Pain in critically ill patients with substance use disorder or long-term opioid use for chronic pain

Opioid tolerance resulting from long-term opioid consumption for chronic pain or from substance use disorder adds a layer of complexity to managing pain in the critical care setting. This article discusses similarities and differences of these 2 conditions. The phenomenon of tolerance and opioid-induced hyperalgesia are presented. Prevention of opioid withdrawal, when patients are on methadone or buprenorphine, is described. An overview of the neurophysiology of pain and substance use disorder is presented. Practical clinical suggestions are given to assist the critical care nurse in caring for these complex patients.     

Characterization of the early pharmacodynamic profile of oral methadone for cancer-related breakthrough pain: a pilot study

Methadone is effective for chronic cancer pain, but its early pharmacodynamic profile and effectiveness for breakthrough pain remain uncertain. This was an open-label, non-randomized, crossover study comparing the use of oral methadone for breakthrough pain with patients' usual opioid. Study variables included pain intensity (pretreatment and at 10-minute intervals post treatment), treatment-related side effects, and treatment satisfaction. In 37 discrete episodes of breakthrough pain, onset of analgesic effect of a titrated dose of oral methadone was rapid for all patients; 3 of 6 study patients experienced an onset of relief by 10 minutes post-ingestion. The adverse effect profile of oral methadone was not different from patients' usual ‘rescue’ opioid, and patients were moderately to completely satisfied with oral methadone as a breakthrough pain medication. These observations suggest that oral methadone can have a rapid onset of analgesic action and may have a legitimate role in the management of cancer-related breakthrough pain.     

Managing Pain in the Setting of Opioid Use Disorder

Specific Clinical IssueHealthcare providers are challenged with managing pain and minimizing morbidity and mortality associated with opioid use disorder.Major Practice Recommendations Based on Best EvidenceThe purpose of this article is to guide acute and ambulatory care clinicians in managing pain in patients with opioid use disorder. Included in this article is a review of medications used for opioid use disorder, a discussion of the management of patients with active opioid use disorder and acute or chronic pain, and a discussion of the management of acute and chronic pain in people in recovery both on and off medications for opioid use disorder.     

Data errors in emt licensure evaluator article

Objective. To examine the effects of transferring nonurgent 911 calls to a telephone consulting nurse. It was hypothesized that the telephone referral program would result in fewer basic life support (BLS) responses with no adverse patient outcome or decrease in patient satisfaction. Methods. A two-phased prospective study was conducted in an urban and rural setting with a population of 650,000. During phase I, a BLS unit was dispatched on all calls and a nurse intervention was simulated. During phase II, no BLS unit was dispatched for calls meeting study criteria. Callers were transferred to the nurse, and consulting nurse protocols were used to direct care. Data were collected from dispatch, BLS, nurse, and hospital records and patient self-assessment. Results. During phase I, 38 callers were transferred to the consulting nurse with no nurse intervention. During phase II, 133 cases were transferred to the nurse line. There were no adverse outcomes detected. The nurse recommended home care for 31%, physician referral for 24%, referral back to 911 for 17%, community resource for 11%, and other referral for 17%. Nurses contacted 85 patients for telephone follow-up. Ninety-four percent of the patients reported feeling better, 6% felt the same, and none felt worse. Patients were satisfied with the outcome in 96% of the cases. Conclusion. Transferring 911 calls to a nurse line resulted in fewer BLS responses and no adverse patient outcomes, while maintaining high patient satisfaction. Dispatch criteria correctly identified cases with minimal medical needs. A high percentage of the patients reported feeling better after the intervention. This study has major implications for communities interested in efficient use of emergency medical services resources.     

Rotation to methadone after opioid dose escalation: How should individualization of dosing occur?

