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Learning Scope #410
1 contact hour
Expires Dec. 3, 2014
You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Matters is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.
Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).
The goal of this continuing education article is to review the latest information on addiction in the surgical patient. After reading this article, you will be able to:
1. Identify post-surgical patients at high risk for addiction.
2. Distinguish between the signs of addiction and pseudo-addiction.
3. Name three physical symptoms of opiate withdrawal and alcohol withdrawal.
- The author has completed a disclosure form and reports no relationships relevant to the content of this article.
Addiction and substance abuse are growing problems in the U.S. According to a 2010 study from the National Institute on Drug Abuse, 8.9 percent of individuals age 12 and older had ingested at least one illicit substance in the 4 weeks prior to the study.1
Among the most commonly abused drugs are prescription medications. In fact, nearly 20 percent of Americans have used prescription drugs for non-medical purposes, according to a National Institutes of Health estimate.2
The most widely abused prescription drugs are narcotic painkillers, which are often prescribed in a post-surgical environment. These include opioid drugs like codeine, hydrocodone, oxycodone, morphine and methadone. While many individuals become addicted to opiates due to non-medical use, a growing number of people become dependent as a result of the treatment of chronic pain.
Understanding & Identifying Addiction
Addiction is a disease that often results from chemical dependency, which is marked by continual use of a drug or substance that leads to increased tolerance and withdrawal symptoms if use is discontinued. Clinically, although addiction is classified as a psychological condition, chemical dependency produces both physical and psychological symptoms.
Addiction is a growing concern in the post-surgical environment, where patients are often prescribed drugs for pain management. Some patients may be addicted before surgery, causing complications in their surgical care and postoperative treatment. Other patients may begin to exhibit addictive behaviors in recovery, some of which may not be true signs of chemical dependency.
Identifying patients at high risk for developing an addiction, recognizing the difference between addictive and pseudo-addictive behaviors and understanding non-pharmaceutical pain management techniques can help healthcare professionals provide the best opportunity for safe treatment and a positive outcome.
Identifying High-Risk Patients
While all post-surgical patients can be at risk for developing an addiction, some are at higher risk than others. Patients who have undergone surgery as a result of chronic pain, for example, are at a higher risk than those who have had an emergency surgery, like an appendectomy or caesarian birth. Patients with a previous history of alcohol or substance abuse and patients with mental illness, such as anxiety, depression or an eating disorder are also at higher risk for developing an addiction.
High-risk patients should warrant closer post-surgical monitoring from the nurses, who will likely be the first ones to identify addictive behaviors and may be able to quickly address the addiction or substance abuse problem.
Addictive vs. Pseudo-Addictive Behaviors
When identifying at-risk patients, it's important to understand the difference between pseudo-addictive behaviors and true addiction. Pseudo-addictive behaviors can be defined as any changes in demeanor, attitude or actions that occur as a result of undertreated pain.3 It is an iatrogenic syndrome that usually presents with acute pain. While pseudo-addictive behaviors often present like those of addiction, the pseudo-addictive behaviors typically subside when pain is effectively treated. It should be considered a relief-seeking behavior. Pseudo-addictive behaviors are more likely to occur in patient care settings where healthcare professionals are inadequately trained in pain management and the rational use of opioids or in a setting where the staff-to-patient ratio is high and a patient may go longer than appropriate to receive medication.
Even to a healthcare professional, pseudo-addictive behaviors can be difficult to differentiate between those of true addiction.4 However, each condition presents its own unique set of symptoms and side effects. These symptoms manifest themselves in a number of ways, many of which are exhibited in outward behaviors and actions. The following pseudo-addictive behaviors are common among patients with undertreated pain:
• "clock-watching" or anxiety concerning dosage times;
• asking medical staff for increased dosages of pain medication;
• dishonesty regarding medications, including types and dosages;
• exaggeration of symptoms with the intention of receiving higher doses of pain medication;
• dramatic shifts in mood, such as euphoria, after pain medication is administered; and
• significant changes in appetite.
Addiction presents with many of these same psychological behaviors but also occurs alongside physical symptoms. A patient experiencing addiction may present with:5
• Euphoria: The euphoric effect of opiates is well-documented. This feeling, or "high," is often powerful and intense and is one of the reasons these drugs are so addictive. Individuals with addiction describe opiate euphoria as an overall feeling of calm, comfort and well-being which affects both the body and the mind. They also may feel invincible and act in grandiose ways, be more direct or more aggressive with staff.
