Discussion:

Ethics and Undertreatment of Pain

in Patients with a History of Drug Abuse

CONTINUING

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

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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.

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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, 2012).

Ethical Considerations Unrelieved pain is a form of suffer­

ing, and according to The International Council of Nurses (ICN) Code of Ethics for Nurses, one of the four responsibilities of the nurse is to relieve suffering (ICN, 2012). In other words, nurses are ethi­ cally responsible for treating pain; how­ ever, this process is complicated in those with substance abuse history. Nurses undertreat pain in patients with substance abuse history for many rea­ sons. Many times, patients who struggle with substance abuse are aggressive, noncompliant, may have committed crimes, frequently discharge themselves against medical advice, and are unlikely to praise the nurse or be grateful for

services rendered (McCreaddie et al., 2010). These circumstances can threaten the self-worth of the nurse and increase a propensity toward stereotypes and sensitivities toward these patients. Many nurses have reported ethical erosion after caring for such patients over a long period of time. Other reasons nurses frequently undertreat pain in patients with drug abuse history include a lack of educa­ tion and experience working with these patients, fear of exacerbating or creating an addiction, fear of respira­ tory depression, and difficulty assessing whether the patient really needs the medication (Blondal & Halldorsdottir, 2009).

Difficult clinical situations like pain management in patients with substance abuse history calls for a review of basic ethical principles nurses must adopt when they accept a position in the nursing field. Deliberate use of these unemotional, transparent ethical princi­ ples – autonomy, beneficence, non­ maleficence, and justice – can guide nurses as they navigate the treatment of these complex patients (Bernhofer, 2012).

Autonomy, as defined by the American Nurses Association (ANA, 2015) Code of Ethics for Nurses with Interpretive Statements, is the right to self-determination. This includes the patient’s right to know all of the pain medications (including their effects and side effects) that are available to them, and how often they can receive these medications, as well as the patient’s right to determine how and when their pain should be treated or not treated. The principle of autonomy is violated when the nurse withholds any of this information from the patient or if he or she makes pain control decisions for the patient without his or her input. When the principle of autonomy is adhered to, patients, including those with substance abuse history, experi­ ence better pain management and report more satisfaction with their care (Bernhofer, 2012). This is evidenced by the increased use of Patient Controlled Analgesia (PCA). In PCA therapy, patients are able to administer a prede-

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Table I. Using Ethical Principles to Guide Pain Management Decisions

Principle Question

Autonomy Are the patient’s preferences in pain treatment given the highest priority?

Beneficence Does the patient benefit from my pain treatment deci­ sions?

Maleficence W hat can 1 do to decrease harm?

Justice Did 1 do my best to protect the most vulnerable patient, treating his o r her pain in the best possible way with respect and w ithout discrimination?

Source: Adapted from Bernhofer, 2012.

Table 2. Guidelines for Safe, Effective Pain Management

1) Define pain syndrome.

2) Distinguish type o f abuser. Do they have a history of abuse, are they receiving methadone maintenance, o r are they using drugs actively?

3) Apply appropriate pharmacologic principles of opioid use. Use appropriate opioid with adequate dosing and dosing intervals, consider the dose of the substance the patient was using, use the appropriate route of administration.

4) Provide non-opioid therapies when appropriate.

5) Recognize specific drug of abuse o r misuse behaviors.

6) Avoid excessive negotiations. Which specific drug will be administered, the dose, o r route o f administration?

7) Arrange fo r early consultations. Psychiatry, addiction medicine, and pain management could all be appropriate consults.

Source: Adapted from Krupnick, 2009.

termined dose of pain medication to themselves when they feel they need it. This kind of therapy has been very suc­ cessful in better treating pain in post­ operative and cancer patients with severe pain (Dev, Del Fabbro, & Bruera, 2011). N ot treating a patient’s pain suf­ ficiently also violates the principle of autonomy because patients in pain can be so consumed with their suffering that they are unable to accurately make other medical decisions related to their care. When patients’ pain is under con­ trol, they can relax and make their deci­ sions independently (Finney, 2010).

Beneficence is the strict obligation of the nurse to secure the patient’s well-being by preventing harm and bringing about good (National

Institutes of Health [NIH], 1979). Pain control is an inextricable part of pro­ viding good care for a patient with sub­ stance abuse history, especially when the task is hard. When nurses do not make pain management a priority, do not provide enough pain medication for these patients, or do not advocate for enough medication, they are guilty of neglecting the principle of beneficence, as well as not preventing harm (Finney, 2010). The principle is upheld when appropriate measures have been taken to ensure adequate pain control in a timely fashion for every patient, includ­ ing those with substance abuse history (Bernhofer, 2012).

