The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

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A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 11: Substance Use ProblemsTable 11-6 presents particular issues that arise in the care of patients being treated in methadonemaintenance programs. It is always best to keep pain management and addiction treatmentsas separate items on the problem list with distinct strategies and approaches.26 picas12 However,at the same time, both pain management and addiction treatment must be integrated into anoverall plan of care.Table 11-6: Treating Pain in Methadone-Maintained PatientsMethadone used as daily maintenance therapy for opioid addiction has no significant analgesiceffects. It is legal and permissible to prescribe opioid analgesics to narcotic-addictedpatients for the treatment of pain if these opioids are clinically justified and prescribedwith appropriate documentation and precautions to prevent abuse. In methadone-maintainedpatients receiving opioid analgesics, these opioids should be given inaddition to the daily maintenance dose of methadone.Due to opioid tolerance, it is generally necessary to use higher and more frequent doses ofopioid analgesics in methadone-maintained patients compared with non-tolerant patients.Methadone is an excellent opioid analgesic agent when used to treat pain (e.g., tid or qiddosing) but due to possible therapeutic confusion, miscommunication and regulatory issues,it is preferable to use another opioid when this class of analgesic is required in methadone-maintainedpatients.In inpatients or homebound patients with chronic severe pain, in the end stages of terminalillness, patients’ entire opioid analgesic dose plus the daily methadone maintenancedose may be converted into a continuous subcutaneous or intravenous infusion of parenteralmethadone or another opioid as clinically indicated.Source: Selwyn PA. Pain management in substance users. In Manual for Primary Care Providers: Effectively Caring for SubstanceAbusers. New York: New York Academy of Medicine, in press.The baseline methadone dose should never be assumed to be sufficient to treat pain. Furthermore,increasing a patient’s daily methadone dosage for purposes of treating pain has seriousdrawbacks, as follows:• It can greatly confuse psychosocial aspects of addiction treatment• It will be ineffective as a means of pain control (methadone when used forpain is dosed q 6 to 8 hrs, and when used for addiction treatment is dosed onlyqd; patients already on methadone maintenance would need significantlyhigher additional doses of methadone to achieve any analgesic effect)• It can potentially expose the palliative care team to legal confusion anddifficulties as it is illegal to prescribe methadone for addiction treatmentoutside of a licensed methadone maintenance programNear the end of life, inpatient or homebound patients on methadone maintenance may benefitfrom a less rigid approach. A total daily opiate dose (e.g., morphine, hydromorphone) can begiven via continuous intravenous or subcutaneous infusion pump.260U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau
A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 11: Substance Use ProblemsGeneral Pain Management IssuesIn patients with substance use histories, as with other patients, the provider must develop anunderstanding26 picasof the pathophysiology of the pain in question and a rational, incremental approachto its pharmacological management. (See Chapter 4: Pain.) After taking a careful historyof the pain complaint (site; quality; exacerbating and relieving factors; temporal quality; onset;associated symptoms and signs; impact on life and psychology; and effect of current treatments),the provider can determine whether the pain is of nociceptive or neuropathic origin. This distinctionis important as it can have treatment implications. Nociceptive pain results from stimulationof afferent receptors and can cause myriad painful sensations: localized or diffuse; somatic(involving skin, muscle, bone and soft tissue) or visceral; mild to severe. Neuropathic painderives from damaged or otherwise compromised nerves and tends to result in shooting, stabbing,burning, electric shock-like pain, or discomfort that is caused by minimal stimulation tothe skin (allodynia).As is true in any patient, effective pain management in the substance-using patient involvesmultiple modalities and usually requires contributions from all members of the palliative careteam. The pharmacological approach is best guided by the World Health Organization (WHO)three-tiered ladder–starting with non-narcotic analgesics (step one); followed by weak narcotics(step two); and finally moving to strong opioids (step three). (See Figure 4-1 in Chapter 4:Pain.) Adjuvant analgesics can be added at any step (e.g., for neuropathic pain). It is importantto be aware, however, that in a patient who has developed tolerance to narcotics, strong opiates(step three) may be needed sooner, at greater frequency, and at higher doses, than would otherwisebe expected. It is better for the primary care provider to work and be comfortable with oneor two drugs in each class (doses, pharmacokinetics, conversions, side effects, interactions etc.)than to have only a superficial knowledge of all of them. As a general rule, it is best to push lowerlevel treatment to the maximum before advancing to the next level. In cases of moderate tosevere pain, therapy can rightly begin at step two.While taking reports of pain seriously, providers should also act to minimize the likelihood ofabuse. This often means opting for the alternative that is least tempting to the patient, avoidinguse of a stronger, more readily abused drug for mild to moderate pain if an alternative is availablethat is less likely to be abused. For example, codeine is weaker, less euphorigenic, moreconstipating, and of lower “street value” than oxycodone, morphine, or hydromorphone. Althoughthis is not a firm rule, long-acting drugs tend to be less likely to be abused than short-actingones, and certain formulations (e.g., the transdermal fentanyl patch) may be less prone to abusethan others (e.g., brand-name oxycodone pills, which have a higher “street value” than genericoxycodone).As noted above, the concepts of tolerance and dependence are very important in assessing andtreating pain in substance users. (See Tables 11-4 and 11-5.) Because of tolerance, patients willhave higher narcotic requirements than patients who are opioid-naïve, meaning that opioidswill have to be prescribed at higher dosages and more frequently. This is sometimescounterintuitive to providers who are reluctant to prescribe opioids to patients with histories ofopioid abuse. However, unless the provider accounts for the patient’s actual dosage needs, thetreatment will be guaranteed to fail. Moreover, a common scenario which then unfolds is thatproviders may interpret patients’ requests for higher doses or early prescription refills as signsof drug-seeking, thus confirming their prejudices about manipulative behavior in substance users,when in fact this patient response is entirely predictable based on the pharmacology ofopioid medications.XIU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 261
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DedicationA Clinical Guide to Suppo
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Lynn A Jansen, RN, PhDAssistant Res
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TABLE OF CONTENTSPart IChapter 1Cha
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IChapter 1.26 picasHIV and Palliati
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IA Clinical Guide to Supportive and
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A Clinical Guide to Supportive and
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IIIChapter 3.Assessment of Physical
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Chapter 6.26 picasPulmonary Symptom
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Chapter 8.26 picasOral ProblemsDavi
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Chapter 9.26 picasDermatologic Prob
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Chapter 10.26 picasPsychiatric Prob
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Chapter 15.26 picasSpecial Populati
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Chapter 17.26 picasEthical IssuesLy
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Chapter 19.Palliative 26 picas Care
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Chapter 26.26 picasResourcesMagda B
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DRUGS AND THERAPIES INDEXNOTES: Ent
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