Running head: PAIN CONTROL FOR THE OPIOID TOLERANT PATIENT

Pain Control for the Opioid Tolerant Patient

Monica Lawson, RN

Western Washington University

301 Information Literacy to Support Academic Discourse

Julie Samms

November 27th, 2016

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Pain Control for the Opioid Tolerant Patient

Opioid tolerance is the lack of effect of an opioid medication related to repeated

administration. (Huxtable, Roberts, Somogyi, & Macintyre, 2011). The Institute for Chronic Pain

(2016), defines drug tolerance In general, tolerance to a drug is a phenomenon that occurs when

an individual over time requires greater amounts of a drug to continue to obtain the original

degree of its desired, therapeutic effect (Tolerance to Opioid Pain Medications, para. 4). The

word phenomenon is used because much is still unknown about the mechanism of opioid

tolerance. It is a common misconception that all patients with opioid tolerance are drug users,

this simply is not true. In fact, some research suggests that opioid tolerance can be related to

differences in genes causing a variability of medication responses. (Manworren, 2015). This

would explain why some patients are very sensitive to opioids the first time being exposed, while

others are quite tolerant even though it is their first exposer. Whether opioid tolerance is related

chronic pain, drug abuse, or genes, it is our responsibility as healthcare professionals to ensure

pain control.

In the past seven years as a healthcare worker I have seen a reoccurring flaw that stands

out and it is the lack of pain control in the opioid tolerant population. It became apparent when I

began working on the Progressive Care Unit (PCU). The PCU is considered a step-down unit,

therefor many of the patients there are critically ill. The main population on PCU are patients

needing open heart surgery or cardiac stents, drug abusers, and any other serious cardiac issues. I

was surprised by the lack of protocol the hospital has and lack of knowledge and consistency the

doctors and nurses have regarding pain control for opioid tolerant patients.

Most recently I had a patient that had just gotten a video-assisted thoracoscopic surgery

(VATS) to her right lung to remove a mass. Most patients that return from a VATS are in
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excruciating pain and require Patient Controlled Analgesia (PCA). However, all too frequently

the nurses must struggle with the doctors to get this ordered and when it is ordered the patients

come out of recovery without it and must wait in agony while pharmacy verifies the medication

and the floor nurse sets it up. This patient was no exception. For purposes of HIPPA this patient

will be referred to as patient B. Patient B came from the Post-Anesthesia Care Unit (PACU)

grimacing in pain. It was relayed in report that the patient had been given large doses of Fentanyl

and Dilaudid but was unable to get her pain under control. The nurse giving report stated that

patient B had no known history of opioid use and she was unsure why she had such a high

tolerance. The orders for patient B were to give two pain pills of Norco every four hours and

morphine 2mg every fifteen minutes. I knew before giving these medications that she would

need more because even though she was given many pain medications in PACU she was awake

and still having pain.

I proceeded to battle with her pain for eight hours despite multiple calls to the doctor for

a PCA. I was told things like Her incision is tiny; I dont know why she is having so much

pain and Does it seem like she is acting? Do you feel like she is actually in a lot of pain?

After making multiple insignificant changes to her medications the patient still couldnt move,

eat, or breath without agony. After the third call with the Doctor the patients medication was

changed to morphine 2-4mg every 30minutes which is basically no change at all. I returned to

my patients room deflated. I told her what was ordered as she sat there trying not to move or

breath because of the pain. You must think I am the patient from hell she said. I looked at her

and said I dont think that at all. I am just frustrated that I cant make you more comfortable.

You deserve to be comfortable. She smiled grimly and said Its okay Monica. I know you are

doing your best. You have worked really hard for me since I got here. She put on a brave face
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and continued to try to tough it out. This woman was in agony for over eight hours and it did not

have to be that way. It was unethical.

