- Email: [email protected]
Medication-Assisted Treatment in the Perianesthesia Setting
PAIN CARE
Medication-Assisted Treatment in the Perianesthesia Setting Kathleen Broglio, DNP, ANP-BC, Maureen F. Cooney, DNP, FNP-BC IN 2015, ONE in 10 Americans (27 million) ages 12 or older used an illicit drug in the past month, and opioid pain relievers were the second most commonly used drug (3.8 million).1 Current trends in opiate morbidity and mortality include increased use of heroin and illicit synthetic fentanyl.2,3 More than 2 million people with a substance use disorder that included pain relievers (opioids) sought treatment in 2015.1 Treatment of opioid use disorder (OUD) may include the use of medications such as methadone, buprenorphine, and naltrexone. The use of these substances to treat OUD is referred to as medication-assisted treatment (MAT). In 2011, about 300,000 people received methadone in opioid treatment programs and more than 32,000 individuals were treated with buprenorphine.4 Because of recent legislation, nurse practitioners and physician assistants are able to prescribe buprenorphine as part of MAT,5 so the number of individuals receiving buprenorphine is expected to grow. Naltrexone is another emerging treatment option for OUD that may be effective for other types of addiction such as alcohol use disorder.6 The increase in OUD and subsequent MAT (methadone, buprenorphine, naltrexone) will impact nursing care in the perianesthesia setting. Nurses must be prepared to care for these patients to ensure that acute pain management needs are met. It is essential for nurses to be knowledgeable about the effects of medications used in MAT and
Kathleen Broglio, DNP, ANP-BC, Palliative Care, Dartmouth Hitchcock Medical Center, Lebanon, NH; and Maureen F. Cooney, DNP, FNP-BC, Pain Management, Westchester Medical Center, Valhalla, NY. Conflict of interest: None to report. Address correspondence to Maureen F. Cooney, Westchester Medical Center, Pain Management, Rm 2108 Macy Pavilion, 100 Woods Rd, Valhalla, NY 10595; e-mail address: [email protected]. Ó 2017 Published by Elsevier Inc. on behalf of American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2017.04.001
260
the impact they may have on the patient in the perianesthesia setting. Multimodal analgesia, the use of two or more analgesic agents or techniques that target different sites along the pain pathways to provide pain relief, should be used in the pain management plan for all perioperative patients, including those with OUD.7 The remainder of this article will address the three most common MATs and the implications for nursing practice in the perioperative setting.
Methadone Methadone is a synthetic opioid first used in the United States in 1947 as a pain reliever and later, in 1965, as an addiction treatment agent.8 Over the years, methadone has continued to be used for the treatment of opioid addiction (heroin as well as prescription opioids), and in recent years, recognition of its unique pharmacodynamics has led to a resurgence in its use as an analgesic.9 As an agent to treat addiction, methadone, in once daily dosing, reduces craving and can block the euphoric effect of opioids. Patients on methadone maintenance must go to a federally licensed opioid treatment program, often daily, to receive the directly observed administered dose of methadone, often in doses ranging from 80 to 120 mg daily.8,10 Although methadone may provide pain relief because of the fact that it is a mu-agonist opioid, the pain-relieving effects are only sustained for 3 to 12 hours, thus a once daily dose will not treat the pain for the 24-hour period.11 Methadone has many unique properties and it can be used safely in those with liver or renal disease. Methadone can cause prolongation of the QT interval correction (QTc) on the electrocardiogram (EKG), and its use with other medications that prolong QTc can place a patient at risk for torsade de pointes, a potentially fatal arrhythmia. Methadone has many drug-drug interactions due to its metabolism through the Cytochrome P450 enzyme system, thus requiring dose adjustments of methadone or
Journal of PeriAnesthesia Nursing, Vol 32, No 3 (June), 2017: pp 260-263
PAIN CARE
the competing medications to avoid adverse side effects.8 Nursing Implications Individuals who have been on methadone maintenance should be maintained on the usual methadone dose while hospitalized.12 Treatment programs should be contacted for dose verification as this information is generally not available through the various state prescription monitoring programs. Ideally dose verification should be completed during the preoperative visit. In the case of emergency surgery, if unable to verify the dose, it may be prudent to divide the patient’s reported dose and schedule it every 6 hours over the 24-hour interval (at a dose of no greater than 40 mg daily or per hospital guidelines) until the dose can be verified. The goal in the perioperative setting is not only to treat the pain, but also to prevent acute withdrawal and increased anxiety that could occur if the patient misses the methadone dose. The patient’s methadone dose used to treat addiction will most likely not be adequate to treat the acute pain from a surgical intervention. Because of the decreased pain tolerance and increased pain