Evidence Based Nursing Practice Group 7 The Narcotic Tolerant Patient and Their Pain Management

1. Evidence Based Nursing Practice Group 7 The Narcotic Tolerant Patient and Their Pain Management Stephanie Bycroft Kaitlyn Baldwin Jessica Olcheske

2. Opioid-tolerant patients are often at risk of their pain being underestimated and undertreated (Bourne, 2010).

3. In this group we come from a diverse nursing background. We have an Emergency Room nurse, a Surgical nurse and a Special Procedures nurse who works in the Angio department. One of the common factors that we all deal with is helping our patients with their pain management goals. Nurses throughout different practices at one point or another have had to help individuals manage their pain and when their patients already take narcotics it makes treating their pain more difficult. This project hopefully will show that it is possible to help our patients manage their pain. Background

4. P I C O Question How does the postoperative patient with narcotic tolerance perceive pain management using the numeric pain scale?

5. Review of the Literature

6. Postoperative pain management- the influence of surgical ward nurses. Journal of Clinical nursing. Ene MSC, Rn, Nordberg PhD, MD, Bergh PhD, RN, Johansson PhD, RN, Sjostrom PhD, RN Despite clinical practice guidelines, patient postoperative pain is still problematic and unsatisfactory. The article states that nurses have the theoretical knowledge about pain management but that it is not necessarily implemented in treating pain. To find this information a survey was given to nurses and patients on two urology surgical units in 2000 (part I) and 2003-2004 (part II). Pain was assessed through the VAS scale and documented, with this pain management was also documented. The study showed that many nurses did not assess pain regularly, especially during activities and did not document patient pain levels in charts. The article points out that patients experience the pain while nurses are determining the treatment plan and that there tends to be a lack of agreement between patients and nurses pain perceptions. Many nurses also rely on non-verbal signs of pain versus reported pain levels which hinders the pain assessment and management process. The study showed that nurses often underestimate severe pain and overestimate mild pain. The articles states the limitations include a small number of nurses and patients. The study makes a great observation that in 2 years with added educational classes the use and documentation of the pain assessment tools has not increased and pain management continues to be an issue for many patients.

7. Nurses strategies for managing pain in the postoperative setting Pain Management Nursing Manias PhD, RN, Bucknall, PhD, RN, Botti PhD, RN This article was based on an observational study rather than a survey or interview study. It was noted in the article that surveys and interview methods can be inaccurate due to being self reported. The study took place on two surgical wards within one hospital over 6 observation times using 316 patients and 52 nurses. The six themes studied were managing pain effectively; prioritizing pain experiences; missing pain cues; regulators and enforcers of pain management; preventing pain; and reactive management. Limitations to the study include nurses increased awareness of pain management due to being observed and audiotape. Another limitation is using one hospital and only two surgical floors. This article states that decreasing deficiencies in communication; interventions should be aimed at improving how information is conveyed can improve pain treatment. Attention is also needed in helping nurses manage competing activities with pain treatment and patient needs. The study showed that the problem with pain management does not come from needing new methods, but using the current methods and communicating with staff and patients.

8. Perioperative Pain Management in the Opioid-Tolerant Patient with Chronic Pain: An Evidence-Based Practice Project Journal of Perianesthesia Nursing singKaren M. Dykstra, BSN, RN, CPAN This article described a project to improve the care of patients who are undergoing surgery and are opioid-tolerant. This was a hospital wide initiative that used evidence-based practice to change how pain was managed with this patient population. This article is a level four strength of the evidence because it was the opinion of nationally recognized experts that was based on research evidence and clinical practice. The identification of problems associated with pain management included analgesic gaps which occur when the patient does not take their medication before surgery. Other shortfalls include postoperative analgesia orders are not sufficient to address the patients pain. Another problem addressed in this article was patients underreport the amount of medication they take for fear of being judged on the amount of usage thus creating undertreatment of the chronic pain. The evidence-based process was a multimodal approach including pharmacists, nurses, surgeons, and anesthesia providers who conducted a literature search and clinical practice based on that search. Conclusions based on the literature formulated recommendations for clinical practice. Evaluations and education was provided and ongoing performance initiatives were tracked. The limits of this research included a lack of baseline data and the target patients were those who take long acting opioids. The clinical practice neglected the other types of patients who may take opioids for recreational purposes.