Even if patient B had an opioid addiction problem, which she didnt, she deserves to

have pain control. As medical providers we have a moral obligation to achieve pain control for

all populations of patients. It was clear that patient Bs Doctor had some implicit bias and needed

some education regarding pain management. However, education is not the only issue, there was

no hospital protocol to help this patient. How different would the outcome have been if this

patient was on a pain protocol that stated when given x amount of narcotic without significant

respiratory depression, or hypotension, and no pain control has been achieved, enact the PCA

protocol. Once she had the PCA the multidisciplinary pain team could evaluate her and set forth

a pain plan that the patient is involved in. This could include a plan to taper off the PCA and

begin oral pain pills. Although research suggests there is a lack of pain control in the opioid

tolerant population related to poor education and implicit bias, they have missed the importance

of having a pain protocol and interdisciplinary pain team for acute pain in the opioid tolerant

population.

Process Used and Rational

Research was done by scouring data bases for any sources on opioid tolerant populations

using key phrases such as opioid tolerant and managing opioid tolerant pain while these

searches did yield a wide variety of articles regarding chronic pain it was difficult to find sources

specific to managing acute pain in the opioid tolerant population. However, after sifting through

the list and adding the search term acute pain some studies were found. Also noted were a lot

of studies on specific drugs in relation to opioid tolerance but these were not used for purpose of

this paper. Scholarly journals were used for this paper because they were peer reviewed and
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touch on most aspects of this issue. One study used in this paper researched poor pain control in

opioid tolerant patients which is key in addressing this problem. Many of the other sources used

were literature reviews which was helpful in looking at the issue in its entirety rather than a

couple of specific studies. Although some of the sources are older than five years there is still

valid information to be gleaned from them.

Lack of Pain Control

Despite the Joint Commission and World Health Organization acknowledging pain

management as an essential component to patient care, adequate pain control is missing in the

acute pain setting. Although the research and recommendations exist to improve pain

management these recommendations have not yet been integrated into practice. This is resulting

in patients having unnecessary physical and psychological suffering. (Glowacki, 2015).

Manwere, Chipfuwa, Mukwamba, and Chironda address this issue by stating pain is the most

disturbing and annoying symptom experienced by medical patients, yet it is poorly managed.

(2015, p. 1). The authors go on to say that knowledge deficit remains a huge obstacle in our

healthcare system even though there have been researches and scientific advancement in regards

to managing pain. We are failing this population of patients by not using the necessary tools to

address pain. In other words, Manwere et al found that implicit bias and deficient education in

regards to pain is a barrier toward effective pain management. This is made clear by the lack of

integration of pain management recommendations into practice that Glowacki speaks of. In order

to lift this barrier healthcare professionals need appropriate protocols to follow and a team in

place to provide better education to combat implicit bias.

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Implicit Bas and Lack of Education

Implicit bias corresponds with lack of education this was discovered in a study issued in

the Health Science Journal held in South Africa sought to investigate attitudes and knowledge

among nurses regarding pain control in medical patients. Their main claim was that knowledge

deficit and implicit bias among nurses was leading to poor pain control in patients. Their

objective was to discover what kind of knowledge of pain control and what attitudes the nurses

had towards their patients in the hospital setting. The result was that many of the nurses had

poor attitudes toward pain control and a knowledge deficit in regards to managing pain.

(Manwere, Chipfuwa, Mukwamba, & Chironda, 2015).

The main theme the researchers found was that nurses were failing to respond to patient

reports of pain because the nurses believed their patients would develop respiratory depression,

either had an addiction issue or were going to develop one, and that the medication would mask

symptoms. Even more startling was that 70% of the nurses that participated in the study thought

that patients had to be medically trained to accurately report pain. The authors mention that there

is a lack of research in regards to adult medical patients and how attitudes and knowledge effect

pain management in that population. (Manwere et al, 2015).

These nurses were managing the patients pain based on what they thought it was and how

genuine they felt it was. The research identified a link between improvement of attitudes and

increased knowledge toward pain management. It was concluded that nurses need proper

continuing education to combat poor attitudes that lead to poor pain control. (Manwere et al,

2015).