sensitivity in this population, anticipate reports of higher pain severity scores and need for opioids in higher doses and at a greater frequency than in opioid na€ıve patients.13 Thus, the use of multimodal therapy, which is the standard of acute pain care will be essential to ensure adequate pain control.7 Acute pain treatment recommendations include dividing the methadone dose into every 6 to 8hour dosing during hospitalization to take advantage of the analgesic effects of the methadone. Although an increased dose of methadone may provide more analgesia, most treatment programs prefer that there not be an increase in the maintenance methadone dose.14 When used to treat OUD, the oral methadone formulation is a disket, not a tablet, which should be dissolved in about 4 ounces of water, orange juice, or another acidic juice prior to administration. Methadone has 80% oral bioavailability, but if the patient is unable to take oral medications, the recommendation is to initiate IV methadone (if available on the hospital formulary) in divided doses using an oral to IV
261
2:1 conversion and assess the patient’s response.15 Some patients and misinformed health care providers believe that methadone blocks the effect of other opioids. This is not correct, and other opioids, along with nonopioid analgesics, may be administered to adequately address the acute postoperative pain. Patient-controlled analgesia (PCA) is a technique that can be used to provide additional opioids to the patient on methadone maintenance therapy. The use of PCA may improve patient satisfaction and reduce the risk of undertreatment of acute pain.15
Buprenorphine Buprenorphine is a semisynthetic partial mu agonist, which has been produced in multiple formulations for MAT and pain management. Buprenorphine treatment for addiction began in 2002, and consists of sublingual tablets, or transmucosal film combined with naloxone,16 in doses ranging from 8 mg to 24 mg daily or as a 6-month implant for the treatment of OUD.17 The oral form is usually combined with naloxone to minimize the risk for tampering and injection of the product.10,16 Pregnant woman with opioid use disorder may be treated with buprenorphine, but the product without the naloxone component should be used because of the naloxone related risks of fetal exposure and possible withdrawal.10,18 The use of buprenorphine for OUD should not be confused with its use for pain management (transdermal weekly patches or transmucosal administration q12h). Buprenorphine has a very high affinity for the mu receptor sites, and therefore prevents other opioids from binding to these receptors and exerting an effect. The ability of buprenorphine to block the effect of other opioids makes it a viable treatment option for OUD.16 The effects of buprenorphine can last as long as 24 to 72 hours and its binding to the mu receptors can make it more difficult to treat pain with opioids.13 Buprenorphine is metabolized through the cytochrome P450 3A4 pathway and can affect or be affected by other medications metabolized in the same pathway. Buprenorphine can provide analgesia as well, but usually doses above 32 mg/day sublingual will not provide additional analgesia. Generally, if used for pain management, buprenorphine is given in divided daily doses every 8 hours.16
BROGLIO AND COONEY
262
Multiple protocols based on expert opinion or case reports exist to manage acute pain in patients who are taking buprenorphine to treat OUD. If an elective surgery is planned, one approach is to wean buprenorphine by 2 mg every 3 days and discontinue it 72 hours before surgery.13 If a more rapid discontinuation of buprenorphine is needed, it can be rapidly weaned over 3 days, recognizing that withdrawal is likely. If there is intolerable pain or withdrawal symptoms, another opioid can be administered. Another option is to divide the daily buprenorphine dose into every 6- or 8-hour dosing intervals while the individual is hospitalized to capitalize on the analgesic properties of the buprenorphine.13 If the patient has a buprenorphine 6-month implant, removal and discontinuation of the medication may not be possible. In this case, it may be necessary to provide higher than usual doses of opioids to override the buprenorphine effect. When it is not possible to stop the buprenorphine effect before surgery, the use of multimodal analgesia is critical to provide adequate pain management. Nursing Care Implications Acute pain management in the patient using buprenorphine for OUD will vary, depending on whether the patient has remained on buprenorphine or has been weaned from it before surgery. Buprenorphine effect remains for 24 to 72 hours after discontinuation. If the buprenorphine effect remains, it can be expected that the patient will require upward titration of opioids beyond usual doses to achieve pain relief by overcoming the partial mu agonist effect of the buprenorphine. If buprenorphine was discontinued, once the effect has cleared (24 to 72 h), the individual may have a decreased tolerance to opioids and may be at increased risk for respiratory depression.19 If buprenorphine is continued, care must be taken to observe for adverse effects related to drug-drug interactions. A safe approach to management may be to place the individual in a monitored setting during this time.
