Abstract
The high prevalence of substance use in the society has made more users to depend on opioid drugs to relieve pains and discomfort because of addiction. The problem contributes to high number of hospital visits and increasing admission rates in hospital’s acute care departments. The following paper aims at reviewing the literature on the acute pain management in chronic pain patients and opioid dependent patients. The outcome of the review plays a critical role in the field nursing practice by assisting professionals to develop strategies that help prevent adverse effects for the patient suffering from acute pain. The research recommends using medications to suppress pain after surgery, educating health providers on methods of managing severe pain, understanding the patient's drug use, and acquiring more knowledge and skills in acute pain management when dealing with opioid dependence patients. The Middle-Range theoretical framework was found appropriate in helping the research achieve its purpose. Moreover, it recommended future researchers to investigate interventions that can ultimately overcome pain among these patients.
Introduction
Problem statement
The aim and goal of the healthcare industry is to improve the health and wellbeing of the people in the community. However, the health system experiences numerous challenges that affect the mode of delivery of care. The high prevalence of substance use in the society increases the rate of medication misuse leading to adverse health effects such as chronic diseases and overdependence on opioid drugs. The condition leads to high numbers of daily hospital admissions for opioids dependence patients. Additionally, healthcare professionals have to deal with daily cases of people suffering from chronic diseases because of drug abuse and other unhealthy lifestyles.
The management of chronic pain and opioids dependent patients introduces a major challenge in the present healthcare sector. The healthcare sector records high cases of deaths resulting from risks related to overdependence on opioids and chronic pains. These risk factors increase the length of stay in the acute care leading to higher costs of health, compromised patient satisfaction, delayed mobilization, and suffering that leads to death (Chapman et al., 2011). The issue creates a significant problem that affects the delivery of safe, quality, and cost-effective care. Experts in the nursing research have conducted numerous studies to establish the appropriate intervention to this problem whose outcomes play a critical role in the nursing practice by assisting professionals to come up with strategies that help prevent adverse impacts in acute pain management. Additionally, nurses have established evidence-based approaches to prevent the issue from reoccurring in the future.
Purpose
The purpose of this paper is to review literature on interventions and approached used in managing pain among chronic pain patients and opioid dependent patients in acute care.
Review of literature
Acute pain management in opioid-tolerant patients before and after surgery
Karen Dykstra conducted an evidence-based practice study on perioperative pain management in the opioid-tolerant patient with chronic pain. The project aimed at establishing methods of improving perioperative pain management among patients with chronic pain under the treatment of long-acting opioids to prevent pain before admission for surgery. Dykstra was concerned with the increasing number of people suffering from chronic pains and the high cost of healthcare incurred while caring for these people in the United States (Dykstra, 2012).
The outcome of the Dykstra’s study led to interventions that focused on improving the practice of nursing during acute pain management. First, the study came up with a recommendation requesting acute care nurses to conduct a prior identification of patients receiving long-term opioid therapy in the outpatient setting to make sure they receive optimal care. Second, the outcome requested healthcare professionals to document different evaluations and prescriptions given to a patient in the patient’s medical records to prevent over-prescription at all times. Over-prescription is the leading cause of opioid dependence among patients that eventually leads to chronic diseases associated with chronic pains (Dyskstra, 2012). Finally, the study recommended an education program for all staff members working in acute care departments to equip them with appropriate pain management strategies and knowledge. The outcome of the study plays a critical role in breaking barriers experienced in the area and allowing nurses understand different conditions presented by patients for quick intervention (Dykstra, 2012). Additionally, results from Dykstra’s review help in acute pain management among chronically ill and opioid dependent patients by helping nurses establish strategies to help reduce and prevent pain during and after treatment.
On the other hand, the Frontline Pharmacist conducted an investigation in the same line with Dykstra to establish pain management of opioid-tolerant patients undergoing surgery. The analysis highlighted some challenges faced by nurses in managing pain among opioid-tolerant patients. The author’s aim was to create solutions to postoperative pain medication, which is a primary cause of discomfort in patients and leads to losses of life. The investigation used preoperative preparations and postoperative activities to establish areas that need more concentration. Moreover, it determined how acute care nurses could manage pains among opioid-tolerant patients after surgery. The program came up with a recommendation that health professionals should identify and adequately treat opioid-tolerant patients booked for surgery. Additionally, the article recommended inclusion of pharmacists in the process to assist in identifying opioid-tolerant patients and recommending appropriate medications that would have limited adverse effects after surgery. Pharmacists play a critical role in identifying and caring for opioid-tolerant patients; hence, saving the healthcare sector and the patient the high cost of healthcare during acute pain management (Frontline Pharmacist, 2010).
