Acute pain management

in the patient with

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By Patricia Kelly Rosier, MS, RN, ACNS-BC

Abstract: Opioid addiction and substance use

disorders are a major problem in the United States.
These conditions are present in many of the patients
admitted to hospitals. This article discusses nursing
assessment, management, and evaluation of acute
pain in the presence of substance use disorder and
what to do when a patient with addiction is already
being treated with medications such as buprenor-
phine or methadone.
Keywords: acute pain, medication-assisted treat-
ment, multimodal analgesia, opioid addiction, pain
management, substance use disorder

Case study
Mr. M, a 48-year-old motorcyclist, was admitted to
the ED after he was sideswiped by a car. He com-
plained of left flank pain and midthoracic back
pain. On assessment, he had multiple rib frac-
tures, a large pneumothorax for which a chest
tube was inserted, a sacral fracture, pubic ramus
PIXELHEADPHOTO DIGITALSKILLET / SHUTTERSTOCK

facture, and acetabulum fracture. Vital signs on

admission to the ED were: BP, 147/75 mm Hg;
heart rate, 57 beats/minute; respiratory rate,
22 breaths/minute; and temperature, 98° F (36.7° C).
His oxygen saturation was 95% on 4 L of oxygen.
Mr. M also rated his pain as a 10 on a 0 to 10 pain
scale (with 0 as no pain and 10 as the worst pain)
on admission.
His urine toxicology screen was positive for
methadone and benzodiazepines; Mr. M reported
that he was taking the methadone for chronic
back pain because he lost his prescription for
oxycodone. He had a history of lumbar surgery

