HomeFeaturesAvoiding iatrogenic opioid dependency and addiction

Avoiding iatrogenic opioid dependency and addiction

Author(s): By Donna J. Purviance, DNP, FNP-BC

Assessment, empathy, and nonpharmacologic options are effective strategies.

Takeaways:

  • Pain perception is multifactorial and includes somatic and medical, cognitive, emotional, behavioral, social, and motivation factors.
  • Iatrogenic refers to a condition inadvertently caused by medical treatment.
  • Applying Watson’s Theory of Human Caring provides the pillars of authentic presence, protection, enhancement, and preservation of human dignity in all aspects of the human process.

The opioid epidemic poses a complex conundrum. Federal and state governments have implemented various policies and appropriated millions of dollars to address the problem, but the epidemic continues. Nurses hold a strategic position to offer hope and care for patients who are suffering.

When caring for patients with pain, validate the patient’s experience, understand the potential for the iatrogenic effects of opioids, and take a practical, holistic approach to pain management. Various models—including Watson’s Theory of Human Caring and Engel’s Biopsychosocial Model—can help guide your nursing care. (See Creating a safe assessment environment.)

Creating a safe assessment environment

To deliver holistic, patient-centered care, nurses and providers must arm themselves with knowledge, including Engle’s Biopsychosocial Model and Watson’s Theory of Human Caring.

The Biopsychosocial Model uses a systematic approach to assess patients with chronic pain using seven domains: pain, somatic factors, cognitive factors, emotional factors, behavioral factors, social factors, and motivation. Applying this model requires exposing vulnerabilities, which patients may perceive as intrusive.

Such intense probing demands a nurse–patient relationship cultivated by Watson’s Theory of Human Caring, which endeavors to ensure compassionate care and includes authentic presence, protection, enhancement, and preservation of human dignity. When a therapeutic relationship is based on respect and dignity, patients will feel safe and able to reveal themselves.

Iatrogenic opioid addiction

An iatrogenic condition is one that’s inadvertently caused by medical treatment. For example, proton-pump inhibitors may cause Vitamin B-12 deficiency dementia, antidepressants may cause tremors, angiotensin-converting enzyme inhibitors may cause angioedema and cough, and opioids may cause addiction. 

Although complicated and controversial, iatrogenic opioid addiction is not new. In 1978, Walker identified medical (iatrogenic) addiction as the “development of narcotic dependency following medical treatment.” A systematic review by Wasan and colleagues—published in 2006, before the opioid epidemic—found that no randomized controlled trials had been completed to investigate iatrogenic opioid addiction. Articles consisted of descriptive studies, case reports, or expert opinions. Reported results were based on subjective opinions.

Fast-forward to 2017, and a systematic review by Lawrence and colleagues resulted in essentially the same information because of limitations associated with varying definitions, sampling quality, and methodology. However, in all of the studies reviewed, psychiatric comorbidities, higher opioid doses, longer duration of opioid use, and personal and family history of addiction to multiple substances (including nicotine) contributed to a higher propensity to develop opioid dependency or addiction.

Dependency, addiction, and pain

In the current environment, the distinction among dependency, addiction, and pain treatment is muddy. The American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) defines opioid use disorder (OUD) as “a chronic lifelong disorder, with serious potential consequences including disability, relapses, and death.” The disputed phenomenon of pseudo-addiction is defined as undertreated pain. Ironically, some definitions of chronic pain include elements of OUD and pseudo-addiction. Regardless of the definition used, those with chronic pain, pseudo-addiction, or OUD all report suffering serious consequences that contribute to disability, negative psychological conditions, and social isolation. Considering these similarities, nurses should suspect OUD when patients report tolerance, withdrawal symptoms between doses, and opioid cravings. (See Diagnostic criteria.)

Diagnostic criteria

The following criteria (with at least two occurring within a 12-month period) are used to diagnose opioid use disorder.

  • Opioids are often taken in larger amounts or over a longer period of time than intended.
  • Persistent desire or unsuccessful efforts to cut down or control opioid use exist.
  • A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
  • Craving or a strong desire compels opioid use.
  • Recurrent opioid use results in failure to fulfill major role obligations at work, school, or home.
  • Opioid use continues despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
  • Important social, occupational, or recreational activities are given up or reduced because of opioid use.
  • Recurrent opioid use takes place in physically hazardous situations.
  • Use continues despite knowledge of having a persistent or recurrent physical or psychological problem likely caused or exacerbated by opioids.
  • *Either of the following defines “tolerance”:
  • need for markedly increased amounts of opioids to achieve intoxication or desired effect
  • markedly diminished effect with continued use of the same amount of an opioid
  • *Either of the following manifests “withdrawal”:
  • characteristic opioid withdrawal syndrome
  • the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

*This isn’t considered to be met for those taking opioids solely under appropriate medical supervision.

