Abstract
The American Society for Pain Management Nursing (ASPMN) and the International Nurses Society on Addictions (IntNSA) hold the position that persons with co-occurring pain and substance use disorder have the right to be treated with dignity and respect, and receive evidence-based, high quality assessment and management for both conditions using an integrated, holistic, multidimensional approach. Non-opioid and nonpharmacological approaches to pain management are recommended. Opioids should not be withheld from anyone if necessary to treat pain, and a team-based approach, including pain and addiction specialists, should be utilized when possible. Pain management should include interventions aimed at minimizing the risk for relapse or escalation of problematic substance use, and actively involve the person and their support persons in the plan of care. Institutions should establish policies and procedures that support this position statement.
Keywords: pain management, substance use disorder, position statement
Persons with co-occurring pain and substance use are at risk for undertreated pain for multiple reasons, including but not limited to, personal or healthcare providers’ concerns about the adverse effects and addictive potential of opioids and other substances and labeling and stigmatization of uncontrolled pain or “drug-seeking behaviors” by health care professionals, patients, and the public. (Hammarlund et al., 2018; Priester et al., 2016; Substance Abuse and Mental Health Services Administration, 2020). Among persons with opioid use disorder, the risk for undertreatment of pain may be compounded by concerns from health care providers about opioid withdrawal symptoms, opioid tolerance, or opioid-induced hyperalgesia. The undertreatment of pain and stigmatization contradict the missions and core values of the American Society for Pain Management Nursing (ASPMN) and the International Nurses Society on Addictions (IntNSA). This position statement reaffirms these Societies’ commitments to safe and effective pain management and addiction treatment for persons within the context of the ongoing national opioid overdose crisis (Oliver et al., 2012).
Background of Issue
Nurses have a duty to provide evidence-based, safe, and effective pain or addiction care to persons at risk of harm from substance use. Unrelieved pain itself can be harmful and is inconsistent with nurses’ ethical and professional duty to alleviate pain and suffering (American Nurses Association [ANA], 2018). Among persons with a history of substance use disorder, this harm may present as a reemergence or escalation of substance use (Myers & Compton, 2018). Nurses are obliged to practice with “compassion and respect for the inherent dignity, worth, and unique attributes of every person” (ANA, 2015, p. 1), even if that person engages in behaviors associated with substance use disorders. Further, the nurse is ethically bound to advocate for the “rights, health and safety of the patient” (ANA, 2015, p. 9); therefore, reports of pain must be acknowledged and responded to. Providing effective and compassionate pain relief persons at risk of harm from substance use is critical to the development of a therapeutic relationship which is foundational for supporting recovery efforts (Goldberg et al., 2020).
It is crucial to have a clear understanding of substance use disorder as a chronic, relapsing brain disease characterized by compulsive use of the substance, cravings, and continued use despite accumulating consequences. A substance use disorder (e.g., alcohol or opioid) is diagnosed when a person meets specific criteria from the Diagnostic and Statistical Manual of Mental Disorder (5th ed.), and is categorized as mild, moderate, or severe (American Psychiatric Association, 2013). The risk of developing a substance use disorder varies among individuals and includes genetic predisposition, family history, co-occurring mental health disorders, early childhood trauma, and environmental stressors and other social determinants of heath (MacNicol, 2017).
Effective, evidence-based treatments exist for substance use disorders, which vary by the involved substance. While they all share similar characteristics and diagnostic criteria, specific substance use disorders, such as tobacco, alcohol, or opioids, may impact groups of people disproportionately, contribute to different adverse health outcomes, and have variable behavioral and biomedical treatments available. As a chronic condition that includes periods of remission and relapse, treatment requires behavioral change and is most effective when treatment is ongoing (National Institute on Drug Abuse, 2019). Approaches for managing pain among persons with substance use disorder have been promulgated in key documents as noted in Pain Management and Risks Associated with Substance Use: Practice Recommendations (Turner et al., 2022)
Position Statement
ASPMN and IntNSA hold the position that persons with co-occurring pain and substance use disorder have the right to be treated with dignity and respect, and receive evidence-based, high quality assessment and management for both conditions using an integrated, holistic, multidimensional approach. Non-opioid and nonpharmacological approaches to pain management are recommended. Opioids should not be withheld from anyone if necessary to treat pain, and a team-based approach, including pain and addiction specialists, should be utilized when possible. Pain management should include interventions aimed at minimizing the risk for relapse or escalation of problematic substance use, and actively involve the person and their support persons in the plan of care. Institutions should establish policies and procedures that support this position statement.
ASPMN mission statement:
The American Society for Pain Management Nursing®’s mission is to advance and promote optimal nursing care for people affected by pain by promoting best nursing practices. This is accomplished through education, standards, advocacy and research.
IntNSA mission statement:
The mission of IntNSA is to advance excellence in nursing care for the prevention and treatment of addictions for diverse populations across all practice settings through advocacy, collaboration, education, research and policy development.
Acknowledgements:
Compton funding:National Institute of Nursing Research (NIH) R21 NR0190472; Pre-op CBT to Reduce the Risk for Development of Chronic Post-surgical Pain in Patients undergoing Total Knee Arthroplasty; Role MPI. Compton funding: Penn Nursing Faculty intramural Award; The Experience of Being Hospitalized for Endocarditis Among Individuals Who Inject Drugs; Role PI. St. Marie funding: NIH/NIDA K23DA043049. Wilson funding: National Institutes of Health (National Institute of Drug Abuse #R01-DA04424801 and #UG1DA013714-20; National Institute of Drug Abuse/National Cancer Institute #1S06GM142130-01); US Department of Health Substance Abuse and Mental Health Services Administration (SAMSHA) #1H79FG000075-01; US Department of Health & Human Services Health Resources & Services Administration (HRSA) #2T94HP30884-03
Footnotes
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Contributor Information
Timothy Joseph Sowicz, The University of Arizona College of Nursing; Tucson, AZ;.
Peggy Compton, van Ameringen Chair in Psychiatric and Mental Health Nursing, Professor of Nursing, University of Pennsylvania School of Nursing;.
Deborah Matteliano, Lakeshore Primary Care;.
June Oliver, Swedish Hospital, Chicago; Adjunct Faculty University of Illinois, Chicago;.
Stephen Strobbe, University of Michigan School of Nursing;.
Barbara St. Marie, The University of Iowa College of Nursing;.
Helen N. Turner, Oregon Health & Science University School of Nursing;.
Marian Wilson, Washington State University College of Nursing;.
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