• Drowsiness or dizziness: Opiates often have a hypnotic effect, especially when used recreationally or in unnecessarily high doses.
• Constipation: Opiate addiction often leads to mild, moderate and severe constipation. This symptom can be attributed to both the dehydrating properties of opiates and to the paralyzing effects these drugs have on the muscles and bowels. Although seemingly benign, constipation can have massive repercussions on health and wellness. Patients with severe or long-term constipation are at a risk for several health complications, including colorectal cancers and blood poisoning as a result of the body's inability to effectively rid itself of waste and impurities.
• Profuse sweating: This symptom can be seen in both addicts currently using opiates as well as those in withdrawal. In some cases, profuse sweating and/or hot flashes can last for several weeks after opiate use is discontinued.
• Dehydration: Dehydration is a major health concern for those experiencing addiction. These drugs cause dehydration while individuals are under the influence and also duringwithdrawal. This symptom manifests in the form of dry mouth and eyes, constipation and difficult urination, and can result in health complications like organ damage, diabetes and high blood pressure.
• Constricted pupils: Small pupils are extremely common among opiate users. With dis
• Cravings for sugars and starches: Increased intake of sugars and starches is often experienced by opiate addicts. This side effect is caused by effects on the endocrine system as a result of prolonged opiate use, which can greatly increase risks for diabetes, obesity, heart disease and other harmful conditions.
• Fluctuating blood pressure: Irregular blood pressure is frequently seen in conjunction with the use of opiates. While blood pressure slows while under the influence of opiates, withdrawing addicts often experience dangerously high spikes in blood pressure. In fact, severe withdrawal in long-term addicts even can lead to stroke as a result of high blood pressure.
Opiate Withdrawal Symptoms
Individuals who experience addiction and substance abuse prior to surgery may present in the post-surgical environment with symptoms of withdrawal. Identifying these symptoms is a critical step in providing patient care, as post-surgical treatment must take into account the physical condition of the body. Treatment for patients experiencing withdrawal should be performed in conjunction with addiction professionals, as withdrawal can be dangerous. Patients generally begin to show signs of opiate withdrawal 8-12 hours after their last use.
Sudden discontinuation of opioid drugs, such as what occurs to an addict after surgery, can cause a variety of withdrawal symptoms, including, but not limited to:5
- dilated pupils;
- rapid pulse (greater than 90);
- abdominal cramps;
- muscle twitching; and
Signs of Alcohol Withdrawal
A patient with a history of alcohol abuse or alcoholism can have extremely severe withdrawal symptoms that are, in some cases, more intense than opiate withdrawal. In fact, in the most severe cases, alcohol withdrawal can be life-threatening.
It is critical to identify the signs of alcohol withdrawal early in the post-surgical patient so steps can be taken to protect the patient's life. Patients can begin to show signs of alcohol withdrawal in as short as 6-8 hours after their last drink.
Mild-to-moderate symptoms of alcohol withdrawal include:5
• shakiness/twitching or other involuntary, abnormal movements, especially of the hands and/or eyes;
• weakness, lack of energy;
• mild hypertension;
• pale, clammy skin;
• dilated pupils;
• loss of appetite; and
Severe withdrawal from alcohol or delirium tremens (DT), presents as a serious and life-threatening condition. Patients may experience the symptoms listed above along with seizures, generally tonic-clonic seizures. This stage of withdrawal often presents itself within 72 hours of giving up alcohol and can last as long as 7-10 weeks. DT brings about an onslaught of uncomfortable and potentially harmful symptoms, which often include auditory and visual hallucinations, skyrocketing blood pressure and heart rate, high fever, tremors and convulsions.
Due to the severe and potentially harmful nature of DT, abrupt discontinuation of alcohol is seldom recommended in those with a long-term history of alcoholism. If you identify a patient with signs of alcoholism or alcohol abuse, it is recommended you request a medical detoxification consult from your behavioral health department.
Post-Surgical Pain Management
Once you have identified a post-surgical patient experiencing addiction or at high risk for addiction, close attention must be paid to the pain management treatment plan. Pain management for opiate addicts can be complicated. While untreated pain may increase the risk of drug use and relapse, exposure to powerful painkillers is harmful as well.
