For some patients, a history of drug or alcohol addiction puts them on the defense when it comes to managing pain. An individual in recovery from abusing drugs or may have a fear of relapse, while an individual still using narcotics or opioids without a prescription may fear disclosing the level of their addiction to a healthcare provider.
In either case, the patient may anticipate judgment from the healthcare provider or that they will be treated differently because of their condition.
A common problem, according to Lisa Rudolph, MS, RN, CNS-BC, is patients are afraid to disclose they are in recovery or that they have been actively taking unprescribed medication for their chronic pain. As med/surg clinical nurse specialist at St. Anthony Hospital in Oklahoma City, Rudolph provides pain consultation services for adult patients at the facility, which is licensed for 800 beds.
When the appropriate dose of the patient's prescribed pain medication is not working, or a staff nurse suspects a patient has had past opioid experience, the staff nurse will call Rudolph to assist in the assessment.
"Some patients are afraid to talk about their past experience with pain. I tell them, 'I understand you're hurting and I'm here to help you,'" Rudolph said. "I'll ask questions like, 'What do you take for pain at home? How much do you need to take so you can function in your daily life?' Once I understand their baseline for pain control, we can move forward - and sometimes there a lot of tears."
Sometimes Rudolph will share stories of addiction issues with her patients to help them open up to her.
"I am careful not to use real names or stories to comply with HIPAA, but rather a composite of the patients I have seen. I will say something like, 'I had a patient one time who was having a hard time with pain after his surgery and the pain medication was not working. When he told me he had been taking his wife's Percocet because he did not have health insurance and could not afford a doctor's appointment, I was able to help him by changing his pain medication and getting his pain under better control.'
"I will then ask the patient, 'Has this happened to you?' By letting the patient know that he is not the only one with these issues, the barriers come down."
Even with Rudolph's empathetic approach, some patients are reluctant to discuss their abuse of pain medication. She will then explain that, if they don't start medication doses at the hospital at the level the patient is accustomed to, it will be difficult to "catch up" to manage the pain the patient is experiencing.
"If the patient is honest with me and tells me they've been taking their neighbor's oxycodone, I'll take that information and perhaps decide we need more dilaudid. We also take a multimodal approach with these patients. We may add heat or ice, or work with positioning," she said.
Patients in recovery present a different challenge, in that they fear relapse and may want to avoid all narcotics and opiates. The key in these cases is a pain-management plan that involves the healthcare provider, patient and family when possible.
A main tenet of the treatment approach at Saint Joseph Hospital's Harborview Recovery Center in Chicago is communication. The medical and nursing staff works with patients to gain their trust and educate them to be honest about their recovery status.
"There are times in life when people need to take opiates, whether they are in recovery or not," said Michael Baldinger, MD, medical director at Harborview. "We need to acknowledge the patient's vulnerability to relapse and assure them we will treat their pain effectively."
In the case of acute pain due to surgery or trauma, Baldinger treats the patient with non-opiate analgesics whenever possible, such as acetaminophen or NSAIDs. When those interventions prove insufficient, opiates may be used for a defined period of time.
"The goal is for the patient to be done with the opiate when they leave the hospital, and we use a dose for a period equivalent to that of a patient with no history of opiate addiction," Baldinger explained. "Individuals early in their recovery may have significant tolerance and may need an upward adjustment in dose, but someone 2 years out may have no more tolerance than a patient who is naïve to the drug. I talk to my patients frankly about the risk of triggering a craving."
If a patient does need to go home with a prescription for an opiate, Baldinger works with the individual to formulate a plan for the meds.
"The goal is to keep the patient comfortable with limited quantities of medication in a controlled situation. The patient in recovery does not have control of the prescription, and we don't expect them to be able to control taking the medication," Baldinger explained. "We may prescribe small amounts and give the meds to another person, such as a family member, who will control the patient's access."
Of course, Baldinger noted, not all pain requires a pill. Ice or heat, preventing pain by avoiding overexertion, stress-reduction techniques and cognitive behavioral approaches may all be incorporated into a pain-management plan.
Beyond the Bedside
Patients don't leave their addiction at the recovery center, and part of their treatment involves learning the tools necessary to navigate life without relapse. Regarding future pain management, this means honest communication with healthcare providers.
"We encourage patients to find a healthcare provider familiar with addiction and to be honest about being in recovery," said Pam Blades, RN, who works at Harborview. "We focus on educating patients that the disease of addiction is deadly and progressive, and they need to try to use alternative strategies."
