Managing Pain in Seriously Ill Patients with SUDs

A new publication co-authored by ARN Board Member Dr. Grace Campbell discusses the challenges of pain management in patients with serious illnesses and a history of substance use disorders (SUDs).

 ARN is proud to highlight the hard work of one of our very own: ARN board member Grace Campbell, PhD MSW BSN CRRN FARN. Along with fellow authors, she contributed to an important new publication, "Managing Pain in Seriously Ill Patients with Substance Use Disorder," which was featured in the January issue of Nursing2021. The article is the result of a joint effort by authors representing Hospice and Palliative Nurses Association, the Oncology Nursing Society, the Gerontological Advanced Practice Nurses Association, and the Association of Rehabilitation Nurses.

"I am honored that ARN was part of the multi-organization group that contributed to such important work," says Dr. Campbell. "This paper is particularly relevant for ARN members, because co-morbid substance use disorders are often a factor in the reasons that patients need rehabilitation services. For example, many of our patients were involved in substance-related trauma resulting in brain injury, spinal cord injury, orthopedic trauma, or a combination of these. Addressing the individual's pain in an evidence-based manner is crucial in order for them to regain function without exacerbating co-morbid substance use disorder. This work provides guidance for rehabilitation nurses on how to manage these very real problems."

Dr. Campbell and her colleagues offer an in-depth look at the challenges facing caregivers charged with managing patients suffering from acute, chronic, and acute exacerbation of chronic pain who also have a history of SUDs.

SUDs are characterized in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) as problematic patterns in the use of intoxicating substances such as alcohol or drugs. The criteria for this disorder include patients who:

• Take substances in larger doses and more often than prescribed or intended
• Want to control or curb usage without success
• Spend a lot of time obtaining, using, and recovering from substances
• Experience cravings or urges to use substances
• Fail to fulfill obligations, such as those related to work, school, or family
• Experience recurrent social or interpersonal issues that are worsened by use
• Give up social, recreational, or professional activities previously regarded as important
• Use substances recurrently despite physical risks
• Continue using substances despite physical or mental health concerns caused by use
• Develop a tolerance
• Experience withdrawal

The timeliness of this study cannot be understated, given the current and ongoing opioid crisis and the fact that pain affects more patients in the United States than heart disease, diabetes, and cancer combined. While the SUD classification is not strictly limited to opioid use, as it includes a wide range of intoxicating substances, including drugs and alcohol, the opioid crisis and the fears surrounding it have complicated the issue of treating pain with opioids.

In most cases where patients are experiencing severe pain, opioids are required to help them manage pain levels and maintain their daily living activities. Unfortunately, SUD patients often don't receive adequate pain management due to a wide range of factors relating to the individual, the healthcare team and/or the healthcare system. These factors include biases, fears, lack of knowledge about properly dosing patients with an established opioid tolerance, misconceptions about opioid abuse, and patients' reluctance to report pain for fear of losing their hard-earned sobriety.

This publication delves into some of the ways healthcare workers can take a fresh approach with SUD patients and eliminate antiquated stereotypes while establishing their patients' trust, all while safely managing pain. Studies show that appropriate short-term use of pain management from opioids is far less of a risk factor for it does not cause a significant likelihood for SUD relapse, especially compared to patients suffering from unrelieved pain. It also indicates that multimodal approaches to pain management that incorporate both opioid and nonopioid medication, as well as nonpharmacologic therapies, can prove quite successful.

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