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UW Health,Ambulatory Education,Educational Opportunities,Grand Rounds,Nursing Grand Round Presentation Video Archive 2012,Clinical Grand Rounds 2012,07/24/2012 - Principles of Pain Management in the Patient with Addiction Disease,Resources

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Presentation - UW Health, Ambulatory Education, Educational Opportunities, Grand Rounds, Nursing Grand Round Presentation Video Archive 2012, Clinical Grand Rounds 2012, 07/24/2012 - Principles of Pain Management in the Patient with Addiction Disease, Resources


SUCCESSFUL COMPLETION
To receive contact hours, participants must sign in on the attendance form, attend the entire program and complete an
evaluation for each presentation attended. Please return your completed evaluation form to a staff member of
Education & Development for Nursing & Patient Care Services at the end of the program.

CONFLICTS OF INTEREST
All activity planners for this program have reported no financial relationships with commercial interest.
All presenters for this program have reported no conflicts of interest related to their presentation

NON-ENDORSEMENT OF PRODUCTS
The presence of commercial exhibits during this program does not imply endorsements by the University of Wisconsin
Hospital and Clinics, Wisconsin Nurses Association for the American Nurses Credentialing Center’s Commission on
Accreditation.

SPONSORSHIP & COMMERCIAL SUPPORT
There is no sponsorship or commercial support for this program

OFF-LABEL USE
All program presenters have agreed to disclose to participants prior to their presentations if off-label (or unlabeled uses)
of commercial products will be discussed during their presentation (s).

Principles of Pain Management in the
Patient with Addiction Disease


• Emily Wilhelmson, BSN, RN, F4/6
• Jennifer Nitka, BSN, RN, F4/6
• Peggy Riley, MN, MPH, CNS
Presenters

Patient Profile
• Presenting Problem: 37 y.o male with
perforated gastric ulcer and pyloric
stenosis. Presents as an elective
admission for a scheduled exploratory
laparotomy, antrectomy, and vagotomy.




Procedure
• Vagotomy
• Removing vagus nerve to reduce acid
section in stomach

• Antrectomy
• Resection of lower portion of stomach

History
• Pyloric Stenosis
• Perforated Chronic Peptic Ulcer
• Tobacco User (0.5 pack per day)
• Previous Heroin, Cocaine, Opioids and
Marijuana use

• Current Methadone Maintenance Therapy
• Ventricular Fibrillation Arrest
• Secondary to high dose methadone and severe
hypokalemia (low 2’s)
• Prolonged QT interval (antiemetics and
methadone)



• Typical Post-Op
– PCA and/or Epidural
– NG tube
– PIV
– Foley
– Incision/wound care
– Frequent Vitals
– Activity Post-Op Day 0
– Expected length of stay: 4-
6 days
• Patient Profile
– PCA with basal rate,
Epidural, and Ketamine
Infusion
• Pain 10/10
• Continually asking for
methadone
– NG tube with restrictions
to use
– PIV
– Foley
– Incision/wound care
– Refusing activity
– Length of stay: 9 days

• Post-op day 1-4
– Felt like Post-Op Day 0
• Pain status not improving
– Medications altered multiple times
• Rates, concentration, dosing
• Using 12 dilaudid 12mg syringes per day
(144 mg IV dilaudid).

Post-Op Day 5-7
• Surgically progressing
• 3/10 pulled NG
• 3/11 am started full liquid diet
– Partial dose of methadone given
• 3/12 am restarted home dose of methadone and
Epidural removed
– Pain status the same
• Diaphoretic, shaking, patient “not feeling well”
• Withdrawal symptoms?
– Consulted Peggy Riley MN, MPH, CNS


Challenges
• Staff frustrated with inability to distinguish
between actual pain vs. possible drug seeking
behavior.
• Patient’s attitude towards staff.
– Hard to form relationship
• Mother
-- Support system
-- Family-centered care
-- Seek out staff with concerns
• Lack of primary RN
– Familiar face may have made it easier to form a bond
and co-ordinate a more efficient plan of care


Addiction
• Primary, chronic, neurobiologic disease
• Genetic, psychosocial and environmental
factors influence its development and
manifestations
• It is a relapsing and treatable disease
AAPM, APS, ASAM, 2001

Addiction
• Characterized by one or more of the
following behaviors
– Impaired control over drug use
– Compulsive use
– Continued use despite harmful consequences

AAPM, APS, ASAM, 2001

Addiction
• More recent research has identified:
– Strong association between stress and drug
craving
– Stress of unrelieved pain
• may contribute to relapse in recovering patient
• or increased drug use in actively using patient

2002 ASPMN Position Statement on Pain Management in Patients with Addictive Disease;
http://www.aspmn.org/Organization/documents/addictions_9pt.pdf; retrieved July 2012

