Case Study Essay: Pathophysiology, Pain Management, And Opioids.

Part 1. This case study assignment is based on the theory, concepts and nursing principles covered in lectures, tutorials and associated resources.

Collect information: pathophysiology

Q1. Outline the pathophysiology of pain in relation to pleuritis. Include the generation and transmission of pain, pain mediators and classification of pain. Avoid writing about different conditions and keep your focus on pleuritic pain.

Process information: Pain management

Q2. Discuss the common fears and myths that interfere with health-care professionals providing adequate pain management to patients?

Q3. Explain why is it important to recognise an opiate-naïve patient? Discuss how the nurse can mitigate the risk of adverse effects from administration of opiate medications in the opiate-naïve patient experiencing acute pain?

Q4. The central principles of social justice in a health care context are self-determination, equity, access and rights and, participation. How do you interpret the actions of the nurse in withholding the prescribed morphine solution (nocté) from Mr. Hunter in relation to social justice principles? Discuss the potential impact on Mr. Hunter if he perceives his treatment for pain to be unfair and unjust? 

Part 2. As you recall, the respiratory consultant reviewed Mr. Hunter and prescribed endone (30mg) rectal suppository PRN and oxycontin 10mg orally 12 hourly PRN. As directed by the consultant, the registered nurse asks you to check a dose of oxycontin for administration to Mr. Hunter immediately.

You are required to give oxycontin 10mg tablet but the available stock in the drug cupboard is 20mg tablets. The registered nurse breaks a 20mg tablet in half with a pill cutter and asks you to administer this to Mr. Hunter.

Making reasoned judgments

5. Should a nurse administer a ‘broken’ tablet of oxycontin to a patient? Apply your knowledge of the absorption properties of ‘controlled-release’ preparations of oxycodone to justify your answer to this question, and comment on what the potential outcome would be for the patient if this medication were administered after being cut in half.

Q6. Give a rationale for why nurses would administer, or withhold concurrent doses of morphine solution (nocté), oxycontin 10mg PO 12 hourly and endone 30mg PR PRN to Mr. Hunter.

Planning care associated with opiate use

7. Relate the mechanism of action of opioids to the adverse effects on the peripheral nervous system to explain how opioids cause constipation?

At what point should laxatives be prescribed for patients taking opioids? What action of Coloxyl (docusate) with Senna prevents/relieves constipation?

What non-pharmacological therapies can be encouraged early to help prevent constipation?

8. What are the advantages of the drug ‘Targin’ compared to controlled–release oxycontin tablets?

Reflection:

• What are the two most important things that you have learned from this scenario?
• What actions will you take in your future practice as a result of what you have learned fromthis scenario?

Collect information: pathophysiology

Mr. Edward Hunter had been admitted to the hospital with end-stage idiopathic pulmonary fibrosis. He was experiencing increased pleuritic pain on inspiration. Pleurisy is caused due to the inflammation of the pleural layer and the inner chest wall. This inflammation causes the innervations of the somatic nerves resulting in pain sensation on the parietal pleura. No such pain receptor is present in the visceral pleura. The transmission of pain occurs when inflammation in the periphery of the lung parenchyma is shifted to the pleural space. This results in the activation of somatic pain receptors and clinical presentation of pleuritic pain. The parietal pleura are also innervated by the intercostal nerves. The pain is localized to cutaneous nerves (Yalcin et al. 2013). Hence, this pathophysiology is the reason for symptoms of chest pain, difficulty in breathing and pain in shoulder or back. It results in increased pain in chest with exacerbated symptoms during shortness of breath.  The shoulder pain occurs due to the transmission of the innervations to each hemidiaphragm (Kass et al. 2017).

The pleuritic pain may be classified on the basis of etiology and symptom onset which are as follows:

1. Acute pain (persisting for minutes to hours)- caused due to myocardial infarctions, pulmonary embolism, pneumothorax and trauma.
2. Subacute pain (continuing for hours to days)- caused by infection and inflammatory process.
3. Chronic pain (for days to weeks)- caused due to rheumatoid arthritis, tuberculosis and malignancy.
4. Recurrent pain- caused due to Mediterranean fever (Kass et al. 2017).

2. Many fears and myths exist that interferes with health care professional’s responsibility of providing adequate pain management to patients. Some people think that they are not experience acute pain, it is just because they are thinking to much about it. Therefore, involvement of the mind and the body is seen in perception of pain. However, in complex cases, pain management is necessary and it should not be avoided due to stressful life events.

Other fear and myths seen in patient having pain includes the following:

• Some people ignore persistence pain with the belief that it is an inevitable experience that will remain with them due to diagnosis of disease or aging.
• Some take pain in a positive way that builds their character.
• Many patients do not report about pain to clinicians as they think it will distract them from other important clinical responsibilities.
• Patient are worried about innumerous side-effects associated with pain and hence, they avoid taking pain medications
• Fear of addiction to pain relief tablets also discourage people to take pain relief drugs
• Many have fear regarding taking strong medications like opioids as they may cause other complications (Patient’s fears and misconceptions about pain and opioids, 2017). 