Methadone is a synthetic opioid agonist and N-methyl-D-aspartate (NMDA) receptor antagonist that is being increasingly used in pain management, particularly for pain that is resistant to conventional opioids. We describe two patients with neurotoxic side effects on escalating doses of parenteral hydromorphone with uncontrolled cancer pain who were successfully converted to oral methadone at a dose much smaller than predicted. The phenomenon of increasing pain despite opioid dose escalation is discussed and the rationale for the use of methadone in this situation is described. While methadone is useful for patients with unremitting pain on another opioid, existing conversion regimens do not specifically take into account the setting of dose escalation. Clinical guidelines for rotation to methadone after dose escalation of the previous opioid are needed to avoid toxicity including respiratory depression. A possible conversion method for rotation to methadone for patients with escalating pain and opioid use is suggested.     

Rediscovery of Methadone to Improve Outcomes in Pain Management

Clinically, methadone is most known for its use in the treatment of opioid maintenance therapy. However, methadone's pharmacological profile makes it an excellent analgesic that can enhance acute and chronic pain management. It is a potent μ-receptor agonist with a longer elimination half-life than most clinically used opioids. In addition, methadone inhibits serotonin and norepinephrine uptake, and it is an N-methyl-D-aspartate antagonist. These distinct analgesic pathways mediate hyperalgesic, allodynic, and neuropathic pain. Its unique analgesic properties provide several essential benefits in perioperative use, neuropathic pain, cancer, and noncancer pain. Despite these proven clinical utilities, methadone has not been used widely to treat acute and chronic pain in opioid naïve patients. This article describes the unique pharmacology of methadone and provides emerging evidence to support its application in acute and chronic pain management. Pain management options and guidelines for surgical patients on methadone are discussed as well.     

Improving cancer pain management through patient and family education

The purpose of this study was to determine if continued access to information following a baseline pain education program would increase knowledge and positive beliefs about cancer pain management, thus resulting in improved pain control during a 6-month follow-up period. Patients with cancer-related pain and their primary caregivers received a brief pain education program, and were then randomized into one of three information groups: a) usual care, b) pain hot line, and c) weekly provider-initiated follow-up calls for 1 month post-education. Sixty-four patients and their primary caregivers were recruited. Both patients and caregivers showed an improvement in knowledge and beliefs after the baseline pain education program. Continued access to pain information with either the pain hot line or provider-initiated weekly follow-up calls did not affect long-term outcomes of pain intensity, interference because of pain, adequacy of analgesics used, or pain relief. In addition, long-term outcomes did not differ between patients who had improvement and those who showed decline in knowledge and beliefs pre-post education. These findings suggest that a brief pain education program can improve knowledge and beliefs of both patient and primary caregiver. Continued access to pain related information using either a patient- or provider-initiated format did not affect long-term pain outcomes.     

Concept of the Ambulatory Pain Physician

Purpose of Review

Given the growing number of ambulatory surgeries being performed and the variability in postoperative pain requirements, early discharge, and inconsistent follow-up, ambulatory surgery presents a unique challenge for this patient population and warrants the presence of an ambulatory pain specialist to evaluate a patient preoperatively and postoperatively to optimize patient safety and satisfaction. This article explores the crucial role that a dedicated pain physician would have in the ambulatory surgery setting.

Recent Findings

The prevalence of chronic pain, opioid use, and substance abuse is growing in this country, while ambulatory and same-day surgery have also experienced considerable growth. Inevitably, more patients with challenging chronic pain or substance abuse are having ambulatory surgery. Increased BMI, advanced age, more comorbidities warranting a higher ASA physical status classification, and longer surgeries are now all components of ambulatory surgery that contribute to increased risk too. Certain surgeries including breast surgery, inguinal hernia repair, and thoracotomy are at higher risk for the conversion of acute to chronic pain, and an ambulatory pain specialist would be beneficial for added focus on these patients.

Summary

Multimodal pain control with non-opioids and regional anesthesia adjuvants are beneficial, while emphasis on a patient’s functional capacity may be more useful than quantifying the severity of pain. Despite the best efforts of patients’ primary care providers or surgeons, patients often are discharged with more chronic opioid therapy than they presented with, and an ambulatory pain specialist can help manage the complications and prevent further escalation of this opioid epidemic. An onsite anesthesiologist with interest in pain management in each ambulatory surgery center administering anesthesia and available onsite to deal with immediate preoperative, intraoperative, and recovery room would be ideal to curb and manage complication from uncontrolled pain and related pain issues.

