PainLink News Vol.2, No. 1: Pain Management and Addiction

Vol. 2, No. 1	Summer, 1997

PainLink, a community of healthcare leaders committed to alleviating pain, is an initiative of Education Development Center, Inc. made possible through the guidance and financial support of The Mayday Fund.

Pain Management in the Person with a History of Addiction: A PainLink Teaching Case

Overview for the session facilitator

Deciding how to manage pain in someone who has a prior or concurrent history of substance abuse poses many concerns for clinicians. Staff may fear exacerbating addiction behaviors in the person who abuses drugs. In the recovering addict, clinicians may be concerned that any effort to manage pain with opioids or other controlled substances will result in a relapse. If pain is well managed with several modalities, including opioids, clinicians often want to taper or discontinue opioids. Staff may be concerned about liability. Physicians express concern about encounters with the Drug Enforcement Agency if they attend to the pain of a person with an addiction history. Although clinicians may not be conscious of their behaviors toward an addict in pain or the reasons for them, behaviors such as ignoring the issue of pain management or withholding analgesia suggest that they believe their actions are beneficial for society, if not for the addict. Yet we know that patients with a history of addiction have surgery or develop chronic illnesses such as cancer, conditions known to be associated with pain. What do we need to know to provide compassionate and appropriate care to those who have abused substances and happen to experience significant acute or chronic pain? Can PainLink clinicians relate any of their experiences on the Decisions project, where we looked at the vulnerable and often disenfranchised population of dying patients, to the Martini case? The case of Mr. Martini is intended to help us look at both the ethical and the clinical aspects of managing pain in the person who has an addiction.

Learning Objectives

This case provides an opportunity to examine and discuss:

specific concerns that arise related to treating pain in the person who abuses substances
values and attitudes regarding addiction that may influence how we care for patients
arguments for attentive pain management in this population
appropriate and inappropriate approaches to managing pain in this population
strategies for initiating and monitoring the use of opioids for pain management in the person who is or has been addicted
criteria for evaluating efficacy of pain therapies in this population
addiction as a complex set of behaviors

The opportunity to discuss the issues involved in managing pain in someone with a history of addiction is intended to assist clinicians in understanding the complexity of the issue more fully and in developing a more knowledgeable approach to similar situations in their own practices.

Introduction to the Case of Mr. Martini

This information is derived from old charts, from the discharge summary of the physician at the acute hospital who referred the patient for rehabilitation (rehab), and from two admissions to a rehab hospital. The experience of a clinician involved in his care has been incorporated into the case. The first segment describes his second admission to a rehab hospital. The second segment provides more clinical information: relevant past medical history (PMH), social history (SH), and a summary of his first rehab hospitalization. The third segment focuses on selected aspects of his second rehab admission.

The Case of Mr. Martini: Segment 1

Mr. Martini is admitted to a rehab hospital following a left hip arthroplasty and left tibial traction pin. During his acute hospitalization, his immediate postoperative course was complicated by a staphylococcus infection at the surgical site, for which he is still receiving IV antibiotics. In 1995, he had an inpatient rehab stay following a girdlestone surgical procedure on his right hip. Mr. Martini is easily frustrated, gets impatient, and expresses his anger verbally. These characteristics are heightened if he is in substantial pain. For example, requests for pain medications are made in demanding and insistent tones. During both rehab admissions, pain was a prominent problem.

Mr. Martini has been on a methadone maintenance program. His most recent use of heroin occurred about three days prior to his acute hospital admission, after being clean for more than a year. Mr. Martini described the incident that led to this relapse. He was so overwhelmed by the thought that something might have happened to his young niece when she accompanied him on an errand and his car caught fire that he sought a fix that night. "If anything had happened to her, I couldn't forgive myself."

Mr. Martini reports pain in his left hip and left lower leg as well as some right shoulder and paralumbar pain. From the nursing assessment, Mr. Martini's pain intensity data are as follows: worst pain is 10/10, least is 9/10, average is 9/10. Despite being on Percocet, 2 tabs every 6 hours, his pain is never below a 9/10.