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a substance use disorder

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Acute pain management in the patient with a substance use disorder
and benzodiazepine abuse. Mr. M was admitted
to the trauma ICU for further observation and
pain control. During his stay, Mr. M frequently
complained of poorly controlled pain, despite an
aggressive multimodal analgesic plan.
On the seventh night of his stay, Mr. M admit-
ted to his nurse that he had been taking metha-
done for years, but was too embarrassed to tell
the physicians when he was admitted. Psychiatry
was consulted, and Mr. M revealed that he had
previously been treated for a substance use
disorder with methadone, but was no longer in
treatment and was obtaining benzodiazepines
from relatives.
Introduction
The problem of opioid addiction and substance
use disorders (SUDs) is widely acknowledged and
increasing in the United States. Currently, numer-
ous efforts are underway to address the issue.1,2
Patients with varying degrees of SUDs are admitted
to hospitals in acute pain almost daily. As opioid
addiction is addressed, more patients are treated
with medication-assisted treatment (MAT) including
buprenorphine, methadone, or naltrexone. These
drugs can complicate patients’ analgesic plan.
Healthcare providers often look for clear, concise,
evidence-based algorithms to guide their practice.
When dealing with a patient in acute pain who has
a SUD, developing a multimodal analgesic plan for
a patient who may be undergoing MAT is often
much more complex.
Describing the problem
The population of patients with SUDs is diverse,
ranging from active users of illegal substances
such as heroin to patients with prescribed opioids
whose use is out of control. This group can also
include patients who misuse prescription opioids
by taking drugs prescribed for someone else, tak-
ing opioids recreationally, or to self-treat chronic
pain.3 In addition, many of these patients also
experience behavioral health issues, such as
depression, anxiety, and posttraumatic stress
disorder, which further complicate their care.
Patients in a recovery program that prescribes
MAT, such as buprenorphine or methadone, pres-
ent their own unique needs. When a hospital
admission is planned, such as a scheduled
42 l Nursing2017Critical Care l Volume 12, Number 1
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surgery, an analgesic treatment plan can be
developed in advance. However, any unplanned
admission (such as trauma following a motor
vehicle crash, as with Mr. M) can be more chal-
lenging, especially if the patient was taking a
medication with a long half-life such as buprenor-
phine or naltrexone. In these cases, healthcare
providers have no opportunity to develop an anal-
gesic plan in advance and the healthcare team
may not have all of the pertinent information they
need regarding the patient’s medication and sub-
stance use history.
The situation can be further complicated by the
fact that patients with SUDs often experience
increased pain levels, as well as a decreased
response to opioids.4,5 This is often because of
neuroplastic changes that are a result of prolonged
exposure to opioids, such as a dysregulated opiate
reward system and opioid receptors that have been
downregulated.4
Currently, there are no strong, evidence-based
guidelines on how to manage analgesia for these
patients. However, the American Society for
Pain Management Nursing (ASPMN) and the
International Nurses Society on Addiction have
published a Position Statement on Pain Management
in Patients with Substance Use Disorders that offers
guidance. Topics addressed in the Position
Statement include a scope of the problem, ethical
considerations, risk stratification, and clinical rec-
ommendations. The statement also provides guid-
ance on assessment and pain management.6
Assessment
The assessment of a patient with a SUD has two
essential components: a report and assessment of
pain, and an understanding of his or her history of
substance use.
Pain is a subjective experience, with no objec-
tive diagnostic test. Assessment of pain begins
with the patient’s self-report, which nurses
should accept.7 In critical care, many patients are
unable to communicate their pain, making pain
assessment more challenging and necessitating
the use of a tool such as the Critical Care Pain
Observation Tool (CPOT). This tool evaluates facial
expressions, movements, muscle tension, and ven-
tilator compliance. Each behavior is scored from
0 to 2. The score indicates the number of painful
www.nursingcriticalcare.com
behaviors rather than the intensity of pain. The
CPOT has been validated for critically ill patients
and is used in many CCUs.7 Nurses should be sure
to obtain a preinjury or baseline level of pain if
possible before starting treatment.7
The complexity of pain assessment increases
when a SUD is also present. Some clinicians may
be suspicious of complaints of pain from this pop-
ulation, concerned that they are drug seeking.
Remember: All patients, regardless of substance
use, are entitled to thorough and compassionate
pain assessment and pain relief.6
The ASPMN recommends using the 10-step
Precautions (see The 10-step Universal Precautions).6
Many of these steps can be applied to the patient
presenting to the acute care setting, who may also
be experiencing acute or chronic pain. ASPMN
recommends conducting further assessment for
possible SUDs in patients with illicit or nonpre-
scribed substances found during urine drug test-
