Handling acute pain in Behcet's patients already taking opioid pain relievers

Some Behcet's patients have pain that can't be controlled with regular, over-the-counter pain relievers. In these cases, stronger doses of pain meds, or even prescription opioids (narcotics), may help -- but what happens when patients taking these meds need surgery? There are horror stories of patients forced to taper or withdraw from opioids before surgery, or denied additional pain relief after surgery, because s/he's "already taking opioids, and doesn't need anything else."

Doctors who feel this way need up-to-date information about treating patients with opioids. No one should have to suffer.

The following interview is reproduced with the permission of painEDU.org, an educational website for clinicians, teaching about pain assessment and management. painEDU.org is produced by Inflexxion, a scientifically-based, multimedia company specializing in healthcare business solutions.

(BTW, I work for Inflexxion)


Acute Pain Management in the Opioid-Tolerant Patient
An Interview with Kathleen M. Colfer, MSN, RN-BC
By Evelyn Corsini, MSW, LICSW
Inflexxion

Kathleen M. Colfer, MSN, RN-BC, is a Clinical Nurse Specialist, Acute Pain Management Service, Department of Anesthesiology, Thomas Jefferson University Hospital in Philadelphia, PA. This interview includes content she presented in a session at the American Society for Pain Management Nursing National Conference in September 2008.

Evelyn Corsini:
How did you become a specialist in pain management?

Kathleen M. Colfer, MSN, RN-BC: I have been a nurse for 23 years and have a Master’s degree from the University of Pennsylvania. My nursing background includes medical/oncology, medical respiratory ICU, post anesthesia care, and legal nurse consulting. While pursuing my Master’s degree I focused on pain and symptom management in the oncology population. After working in the ICU for ten years, I decided to explore opportunities in pain management. It was then, in 2000, when I became an acute pain management nurse. I have been in my current position for eight years. I received my certification in pain management in 2006.

My interest in acute pain management in the opioid tolerant patient has grown out of my own daily experience on an inpatient pain management service. As an example, my hospital has a very large orthopedic surgery program and I see many patients come in for joint replacement or back surgery who have been on large doses of long acting or short acting opioids. This makes post-operative pain management a challenge.

EC: Do you believe that problems with post-operative pain management among opioid-tolerant patients are rising?

KMC: I most definitely see the problem of lack of knowledge about opioid tolerance growing as opioids are being prescribed more frequently. In my practice when I started to notice that the number of acute pain consults was rising, I was curious to see what was behind it. I conducted a small retrospective chart review and found that 95% of the consults were for uncontrolled post-operative pain. Of that 95%, at the time of their admission, 79% of the patients were taking 20 mg or more per day of oxycodone or hydrocodone. The fact that the pain consults were increasing indicated to me that there was insufficient pain management knowledge in the primary teams, and that this lack of knowledge was leading to post-operative problems.

EC: What are some common "myths" or misinformation about pain management in the opioid-tolerant patient that you have found among health care providers?

KMC: In my experience, the most common myths about pain management in the opioid-tolerant are:

• Some practitioners believe that since the patient is on an opioid medication, they are already receiving enough of an opioid to cover them during the new acute pain episode. They do not recognize that the basal rate of pain control will not be effective when the surgery adds more pain.
• Some practitioners advise their patients to wean down or stop their opioids prior to coming into the hospital for surgery. They believe that it will then make it easier to treat their pain post- operatively. This is not true. It most likely will lead to withdrawal and increased pain, and it will not decrease the post surgical opioid requirement.
• Some practitioners believe that one agent will manage the post-op pain. They are not aware that the current standard of care for all patients with acute pain now includes a multi-modal approach. This multi-modal approach is most important for the opioid tolerant patient. It helps to minimize the escalation of opioid doses while achieving analgesia in the acute pain setting.
• Some health care providers have the misconception that all patients who are opioid tolerant are addicted to the opioids. Of course, this is not true.
  
  

EC: What works to help health care providers "unlearn" bad habits?

KMC: I think what helps providers unlearn bad habits is when they witness the outcomes from the application of the new information, or the evidenced based practice. I find that when nurses and physicians see good outcomes it is very convincing and conducive to behavior change.

EC: Is there a need for more provider education about management of the opioid tolerant patient?

KMC: There is definitely a need for more education. The professional pain management organizations are doing an excellent job of disseminating the most up to date pain care information. It is the responsibility of the recipients of this information to use it in their own practice settings and pass it on to other areas of medicine and nursing that face pain management problems. I also try to spend as much time as possible teaching other nurse specialists and physician assistants. Once they acquire and apply this new pain care knowledge, they then pass this information on to the physicians on their teams.

(End of interview) From JZ: Refer your physician(s) to the painEDU.org website for pain management information that's specifically aimed at the medical community. You might also want to order copies of the painEDU Manual, and/or the book, Managing Chronic Pain with Opioids in Primary Care. Both books are available for FREE, for patients AND doctors, at http://painedu.org/manual.asp