Pain is considered acute when it is self-limited. It is usually associated or caused by disease or acute medical condition, trauma, inflammatory process, surgery, or a physiological process such as labor. In acute pain, the nervous system is usually intact, and a variety of autonomic changes which may potentially be harmful are identifiable. These include tachycardia, hypertension, sweating or vasoconstriction, increased rate and decreased depth of respiration, increased gastrointestinal secretions, decreased intestinal motility, skeletal muscle spasm and immobility, increased sphincter tone, venous stasis, or urinary retention. Other potential harmful effects include thrombosis or pulmonary embolism, anxiety, confusion, or delirium. Acute pain usually decreases or ceases as wound or injury heals or as medical condition improves.
Acute and chronic pain may, in some instances, overlap. Certain severe and prolonged acute pain may progressively become more like chronic pain. Patients with chronic pain may have superimposed acute pain such as when they develop bone fracture secondary to metastatic malignancy or when they require surgery. In such cases, the nervous system may not be intact and they may have significant pre-existing psychological problems, opioid tolerance, and other complicating conditions.
Opioids are the mainstay for treatment of severe acute pain in the addicted patient. Because pharmacologic tolerance to opiates is common in these individuals, the doses required are usually higher than in the non-addicted patient. Concerns of abuse of opiates in these individuals having been documented escalating, a collaborative effort by the clinician, the psychiatrist, and the addiction medicine should be attempted.
Guidelines for successful management of acute pain in the known or suspected opiate addict have been published by Portenoy and Payne (1992). The recommended first step is to define the pain syndrome and provide treatment for the underlying disorder. As mentioned in the prior sections, it is important to distinguish the patient with a remote history of drug abuse from one who is actively abusing drugs and one who is receiving methadone maintenance. This is followed by appropriate pharmacologic principles of opioid use. Opioids are used in adequate doses, dosing intervals, and appropriate route of administration. The use of concomitant nonopioid therapies such as nonopioid analgesics and nonpharmaco-logic therapies when appropriate are encouraged. Specific drug abuse behaviors need to be recognized. Excessive negotiation over specific drugs and doses is discouraged. Early consultation to appropriate services such as psychiatry and substance abuse services, and if available, pain service is advocated. If outpatient treatment is required, problems associated with opioid prescription renewals should be anticipated.
In surgical pain, other therapeutic options include alternative route of administration of either opioid, local anesthetic, or both. The use of regional analgesia (e.g., intrathecal or epidural techniques) and/or peripheral nerve blockade is used to increase control of pain in addicted patients. In certain cases, pain treatment may require extensive and sympathetic blockade to relieve acute pain such as during major surgery or in profoundly severe acute pains refractory to other modalities of treatment. Patient-controlled analgesia (PCA) modality is often withheld from these individuals because of the concern that self-administered analgesic delivery may reinforce drug-seeking behavior (Sinatra 1998), and neural blockade or epidural analgesic techniques are substituted. More recent thinking allows selected patients presenting with cocaine and alcohol abuse to use PCA in well-supervised settings. Patients with a history of chronic pain and significant opioid tolerance require increased amounts of drug to compensate for both baseline requirements, as well as that needed to control pain following surgery. In general, health providers tend to limit opi-oid administration to patients who have a history of substance abuse despite the fact that perioperative patients with history of substance abuse or tolerance experience the same intensity of postsurgical discomfort. Physicians fear that pain medications may mask status changes and risk patient addiction. It appears, however, that iatrogenic addiction may not be a concern of significant magnitude as one would expect (Sinatra 1998). In a survey of over 10,000 patients from 151 burn centers, for example, no cases of iatrogenic opioid addiction were reported (Perry and Heidrich 1982). In the patient with history of addiction the chronic use of opiates poses a significant risk of exacerbating a substance abuse problem.
Management should be centered in recognizing and accepting the addiction problem and on providing structured, consistent care, preferably with input from addiction or psychiatric specialists. Multimodal, team-oriented approach to treatment, although cumbersome and impractical, may well be cost-effective for this complex type of patient. The incidence of addiction in the opioid-treated population ranges from 3 to 19%. Incorrectly assuming that patients with addictive illness will develop addiction plays a negative role in effectively treating pain.
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