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Acute Pain Management in Patients with Drug Dependence Syndrome Jane Quinlan, FRCA, Ffpmrcaa,*, Felicia Cox, Frcnb

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Acute Pain Management in Patients with Drug Dependence Syndrome Jane Quinlan, FRCA, Ffpmrcaa,*, Felicia Cox, Frcnb Acute pain management in patients with drug dependence syndrome Jane Quinlan, FRCA, FFPMRCAa,*, Felicia Cox, FRCNb Keywords: acute pain, opioid substitution therapy, analgesics, opioid, behavior, addiction The patients we describe in this review are those who use illicit Key Points opioids, such as heroin, those who use diverted prescription opioids for nonmedical use, or those who take other illicit drugs. These drugs include stimulants (amphetamines, cocaine), 1. Engaging in open and honest discussions with the patient depressants (alcohol, barbiturates, benzodiazepines), and others and caregivers to agree to a management and discharge including cannabis, mescaline, and LSD. plan with clear, achievable goals. 2. Using strategies that both provide effective analgesia and prevent withdrawal syndrome, which are 2 separate 1. Definitions goals. The nomenclature around the illicit use of drugs remains 3. The early recognition and treatment of symptoms and confusing, but the recent International Statistical Classification behavioral changes that might indicate withdrawal. of Diseases and Related Health Problems (ICD-10, released by 4. Using tamper-proof and secure analgesia administration the World Health Organization in 2016) uses “dependence procedures. syndrome” as the preferred term.32 Other terms such as 5. Using regional analgesia where possible, although it may “addiction,” “substance use disorder,” and “substance misuse” be a challenge in patients who have depressed immunity relate to the same condition, but for the purpose of clarity and or local or systemic sepsis from injections. simplicity we use “dependence syndrome” in this review. Dependence syndrome is defined as follows: abstinent are no longer physically dependent on the drug but are particularly vulnerable to relapse, owing to the chronic A cluster of behavioral, cognitive, and physiological phe- changes induced by drug use. The American Society of Addiction nomena that develop after repeated substance use and that Medicine defines “addiction” (or “dependence syndrome” in the typically include a strong desire to take the drug, difficulties newer nomenclature) as a chronic disease of brain reward, in controlling its use, persisting in its use despite harmful motivation, memory, and related circuitry.2 consequences, a higher priority given to drug use than to In the context of pain management, we also need to be other activities and obligations, increased tolerance, and aware of pseudoaddiction, a syndrome associated with the 32 sometimes a physical withdrawal state. undertreatment of pain, characterized by problem behaviors around seeking more opioid analgesia. Pseudoaddiction can Patients may have active dependence, where they are currently be distinguished from true addiction in that the behaviors using the drug, or controlled dependence, where they are on cease when pain is effectively treated. a clinically supervised maintenance or replacement regimen, or they may be currently abstinent. Those who are currently 2. Background Globally, the United Nations estimate that around 250 million a University of Oxford, Oxford, United Kingdom, b Pain Management Service, Royal people (5% of the world’s adult population) used an illicit drug at Brompton and Harefield NHS Foundation Trust, London, United Kingdom least once in 2014, whereas the number of people classified as 29 *Corresponding author. Address: Anaesthesia and Pain Management and Lead having a drug use disorder is estimated to be 29 million. Of the for Pain Services, Oxford University Hospitals NHS Foundation Trust, Honorary drugs abused, opioids are used less often than cannabis, Senior Clinical Lecturer, University of Oxford, Oxford, OX3 7LE, United Kingdom. cocaine, or amphetamine but contribute to 82% of fatal 1 Tel.: 44 (0) 1865 572080. E-mail address: [email protected] (J. Quinlan). overdoses. Alcohol is one of the most frequently used drugs, © Copyright 2017 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf with Germany citing 1 in 5 perioperative patients having an of The International Association for the Study of Pain. This is an open access article 14 distributed under the Creative Commons Attribution-NoDerivatives License 4.0 (CC alcohol use disorder. BY-ND) which allows for redistribution, commercial and non-commercial, as long as Recent figures suggest that there are 1.3 million high-risk it is passed along unchanged and in whole, with credit to the author. opioid users in the European Union. Approximately 435,000 PR9 00 (2017) e611 people in the United States use heroin, whereas almost 5 times http://dx.doi.org/10.1097/PR9.0000000000000611 