All this fears and beliefs about pain and opioids shows the health care professionals face challenges in providing adequate pain management to patients.

3. Opioid is the main treatment option for providing relief to patients. However, during carrying out pain management, it is necessary to differentiate between opioid-naïve and opioid tolerant person. This is because Opioid naïve patients are susceptible to the adverse effects of opioid. Recognising this group of patients guides clinicians to engage in appropriate treatment process. In case of opioid naïve patients, they will not need to increase the dose of the drug as done for opioid tolerant person. Opioid naive patients do not receive opioid analgesics on a daily basis (Sun et al. 2016). This person does not take the below specified drug in the specified amount for 1 week or longer:

• oral morphine/day
• 30 mg/day Oxycidone
• 60 mg Oral morphine/day
• 30 mg Oxycodone/day
• Dose of other opioid.

When administering opioid medication to opioid naïve patients, the nurse may face various challenges in deciding the dose. These patients may be at risk of over-sedation and respiratory depression. This is seen in patient because they lack recent use of opioid or they may require higher opioid dosage. They can mitigate the effect of adverse effect by monitoring regarding the risk of oversedation in opioid-naïve patients. Nurse can do this by checking the pulse oximetry, blood pressure and respiratory rate of patients. However, respiratory rate cannot indicate respiratory distress accurately (Cushman et al., 2017). Therefore, assessment of early signs of hypercapnia might help to detect risk and complication after administration of opioid.

Process information: Pain management

Opioid naïve patients taking opioid may also experience nausea and vomiting. In this case, nurse must giving solid food to patients and avoids liquid diet. During pain management, route of administration must also be considered. This is because transdermal route may not be effective for opioid naïve patients. The absorption process of medication might be hampered (Principles Of Opioid Management 2017). Secondly, as various opioid drugs are available, it is necessary for identify the appropriate administration process for each type of opioids. For example, Fentanly patch may not be appropriate for opioid naïve patients. The clinical effect of the drug may be hampered in this grpup of  patients (Grissinger 2010). In case of dose titration with sufetanil, precautions must be taken in giving it to opioid naïve patients (Principles Of Opioid Management 2017).

4. Social justice principle emphasizes on taking measures that eliminate inequity, promote inclusiveness of diversity and establish supportive environment for all people. This values justice the value of equity, diversity and supportive environrment  in achieving desired health outcome (Thompson 2016). The nurse action to reduce the dose of morphine also reflects the nurse followed the value of the social justice principle. This is because as Mr. Hunter was a palliative patient and high dosage of morphine was leading to oversedation in him. In such scenario, the patient condition may further deteriorate. Therefore, nurse action is justified because if she blindly followed the prescribed medication regimen, it would have exposed Mr. Hunter to other risk. Hence, nurse action helped to provide a supportive environment to patient while delivering care. The nurse decision to reduce the dosage of morphine is also ethically correct decision as she followed the values of beneficence in care.

If Mr. Hunter perceives the treatment of pain to be unjust and fair, then it may have a psychological impact on patient. He may feel that patients value in care is not respected and he has been wrongly provided a treatment. Such feeling hampers therapuetic relationship with health care staffs as Hunter may not trust nurse or staff during the care process. The ultimate impact of this will be that patient may not be involved in care and may not follow medical advice. This may create adverse condition for patient (Fortin et al. 2016). Therefore, it is important to take fair and just decision for patient during treatment process.

5. According to Bobeck et al. (2017), the nurse should be careful about applying the oxycontin. Te tablte sould not be taken as broke, crushed or divided. The ‘broken’ tablet of oxycontin can be fatal for the patient. Therefore, the nurse should not provide the ‘broken’ tablet of oxycontin to the patient. Due to the broke oxycontin, more amount of oxcontin can enter into the body of the patient. As a result, the patient may face serious health issues including death due to the overdose.

The appropriate treatment of the pain remains as a challenge in the medical field. The oxycontin is an opioid. Therefore, the broken tablet of oxcontin leads to the rapid release and with the time it is absorbed in the body. The absorption of the overdose of oxycontin is fatal. 60%- 80% dosage of oxycontin reaches to central compartment. The tablet exhibits the biphasic absorption pattern, which is fatal when overdose is taken (Cicero and Ellis 2015). Therefore, before applying the oxycontin, the nurse needs to be careful about its dosage. Oxycontin is metabolized extremely in the body and excreted through urine. Before applying the oxycontin, the nurse needs to examine the patient if he has the abilty to tolerate the oxycontin.

Making reasoned judgments

If the patient would given the oxycontin after being cut in the halves, the side effects can be seen in the patient.  The problems of the patient can develop. Oxycontin is absorbed in the body slowly and may take 12 hours (Jones, Muhuri and Lurie 2017). It can provide relief to the patient by reducing the pain. However, it causes the serious problems like serious breathing problems, sedation, and coma. The patient becomes vulnerable and this can lead the patient towards death (Huxtable et al. 2011).

6. 

