Management of pain in addicted/illicit and legal substance abusing patients

A retrospective review of unintentional opioid overdose risk and mitigating factors among acutely injured trauma patients

BACKGROUND

Opioid medication to treat acutely injured patients is usual care in trauma settings. A higher prevalence of alcohol and other substance misuse in this population compared to the general population increases the vulnerability of such patients to both misuse of their prescribed opioids, and also unintentional opioid overdose. The primary purpose of this study was to assess the prevalence of substance use and unintentional opioid overdose risk among acutely injured trauma patients, and to examine the frequency and predictors of high opioid dose at discharge.

METHODS

A retrospective electronic medical record (EMR) review of three-months of data from two Level 1 trauma centers. We assessed the prevalence of substance misuse, unintentional opioid overdose risk, and presence of documentation of clinical strategies to mitigate these risks, such as co-prescription of the opioid agonist naloxone.

RESULTS

In total, 352 patient EMRs were examined. Over 40% of the patients reviewed had at least one indication of substance misuse (42.5% [95%CI: 37.3, 47.7]); at least 1 unintentional opioid overdose risk factor was identified in 240 EMR reviewed (68.2% [95%CI: 63.3, 73.1]). Dose of opioid medication was not significantly different for patients with substance misuse versus those without. There was no co-prescription of naloxone for any of the discharged patients.

CONCLUSIONS

Our results indicate that despite the high rates of substance misuse, the potential for misuse, dependence and unintentional overdose risk from prescribed opioid medications are prevalent among acutely injured trauma patients. Prescribing after acute trauma care should address these risk factors.

Pain Management of Patients with Substance Abuse in the Ambulatory Setting

PURPOSE OF REVIEW

Abuse of illicit substances and prescription opioids is a growing problem that presents challenges for pain management in the inpatient and outpatient setting. With future patient care models shifting toward shorter hospital stays and more same-day surgeries, it is crucial that clinicians learn to manage this patient population and strike a balance between the overtreatment of pain that can subsequently worsen tolerance and addiction, and the undertreatment of pain that can lead to pseudoaddiction.

RECENT FINDINGS

Through recognition of maladaptive behaviors, use of screening programs, and pain contracts, physicians in the outpatient setting can improve their oversight and shepherding of these patients. In the inpatient setting, regularly scheduled rather than PRN opioids are recommended for chronic opioid users, and good communication with the patient's outpatient prescriber of pain medications is essential. For surgical patients on chronic opioid therapy, making a multimodal plan in advance of the day of surgery that may incorporate NSAIDs, tricyclics, gabapentinoids, anticonvulsants, opioid tapering, and regional anesthesia can help alleviate high postoperative pain control requirements. In conjunction with such medication management, setting realistic expectations for pain control with preoperative counseling may be highly beneficial. For postoperative pain refractory to other strategies, the use of inpatient low-dose ketamine infusions is a novel approach that is gaining popularity, but this does require monitoring by a dedicated pain service.

Pain Control in the Presence of Drug Addiction

Drug addiction is present in a significant proportion of the population in the USA and worldwide. Drug addiction can occur with the abuse of many types of substances including cocaine, marijuana, stimulants, alcohol, opioids, and tranquilizers. There is a high likelihood that clinicians will encounter patients with substance abuse disorders on a regular basis with the prevalence of the use of illicit substances and the high rate of abuse of prescription drugs. The use of abuse deterrent formulations of prescription opioid agents, pill counts, and urine drug abuse screenings are all useful strategies. Optimum pain management of patients with addiction in the outpatient and inpatient setting is essential to minimize pain states. Careful selection of medications and appropriate oversight, including drug agreements, can reduce drug-induced impairments, including sleep deficits and diminished physical, social, and sexual functioning. This review, therefore, discusses the prevalence of illicit and prescription drug addiction, the challenges of achieving optimum pain control, and the therapeutic approaches to be considered in this challenging population. More research is warranted to develop improved therapies and routes of treatments for optimum pain relief and to prevent the development of central sensitization, chronic pain, and impaired physical and social functioning in patients with drug addiction.

Use of psychoactive substances in persons with spinal cord injury: a literature review

OBJECTIVE

To undertake a critical review of literature on use of legal and illegal psychoactive substances (PAS) in persons with spinal cord injury (SCI) before and after trauma.

MATERIAL AND METHODS

Hundred and five articles published between 1980 and 2014 on alcohol and drug use in persons with SCI before and after trauma were retrieved from the PubMed and PsycInfo search engines.

RESULTS

Before injury, 25% to 96% of people with SCI reported using alcohol, while 32% to 35% had used illegal drugs. At the time of injury, 31% to 50% of individuals with SCI were intoxicated with alcohol, 16% to 33% with drugs and 26% with a combination of drugs and alcohol. Among those reporting PAS use before injury, up to 50% stated that they had reduced their use during active rehabilitation, during which time only 6% consumed psychoactive substances for the first time. A variety of risk factors are associated with consumption subsequent to spinal cord injury: personality alteration (impulsiveness, aggressiveness), posttraumatic depression, poor coping skills, lack of social support and pain. PAS use can affect the process of rehabilitation, diminish the effectiveness of medication and result in various medical complications.

