Keeping a patient’s pain in check can be a challenge, particularly when co-morbidities or concerns about physical function affect dosing or overall management. But that balancing act becomes even more complicated when physicians are treating pain in patients who also have a drug addiction.
Related article: Treating addiction in the hospital, not just withdrawal. August 2017
Although hospitalists have legitimate concerns – including fears of potential overdose – about managing pain in addicted patients, they shouldn’t let those concerns drive medical decision-making or dosing in the wrong direction.
“Patients with addiction, regardless of the type of addiction, should be treated like any other patient post-operatively “with the appropriate medications,” says Howard Heit, MD, an assistant clinical professor at Georgetown University in Washington who specializes in addiction medicine and chronic pain management. “And if opioids are indicated, you titrate to effect, using the art and science of medicine.”
Addicted patients make up an estimated 3% to 16% of the overall population. And when treating them, plenty of complications can arise, from devising a workable opioid wean schedule to dealing with difficult patient behavior. (See “Patient behaviors and physician reactions.”)
But according to Dr. Heit, the biggest barrier to effective pain management may lie in the fears and misperceptions of treating clinicians and hospital staff.
Often, he explains, physicians give addicted patients lower doses of pain medication than they might prescribe to non-addicted patients. Doctors may even avoid opioids, even after nonopioids and adjunctive analgesics have proved inadequate, partly out of fear that patients may be just drug-seeking and not legitimately in pain.
What many physicians don’t realize is “that pain is a tremendous antagonist to euphoria, on a molecular and cellular basis,” says Dr. Heit. “The majority of patients “even those with addiction- “want pain relief and are not seeking euphoria.”
The problem with strategies that under-treat patients for pain is that patients addicted to opioids or other narcotic substances typically have high tolerance levels to begin with.
Hospitalists may, for instance, be inclined to keep morphine doses low out of fear of respiratory suppression. While that can be a valid concern, Rachelle Bernacki, MD, a geriatrician and palliative care specialist at University of California, San Francisco (UCSF), says it’s not a big risk for patients with a high tolerance level to opioids.
“Patients become tolerant to respiratory suppression quickly,” says Dr. Bernacki, “but they don’t usually become tolerant to the pain effect.”
Dr. Heit agrees that, as long as physicians use a reasonable titration schedule and careful monitoring, overdosing isn’t a major issue. “What one doesn’t want to do with a patient who has addiction and is in pain is get hung up on milligrams,” he says. “Choose the appropriate medication and titrate to effect.”
Other treatment barriers
Another big barrier to appropriate pain management for addicted patients is concerns about landing in trouble with the Drug Enforcement Agency (DEA). But physician fears about DEA sanctions, says Dr. Bernacki, are often “overblown.”
While the DEA has not set standards for treating pain in addicted patients, she says, agency regulations do not advise against using opioids as liberally as required to treat pain in addicted patients.
The agency does counsel physicians who think they need help in managing pain to consult with addiction medicine or pain specialists. But pain experts say that physicians who carefully document how they treat these patients, as well as what they prescribe and why, should be on solid ground.
Physicians may also harbor another misconception: that treating pain may derail patient efforts to recover from or manage their addiction.
In fact, the opposite is more likely to be true, according to Catherine Crone, MD, an associate professor of psychiatry at George Washington University in Washington, who specializes in psychosomatic medicine. Inadequate pain relief, she says, may trigger issues or behaviors that feed addictive disorders.
“In the hospital, physicians sometimes worry that they will make the addiction worse,” says Dr.Crone, who practices at Inova Fairfax Hospital in Fairfax, Va., and frequently consults on managing pain in addicted patients. “But if you leave the patient in pain or treat them inadequately, that puts them at higher risk for problems,” including greater anxiety, that could compromise recovery efforts.
Dr. Heit agrees. “There’s nowhere in the [12-step] program that states that the valid treatment of any medical, surgical, psychiatric or emergency condition “including pain “is contraindicated for a person in recovery,” he says. “Rational pharmacotherapy should be reserved for all who need it.”
At the same time, hospitalists who under-treat pain may run a greater risk of violating Joint Commission standards regarding the “fifth vital sign,” Dr. Heit cautions, and could find themselves in malpractice trouble by not treating pain in an addicted patient. While hospitalists clearly aren’t required to prescribe opioids, he adds, they “better give a good reason on the chart indicating why they aren’t treating the pain” if they choose other routes.
So how can hospitalists appropriately manage pain in addicted patients? Start by taking a comprehensive history regarding substance use and abuse, current and past, notes Dr.Crone “a step she says admitting physicians don’t complete often enough.
“It’s important to incorporate that history into the standard evaluation of every patient,” she says, “and to explain, if patients ask about it, that it’s an issue that may be pertinent to their management.”
When addiction is present, experts say that physicians need to acknowledge it.
“When you admit someone with addiction and with legitimate pain, the first thing to do is inform the patient of your concern about their addiction,” says hospitalist Steven Pantilat, MD, director of UCSF’s palliative care program. “At the same time, reassure that you believe them, that you see they’re in pain and you want to treat them.”
Physicians then need to take appropriate steps to ensure that the patient is “covered” for both the addiction and the pain, he adds, an approach that applies to all patients with addiction, including those in active treatment programs. Physicians should find out what patients are already taking and start with that dose for withdrawal, then add on medications separately for pain control.
“You have to separate the pain treatment from addiction treatment,” says Dr. Pantilat, explaining that a patient on methadone maintenance, for example, should receive methadone and “something else for pain.”
