Opioid Administration for Severe Neuropathic Pain in a Patient With Depression and Prior Heroin Use

CONTINUUM: Lifelong Learning in Neurology
February 2012; Volume 18(1); p 176–180

Elliott, Kathryn J. MD, JD, MSc

Address correspondence to Dr Kathryn Elliott, Mount Sinai Medical Center, Annenberg Building, 1468 Madison Avenue, 2^nd Floor, Room 218, New York, NY 10029, kathryn.elliott@mssm.edu.

Relationship Disclosure: Dr Elliott is the principal or co-investigator for clinical trials supported by CSL Behring, Eli Lilly and Company, NIH, and Pfizer Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Elliott reports no disclosure.

Duty to Treat

Opioids for Neuropathic Pain

Laws, Regulations, and Guidelines Governing Opioid Prescribing by Physicians

conclusion
references

Abstract

ABSTRACT: The treatment of pain can raise ethical dilemmas. This article presents a case of a young woman with a pain crisis from severe neuropathic pain that is complicated by comorbidities of depression and prior (but not active) heroin use. Medical and ethical justifications for either withholding or providing opioids for her pain are examined. State and federal laws governing opioid prescriptions by physicians for pain management are reviewed.

Case

Note: This is an actual case with details altered to protect the patient’s identity.

A 34-year-old woman was admitted to the intensive care unit (ICU) following a suicide attempt. She had consumed large amounts of alcohol with a combination of prescription drugs she had purchased on the street, including sedatives and major tranquilizers, with an intent to die because of recurrent thoughts of loss surrounding the death of her spouse several years ago. She had recently become homeless and described a recent binge of alcohol drinking lasting 4 weeks during which she had little to eat. When she woke in the ICU, she noted severe pain that she rated as 10 out of 10 on a neuropathic pain scale. She had burning pain below her knees, painful paresthesia of all her toes and the soles of her feet bilaterally, and shooting pain down the backs of both legs. She reported having intermittent tingling and numbness of the toes of both feet for “years,” but she has not had chronic pain. She used heroin as a teenager, but she stated that she had not used heroin for 10 years. She has had HIV infection for 10 years, but she had not been taking her HIV medications recently. She also had a prior psychiatric diagnosis of major depression. She had not seen a physician “for at least a year.” The neurologic examination was consistent with severe neuropathy, including muscle atrophy, hair loss on the legs, stocking glove sensory loss, and absent reflexes. She grimaced in pain, withdrew, and became tachycardic whenever her feet were touched. Spinal MRI showed no structural lesions. Metabolic work-up revealed vitamin B₁₂ and folate deficiencies.

The neurologist diagnosed multifactorial neuropathic pain from HIV, malnutrition, and alcoholism and recommended patient-controlled low-dose parenteral hydromorphone for the acute neuropathic pain crisis while adjuvant analgesics were being started. Even though the patient appeared to be in excruciating pain, the ICU team was worried about respiratory depression with the use of opioids, and her psychiatrist was concerned that opioids may “retrigger” her heroin addiction disorder. Her infectious disease doctor was concerned that she may divert opioids, but there was no evidence that the patient had diverted drugs in the past. Some members of the team believed she had more psychological than physical pain. Except for the neurologist, all the physicians stated that federal and state law prevented them from providing opioids to this patient.

COMMENT

Pain is a common symptom of patients who present to neurologists. In the outpatient setting, two out of three newly referred patients may have pain as their presenting symptom.1 Neuropathic pain is difficult to treat and is often incompletely responsive to opioids and nonopioid adjuvant analgesics. For patients who do not have terminal cancer or who have histories of substance abuse and psychiatric disorder, use of opioids for the management of pain is fraught with controversy. This case raises several ethical considerations in the treatment of patients with pain:

1. Do neurologists have an ethical duty to treat pain?

2. Is there a sufficient medical and ethical rationale to justify using opioids to treat this patient’s neuropathic pain? Alternately, is there a sufficient medical and ethical rationale to justify withholding opioids for treatment of her neuropathic pain?

3. Are worries about state and federal laws governing narcotic prescription a justification for not providing opioids to this patient?

