Blog Viewer

Managing pain and withdrawal in patients who are experiencing opioid use disorder in acute care

3 effective strategies to help patients who are in pain

By Tacie McNeil
June 10, 2024
Pain is a complex phenomenon on its own. When it occurs in the context of opioid use disorder, it can be a challenge for both nurses and patients to manage.

This article is part of the Canadian Nurse series, Harm Reduction Saves Lives.

Substance use disorders are highly stigmatized and often poorly understood by health-care providers, leaving some patients feeling judged, without adequate pain management. Nurses may feel frustrated and at a loss as to how to support patients with substance use disorders. In acute care, poorly controlled pain and opioid withdrawal are often precursors for conflict between patients and the health-care team, premature discharge and worsening, untreated health conditions.

Courtesy of Tacie McNeil
“When nurses manage patients’ pain and withdrawal in acute care, patients are much more likely to engage with the health-care team and receive the care they need,” Tacie McNeil says.

Opioid use disorder is a medical condition that is characterized by using more of the substance over time, inability to quit or cut down the amount used or frequency of use, and ongoing use despite hazards or consequences and physical dependence (tolerance and withdrawal). It can involve any opioid, natural or synthetic, illicit or prescribed. In the Canadian context, fentanyl is prominent. Opioid use disorder is a chronic, relapsing condition that requires specialized treatment, including medication, counselling, and psychosocial support, to manage it effectively. Due to the potency and toxicity of illicit fentanyl, patients often present to acute care with a very high tolerance to opioids and require much higher doses and frequency of opioids to treat pain and withdrawal.

Pain is a complex phenomenon on its own. When it occurs in the context of opioid use disorder, it can be a challenge for both nurses and patients to manage. Pain can be physical, such as musculoskeletal pain as a result of injury. Pain can also be emotional or psychological and may be rooted in childhood trauma, such as abuse or neglect, or ongoing traumas, such as violence, or factors related to social determinants of health.

Pain is a major contributor to ongoing substance use and acts as a barrier to recovery. Untreated pain increases the intensity and frequency of cravings and reinforces reliance on more dangerous substances to find relief. Additionally, patients with opioid use disorder may have more pain and fewer skills and strategies to manage it compared to other populations. For example, patients who have been using opioids for a long period of time may have an intensified physiological experience of pain (opioid-induced hyperalgesia). Many people who have experienced significant trauma may have mental health comorbidities and impaired or underdeveloped coping and reduced tolerance for pain. The root cause of pain may be unknown or invisible for patients, but this does not mean that it is not real. As nurses, we must believe and validate patients when they tell us they are in pain. So how can we, as nurses, help? Here are three strategies to consider.

1) Treat the patient’s subjective experience of pain promptly and adequately

It is imperative to treat the patient’s subjective experience of pain promptly and adequately.  Medications, often opioids, should be administered to meet the patient’s needs and adjusted accordingly. A flexible approach to opioid administration ensures that the patient’s experience of pain is being treated, creates trust and therapeutic rapport, facilitates the establishment of common goals between the patient and nurse, and improves patient engagement.

As with all patients, it is important to include the patient in decision-making about medications and seek their feedback about effectiveness without our personal biases clouding our clinical judgment. An example is to discuss the experience of pain with our patients, discuss their long-term goals regarding opioids, and follow up after administering pain medication to ensure that their pain relief needs have been met. It can take some time to understand a patient’s level of opioid tolerance and what their medication needs are. Nurses require empathy, communication and trust.

Treating pain may include a complex mix of long- and short-acting opioids, non-opioid medications, and non-pharmacological treatments. Nurses’ worries about patients’ sedation or decreased respirations can be mitigated by enhanced monitoring strategies and recognition that some euphoria or drowsiness may be acceptable in this population given the need for higher and more frequent doses. Nurses can check for patient responsiveness more frequently, monitor oxygen saturation, ensure that they have naloxone training, have naloxone at the bedside, and employ other safety measures.

2) Use prescribed opioids to avoid withdrawal

Opioid withdrawal is extremely unpleasant and an unnecessary experience for patients that can exacerbate their pain. Withdrawal can be avoided with the appropriate use of prescribed opioids and/or opioid agonist treatments. Patients who experience withdrawal often have difficulty engaging in care and may be off unit for extensive periods of time to obtain and use substances to self-medicate. Patients may also self-discharge.

