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Managing Pain in Addiction, Opiates: principles of acute pain management,…

- - - - Addiction and Pain separated by separating psychological and physiological aspects of Addiction.
        
        Pain - the 85% to 94%
        
        Can be 'mislabelled' as addicts and under treated because of 'real addicts'
        
        Addicted - 6% to 15% of population
        
        Can be denied access to analgesia when they need it.
        
        Hegemonic position is that Hx of problem substance abuse raises risk of addiction when in need of analgesia.
        
        However some clinicians have argued that it is against human rights of problem drug users to be excluded from analgesia.
        
        Differential treatment can be achieved through careful monitoring, clear agreements etc.
      - There is evidence for compulsion led addiction
  - - - Physicians lack technical competence
      - Criminal and regulatory framework put clinicians off
      - Physicians attitudes and opiophobia
    - - Leading to distinctions between 'legitimate' and 'illegitimate' drug use.
  - - - Iatrogenic
      - Not to be treated as addiction but can only be retrospectively diagnosed after pain properly treated - by which time pt maybe well and truly addicted if you have got it wrong.
        
        Making this call can lead to discrimination; sickle cell, HIV and prisoners all get under treated.
        
        White middle class patient more likely to be diagnosed 'pseudo-addicted' and get their pain control.
        
        Issues around results in terms of resumption of social functioning and 'getting back to work'.
        
        The social worth of the patient
  - - - The under treated pain patient who steals prescriptions is labelled an addict.
      - The addict whose Hx is not properly taken and gets craving treated as pain is labelled 'pseudo addict' - my comment
      - Addiction as an aberrance from a legal rather than medical norm
  - - - Where addicts need analgesia the right is asserted but only in context of extra supervision.
        
        Addict is thus treated medically and administratively different.
        
        Underlying contradiction in rights based argument.
        
        Addict = illegitimate and to be policed
        
        Leading to denial of right of persons to use drugs.
        
        Disagree with this - people may or may not have the right to use drugs, addicts have lost ability to exercise choice
        
        Pain patient = legitimate, rights to be protected
        
        Many rights come in contradictory pairs.
        
        Rights of the pain patient vs. rights of the addict
  - - - Judgements about patients' value lead to provision of resource to manage pain.
        
        Addicts have the responsibility to manage pain but do not get the resources.
        
        Pain patients have the responsibility to manage pain and get the resources.
        
        WHOSE PAIN IS LEGITIMATE?
        
        A MORAL AS WELL AS CLINICAL DECISION
- - - - Patient concerns
        
        Fear of pain not being taken seriously
        
        Fear of discrimination - possible due to previous experiences
        
        Fear of withdrawal
        
        If abstinent - fear of relapse
      - Clinician concerns
        
        Mistrust of addicts
        
        Fabrication of pain symptoms to obtain drugs to achieve euphoria
        
        Over treatment leading to respiratory depression
        
        Diversion of prescribed opiates
        
        Leaving ward to top-up with illicit supply
    - - Social network and vulnerabilities; home, work associates or family
        
        MH Co-morbidity
        
        Support systems post discharge
      - Other Px'd, OTC, illicit, alcohol or cigarettes
        
        Routes of administration: oral, IV, inhaled, transdermals etc
        
        Establish & verify substitution doses
      - Medical diagnosis & co-morbidities
    - - Mental Health problems are highly relevant and need to be screened, assessed and included in care planning.
    - - Prevent withdrawal
        
        Adequate analgesia
        
        Avoid relapse
      - Table 2
        
        Create supportive non-judgemental environment
        
        Establish what other drugs are used
        
        Analgesia plan
        
        Use higher doses of opiates than you would with opiate naive but monitor closely
        
        Change from parenteral to oral ASAP
        
        Optimize non-opiate analgesia
        
        Withdrawal plan
        
        Continue opioid substitution or replace with another opioid
        
        Consider withdrawal syndrome of other drugs
        
        Minimize stress
        
        Multidisciplinary discharge meeting
      - Non-opioids
        
        Depressants
        
        Alcohol: should always be screened for and withdrawal assessed and managed.
        
        No cross tolerance between alcohol and opioids
        
        Barbiturates: withdrawal (agitation, febrile, seizures) v.risky. Little evidence for how to manage this.
        
