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Patients with Substance Use Disorder 

Patients with Substance Use Disorder
Chapter:
Patients with Substance Use Disorder
Author(s):

Jeannine M. Brant

DOI:
10.1093/med/9780190204747.003.0054
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Key Points

  • Substance use disorders (SUDs) are a growing concern across the United States and pose significant challenges in assessment and management.

  • A variety of risk assessment tools exist to help identify and manage patients with SUDs.

  • DSM criteria are used to diagnose SUDs.

  • Palliative advanced practice registered nurses (APRNs) who manage patients with SUDS monitor analgesic response, activities of daily living, adverse events, and aberrant behaviors.

Case Study

Allen was a 38-year-old man who had recently completed treatment for head and neck cancer. He had a history of a substance use disorder and prior to his diagnosis he had attended Narcotics Anonymous, a 12-step recovery program. He had undergone a surgical resection followed by combined chemotherapy and radiation therapy. During treatment he suffered severe mucositis and complained of neuropathic pain in the neck and jaw, for which he was prescribed opioids and gabapentin. The palliative APRN saw Allen for his 6-week follow-up appointment. While the oral cavity had improved, Allen continued to complain of neck and jaw pain and requested additional refills of his pain medication. He also reported that the pain had been so severe that he ran out of his prescription early.

The palliative APRN saw Allen following the initial diagnosis and initiated Universal Precautions (see Box 54.1) throughout the treatment trajectory. Allen was initially stratified as high risk and was placed on a substance use agreement. Opioids were prescribed on a weekly basis, and Allen was assessed for the 5 A’s (analgesia, adverse events, ADLs, aberrancy, and affect). Random urine drug screens had been positive for opioids but negative for other illicit substances. One early request for a refill occurred during the height of Allen’s mucositis.

During this visit, the palliative APRN observed that Allen was also agitated and yawning profusely. The need for a random urine screen was determined by a flip of a coin during the visit, and Allen refused the screen. The APRN reviewed the substance use agreement with him and verbalized concern for his choice. Because Allen continued to refuse the random urine screening, the palliative APRN informed Allen that she could no longer prescribe opioids for him. She encouraged him to share how he was doing both physically and emotionally. While opioids were not prescribed, Allen was encouraged to return for his 3-month follow-up visit.

Introduction

APRNs are on the frontline of managing symptoms in patients with serious illnesses, and inevitably some of these patients will have a substance use disorder. Managing these patients is challenging for APRNs: prescribing opioids can contribute to the problem, yet underprescribing can lead to suboptimal pain management. Fears about loss of licensure can also surface, reinforcing the need for APRNs to have adequate knowledge about caring for this population.

Substance use disorder is a growing concern in the United States. According to the Substance Abuse and Mental Health Services Administration 2012 survey, 9.2% of the U.S. population had used an illicit drug in the past month, an increase from 8.1% in 2008, and approximately 8.5% of the population was estimated to have a substance use disorder. Of those with a substance use disorder, 13% use alcohol and illicit drugs, 20% use illicit drugs, and 67% are alcohol users. Not just illicit drugs are a concern: 2.6% of the population reportedly used psychotherapeutic prescription drugs nonmedically in the past month.1 Patients with chronic pain are at a greater risk for substance use disorders: the prevalence of addiction in this population is estimated at 15% to 20%.2

The high prevalence of substance abuse in the overall population will be reflected in the palliative care environment, posing significant challenges in terms of managing pain and accompanying symptoms and providing overall care. Palliative APRNs need to understand substance use disorder, how to assess for it, and how to manage pain, according to the risk stratification of the specific patient. A tailored approach to care will ensure the best possible outcomes while minimizing abuse, misuse, and diversion.

Definitions

Many definitions apply to the concepts of addiction and substance abuse. Some definitions, such as tolerance and physical dependence, can be confusing and are often used erroneously when referring to patients with substance use disorder. For example, addiction involves genetic and biobehavioral influences, while tolerance and physical dependence are strictly physiologic phenomena.3 Table 54.1 defines terms related to this topic.