Contrary to Frontline Pharmacist’s approach, another study by Chapman, Donaldson, Davis, Ericson, and Billharz (2011) investigated varying patterns of pain experienced by opioid dependent patient. Opioid dependent postoperative patients experience different patterns of pain with women suffering more than men do. The study employed a linear mixed effects model to determine differences in repeated measures of pain in two groups of patient for six days after surgery. Patients diagnosed with chronic diseases reported higher levels of pain compared to normal patients (Chapmab et al., 2009). Chapman and his team also reported an increase in pain level among opioid dependent patients after surgery after two weeks of observation. The study revealed that prolonged exposure to opioids leads to opioid-tolerant condition (Chapman et al., 2011).
The outcome of the study by Chapman and his team led to the establishment of strategies for pain management among chronic ill and opioid-dependent patients. Karatas, Etu, Saracoglu, and Gogus (2015) conducted a study that established the effect of opioids (algentanil, remifentanil, and morphine) on reducing pain when intravenously infused after surgery in an opioid-tolerant patient. The study randomized a population of 60 patients between ages of 20 and 60 years undergoing a major abdominal surgery into four groups. Patients were analyzed based on age, weight, gender, and duration of surgery characteristics. The outcome of the study revealed a negative relationship between administration of opioid drugs and acute opioid tolerance. Moreover, the study realized an improvement in pain for patients induced with morphine and remifentanil drugs after the abdominal surgery (Karatas, Etu, Saracoglu, and Gogus, 2015). Hence, morphine and remifentanil drugs are a good strategy for controlling pain among chronic ill and opioid-dependent patients.
On the other hand, a study by Loftus et al., (2010) recommended another strategy that utilizes Katamine and N-methyl-D-asparate receptor to reducing acute postoperative pain. These drug reduce opioid consumption and pain intensity without any side effect in patients after surgery. However, it has a disadvantage because it only works for 48 hours. The presence of these alternative drugs help in acute pain management; hence, eliminating risks associated with chronic diseases and overdependence on opioids such as long increased hospital admission periods and death.
Managing long-term pain caused by chronic illnesses and opioids addiction
Nurses must possess adequate skills on how to manage long-term pains associated with chronic illnesses and risks associated with opioids addiction. Medication-assisted treatments that use opioids alter the pain pattern of the patient but do not have a long-term solution to the problem. Wachholtz and Gonzalez (2014) study evaluated changes in pain sensitivity and tolerance for patients treated using opioids. The study also tested the duration associated with the effect of the treatment. The primary measures used included pain sensitivity, pain tolerance, pain rating, craving rate, general pain levels, and desires for drugs. The overall outcome of the study showed a high rate of response to pain on individuals under opioids treatment. Additionally, people highly dependent on opioid showed low tolerance and sensitivity to pain compared to those starting to use the drug (Wachholtz and Gonzalez, 2014). The outcome of the study plays a critical role in acute pain management by assisting nurses establish strategies that make individuals more tolerant to pain and improve their senses of control over opioid to minimize acute pain challenges.
Additionally, Yarmush et al. (1997) investigated strategies applied by nurses and other health professionals in managing acute pain for patients suffering from chronic illnesses and opioid dependence patients after undergoing surgery. Health care providers must give post surgery patients effective drugs to relieve pain especially after undergoing surgery under general anesthesia. The study tested the effect of remifentanil hydrochloride, which is a potential pain depressant of the opioid family. Half of the participants tested during the survey showed pain improvements after surgery. The study concluded that remifentanil acts as an effective dose that anesthesia practitioner could use to offer safe and efficient pain management in acute care. The effectiveness of the drug depends on the quantity administered. The research outcomes have a lot of significance in offering a solution to acute pain management in chronically ill and opioid dependent patients. Moreover, the study provides doctors with alternatives to acute pain management for patients suffering from chronic diseases and opioid dependence patients in acute care centers. However, the study does explain any side effect associated with continuous use of the drug.
Nurses continue presenting more opioid dependent patients for surgery as the prevalence for non-medical opioid consumption grows. The study by Carroll, Angst, & Clark investigated the characteristics and prevalence of opioids use and their impact in managing postoperative pain among opioid dependent patients. According to Carroll, Angst, & Clark (2004), these patients experience increasing pain after the surgery that requires effective pain management strategies. The survey revealed that using opioids to manage pain in chronically opioid dependent patients after surgery creates less impact. Researchers recommended other alternatives that would assist reduce pain among these patients such as identifying patients with high dependency on opioids before surgery, effective management of opioid use in perioperative period, and collaborate with patients on strategies for managing opioid intake and relieving pain (Carroll, Angst, & Clark, 2004).
The role of nurse’s experience in managing acute pain
The level of education achieved and the number of years in practice determines the amount of experience of a critical care nurse. Experience influences the outcome of the pain management procedure and caring for chronically ill and opioid dependent patients. Most barriers encountered by health professionals arise from limited knowledge on the relationship between opioid use, pain, and withdrawal syndromes. Alizadeh et al., (2014) did research to compare the efficacy of intravenous (IV) morphine and sublingual (SL) Buprenorphine for post-operative analgesia. The study selected a random sample of 68 patients aged between 20 and 60 years scheduled for abdominal surgery. After the surgery, the team evaluated the level of abdominal pain and withdrawal syndrome using a visual analog scale. Patients administered with buprenorphine showed fewer withdrawal symptoms. The study showed SL buprenorphine as an efficient and effective method of managing pain in opioid dependence patients compared to intravenous (IV) morphine. Additionally, nurses’ experience in administering the drug influences the outcome of the method.