Naltrexone Naltrexone, approved for use in 2010, is a mu receptor antagonist used for the prevention of relapse into opioid dependence after the individual has gone through detoxification.10 Naltrexone
blocks the euphoric effects of opioids, can reduce alcohol craving, and has also been studied in a variety of addictions.6,20 Naltrexone has no analgesic properties. It should not be confused with naloxone, which is also a mu receptor antagonist with a shorter half-life, used to reverse opioidinduced respiratory depression. Naltrexone can be administered as a monthly intramuscular depot injection (380 mg/month) or in an oral formulation (50 mg/day).13 Optimally, if the individual is admitted for elective surgery, the oral naltrexone should be discontinued 72 hours before surgery. The intramuscular depot of naltrexone should be discontinued 1 month before surgery in the case of a planned admission.13 Nursing Care Implications In the case of an unplanned admission such as trauma or acute illness, a multimodal analgesia approach, including regional anesthesia if appropriate, is necessary for the patient on naltrexone. It would require 10 to 20 times the usual opioid dose to overcome the naltrexone blockade. If high doses of opioids are used, individuals should be placed in a monitored setting during this time.13 If the patient has been receiving naltrexone, it will be important to monitor liver function as higher doses of naltrexone can cause hepatotoxicity.20 Care must be taken when using concurrent hepatotoxic medications.
Conclusions Nursing care of patients on MAT can be complex and requires an understanding of the medications used for MAT. It is of utmost importance that nurses recognize that these patients are at increased risk for inadequate pain control. It is also imperative to recognize that when opioids are used in this patient population, the higher doses that may be necessary for pain relief increase the risks of opioid-related respiratory depression. It is important to advocate for longer recovery periods for these patients to assure adequate analgesia and safety. Nurses also need to advocate for placement of these patients in postoperative settings where frequent nursing assessments of pain, sedation level, and respiratory status as well as mechanical monitoring of pulse oximetry, capnography, and other vital signs can be provided. The perioperative management of patients on
PAIN CARE
263
medication-assisted therapy requires sensitivity to the psychological needs of these patients and a nonjudgmental approach by health care providers, as they may experience fear and anxiety related to concerns about uncontrolled pain and relapse. As more attention is directed to the development of
safer analgesics, and new discoveries in the areas of OUD prevention and treatment are made, it will be necessary for nurses to acquire the knowledge and skills necessary to provide care that will achieve safe and effective pain management in these individuals.
References 1. Center for Behavioral Health Statistics and Quality. Key Substance Use and Mental Health Indicators in the United States: Results From the 2015 National Survey on Drug Use and Health. 2016. Available at: https://www.samhsa.gov/ data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/ NSDUH-FFR1-2015.htm. Accessed February 15, 2017. 2. Centers for Disease Control and Prevention. Heroin Overdose Data. 2017. Available at: https://www.cdc.gov/drugov erdose/data/heroin.html. Accessed February 6, 2017. 3. Gladden RM, Martinez P, Seth P. Fentanyl law enforcement submissions and increases in synthetic opioid-involved overdose deaths - 27 States, 2013-2014. MMWR Morbidity Mortality Weekly Rep. 2016;65:837-843. 4. Alderks CE. Trends in the Use of Methadone and Buprenorphine at Substance Abuse Treatment Facilities: 2003 to 2011. The CBHSQ Report. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2013. 5. American Society of Addiction Medicine. Summary of the Comprehensive Addiction and Recovery Act. 2016. Available at: http://www.asam.org/advocacy/issues/opioids/summaryof-the-comprehensive-addiction-and-recovery-act. Accessed February 6, 2017. 6. Aboujaoude E, Salame WO. Naltrexone: A pan-addiction treatment? CNS Drugs. 2016;30:719-733. 7. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17:131-157. 8. Salsitz E, Wiegand T. Pharmacotherapy of opioid addiction: ‘‘Putting a real face on a false demon’’. J Med Toxicol. 2016;12:58-63. 9. Chou R, Cruciani RA, Fiellin DA, et al. Methadone safety: A clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. J Pain. 2014;15:321-337.
