Patients with cancer who experience moderate to severe pain may be prescribed opioids and could become addicted to them; thus, it is important for oncology nurses to understand addiction and how to assess and manage pain in this patient population.
Patients with cancer who experience moderate to severe pain may be prescribed opioids and could become addicted to them; thus, it is important for oncology nurses to understand addiction and how to assess and manage pain in this patient population. In a session entitled “Pain Management in the Patient with Addictive Disease: Responsible Use of Opioids,” Susan Pillet, RN, CPNP, CPON®, Advanced Practice Nurse, Cancer Institute of New Jersey, New Brunswick, uses a case-based approach to provide oncology nurses with the necessary tools to manage cancer pain in patients with substance abuse issues.
Pillet reviews some key definitions, including physical dependence, tolerance, and addiction. She defines physical dependence as an expected response to the prolonged use of a drug. In patients with physical dependence, “withdrawal syndrome can be produced by stopping the drug, rapid dose reduction, lowering the drug level in the blood, and/or giving an antagonist.” With tolerance there is a loss of treatment effect, requiring higher doses of pain medication. This can result from numerous causes, including disease progression, anxiety, depression, and opioid-induced hyperalgesia. Finally, there is addiction, which involves physiological, behavioral, and cognitive phenomena, all of which culminate in the drug becoming the patient’s highest priority. Addiction is considered a neurobiological disease, as each time an addicted individual uses the drug, dopamine is released, reinforcing further drug use.
Pain Assessment: The 4 A’s
When assessing patients with addiction, oncology nurses can expect a high level of abuse, but should remain nonjudgmental. Pillet offers nurses four “A’s” for assessment: analgesia, activities of daily living, adverse events, and aberrant behaviors. When it comes to analgesia, the goal is to reduce pain. To find out if the therapy is effective in meeting this goal, pain assessments need to be conducted using a pain scale and questioning that examines quality and temporal factors and duration of pain relief. Nurses also need to assess the activities of daily living, namely, is the patient able to work, how are their family relationships, are they sleeping? Numerous functional assessment tools are available to assist with this, including the Karnofsky Performance Scale Index. Patients should also be asked if they are experiencing any opioid-induced side effects, such as constipation or itching, and if so, measures should be taken to minimize these adverse events.
Last, aberrant behaviors, which are the hallmark of addiction, should be assessed. Such behaviors can be classified into two types: less predictive and more predictive. Less predictive aberrant behaviors may include aggressive demands for a higher drug dose, unsanctioned dose escalation, and drug hoarding when symptoms are improved. More predictive aberrant behaviors include selling prescription drugs, stealing and borrowing drugs, concurrent illicit drug use, and forgery of drug prescriptions. Some risk factors for more aberrant behaviors include a family history of substance abuse, legal problems, personal drug or alcohol abuse, mental health problems, a history of multiple motor vehicle accidents, and cigarette smoking.
Pain Management in the Setting of Addiction
Opioid management requires a multidisciplinary team approach, which may include the physician, nurse, psychologist, social worker, counselor, and addictionologist. Nurses serve as the patient advocate and a collaborative member of the team, communicating with the patient’s family, assessing pain, and documenting any aberrant behaviors or abuse techniques. Some abuse strategies that nurses should be cognizant of include liquefying and injecting tablet or capsule contents, injecting transdermal (TD) fentanyl contents, and increasing absorption of TD fentanyl with a heating pad or lamp. Patients who are discovered to be addicted require close follow-up, including urine toxicology screenings. The amount of medication that they are given at any one time also should be limited, with 2- to 3-day or weekly prescriptions being recommended. Pill counts can determine if the patient has independently escalated their dose. In select cases, enrollment into a 12-step program may be warranted, though this can be difficult in patients with cancer, who will need to continue some level of opioid therapy.