Compassion in Care: Rethinking Pain Management for Patients with Opioid Use Disorder
Submitted by Kaleigh Meng, BSN, RN
Tags: opiods pain management pain relief
It was often the same response: "This patient abuses so much heroin; nothing we can give them will cover their pain." As an ICU nurse, I had just received a post-op patient with septic pulmonary emboli from intravenous drug use. They had undergone a VATS procedure, leaving them with chest tubes that caused intense pain when repositioned. "I need something for the pain!" they exclaimed, even as a Dilaudid PCA infused. The resident rolled his eyes-"typical drug-seeker" was clearly on his mind. But I saw the genuine pain and fear in the patient's face. "It's going to be okay," I said, even as I anticipated no additional orders for pain relief measures other than the standardized Dilaudid PCA. I knew I'd spend the rest of my shift trying to ease their discomfort.
Opioid use disorder (OUD) is a widespread chronic disease that affects approximately 2.1 million individuals in the United States today. Opioid abuse remains a top public policy issue as reflected in legislation such as the 2018 SUPPORT Act (The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment). Its primary aim is to foster long-term recovery and lessen the profound impact of opioid misuse on individuals, families, and communities nationwide. The SUPPORT Act includes updated Medicare and Medicaid policies to cover treatment for opioid use disorder as well as non-opioid options for pain management. These non-opioid analgesics are poised to play a crucial role in the treatment and ongoing management of patients with opioid use disorder, particularly in the realm of postoperative pain.
Patients with OUD undergoing surgery experience acute pain, which often goes undertreated and can lead to more deleterious effects, such as chronic pain and continued opioid abuse.
Postoperative pain is challenging under the best of circumstances, but it becomes particularly complex for patients with high opioid tolerance due to OUD. For these individuals, standard pain management strategies often fall short, as opioid tolerance may necessitate high doses that are both medically risky and psychologically triggering. A one-size-fits-all approach simply doesn't work here. Instead, we need a protocol tailored to address the unique needs of patients with high opioid tolerance, focusing on multimodal pain management that leverages non-opioid options, regional anesthesia, and comprehensive behavioral support.
One might say that a pitfall to implementing standardized postoperative pain management protocols is that managing various protocols tailored to patients' addiction histories could introduce complexity, increasing the risk of errors or inconsistent application. To address this, it is essential to start by tailoring protocols to specific procedures. For instance, implementing a regional anesthesia technique like the Serratus Anterior Plane Block (SAPB) for a VATS procedure can be effective. The SAPB specifically targets the anterolateral chest wall, providing localized anesthesia with minimal systemic impact. Additionally, combining this approach with systemic non-opioid medications can enhance pain management. This multimodal strategy may include gabapentin, dexmedetomidine, ketamine, and NSAIDs to provide comprehensive analgesia while minimizing opioid use.
This initiative aims to develop and implement procedurally based postoperative pain management protocols that focus on using non-opioid analgesics and regional anesthesia. To aid with the success and feasibility of this initiative, these protocols must be introduced individually for specific procedures. A great place to start would be a postoperative pain protocol for a VATS procedure. I propose introducing this framework as a protocol to your hospital administrators and pain management teams, starting with a specific procedure like VATS. The goals of a protocol for VATS would aim to improve patient-reported pain control by 25%. The initial rolling out and assessment phase would be over the course of 6 months. Staff training sessions on multimodal pain management for OUD will be held monthly, and the program's effectiveness will be evaluated through quarterly reviews of pain scores, patient satisfaction surveys, and opioid utilization metrics.
Every patient deserves adequate pain control, no matter their personal or medical history. Ensuring adequate pain control for all patients is a fundamental aspect of compassionate, effective healthcare, but it is especially crucial for patients with OUD. A carefully designed, multimodal protocol that reduces opioid use but still provides relief allows patients with OUD to recover safely and with dignity. This, in turn, lowers their risk of dependency complications while supporting both their physical and psychological healing.
Kaleigh Meng is a Doctoral Nurse Anesthesia student at Duke University in Durham, NC.