Ethics and Undertreatment of Pain
in Patients with a History of Drug Abuse
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CNE NURSING EDUCATION
Ethics and Undertreatment of Pain in Patients with a History of Drug Abuse
Brooke Faria da Cunha
Deadline fo r Submission: February 28, 2017
MSNNI50I To Obtain CNE Contact Hours 1. For those wishing to obtain CNE contact hours,
you must read the article and complete the evaluation through the AMSN Online L ibrary. Complete your evaluation online and print your CNE certificate immediately, or later. Simply go to www.amsn.org/library
2. Evaluations must be completed online by February 28, 2017. Upon completion of the evaluation, a certificate for 1.3 contact hour(s) may be printed.
Fees Mem ber: FREE Regular: $20
Objectives The purpose of this continuing nursing education article is to increase nurses’ and other health care professionals’ awareness of the ethics surrounding the treatment of patients in pain who have a history of drug abuse. After studying the information pre sented in this article, you will be able to: 1. Define tolerance, physical dependence,
addiction, and pseudoaddiction. 2. Discuss the ethical considerations surrounding
pain management in patients with a history of substance abuse.
3. Explain autonomy, beneficence, nonmaleficence, and justice in health care.
Note: The author, editor, editorial board, and education director reported no actual or potential conflict of interest in relation to this continuing nursing education article.
This educational activity is jointly provided by Anthony J. Jannetti, Inc. and AMSN.
Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Anthony J. Jannetti, Inc. is a provider approved by the California Board of Registered Nursing, provider number CEP 5387. Licensees in the state of CA must retain this certificate for four years after the CNE activ ity is completed.
Patients with substance abuse history make up 14% of inpatient admissions to acute care units, where it has been reported a great deal of patient pain is unrelieved (Substance Abuse and Mental Health Services Administration [SAMHSA], 2009). Definitions o f substance abuse terms including tolerance, dependence, addiction, and pseudoaddiction are essen tial to a nurse’s understanding of pain medication administration in patients with substance abuse history. Pain management is one o f the nurse’s main responsibilities, and using the principles o f autonomy, beneficence, nonmaleficence, and justice can guide the nurse to making appropriate pain management decisions for and with these patients. Nursing implications and resources for more information are dis cussed.
Imagine being in an unfamiliar room, constantly barraged by unfamiliar people and invasive instruments, very sick, and in excruciating pain, with no end to that pain in sight. This is the plight of thousands of patients with drug abuse history admitted to acute care units right now. According to the Center for Behavioral Health Statistics and Quality (2010) – a division of SAMHSA – in 2010, 2 1.5% of adults ages 18-25 reported using illicit drugs in the last month, and 6.6% of adults ages 26 and older reported the same. Recent statistics also show that pain management is still grossly inadequate in U.S. hospitals. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Hospital Survey (2012) reported that from 2010-2011, only 70% of patients stated their pain was controlled during their hospital stay. From these statistics, it can be concluded that 30% of patients reported having uncontrolled pain; many of them are drug abusers, a label that consistently leads to espe
cially poor pain management. SAMHSA also reported that 14% of all inpatient admissions consist of patients with drug abuse history and that 20% of all Medicaid costs and $ l out of every $4 Medicare spends on inpatient care is associated with substance abuse (SAMHSA, 2009). Managing patients’ pain is the complex responsibility of many team members on an acute care unit; however, nurses are on the front line. Unfortunately, many nurses begin and practice for years without ade quate training in pain management and almost no training in pain management for patients with a history of drug abuse.This lack of education and expe rience is costly to millions of patients. In order to remedy all this unrelieved suf fering, nurses need to understand the meaning of drug abuse, its implications for pain control, and the moral respon sibilities they have to treat pain in all individuals, including those with drug abuse history.
Definitions The American College of
Emergency Physicians, the American Pain Society, the Emergency Nurses Association, and the American Society fo r Pain Management Nursing (ASPMN) have come together to pro vide clear, working definitions for drug- abuse related terms including tolerance, physical dependence, and addiction (ASPMN, 2010).A better understanding of these terms is crucial to providing adequate pain management because patients can experience one or all of theses states during hospital admission, they are easily confused with one another, and they require different care. In addition, an understanding of these terms can define and explain behaviors in patients with substance abuse his tory that may lead to undertreatment of pain.
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Tolerance is “ a state of adaption in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time” (Dunn & Neuman, 2012, p. 2). Tolerance is a physiologically expected response that is different from addic tion; however, those who are addicted have physical tolerance, which is why they need more medication to achieve the same relief from pain as non-drug users (Dunn & Neuman, 2012).
Physical dependence is another “ state of adaption that often includes tolerance and is manifested by a drug- class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist” (ASPMN, 2010, p. 2). Physical dependence is also a normal physiologic response to chronic use of a potentially harmful substance, such as opioids. Withdrawal syndromes can lead to symptoms such as nausea, vom iting, chills, diarrhea, and changes in vital signs (Dunn & Neuman, 2012). One can imagine how much worse a painful dis ease process or surgical recovery would be when exacerbated by with drawal symptoms.
Dependence is not to be confused with addiction, which is “ a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmen tal factors influencing its development and manifestations” (ASPMN, 2010, p. 2.) It is characterized by the four Cs; Compulsive use, Continued use despite harm, lack of Control over substance, and Craving (Dunn & Neuman, 2012).
Finally, addiction is not to be con fused with pseudoaddiction, or behaviors associated with addiction, but which occur because of inadequate pain man agement (Dunn & Neuman, 2012). Patients with unrelieved pain will resort to behaviors such as “ clock-watching” and will even resort to deception to get relief. These patients are frequently labeled “ drug seekers” because their excruciating pain is all they can think about (Krupnick, 2009). Pseudoaddictive behavior is recognizable by cessation of these behaviors and an increase in func tion when adequate analgesia is achieved.
When nurses encounter drug seeking behaviors in patients who have used illicit drugs in the past, it is easy to confuse which patients are tolerant, dependent, or pseudoaddicted with those who are addicted.This confusion can lead to the undertreatment of pain (ASPMN, 2010). Patients with addictive disease may even have uncontrolled pain, exacerbated by the fact that they are both tolerant to and dependant on medications. Uncontrolled pain has a myriad of negative health consequences that affect quality of life, ranging from anxiety to depression and chronic stress to suicide (Bernhofer, 2012). O ther physical responses include increased heart rate, systemic vascular resistance, circulating catecholamines, decreased mobility, loss of strength, dis turbed sleep, and immune system impairment (Finney, 2010). Post operative patients with uncontrolled pain are more likely to experience myocardial ischemia, stroke, bleeding, and delays in healing. From the hospi tal’s perspective, unrelieved pain can lead to increased length of stay, fre quent re-admissions, and increased emergency room utilization instead of primary care providers (Finney, 2010). In some cases, unrelieved pain can lead to a vicious cycle of anxiety and dis comfort, leading to a greater need for pain medication, which can lead to neu rological changes and cause addiction or make addiction worse (Dunn & Neuman, 20