Nonmaleficence is defined as to do no harm (Purtillo & Doherty, 2011). By

modern professional standards in med­ icine, deliberate inaction is considered an action; therefore, to withdraw or withhold treatment of pain for an indi­ vidual equates to doing them harm. Some might even consider this torture (Keane, 2010). Others argue that when nurses stereotype and discriminate against a patient with substance abuse history, they are dehumanizing the patient and championing prejudice (Finney, 2010). Interestingly, many times nurses cite the principle of nonmalefi­ cence when trying to justify inadequate pain management in patients, stating they do not want to cause respiratory depression; however, there are precau­ tions that can be put in place (for example, a continuous oxygen satura­ tion monitor), and the benefits of avoid­ ing inadequate pain management far outweigh the risks of treating pain ade­ quately (Bernhofer, 2012).

Justice is the principle that dictates all patients should be treated fairly, or that equals be treated equally (NIH, 1979). When patients with drug abuse history have pain and are treated differ­ ently from other patients because of a stigma or stereotype, the principle of justice is violated. In some cases, this can be labeled discrimination and can be punished by legal means (Finney, 2010). For example, a nurse would most likely not judge the behavior of a patient needing increasing amounts of medication to treat hypertension, yet he or she may label a patient seeking increasing amounts of pain medication to treat pain as a drug seeker (Bernhofer, 2012). Nurses have no choice but to treat all patients as equals, to trust what each patient has to say about the severity of his or her pain, and to treat and advocate for the treat­ ment of that pain with all of their resources.

Nursing Implications One author (Bernhofer, 2012) sug­

gests nurses use these principles by asking themselves:“ I) Are the patient’s preferences in pain treatment (auton­ omy) given the highest priority? 2) Does the patient benefit (experience good) from my pain treatment deci­ sions? 3) What can I do to decrease

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Table 3. Resources for More Information

National Institute on Drug Abuse NIDA MED Program www.drugabuse.gov

National Institute of Alcohol Abuse and Alcoholism www.niaaa.gov

American Academy of Pain Medicine www.painmed.org

American Pain Society www.ampainsoc.org

American Society of Addiction Medicine www.asam.org

International Association of Pain and Chemical Dependency www.iapcd.org

Source: Adapted from Krupnick, 2009.

harm (maleficence)? 4) Did I do my best to protect the most vulnerable patient, treating his or her pain in the best pos­ sible way, with respect and without dis­ crimination (justice)?” (p. 11) (see Table I (.Asking themselves these questions can help nurses identify their own biases and provide pain treatment effectively and equally to all patients while avoiding a substantial amount of suffering (Bernhofer, 2012).

Other nursing considerations for the best care of patients in pain who have a history of substance abuse include developing a patient-centered approach by involving the patient in the plan for pain management, appropri­ ately assessing the patient’s pain man­ agement needs in conjunction with input from the family, assessing support systems, providing education to the patient in his or her preferred learning style, and maintaining open communica­ tion without bias.

Another author, Susan Krupnick (2009), provides more guidelines for safe, effective management of pain in patients with substance abuse history: “ I) Define the pain syndrome, 2) Distinguish among the patient who has a remote history of drug abuse, the patient receiving methadone mainte­ nance, and the patient who is using drugs actively, 3) Apply the appropriate pharmacologic principles of opioid use (use appropriate opioid with adequate doses and dosing intervals; consider daily the dose of opioid [or other sub­ stance the patient has been consum­ ing]; use the appropriate route of administration), 4) Provide non-opioid therapies when appropriate, 5) Recognize specific drug abuse or mis­ use behaviors, 6) Avoid excessive nego­ tiations over specific drugs/doses/ routes of administration, 7) Arrange for early consultation with psychiatry, addiction medicine, and pain manage­ ment if specialists are available” (p. 383) (see Table 2).

Krupnick (2009), also lists several resources for more assistance in caring for patients with pain and substance abuse history, including:

• The National Institute on Drug Abuse NIDAMED Program

• The National Institute on Drug Abuse

• The National Institute of Alcohol Abuse and Alcoholism

• Organizational websites such as ♦ The American Academy of

Pain Medicine (http://www.painmed.org)

♦ The American Pain Society (http://www.ampainsoc.org)

♦ The American Society of Addiction Medicine (http://asam.org)

♦ The International Association of Pain and Chemical Dependency (http://www.iapcd.org)

By utilizing these resources, nurses can eliminate any barriers to the best care of patients with drug abuse history stemming from a lack of education in this area (see Table 3).

