

25. Evidence of declining ability to function at work, in family, or socially that appears to be related to drug use. • Repeated resistance to changes in therapy despite clear evidence of adverse effects of drug. (Benedict, 2008)

26. SPECIAL POPULATIONS • Patients in recovery -Discuss with pt ahead of time intent/need to use opioids, benzos etc -Explain risks of untreated/undertreated pain -Encourage pt to discuss concerns

27. Methadone maintenance • Pt should remain on scheduled dose unless contra-indicated medically • Maintenance dose should not be used for analgesia • Can add another opioid or increase methadone dose • Methadone given for analgesia requires >qd dosing

28. NURSING INTERVENTIONS • Consider psychiatric co-morbidities (anxiety and depression) • Educate pt about different types of pain and their treatments • Consider approaches other than meds— acupuncture, meditation, music, relaxation, exercise, distraction (most effective with chronic pain)

29. To Summarize • Pain adequately treated results in improvement of functioning and quality of life • Look for patterns of behavior, not isolated incidences

30. Assessment for Alcohol • Moderate ETOH use-no more than 1 drink/d for females. No more than 2 drinks/d for males. • Standard drink—12oz beer, 5oz wine, 1 to 1.5oz spirits. • Incorporate screening questions into your assessments. • Start with less threatening items such as caffeine and tobacco

31. Sample Questions • On average, how many days/wk do you drink ETOH? • When you do drink, how many drinks do you usually have? • What is greatest number of drinks you have had in past month? • When was last time you had a drink?

32. Avoid • Asking pts if they drink, assume they do. • Asking yes or no questions. • Assuming you know what someone with ETOH problems looks/behaves like. • Stereotyping

33. Assessment for Withdrawal Can begin as soon as 3 hrs or up to 7 days after last drink. Peak is at 48-72hrs. Early stages • Includes—tremors, anxiety, n/v, insomnia, diaphoresis, elevated HR and B/P, irritability, restlessness

34. Later stages including withdrawal delirium In addition to above • Disorientation to time, place, person • Perceptual disturbances (visual and/or tactile hallucinations) • Fluctuating levels of consciousness from lethargy to hyperexcitability

35. Interventions • Correction of fluid and electrolyte imbalances • Correction of vitamin/mineral deficiencies thiamine, folate, multivitamins • Benzodiazapines—Librium or Ativan. • Use Ativan in elderly or those with impaired liver functioning.

36. Continuing Care • Residential treatment • Intensive outpatient program • Outpatient therapy • Alcoholics Annonymous

37. Case Study Care of the Patient with Alcohol Abuse and Pain Management Issues

38. 30 yo female admitted to Orthro service after failing down flight of stairs • Sustained compound fx lower extremity requiring surgical repair • States “she doesn’t drink much” • BAL—286 in ED • Family states pt drinks 6(12oz) beers 2-3d/wk • Third time in past 2 yrs pt has had fx

39. Post –Op Day 2 • Pt is prescribed hydrocodone 5mg/acetomimophen 325mg one tab q 6h for pain • She complains “pain meds aren’t helping me” • Demands MD be notified

40. What is your assessment? • Does pt have tolerance to ETOH? • How adequately is pain being treated? • What will you say when you talk with MD?

41. Case Study of PatientwithOpioid Dependence

42. Pt is 68 yo male admitted to Medicine Service with complaints of fever and chills • Has open, draining wound to forearm • Uses 1gm heroin IV qd, last use ~24h PTA • In addition to antibiotics pt is prescribed oxycodone 5mg/acetominophen 325 mg 2 tabs q 4h prn pain

43. On day 3 of admission pt states “I need something else for pain. I feel terrible. I’m having withdrawals too.” • How will you address pt request for pain meds? • How will you address pt request for his”withdrawals”?

44. My Contact Information • Linda York • Office—314-362-8887 • Cell—575-7815