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Pain management is not a one-size-fits-all practice

Addiction concerns put healthcare professionals in precarious position
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By Carole Jakucs, MSN, RN, PHN
EDITOR'S NOTE: Carole Jakucs, MSN, RN, PHN, is a freelance writer.

“It’s important to adequately treat a patient in pain, as studies show that inadequately treated pain can lead to the stress response being triggered,” Almgren said. “A triggered stress response can impact the patient’s overall recovery, including tissue healing, ventilation and gut motility. But inadequately treated pain and addiction are not necessarily a cause and effect relationship. Someone who is biologically wired for addiction may have poor pain control and go on to develop addiction problems, while another patient with no predisposition for addiction, given equally poor pain control, will have no issues.” “Addiction is a brain disease and not everyone has it. Many people become addicted, not just patients,” said Esther Bernhofer, PhD, RN-BC, CPE, nurse scientist II at the Cleveland Clinic in the Office of Nursing Research and Innovation. “People with Substance Use Disorder, that is the disease of addiction, did not all suffer the onset of their disease by having been prescribed opioids for pain.”   

When patients do become addicted to substances, thus far it does not appear to be related to the length of their hospital stay or the level of pain relief achieved as an inpatient, but rather the patient’s personal profile, the brain disease of addiction and the availability of drugs, Bernhofer said.      

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For providers who oversee pain management in acute care settings and nurses who administer pain medications, alleviating pain for patients can be an ongoing challenge. In an era when one only has to turn on the news to hear about the opioid crisis, finding the sweet spot to achieve pain relief for patients while addressing concerns about preventing future addiction is no easy task.
Treating pain and society’s view of pain management In the 1980s and 1990s, the general consensus was pain was being under treated, said Nhat Tran, MD, MPH, pain specialist at Torrance Memorial Medical Center and Providence Little Company of Mary Medical Center in Torrance, Calif. “Then there was a big push to change practices and treat pain more aggressively. Now there is a belief by some in the media and policy makers that the opioid crisis stems only from prescribers and pain patients,” he said. “However, good pain management is a complex issue, and the concern about addiction is a complicated problem that requires complex solutions.” There are growing concerns now about the use of opioids and what is being prescribed, said Christina Almgren, MSN, RN, CPNP, pediatric pain management nurse practitioner at Lucile Packard Children’s Hospital Stanford in Palo Alto, Calif. “Limits are being looked at as to amounts of opioids that may be dispensed," she said. "Some insurance companies limit the amount they’ll cover in a certain period. There have been misguided beliefs that having access to pain medications for post-op pain creates addiction, but we know this is not the whole picture. One needs to consider the societal, genetic and psychological predictors when evaluating the use of pain medications. Even the addict can have a catastrophic injury or surgery and require pain medications.”

Pain is subjective and differs from patient to patient, Bernhofer said. “Managing pain should be individualized to the patient’s needs. This requires looking at a variety of factors for each patient such as, but not limited to, their age, health history, current co-morbidities and history of past responses to analgesics that cannot be addressed using only the 0 -10 scale.” Adding to the pain management challenge is that hospitals differ in their protocols regarding how medications should be ordered according to the intensity of pain (0-10) reported by the patient, Bernhofer said. This creates difficulties for addressing the individual needs of the patient. “A patient with a pain intensity level of a 7 or 8 may want only acetaminophen and feels this will work, but the protocol says morphine is the drug for this level of pain,” she said. “Someone with a 4 or 5 may feel they need morphine, but if that drug is not part of the protocol assigned to that pain intensity level, the patient can’t get it.” Researchers are looking at new models for better pain management that don’t revolve around the 0-10 scale Bernhofer said. “The truth is individuals suffer pain differently and trying to fit an algorithm to all patients simply doesn’t work for everyone.” When a patient responds outside the model, it can be perplexing for staff, with some staff suspecting a patient is seeking drugs, is manipulative or may be having psychological issues, instead of getting to know the patient and his or her individual needs and history, she said. Educating more providers on various methods to better treat different types of pain can help patients, Tran said. “Pain is a complex and dynamic process and there are different types of pain -- physical, emotional and psychological,” Tran said. “Some narcotics like hydromorphone hydrochloride (Dilaudid) helps to reduce both physical and emotional pain (anxiety). Patients want relief from their pain and generally ask their doctor for the same medication that helped them in the past.”

Will inadequate pain control lead to addiction later?
Ideas to improve pain treatment in acute care settings

Address concerns about long-term opioid use “All stakeholders need to come together,” said Tran, who sees a three-pronged approach that could be used to reduce the use of opioids in patients. “First, connecting patients with multiple disciplines such as physical therapy, massage therapy, psychotherapy, acupuncture, water therapy, are some examples of alternative therapies that can provide pain relief,” he continued. “Second, we need to figure out at a policy level who is going to pay for these treatments. If we want to reduce dependency on pain medication, we need to look at paying for additional therapies that can help make that happen. Third, follow-up with a pain specialist is also part of the equation, to work with patients in determining what’s working and what’s not, while managing their medication and weaning them down when their pain subsides.” Educating patients on medications is key, Almgren said. “Patients should be instructed on appropriate use of opioids as well as how to dispose of any extras,” she said. “Bottles of leftover pills in the home can be tempting to curious adolescents.” Nonpharmacological techniques should also be utilized for both acute and chronic pain, Almgren said. “Distraction methods such as virtual reality goggles worn during wound dressing changes can decrease the amount of medication a patient requires for the procedure. It’s important to connect patients with nonpharmacological options they find effective.”

Someone who is biologically wired for addiction may have poor pain control and go on to develop addiction problems, while another patient with no predisposition for addiction, given equally poor pain control, will have no issues.”  
— Christina Almgren, RN

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