Table 54.1 Definition of Terms

Term

Definition

Aberrant behavior

Behaviors to be recognized as indicating prescription opioid abuse

Addiction

A neurobiological disorder with genetic and environmental influences that results in psychological dependence on the use of substances for their psychic effects and is characterized by craving and compulsive use despite harm

Compulsive

An irresistible urge, especially against conscious wishes

Craving

A strong desire to obtain and use a psychoactive substance for its intoxicating effects

Drug misuse

Use of prescription or over-the-counter drugs that does not follow medical indications or prescribed dosing

Drug abuse

Use of a drug for nontherapeutic purposes to obtain psychotropic effects

Diversion

Unlawful channeling of pharmaceuticals from legal sources to the illegal marketplace

Euphoria

A sense of intense happiness and well-being

Illicit drug

A drug that is not legally permitted or authorized

Nonmedical use

Use of a prescription drug without a prescription or in a manner that is not prescribed

Physical dependence

A physiological neuro-adaptation characterized by a withdrawal syndrome if the drug is stopped or decreased abruptly, or if an antagonist is administered

Pseudotolerance

A need to increase dosage that is due not to tolerance but to other factors, such as disease progression, new disease, increased physical activity, lack of compliance, change in medication, drug interaction, addiction, and deviant behavior

Pseudoaddiction

Pattern of drug-seeking behavior in patients with pain who are receiving inadequate pain management; can be mistaken for addiction

Substance abuse

The use of any substance for nontherapeutic purposes to obtain psychotropic effects

Tampering

Manipulating a pharmaceutical to change its drug delivery performance

Tolerance

A physiologic response resulting from the regular use of a drug in which an increased dosage is needed to produce the same effect

Data from references 3, 15, and 41.

Barriers

One of the challenges of working with patients with substance use disorder is the lack of knowledge on the part of healthcare providers. One survey of hospice and palliative care physicians in training revealed that only half stated they had a working knowledge of addiction and only 40% thought their training had prepared them to manage misuse of opioids. While 38% thought they could differentiate between opioid misuse and addiction, 79% were uncomfortable managing symptoms in this population.4 Often, practitioners feel that opioids should be avoided in patients with substance use disorder; however, current literature suggests that many of these patients can be safely managed using a detailed and vigilant monitoring program.5,6,7

Stigma is another barrier associated with substance use disorder, and it is often rooted in shame and guilt. The more stigmatized patients feel, the less likely they are to disclose a substance use disorder. Using judgment-free language, avoiding terms like drug-seeking or junkie, and categorizing substance abuse as a disorder can encourage a more open therapeutic relationship.8

Using objective measures to assess the risk for substance use can help to eliminate personal biases.9,10 For example, the palliative APRN may overestimate the risk in an individual who is heavily tattooed and underestimate the risk in a high-profile bank manager. Racial stereotypes can also contribute to inadequate assessment. One study reported that black patients were more likely to undergo urine drug testing, were required to attend more office visits, and were given more restrictive opioid prescriptions than whites.9 Patients with poorly managed pain can also exhibit addictive behaviors (i.e., pseudoaddiction). Assessment for substance use disorder risk is further discussed below.

Specific barriers exist for palliative APRNs in managing patients with substance use disorders. State by state variation in APRNs’ prescribing privileges for opioids reveals more restriction in medication management. Buprenorphine, in particular, cannot be prescribed by APRNs for addiction.11

Pathophysiology

Substance abuse and addiction are complex phenomena that involve an interplay of neurobiological, genetic, and behavioral components. A wide array of neuroadaptive theories apply to the development of, and permanent brain changes that occur with, substance abuse and addiction. Physiologically, neural systems, including dopamine neurons and the mesolimbic system, are sensitized when introduced to a potentially addictive substance.12,13 Changes in the glutamatergic connections within various parts of the brain (ventral tegmental area, nucleus accumbens, prefrontal cortex, and amygdala) are thought to contribute to this sensitization. Neurocognitive imbalance between the impulsive amygdala, which signals pleasure, and the prefrontal cortex, which signals future decision making, is also thought to occur. These brain changes endure even after the individual stops taking the substance, which explains why relapse rates for addiction are as high as 80%. Fewer than 50% of addicts remain drug-free following 6 months of abstinence from a substance and fewer than 15% are drug-free at 12 months.13 Genetic influences are also involved, and over 1,500 human addiction genes have been identified.14 Further research is needed to determine which genes play the greatest role and to understand the exact influence the genes have on the development of addiction.