DISCUSSION/CONCLUSIONS

Few studies have explored the use of alcohol, drugs and psychoactive medications before SCI and during active rehabilitation. To our knowledge, no study has analyzed the evolution of PAS use after hospital discharge, even though return home is associated with new stressors that may trigger risky behaviors. It should be a priority, as early as possible during rehabilitation, to detect persons at risk of developing PAS abuse.

Pain, affective symptoms, and cognitive deficits in patients with cerebral dopamine dysfunction

Converging preclinical, and human epidemiological, neuroimaging, and genetic evidence suggests a central role for dopamine neurotransmission in modulating pain perception and analgesia. Dysregulation in dopamine signaling may modulate the experience of pain both directly, by enhancing or diminishing the propagation of nociceptive signals, and indirectly, by influencing affective and cognitive processes, which affect the expectation, experience, and interpretation of nociceptive signals. Hypersensitivity to pain and high rates of comorbid chronic pain are common in disorders linked with deficits in dopamine system function, including disorders of mood and affect, substance abuse, and Parkinson disease. Hyposensitivity to pain, however, is common in patients with schizophrenia, which has been linked with excessive dopamine neurotransmission. Although patients are typically affected most by the primary symptoms of their disorders, alterations in pain perception may further increase the burden of their illness, compromising their quality of life. The present review focuses on this relationship, and discusses clinical and potential therapeutic implications for both patients with dopamine-related disorders and those with chronic pain syndromes.

A review of opioids for in-hospital pain management

In the postoperative pain setting, the use of opioid analgesics remains essential in achieving effective analgesia and in avoiding the deleterious sequelae of uncontrolled pain that can worsen patient outcomes. However, postoperative pain remains undertreated in many patients. Choosing the most appropriate use of opioids in the postoperative setting, especially for patients undergoing ongoing opioid treatment for chronic pain, can pose daunting challenges for many clinicians. In this article, we examine the pitfalls that may be encountered when implementing postoperative pain management strategies with opioid analgesics, especially in patients receiving chronic opioid therapy prior to admission, and the critical steps for appropriate and effective analgesia in this setting.

Can Heterogeneity of Chronic Sickle-Cell Disease Pain Be Explained by Genomics? A Literature Review

This literature review explores the potential of genomics to explain, or at least contribute to the discussion about, heterogeneity in chronic pain in sickle-cell disease (SCD). Background: Adults with SCD, a single-gene disorder, are living longer than in years past, yet report being burdened by chronic pain. With only a few studies on chronic pain in this population, the epidemiology is unclear. However, research in the area of pain genetics continues to advance since the conclusion of the Human Genome Project. Two pain susceptibility genes, catechol-O-methyltransferase (COMT) and cytochrome P450, have, to date, been discovered that can increase individual susceptibility to the development of chronic pain. Method: A search was conducted in PubMed, CINAHL, and EBSCO using the terms ``sickle cell,'' ``chronic pain,'' ``polymorphism,'' ``genetics,'' ``pain genetics,'' ``human,'' ``adult,'' ``association studies,'' and ``pain susceptibility genes'' to search for articles published between 1970 and 2008. Findings: Chronic pain generally is more prevalent and severe than previously reported, and individuals with SCD report daily pain. The genomic era has made it possible for scientists to identify pain susceptibility genes that contribute to variability in the interindividual experience of chronic pain. Conclusion: Nurses are well positioned to generate and translate genomic research, thus improving care delivery. Such research may lead to the identification of polymorphisms associated with pain sensitivity in individuals with SCD.

Hospitalization for caffeine abuse is associated with abuse of other pharmaceutical products

STUDY OBJECTIVE

The aim of this study was to examine the characteristics and outcomes of patients seeking treatment for abuse of supplemental caffeine.

METHODS

This was a 3-year analysis conducted of all consecutive cases involving caffeine abuse in patients 10 years and older reported to a regional poison center. Excluded were suicide attempts, therapeutic errors, and cases involving only a coffee or tea product.

RESULTS

Two hundred fifty-four cases met inclusion criteria. Mean age was 20.5 years, 50% were women. Caffeine was in the form of a nondietary medication in 201 cases, a dietary supplement in 35 cases, and a caffeine-enhanced beverage in 35 cases. Caffeine was abused alone in 174 (68%), with alcohol in 7, illegal drugs in 6 cases, and with other pharmaceutical products in 81 (29%) cases. Thirty-four patients (13% of total) were hospitalized for medical complications from caffeine. Only concomitant abuse of other pharmaceutical products was associated with hospitalization (odds ratio, 3.8; 95% CI, 1.8-8.8; P = .0004).

CONCLUSION

In this cohort, supplemental caffeine was abused primarily by young adults. Concomitant recreational abuse of other pharmaceuticals was associated with hospitalization and warrants further investigation.