No matter what substance an addict is using, they still have the right to have their pain treated. The prescriber, on the other hand, has the responsibility of safe prescribing habits and focusing on the patient's pain needs. Opioids for these patients should be given only for pain relief, and careful documentation should be done at every clinical visit and for every phone call request.
If patients are known to be abusing substances, there are some rules that can make the care of these patients a little easier to manage.
■ There should be a written treatment agreement that is discussed and signed by both the patient and provider.
■ Only one prescriber should be writing opioids for the patient.
■ The prescriber should know what other physicians that the patient sees so that all health care providers know who will be managing the patient's medications.
■ Random, observed drug screens should be done frequently, and if illicit substances or prescription medications show up, there should be clear penalties for violating the agreement.
■ If the treatment agreement is broken, the patient should be exited from any opioid prescribing but continued in the practice for treatment without opioids and treating the pain with other nonopioid medications and interventions (see Chapter 10).
Common signs of addiction include becoming more and more unkempt, injecting oral medications, stealing/forging prescriptions, performing sex for drugs, stealing drugs from others, trying to get opioids from more than one source, and buying pain medication from a street dealer (Fine & Portnoy, 2007). Behaviors that are seen as less indicative of addiction include expressing anxiety about current symptoms, hoarding medications, taking someone else's pain medication, requesting a specific drug or medication, raising dose of opioids on their own, asking for a second opinion about pain medications, drinking more alcohol when in pain, smoking cigarettes to relieve pain, and using opioids to treat other symptoms (Fine & Portnoy, 2007). Of the total pain clinic population using opioids for pain relief, 40% will exhibit aberrant behaviors, 20% will abuse/misuse their medications, and 2%—5% will become addicted. Although this population is not typical, it does give us a picture of a group of patients who are exposed to high usages of opioid medications.
Many health care providers are reluctant to ask these personal types of questions. It is important to know if the patient is drinking as an adjunct method for pain relief. Because alcohol is cheap and easy to get, alcohol can be combined with pain medications to help augment the effect of the prescribed medications, but it significantly increases the risk of sedation and respiratory depression.
For all health care providers working with patients with chronic pain, it is essential to become comfortable with asking the hard questions. It is also critical that, when the patient responds honestly, they are treated with a nonjudgmental approach. One way to address this is to tell the patient you are not truly interested in all of the drug-taking behaviors, but that you need to know what he or she is taking or using so that you can treat the pain more effectively. Patients with a history of substance abuse or who are actively using illicit substances will require higher doses of medication than patients with similar injuries who are not using other drugs, and the patients without a history of substance abuse will not have the same dose requirements as the patient who is addicted to an opioid substance. Over time the patient has become more sensitive to pain but less responsive to medications used to treat pain.
The primary care practitioner may not be aware that the patient they have started to treat is an addict. In this case, once the addiction is detected, using a team of specialists can help the provider give the patient adequate care while being supported by a team of experts in the area.
You are assigned to Sara Peters, 35, who is coming in to see you with complaints of neck pain for a motor vehicle accident two years ago. Sara was intoxicated and hit a telephone pole, and she sustained a whiplash injury to her neck and ruptured several cervical discs. She is not a surgical candidate and needs to have pain relief. You ask her who she has been seeing for her pain management needs and she tells you, "Really, I just need some Percocet is all. My last doctor said I couldn't have any more, and so I really need to find someone who can help me with this pain and Percocet seems to do the best job. The last doctor said I was addicted to the pills and wanted me to try other types of pain medication. I can't sleep unless I have my Percocet, and I need to sleep to be able to go to work."
When you ask her about other drugs she says, "Well yeah, I used to smoke marijuana and did some cocaine when I was younger, but now I don't have the money to buy drugs and I don't have the urge." She has copies of her most recent radiographic studies that show ruptured cervical vertebrae at several levels.
How are you going to treat Sara's pain?
(Questions to Consider
1. Is Sara addicted or dependent on her Percocet? Does she exhibit behaviors that are more or less predictive of addiction?
2. Does she have a source of pain? If so what is the best approach to treat it? Short-acting pain medications, such as Percocet, or an extended-release medication?
3. Is she drug seeking?
4. Do you feel comfortable giving Sara opioids for pain? Are there other options you could try for pain relief?
5. What types of protective measure can you take to ensure that the medications you give Sara are not diverted?
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