Blades noted there are a number of medicinal alternatives to opiates. Drugs such as Neurontin and Lyrica may be safely used by patients in recovery, as well as some selective serotonin reuptake inhibitors like Effexor or Cymbalta.
Additionally, Suboxone often is prescribed for patients in recovery to assist with withdrawal, and the medication also delivers some pain relief.
Back in Control
Patients do sometimes encounter healthcare providers who are dismissive of their past addiction.
"A provider may say, 'Oh, you're an alcoholic, so you don't need to worry about opiates,' or 'your addiction issues were a long time ago,'" Baldinger said. "We tell patients they are responsible for their own safety and they need to be firm about it. There is a level of personal responsibility. The patient can't blame a doctor for prescribing a drug [that puts the patient at risk]."
In other cases, a healthcare provider may be wary of prescribing any medication for fear of being manipulated by the addict.
Baldinger advises clinicians to employ the basic strategies of motivational interviewing: ask the patient about their goals for pain management, listen to what they need and reflect your understanding back to them.
"Clinicians should be aware the addicted patient requires proper pain management like any other patient," Badinger added. "This patient may need more meds due to their tolerance level, but the clinician should make sure the patient is given small amounts to take home, and to schedule more frequent follow-up visits."
Sometimes the patient himself is so wary of relapse, he'll refuse opiates altogether. Becky Wolf, NP, who currently at Advanced Pain Management in Green Bay, WI, tries to provide the post-surgical patient with knowledge and perspective.
"When I worked with inpatients at St. Vincent Hospital in Green Bay, I tried to educate the patient that a part of their body had been cut, so we knew the reason for their pain, and I would try to treat them the same as anyone with the same type of surgery or injury. That usually included the use of opioids along with nonopioids, as well as ice, elevation of the affected limb, anti-inflammatory medications or muscle relaxants.
"[This was all done] with a heightened concern for their past history of opioid addiction, "she added. "I would meet with the patient daily to discuss their pain control plan for both in the hospital and after discharge from the hospital."
Wolf said some patients in recovery from opioid addiction agree to use IV opioid medications early in their hospital stay but, most of the time, these patients want to set the limits for their opioid use to maintain their sense of control over these medications.
"[In my experience with inpatients], they usually wanted to get off of opioids as soon as possible," she explained. "At that point, they may need further education regarding postop pain management. I would let them know I understand their feeling for the necessity to get off opioids as soon as possible, but pain will not make them heal faster. In fact, pain may cause a longer postop recovery period if the patient cannot do the exercises or activities required postop."
For example, a patient may need to be able to breathe deeply and move about to prevent blood clots, or he may need to exercise or bend a limb to prevent a loss of range of motion in that limb.
If pain prevents the patient from doing the required postoperative activities, Wolf thinks just as the individual should be aware of his increased risk for opioid overuse, the patient should also we aware of the consequences of not using opioids for pain control if nonopioids have been ineffective.
Wolf has found most patients who refuse postoperative pain medications come prepared with an array of other options, and she works with them to the best of her ability.
At St. Anthony, Rudolph recommends distraction and laughter therapy for patients seeking medication-free pain management.
"I tell the patient to pull out the comedies; watch the Three Stooges or The Simpsons," Rudolph said. "Laughing produces endorphins quite similar to morphine and that helps more than anything else. If the patient doesn't have pain involving the back, I also recommend back rubs."
Patients with chronic pain, as from migraine headaches or back pain for example, may choose to take a long-term complementary approach to pain management.
Similar to Wolf's observation that patients committed to remaining medication-free have often educated themselves about available options, Bonnie Groessl, MSN, APNP, noted patients who come to her for treatment are usually knowledgeable about a holistic approach to care and prepared to embrace it.
At The Bridge to Health in Green Bay, WI, Groessl often receives patient referrals from neurologists and pain management specialists. Some of her patients are in recovery, and find physical comfort and emotional hope in Groessl's assertion that individuals possess a great amount of power and control within themselves.
While Groessl is not opposed to the use of medication when warranted, she tries first to help patients manage their pain through other means.
"I start with what is naturally occurring, then may supplement with herbals and work with the patient's primary care physician regarding medications, if necessary," Groessl said. She is as much counselor as healthcare provider, working with patients to achieve optimal nutrition as well as emotional balance.
"Whether we use hypnosis or energy therapy, such as Reiki, I help patients fill their toolbox with what they need to help with whatever they are dealing with."
Whether they are dealing with chronic pain or facing a surgical intervention, healthcare providers can help patients in recovery manage their pain while maintaining their sobriety.
Barbara Mercer is senior associate editor at ADVANCE.