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Undertreatment of Pain and Fears of Addiction in Pediatric Chronic Pain Patients: How Do We Stop the Problem?

Posted on: Sunday, 12 February 2006, 03:03 CST

By Popenhagen, Mark P

Collaborative Practice provides a forum for healthcare professionals to share expertise and enhance communication.

Column Editor: Kathleen Ryan Kuntz

Undertreatment of pain, or oligoanalgesia, is a serious worldwide problem in the pediatric setting (Alexander & Manno, 2003; Lander, 1990; Rupp & Delaney, 2004; Wolfe et al., 2000) that can lead to patient anger, frustration, depression, low self-worth, anxiety, mistrust, isolation, or even suicide (Fishbain, Goldberg, Rosomoff, & Rosomoff, 1991; Stimmel, 1989; Weissman & Haddox, 1989). In an effort to quell this "public health problem," the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) developed standards that deemed pain assessment to be the "fifth vital sign" and pain treatment to be a patient right.

Marks and Sachar's historic study (1973) first brought light to the problem of poor pain management, implicating the lack of pharmacologic information, misunderstanding about addiction and its prevalence, or even "puritanical counter-reactions" about prescribing a drug that could cause euphoria as some of the root causes. These same problems exist today and are unfortunately compounded by stereotyping based on cause of pain, race, culture, gender, socioeconomic status, age, lack of parental understanding of the pros and cons of pain medication, and lifestyle (Blander, Lusher, Bevan, & Telfer, 2003; Goldfrank & Knopp, 2000; Hostetler, Auinger, & Szilagyi, 2002; Rupp & Delaney, 2004; Stimmel, 1989).

Despite the overwhelming evidence to the contrary, many physicians cite fear of addiction as their primary reason for not prescribing additional opioids when their patient complains of pain (Fishbain, Rosomoff, & Rosomoff, 1992; Friedman, 1990; Lander, 1990; Portenoy, 1990; Rupp & Delaney, 2004; Schnoll & Weaver, 2003). As a result of this opiophobia (Furrow, 2001), many patients up the ante by displaying progressively worsening symptoms in an attempt to get the medication they need to feel relief. They may even resort to extreme behaviors they would have normally considered unconscionable had their pain been adequately controlled (Kirsh, Whitcomb, Donaghy, & Passik, 2002; Porter-Williamson, Heffernan, & von Gunten, 2003). This phenomenon, called pseudoaddiction, was first described in 1989 by Weissman and Haddox (1989) and is often misdiagnosed as a true addiction.

It is not surprising that there is some confusion surrounding the term addiction, considering the multitude of definitions. Many medical personnel simply define an addict as a person who displays physical dependence, tolerance, or withdrawal. This definition is too simplistic in that these symptoms are not descriptive enough and are even anticipated in patients undergoing long-term opioid therapy (Friedman, 1990). For example, even though no one would ever say that a person is addicted to his or her corticosteroids taken for asthma, this same person would likely be physically dependent on the drug, show tolerance after a period of time, and go through withdrawal if treatment were abruptly stopped. Thus, a person can be physically dependent on a drug without being addicted to it, or addicted without being dependent or tolerant (Fishbain et al., 1992; Savage, 2002).

The Diagnostic and Statistical Manual of Mental Disorders ([DSM- IV-TR]; American Psychiatric Association, 2000) uses the diagnostic term substance dependence rather than addiction. However, this term is also inadequate for a patient in chronic pain, as many patients on chronic opioid therapy may be distressed about having to take the medicine, display physical tolerance, experience withdrawal if their medication is discontinued, and/or wish to stop taking the medicine but find that they cannot without experiencing undue pain. They may feel the need to spend a great deal of time and effort, even to the detriment of important activities, in pursuit of relief. They may even be willing to experience a significant number of problems or side effects that are outweighed by their desire to be pain-free.

Unhappy with the shortfalls of existing definitions, the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine formed the Liaison Committee on Pain and Addiction (LCPA) and developed a more comprehensive definition. They stated that "Addiction is a primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving" (Heit, 2003, p. 18). For the purposes of this article, the term addiction will follow the LCPA definition.

Assessment

Assessing whether a patient's "drug-seeking behavior" is a result of addiction or inadequate pain management is sometimes difficult. Establishing trust between the chronically undertreated patient and healthcare providers is essential in order to eradicate drug- seeking behaviors. As there are no medical tests for pain other than self-report and reduction in activity level, there is no better way to establish trust than to tell the patient that you believe their story and then to provide treatment accordingly. Relying on sympathetic responses to pain, such as tachycardia, tachypnea, hypertension, grimacing, and crying, to determine whether pain is "real" is inaccurate because these symptoms tend to completely disappear in patients with chronic pain. As a result, these patients may outwardly appear normal while rating their pain as moderate to severe.