Physicians should tailor that “something else” to the needs of the individual patient, beginning with a good sense of what that patient is already taking, then titrating medicine and monitoring for pain relief, function and side effects. Clinicians should avoid what Dr. Heit calls an “opioid debt” where patients are given too small of a dose to be effective.
Generally speaking, nonopioids may be effective for mild to moderate pain in addicted patients, Dr. Pantilat adds. Opioids are indicated for moderate to severe pain, with bolus dosing of 25% to 50% for moderate breakthrough pain and up to 100% of the dose for severe breakthrough pain.
To avoid potentially toxic doses, patients should be frequently monitored and evaluated so that weaning can begin as soon as possible. Patients who are “drug free and doing well” on admission are easier to treat, says Dr. Bernacki, compared to those who come in testing positive for opiates in their urine.
Physicians should also make sure that only one physician is charged with prescribing pain medication and overseeing treatment. That prevents multiple doctors from combining medications, leading to even higher doses, and allows one physician to set therapeutic boundaries.
“PRN” doesn’t work
Experts emphasize that this guiding principle for treating pain in addicted patients: Avoid PRN dosing. “As far as I’m concerned,” says Dr. Heit, “PRN stands for ‘pain relief nil.’ ”
Instead, physicians should dose patients on a 24/7 schedule for general pain control, which can be achieved by administering medications through a PCA pump, with orders for incorporating oral or IV medication at 10% of the daily dose every two or three hours for breakthrough pain.
“That’s important,” says Dr. Crone, “because by the time the patient realizes he needs more medication, rings for the nurse and has the medication delivered from the pharmacy, there’s usually a big delay.”
The added importance of discharge summaries
When it comes to discharging patients, Dr. Bernacki adds this note of caution about methadone: Physicians should not prescribe methadone as a discharge medication for patients in a methadone maintenance program.
Instead, the management program should provide the medication after discharge, as well as details about dosing and patient status in treatment.
“The hospitalist should not provide the drug even as a bridge to the outpatient setting,” she explains. Dr. Bernacki says she notifies the maintenance program if she prescribes additional drugs at discharge for acute pain. For patients who need longer-term pain management, she adds, physicians should consider discharging them to a monitored setting.
Regardless of where patients go when they leave the hospital, Dr. Bernacki points out, hospitalists managing them should include detailed notes in their discharge summary on what pain medications and doses were used and what patients are being prescribed at discharge.
Dr. Bernacki relies on conversion tables readily available on the Internet to change IV to oral doses, and she makes sure to include those details. She also includes details of patients’ taper and wean schedules in the summary as well.
“You don’t want to send these patients out with a hundred pills “just a few days’ worth,” says Dr. Heit. And regardless of whether it’s heroin or another type of addiction, or whether the patient is in treatment or not, hospitalists should always follow up a detailed discharge summary with a phone call.
“What should be done, but often isn’t,” Dr. Heit says, “is that the hospitalist should pick up the phone and call whoever will next see the patient.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.
Patient behaviors “and physician reactions
In parsing out why physicians tend to under-treat addicted patients, pain experts say one problem is physicians’ lack of training in pain management techniques.
But experts also point to other obstacles, such as patients’ behavioral issues and the reactions those evoke in physicians. Some patients with an addiction to heroin or other substances may display drug-seeking behavior, demanding drugs or even exhibiting threatening or violent behaviors. That can lead doctors to take a stand and withhold drugs, even when pain medication is warranted.
Or patients may be agitated or hard to communicate with, either because they’re in withdrawal or because they fear they soon will be.
“These patients may be demanding, difficult and even hostile,” says psychiatrist Catherine Crone, MD, who practices at Inova Fairfax Hospital in Fairfax, Va., and frequently consults on managing pain in addicted patients. Because such behaviors are the opposite of the ideal of the cooperative patient, they often raise negative feelings among physicians.
“You have to recognize those feelings,” cautions Dr.Crone. “They may contribute to a tendency to under-treat or ignore the patient.”
When physicians struggle to separate addiction-associated behavior from a valid request for pain relief, experts urge them to err on the side of the patient. “At that point, the hospitalist has to do the unbelievable thing: trust the patient,” says Howard Heit, MD, an assistant clinical professor at Georgetown University in Washington who specializes in addiction medicine and chronic pain management.
Recognizing emotional pain
Rachelle Bernacki, MD, a geriatrician and palliative care specialist at University of California, San Francisco, points to another big challenge in managing pain in these patients: distinguishing among physical pain and other types of pain, such as emotional pain, and prescribing accordingly. While that’s hard to do, she says, it is necessary.
“You have to try to tease out physical vs. emotional pain because if you try to treat emotional pain with narcotics, you won’t get anywhere,” she says. People with addictive disorders often have deep-seated psychological issues that may or may not contribute to their past or current substance abuse.
Addicted patients are often depressed, for instance, which they may express as “being in pain” “and that “can take a lot of time to sort out,” says Dr. Bernacki.
Physicians who find themselves confused or stymied when treating these patients shouldn’t hesitate to consult in-house or other psychiatric or addiction-treatment resources, she adds. She considers calling for a psychiatric consult if patients have hallucinations; depression that is not responding to selective serotonin reuptake inhibitors; or an underlying psychiatric diagnosis, such as schizophrenia.
For additional information on managing pain in addicted patients, refer to the following Web sites:
- American Academy of Pain Medicine [http://www.painmed.org]
- American Pain Society [http://www.ampainsoc.org]
- American Society of Addiction Medicine [http://www.asam.org]
- Emerging Solutions in Pain [http://www.emergingsolutionsinpain.com]