Four out of five heroin users are first introduced to opiates via a doctor-prescribed opioid medication.
That statistic, cited by the National Safety Council in a 2016 report on America's prescription drug epidemic, encapsulates a common conundrum for today's hospital leaders and clinicians: on the one hand, they want to help patients manage often debilitating levels of pain, whether acute or chronic; on the other, they fear contributing to another addiction in what today is widely known as America's deadliest drug epidemic on record.
The same dilemma only intensifies when the hospital patient receiving treatment is a recovering painkiller addict. What then?
The CDC Guideline for Prescribing Opioids for Chronic Pain released earlier this year is a helpful starting place. So is a graduated treatment approach to pain severity with narcotics being a later resort for pain relief, as embodied by the World Health Organization's "stepladder" model. But there are other recommendations that can help.
First, consideration should be given to whether patients in recovery from narcotic painkillers—especially those new to recovery—could be dealing with heightened pain sensitization as the result of hyperesthesia and opioid-induced hyperalgesia. This potential reality may make it harder for these patients to distinguish between pain from an injury and pain from opiate cravings. Education about this fact can thus be helpful, and can encourage patient self-advocacy regarding pain management needs.
The distinction between acute and chronic pain management is also critically important, according to addiction psychiatrist Dr. Edward Zawadzski, who serves as the medical director of a Florida-based recovery program. Dr. Zawadzski said recovering painkiller addicts deserve to have their pain successfully managed just like anyone else. In general, however, treating acute pain with an opiate medication presents less relapse risks than treating chronic pain with an opiate medication. While both cases can entail certain opioid prescribing precautions (like conservative limitations on amount prescribed and physician follow-up, for example), chronic pain that requires opiate medication is a more complicated predicament altogether.
In these thornier situations where chronic pain is the issue, the recommendations of Dr. Daniel Alford, in a clinician roundtable on pain management, are useful. Dr. Alford is an internist at Boston Medical Center and is also the director of the Safe and Competent Opioid Prescribing Education program at Boston University's School of Medicine. He requires patients with a history of opiate addiction to provide documentation verifying their active involvement in substance abuse counseling or 12-step meetings. He also requires them to sign a release form allowing joint communication between their substance abuse treatment provider and his office.
"Ideally I will call the substance abuse treatment provider during the primary care visit to reinforce to the patient that I take their addiction treatment seriously," Dr. Alford wrote.
What other precautions can hospital leaders and clinicians take when opioids are unavoidable in treating a patient in recovery from painkillers? Dr. Zawadzski recommends longer-acting agents over shorter-acting ones (which are more prone to abuse) and round-the-clock pain medication schedules over taking prescriptions only as needed. The latter guideline can sound counter-intuitive, but in its absence patients can tend to stockpile medications until their pain more dramatically resurfaces, at which point they are more susceptible to taking higher and more potent and euphoric doses of the drug.
In situations where a Patient-Controlled Anesthesia pump is necessary, patients with a known addiction history should be monitored for drug-seeking behaviors. Here Zawadzski recalled doing a psychiatric consultation with a recovering addict who "every five seconds pressed the button" to self-administer pain medication, presumably unaware of the PCA's built-in safety limit.
While it goes without saying that a recovering painkiller addict's concerns about pain management should be respected, these concerns also do not need to lock a patient into a plan of pain management that is ineffective at relieving pain. Doctors can be flexible in working closely with their patients to provide care that both safely and effectively answers pain management needs.
Kristina Robb-Dover is a full-time writer for Beach House Center for Recovery, and her latest book is The Recovery-Minded Church: Loving and Ministering to People with Addiction (InterVarsity Press, January 2016).
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