Environmental factors, stress, reward-based learning, and conditioning effects also contribute to substance abuse and the development of addiction. Exposure to the drug (e.g., opioid, benzodiazepine, ETOH) can initially create a pleasurable response, thereby reinforcing the desire for the drug when it is not present. Eventually, chronic and excessive levels of the drug correspond with increased salience, producing a greater yearning and physiologic need for the drug.15 This pattern underlies the stimulus–response habits, aberrant memories, and maladaptive behaviors that characterize addiction (Fig. 54.1).13 Interestingly, the neurobiological and genetic aspects of substance addiction parallel changes observed in behavioral addictions, such as gambling, Internet/video game use, and shopping.


Figure 54.1 Pathophysiologic aspects of addiction

Figure 54.1 Pathophysiologic aspects of addiction

Assessment for Substance Use Disorder

Routine assessment for substance use disorder is important due to the high prevalence of the problem. A baseline should be obtained, along with subsequent assessments. However, assessment is difficult due to the stigma attached to substance abuse. A perceived lack of trust may lead to nondisclosure of a substance use disorder. The palliative APRN should use interview techniques to promote open dialogue (Box 54.1).

Data from references 35, 40, and 42.

Identifying patients at greatest risk for substance abuse is a key component of the assessment. Sociodemographics, psychological factors, drug-related factors, family history, and genetics have all been linked to addiction risk. The strongest link appears to be the presence of psychosocial, drug-related, and genetic factors combined. Therefore, a social history must include a history of drug abuse and a family history of alcoholism.

Mental health screening is especially important in determining risk of addiction, as there is a high prevalence of mood disorders coexisting with both chronic pain and substance use disorder. Patients with a substance use disorder are more likely to have more mental health concerns, use higher doses of opioids, drink more alcohol, smoke more tobacco, use more benzodiazepines, and have a higher rate of depression.2 Being aware of this cluster can lead to earlier detection of a problem. Once aberrant behaviors are detected, the palliative APRN should discern and carefully interpret the meaning of the behaviors and their influence on the treatment plan. Current guidelines recommend assessment of mood when pain is present.16 Opioid risk assessment tools, described below, contain items about mood, but further evaluation is warranted. The Beck Depression Inventory and the Profile of Mood States (POMS) are two tools that are routinely used in clinical practice. History of sexual abuse and family history are also included in risk stratification.

Several screening tools exist to identify potential problems (Table 54.2).17 Some of the more common tools include the CAGE, which is widely used to assess for alcoholism, and the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R)18,19 and the Opioid Risk Tool (ORT),20 which screen for opioid abuse. The SOAPP-R has 24 items and takes less than 10 minutes to complete. Items include assessment of psychological responses to situations, pain medication-related perceptions and behaviors, and social and familial influences. The ORT contains five items, including personal and family history of substance use, age, history of sexual abuse, and psychological disease, and takes less than 1 minute to administer and score. While these tools have good internal consistency, they are not “lie detector tests,” and the accuracy of the assessment depends on how honestly the individual completes the responses. Aberrant behaviors and risk factors for substance abuse are included in Table 54.3.21 Risk should be evaluated so that strategies can be employed to regain control over the plan.22

Table 54.2 Substance Use Disorder Risk Screening Tools

Tool

Description

Comments

CAGE (Cut, annoyed, guilty, eye)

4 items

  • Interview to screen for alcohol use

  • One positive response warrants caution.

  • Two affirmative responses are considered a positive result.

CAGE–AID (Adapted to include drugs)

4 items

  • Interview to screen for drug and alcohol use

  • Consider modifying yes/no questions to open-ended questions.

COMM (Current Opioid Misuse Measure)

17 items

  • Self-administered

  • Use during chronic opioid monitoring.

  • Score of 9 or higher suggests aberrancy.

DAST (Drug Abuse Screening Test)

20 items

  • Self-administered

  • Questions refer to past 12 months.

