Argumentative Research Essay (RasWriter Only)
FIRST DRAFT 1
FIRST DRAFT 9
First Draft
Erica K. Fernandez
Argosy University
Pain Management for Patients with Addiction Problems
Thesis Statement
The ability of clinicians to keep patients in check has proven to be a challenge, especially with concerns regarding the legitimacy and physical functions affecting overall pain management in patients with an addiction problem.
Background
The treatment modalities for chronic pain using COT in active drug users or those who are in remission present a significant challenge for clinicians who oversee the effectiveness of the intervention. Moreover, such notions are correlated to the concerns of patients experiencing a relapse to substance abuse during the duration of therapy since analgesics may obscure drug-seeking behaviours that are characteristic of addictive diseases. This results in poor treatment outcomes where patients are likely to be discharged prematurely from pain care treatment (Ballantyne & Mao, 2003). Additionally, there is the widespread misconception that chronic pain patients with an addiction problem often encounter health professionals who possess inadequate training in clinical guidelines that are related to comorbidities of chronic pain and related addiction issues. Moreover, there exists a dilemma for the treatment of abstinent and former heroin addicts as they are at a high risk of relapsing to addiction if they are exposed to opioid drugs. They also face the risk of relapsing if they are not accorded sufficient care. For people who are already on opioid medication such as methadone often experience challenges responding to pain relievers when they are hospitalized. In such as case, the fundamental principle of management denotes the prevention of withdrawals by initiating methadone for heroin users while providing additional analgesia as recommended while confirming whether the pain relief is satisfactory (Chou et al., 2009). Additionally, most physicians have developed a phobia of over prescribing narcotics as pain relievers. Perhaps this may be attributed to the fear of the legal repercussions that may ensue including the divergences in federal guidelines on matters about the use of narcotics as a pain reliever. Thus, it is the responsibility of the individual practitioner to offer pain management using opioids for legitimate standard and by the regulation of medical practice.
Objective
The purpose of this research is to evaluate the challenges that are faced by clinicians in pain treatment for patients with addiction problems. On the other hand, the study focuses on offering a counter-argument to the thesis by providing ideal solutions for pain management for patients with SUDs. Additionally, the research intends to highlight the complex interconnection that exists between pain management and addiction to opioids.
Supporting Points
For clinicians, the hardest challenge is perhaps knowing the right way to handle patients who require pain medication, yet they have a history of addiction to drugs. When speaking about pain medication, opioids are among the first class of drugs to come to mind. There is also a clash that exists between prescribing opioid medication to patients with a history of heroin abuse. Most doctors, fearing the legal ramifications of their actions, often shy away from overprescribing pain medication to patients with a history of drug addiction. Numerous misconceptions are surrounding this topic, such as patients with chronic pain symptoms encountering physicians who do not have enough experience to handle their unique needs (Fishbain et al., 2007). Important to note is that, the main issue of concern is knowing the right way to treat a patient with a history of drug abuse without causing abstinent patients to relapse, or to administer small dosages of pain medication which may lead to the patients being discharged before the right time for their therapy has elapsed, or even designing the proper care interventions that will ensure patients do not relapse. Consequently, the fundamental principle of care for patients with SUDs prompts the need for identification of physical dependence on illicit opioid use or the addictive ailment well in advance to facilitate the formulation of an effective treatment plan. Moreover, addiction ought to be perceived as a co-occurring medical issue which is pervaded by challenges such as increased medication requirement and tolerance and such problems need to be accommodated while also according respect to the patient during treatment.
There exists no perfect formula for calculating the right amount of opioid doses to administer for pain medication therapies. There are no studies that deeply delve into the issue of how patients with a history of substance abuse should be handled when it comes to administering pain medication to them. For the patients already using opioids illegally, there is a serious challenge during pain management should a time come when they require such interventions (Michna, 2004). With the current legal system, physicians may face legal ramifications for over prescribing, meaning they are almost always afraid to make prescriptions. In a bid to safeguard against the advent of adverse legal implications in pain management, clinicians are advised to prescribe long-acting, scheduled or continuous opioids with the reservation to utilize the pro re nata medication scheme solely for dose titration (Oderda, 2012). In the long run, the pain physician can provide analgesia at the same time he avoids compelling the patient to make frequent requests for opioids thus averting the controversy that is associated with misinterpretation for drug-seeking behaviors. In extreme cases that is characterized with medical challenges such as trauma, surgery or illness, the patient with an active addiction ought to be particularly open to the possibilities of entering addiction treatment.
In the medical world also, there exists a complicated relationship between pain management and patients with addiction problems. Physicians may discharge patients early from pain management programs, meaning the patients encounter problems both regarding pain and also regarding their drug abuse problem (Martell, 2007). More so, improper communication has made physicians shy away from taking on patients with substance abuse problems, especially since opioids are the essential components required for pain management, and administering such medication exposes the patients to a high risk of a relapse during or after the pain management therapy. Moreover, patients who have experiences with untreated pain and addiction are likely to develop the syndrome dubbed pain facilitation (Volkow et al., 2014). This phenomenon may be attributed to the alternating intoxication ad withdrawal as a result of unstable blood levels of the drug. COT patients may also experience such challenges where the sympathetic nervous system may be activated leading to the advent of irritability and tension further aggravating discomfort and pain.
