“Some hospitalized patients do abuse opioids,” says Dr. Bekanich. “We catch people with drug paraphernalia or actually shooting up in their rooms.” Providers can exercise some control over what patients do in the hospital, but it is probably not realistic to expect that a hospitalist will be able to resolve long-standing substance abuse problems during the patient’s brief stay in the hospital.
As part of a comprehensive pain assessment, it is appropriate to ask if the patient has a history of drug use. Many patients will freely admit to such a history, may be actively in recovery or on a methadone maintenance program, or may even resist opioid analgesics despite severe pain because of their commitment to recovery. Without the benefit of such candor, however, it will be difficult to reach a conclusive diagnosis of drug addiction during the patient’s acute inpatient stay, because that ordinarily requires observations over time.
“It is not our job as hospitalists to get patients off opioids; there are other institutions and services for that,” Dr. Bekanich adds. “For us to try to do it in a few days in the hospital seems like a hopeless task. That is not to say we shouldn’t be mindful of the issues involved, talking to the patient or even offering a referral to a drug rehabilitation program. But we should not be trying to do drug rehab.”
The basic principles of believing patients’ reports of pain and providing analgesic doses sufficient to relieve the pain still apply—unless side effects or the patient’s problematic behavior demand a modification in this approach. Pain physicians often cite the maxim “trust but verify.” There are various screening tools that can be used for indicating the possibility of substance abuse, and it is imperative the use of controlled substances always be closely monitored.
Urine drug screening tests are easy to order in the hospital and may encourage compliance for patients who have a drug history when presented up front as a routine aspect of pain management. The urine test can detect prescribed medicines that are being taken by the patient as well as non-prescribed opioids, but it is important to be aware of false positives and negatives and opportunities for gaming the system by those who are determined to do so.
“Just as it is a myth that treating pain appropriately leads to addiction, it is also a myth that people with drug histories can’t have their pain treated effectively,” says Scott Irwin, MD, PhD, medical director of palliative care psychiatry at San Diego Hospice and Palliative Care. “The first thing to ask these patients is what are their goals for pain management. Get as much objective information as you can about the pain and the patient’s history. Fully inform the patient about options. Treat the pain just as you would for anyone else.”
Then, if things don’t add up, Dr. Irwin says, it may be necessary to go back and reassess the patient’s pain and history. Is there psychological distress? Perhaps the analgesic dose isn’t adequate. Maybe financial pressures or complicated social relationships are leading to drug diversion.
If the patient is participating in a methadone maintenance program or similar protocol, it is advisable for the hospitalist to speak to the medical director of that program. But effective pain control also supports maintenance. Emphasize long-acting analgesics, add non-opioid adjuvants and, when possible, find alternatives to intravenous administration. But if the patient is addicted, trying to minimize adverse effects from analgesic treatments might be the best the hospitalist can do.
Another approach to managing the patient with a history of drug abuse is the use of a contract or opioid agreement, in which the patient promises to do certain things with a clear understanding of the consequences for not doing so. Establish the rules early and be prepared to enforce them. Explain expectations for the patient and the physician’s role, designate a single pharmacy and a single physician responsible for pain prescribing, and get consent for treatment and drug testing. If a repeat offender breaks the agreement, it may be time to call in an addiction specialist. Such agreements should be negotiated in person by the physician, not delegated to nurses or other professionals, but then make sure other team members are in the loop. For an example of such an agreement, see http://tinyurl.com/y2bbh6.