In Acute Pain Management in the Opioid Tolerant Patient Bourne states doctors and

nurses attitudes and knowledge deficits toward pain as well as fear of opioid addiction put
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opioid tolerant patients at a high risk for being undertreated. She emphasizes the importance of

having a plan that is goal oriented toward effective pain control, steering clear of withdrawal

symptoms and overdose, treatment of psychological disorders, and patient acceptance of opioid

regiment. She concludes that knowledge of concepts and vocabulary related to managing pain in

the opioid tolerant population helps combat common misconceptions regarding pain

management. (2010).

According to the authors of Analgesic Management of Acute Pain in the Opioid-

Tolerant Patient opiate abusers have poor pain control and develop withdrawal symptoms

related to receiving less opiates then other patients which is a result of stigma towards drug

abusers. Not only are we not controlling this populations pain but little research is done in

regards to pain management in this population. (Shah, Kapoor, & Durkin, 2015). This is pointed

out by Shah et al when they state There is a lack of randomized controlled trials to evaluate

effective strategies of pain control in this population (2015, p. 398).

Although more research studies would be beneficial the current research that exists

illustrates that these implicit biases toward patients is leading to undermanaging pain and that the

reason for this is lack of education. It was established by Manwere et al and Bourne that implicit

bias is prevalent and is linked to lack of education. An interdisciplinary team and protocol would

better educate providers and patients on what is effective and appropriate for pain management

which in turn would break down the barrier of implicit bias. For example, if patient B had been

on a protocol for pain management it would have combated the Doctors implicit bias by having

a set system in place regardless of personal feelings.

Protocol and Interdisciplinary Teams Lead to Better Patient Outcomes

Glowacki states that use of interdisciplinary teams will lead to better patient outcomes

and satisfaction. An inter-disciplinary team would include a representative from anesthesiology,

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surgery, post-anesthesia care, nursing, pharmacy, and physiotherapy. These individuals would

research current pain practice, identify areas of improvement, and develop a plan to improve

practices. She references a study done at Mercy Hospital at Buffalo which developed a pain team

consisting of nurse specialist, nurse manager, pharmacist, and four registered nurses on staff.

This team developed a plan of action and specific goals for pain management. The patients were

given a survey/questionnaire approved by the board and administered by the nurses. The results

were better pain management and satisfaction among patients correlating with the goals set by

the pain team. (2015).

Nicola Bourne tackles the lack of protocol in regards to managing pain in opioid tolerant

patients in her article Managing acute pain in opioid tolerant patients. She explores the

practices in London hospitals in regards to current practice for managing acute pain in the opioid

tolerant population. A questionnaire was distributed to hospitals in London which touched on

protocols for managing pain in opioid tolerant individuals, PCA use, conversion of regular

opioids to other forms, and managing opioid dependent patients. Of the 23 hospitals that were

sent these questionnaires only ten returned them. Six of these hospitals provided acute pain

services and the remaining four dealt with acute as well as chronic pain services. It was found

that of these ten hospitals only one hospital had a protocol for opioid tolerant patients. Other

hospitals do claim to have a practice in regards to dealing with the opioid tolerant population and

approach it on an individual basis. Bourne points out that while this sounds ideal it is quite

difficult to accomplish. (2008).

Bourne goes on to establish that a protocol would help those that are missed or are

operated on after hours. Such a protocol would benefit a healthcare practitioner that is not

seasoned at dealing with opioid tolerant individuals effectively. (2008). Having a protocol in
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regards to pain management as well as a pain team would provide support to nurses on the floor

as well as guidelines on what is safe and effective for the opioid tolerant patient. That does not

mean that opioids are the sole solution to pain management but more of a multimodal approach

in the protocol would be a focus.