     

Emergency Nurse Perceptions of Pain and Opioids in the Emergency Department

The opioid crisis is a national health emergency with immense morbidity, mortality, and socioeconomic cost. Emergency department (ED) pain management is tightly linked to the issue of opioid use disorder (OUD), because opioid exposure is necessary for development of OUD. Emergency nurses are on the frontlines of this complex problem, yet little, if any, attention has been paid to the role they play in the prevention and management of either pain or OUD in this unique and important setting. A framework that conceptualizes and optimizes emergency nurses as change agents in the opioid epidemic is urgently needed. While ED pain management and OUD prevention is dependent on the entire care team, this innovative study qualitatively characterizes emergency nurse perceptions of pain management, OUD prevention, and their potential role in each. Content analysis produced 14 categories that were clustered into two themes, “nurses influence ED pain management” and “adjustments in ED pain management”, and an overarching message that “pain management depends on the care team.” By generating a more comprehensive and nuanced understanding of the role played by emergency nurses, our findings provide essential insights into potential interventions and frameworks.     

App-Based Pain Management and Opioid Education Program for Patients in Clinic Waiting Rooms

BackgroundBest approaches to delivering patient education related to pain management and opioid safety are understudied.AimsThis study assessed the feasibility, acceptability, and preliminary patient-reported impact of an app-based patient pain education program.DesignPilot study with data collection occurring on 43 weekdays between August 2019-February 2020.SettingWaiting rooms at the pain clinic and a primary care medical home within two military treatment facilities.ParticipantsMilitary health system beneficiaries seeking general care at the primary care medical home or pain-specific care at the pain clinic.MethodsThe Joint Pain Education and Project curriculum includes patient-focused videos describing the biopsychosocial aspects of pain and pain management, medication take-back and safe disposal, and multidimensional pain assessments. The app-based videos were available on tablets in the waiting rooms for patients to view and complete surveys on after.ResultsOverall, 152 patients viewed the videos and completed surveys. Most viewers were interested in receiving other tablet-based health education while in the waiting room (62%). Most viewers found videos to be moderately or very helpful (73%) and were satisfied or very satisfied with the information provided (85%). Participants at the primary care medical home were more likely to find videos helpful compared to participants at the pain clinic (OR = 2.11; 95% CI: 1.07, 4.20; p = .03).ConclusionImplementing app-based pain management education is feasible across clinic settings and is well received by patients. Clinics should consider providing pain education across care setting, rather than just pain specialty clinics, to help foster discussions between clinicians and patients regarding pain management and opioid safety.     

Assessment of Chronic Pain Management in the Treatment of Opioid Use Disorder: Gaps in Care and Implications for Treatment Outcomes

Chronic pain is a significant comorbid condition among individuals with opioid use disorder (OUD). However, due to conflicting perceptions of responsibility, structural barriers, and a lack of widely applied standards of care, it is unclear what the landscape of chronic pain management looks like in addiction medicine. Using a national opioid surveillance system, we analyzed survey data from new entrants (n = 14,449) to 225 OUD treatment centers from 2013 to 2018, as well as an online survey among a subset of respondents (n = 309). While chronic pain was reported by 33.4% of the sample, two-thirds of the chronic pain group (66.0%) reported their pain was not managed through their OUD treatment program, with 47% reporting worsening pain. Pain that was managed was primarily done so through pharmaceuticals (75.2%), notably as a secondary effect of medication-assisted treatment. In addition, 43.2% reported chronic pain as a primary factor in their opioid relapse. These data suggest that chronic pain is commonly reported, yet not managed by many OUD treatment programs, increasing the likelihood of opioid relapse. In order to improve poor outcomes among OUD patients, interdisciplinary collaboration/care, along with evidence-based policies or processes for quality pain management in addiction care need to be prioritized.PerspectiveThis article suggests chronic pain is commonly reported, yet not managed by many OUD treatment programs, increasing the likelihood of opioid relapse. In order to improve low retention and success rates among OUD patients, interdisciplinary collaboration, evidence-based policies or processes (eg, referral) for quality pain management in addiction care need to be prioritized.     