9. Acute pain management in the opioid-tolerant patient Nursing Standard Nicola Bourne CNS Treating pain in patients who have a tolerance to opioids is challenging and difficult. This article provides an overview of issues that nurses need to know to address acute pain. The first issue is identifying the opioid-tolerant patient in practice. There are three main groups; patients who have cancer pain, chronic non-cancer pain, and patients who have or have had recreational addiction to opioids. Patients who are opioid-tolerant can have their pain underestimated or undertreated. This article did a great job with defining the differences between tolerance and addiction. Tolerance is when the patient is exposed to opioids on a regular basis and they require increased amounts of drugs to maintain good pain control. Addiction is a disorder which results in opioid use for the psychological and physical effects rather than for clinical pain relief. An additional issue addressed in this article is prevention of withdrawal symptoms. Withdrawal symptoms can occur if the patients do not receive the same amount of medication that they are used to having in their system. Some signs and symptoms were itemized in this article and include; sweating, tachycardia, vomiting, diarrhea, restlessness, irritability abdominal cramping and increased sensitivity to pain. This article also described multimodal techniques to treating acute pain. Chronic pain should be treated with usual regimen of medications and acute pain should be treated with additional medication such as patient controlled analgesia or ketamine administration.

10. Problem • Even with clinical practice guidelines for pain management, effectiveness, and drug administration, management of post-op pain it continues to be problematic for patients. • Surveys over years show patients still suffer from moderate to severe post-op pain even with management. • There are discrepancies between nurses and patients pain perception and postoperative management. (Ene, Nordberg, Bergh, Johansson, Sjostrom, 2008)

11. Research shows patients with opioid treatment require much higher doses of opioids postoperative compared to patients who don't take opioids, yet these patients are underdosed. • Treating chronic pain patients can present the health team with a significant challenge • Most challenging are those patients on long term opioid therapy. (Dykstra, 2012) Narcotic tolerant postoperative patient

12. Research Different research was used for data collection • One study used cross-sectional, descriptive, two-part study based on survey data from both patients and nurses on two urology surgical wards (Ene, 2008). • single group, noncomparative design was used,which included observations and individual interviews to examine pain activities in two surgical units of a metropolitan teaching hospital in Melbourne, Australia (Manias, 2005). • A four-member multidisciplinary group, drawn from the group that conducted the literature search, formulated EBP recommendations for the perioperative pain management in patients who were receiving long-term opioid therapy for their chronic pain (Dykstra, 2012).

13. According to research it is possible for patient's with narcotic tolerance to have good pain management • Using a PCA pump along with the patient's current pain medications (Bourne, 2010). • have the surgeon include non-opioid medication for pain control (Dykstra, 2012) • Educating the patient on the use of their PCA, on reporting their pain, how frequently they can have pain medication both opioid and non-opioid (Manias, 2005) Pain Management

14. The pain scale is used to determine the amount of pain that an individual is experiencing while being assessed for pain. • The scale ranges from 0-10 with 0 equating to having no pain and 10 being the highest score that a patient can assign the pain that they are experiencing • Pain is subjective to the individual who is experiencing the pain Pain Scale and Patient perception

15. Quality Improvement • Identify patients who are opioid-tolerant. • Educate staff about adequately providing appropriate pain management. • Address barriers and differentiate between tolerance and addiction. • Form a baseline of data for this patient population to measure pain management and multimodal pharmacologic interventions. • Continuously monitor new data and make adjustments as necessary to quality improvement initiative. (Dykstra, 2012)

16. Evidence-Based Practice • Begin pain management in preoperative stage. Notify surgeon and anesthesia provider of patients opioid tolerance. • During intraoperative and postoperative stage continue maintenance dose of opioid for chronic pain and give adequate analgesia for the new surgical pain. • Use multimodal approach for pain control. (Dykstra, 2012) • Use non-opioid analgesics on a schedule such as acetaminophen or NSAIDS. • Initiate a pain service consultation. • Use an opioid conversion chart to assist with weaning patient off of intravenous opioids to oral dose. • Expect higher doses of opioids for acute pain and management of new surgical pain. (Bourne, 2010)

17. References Bourne, N. (2010). Managing acute pain in opioid tolerant patients. Nursing Standard, 25(12), 35-39. Retrieved from: http://search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=2009502665&site=ehost-live April 06, 2013 Dykstra, K. M. (2012). Perioperative pain management in the opioid-tolerant patient with chronic pain: An evidence-based practice project. Journal Of Perianesthesia Nursing, 27(6), 385-392. doi:10.1016/j.jopan.2012.06.006 Ene, K., Nordberg, G., Bergh, I., Johannson, F., & Sjostrom, B. (2008). Postoperative pain management – the influence of surgical ward nurses. Journal of Clinical Nursing, 17, 2042–2050.doi: 10.1111/j.1365-2702.2008.02278.x Manias, E., Bucknall, T., & Botti, M. (2005). Nurses strategies for managing pain in the postoperative setting. Pain Management Nursing, 6(1), 18-29. doi:10.1016/j.pmn.2004.12.004