ing.6 It is essential to investigate unexplained
results.
An accurate history from the patient is also impor-
tant. Often, patients present with unclear, confusing,
or contradictory histories. They may distrust health-
care providers or seem demanding; they may fear
being stigmatized, having their therapy disrupted, or
experiencing withdrawal. As in the case study,
patients may be reluctant to share a full history until
they build trust. However, the presence of medica-
tions such as buprenorphine can significantly impact
their treatment plan from the start. Additional infor-
mation should be obtained from family and friends
as available.
Urine toxicology screens can be helpful and are
often standard for trauma admissions. Interpret
the results with caution, because this is a screen-
ing tool only. In an emergent situation, the patient
may receive opioid medications prior to the sam-
ple being obtained. Further, the lab threshold may
be set too high to detect low doses of opioids,
resulting in a false negative. As a result, it may
appear that the patient is not taking prescribed
opioids, leading to questions of drug diversion. Be
sure to communicate unresolved questions to the
next shift or clinician. Contact providers, clinics,
and pharmacies outside of the admitting institu-
tion where the patient may have received care to
obtain all relevant information.
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The 10-step Universal Precautions
1. Make a pain diagnosis with appropriate differential.
2. Conduct a psychological assessment, including risk
of addictive disorder.
3. Obtain informed consent.
4. Have patient sign a treatment agreement.
5. Assess pre-/postintervention assessment of pain
level and function.
6. Start with an appropriate trial of opioid therapy with
or without adjunctive treatment.
7. Reassess patient’s pain level and level of functioning.
8. Regularly assess the “5 As” (analgesia, activities of
daily living, adverse reactions, aberrant behavior,
and affect) of pain medication.
9. Periodically review pain diagnosis, treatment plan,
and coexisting conditions including the presence of
a SUD.
10. Document everything.6
Multimodal analgesia
Multimodal pain management is the use of two or
more classes of analgesics to target different pain
mechanisms in the peripheral or central nervous
system. It relies on the combination of analgesics
to maximize pain relief, prevent gaps in analgesia,
and reduce adverse reactions.7 All new guidelines
on the treatment of pain recommend a multimodal
approach that includes nonpharmacologic options
such as Reiki, massage, and cold therapy.1,6,8,9
These recommendations are appropriate for
the patient with a SUD experiencing acute pain,
because a multimodal approach includes nonopioid
analgesic options that may be more effective. In
some situations, satisfactory pain relief can be
achieved without the use of any opioid medications.
For other patients, multimodal analgesia can signifi-
cantly reduce the use of opioids, thus lessening the
risk of dependence and adverse reactions. I.V. non-
opioid analgesics such as acetaminophen, ketorolac,
or ketamine (a rapid-acting general anesthetic agent)
are options to consider. Regional analgesic tech-
niques, such as continuous peripheral nerve blocks
utilizing local anesthetics, are also very effective.
Newer, long-acting local anesthetic agents, such as
liposomal bupivacaine, are also available.10
Medication-assisted treatment
MAT is an approach that combines approved
medications with counseling to treat patients with
January l Nursing2017Critical Care l 43
Acute pain management in the patient with a substance use disorder
opioid use disorders.11 Any patient who is physi-
cally dependent on methadone or buprenorphine
must maintain their daily dose of the drug before
they realize any analgesic effect from additional
opioids used to treat their acute pain. Some
healthcare providers do not realize or accept
that analgesic needs are higher in patients with
an existing SUD because of increased pain sensi-
tivity and cross-tolerance. However, untreated
pain can pose a greater risk of relapse to the
patient in recovery than the adequate use of
opioids to treat their acute pain.4 Consult with
behavioral health, addiction specialists, and
social workers for help.
Methadone. Methadone is a long-acting mu-
agonist used to treat addiction. It may also be used
as an analgesic, usually in the treatment of chronic
pain. At sufficiently high doses, methadone blocks
the ability of other opioids to bind to the brain’s
mu receptors and suppresses opioid craving.12
Methadone has a long, variable elimination half-
life that averages 24 to 36 hours. There is a wide
variability in drug absorption, distribution, metab-
olization, and excretion from the body.13 The anal-
gesic effects of methadone do not last longer than
6 to 8 hours; patients dosed every 24 hours will
not experience a significant analgesic response.14
Some patients in acute pain may require a higher
than average dose administered at shorter intervals
to experience a good effect.5
Carefully evaluate the patient’s response to
methadone and monitor the patient for any adverse
drug reactions. When a patient presents with a his-
tory of methadone use, ask if the indication is for
the treatment of opioid addiction or chronic pain.
Contact the prescriber for additional information;
this may be required if methadone is being used to
treat a SUD.
Buprenorphine. Buprenorphine is an opioid
partial agonist with a very high affinity for mu