10. Kampman K, Jarvis M. American Society of Addiction Medicine (ASAM) National practice guideline for the use of medications in the treatment of addiction involving opioid use. J Addict Med. 2015;9:358-367. 11. Pasero C, Quill T, Portenoy RK, McCaffery M, Rizos A. Guidelines for opioid drug selection. In: Pasero C, McCaffery M, eds. Pain Assessment and Pharmacologic Management. St Louis, MO: Mosby Elsevier; 2011:323-367. 12. Stromer W, Michaeli K, Sandner-Kiesling A. Perioperative pain therapy in opioid abuse. Eur J Anaesthesiol. 2013;30: 55-64. 13. Bryson EO. The perioperative management of patients maintained on medications used to manage opioid addiction. Curr Opin Anaesthesiol. 2014;27:359-364. 14. Taveros MC, Chuang EJ. Pain management strategies for patients on methadone maintenance therapy: A systematic review of the literature. BMJ Support Palliat Care. August 26, 2016; doi:10.1136/bmjspcare-2016-001126. 15. Sen S, Arulkumar S, Cornett EM, et al. New pain management options for the surgical patient on methadone and buprenorphine. Curr Pain Headache Rep. 2016;20:16. 16. Silverman S. Buprenorphine for pain and opioid dependence. In: Kaye A, Vadivelu N, Urman RD, eds. Substance Abuse: Inpatient and Outpatient Management for Every Clinician. New York, NY: Springer; 2015:311-318. 17. Ling W. Buprenorphine implant for opioid addiction. Pain Manag. 2012;2:345-350. 18. Wiegand SL, Stringer EM, Stuebe AM, Jones H, Seashore C, Thorp J. Buprenorphine and naloxone compared with methadone treatment in pregnancy. Obstet Gynecol. 2015;125:363-368. 19. Wenzel JT, Schwenk ES, Baratta JL, Viscusi ER. Managing opioid-tolerant patients in the perioperative surgical home. Anesthesiol Clin. 2016;34:287-301. 20. Kjome KL, Moeller FG. Long-acting injectable naltrexone for the management of patients with opioid dependence. Subst Abuse. 2011;5:1-9.
Medication-Assisted Treatment in the Perianesthesia Setting Kathleen Broglio, DNP, ANP-BC, Maureen F. Cooney, DNP, FNP-BC IN 2015, ONE in 10 Americans (27 million) ages 12 or older used an illicit drug in the past month, and opioid pain relievers were the second most commonly used drug (3.8 million).1 Current trends in opiate morbidity and mortality include increased use of heroin and illicit synthetic fentanyl.2,3 More than 2 million people with a substance use disorder that included pain relievers (opioids) sought treatment in 2015.1 Treatment of opioid use disorder (OUD) may include the use of medications such as methadone, buprenorphine, and naltrexone. The use of these substances to treat OUD is referred to as medication-assisted treatment (MAT). In 2011, about 300,000 people received methadone in opioid treatment programs and more than 32,000 individuals were treated with buprenorphine.4 Because of recent legislation, nurse practitioners and physician assistants are able to prescribe buprenorphine as part of MAT,5 so the number of individuals receiving buprenorphine is expected to grow. Naltrexone is another emerging treatment option for OUD that may be effective for other types of addiction such as alcohol use disorder.6 The increase in OUD and subsequent MAT (methadone, buprenorphine, naltrexone) will impact nursing care in the perianesthesia setting. Nurses must be prepared to care for these patients to ensure that acute pain management needs are met. It is essential for nurses to be knowledgeable about the effects of medications used in MAT and
Kathleen Broglio, DNP, ANP-BC, Palliative Care, Dartmouth Hitchcock Medical Center, Lebanon, NH; and Maureen F. Cooney, DNP, FNP-BC, Pain Management, Westchester Medical Center, Valhalla, NY. Conflict of interest: None to report. Address correspondence to Maureen F. Cooney, Westchester Medical Center, Pain Management, Rm 2108 Macy Pavilion, 100 Woods Rd, Valhalla, NY 10595; e-mail address: [email protected]. Ó 2017 Published by Elsevier Inc. on behalf of American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2017.04.001
260
the impact they may have on the patient in the perianesthesia setting. Multimodal analgesia, the use of two or more analgesic agents or techniques that target different sites along the pain pathways to provide pain relief, should be used in the pain management plan for all perioperative patients, including those with OUD.7 The remainder of this article will address the three most common MATs and the implications for nursing practice in the perioperative setting.