DSM-V Structured Clinical Interview

Interview

  • Assessment of the 11 characteristics in the DSM-V criteria

  • Takes 30–60 minutes to complete

ORT (Opioid Risk Tool)

5 items

  • Self-administered

  • For initial visit for pain treatment

  • Predictive of substance abuse

PDUQ (Prescription Drug Use Questionnaire)

42 items

  • Interview

  • Score >15 indicates a substance use disorder.

  • Predictive of substance abuse

RAFFT (Relax, alone, friends, family, trouble)

5 items

  • Self-administered

  • Three affirmative responses are considered a positive result.

SOAPP-R (Screener and Opioid Assessment for Patients with Pain-Revised)

24 items

  • Self-administered or interview to screen for drug and alcohol use

  • Intended for patients with chronic pain on long-term opioid therapy

  • Score of 7 or higher indicates the person is likely to abuse.

Data from references 17 and 35.

Table 54.3 Aberrant Behaviors and Risk Factors for Substance Abuse/Addiction

Behaviors Less Suggestive of Addiction

Behaviors More Suggestive of Addiction

Risk Factors for Addiction

Drug hoarding when symptoms are improved

High opioid dose

Caucasian male

Acquiring drugs from multiple medical sources

Selling prescription drugs

Younger age

Aggressive complaining about the need for a higher dose

Forgery of prescriptions

Higher pain intensity and lower pain tolerance

Unapproved use of a medication to treat a symptom (e.g., use of an opioid to treat anxiety)

Concurrent illicit drug use

More pain complaints

Unsanctioned dose escalation (once or twice)

Multiple prescription/medication losses

More pain-related limitations

Reporting psychic effects

Ongoing unsanctioned dose escalations

Depression and psychotropic medications in younger populations

Requesting specific drugs

Stealing or borrowing drugs

Psychological comorbidity: panic, anxiety, depression, agoraphobia, low self-reported health status

Second opinion for pain requested

Obtaining prescription drugs from nonmedical sources

Substance abuse history

Smoking cigarettes to relieve pain

Repeated resistance to change—inflexibility

Genetic predisposition

Drinking alcohol to relieve pain

Prostitution for drugs or for money to obtain drugs

Urine toxicology screens positive

Unanticipated positive results in urine toxicology

Nonadherence to appointments

Frequent pain clinic or emergency department visits

Data from reference 20, 21, and 42.

The Current Opioid Misuse Measure (COMM), a 17-item measure that takes less than 10 minutes to complete and score, can be used during the monitoring phase.23 A score of 9 or higher is associated with a higher degree of aberrant behaviors.24 A systematic review of tools used to monitor ongoing opioid therapy indicated that further testing of these tools is needed, as there is limited evidence to support their ability to detect misuse and substance use disorder in patients taking opioids.25

Prescription Drug Monitoring Programs

Prescription Drug Monitoring Program (PDMP) evaluation can be used to evaluate risk but should be used on an ongoing basis to assess for aberrant behaviors. PDMPs are statewide databases containing prescriber- and patient-level data on drugs with high misuse and abuse potential, including opioids and benzodiazepines.26 The PDMPs are efforts by the states to ensure appropriate prescribing and dispensing of controlled substances in order to prevent misuse, abuse, and diversion. Using their individual Drug Enforcement Agency (DEA) numbers, healthcare providers can register for their state’s PDMP and access the databases to examine patterns of prescription drug use in patients. Databases will show if a patient is using multiple prescribers or multiple pharmacies, which both suggest abuse or illegal activities. One study that evaluated the effectiveness of PDMPs found that Poison Center intentional exposures of drugs increased by 1.9% in states without PDMPs and by 0.2% in states with PDMPs. Opioid treatment hospital admissions increased 4.9% per quarter in states without PDMPs versus 2.6% in states with PDMPs.27 Efforts are underway to link PDMPs between states so that misuse, abuse, or diversion of opioids across state lines can be detected. While not diagnostic, PDMPs are another tool that should be used at baseline and during follow-up to evaluate aberrant behaviors and drug use patterns.28