Similarly, placebos should never be used to determine whether someone is "faking" his or her pain or is "crazy." The "power of suggestion" that comes with a placebo can be extremely strong, and as a result, most people will respond whether they are malingering or not (Lander, 1990). The American Society of Pain Management Nurses (ASPMN, 2002b) has taken a strong position on placebos stating that they ". . . should not be used by any route of administration in the assessment and management of pain in any patient regardless of age or diagnosis" (http://www.aspmn.org/ html/ Placebos%20revised_2005.pdf). Patients who learn that they have been "tricked" by their treatment team will learn to distrust medical personnel and may feel the need to resort to even more pseudoaddictive behaviors.

Finally, research has shown time and again that parents and medical care providers provide less than accurate estimates of patient pain (Harrison, 1991; Lander, 1990; Schneider & LoBiondo- Wood, 1992; Sutherland et al., 1988), and proxy reports should, therefore, be used with some caution. Thus, patient report and desired versus actual activity level tend to be the best and most accurate assessment tools.

A proper addiction assessment includes a thorough clinical interview, screening instruments such as toxicology tests and the CAGE (Have you ever tried to cut down? Do people annoy you by criticizing your use? Do you ever feel guilty about your use? Do you need an eye-opener to get started in the morning?), and physical examination (looking for both signs of acute intoxication or withdrawal and of chronic use). Interviews performed matter-of- factly with a nonjudgmental attitude are likely to provide the most accurate information.

The key to differentiating addictive from pseudo-addictive behaviors is that the latter quickly disappears as soon as the pain is adequately controlled (Weaver & Schnoll, 2002). Although sedation and euphoria can also occur in the nonaddict, these side effects typically disappear and the patient quickly reestablishes function. The nonaddict may even request a reduced analgesic dose in an effort to reduce or minimize side effects, knowing that some pain could be a potential consequence (Elander et al., 2003; Weaver & Schnoll, 2002). In contrast, true addicts actively seek out sedation and euphoria.

When assessing for addiction, care providers should also consider the patient's disease and emotional state. Disease progression can be a major factor in increasing opioid doses. Chronic pain can weaken the immune system, thereby opening the door for infection, decreased healing time, and alternative routes for new pain. Similarly, stress can serve to increase patients' perception of pain. When a patient begins to feel better or simply begins to yearn to "be like everyone else," he or she may then attempt to return to "normal" levels of activity too quickly, causing overexertion and pain (Schnoll & Weaver, 2003).

Improper choice of medications may be another reason a patient may show "drug-seeking" or "addictive" behaviors. For example, it is well known that 4% to 12% of the general population cannot effectively metabolize codeine (Caraco, Sheller, & Wood, 1996). As a result, no amount of codeine will provide the desired analgesic effect. For this patient, a medication evaluation and opioid rotation would be the most beneficial course of action.

Pain should also be treated based on its type and symptomatology. Although nociceptive pain is best treated with nonsteroidal anti- inflammatory drugs and/or opioids, these medications do little if anything to treat neuropathic pain (Arner & Meyerson, 1988), which is best treated with sodium channel blockers, anticonvulsants, and tr\icyclic antidepressants such as lidocaine, gabapentin, and amitriptyline, respectively (Krause, 2005). Sedatives or antihistamines such as diazepam, lorazepam, or diphenhydramine, although effective at reducing anxiety and increasing sleep, do nothing to stop pain and can lead to addictive behaviors as well. However, muscle relaxants, although not analgesics, reduce or eliminate spasms that may be at the root cause of pain.

Just as there are frequent errors in the type of medication given, many providers do not prescribe enough medication (Savage, 2002). Lack of knowledge of equianalgesic doses or mathematical errors during drug conversion (Stimmel, 1989) may be one of the easiest mistakes to make when prescribing medications. Patients with an established tolerance to a drug, such as patients receiving chronic opioid therapy for pain or addicts in methadone maintenance treatment programs, may require significantly higher doses of opioids to effectively manage their pain than those who are opioid nave (Stimmel, 1989). Similarly, patients treated for chronic pain or acute pain that is known to be long lasting should be treated with both a long- and short-acting medication rather than either alone.