Questions

If you have ever cared for a patient like Mr. Martini, you might want to remember that experience as you discuss the following questions.

Do you believe Mr. Martini has pain?
How does the fact that he has used heroin influence your interpretation of his reported pain intensity?
Based on the information given, do you have any concerns about his behavior?
Mr. Martini's reported pain intensities on average and at its least suggest that he is in severe pain much of the day. What, if any, steps would you take to further assess and treat his pain?

The Case of Mr. Martini: Segment 2

To be able to discuss the questions at the end of this segment, additional information about Mr. Martini's health history and first rehab hospitalization might be helpful.

Additional Background Information

Past Medical History

In 1983, Mr. Martini had a work-related back injury that occurred when he lifted a large pane of glass. This injury was diagnosed as lumbar disc bulge with intermittent nerve root compression, for which he received outpatient rehab.

In 1990, Mr. Martini had bilateral femoral osteotomies and total hip replacements subsequent to posttraumatic avascular necrosis of both hips.

In 1995, he had a septic right hip, believed to be caused by using an unsterile needle. He had a right girdlestone procedure, complicated by a postoperative staph infection. During this acute hospitalization, he was seen by psychiatry for "suicidal ideation," major depression was diagnosed, and amitriptyline was initiated. He was admitted for his first inpatient rehab stay following this acute hospitalization.

Social History

A review of his old charts indicated that Mr. Martini had completed his outpatient rehab in 1983 but could return only to light duty. A vocational counselor who saw Mr. Martini at that time noted that although he was a high school graduate, Mr. Martini believed his education had been hampered by the busing conflicts going on in his community.

During his 1995 rehab hospitalization, a member of the rehab hospital's pain team interviewed Mr. Martini and obtained more information about the history of his addiction and its current status. Mr. Martini began using heroin for pain when he was unable to get any help from health providers for the pain after his 1991 injury and surgeries. He needed pain relief in order to continue to work and began using heroin to relieve his pain. He was not referred to an inpatient or outpatient pain rehab program. When his sisters refused to let him see his young niece and nephews because of his addiction, he began a methadone maintenance program. He reports that he has a good relationship with his counselor in the program, and when not hospitalized, he participates in a support group for addicts. Mr. Martini has been clean for nearly a year, with two exceptions, one related to the acute pain he experienced immediately prior to his first acute hospitalization and the second related to psychological distress.

Mr. Martini is concerned about how he will manage to get his "dailies" (daily methadone prescription from the methadone clinic) and participate in outpatient rehab following his discharge. He is unable to drive, because of mobility restrictions, and will have to rely on government-subsidized transportation to take him from home to the methadone clinic to the rehab clinic. He is hoping he will be able to obtain three-day supplies of methadone.

Mr. Martini's parents are divorced. After his 1995 hospitalization, he had to move in with his mother who lives in a small apartment in the "projects." He acknowledges that his mother cares about him but feels that she "nags" him and "worries too much." He would rather not live with her but sees no alternative. His father is disabled, and Mr. Martini remains in contact with his dad. Mr. Martini has not been able to work for several years, because of his pain and addiction. He also reports that his chronic pain led to the breakup of a 14-year relationship with his female partner, in 1992.

Mr. Martini has two sisters, with whom he has close ties, and a niece and two nephews, whom he adores. When you observe Mr. Martini's interactions with these children, it shows a side of him not readily apparent in typical clinical interactions. When the kids visit, he plays with them, it is clear there is mutual affection, and he seems distracted from his problems.

Mr. Martini gets frustrated easily--sometimes it's because he hasn't received his pain medicine; at other times it's because of his slow progress in ambulating. He has a habit of "catastrophizing"--that is, he does not see things as getting better. It is hard for him to recognize progress or the positive side of a situation.