For this reason, safe and effective pain management is vital in preventing abuse and/or relapse. When pain is severe for high-risk patients or patients presenting signs of addiction or withdrawal, the following considerations should be made:
• Administer tapering doses. Treating acute pain often can lead to extended use and addiction. Tapering doses can help reduce the risk of addiction, as this method weans the patient off the drug in question, giving the body time to adjust to smaller and smaller dosages until pain management is complete.
• Pharmaceutical substitutions. When treating pain in opiate addicts, many health care professionals make the mistake of substituting opiates with other drugs that may reduce pain and related symptoms. These drugs often include sleep aids, anti-anxiety drugs and muscle relaxers, all of which carry their own risks of dependency and other harmful side effects. For example, the sleep aid Ambien is often administered in attempt to lessen pain and the effects of withdrawal; however, in addition to being highly addictive, Ambien can cause side effects like hallucinations, sleepwalking and other potentially dangerous behaviors.
As pharmaceutical pain management may be detrimental to overall health for high-risk patients or those experiencing addition and withdrawal, it is critical to understand non-pharmaceutical pain management options that may provide the patient with some relief.
However, it's important for patients and staff alike to understand that managing pain is not the same as eliminating pain. Effective pain management involves reducing pain to bearable, manageable levels. These techniques may not reduce the pain completely but can help make the patient more comfortable.
• Heat and ice therapies: Alternating heat and ice compresses at the site of pain and inflammation may prevent the need for high dosages of medication.
• Physical therapy: Physical therapy can provide several benefits to the post-surgical patient, including pain relief and increased healing. Physical therapists are trained to accommodate each patient's unique set of circumstances and can therefore formulate individual therapy plans, which can greatly improve the chances of success concerning pain management and overall treatment.
• Massage therapy: Massage therapy offers several advantages. First, the rubbing and kneading associated with massage therapies can ease tension, improve circulation and relax muscles, which significantly reduces pain, stiffness and soreness. Secondly, there are several types of massage available, each with its own techniques and benefits. Further, massage techniques can increase the body's production of natural painkillers. These chemicals - namely, endorphins, dopamine and serotonin - reduce pain, improve mood and promote healing.
• Ultrasound: Ultrasound is often used as a method of pain management. This technique is used to generate heat to trouble spots, which can reduce pain and inflammation as well as improve circulation. Ultrasound therapy also can be used prior to massage, stretching and other manual pain-relief techniques. This can loosen joints and tissue in an effort to make them respond better to other forms of treatment.
• Stretching: Stretching can greatly reduce pain in the joints, muscles and bones, and also can increase circulation, flexibility, balance and range of motion. To prevent injury, stretching should be done under the guidance of a trained professional, such as medical personnel or a yoga instructor. Yoga, especially, can decrease pain and discomfort as well as increase mood and overall well-being.
• Nutrition therapy: Malnutrition and dehydration can cause undue strain on the body that can exacerbate pain and other symptoms in post-surgery patients. A diet rich in vitamins and minerals, as well as sufficient intake of water, can reduce pain, promote healing and lead to better overall health and quality of life.
Changes in Pain Management
The growing addiction and substance abuse problem across the country has led to changes in the healthcare industry. In addition to increased attention by local, state and the federal government, many hospitals and pharmaceutical companies are taking action to reduce prescription drug abuse.
Steps such as the reformulation of opiate-based pharmaceuticals and increased tracking of opiate prescribing and distribution have made it more difficult for individuals experiencing addiction to continue to abuse prescription drugs. Nurses and other healthcare professionals are likely to come into contact with these new regulations or formulas and should understand the resulting changes in pain management therapy.
Many prescription painkillers are available in time-release form, which means the drug dissolves slowly and effects are felt over an extended period of time. However, prescription drug abusers often tamper with time-release pills in order to release the complete dose of medication all at once.
This tampering usually involves crushing, cutting, chewing, removing coatings and/or dissolving the drugs in water. These practices are quite common among opiate addicts and can greatly increase the risk of overdose, organ damage and other harmful side effects and complications.
In recent years, pharmaceutical companies have been playing an important role in preventing prescription drug abuse by reformulating their medications to make them more tamper-proof.6 This reformulation is done in a number of ways, including:
• Formulating pills so they are resistant to cutting and/or crushing.