Methadone therapy for opioid dependence.

The 1999 Federal regulations extend the treatment options of methadone-maintained opioid-dependent patients from specialized clinics to office-based opioid therapy (OBOT). OBOT allows primary care physicians to coordinate methadone therapy in this group with ongoing medical care. This patient group tends to be poorly understood and underserved. Methadone maintenance therapy is the most widely known and well-researched treatment for opioid dependency. Goals of therapy are to prevent abstinence syndrome, reduce narcotic cravings and block the euphoric effects of illicit opioid use. In the first phase of methadone treatment, appropriately selected patients are tapered to adequate steady-state dosing. Once they are stabilized on a satisfactory dosage, it is often possible to address their other chronic medical and psychiatric conditions. The maintenance phase can be used as a long-term therapy until the patient demonstrates the qualities required for successful detoxification. Patients who abuse narcotics have an increased risk for human immunodeficiency virus infection, hepatitis, tuberculosis and other conditions contributing to increased morbidity and mortality. Short- or long-term pain management problems and surgical needs are also common concerns in opioid-dependent patients and are generally treatable in conjunction with methadone maintenance.     

The role of the outpatient clinic nurse in monitoring opioid therapy

Outpatient clinical nurses specialize in patient care in a particular area of nursing practice. Typically, the registered nurse also holds a professional certification in that specialty or subspecialty. The only nursing certification related to pain and symptom management is the Hospice and Palliative Care certification. Managing the patient with chronic pain is a common clinical challenge, especially when opioid therapy is indicated. Chronic pain often is undertreated in patients with cancer and in those with non-malignant conditions. Because chronic pain can be complex, successful long-term treatment is more difficult for providers. Professional nurses are the primary team members who assess, coordinate, direct, and evaluate patient care needs during times of illness. A nurse is one of the first contacts in the health care system that the patient encounters. Nurses must possess unique qualifications and be able to deal compassionately with a demanding and sometimes hostile group of patients. How the patients are accepted into a pain medicine practice and managed is discussed in this article.     

Hyperalgesia in Opioid-Managed Chronic Pain and Opioid-Dependent Patients

This observational study aimed to determine whether pain sensitivity in patients with noncancer chronic pain, taking either methadone or morphine, is similar to patients maintained on methadone for dependence therapy, compared with a control group. Nociceptive thresholds were measured on a single occasion with von Frey hairs, electrical stimulation, and cold pressor tests. In all subjects receiving methadone or morphine, nociceptive testing occurred just before a scheduled dose. Cold pressor tolerance values in patients with noncancer, chronic pain, treated with morphine and methadone, were 18.1 ± 2.6 seconds (mean ± SEM) and 19.7 ± 2.3 seconds, respectively; in methadone-maintained subjects it was 18.9 ± 1.9 seconds, with all values being significantly (P < .05) lower than opioid-naïve subjects (30.7 ± 3.9 seconds). These results indicate that patients with chronic pain managed with opioids and methadone-maintained subjects are hyperalgesic when assessed by the cold pressor test but not by the electrical stimulation test. None of the groups exhibited allodynia as measured using the von Frey hairs. These results add to the growing body of evidence that chronic opioid exposure increases sensitivity to some types of pain. They also demonstrate that in humans, this hyperalgesia is not associated with allodynia.PerspectiveThis article presents an observational study whereby the pain sensitivity of patients with chronic pain managed with opioids and opioid-maintained patients were compared with opioid-naïve patients. The results suggest that opioid use may contribute to an increase in the sensitivity to certain pain experimental stimuli.     