It is not uncommon for patients with chronic pain to be referred to as addicts when they request specific medications and doses; however, as most have been to multiple physicians and have been prescribed multiple medications, they may simply know what has worked well for them in the past. A thorough chart review might serve to reduce this confusion.

Because "addicts" tend to abuse multiple substances, a urine toxicology screen can sometimes be an effective means of providing more evidence that a person is misusing or diverting medication (Fishbain et al., 1992). These tests are not without their limits; therefore, it is best to give the patient the benefit of the doubt until a positive drug screen can be verified with a more conclusive test (Schnoll & Weaver, 2003; Weaver & Schnoll, 2002).

Addiction occurs in chronic pain patients with no greater frequency than in the general population, especially in those without a history of addiction; it is, therefore, extremely rare (Kowal, 1999; Weaver & Schnoll, 2002). Some pain services, however, may be faced with an addict trying to obtain opioids through malingering. Fortunately, these patients are the exception rather than the rule. Although there will never be definitive numbers, Fishbain and colleagues' (1992) meta-analysis found the rate of addiction in chronic pain patients to range from 3.2% to 16%. They found that much of the research was flawed, however, and believed that the actual rate was likely to be much lower.

Interestingly, a PubMed literature search (using combinations of the terms addiction, pediatrics, children, drug abuse, and chronic pain) revealed no research focusing primarily on addiction within the pediatric chronic pain population. Psychiatric illness, such as personality disorders or a personal or family history of opioid or prescription drug addiction or abuse (especially prescription medications), is a risk factor for future abuse, and these patients should be monitored closely (Savage, 2002; Weaver and Schnoll, 2002). A family history of addiction is a potential risk factor for medication diversion as well (Savage). Other risk factors of potential addiction include frequent lost prescriptions, dose escalations without consultation despite warnings, deterioration of functioning, unwillingness to try nonpharmacologic approaches, taking medications from others, use of other illicit substances, altering medication so that it can be taken by another route (e.g., injecting or inhaling oral medication), sleep disturbance, anxiety, depression, and prescription forgery (Savage; Weaver & Schnoll). Although the patient with chronic pain may demonstrate some of these behaviors from time to time, a consistent pattern is more indicative of an addiction problem. It is very important to talk openly with patients about any concerns that the treatment team may have.

Treatment

First and foremost, the medical staff must believe their patients' reports of pain and help remove the barriers to forming a trusting relationship. Leaving judgments, biases, and stereotypes behind will go a long way toward developing rapport and trust between the patient and the medical staff. Thoroughly reviewing history and all medications with the patient allows the patient to be part of the treatment team and helps to develop a more comprehensive treatment plan.

Opioid contracts are frequently used in pain clinics in an attempt to increase treatment compliance. Although they vary by clinic, these contracts are typically a signed document provided by the physician that describes what the physician will and will not do and the expectations of the patient during treatment. However, because of potential legal complications and issues of trust, the use of this type of contract is still being debated (Fishman & Kreis, 2002). Prior to contract implementation, therefore, the pain clinic staff (including legal services) should discuss what the contracts will say, how they will be used, and the consequences for both patients and staff for breaking the contract. It is important to treat pain quickly with an initial dose that relieves most or all of the pain (Weaver & Schnoll, 2002).

Healthcare providers must schedule breakthough medications rapidly and frequently enough so that the patient does not have to wait in agony for the next dose. Pro re nata (PRN) dosing at the lowest level over the longest interval may serve to increase pseudoaddictive behaviors because this practice can lead to rapidly fluctuating blood serum levels, resulting in the euphoric feelings that can cause craving and drug-seeking behaviors. Alternatively, prescribing long-acting opioids alone leads to drug-seeking behaviors when the patient's pain escalates beyond that which is controlled by the medication, and the patient has to find another way to manage the pain (Schnoll & Weaver, 2003; Stimmel, 1989).

In the outpatient setting, it is important to prescribe not only enough medication to last until the next appointment, but the patient should also be given several extra rescue doses for more difficult days or for the unexpected missed appointment because of scheduling error or illness. Additionally, counting the remaining pills each visit and providing a pain diary where the patient documents his or her pain status for each rescue dose taken can help the treatment team monitor the patient's actual use and disease status. Whenever possible, it is best if only one treatment team prescribes pain medications and that they are dispensed from only one pharmacy. This helps prevent confusion and reduce the risk of potentially dangerous medication interactions (Weaver & Schnoll, 2002).