        Benzodiazepines: no need for higher doses of analgesia opioid or otherwise.
        
        Stimulants
        
        Khat: physiological withdrawal unclear additional analgesia not indicated.
        
        Cocaine: associated with cardio-thoracic pain
        
        Amphetamines: unlikely to need more analgesia than other patients.
        
        Hallucinogens
        
        Mescaline: no indication of need for additional opioids
        
        LSD: no indication of need for additional opioids
        
        Cannabis: some limited evidence of the need for higher doses of opioids.
        
        Synthetic cannabis: withdrawal may mimic opiate withdrawal, needs close supportive care for 8+ hours due to CV effects.
        
        Full medical history
        
        Risk of under treatment of pain "pseudo addiction"
        
        Risk of discharge against medical advice
    - - Drug misuse and dependence - there's a lot of it about. Stats etc
    - - Controlled
        
        On Methadone or Buprenorphine maintenance
      - Abstinent
        
        In recovery - how long? how'd they get there?
      - Active
        
        Currently using illicitly
      - Pseudo addiction
        
        Under treated pain leading to drug seeking behaviour
    - - Communicate, meet with community resources, include patient in planning.
- - - - Addiction
      - Abuse
      - Misuse
    - - Formulate Dx with differentials
        
        Psychological assessment including risk of addictive disorder
        
        Informed consent
        
        Treatment agreement
        
        Assessment of pain level and functioning for pre- and post- intervention evaluation
        
        Trial opiate therapy and adjunctive meds
        
        1 more item...
    - - Urine Drug Screen
      - Screening tools
        
        Pain Assessment and Documentation Tool
        
        On referral / assessment
        
        Initial Hx & examination
        
        Claims of tolerance less credibility if pain is the problem & not addiction
        
        If analgesia is inadequate then increased dosage / longer acting / breakthrough dosage should reslove problem
        
        Past notes - medication shopping?
        
        1 more item...
        
        Current Opioid Misuse Measure
        
        Screener & Opioid Assessment for Patients with Pain
      - Medical Record Audit
      - Psychological Screening
        
        PHQ-9 / GAD-7 or equivalent
      - Sleep assessment
        
        Pittsburgh Sleep Questionnaire PSQ
      - Assessment of Function
        
        Brief Pain Inventory BPI
    - - Group 1: Low Risk
        
        No family history
        
        No co-existing MH issue
        
        Some coping issues needing extra support
        
        No pre-existing SUD
      - Group 2: Medium Risk. Specialist Liaison, clear boundaries, management planand extra support.
        
        Family history
        
        Past Hx of SUD
        
        Current moderate MH problem
      - Group 3: High Risk. Referral to addiction / MH crisis services. ? in-patient admission for stabilization / detox.
        
        Family Hx & current problem
        
        Actively using and involved in using network
        
        Current instability makes MH assessment challenging
  - - - Discussion of result
    - - Interventional Pain Management
        
        Epidural
        
        Radio Frequency Neurotomy
        
        Sympathetic blocks
        
        Scaro illiac joint injection
        
        Spinal Cord Stimulation
        
        Screen for understanding of treatment and no mood disorder
      - Non-pharmacological Treatment
        
        Complimentary & Alternative Therapy
        
        Cognitive Behavioural Therapy
        
        Physiotherapy
      - Non-opioid pharmacotherapy
        
        Fibromyalgia - highly prevalent in this population; also for neuropathic pain
        
        Tricyclics, SNRI's & Gabapentinoids
        
        Adjuvants from lower down the pain ladder: Paracetamol, Ibuprofen, Naproxen (COX-2), Aspirin etc
        
        Lidocaine patch
    - - 12-Step
      - Pharmacotherapy
        
        Medication assisted therapy
- - - - Gabapentinoids and alpha-2 agonists (Clonidine)
        
        Ketamine can address this acutely
- - - - Objective = actual withdrawal
      - Subjective = distress either due to pain or MH issue
  - - - Lengthened QTc esp in presence of other medications
  - - - Splitting in to 2-3 doses daily can reduce this.
  - - - Regular monitoring of NEWS & COWS