A Pilot Randomized Controlled Trial of Outcomes Associated with Parent-Nurse Controlled Analgesia vs. Continuous Opioid Infusion in the Neonatal Intensive Care Unit

PurposeProspectively compare parent/nurse controlled analgesia (PNCA) to continuous opioid infusion (COI) in the post-operative neonatal intensive care unit (NICU) population.Design/MethodsA randomized controlled trial compared neonates treated with morphine PNCA to those treated with morphine COI. The primary outcome was average opioid consumption up to 3 post-operative days. Secondary outcomes included 1) pain intensity, 2) adverse events that may be directly related to opioid consumption, and 3) parent and nurse satisfaction.ResultsThe sample consisted of 25 post-operative neonates and young infants randomized to either morphine PNCA (n = 16) or COI (n = 9). Groups differed significantly on daily opioid consumption, with the PNCA group receiving significantly less opioid (P = .02). Groups did not differ on average pain score or frequency of adverse events (P values > .05). Parents in both groups were satisfied with their infant's pain management and parents in the PNCA group were slightly more satisfied with their level of involvement (P = .03). Groups did not differ in nursing satisfaction.ConclusionsPNCA may be an effective alternative to COI for pain management in the NICU population. This method may also substantially reduce opioid consumption, provide more individualized care, and improve parent satisfaction with their level of participation.Clinical ImplicationsPatients in the NICU represent one of our most vulnerable patient populations. As nurses strive to provide safe and effective pain management, results of this study suggest PNCA may allow nurses to maintain their patients' comfort while providing less opioid and potentially improving parental perception of involvement.Study TypeTreatment study.Level of EvidenceI.     

Effectiveness of an Organized Follow-up System for Elder Patients Released from the Emergency Department

Objectives : To determine whether an effective telephone callback system can be successfully implemented in a busy ED and to quantify the benefits that can be obtained related to the follow-up care of elder patients.
Methods : This was a prospective, cohort study conducted at a community teaching hospital during a 6-month period. Consecutive patients ≥60 years old and released from the ED were selected for telephone follow-up. Calls were made by a research nurse within 72 hours after the patient's ED visit. Follow-up information included current medical status, problems encountered during the ED visit, compliance, and impact of the illness on self-care capabilities.
Results : Seventy-nine percent (831/1,048) of the patients selected for telephone follow-up were successfully contacted. The calls lasted an average of 4 ± 2.5 minutes. Although 94% (778/831) of these patients had a regular physician, 14% failed to make their recommended follow-up arrangements. Compliance was significantly improved when a follow-up physician was contacted during the patient's ED visit. Approximately 96% of the patients were either satisfied or very satisfied with their ED care. However, 13% (109/831) had moderate deterioration in their ability to care for themselves. Of the patients contacted, 333 (40%) required further clarification of their home care instructions, 31 were advised to return to the ED for reevaluation, and 26 were referred to a medical social worker for psychosocial concerns.
Conclusion : A telephone callback system is a feasible and effective method to improve follow-up care of elder patients released from the ED.     

Opioid switching from morphine to methadone causes a minor but not clinically significant increase in QTc time: A prospective 9-month follow-up study

Case reports and retrospective studies suggest that methadone causes an increase in QTc (QT time corrected for heart rate) time and risk of torsades de pointes arrhythmia. No prospective studies in pain patients have been conducted, and data on whether a methadone-induced increase in QTc time persists during long-term treatment have not been reported. Eight chronic nonmalignant pain patients experiencing insufficient pain control or intolerable side effects during treatment with oral morphine switched to oral methadone and were included in this study. Electrocardiograms were obtained at baseline and at follow-up 2 weeks, and 3 and 9 months after the opioid switch. Start of methadone caused a minor but statistically significant increase in QTc time, while fluctuations in QTc during treatment with stable doses of methadone were neither clinically nor statistically significant. We observed no episodes of arrhythmias.     

Effects of a Multimodal Pain Rehabilitation Program: A Pilot Study

The purpose of this pilot study was to examine the effects of a multimodal pain rehabilitation program on pain perceptions, opioid usage, activity, down time, sleep, and role function status of 23 chronic pain patients. Data were collected at the start of the program, at the program's completion, and again during a follow-up period (3–11 months afterwards). At the end of the program, patients reported a significant reduction in pain levels, opioid usage, and hours of disturbed sleep. During the follow-up period, patients continued to report significant improvements in activity and role functions as well as significant reductions in opioid usage, sleep disturbance, and down time. These findings provided encouraging preliminary evidence that multimodal pain rehabilitation programs for chronic pain patients may be effective in pain management and functional restoration.