Withdrawal results in patients not receiving the medical care they need, and nurses can lose opportunities to provide life-saving harm reduction services or addiction treatment options. Harm reduction can include teaching about safer substance use, providing safer medications such as morphine or hydromorphone and maintaining patients’ tolerance to opioids to avoid the increased risk of opioid poisoning and death in the event of relapse or return to use. Patients whose pain and withdrawal are well managed are also more likely to engage in substance use treatment options including outpatient counselling, residential treatment, and opioid agonist treatment.

The Clinical Opioid Withdrawal Scale (COWS) is a validated tool that measures the severity of opioid withdrawal by assessing symptoms including increased pulse rate, sweating, tremor, dilated pupils, gooseflesh skin, runny nose, tearing eyes, nausea and vomiting, diarrhea, yawning, restlessness, anxiety or irritability and bone or joint aches. It can be useful to assess patient symptoms, but it can also be problematic when used incorrectly. There is often significant variability in scores between nursing assessments, and the tool has limited use in managing opioid withdrawal.

Although COWS can demonstrate the presence and severity of opioid withdrawal, which is helpful when initiating buprenorphine/naloxone, it should not be used to justify withholding opioid medication when requested by the patient (i.e., proving that the patient is not in withdrawal and therefore does not need medication). Patients can feel withdrawal starting before it can be measured by COWS, so, as with pain, patients should be believed and treated when they request medication. Nurses should only withhold or delay PRN opioids for withdrawal management when there are immediate concerns about patient sedation and/or respiration.

3) Consider opioid agonist treatment (OAT)

Opioid agonist medications are prescribed to stabilize and treat opioid use disorder. In Canada, opioid agonist options include Suboxone (buprenorphine/naloxone), methadone or Kadian (slow-release oral morphine). It is best practice to offer agonist therapy to all patients who are experiencing this disorder. Acute care admissions are a valuable opportunity for nurses to discuss these medication options with patients. If patients are willing, hospitalization is often a good opportunity to stabilize opioid use disorder with these medications. The purpose of these medications is to replace other opioids (i.e., illicit fentanyl) and relieve the patient of cravings and withdrawal symptoms for at least 24 hours. Researchers have found that when patients are engaged in some form of OAT, there are significantly improved outcomes, including reduced occurrence of opioid poisoning and death.

In hospital, it is common for people to be prescribed other opioids while they are being titrated on OAT in order to manage pain and withdrawal. Over time, the goal is to stop other opioids being used for acute pain or withdrawal. Induction phases vary, but in general, stabilization on Suboxone takes hours to days, whereas methadone and Kadian can take days to weeks to achieve stability. Some people on OAT will continue to use other substances but still have decreased morbidity and mortality rates if they remain on medication. It is appropriate for nurses to administer PRN medications while patients are adjusting to OAT medications.

It is a misconception that patients on OAT do not require additional pain medication. OAT does not treat acute pain adequately by itself. Pain management is over and above OAT, and patients may require higher doses of opioids than for other populations. Unless contraindicated, OAT should be maintained in hospital for people who have had the treatment initiated in another care facility. If these medications are stopped abruptly, patients’ pain and withdrawal will be difficult to manage. Patients can also experience a heightened risk of return to using substances, substance poisoning and death. An accurate patient medication history, including the date of their last dose, is essential to ensure safety. Doses may need to be adjusted and retitrated if the patient has missed consecutive doses as they may have reduced tolerance. Nurses can communicate with patients often about how to balance medication administration to prevent withdrawal and manage acute pain.

Harm reduction puts focus on patients’ needs

Opioid use disorder is a chronic, relapsing condition, and it is not safe to detox or taper patients completely from opioids in acute care. Patients’ potential loss of substance tolerance puts them at extremely high risk of poisoning and death if they resume substance use after discharge. Not all acute care patients are ready for OAT. In these cases, nurses can manage withdrawal with prescribed opioids. Best practice is to administer liberally (as prescribed) to avoid withdrawal as prescription medications are much safer than illicit fentanyl.

When nurses manage patients’ pain and withdrawal in acute care, patients are much more likely to engage with the health-care team and receive the care they need. Nurses can support patients in acute care by communicating with them about pain and withdrawal, advocating for patients to receive appropriate pain management and providing PRN medication.

Tacie McNeil, RN, BScN, MPH, is a clinical nurse educator at the Peter Lougheed Centre in Calgary, Alta.