Severity: Mild = 2–3 symptoms, Moderate = 4–5 symptoms, Severe = ≥6 symptoms

Source: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)

Screening for dependency and addiction

Addiction screening should follow guidelines supported by the Centers for Disease Control and Prevention, the American Nurses Association, and state boards of nursing. Most states require patient risk stratification for dependency or addiction. However, patients may view this as intrusive, so approach them with genuine respect. (See Screening and treatment resources.)

Screening and treatment resources

Considers these tools when screening for opioid dependency risk:

  • Screening Instrument for Substance Abuse Potential
  • Substance Abuse Symptom Checklist (bit.ly/3valMFB)
  • Prescription Drug-Use Questionnaire
  • Pain Assessment and Documentation Tool
  • Pain Medication Questionnaire
  • Screener and Opioid Assessment for Patients with Pain.

An extensive list of evidence-based screening tools is available at drugabuse.gov/nidamed-medical-health-professionals/screening-tools-resources/chart-screening-tools.

If opioid use disorder or iatrogenic addiction is suspected, use evidence-based treatment options. The Substance Abuse and Mental Health Administration provides guidance for medication-assisted treatment using methadone, naltrexone, and buprenorphine. National and state governments have enacted regulations that broaden reimbursement for addiction treatment. Access resources at integration.samhsa.gov/clinical-practice/mat/mat-overview

As you screen, keep in mind that alcohol and nicotine are the most addictive substances but are easily overlooked because they’re more “accepted” in today’s culture.

Tips for avoiding dependency and addiction

To help patients avoid dependency and addiction, practice with empathy, conduct a comprehensive physical exam, assess the patient’s psychological state, and consider non-opioid treatment options.

Practice with empathy

Start from an understanding that the patient’s pain is real, subjective, and complex. Each patient’s experience includes recognizing and integrating the sensory input, memory, and value ascribed to the pain. This coordinated activity also involves the reward and aversion process. Chronic pain begins with an acute painful experience and becomes chronic as it moves beyond normal healing. As time passes and stress increases, patients may experience depression and anxiety, and preoccupation with finding a cure amplifies suffering. Disability can add to pain and addiction, and maintaining a sick role means the patient receives attention that reinforces the painful condition.

With kindness, truthfulness, and respect, you can build symbiotic interpersonal relationships in which acceptance, support, and care can help patients make positive behavior changes and improve coping strategies. Authentic communication is key to uncovering destructive patterns, life traumas, and abuse that may contribute to pain perception. Dispelling shame and negative beliefs and inspiring resilience leads to empowerment and modifies the pain experience.

Conduct a comprehensive physical exam

A comprehensive physical exam before prescribing opioids can help differentiate somatic factors from medical pathology. Use the exam to detect movement patterns, evaluate muscle strength and tone, and measure exercise tolerance. Quantifying physical strength and movement will help you identify aberrant pain posturing vs. authentic patterns of dyskinetic movement. Look for pain provocation factors and relief positions.

Identifying a pathophysiological cause for the pain, for example Parkinson’s disease for a patient with chronic low back pain, can lead to definitive treatment options and provide cognitive and emotional relief for the patient by validating the “real” cause for the pain. Consider referring the patient to a physical therapist or physiatrist who specializes in chronic pain, muscle energy, movement patterns, and soft-tissue abnormalities.

Addressing peculiar movement patterns can bolster continued participation in pleasurable physical activities. Remember, a body in motion stays in motion. Increased movement leads to more movement and increases the release of positive endorphins, which can improve a patient’s sense of well-being.

Assess the patient’s psychological state

People frequently embrace and embody both good and bad thoughts, which can affect how they experience pain and pleasure. Cognitive factors (such as memory) and behavioral and emotional factors play a role in pain perception, as does pain catastrophizing, anxiety, anger, fear, and depression.

Several tools can help assess cognitive and emotional factors, including the Brief Illness Perception Questionnaire, Pain Catastrophizing Scale, State-Trait Anxiety Inventory, General Anxiety Disorder Scale-7, and the Tampa-Scale of Kinesiophobia. Anger, which can be a reaction to feelings of victimization from unexpected injury, may create an impasse to healing. Measure anger with the Injustice Experience Questionnaire or Dimensions of Anger Reactions-5 Scale. Treatments that target changing thought processes—cognitive behavioral therapy, mindfulness-based cognitive behavioral therapy, cognitive behavioral stress therapy, and eye movement desensitization and reprocessing—have been found beneficial in addressing a patient’s pain expression.

Depression has a bidirectional exchange with pain, suggesting it can amplify pain or be a consequence of pain. Depression results in decreases in neurotransmitters—serotonin, norepinephrine, and dopamine—which also are responsible for pain perception, so pain treatment may include antidepressants. Consider using the Patient Health Questionnaire-9 to measure depression quickly in the clinical setting.