Methadone Methadone is a synthetic opioid first used in the United States in 1947 as a pain reliever and later, in 1965, as an addiction treatment agent.8 Over the years, methadone has continued to be used for the treatment of opioid addiction (heroin as well as prescription opioids), and in recent years, recognition of its unique pharmacodynamics has led to a resurgence in its use as an analgesic.9 As an agent to treat addiction, methadone, in once daily dosing, reduces craving and can block the euphoric effect of opioids. Patients on methadone maintenance must go to a federally licensed opioid treatment program, often daily, to receive the directly observed administered dose of methadone, often in doses ranging from 80 to 120 mg daily.8,10 Although methadone may provide pain relief because of the fact that it is a mu-agonist opioid, the pain-relieving effects are only sustained for 3 to 12 hours, thus a once daily dose will not treat the pain for the 24-hour period.11 Methadone has many unique properties and it can be used safely in those with liver or renal disease. Methadone can cause prolongation of the QT interval correction (QTc) on the electrocardiogram (EKG), and its use with other medications that prolong QTc can place a patient at risk for torsade de pointes, a potentially fatal arrhythmia. Methadone has many drug-drug interactions due to its metabolism through the Cytochrome P450 enzyme system, thus requiring dose adjustments of methadone or
Journal of PeriAnesthesia Nursing, Vol 32, No 3 (June), 2017: pp 260-263
PAIN CARE
the competing medications to avoid adverse side effects.8 Nursing Implications Individuals who have been on methadone maintenance should be maintained on the usual methadone dose while hospitalized.12 Treatment programs should be contacted for dose verification as this information is generally not available through the various state prescription monitoring programs. Ideally dose verification should be completed during the preoperative visit. In the case of emergency surgery, if unable to verify the dose, it may be prudent to divide the patient’s reported dose and schedule it every 6 hours over the 24-hour interval (at a dose of no greater than 40 mg daily or per hospital guidelines) until the dose can be verified. The goal in the perioperative setting is not only to treat the pain, but also to prevent acute withdrawal and increased anxiety that could occur if the patient misses the methadone dose. The patient’s methadone dose used to treat addiction will most likely not be adequate to treat the acute pain from a surgical intervention. Because of the decreased pain tolerance and increased pain sensitivity in this population, anticipate reports of higher pain severity scores and need for opioids in higher doses and at a greater frequency than in opioid na€ıve patients.13 Thus, the use of multimodal therapy, which is the standard of acute pain care will be essential to ensure adequate pain control.7 Acute pain treatment recommendations include dividing the methadone dose into every 6 to 8hour dosing during hospitalization to take advantage of the analgesic effects of the methadone. Although an increased dose of methadone may provide more analgesia, most treatment programs prefer that there not be an increase in the maintenance methadone dose.14 When used to treat OUD, the oral methadone formulation is a disket, not a tablet, which should be dissolved in about 4 ounces of water, orange juice, or another acidic juice prior to administration. Methadone has 80% oral bioavailability, but if the patient is unable to take oral medications, the recommendation is to initiate IV methadone (if available on the hospital formulary) in divided doses using an oral to IV
261
2:1 conversion and assess the patient’s response.15 Some patients and misinformed health care providers believe that methadone blocks the effect of other opioids. This is not correct, and other opioids, along with nonopioid analgesics, may be administered to adequately address the acute postoperative pain. Patient-controlled analgesia (PCA) is a technique that can be used to provide additional opioids to the patient on methadone maintenance therapy. The use of PCA may improve patient satisfaction and reduce the risk of undertreatment of acute pain.15