Urine Drug Testing

Urine drug monitoring is another assessment tool available to monitor for controlled substance misuse, abuse, and diversion. Recent recommendations from a panel of experts state that all patients on long-term opioid therapy (more than 3 months) should undergo urine drug monitoring. They further recommended that patients should understand the purpose of monitoring and how the results will be used; this reinforces that testing is not punitive but rather is done to provide consistent monitoring of patients. Guidelines for surveillance are included in Table 54.4. While the American Pain Society and the American Academy of Pain Medicine both recommend periodic testing in all patients on chronic opioid therapy, it is actually used in only 8% to 30% of them.29 This may be due to a lack of knowledge about how to interpret the results and how to apply them to practice.30 Essential information includes which medications are appropriate for urine testing, opioid metabolism that would affect their presence or absence, and other medications that the patient is taking. Being knowledgeable about these factors will enable palliative APRNs to interpret results correctly.31

Table 54.4 Urine Drug Testing (UDT) Recommendations

Recommendation Category

Recommendation

Rationale

1. Who to test

  • Test all patients receiving chronic opioid therapy (>3 months).

Removes APRN subjectivity and makes testing consistent with chronic disease management paradigm

2. How to test

  • Patients should be clear about UDT purpose.

  • Removes fear; informs patients that UDT is not punitive but rather part of standard procedures

  • UDT parameters can be included in a Controlled Substance Agreement.

  • Clearly delineates UDT role in therapy

  • Comprehensive medication testing should be conducted, which includes illicit drugs, opioids, and other substances, such as benzodiazepines.

  • Tests for suspected therapeutic metabolites and other substances

  • Tests should be performed by a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory with knowledge about UDT, with results available on same day.

  • Results can be falsely positive or negative; laboratory proficiency will minimize this variability.

  • Point-of-care (POC) testing can be used on the initial visit, but inconsistent results should be verified with UDT.

  • POC testing is for screening only.

  • Test temperature and specific gravity; consider chain of custody (proper administration of the sample to safeguard it from tampering) if concern exists about samples.

  • Indicates if the sample has been tampered with

3. When to test

  • Initiate UDT when starting chronic opioid therapy.

  • Aids in risk stratification

  • Test according to risk stratification via SOAPP-R/ORT and other factors.

  • Allows for more frequent screening for high-risk patients

  • Consider developing a procedure to determine frequency of UDT while maintaining minimum requirements (e.g., having patient flip a coin or roll dice at each visit).

  • Removes burden from staff tracking while providing fairness for random testing

4. How to interpret results

  • Confirm appropriate interpretation from laboratory that performs testing.

  • Classify findings as (1) prescribed drug not detected, (2) illicit drug detected, (3) nonprescribed drug of concern detected.

  • Identifies the type of aberrant behavior present so that behavior can be specifically addressed

  • Construct a differential diagnosis if (1) drug not detected (e.g., diversion, hoarding, lab error); may need additional testing to determine absence; (2) illicit drug detected (e.g., addiction, seeking additional pain relief, lab error); (3) nonprescribed drug detected (e.g., multiple providers).

  • Allows the APRN to understand the finding; absence of prescribed drug with presence of illicit drug requires immediate action

5. How to handle test discrepancies

  • Verify discrepancies with laboratory.

  • Lab tests should always be verified.

  • Schedule an immediate follow-up visit to discuss findings with patient in nonjudgmental manner.

  • The patient may disclose the reason for the discrepancy; promotes therapeutic communication.

  • Develop a plan based on the findings.

  • The plan will vary and depends on the problem detected.

Data from references 30 and 34.

Diagnosis of Substance Use Disorder

The palliative APRN can use the DSM-V criteria to diagnose a substance use disorder.32 The 11 criteria combine substance abuse and dependence into a single disorder. They include the following:

  • Perceptions about use, such as taking more of a substance than intended, desire to cut down or stop using the substance, craving the substance, and being consumed with obtaining the substance

  • Functional elements, including inability to manage current roles and responsibilities and forgoing opportunities (e.g., family outings, social relationships)

  • Continued use despite harm and endangerment physically, psychologically, and socially

  • Development of tolerance and physical withdrawal

Mild substance use disorder requires the presence of two or three symptoms from the list, a moderate substance use disorder includes four or five symptoms, and six or more symptoms indicate severe substance use disorder. A long-standing criticism of the DSM criteria is that patients with cancer often exhibit some of these symptoms and yet they may not have a substance use disorder.