Lastly, the bureaucracies associated with pain management for patients with drug abuse problems make it difficult for healthcare settings to do their work properly. Notably, physicians lack the proper support from their healthcare facilities to address pain management for patients who have a history of drug abuse (Gourlay, 2005). The absence of acute management teams in most facilities also means that for a healthcare facility to take on patients struggling with drug use, there needs to be written procedures and policies, which are mostly not properly adhered to. For instance, the employment of collaborative efforts amongst pain clinicians and mental health professionals would be instrumental in reconciling the ambiguities that exist between personality disorders and pain management. Research indicates that chronic pain patients with untreated depression respond poorly to pain treatment mechanisms (Pud, Zlotnick & Lawental, 2012). This problem is further compounded by functional limitations where pain patients become isolated and are incapacitated in regards to participation in social and physical activities which significantly contributes to severity of chronic pain experience
Counter Arguments
Before admitting patients into the COT program, clinicians need to conduct a comprehensive risk assessment for opioid misuse. The evaluation comprises of identified risk factors for addiction problems such as family or personal history of substance use, psychiatric symptoms, functional impairments and childhood adverse events (Oliver et al., 2012). As such the identification of pain symptomologies would comprise of identifying the causative factors that perpetuate pain; the documentation of pain-related risk factors for relapse and opioid abuse and the demarcation of efficient and nociceptive components of the occurrence of pain. Moreover, screening tools such as Addiction Behaviour Checklist (ABC) and Diagnosis, Intractability, Risk, Efficacy (DIRE) may be used in the stratification of patients as being either high, medium or low-risk group of opioid misuse (Ives et al., 2006). Consequently, patients who are categorized as being high or moderate risk require frequent monitoring, especially in medication use. Moreover, frequent urine drug testing and monthly reviews of Prescription Monitoring Program (PMP) reports are recommended including the attempt to prescribe opioids in small doses.
The pain medication given to patients needs to be regulated. Access to more pain medication drugs may lead to a false sense of pain in the patients. Knowing the pain medication is at their disposal, patients may take medication for pain that is not severe enough to warrant medication (Thorn, 2017). The success of the COT module may be determined through the regulation of the number of units of opioid medication that is made available to the patient and the frequency in which the drugs are dispensed. In contemporary practice, patient commonly receives analgesics on a monthly basis while those who indicate minimal risk of substance abuse are provided with up to 3-month supply. Nonetheless, it is recommended that for pain patients with SUDs smaller quantities be administered more frequently to avoid instances of misuse. Pain medication should be administered through a third party, and not directly to the patient. This may work to reduce the possibility of a relapse in the patients. Therefore, administration of pain medication, especially opioids, should be structured in such a way that patients have limited direct access to the drug (Chou, 2009). The medication is only availed to the patients at the prescribed times and for the specified amount of time.
Conclusion
It is complicated to accurately ascertain the amount of pain that a patient is going through. The limited nature of research into the correlation between pain therapy and patients with a history of drug use also makes it difficult to correctly match the level of pain as described by the patient, with the right pain medication dosage. With the current legal system defining the conduct of healthcare practitioners, most physicians are afraid of the legal issues they may face when they are accused of prescribing more opioid pain medication that is supposed to be.
References
Ballantyne, J. C., & Mao, J. (2003). Opioid therapy for chronic pain. New England Journal of Medicine, 349(20), 1943-1953.
Chou, R., Fanciullo, G. J., Fine, P. G., Adler, J. A., Ballantyne, J. C., Davies, P., ... & Gilson, A. M. (2009). Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain, 10(2), 113-130.
Fishbain, D. A., Cole, B., Lewis, J., Rosomoff, H. L., & Rosomoff, R. S. (2007). What percentage of chronic non-malignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain medicine, 9(4), 444-459.
Gourlay, D. L., Heit, H. A., & Almahrezi, A. (2005). Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Medicine, 6(2), 107-112.
Ives, T. J., Chelminski, P. R., Hammett-Stabler, C. A., Malone, R. M., Perhac, J. S., Potisek, N. M., ... & Pignone, M. P. (2006). Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC health services research, 6(1), 46.
Martell, B. A., o'Connor, P. G., Kerns, R. D., Becker, W. C., Morales, K. H., Kosten, T. R., & Fiellin, D. A. (2007). Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Annals of internal medicine, 146(2), 116-127.
Oderda, G. (2012). Challenges in the management of acute postsurgical pain. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 32(9pt2).
Oliver, J., Coggins, C., Compton, P., Hagan, S., Matteliano, D., Stanton, M., ... & Turner, H. N. (2012). American Society for Pain Management nursing position statement: pain management in patients with substance use disorders. Pain Management Nursing, 13(3), 169-183.
Pud, D., Zlotnick, C., & Lawental, E. (2012). Pain depression and sleep disorders among methadone maintenance treatment patients. Addictive behaviors, 37(11), 1205-1210.
Thorn, B. E. (2017). Cognitive therapy for chronic pain: a step-by-step guide. Guilford Publications.
Volkow, N. D., Frieden, T. R., Hyde, P. S., & Cha, S. S. (2014). Medication-assisted therapies—tackling the opioid-overdose epidemic. New England Journal of Medicine, 370(22), 2063-2066.