Untreated Addiction

From Clinicaltools.com

Contents 1 Course Alternative 5: Untreated Addiction 1.1 Need 1.2 Goal 1.3 Objectives 1.3.1 Objective A. Treat Addicted Patient 1.3.2 Objective B. Decrease Abuse/Increase Safety 1.3.3 Objective C. Address Abuse 1.4 Case Study/Simulated Patients 1.4.1 Case 1 1.4.2 Case 3

Course Alternative 5: Untreated Addiction

Managing Pain Patients Who Have Untreated Addiction

Need

Clinicians need to manage substance-abusing patients who are not in treatment for their addiction and who develop pain that is usually treated with opioids.

Goal

The learner will be able to assess the severity of the patient's pain within the context of addiction and determine an appropriate treatment plan.

Objectives

After completing this course, the learner will be able to:

Objective A. Treat Addicted Patient

Take patient's addiction into consideration while managing pain

1. Continue to encourage recovery
2. Develop a treatment agreement appropriate for a pain patient with untreated addiction
3. Evaluate pain symptoms to determine their relationship to the substance abuse, e.g., withdrawal symptoms, opioid-induced hyperalgesia, rebound phenomenon, consulting with or refering to a specialist if needed
4. Require patients to be actively involved in addiction treatment in order to receive a pain medication prescription (when necessary for patient safety)
5. Prescribe further pain medication only after evaluating for addiction and when there has been periodic assessment for persistence of the pain-causing condition

Objective B. Decrease Abuse/Increase Safety

Follow clinical guidelines to decrease the likelihood of abuse and increase patient safety when treating pain in a patient with untreated addiction

1. Use sensitive interviewing techniques to ask at each appointment about all drug use
2. Develop a treatment plan that relies on alternatives to addictive pain medications as much as possible
3. Develop a treatment agreement appropriate for a person with untreated addiction
4. Use urine drug testing for the prescribed medication and other drugs as well as pill counts to guide decisions regarding safety
5. Weigh safety concerns against pain management
6. Prescribe addictive pain medications for a short time period and schedule frequent follow-up visits
7. Prescribe scheduled doses rather than "as needed" when appropriate
8. Consider enlisting the help of a trusted other person to dispense daily medication
9. Choose medications that provide stable blood levels (long acting, slower onset) if appropriate
10. Establish a plan for follow-up to evaluate pain and verify correct use of pain medication
11. Co-manage patients with specialists and other healthcare providers (Described in detail in core course)

Objective C. Address Abuse

Address abuse of prescribed pain medications if it occurs

1. Document abuse in the patient's medical record, including type, quantity, and duration of substances used
2. Revise treatment agreements in accordance with new treatment plan

Case Study/Simulated Patients

- IN DEVELOPMENT

Case 1

Depressed David With Substance Use Disorder and Acute Pain From Trauma: 44YOBM

• Chief Complaint: Ran out of his back pain medication.
• Narrative: David sustained a back injury and broken arm when a car crashed into his bicycle. He went to physical therapy for 6 months and also took oxycodone for 1 month. He says that he "just felt better" while taking the oxycodone and he started buying it illegally on the Internet after his prescription ran out. He "isn't sure" how much oxycodone he takes now, but he said that he re-injured his back moving furniture and he needs some more.
• Objective Addressed: 1. Follow clinical treatment steps to increase safety and decrease the likelihood of abuse while treating pain in patients with untreated addiction
• Skills-Training Goals:

1. Diagnose substance abuse/dependence using DSM criteria
2. Discuss with the patient the importance of obtaining an accurate history and information about current substance use
3. Prescribe further pain medication only after evaluating for addiction and when there has been periodic assessment for persistence of the pain-causing condition
4. Prescribe scheduled doses rather than "as needed" when appropriate
5. Choose medications that provide stable blood levels (long acting, slower onset) if appropriate
6. Treat the addiction or refer for treatment

• Objective Addressed: 2. Consider the interaction between addiction symptoms and pain symptoms
• Skills-Training Goals:

1. Evaluate pain symptoms to determine their relationship with the substance abuse, e.g., withdrawal symptoms, opioid induced hyperalgesia, rebound phenomenon
2. Use a short trial of medication for diagnostic purposes

Case 3

Herman Heroin in Acute Pain from Trauma: 44YOWM

• Chief Complaint: Acute pain due to ankle fracture
• Narrative: Herman is open about his long-standing heroin addiction. He broke his ankle this weekend and it was treated in an emergency clinic.
• Challenge: He has repeatedly refused addiction treatment.
• Objective Addressed: 1. Follow clinical treatment steps to increase safety and decrease the likelihood of abuse while treating pain in patients with untreated addiction
• Skills-Training Goals:

1. Determine the severity of the addiction (to determine safe dosing for treatment)
2. Prescribe scheduled doses rather than "as needed" when appropriate
3. Consider having a trusted person dispense the medication on a daily basis if needed

• Objective Addressed: 2. Consider the interaction between addiction symptoms and pain symptoms
• Skills-Training Goals:

1. Make pain medication contingent on active involvement in addiction treatment when necessary for safety