Pain and Symptom Management

Managing pain and symptoms and providing overall care in patients with substance use disorder can be challenging. Many palliative care patients will require chronic opioid therapy or other treatments, such as benzodiazepines, that may pose risks for those with substance use disorders. Risk of relapse for those in remission is a valid fear, and yet undertreatment of pain and symptoms is also common due to a lack of understanding of appropriate care of these patients.7 Having a well-defined plan in place that focuses on the goals of care and stratifies patients according to addiction risk allows for individualized pain and symptom care while monitoring patients for aberrant behaviors and signs of addiction. This will provide the best care for the patient while at the same time preventing misuse, abuse, and diversion.5,6,18

Goals of Care

Pain and symptom management goals provide a foundation for the plan of care. The 5 A’s can be used to measure the success of a management plan: analgesia, activities of daily living, adverse events, aberrant behaviors, and affect7,33 (Table 54.5). Goals should be clear to the patient when treatment is started. Physiologic and psychosocial functioning should be included in the plan because they reflect an improvement in overall quality of life. Both pain and substance use disorder lead to dysfunction, so management should lead to optimal functioning. This focus on function allows the palliative APRN to individualize care and prescribing options.34

Table 54.5 Goals of Pain Management

5 A’s

Definition

Assessment

Analgesia

Level of comfort

  • Decrease in pain intensity

  • Effectiveness of the intervention on the pain

Activities of Daily Living

Functional status

  • Increased physical capabilities

  • Psychologically intact

  • Family/social relationships intact

  • Appropriate medication and healthcare utilization

Adverse Events

Side effects related to treatment

  • Sedation

  • Euphoria

  • Other physical and psychological effects

Aberrant Activities

Behaviors that warn of potential substance misuse, abuse, or addiction

  • Behaviors that suggest concern; see Table 54.3

Affect

Psychological functioning

  • Improved psychological affect

  • Ability to cope with illness

Data from references 7 and 21.

Risk Stratification

A chronic disease management model provides a background for managing patients with substance use disorder, in that risk assessment, ongoing monitoring, and corrective action as needed can be readily employed.5 Stratifying patients according to their risk for a substance use disorder is the first step in the management plan. Risk assessment tools can guide stratification, with the understanding that risk may change as the APRN observes the patient’s behavior over time (Table 54.6).18,20

Table 54.6 Management According to Risk

Risk Stratification

Risk Assessment Tools

Other Risk Considerations

Management Strategies

Low

  • SOAPP-R score <10

  • ORT score <4

  • No family history

  • No past/current history of substance use disorder

  • No psychological comorbidity

  • Annual adherence monitoring

  • Review prescription drug monitoring program (PDM) twice per year

  • Urine drug testing every 1–2 years

Medium

  • SOAPP-R score 10–21

  • ORT score 4–7

  • Family history positive

  • Treated substance use disorder; can be on pharmacotherapy for addiction

  • Psychological comorbidity, past or current

  • <25 years of age

  • Adherence monitoring every 6 months

  • Review PDM 3 times per year

  • Urine drug testing every 6 months to 1 year

High

  • SOAPP-R score >21

  • ORT score <7

  • Current substance use disorder or addiction

  • Current aberrant behaviors (those more suggestive of addiction)

  • Major psychiatric disorder that is untreated

  • Weekly to monthly adherence monitoring

  • Management by pain and addiction specialists recommended

  • Review PDM 4 times per year

  • Urine drug testing every 3–6 months

  • Prescribe opioids cautiously; chronic opioid therapy may be prohibitive in terms of risk to the patient.

Data from references 7 and 40.

Substance Use Agreements

Substance use agreements have been shown to improve provider satisfaction, decrease emergency department visits, and improve patient adherence.34 Substance use agreements should be employed for all patients taking controlled medications or chronic opioid therapy for greater than 3 months, regardless of risk.5,34 Agreements should spell out the risks and benefits of treatment, provide education about the plan of care, outline the responsibilities of the patient and the palliative APRN, and allow a transparent conversation to occur between the patient and the APRN.35 Agreements should include the following:

  • Designated prescriber

  • Designated pharmacy

  • Frequency of refills

  • Times when refills are prohibited (e.g., after hours, weekends)

  • Dosage changes

  • Screening and consequences for positive screens (e.g., urine, blood, pill counts)

  • Need to secure medications and dispose of them safely if needed

  • Supportive therapy requirements (e.g., psychiatry)

  • Safe use of medications35

Management of Pain

The pain management plan should be based on a systematic approach that includes the following:

  • Diagnosis of the problem

  • Conservative approaches (e.g., physical therapy, non-opioids, co-analgesics) for initial management

  • Nonpharmacologic modalities

  • Therapeutic interventions such as anesthetic blocks

  • Chronic opioid therapy and other controlled co-analgesics (e.g., benzodiazepines) only when conservative approaches are not effective.