Summary of First Rehab Admission

During Mr. Martini's 1995 rehab admission, initial and ongoing pain assessments were done using the Brief Pain Inventory, which elicits information on pain intensity and quality of life. Several interventions were tried and found effective. He learned relaxation techniques, which he used consistently; a TENS unit had been prescribed for right hip pain; and an around-the-clock (8:00 a.m. to 8:00 p.m.) schedule of 10 mg of oxycodone (Tylenol was contraindicated at the time) q.i.d.; this dose, combined with the nondrug interventions, enabled him to participate in his therapies while keeping his pain intensity at 3. Pain no longer interfered with his sleeping, and pain interference with other quality-of-life measures had decreased markedly. Upon discharge from the rehab hospital, he was referred to an outpatient pain clinic. There his q.i.d. oxycodone was changed to long-acting oxycodone (20 mg b.i.d.). His psychiatrist, in collaboration with the pain clinic, changed his antidepressant to nortriptyline. Mr. Martini showed up for all clinic appointments, and on the rare occasion when he had to cancel an appointment, he notified the staff. He continued to make progress during his outpatient rehab, resumed driving, and provided child care periodically for his sisters' children. He also began training in computer electronics and completed one of the required courses one month prior to his second rehab admission.

Questions

Given your discussion of the questions in Segment 1, is there anything about this additional information that surprises you?
How was the treatment of Mr. Martini's pain different from what you would expect?
Given the events described thus far, if you were to have a patient with a history of prior or current substance abuse, what steps would you take to assess and treat the person's pain?
When is it useful to talk with patients about their lives and medical histories and who should do this?

The Case of Mr. Martini: Segment 3

Second Rehabilitation Admission

Mr. Martini presented to an emergency room with severe left hip pain. He was diagnosed with a left hip infection thought to have originated from an abscessed tooth and was admitted to the acute hospital. He had a left hip arthroplasty and a tibial traction pin placed. He was then admitted to the rehab hospital and reported the following pain intensities (on the Brief Pain Inventory): worst, 10/10; least, 9/10; mean, 9/10; and now, 10/10. Breakthrough pain associated with therapies escalates past a 10. Pain interference with quality-of-life parameters (mood, walking, etc.) were between 9/10 and 10/10 (nearly complete interference). Mr. Martini acknowledged being depressed despite the current dose of antidepressant. He attributes this to the car fire incident with his niece and his belief that he won't do as well with this hospitalization, since his right hip, operated on last year, cannot compensate for the limitations of his left hip. Last year, he was able to use his left hip and leg to compensate for limitations of his right side. As with prior hospitalizations, he has limited tolerance for pain.

Medications on Admission to the Rehab Hospital

During his hospitalization at the acute hospital, his pain had been managed with an epidural infusion (drug unknown). Efforts to establish an adequate dose of oxycodone were unsuccessful, according to the patient. Therefore, at the acute hospital his methadone was increased from 80 mg q am to methadone 70 mg q 12 hours and then increased again.

Methadone 90 mg q 12 hrs.
Percocet¨ 2 tabs q 6 hrs.
Klonopin¨ 1 mg 6 x's day
Clonidine 0.1 mg qd
Nefasodone¨ 150 mg bid

The goals for Mr. Martini's rehab are to enable him to be independent in ADLs (activities of daily living), including using the toilet, and making independent transfers and being independent in mobility, although whether this will be at the wheelchair or crutch level remains to be determined, since his weight-bearing status is unclear. In addition, the clinical nurse specialist and the psychologist believe this hospitalization offers an opportunity to address Mr. Martini's tendency to catastrophize (which at least affects his mood, if not his pain), thus building on interventions that were successful during his last hospitalization.

Questions

What pain management goals would you want to negotiate with Mr. Martini?
Is it appropriate to escalate methadone maintenance doses to manage acute pain associated with surgery and orthopedic rehabilitation? Why? or Why not?
Should the patient's opioids be tapered? What criteria should be used in deciding to continue or taper opioids in a patient with a history of addictions?
How would you manage breakthrough pain? His activities during physical therapy increase his pain to beyond 10. What modifications would you make to his treatment or analgesic regimen?
What strategies would you use to deal with his negative thought patterns, depression, anger, and frustration?
Does your discussion of this case make you think any differently about your institution's past treatment of patients like Mr. Martini? Is there anything you think you and your colleagues might now do differently in your individual encounters with similar patients? Is there anything your institution might do differently?

This article was prepared by Judith A. Spross

Last Updated: April 18, 2000