Acute Pain Management & Addiction Clinical Nurse Specialist Acute Pain Management Inge Bateman Inge Bateman

Do we have a problem? Inge Bateman Clinicians confuse addiction and opioid-induced analgesia and this adversely affects the care of both patients with substance abuse disorders and those with pain. Fear, misconceptions and a general lack of knowledge about the nature and course of addiction have profoundly affected the provision of opioid analgesics to patients in pain. Confusion about what constitutes addiction results in patents with pain who receive opioid analgesics on a chronic basis to be mistakenly labelled ‘addicted’. These issues become exaggerated in the case of providing pain management to a person with active or remitted addictive disease and are complicated by criminal justice and moral Reponses to addiction. l Inge Bateman

Definitions Addiction Physical dependency Tolerance Inge Bateman

Addiction An acquired, chronic disease of subcortical brain structure. Characterized by persistent pattern of dysfunctional drug use and aberrant behaviour involving loss of control over use and continue despite adverse physiological, psychological and/or social consequences. Opioid addiction is a pattern of compulsive drug use characterized by a continuing craving for the opioid and the need to use the opioid for effects other than pain relief. Inge Bateman

Physical dependency A neruadaptive state resulting from chronic drug administration in which abrupt cessation of the drug, or administration of an antagonist to the drug, results in a drug-specific withdrawal syndrome. Physical dependency is an expected physiologic occurrence in all individuals in the presence of continuous use of a certain drugs, such as opioid analgesics, for therapeutic and no therapeutic purpose. It doesn’t in and on itself imply addiction and does not cause addiction. Inge Bateman

Tolerance A neuroadaptive state resulting from chronic drug administration that results in diminution of drug effect over time, requiring increased amounts of drug to induce the same effect as obtained with original dose. Inge Bateman

APM & addiction Good pain management (Accepting that good pain management is a primary goal in caring for all patients with pain, regardless of how they have used or currently use drugs of abuse) Not the time for aggressive addiction intervention Acknowledge own biases about addictive disease and conscious effort to effectively put them aside (As health care professional we are charged with providing effective and compassionate care to all patients without bias) Inge Bateman

What to do? Assessment of pain Assessment of addiction status Risk assessment Multi model approach Pain management plan agreed Multi disciplinary approach involving substance misuse team Inge Bateman

Management plan Agreement of actions by healthcare professionals and the patients with parameters for unacceptable behaviour and consequences of these as well as agreement of Acute Pain Management treatment offered. Inge Bateman

Withdrawal symptoms Opioids Benzodiazepines Alcohol Cocaine Shivering, goose bumps, runny nose, abdominal cramping, diarrhoea Insomnia, anxiety, agitation, muscle twitching/tremors, headaches, nausea Restlessness, agitation, tremor, sweating, tachycardia, hypertension, pyrexia, fits, anxiety, panic attacks, depression, insomnia, hallucinations, clouded consciousness. Depression,anxiety, malaise, dysphoria, insomnia craving. Inge Bateman

Behaviours which should cause concern! Simulating withdrawal symptoms with drug reduction or refusal of drugs Simulating an exacerbation of the underlying medical condition if drug reduced or refusal of drugs Giving history of inefficacy or poor tolerance of alternative medicines without misuse potential or non pharmacological treatment Requesting drugs from various sources Stealing or buying supplies Making threats or offer bribes. Inge Bateman

Features that may support diagnosis of substance misuse Current intoxication or withdrawal Assertive personality that demands immediate action Unusual knowledge of controlled substances Medical history with textbook symptoms or vague or evasive answers to questions regarding medical history No GP, unwilling to provide information on request Request specific drugs and reluctant to try different drug No interest in diagnosis Cutaneous signs of drug misuse. Inge Bateman

Drugs Methadone Buprenorphine Naltrexone Inge Bateman