Reassessing the level of analgesia frequently, especially initially, serves to increase patient trust and also to help the medical treatment team keep ahead of the pain. Remember that there is no upper dose limit with opioid pain relievers if they are titrated to stay ahead of the pain and the patient is closely monitored for respiratory depression and other negative side effects. When it is time to begin withdrawing medication, do so gradually by reducing the dose while keeping the interval constant. As a result, pseudoaddictive behaviors virtually can be eliminated (Porter-Williamson et al., 2003; Schnoll & Weaver, 2003; Weaver & Schnoll, 2002; Weissman & Haddox, 1989).

Although addiction does occur in the chronic pain population, it is extremely rare. Opioid treatment of pain very rarely induces abuse or a new addiction, or stimulates past abuse (Cohen, Jasser, Herron, & Margolis, 2002). Those patients who are addicts, however, have every right to have adequate analgesia and are typically easy to treat once therapeutic levels have been reached (ASPMN, 2002a; Savage, 2002; Stimmel, 1989). These patients may need more opioids than the nonaddict because of increased tolerance levels (Schnoll & Weaver, 2003); keep an open line of communication regarding cravings, use of alcohol or illicit drugs since the last appointment, recovery program progress, and any potential problematic behaviors. Regular communication with the patient's family (especially in the pediatric setting) and the primary care provider can provide invaluable information, build alliances, and open avenues of discussion regarding questions and concerns about behaviors, compliance, and treatment options.

Pharmaceutical interventions are often the treatment mainstay for patients with chronic pain. However, a multidisciplinary approach that includes nonpharmacologic interventions such as behavioral medicine (e.g., biofeedback, relaxation, hypnotherapy, individual and family psychotherapy, etc.), physical and occupational therapies (e.g., strengthening, stretching, orthotics, transcutaneous electrical nerve stimulation, etc.), massage, yoga, and acupuncture have long been documented to reduce subjective levels of pain and can serve to dramatically increase function.

Fear of legal sanctions and disciplinary action is a common reason for undertreating pain, especially with opioids. However, there is currently no federal law that states that it is unlawful to prescribe, administer, or dispense controlled substances that are specifically for pain to patients who are known addicts or those receiving care in an opioid treatment program (Gilson & Joranson 2002). In fact, the Pain Relief Act of 1996 works to protect the prescriber from more restrictive and less up-to-date state statutes. Although some physicians have been sanctioned for their treatment of patients' pain with opioid analgesics (Johnson, 1996), recent lawsuits filed against medical professionals charging elder abuse because of undertreated pain (Rich, 2004; Shapiro, 1996; Tucker, 2004) have res\ulted in lost licenses and multimillion dollar settlements. Although similar lawsuits have not been described in the pediatric pain literature, these cases set legal precedence, and it is likely only a matter of time before parents begin suing for child abuse.

Conclusion

Oligoanalgesia, undertreatment of pain, is a serious problem in the pediatric healthcare setting and is caused typically by a multitude of factors, including irrational fears of addiction on the part of the healthcare professionals. Addiction, as defined by the LCPA, is quite rare in patients with chronic pain and is no more prevalent than in the general population. Pseudoaddiction and pseudoaddictive behaviors, unfortunately, are common experiences for the patient suffering in pain. These experiences lead to patients and healthcare professionals not trusting each other, the patient being mislabeled, the patient increasing his or her symptoms, and the vicious circle continuing with another provider until the patient finds relief.

A multidisciplinary treatment approach that builds a trusting relationship with the patient through open lines of communication, a thorough assessment, adequate pain relief using the correct medication at the correct dose and at the correct interval, and adjuvant therapies are required for pain to be relieved and pseudoaddictive behaviors to disappear. Automatically assuming a patient is an addict and refusing to prescribe proper analgesics for his or her pain will serve only to create more problems.

Although it is possible to be misled by the occasional patient, as medical and mental health providers, ethically, which is worse- giving at most 16 of every 100 chronic pain patients medicine that they may not need or letting 84 of those same 100 patients suffer needlessly? Therefore, in an effort to reduce further pain and agony in the pediatric chronic pain population, it is imperative that healthcare practitioners provide adequate pain management for all patients instead of denying proper medical care because of bias, stereotyping, or opiophobia.

Search terms: Chronic pain, healthcare disparities, pain

References

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Mark P. Popenhagen, PsyD

Clinical Psychologist

Pain Specialist

The Children's Hospital

Denver, CO

Author contact: popenhagen.mark@tchden.org, with a copy to the Editor: roxie.foster@uchsc.edu

Copyright Nursecom, Inc. Jan 2006

Source: Journal for Specialists in Pediatric Nursing

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