Buprenorphine Buprenorphine is a semisynthetic partial mu agonist, which has been produced in multiple formulations for MAT and pain management. Buprenorphine treatment for addiction began in 2002, and consists of sublingual tablets, or transmucosal film combined with naloxone,16 in doses ranging from 8 mg to 24 mg daily or as a 6-month implant for the treatment of OUD.17 The oral form is usually combined with naloxone to minimize the risk for tampering and injection of the product.10,16 Pregnant woman with opioid use disorder may be treated with buprenorphine, but the product without the naloxone component should be used because of the naloxone related risks of fetal exposure and possible withdrawal.10,18 The use of buprenorphine for OUD should not be confused with its use for pain management (transdermal weekly patches or transmucosal administration q12h). Buprenorphine has a very high affinity for the mu receptor sites, and therefore prevents other opioids from binding to these receptors and exerting an effect. The ability of buprenorphine to block the effect of other opioids makes it a viable treatment option for OUD.16 The effects of buprenorphine can last as long as 24 to 72 hours and its binding to the mu receptors can make it more difficult to treat pain with opioids.13 Buprenorphine is metabolized through the cytochrome P450 3A4 pathway and can affect or be affected by other medications metabolized in the same pathway. Buprenorphine can provide analgesia as well, but usually doses above 32 mg/day sublingual will not provide additional analgesia. Generally, if used for pain management, buprenorphine is given in divided daily doses every 8 hours.16
BROGLIO AND COONEY
262
Multiple protocols based on expert opinion or case reports exist to manage acute pain in patients who are taking buprenorphine to treat OUD. If an elective surgery is planned, one approach is to wean buprenorphine by 2 mg every 3 days and discontinue it 72 hours before surgery.13 If a more rapid discontinuation of buprenorphine is needed, it can be rapidly weaned over 3 days, recognizing that withdrawal is likely. If there is intolerable pain or withdrawal symptoms, another opioid can be administered. Another option is to divide the daily buprenorphine dose into every 6- or 8-hour dosing intervals while the individual is hospitalized to capitalize on the analgesic properties of the buprenorphine.13 If the patient has a buprenorphine 6-month implant, removal and discontinuation of the medication may not be possible. In this case, it may be necessary to provide higher than usual doses of opioids to override the buprenorphine effect. When it is not possible to stop the buprenorphine effect before surgery, the use of multimodal analgesia is critical to provide adequate pain management. Nursing Care Implications Acute pain management in the patient using buprenorphine for OUD will vary, depending on whether the patient has remained on buprenorphine or has been weaned from it before surgery. Buprenorphine effect remains for 24 to 72 hours after discontinuation. If the buprenorphine effect remains, it can be expected that the patient will require upward titration of opioids beyond usual doses to achieve pain relief by overcoming the partial mu agonist effect of the buprenorphine. If buprenorphine was discontinued, once the effect has cleared (24 to 72 h), the individual may have a decreased tolerance to opioids and may be at increased risk for respiratory depression.19 If buprenorphine is continued, care must be taken to observe for adverse effects related to drug-drug interactions. A safe approach to management may be to place the individual in a monitored setting during this time.
Naltrexone Naltrexone, approved for use in 2010, is a mu receptor antagonist used for the prevention of relapse into opioid dependence after the individual has gone through detoxification.10 Naltrexone
blocks the euphoric effects of opioids, can reduce alcohol craving, and has also been studied in a variety of addictions.6,20 Naltrexone has no analgesic properties. It should not be confused with naloxone, which is also a mu receptor antagonist with a shorter half-life, used to reverse opioidinduced respiratory depression. Naltrexone can be administered as a monthly intramuscular depot injection (380 mg/month) or in an oral formulation (50 mg/day).13 Optimally, if the individual is admitted for elective surgery, the oral naltrexone should be discontinued 72 hours before surgery. The intramuscular depot of naltrexone should be discontinued 1 month before surgery in the case of a planned admission.13 Nursing Care Implications In the case of an unplanned admission such as trauma or acute illness, a multimodal analgesia approach, including regional anesthesia if appropriate, is necessary for the patient on naltrexone. It would require 10 to 20 times the usual opioid dose to overcome the naltrexone blockade. If high doses of opioids are used, individuals should be placed in a monitored setting during this time.13 If the patient has been receiving naltrexone, it will be important to monitor liver function as higher doses of naltrexone can cause hepatotoxicity.20 Care must be taken when using concurrent hepatotoxic medications.