Theoretical framework
Pain acts as a common problem for all nurses working in the acute-care setting. Nurses must establish methods of assessing, treating, and evaluating pain among patients. The type, source, and etiology of pain experienced by patients in acute care varies calling upon nurses to establish specific therapies that effectively manage acute pain while causing minimum negative effects. Chronically ill and opioid dependent patients suffer from a range of pains that need effective management using appropriate nursing theories. The following research uses the middle-range theory of acute pain management. Good’s Middle-Range Theory balances between pain reduction and prevention methods and side effects in managing acute pain. The theory offers the best framework for nurses to develop a pain management program with an outcome that offers effective pain control with minimal negative effects especially for patients under potential pain prevention medications (Good, 1998).
Middle-Range Theory of pain management provides a framework with three primary prepositions that provide intervention concepts for acute pain management. These are multimodal interventions, attentive care, and patient participation (See fig. 1). The research will utilize all three concepts to help manage pain among chronic ill and opioid dependent patients in acute care. Multimodal interventions will be implemented by using appropriate pain medications as prescribed by professional pharmacists to help achieve an effective pain control process with less negative effects. On the other hand, attentive care will apply normal assessment of the patient to establish the level of pain, side effects present, and the effectiveness of medications administered to manage pain. Finally, patient participation plays a critical role in the success of the intervention implemented. Nurses will engage patients in continuous education programs to encourage help them set goals for acute pain management.
Figure 1: The Middle-Range Theoretical framework for acute pain management in chronic ill and opioid dependent patients
Conclusion
Acute pain management in chronic pain and opioid-dependent patients is a big challenge to the healthcare sector. The review of the literature shows different interventions proposed by researchers in trying to determine a solution to the problem. Many studies concentrated on the methods of minimizing pain to reduce the cost of healthcare and prevent deaths. On the other hand, strategies and recommendations established in these studies help to reduce the pain, but none offers a method of preventing the pain. Future researchers should conduct a broad analysis of the issue and come up with an intervention to help eliminate the pain. The outcome of these studies have significant impacts to the nursing practice. It equips nurses with adequate knowledge on how to manage acute pain in patients suffering from chronic diseases and depending on opioids. Additionally, it improves research in the nursing practice by introducing gaps that form a platform for future investigations.
References
Alizadeh, S., Mahmoudi, G. A., Solhi, H., Sadeghi-Sedeh, B., Behzadi, R., & Kazemifar, M. A.
(2014). Post-operative analgesia in opioid dependent patients: comparison of intravenous morphine and sublingual buprenorphine. Addict Health, 7(1-2), 60-65.
Chapman, C. R., Donaldson, G., Davis, J., Erickson, D., & Billharz, J. (2009). Psostoperative
pain patterns in chronic pain patients: A pilot study. Pain Medicine. 10(3), 482-487.
Chapman, C. R., Davis, J., Donaldson, G. W., Naylor, J., & Winchester, D. (2011). Postoperative
pain trajectories in chronic pain patients undergoing surgery: the effects of chronic opioid pharmacotherapy on acute pain. The Journal of Pain, 12(12), 1240-1246.
Carroll, I. R., Angst, M. S., & Clark, J. D. (2004). Management of perioperative pain in patients
chronically consuming opioids. Regional Anesthesia and Pain Medicine, 29(6), 576-591.
Dykstra, K. (2012). Perioperative Pain Management in the Opioid-Tolerant Patient With Chronic
Pain: An Evidence-Based Practice Project. Journal of PeriAnesthesia Nursing, 27(6), 385-392.
Frontline Pharmacist. (2010). Pain management of opioid-tolerant patients undergoing surgery.
Good, M. (1998). A middle-range theory of acute pain management: Use in research. Nursing
Outlook, 43(3), 120
Karatas, S. S., Eti, Z., Saracoglu, K. T., and Gogus, F. Y. (2015). Does perioperative opioid
infusion increase postoperative opioid requirement? AGRI, 27(1), 47-53.
Loftus, R. W., Yeager, M. P., Clark, J. A., Brown, J. R., Abdu, W. A., & Sengupta, D. K. (2010).
Intraoperative Ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic back pain undergoing back surgery. Anesthesiology, 113(3), 639-646.
Wachholtz, A., and Gonzalez, G. (2014). Co-morbid pain and opioid addiction: Long-term effect
of opioid maintenance in acute pain. Drug Alcohol Depend, 1(145), 143-149.
Yarmush, J., D’Angelo, R., et al., (1997). A comparative of Remifentanil and morphine sulfate
for acute postoperative analgesia after total intravenous anesthesia with Remifentanil and Propofol. Anesthesiology, 87(2), 235-243.