receptors, providing adequate pain relief while
reducing the risk of opioid-related respiratory
depression.12 Buprenorphine is often coformulated
with naloxone as an abuse deterrent and adminis-
tered sublingually. The naloxone blocks any opi-
oid agonist effect if the buprenorphine is injected,
but passes through the gastrointestinal tract with-
out being absorbed if the medication is taken as
instructed.12
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Acute pain management in patients who are tak-
ing buprenorphine can be challenging. The drug’s
half-life is long, up to 37 hours.10 As a result, addi-
tional opioids have very limited, if any, ability to
bind to the brain’s receptors and provide analge-
sia. Alford and colleagues provide one of the
most-cited strategies for managing acute pain in
a patient taking buprenorphine.5 Strategies include
the following:5,14
• Continue buprenorphine maintenance therapy
and titrate short-acting opioids.
• Divide the buprenorphine daily dose into 6- to
8-hour doses. Buprenorphine needs to be dosed
three times per day, or every 8 hours, to provide
an analgesic effect.
• Discontinue buprenorphine maintenance therapy
72 hours prior to any planned procedure and use
opioid analgesics.
• Discontinue buprenorphine, treat opioid depen-
dence with methadone, and use short-acting
opioids to treat acute pain.
A long-acting buprenorphine implant is now
available for treatment of opioid dependence; it
was approved by the FDA in May 2016.11 It pro-
vides a constant, low dose of buprenorphine that
can last up to 6 months.11 These patients will need
a nonopioid option to manage their pain.
Naltrexone is an opioid receptor antagonist
administered as a monthly, extended-release
I.M. injection to treat opioid dependence. Its
concentration peaks in the serum plasma after
2 to 3 days and its effect begins to decline at 14
days.15 If the patient requires pain management,
options include regional analgesia and nonopi-
oid analgesics.16
Evaluation
All interventions must be continually assessed for
effectiveness, which may be more difficult to do
in patients with a SUD. When asking patients
about their pain, be clear about whether you are
asking about preexisting pain or the pain related
to the current injury. Ask the patient focused
questions, such as “Is the pain in your injured
leg better?” instead of “Is your pain better?”
Further, ask questions in terms of function. “Is
your pain relieved enough for you to get out of
bed?” and “Are you able to participate in physical
therapy?”
www.nursingcriticalcare.com
 If the patient reports The delay in obtaining complete,
unrelieved pain or requests accurate information impacted
additional medication, conduct Mr. M’s analgesic care. It is also not
further assessments. If there clear whether Mr. M’s preinjury
are continued concerns about baseline level of pain was assessed.
the accuracy of the patient’s The presence of methadone on his
reports of pain, or concerns urine toxicology screen should have
regarding requests for addi- prompted a more thorough investi-
tional pain medication or gation of his substance use history.
patient behavior, seek help His self-reported use of oxycodone
from behavioral health or for back pain should also have been
addiction specialists. questioned, as should the presence
of benzodiazepines in his urine,
The ethics of pain relief especially in light of the increased
If a patient is experiencing Be clear about whether recognition of its misuse.18
acute pain, it is not the time to you are assessing It is concerning that it took 7 days
attempt to treat his or her preexisting pain or for the patient to trust his caregiv-
addiction or limit the use of pain related to a ers enough to disclose his use of
opioids. Carefully monitor the methadone. A review of this case
current injury.
patient to prevent an acute reinforced the importance of skilled
withdrawal episode. communication to Mr. M’s provid-
Nonopioid options can and ers. It is essential to ask additional
should be considered as part questions and pursue further infor-
of a multimodal plan. Consider this issue from an mation when conflicting information is obtained
ethical perspective. Bernhofer poses the following during the admission process.
ethical questions regarding pain management:17
• Are the patient’s preferences in pain treatment Conclusion
given the highest priority? This respects their right All patients deserve excellent pain management.
to autonomy. While it may not be possible to totally relieve
• Does the patient benefit from my pain treatment all pain, all patients should receive a thorough
decisions? Providers must practice beneficence. assessment of their pain from compassionate cli-
• What can I do to decrease harm? Maleficence is nicians resulting in an individualized plan of care.
often the principle that clinicians are most trou- Good communication with the patient is the key
bled by—the fear that treating acute pain in a to success. ❖
patient with a SUD with opioids is more harmful
than the pain they are experiencing. REFERENCES
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Patricia Kelly Rosier is a surgical clinical nurse specialist at Berkshire Medical
11. U.S. Food and Drug Administration. FDA approves 1st buprenor-
Center, Pittsfield, Mass.
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gov/NewsEvents/Newsroom/PressAnnouncements/ucm503719.htm.
The author has disclosed that she has no financial relationships related to
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