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4 Managing the Drug-Seeking Patient in Hospital Settings Christina M. Delos Reyes, MD Medical Consultant Center for Evidence-Based Practices BHO Videoconference Series March 28,

5 Learning Objectives List the differential diagnosis of the drug-seeking patient Review how the treatment of acute pain differs from the treatment of chronic pain Discuss how IDDT principles and strategies can assist in the management of the drug-seeking patient 5

6 JCAHO Pain Management Standards Approved in summer 1999 Scored for compliance as of 1/1/2001 Intent of the standards is to incorporate the basic principles of pain assessment and treatment into the patterns of daily practice 6

7 JCAHO Pain Management Standards 1. Recognize patients rights to appropriate assessment and management of pain 2. Screen for pain 3. When pain is present, perform a complete assessment 4. Record assessment in a way that facilitates re-assessment & follow-up 7

8 JCAHO Pain Management Standards 5. Set a standard for monitoring and intervention 6. Educate providers and assure staff competency 7. Establish policies supporting appropriate prescription of pain meds 8. Educate patients and families 8

9 JCAHO Pain Management Standards 9. Include patients needs for symptom control in discharge planning 10. Collect data to monitor the effectiveness & appropriateness of pain management 9

10 Defining the Drug-Seeking Patient Frequently used but poorly defined term Definition may vary depending on setting (inpatient, outpatient, ER) or provider role (RN, MD, counselor) Tends to be a stigmatizing term in clinical practice 10

11 Defining the Drug-Seeking Patient Survey of RNs by McCaffery et al (2005) Drug seeking Patient is addicted to opiates Patient is abusing pain medicine Patient is manipulative Drug seeking behavior Going to different ERs to get opioids Telling inconsistent stories re: pain Asking for a refill because Rx lost/stolen 11

12 Barriers to Pain Control in a Hospital Setting Survey of 50 patients in pain, RNs, and MDs by Drayer et al (1999) 4 barriers to better pain control: Exaggerated fear of iatrogenic addiction Staff attitude patients exaggerate pain intensity Poor correlation between pain behavior and pain intensity may mislead staff Lack of agreement between doctor and nurse in estimating patient s pain intensity 12

13 Differential Diagnosis of the Drug Seeking Patient Physical Pain Emotional Pain Craving, Post-Acute Withdrawal (Pain related to the disease of addiction) Pseudoaddiction Manipulative behavior Other causes? 13

14 Understanding the Psychology of Pain Context pain perceived in battle wounds has little relationship to extent of wounds Attention focusing attention on pain makes the pain worse Anxiety/fear/loss of control contribute to patient suffering Pain as a learned response 14

15 Understanding the Psychology of Pain Expectations influence how much pain one feels, response to treatment, and whether or not condition becomes disabling Beliefs and coping patients beliefs about pain, coping skills, self-efficacy, tendency to catastrophize, involvement in sick role impact patients pain perception and how it affects them 15

16 Assessment of Physical Pain 4 single-item instruments Numerical Rating Scale (NRS) 0-10 scale (no pain vs. worst pain possible) Visual Analog Scale (VAS) Mark a 10-cm line (least possible vs. worst possible pain) Graphical Rating Scale (GRS) The Faces Pain Scale Verbal Rating Scale (VRS) Pain descriptors: None, mild, moderate, severe 16

17 Acute vs. Chronic Pain Acute pain: lasting < 30 days Subacute pain: lasting > 30 days but < 6 months Chronic pain: lasting > 6 months Some define chronic pain, not in terms of time, but rather pain that extends beyond the expected period of healing 17

18 Acute vs. Chronic Pain Acute pain arises suddenly in response to a specific injury and is short-lived It is very rare to cause a new addiction to opiates by treating acute pain on an inpatient unit In a patient with addiction or dual disorders, treat acute physical pain in the same way as you would treat it in any other patient 18

19 Acute vs. Chronic Pain Chronic pain usually requires a long-term multidisciplinary approach Concept of opioid-induced hyperalgesia (increase in pain signals): the long-term use of opiates can paradoxically INCREASE PAIN, and one remedy may be to taper/stop the opiate mechanism not fully understood (Glutamatemediated?) 19

20 Non-verbal pain indicators Facial wrinkling, blinking eyes, grimacing Guarding an area of the body Crying, moaning Decrease in social interaction Change in routines Aggression Increase in body movements (squirming) Irritability, increased confusion 20

21 Emotional pain Encourage patient to describe feelings Give verbal and non-verbal support Acknowledge that physical symptoms may be a part of emotional pain What has helped in the past? What can staff do now/today to help? 21

22 Pain related to addiction Patients with addiction tend to be more sensitive to pain in general, and to the pain of withdrawal Post-acute withdrawal may last for weeks/months after patient stops using Psychoeducation, self-help groups, anticraving meds may help patients handle cravings 22

23 Pseudoaddiction Behavior that appears similar to addiction that results from poorly managed pain When pain is effectively treated, drug seeking behaviors resolve It may be extremely difficult to distinguish pseudoaddiction from true addiction 23

24 Putting it all together Framework Three kinds of drug-seeking patients : 1. Patients who have addiction only and are seeking meds 2. Patients who have acute/chronic pain only and are seeking meds 3. Patients who have both addiction and acute/chronic pain and are seeking meds 24

25 Interventions Strategies Based on the IDDT Model Principles of IDDT that also apply to the drug-seeking patient Recognition of client preferences Stage-wise approaches to care Close monitoring Flexibility Comprehensiveness Optimism 25

26 Intervention Strategies Clarify patient vs. staff goals Empathy Psychoeducation Communication and feedback Menu of choices 26

27 Patient vs. staff goals Patient goals may include: Relief of physical pain Wanting emotional support Learning self-management/coping skills (?) Staff goals may include: Withholding potentially addictive medication Maintain work duties without disruption 27

28 Empathy A little goes a long way Lack of empathy may actually escalate drug seeking behaviors Empathic approach may decrease the need for extra medications 28

29 Psychoeducation Recovery involves making positive decisions in addressing all 5 areas Interrelationship of the PMESS spheres Physical Mental Emotional Social Spiritual 29

30 Communication and Feedback Make sure the patient knows that her concerns are taken seriously Clarify the degree and location of the patient s pain, using one of the singleitem assessment tools Follow-up and follow through with planned interventions 30

31 Menu of Choices Types of interventions Non-medication approaches Non-addictive medications Potentially addictive medications 31

32 Non-medication Approaches Distraction Meditation Deep breathing, Relaxation Rest, elevation Heat, cold Physical therapy and massage Exercise Other Snoezelen rooms, comfort carts, etc. 32

33 Non-addictive Medications Tylenol Advil Other NSAIDs Gabapentin Low-dose tricyclic antidepressants SSRIs, SNRIs 33

34 Examples of controlled medications Opiates Used widely for acute/chronic pain relief Benzodiazepines May act as a muscle relaxant May decrease anxiety associated with pain Stimulants i.e. use of caffeine in some headache preparations 34

35 Summary Pain management standards should be part of our daily practice Many causes may lead to drug-seeking behavior Successful intervention is based on the principles of IDDT Controlled medications are one of many options for acute pain control 35

36 Discussion Questions See Handout 36

37 Contact Information Christina M. Delos Reyes, MD Medical Consultant, Center for EBPs at Case CCO, ADAMHS Board of Cuyahoga County x 728 delosreyes@adamhscc.org Patrick Boyle, MSSA, LISW-S, LICDC Center for EBPs at Case patrick.boyle@case.edu 37