The Addicted Patient
A 22-year-old woman was admitted to the cardiovascular ICU (CVICU) following a tricuspid valve replacement related to recurrent subacute bacterial endocarditis. She had a selfreported history of heroin use (approximately 2 g/day).
She was cxtubated within the first 24 hours after surgery, but remained in the CVICU for stabilization of fluid balance. During the change-of-shift report, the off-going nurse commented that: "She is a constant whiner. She refuses to do anything. All she wants is to go out for a smoke and more drugs. She had 10 mg ofIV morphine so far this shift".
When the nurse came in to make her initial assessment, the patient said: "I can't take much more of this pain." The nurse probed further and asked her to use some numbers to describe her pain. She replied, "It's at 10!"
The nurse noticed that the patient was reluctant to move and refused to cough. Her vital signs were;
The nurse was concerned that due to the patient's preoperative use of heroin, she might not be receiving adequate doses of morphine to control her pain. She consulted the clinical nurse specialist for assistance in calculating an equivalent dose of morphine based on the usual heroin use. Using an estimated equivalence of heroin of 1 g = 10 to 15 mg morphine, the nurse calculated that the patient would need approximately 20 to 30 mg of morphine per day to account for her precxisting opioid tolerance. Consequently, analgesic dosing related to her surgery would also need to be relative to this baseline requirement. The patient's nurse approached the surgical team to discuss the potential benefits of using a PCA pump in addition to a continuous infusion of morphine. "By doing this," the nurse explained, •she will receive her baseline opioid requirements related to her drug tolerance". The con - tinuous infusion will address her baseline opioid requirements while the patient-controlled boluses will allow her to treat the new surgical pain. The PCA may also offer her some control during a time in her recovery when there are few options to do so." In addition to starting the PCA with a continuous infusion, the surgical team and the primary nurse also discussed using other non-opioid agents such as NSAIDs to augment her analgesia. The team also discussed adding morphine sulphate controlled-release (MS-Contin) to the patient's regimen once she was more comfortable on the PCA and titrating the oral medication doses up while decreasing the PCA. Once the MS-Contin was titrated to an effective dose, the PCA would be discontinued and short acting oral breakthrough medication used for additional pain relic£ The nurse noted she would also need to monitor the patient for any signs or symptoms of withdrawal.
In addition to the changes in the medications, the primary nurse worked with the patient to use relaxation techniques. The nurse explained that relaxation techniques could be thought of as "boosters" to her pain medications and were something that she could do to help control the pain. They also agreed to try massage in the evening to promote sleep and relaxation.
In order to maintain adequate pain control after surgery in a patient who ii addicted to heroin or takes regular opioids the nurse will need to:
(A) Provide a continuous rate on the PCA
(B) Provide a continuous rate on the PCA to account for her presurgical heroin usage and add additional pain medications for the surgical pain
(C) Try to limit the patient's opioid use because she is an addict
(D) Substitute a non-opioid medication such as acetaminophen or ketoralac because the patients is an addict
The best way to control postoperative pain is to:
(A) Use opioids exclusively
(B) Use only medications
(C) Encourage the patient to cough and deep breathe
(D) Use a multimodal approach with medications and complementary techniques such as relaxation