A case study done by Silow-Carroll, Alteras, and Meyer which focused on hospital

performance. The study followed four hospitals that had a marked improvement in performance.

It was discovered that there was a consistent pattern that led to such improvements. This pattern

began with a crisis that led the hospital to make changes. These changes involved new quality-

related committees, multidisciplinary teams, and technological advancements. These

advancements led to new problem solving processes which then enacted new protocols and

practices. The overall effect of this was improved patient outcomes including a reduction in

mortality rates, blood infections, pneumonia, complications, readmission rates, patient falls, and

use of restraints. This in turn improved patient satisfaction as well as staff morale. It resulted in

shorter length of stay for certain conditions and reduction of cost per hospitalization. (2007).

Bourne points out the lack of interdisciplinary teams and protocol while Glowacki

illustrates the importance of interdisciplinary teams in regards to education and better pain

control. Silow-Carroll et al shows the effectiveness of protocol in regards to better patient

outcomes. When applying this knowledge of successful interdisciplinary teams and protocols it

would seem that having such mechanisms in place would lead to increased staff education which

according to Manwere et al is linked to decreased implicit bias and better pain control.
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Counter Argument

Dr. John Foggle a professor in the emergency medicine department at Brown University

wrote an article claiming that physicians are over prescribing narcotics because the joint

commission has linked physician reimbursement to patient satisfaction. He believes many of his

patients have unrealistic attitudes toward pain control and that pain should not be a fifth vital

sign as it is subjective. He argues that the reason for this opioid epidemic is not because of lack

of training and knowledge but rather the pressure the joint commission put on physicians to

address pain as if it were a vital sign. He believes the reason we have seen a rise in over

prescribing is because of this pressure to satisfy patients. (2016).

What Dr. Foggle is failing to realize is that as the population ages there is a rise in

chronic disease which leads to a rise in pain. However, the rise in the opioid tolerant population

is a complex issue it is likely also related to opioids being considered an appropriate method of

pain control as well as the drugs becoming more convenient in modes of administration.

(Bourne, 2015). Especially significant is that the baby boomers are advancing in age leading to

increased incidences of pain.

By educating physicians we can better educate our patients in regards to expectations and

pain management. This is how we avoid over prescribing and under prescribing. It is said that

Pain education alone may be the most effective treatment provided by health care

professionals. (Glowacki, 2015, p. 35). There is a large gap in pain management education, in

fact 80% to 90% of physicians have had no formal training prescribing controlled substances and

very few medical schools have pain management as part of the curriculum in the United States.

(Glowacki, 2015). This lack of educations is one of the factors leading to poor management of

pain. The other is this implicit bias, Dr. Foggle demonstrates this bias by stating:
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Patients seeking narcotics are a daily presence where I work. Patients often expect to be

pain-free, and many feel entitled to receive opioid prescriptions on demand. A legitimate

quest for pain relief from an injury or illness can quickly morph into a need for opioids to

relieve the pain of addiction. (2016, para. 9).

This type of jaded attitude is one of the barriers to effectively managing pain demonstrated by

the majority of sources in this paper.

Synthesis of Material and Conclusion

Integrating multimodal medicine into protocol and enacting a pain team for managing

pain would likely lead to better or appropriate use of opioids. Glowacki, Manwere et al, and

Shah et al seem to agree that bias is a major barrier toward pain control and that education is the

solution to this bias however none reference the importance of protocol. Bourne acknowledges

the bias and illustrates that education is the answer, however in her article Managing Acute Pain

in Opioid Tolerant Patients she goes a step further and points out the lack of protocol for the

opioid tolerant patients. Continuing education is important however it is easy to get complacent

in our old ways and a protocol would counteract this. Having a protocol would likely combat

biases and help to better educate nurses and doctors.