Scope of the Problem
• Primary Care; 2004; cancer and non-cancer;
excludes opioid maintenance programs – 2.5
million “strong” opioid prescriptions*
• In 2009 in Wisconsin, 5.5 million prescriptions
per month (all drugs; includes refills; not just
opioids)**
• In Wisconsin, 2007-2008 15% of adults
reported using pain reliever for non-medical
use**
* 2005 Mehta and Langford: Acute pain management for opioid dependent patients. Anesthesia 61: 269-
276.
** 2012 Reducing Wisconsin’s Prescription Drug Abuse: A Call to Action: Wisconsin Council on Alcohol
and Other Drug Abuse Prevention Committee

Effects of Opioids on the Brain
• Decreased gray matter volume in in the
bilateral amygdala (H)
– Key reward modulating structure
• Decreased µ-opioid receptor sensitivity (A)
• Modulated gama-aminobutyric acid
receptor function (A)
• Modified glutmate receptor targeting (A)

H=Human study A=Animal study

Treatment Recommendations
• Identification of appropriate population for
opioid medication therapy
• Understand the risks of misuse/abuse
– Hx of family member or personal hx of abuse or
misuse of alcohol or other drug – most predictive of
aberrant drug related behavior
• Involve patient in pain management planning
– Have exit strategy for all medications – discuss it with
patient when medication initiated

Treatment Recommendations
• Use oral route whenever possible
• If unable to use oral route, consider use of
PCA or epidural if possible for acute pain
• Recognize that more drug may be needed
than with “typical” patient due to tolerance
to opioid benefits or hypersensitivity due to
prolonged use
– 2-3x starting dose recommended


Treatment Recommendations
• Encourage use of adjuvant therapy when
appropriate
• Encourage use of non-drug therapies
• Encourage support from family and friends
• Provide support if needed
– AODA counselors
– Health Psychology
– Spiritual Care


Treatment Recommendations
• Try to have open and honest
conversations with patient and family
• Try to be non-judgmental about the drug
use
• Don’t be afraid to ask questions both to
staff and to patients

Resources
• Alcohol and Other Drugs Consult Service (pager
____)
• Addiction Medicine Physicians
• Inpatient Pain Consult Service (pager 1010)
• Opioid Withdrawal Fast Fact (Pain Management
Resources on Unconnect)
• Opioid Addiction Fast Fact (coming soon)
• Psychiatric Liaisons (support for nursing staff)
• Health Psychologists (coping support)
• Pharmacists

Key Points
• Addiction is a disease
• Nonjudgmental attitude
• Treating chronic pain vs. acute pain
– Important to recognize early and act on the
issue
• Getting resources involved sooner
• Involving patient in pain management



References
• 2011 Younger, JW; Chu, LF; D’Arcy, NT; Trott, KE; Jastrzab, LE; Mackey; SC: Prescription opioid analgesics
rapidly change the human brain. Pain 152: 1803-1810.
• 2010 Upadhyay, J; Maleki, N; Potter, J; Elman, I; Rudrauf, D; Knudsen, J; Wallin, D; Pendse, G; McDonald, L;
Griffin, M; Anderson, J; Nutile, L; Renshawk, P; Weiss, R; Becerra, L; Borsook, D: Alterations in brain structure
and functional connectivity in prescription opioid-dependent patients. Brain 133: 2098-2114.
• 2009 Zhang, Y; Picetti, R; Butelman, ER; Schlussman, SD; Ho, A; Kreek, MJ: Behavioral and neurochemical
changes induced by oxycodone differ between adolescent and adult mice. Neuropsychopharmacology 34:912-
922.
• 2005 Mehta and Langford: Acute pain management for opioid dependent patients. Anesthesia 61: 269-276.
• 2012 Childers, JW; Arnold, RM: “I feel uncomfortable “Calling a patient out” “: Educational needs of palliative
medicine fellows in managing opioid misuse. Journal of Pain and Symptom Management 43(2): 253-260.
• 2006 Mehta, V; Langford RM: Acute pain management for opioid dependent patients. Anaesthesia 61:269-276.
• 2010 D’Arcy, Y: How to manage pain in addicted patients. Nursing 2010 August 61-64
• 2002 ASPMN Position Statement on Pain Management in Patients with Addictive Disease;
http://www.aspmn.org/Organization/documents/addictions_9pt.pdf; retrieved July 2012
• Chu, R; Fanciullo, GJ; Fine, PG; Adler, JA; Ballantyne, JC; Davies, P; Donovan, MI; Fishbain, DA; Foley, KM;
Fudin, J; Gilson, AM; Kelter, A; Mauskop, A; O’Connor, PG; Passik, SD; Pasternak, GW; Portenoy, RK; Rich, BA;
Roberts, RG; Todd, KH; Miakowski, C: Clinical Guidelines for the use of chronic opioid therapy in chronic
noncancer pain. The Journal of Pain: 10 (2) 113-130.
• ** 2012 Reducing Wisconsin’s Prescription Drug Abuse: A Call to Action: Wisconsin Council on Alcohol and Other
Drug Abuse Prevention Committee