that number—1.9 million—meet criteria for prescription opioid 00 (2017) e611 www.painreportsonline.com 1 2 J. Quinlan, F. Cox·00 (2017) e611 PAIN Reports® use disorder.26 Australia has seen a similar increase in pre- emergency department or immediately after admission to scription opioid misuse, with 3.3% of Australians having used the hospital, when the drug has not yet been prescribed or prescribed opioid analgesics for nonmedical purposes in the past released by the pharmacy. If doses are omitted or delayed, year, compared with 0.1% using heroin.1 Those misusing there will be a re-emergence of withdrawal symptoms and prescription opioids may tamper with tablets to adapt them for drug cravings. inhalation, intravenous use, or smoking, leading manufacturers to (2) The fear of pain not being taken seriously, with restricted investigate abuse-deterrent formulations. access to analgesia and pain left unrelieved. (3) The fear of discrimination, often based on previous poor hospital experiences, leading to clinician distrust. 3. Assessment and screening of patients (4) In those currently abstinent, the fear of relapse if re- The stigma associated with addiction, often fueled by mis- exposed to opioids or untreated pain. information or prejudice on the part of health care professionals, is Clinician concerns center on the following: often a barrier to good medical care for those with a current or (1) Mistrust of those with addiction. history of dependence. Competence in managing patients with (2) Overtreatment of pain, leading to opioid-induced ventila- dependence requires knowledge of pharmacology; an under- tory impairment. standing of the diagnosis of dependence and recognition of (3) The possibility that reports of pain may be fabricated to withdrawal; skills in communication and collaborative working; acquire opioids for euphoria. and a nonjudgmental, empathic attitude. It is essential to (4) The diversion of prescribed opioids. establish good patient–clinician rapport to promote an atmo- (5) Fear that patients may leave the hospital against medical sphere of trust and understanding. This will allow an open dis- advice (elopement) and not completing essential medical cussion to accurately ascertain which drugs the patient is care (eg, infection control). currently taking, address the patient’s anxieties, manage expectations, and plan care collaboratively, thus reducing dis- 5. Key issues to assess on hospital admission for cord between the patient and the health care team. dependence syndrome On or before admission, clinicians should reconcile the patient’s medicines with the patient’s primary care physician and/or drug (1) The appropriate use and dosage of opioid substitution and alcohol worker. In preparation for discharge, the team should therapies (OSTs) (methadone and buprenorphine); doses arrange community support to provide follow-up and manage the will need to be verified by the opioid prescriber and the process of analgesia reduction during the recovery phase. dispensing pharmacist.12 There is a high prevalence of psychiatric comorbidities in those (2) Other prescribed medications, over-the-counter drugs, or with drug dependence, with more than 50% of patients showing illicit substances including heroin, alcohol, nicotine, benzo- evidence of significant psychopathology, particularly anxiety diazepines, cannabis, and cocaine (polyabuse is common). disorders and affective disorders, including depression.5 Such (3) Routes of administration—some patients may be injecting comorbidities may further complicate patients’ behavior and their prescription drugs intended for oral, transdermal, or interaction with staff while in the hospital. sublingual use. In some cases, urine screening could be considered to detect (4) Medical comorbidities, eg, HIV/AIDS, hepatitis, cirrhosis, drugs and assist in formulating a treatment plan while in hospital. tuberculosis, endocarditis, cellulitis, abscesses, and Table 1 lists the duration of time that drugs may be detected in urine. chronic pain. (5) Psychiatric comorbidities, eg, anxiety, depression, per- sonality disorder, and posttraumatic stress disorder. 4. Concerns in treating acute pain in patients with (6) Social factors, eg, abuse, interpersonal violence, and drug dependence syndrome homelessness. On admission to hospital, patient concerns center on the (7) Support systems after discharge. following: (1) The fear of withdrawal, such as when the usual opioids 6. Principles of acute pain management in opioid- used in substitution therapy are not given promptly. These dependent patients anxieties are most obvious after long waits in the The goals of treating acute pain in patients using opioids are to Table 1 provide adequate analgesia, prevent withdrawal, and avoid Urine detection of drugs (approximate duration in h/d). triggering a relapse or worsening of the addiction disorder. Buprenorphine
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