• The use of substances that cause pills to "gel" when mixed with water, therefore preventing the liquid from passing through a hypodermic syringe.
• The addition of irritating substances that cause burning and stinging when the drug is chewed or inhaled through the nasal cavities.
• The use of opiate antagonists such as naloxone and naltrexone. These antagonists are used as an addition to opioid drugs, which can result in effective pain relief without the euphoria associated with narcotic painkillers.
Reformulations also can change the way a drug may be administered. For example, OxyContin OP, the reformulated version of OxyContin OC, is not labeled for rectal use, a common way to administer drugs for patients who cannot swallow, who have digestive tract issues that prevent the absorption of drugs or who are in hospice care.
Watch for post-surgical patients who request a specific type of drug, especially those that have not yet been reformulated or request a drug to be administered using an off-label or non-prescribed method. Check with your pharmacy before administering these drugs for the first time, as absorption rates may be different.
Managing & Tracking Opiates
Government regulations have led to increased tracking and monitoring of narcotic pharmaceuticals in the U.S. Many post-surgical nurses now may be required to track and register narcotic drugs, or maintain pharmaceutical monitoring logs. The management of prescription drugs is done in a number of ways, many of which vary by state.7,8
• Stricter marketing guidelines: Several states have passed laws that require pharmaceutical companies to fully disclose all gifts and contributions, as well as annual marketing and advertisement budgets.
• Electronic monitoring: Several states currently utilize electronic monitoring when it comes to the sale of prescription drugs. When an individual fills a narcotic prescription, this information is added to a database. In many cases, electronic monitoring prevents individuals from filling prescriptions from multiple physicians, i.e., "doctor shopping" and also can alert law enforcement to physicians who may be overprescribing medications.
• Federal laws: In addition to state laws regarding the manufacture and distribution of opioid medications, there are also federal laws mandating the handling of these types of drugs. The Federal Food, Drug and Cosmetic Act (FFDCA) and the Controlled Substances Act (CSA) are the primary laws affecting the distribution of narcotics in the U.S. Administered by the Drug Enforcement Administration and the FDA, these laws provide for close monitoring and registration of narcotics, as well as a system for identifying manufacturers, prescribing physicians and pharmacists who make and distribute these drugs.
The post-surgical environment presents many challenges for nurses who must identify, recognize and treat symptoms of addiction alongside other post-surgical concerns.
1. DrugFacts: Nationwide trends. (2012). Retrieved Sept. 8, 2012 from the World Wide Web: http://www.drugabuse.gov/publications/drugfacts/nationwide-trends
2. Prescription drug abuse. (2012). Retrieved Sept. 7, 2012 from the World Wide Web: http://www.nlm.nih.gov/medlineplus/prescriptiondrugabuse.html
3. Weissman, D.E. (2006). # 069 Pseudoaddiction, 2nd ed. Retrieved Sept. 7, 2012 from the World Wide Web: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_069.htm
4. Alford, D.P., Compton, P., & Samet, J.H. (2006). Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Annals of Internal Medicine, 144(2), 127-134.
5. Substance abuse information card: Courtesy of division on addictions, Cambridge Health Alliance, an affiliate of Harvard Medical School. Retrieved Sept. 8, 2012 from the World Wide Web: https://divisiononaddictions.org/html/publications/redcard.pdf
6. Wick, J.Y. (2009). Drug abuse deterrent formulations. The Consultant Pharmacist, 24(5), 356-362, 365.
7. 2007 prescription drug state legislation. (2008, June 17). Retrieved Sept. 7, 2012 from the World Wide Web: http://www.ncsl.org/issues-research/health/archive-2007-prescription-drug-state-legislation.aspx
8. Joranson, D.E. (1990). Federal and state regulation of opioids. Retrieved Sept. 8, 2012 from the World Wide Web: http://www.medsch.wisc.edu/painpolicy/publicat/90jpsmf.htm
Ben Brafman is the clinical director, president and CEO of Destination Hope, a nationally recognized substance abuse and dual diagnosis treatment facility in Fort Lauderdale, FL. With more than 2 decades of hands-on experience in the field of substance abuse and addiction, Brafman is a leading authority on substance abuse, addiction and treatment protocols.