See Chapter 23, Pain, for more information.

Risk stratification guides the management plan. The palliative APRN should document the 5 A’s at each visit to assess the patient’s response to the treatment plan. The higher the risk, the more frequent the monitoring and the more cautious the dosing of opioids should be.

Dosing can be challenging in this population, especially in terms of drug tolerance. Patients with active opioid use will be tolerant of opioids and may require higher doses, but aberrant behaviors may preclude the palliative APRN from prescribing opioids for these patients. Contributing to addiction and diversion can result in loss of licensure, so caution is warranted. The most important component is careful surveillance for all patients: some high-risk patients may show substantially improved function using opioids, while some low-risk patients may experience deterioration in function.

Prescribing medications may be complicated. Palliative APRNs may prescribe certain medications for pain management, but not for substance abuse issues, unless they have completed addiction graduate education or specific coursework. APRNs should refer to their state rules for scope of practice regarding opioid prescribing.

Determining the right opioid can be difficult, as all opioids can be potentially abused. When initiating chronic opioid therapy, long-acting dosing should be optimized while the need for breakthrough doses is minimized. This allows for a therapeutic blood level to control pain while avoiding peaks and troughs and “clock-watching” to take the next dose.5,35 Abuse-deterrent opioids are another option. These opioids resist manipulation, such as crushing, dissolving, or extracting; any attempts to do so will inactivate the opioid. While this property can be of benefit in high-risk patients, these drug formulations can be expensive, and more evidence is needed to determine their role in managing high-risk patients taking chronic opioid therapy.36,37

While methadone cannot be crushed and abused due to its high protein-binding affinity, safety concerns relate to the potential for accumulation, oversedation, and potential death.38 Palliative APRNs can prescribe methadone for pain, but only licensed methadone maintenance clinics can prescribe it for addiction. Buprenorphine, a partial opioid agonist that is used in opioid addiction, may be useful for pain management. While APRNs can prescribe buprenorphine for pain, restrictions exist on prescribing the agent for addiction. Buprenorphine has a ceiling dose and therefore should be used only in patients with anticipated lower doses of opioids.39

Universal Precautions should be used in managing all patients with chronic persistent pain. These precautions allow risk stratification and improved care (see Box 54.1).40 Misuse, abuse, addiction, and diversion demand immediate action. If misuse or abuse is suspected, counseling may help to change the behavior, or the palliative APRN can decide to discontinue opioids and other controlled substances. The palliative APRN should discuss aberrant behaviors and drug-testing findings with team members. The patient should be given an opportunity to explain the findings, and retesting can be an option if the findings are questioned. When diversion is suspected, the palliative APRNs should follow the 5 S’s plan: limiting the opioid supply, selecting a drug with a lower street value, scheduling more frequent visits, scheduling more frequent urine drug testing, and involving a substance abuse specialist. Actual proof of diversion calls for the discontinuation of opioids. APRNs should follow the rules listed in the opioid contract, which may include discharge from the practice, discontinuance of opioids, transition to non-opioids, and the need to include substance abuse providers. All efforts should be made to maintain the patient within the practice, even though opioids may not be continued. When the palliative APRN decides to discontinue opioids, a plan of tapering medications should be initiated.

Conclusion

The palliative APRN should understand the challenges inherent to managing patients with substance use disorder but should still approach patients with compassion and in a nonjudgmental manner. Occasionally, as with Allen in the case study, the palliative APRN may have to cease prescribing opioids for some patients. However, palliative APRNs should understand that by using a systematic approach and a chronic disease model, the majority of patients can be well managed and can achieve both comfort and an improved quality of life.

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