Conclusions Nursing care of patients on MAT can be complex and requires an understanding of the medications used for MAT. It is of utmost importance that nurses recognize that these patients are at increased risk for inadequate pain control. It is also imperative to recognize that when opioids are used in this patient population, the higher doses that may be necessary for pain relief increase the risks of opioid-related respiratory depression. It is important to advocate for longer recovery periods for these patients to assure adequate analgesia and safety. Nurses also need to advocate for placement of these patients in postoperative settings where frequent nursing assessments of pain, sedation level, and respiratory status as well as mechanical monitoring of pulse oximetry, capnography, and other vital signs can be provided. The perioperative management of patients on
PAIN CARE
263
medication-assisted therapy requires sensitivity to the psychological needs of these patients and a nonjudgmental approach by health care providers, as they may experience fear and anxiety related to concerns about uncontrolled pain and relapse. As more attention is directed to the development of
safer analgesics, and new discoveries in the areas of OUD prevention and treatment are made, it will be necessary for nurses to acquire the knowledge and skills necessary to provide care that will achieve safe and effective pain management in these individuals.
References 1. Center for Behavioral Health Statistics and Quality. Key Substance Use and Mental Health Indicators in the United States: Results From the 2015 National Survey on Drug Use and Health. 2016. Available at: https://www.samhsa.gov/ data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/ NSDUH-FFR1-2015.htm. Accessed February 15, 2017. 2. Centers for Disease Control and Prevention. Heroin Overdose Data. 2017. Available at: https://www.cdc.gov/drugov erdose/data/heroin.html. Accessed February 6, 2017. 3. Gladden RM, Martinez P, Seth P. Fentanyl law enforcement submissions and increases in synthetic opioid-involved overdose deaths - 27 States, 2013-2014. MMWR Morbidity Mortality Weekly Rep. 2016;65:837-843. 4. Alderks CE. Trends in the Use of Methadone and Buprenorphine at Substance Abuse Treatment Facilities: 2003 to 2011. The CBHSQ Report. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2013. 5. American Society of Addiction Medicine. Summary of the Comprehensive Addiction and Recovery Act. 2016. Available at: http://www.asam.org/advocacy/issues/opioids/summaryof-the-comprehensive-addiction-and-recovery-act. Accessed February 6, 2017. 6. Aboujaoude E, Salame WO. Naltrexone: A pan-addiction treatment? CNS Drugs. 2016;30:719-733. 7. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17:131-157. 8. Salsitz E, Wiegand T. Pharmacotherapy of opioid addiction: ‘‘Putting a real face on a false demon’’. J Med Toxicol. 2016;12:58-63. 9. Chou R, Cruciani RA, Fiellin DA, et al. Methadone safety: A clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. J Pain. 2014;15:321-337.
10. Kampman K, Jarvis M. American Society of Addiction Medicine (ASAM) National practice guideline for the use of medications in the treatment of addiction involving opioid use. J Addict Med. 2015;9:358-367. 11. Pasero C, Quill T, Portenoy RK, McCaffery M, Rizos A. Guidelines for opioid drug selection. In: Pasero C, McCaffery M, eds. Pain Assessment and Pharmacologic Management. St Louis, MO: Mosby Elsevier; 2011:323-367. 12. Stromer W, Michaeli K, Sandner-Kiesling A. Perioperative pain therapy in opioid abuse. Eur J Anaesthesiol. 2013;30: 55-64. 13. Bryson EO. The perioperative management of patients maintained on medications used to manage opioid addiction. Curr Opin Anaesthesiol. 2014;27:359-364. 14. Taveros MC, Chuang EJ. Pain management strategies for patients on methadone maintenance therapy: A systematic review of the literature. BMJ Support Palliat Care. August 26, 2016; doi:10.1136/bmjspcare-2016-001126. 15. Sen S, Arulkumar S, Cornett EM, et al. New pain management options for the surgical patient on methadone and buprenorphine. Curr Pain Headache Rep. 2016;20:16. 16. Silverman S. Buprenorphine for pain and opioid dependence. In: Kaye A, Vadivelu N, Urman RD, eds. Substance Abuse: Inpatient and Outpatient Management for Every Clinician. New York, NY: Springer; 2015:311-318. 17. Ling W. Buprenorphine implant for opioid addiction. Pain Manag. 2012;2:345-350. 18. Wiegand SL, Stringer EM, Stuebe AM, Jones H, Seashore C, Thorp J. Buprenorphine and naloxone compared with methadone treatment in pregnancy. Obstet Gynecol. 2015;125:363-368. 19. Wenzel JT, Schwenk ES, Baratta JL, Viscusi ER. Managing opioid-tolerant patients in the perioperative surgical home. Anesthesiol Clin. 2016;34:287-301. 20. Kjome KL, Moeller FG. Long-acting injectable naltrexone for the management of patients with opioid dependence. Subst Abuse. 2011;5:1-9.