Conclusion Pain is a subjective experience,

which makes it hard to treat and sub­ ject to bias and emotion (Bernhofer, 2012). Patients with a history of drug abuse experiencing pain make treat­ ment even harder. These patients need to be viewed as people, not problems (McCreaddie et al., 2010). Nurses have an ethical responsibility to use every means possible to relieve pain. By gain­ ing a deeper understanding of sub­ stance abuse terminology and behav­ iors such as tolerance, dependence, addiction, and pseudoaddiction; by

enlisting ethical principles such as autonomy, beneficence, nonmalefi­ cence, and justice for pain management decisions; and by utilizing the many resources out there to help them deal with pain management in substance abusers, nurses can fulfill their duty and stop the nightmare of unrelieved pain in a significant number of patients in acute-care settings.

References American Nurses Association (ANA). (2015).

Code o f ethics for nurses with interpretive statements. Retrieved from http:// www.nursingworld.org/MainMenuCateg ories/EthicsStandards/CodeofEthicsfor Nurses

American Society for Pain Management Nursing (ASPMN). (2010). Optimizing the treatment o f pain in patients with acute presentations. Retrieved from http://www.american painsociety.org/upioads/pdfs/APS 10_ Optimizing%20PositionPaper.pdf

Bernhofer, E. (2012). Ethics: Ethics and pain management in hospitalized patients. Online Journal o f Issues in Nursing, 17(1), I I .

Blondal, K„ & Halldorsdottir, S. (2009). The challenge of caring fo r patients in pain: From the nurse’s perspective. Journal o f Clinical Nursing, 18(20), 2897-2906.

Center fo r Behavioral Health Statistics and Quality. (2010). Results from the 2010 national survey on drug use and health: Summary o f national findings. Retrieved from http://oas.samhsa.gov/NSDUH/ 2k 10NSDUH/2I< I OResults.pdf

Dev, R., Del Fabbro, E., & Bruera, E. (201 I). Patient-controlled analgesia in patients with advanced cancer: Should patients be in control? Journal o f Pain and Symptom Management, 42(2), 296-300.

continued on page 16

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Pain in Patients with a History of Drug Abuse continued from page 7

Dunn, D., & Neuman, J. (2012). How substance abuse impacts pain management in acute care. Nursing, 42(8), 66-68.

Finney, L. (2010). Nursing care fo r the patient w ith co-existing pain and substance misuse: Meeting the patient’s needs. MEDSURG Nursing, 19(1), 25-53.

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). (2012). CAHPS hos­ p ita l survey: HCAHPS tables. Retrieved from http://www.hcahpsonline.org/SummaryAnalyses.aspx

International Council o f Nurses (ICN). (2012). The ICN code o f ethics fo r nurses. Retrieved from http://www.icn.ch/about-icn/code-of-ethics-for-nurses

Keane, M. (2010).The opioid emperor has no clothes. The Am erican Journal o f Bioethics, 10(11), 25-27. Krupnick, S. (2009). Navigating clinical care at the intersection o f pain and addiction. MEDSURG Nursing,

/ 8(6), 381-384. McCreaddie, M., Lyons, l.,Watt, D., Ewing, E„ Croft, J., Smith, M., & Tocher, j. (2010). Routines and rituals:

A grounded theory of the pain management of drug users in acute care settings. Journal o f Clinical Nursing, 19( 19-20), 2730-2740.

National Institutes of Health (NIH). (1979). The Belm ont Report: Ethical principles and guidelines fo r the protection o f hum an subjects o f research. Retrieved from http://science.education.nih.gov/ supplements/nih9/bioethics/guide/teacher/Mod5_Belmont.pdf

Purtillo, R.B., & Doherty, R.F. (2011). Ethical dimensions in the health professions (5th ed.). St. Louis, MO: Elsevier Saunders.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2009). Treatment Episode D ata Set (TEDS) highlights – 2 0 0 7 national admissions to substance abuse trea tm ent services. Retrieved from http://oas.samhsa.gov/TEDS2k7highlights/toc.cfm

Brooke Faria da Cunha, BSN, RN, is a Registered Nurse, Medical Telemetry Unit, Stormont-Vail Healthcare, and a Medical-Surgical Adjunct Clinical Instructor, Baker University School of Nursing,Topeka, KS. She is currently pursuing her MSN to become a Family Nurse Practitioner.

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