Glowacki speaks to the success of having an interdisciplinary pain team in regards to

patient outcomes. This idea is especially inspiring because it would open a door to better

communication among patients, doctors, and nurses. Having a pain team would benefit my

hospital greatly. Knowing what is best practice and what is appropriate for the opioid tolerant

would be useful. While protocol may be viewed as a broad solution that may not fit every

situation that is where the pain team would come into play assessing the individual patients
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needs and what the best practice to accomplish this would be. While implicit bias and lack of

education is clearly a problem, what seems to be missed is the lack of protocol.

I agree with Bourne that it would be beneficial if more research was done in regards to

successful pain management in the opioid tolerant patient that way hospitals could develop more

specific protocols and recommendations. However, the research that has been done can still be

used. It is clear from Sillow-Carrols analysis of improved hospital performance that protocols are

successful in improving patient outcomes. It would be beneficial to apply this knowledge to the

concept of pain management.

The problem of opioid tolerant patients has increased and will likely continue to do so. It

is time for a wakeup call. As health care professionals we need to collaborate and advocate for

protocols and interdisciplinary teams so that we can provide the best possible care to this

misunderstood population.

Improved Skills

Through this project I have become much more proficient at searching databases, critical

reading, and academic writing skills. I continue to struggle with critically reading and academic

writing however this will likely always be a work in progress. The synthesis portion of the paper

was particularly difficult for me especially connecting each of my summaries back to my

synthesis. However, by challenging me this paper has strengthened my synthesis skills.

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References

Bourne, N. (2010). Acute pain management in the opioid-tolerant patient. Nursing Standard 25(12)

3539. Retrieved from http://ezproxy.library.wwu.edu/login?

url=http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=104974909&site=ehost-

live.

Bourne N. (2008). Managing Acute Pain in Opioid Tolerant Patients. Journal of Perioperative

Practice 18(11)498503. Retrieved from http://ezproxy.library.wwu.edu/login?

url=http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=105582823&site=ehost-

live.

Foggle, J. (2016). Doctors must say no to overprescribing opioids. Retrieved from

http://www.courant.com/opinion/op-ed/hc-op-foggle-doctors-give-too-many-opioids-0703-

20160701-story.html.

Glowacki, D. (2015). Effective pain management and improvements in patients outcomes and

satisfaction. Critical Care Nurse 35(3), 3343. doi:10.4037/ccn2015440.

Huxtable C.A., Roberts L.J., Somogyi A.A., MacIntyre P.E.(2011). Acute pain management in opioid-

tolerant patients: A growing challenge. Anaesthesia & Intensive Care 39(5).80423. Retrieved

from http://ezproxy.library.wwu.edu/login?url=http://search.ebscohost.com/login.aspx?

direct=true&db=ccm&AN=104697841&site=ehost-live.

Institute for Chronic Pain. Tolerance to opioid pain medications. (2016). Retrieved from

http://www.instituteforchronicpain.org/treating-common-pain/tolerance-to-opioid-pain-

medications

Manwere, A., Chipfuwa, T., Mukwamba, M.M., Chironda, G. (2015). Knowledge and attitudes of

registered nurses towards pain management of adult medical patients: A case of bindura hospital.
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Health Science Journal 9(4).16. Retrieved from http://ezproxy.library.wwu.edu/login?

url=http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=109839293&site=ehost-

live.

Manworren, R. (2015) Multimodal pain management and the future of a personalized medicine

approach to pain. AORN Journal 101(3). 30718. doi:10.1016/j.aorn.2014.12.009.

Shah, S., Kapoor, S., Durkin, B. (2015) Analgesic management of acute pain in the opioid-tolerant

patient. Current Opinion in Anesthesiology 28(4).398402.

doi:10.1097/ACO.0000000000000218.

Silow-Carroll, S., Alteras, T., Meyer, J.A.(2007) Hospital quality improvements: Strategies and

lessons from U.S. hospitals. Retrieved from

http://www.commonwealthfund.org/usr_doc/Silow-

Carroll_hosp_quality_improve_strategies_lessons_1009.pdf.