Duty to Treat

There is an ethical duty to treat pain and suffering, and adequate pain treatment is an emerging human right.2 Neurologists should be competent in the use of both nonopioid adjuvants and opioids for the management of neuropathic pain, which involves understanding the relevant neuropharmacology, including half-life, side effects, and analgesic tolerance, and the risks, such as the development of opioid addiction or diversion.3,4 The AAN recommends that patients with pain undergo careful diagnostic evaluation to reach a pain diagnosis and that documentation of history, physical examination, and treatment plans be maintained.5

Physician concern for possible opioid diversion is not, by itself, enough to justify withholding opioid treatment from patients in severe pain. Evidence of diversion can be difficult to obtain, however, as patients know that this is illegal behavior and will not volunteer such information. Some clinicians screen for opioids in patients about whom they have doubts; the absence of opioids in the urine of a patient with a standing opioid prescription may suggest diversion.6

Opioids for Neuropathic Pain

Neuropathic pain is one of the most difficult pain syndromes to treat, and many patients are inadequately treated.7 Opioids and nonopioid adjuvant analgesics each provide, at best, approximately a 30% decrease in pain intensity.7 For neuropathic pain, opioids work about as well as amitriptyline.8 The World Health Organization analgesic ladder for cancer pain uses a three-step approach based on pain severity, and this approach has been considered for the management of nonmalignant neuropathic pain.7 Step 1 and Step 2 use anti-inflammatories and adjuvant analgesics, such as tricyclics and anticonvulsants, for mild to moderate pain, and both Step 2 and Step 3 consider the addition of opioids for moderate to severe pain.4 On the basis of the severity of her pain syndrome alone, this patient qualifies for a short-term opioid trial for a pain crisis while adjuvant analgesics are introduced and maintained long enough to take effect.

Despite her homelessness and ill health, the patient in the case possesses decisional capacity and autonomy and should be involved in directing her own care using a patient-centered model. Like any other patient with severe neuropathic pain, she should be offered opioids unless there is a valid medical reason not to do so. The use of opioids should be addressed using the principles of informed consent. An important potential risk to disclose and discuss in advance is that the use of a strong opioid may retrigger her addiction. In a study of physicians with substance abuse disorders, those with major opioid use, a major psychiatric disorder, and a history of alcohol use had a hazard ratio for relapse of 13.25 (95% confidence interval, 5.22-33.59).9 While there is no similar research for patients such as the one in the case, the presence of this “triple threat”10 may be sufficient justification for not using long-term opioid therapy for this patient. The risk of harm from opioid addiction relapse could be prevented by the use of a combination of nonopioid adjuvant analgesics, but the patient would remain in severe pain for days or weeks until appropriate doses and analgesic effect could be attained.3 The risk of harm from putative respiratory depression is mitigated by the fact that the patient is currently in the ICU, where close monitoring and interventions are available.

Laws, Regulations, and Guidelines Governing Opioid Prescribing by Physicians

Most state medical boards have adopted guidelines promoting the treatment of pain11 that reflect policy statements from the Federation of State Medical Boards and that recognize that opioids are a valid treatment option for severe pain. The United States Drug Enforcement Agency (DEA) enforces the Controlled Substances Act (CSA), which is a federal criminal statute regulating drug abuse and trafficking of controlled substances, including prescription opioids. Physicians may face questions about their opioid prescribing practices from a medical licensing board, face a civil action for negligence,12 or face potential criminal charges as a drug trafficker under a CSA action, following a DEA investigation. The pattern of CSA court decisions is changing, and there was a one-third increase in the number of DEA criminal investigations of physicians from 2003 to 2006.13 A recent appellate court pointed out that a physician named McIver treated chronic pain patients, examined and documented charts on his patients, and created pain contracts, but he also prescribed a large amount of opioid pills, tolerated aberrant opioid-taking behavior, including patient loss of opioids and early prescription requests, and continued to prescribe opioids to an addict.14 These data suggest that there is a small, but justified, concern that physicians who prescribe opioids for pain may undergo a DEA investigation. Recent court cases suggest that even if a physician follows pain guidelines, factors such as the amount of opioids prescribed and whether the patient abuses opioids are considered in determining whether to charge the physician. Because the opioids prescribed in the case described above were started in the ICU, only continued during the hospitalization, and carefully monitored by nursing staff and attending physicians, the legal risks seen with opioid outpatient therapy did not arise in this patient.

CONCLUSION

In this example, the neurologist has a duty and an obligation to use appropriate medications, including opioids, to treat the patient who is in severe pain, but not necessarily to use long-term opioid therapy for neuropathic pain. The neurologist used short-term IV opioids via patient-controlled analgesia in the ICU for her pain crisis while adjuvant analgesics for neuropathic pain were started and nutritional deficiencies, alcohol withdrawal, and depression were treated. The patient was reintroduced to medical care, followed in clinic, and kept on adjuvant analgesics that did not include opioids, as the risks were considered too high and the benefits too low for long-term use. While the use of opioids was justified in this example, it is possible that this will not be the case for all similar patients. The issues are complex, and analysis of risks and benefits to both patient and physician must be considered on a case-by-case basis. If physicians do not wish to consider a short-term trial of opioids, then appropriate referral to pain or palliative care service may be considered.