To gauge a patient’s self-efficacy, anxiety, depression, fear, pain catastrophizing, and inflexibility, administer the Chronic Pain Acceptance Questionnaire-8. Patients with a greater acceptance of their pain express lowered pain severity and emotional distress.

Keep in mind that the behavior and social factors that influence pain perception can be consequences of conditioning from positive and negative reinforcement. Assess a patient’s activity avoidance, social isolation, and pain posturing with the 16-item Psychological Inflexibility in Pain Scale. Use the results to promote a patient’s readiness and motivation for change, improve their ability to care for themselves, and reinforce a positive self-image that enhances self-esteem and resilience. A patient may continue to report the same pain score per the Visual Analog Scale, but when dignity is restored, they’ll improve functionally and express improved coping skills.

Consider non-opioid treatment options

Engaging chronic pain patients in activities that promote a sense of well-being also increases depleted serotonin, norepinephrine, and dopamine and augments the release of endogenous opioids. Options include education, progressive exercise, aerobic and strength training, yoga, Hatha Yoga, Gua Sha, Tai Chi, massage, chiropractic medicine, acupuncture, transcutaneous electric nerve stimulation, goal-setting activities, smoking cessation, weight loss, diabetes control, diaphragmatic breathing, relaxation therapy, aquatic exercise, guided imagery, cognitive behavioral therapy, mindfulness, improved sleep, and service to others.

Promote dignity

Nurses hold a perfect position to build caring relationships with patients, which promote dignity and thwart the stigma associated with chronic pain and opioid addiction. Nurses who embrace caring as a practice model meet the Dali Lama’s expectation: “Our prime purpose in this life is to help others. And if you can’t help them, at least don’t hurt them.”

Donna J. Purviance is an assistant professor of advanced practice nursing at Indiana State University and a neurosurgical spine triage nurse practitioner Indiana University Health Providers Project ECHO contributor in chronic pain management at Indiana University School of Medicine in Indianapolis and Terre Haute.

References

Alligood MR. Nursing Theorists and Their Work. St. Louis, MO: Elsevier; 2016.

American Psychiatric Association. Opioid use disorder. November 2018. psychiatry.org/patients-families/addiction/opioid-use-disorder/opioid-use-disorder

Asadbeygi A, Ahadi H, Mirzaei H. Assessing the effectiveness of cognitive behavioral stress management (CBSM) on pain perception of cancer patients. Novelty Biomed. 2019;7(3):130-3. doi:10.22037/nbm.v7i2.24272

Egan A, Lennon O, Power CK, Fullen BM. “I’ve actually changed how I live”—Patient’s long-term perceptions of a cognitive behavioral pain management program. Pain Med. 2017;18(2):220-7. doi:10.1093/pm/pnw148

Ehde DM, Alschuler KN, Day MA, et al.  Mindfulness-based cognitive therapy and cognitive behavioral therapy for chronic pain in multiple sclerosis: A randomized controlled trail protocol. Trials. 2019;20(1)774. doi:10.1186/s13063-019-3761-1

Gurza S, Jung I. Textbook of Iatrogenic Pathology. Shajah, UAE: Bentham Science Publishers; 2017.

Lawrence R, Mogford D, Colvin L, Systematic review to determine which validated measurement tools can be used to assess risk of problematic analgesic use in patients with chronic pain. Br J Anaesth. 2017;119(6):1092-1109. doi: 10.1093/bja/aex316

Ling C, Zhang G, Hu M, Liang X.  Eye movement desensitization and reprocessing versus cognitive-behavioral therapy for adult posttraumatic stress disorder: Systematic review and meta-analysis. J Nerv Ment Dis. 2015;203(6);443-51. doi:10.1097/NMD.0000000000000306

National Institute on Drug Abuse. Screening and assessment tools chart. May 6, 2021. drugabuse.gov/nidamed-medical-health-professionals/screening-tools-resources/chart-screening-tools.

Walker L. Iatrogenic addiction and its treatment. Int J Addict. 1978;13(3):461-73. doi: 10.3109/10826087809045261

Wasan AD, Correll DJ, Kissin I, O’Shea S, Jamison RN. Iatrogenic addiction in patients treated for acute or subacute pain: A systematic review. J Opioid Manag. 2006;2(1):16-22. doi: 10.5055/jom.2006.0003

Wijma AJ, van Wilgen CP, Meeus M, Nijs J. Clinical biopsychosocial physiotherapy assessment of patients with chronic pain: The first step in pain neuroscience education. Physiother Theory Pract. 2016;32(5):368-84. doi: 10.1080/09593985.2016.1194651

 

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