Article Summary: Nursing

Ethics and U ndertreatm ent of Pain

in Patients w ith a History of Drug Abuse

CONTINUING

CNE NURSING EDUCATION

Ethics and Undertreatm ent of Pain in Patients w ith a H istory o f Drug Abuse

Brooke Faria da Cunha

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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 treatm ent of patients in pain who have a history of drug abuse. After studying the information pre­ sented in this article, you w ill be able to: 1. Define tolerance, physical dependence,

addiction, and pseudoaddiction. 2. Discuss the ethical considerations surrounding

pain management in patients w ith a history of substance abuse.

3. Explain autonomy, beneficence, nonmaleficence, and justice in health care.

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Patients with substance abuse history make up 14% o f inpatient admissions to acute care units, where it has been reported a great deal o f 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 o f 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, w ith no end to that pain in sight. This is the plight o f thousands of patients with drug abuse history admitted to acute care units right now. According to the Center fo r Behavioral Health Statistics and Quality (20 10) - a division of SAMHSA - in 2 0 10, 2 1.5% o f adults ages 18-25 reported using illicit drugs in the last month, and 6.6% o f 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 o f Healthcare Providers and Systems (HCAHPS) Hospital Survey (2 0 12) reported that from 2 0 10 -2011, only 70% of patients stated their pain was controlled during their hospital stay. From these statistics, it can be concluded that 30% o f patients reported having uncontrolled pain; many o f them are drug abusers, a label that consistently leads to espe­

cially poor pain management. SAMHSA also reported that 14% o f all inpatient admissions consist of patients w ith drug abuse history and that 20% o f all Medicaid costs and $ l out of every $4 Medicare spends on inpatient care is associated w ith 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 fo r years w ithout ade­ quate training in pain management and almost no training in pain management fo r patients w ith a history of drug abuse.This lack o f 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 o f drug abuse, its implications fo r pain control, and the moral respon­ sibilities they have to treat pain in all individuals, including those w ith 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 fo r drug- abuse related terms including tolerance, physical dependence, and addiction (ASPMN, 2 0 10).A better understanding o f these terms is crucial to providing adequate pain management because patients can experience one o r all of theses states during hospital admission, they are easily confused w ith one another, and they require different care. In addition, an understanding o f these terms can define and explain behaviors in patients w ith substance abuse his­ to ry that may lead to undertreatment of pain.

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Tolerance is “ a state o f adaption in which exposure to a drug induces changes that result in a diminution of one o r more o f the drug’s effects over tim e” (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 o f 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. W ithdrawal syndromes can lead to symptoms such as nausea, vom­ iting, chills, diarrhea, and changes in vital signs (Dunn & Neuman, 2 0 12). One can imagine how much worse a painful dis­ ease process o r surgical recovery would be when exacerbated by w ith­ drawal symptoms.

Dependence is not to be confused w ith 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 C ontrol over substance, and Craving (Dunn & Neuman, 2012).

Finally, addiction is not to be con­ fused with pseudoaddiction, o r 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.

W hen 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, o r pseudoaddicted w ith those who are addicted.This confusion can lead to the undertreatment o f 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 o f negative health consequences that affect quality o f life, ranging from anxiety to depression and chronic stress to suicide (Bernhofer, 2012). O th e r physical responses include increased heart rate, systemic vascular resistance, circulating catecholamines, decreased mobility, loss o f strength, dis­ turbed sleep, and immune system impairment (Finney, 2010). Post­ operative patients w ith 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 o f 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 o f anxiety and dis­ comfort, leading to a greater need fo r pain medication, which can lead to neu­ rological changes and cause addiction o r make addiction worse (Dunn & Neuman, 2012).

Ethical Considerations Unrelieved pain is a form of suffer­

ing, and according to The International Council o f Nurses (ICN) Code o f Ethics for Nurses, one o f the four responsibilities of the nurse is to relieve suffering (ICN, 2 0 12). In other words, nurses are ethi­ cally responsible fo r treating pain; how­ ever, this process is complicated in those w ith substance abuse history. Nurses undertreat pain in patients with substance abuse history fo r 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 o r be grateful fo r

services rendered (McCreaddie et al., 2010). These circumstances can threaten the self-worth o f the nurse and increase a propensity tow ard stereotypes and sensitivities toward these patients. Many nurses have reported ethical erosion after caring fo r such patients over a long period of time. O ther reasons nurses frequently undertreat pain in patients with drug abuse history include a lack of educa­ tion and experience working w ith these patients, fear o f exacerbating or creating an addiction, fear of respira­ to ry 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 fo r a review of basic ethical principles nurses must adopt when they accept a position in the nursing field. Deliberate use o f 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 o f Ethics for Nurses with Interpretive Statements, is the right to self-determination. This includes the patient’s right to know all o f 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 o r not treated. The principle o f autonomy is violated when the nurse withholds any o f this information from the patient o r if he or she makes pain control decisions for the patient w ithout his o r 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, 2 0 12). 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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Tab le I. Using Ethical Principles to Guide Pain Management Decisions

Principle Q uestion

Autonom y A re the patient’s preferences in pain treatm ent given the highest priority?

Beneficence Does the patient benefit from my pain treatm ent deci­ sions?

Maleficence W h a t can 1 do to decrease harm?

Justice Did 1 do my best to p ro te ct the m ost vulnerable patient, treating his o r her pain in the best possible way w ith respect and w ith o u t discrimination?

Source: Adapted from Bernhofer, 2 0 12.

Tab le 2. Guidelines for Safe, Effective Pain Management

1) Define pain syndrome.

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

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

4) Provide non-opioid therapies when appropriate.

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

6) Avoid excessive negotiations. W hich 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 o f pain medication to themselves when they feel they need it. This kind o f therapy has been very suc­ cessful in better treating pain in post­ operative and cancer patients w ith severe pain (Dev, Del Fabbro, & Bruera, 2011). N o t 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 th eir deci­ sions independently (Finney, 2010).

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

Institutes o f Health [N IH ], 1979). Pain control is an inextricable part o f pro­ viding good care fo r a patient w ith 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, o r do not advocate for enough medication, they are guilty of neglecting the principle o f 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 fo r every patient, includ­ ing those with substance abuse history (Bernhofer, 2 0 12).

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 o f pain fo r an indi­ vidual equates to doing them harm. Some might even consider this to rtu re (Keane, 2 0 10). Others argue that when nurses stereotype and discriminate against a patient w ith substance abuse history, they are dehumanizing the patient and championing prejudice (Finney, 2010). Interestingly, many times nurses cite the principle o f 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 o f avoid­ ing inadequate pain management far outweigh the risks of treating pain ade­ quately (Bernhofer, 2 0 12).

Justice is the principle that dictates all patients should be treated fairly, or that equals be treated equally (NIH, 1979). When patients w ith drug abuse history have pain and are treated differ­ ently from other patients because o f a stigma o r 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 o f a patient needing increasing amounts of medication to treat hypertension, yet he o r she may label a patient seeking increasing amounts of pain medication to tre a t 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 o f his o r her pain, and to treat and advocate fo r the treat­ ment o f that pain w ith all of their resources.

Nursing Implications One author (Bernhofer, 2 0 12) 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) W hat can I do to decrease

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Table 3. Resources fo r More Inform ation

National Institute on Drug Abuse N ID A MED Program www.drugabuse.gov

National Institute o f Alcohol Abuse and Alcoholism www.niaaa.gov

American Academy o f Pain Medicine www.painmed.org

American Pain Society www.ampainsoc.org

American Society o f Addiction Medicine www.asam.org

International Association o f 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 o r her pain in the best pos­ sible way, with respect and w itho ut dis­ crimination (justice)?” (p. 11) (see Table I (.Asking themselves these questions can help nurses identify their own biases and provide pain treatm ent effectively and equally to all patients while avoiding a substantial amount of suffering (Bernhofer, 2 0 12).

O th e r nursing considerations for the best care o f patients in pain who have a history o f substance abuse include developing a patient-centered approach by involving the patient in the plan fo r 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 o r her preferred learning style, and maintaining open communica­ tion w ithout bias.

Another author, Susan Krupnick (2009), provides more guidelines fo r 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 o f opioid [o r 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 o r mis­ use behaviors, 6) Avoid excessive nego­ tiations over specific drugs/doses/ routes of administration, 7) Arrange for early consultation w ith psychiatry, addiction medicine, and pain manage­ ment if specialists are available” (p. 383) (see Table 2).

Krupnick (2009), also lists several resources fo r more assistance in caring fo r patients w ith pain and substance abuse history, including:

• The National Institute on Drug Abuse NIDAMED Program

• The National Institute on Drug Abuse

• The National Institute o f 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 o f 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 w ith a history o f 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 fo r pain management decisions; and by utilizing the many resources out there to help them deal with pain management in substance abusers, nurses can fulfill th eir duty and stop the nightmare o f unrelieved pain in a significant number of patients in acute-care settings.

References American Nurses Association (A N A ). (2015).

Code o f ethics for nurses with interpretive statements. R etrieved fro m h ttp :// www.nursingworld.org/MainMenuCateg ories/E thicsStandards/C odeofE thicsfor Nurses

American Society fo r Pain Management Nursing (ASPMN). (2010). Optimizing the treatment o f pain in patients with acute presentations. Retrieved from http://www.american p a in so cie ty.o rg /up io a d s/p d fs/A P S 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 „ & H alldorsdottir, S. (2009). The challenge o f caring fo r patients in pain: From the nurse’s perspective. Journal o f Clinical Nursing, 18(20), 2897-2906.

C enter 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 fro m 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 w ith 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 co n tin u e d fro m page 7

Dunn, D., & Neuman, J. (2012). H o w substance abuse impacts pain management in acute care. N ursing, 42(8), 66-68.

Finney, L. (2 0 10). Nursing care fo r the patient w ith co-existing pain and substance misuse: Meeting the patient’s needs. M E D S U R G N ursing, 19(1), 25-53.

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Keane, M. (2010).The opioid em peror has no clothes. The A m e rica n J o u rn a l o f Bioethics, 1 0 (1 1 ), 25-27. Krupnick, S. (2009). Navigating clinical care at the intersection o f pain and addiction. M E D S U R G N ursing,

/ 8(6), 3 8 1-384. McCreaddie, M., Lyons, l.,W att, D., Ewing, E„ C ro ft, J., Smith, M., & Tocher, j. (2010). Routines and rituals:

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National Institutes o f Health (N IH ). (1979). The B e lm o n t R ep o rt: Ethical prin ciple s a nd guidelines fo r the p ro te c tio n o f h u m a n subjects o f research. Retrieved from http://science.education.nih.gov/ supplements/nih9/bioethics/guide/teacher/Mod5_Belmont.pdf

Purtillo, R.B., & D oherty, R.F. (2 0 1 1). E th ica l dim ensions in th e h ea lth professions (5th ed.). St. Louis, M O : Elsevier Saunders.

Substance Abuse and Mental Health Services Adm inistration (SAMHSA). (2009). T re a tm e n t Episode D a ta Set (TEDS) highlights - 2 0 0 7 n atio n a l adm issions to substance abuse tre a tm e n t services. Retrieved from http://oas.samhsa.gov/TEDS2k7highlights/toc.cfm

Brooke Faria da C unha, B SN , R N , 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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