                                                                        Table 1: Rationale of using drugs

7. Though opioids are used for the pain management, it may have adverse effects on the patient. The adverse effects include the itching, constipation, vomiting, nausea, and dry mouth. Moreover, the patient may addicited to the opioids as it belongs to the drug family.  Opioid increases the risk of constipation to 90- 95% (Huxtable et al. 2011). This mainly occurs due to the long term effect of opioids on body (Perrino, P.J., Colucci et al. 2013). The opioids like morphine are responsible for the metabolic breakdown as well  as responsible for the opioid metabolism (Bobeck et al.  2017). Opioids mainly produce pharmacological actions that include the analgesia. The opioids inhibit the release of neurotransmitter. This is considered as the major effect in nervous system. It interacts with the µ, ? and k opioid receptors. The opioids are used for the pain management but it increases the risks of constipation (Opioids 2011). This can be uncomfortable for the patient and the condition of the patient can be worse. It is the side effect of the three drugs such as morphine, oxycontin, and endone. This mainly occurs due to the long- term effect of opioids on body. The path of the clearance of stool can be blocked due to the long- term use of opioids. It can be fatal for the patient if not treated properly (Bruehl et al. 2014). As a result, the patient may face serious health issues including death due to the overdose. Therefore, it is necessary to use the drugs properly in case of pain management.

8. From the case scenario, it is seen that overdose of oxycontin can be fetal for the patient. Moreover, the oxycontin cannot be used as the form of half tablet. On the other hand, ‘Targin’ is more useful in case of pain management. However, as a nurse, I should be more careful about the usage of the drugs like oxycontin. As Targin is the combination of oxycontin and naloxone, I needs to use it carefully. I have learnt about man drugs from the case scenario. The side effects of the drug are also known from the case scenario. I need to remind the side effects of the drugs before sig them for the patient care. I need to be careful to treat the patient and manage the pain of the patient.  

Planning care associated with opiate use

In future, before using the drugs, I shall check the dosage and route of using the drugs. I shall be careful to use it. I shall remind the side effects of the drugs. I shall be more careful about the usage of the drugs like oxycontin. I shall remind about the patient safety and will try to reduce the mortality and morbidity rate. Therefore, it is necessary to use the drugs properly in case of pain management. I shall be careful so that the patient may not get addicted to the opioids. As the nurse, I need to be careful about the dosage and route of the drugs. I need to be careful about the parameters of the health such as blood pressure, heart rate, and breathing problem can occur due to the overdose. I also need to careful about the side effects of drugs and provide appropriate care to the patient.

Reference

Bobeck, E.N., Pena, D., Gomes, I., Fakira, A. and Devi, L., 2017. Blockade of a Novel Neuropeptide Receptor System, BigLEN-GPR171, Reduces Adverse Effects of Prolonged Morphine Administration. The FASEB Journal, 31(1 Supplement), pp.985-8.

Bruehl, S., Burns, J.W., Gupta, R., Buvanendran, A., Chont, M., Schuster, E. and France, C.R., 2014. Endogenous Opioid Inhibition of Chronic Low Back Pain Influences Degree of Back Pain Relief Following Morphine Administration. Regional anesthesia and pain medicine, 39(2), p.120.

Cicero, T.J. and Ellis, M.S., 2015. Abuse-deterrent formulations and the prescription opioid abuse epidemic in the United States: lessons learned from OxyContin. JAMA psychiatry, 72(5), pp.424-430.

Cushman, P.A., Liebschutz, J.M., Hodgkin, J.G., Shanahan, C.W., White, J.L., Hardesty, I. and Alford, D.P., 2017. What do providers want to know about opioid prescribing? A qualitative analysis of their questions. Substance Abuse, pp.1-8.

Fortin, M., Cojuharenco, I., Patient, D. and German, H., 2016. It is time for justice: How time changes what we know about justice judgments and justice effects. Journal of Organizational Behavior, 37(S1).

Grissinger, M., 2010. Inappropriate prescribing of fentanyl patches is still causing alarming safety problems. Pharmacy and Therapeutics, 35(12), p.653.

Huxtable, C.A., Roberts, L.J., Somogyi, A.A. and MacIntyre, P.E., 2011. Acute pain management in opioid-tolerant patients: a growing challenge. Anaesthesia and intensive care, 39(5), p.804.

Jones, C.M., Muhuri, P.K. and Lurie, P.G., 2017. Trends in the Nonmedical Use of OxyContin, United States, 2006 to 2013. The Clinical journal of pain, 33(5), pp.452-461.

Kass, S., Williams, P. and Reamy, B. 2017. Pleurisy. [online] Aafp.org. Available at: https://www.aafp.org/afp/2007/0501/p1357.html#sec-1 [Accessed 23 May 2017].

Macintyre, P.E. and Schug, S.A., 2014. Acute pain management: a practical guide. CRC Press.

Opioids, A., 2011. Pain Management. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 12th ed. New York, NY: McGraw-Hill, pp.481-525.

Patient’s fears and misconceptions about pain and opioids.  (2017). Teaching guide [online] Available at: https://trc.wisc.edu/videoguide/Fears_inserts/fear_insert.pdf [Accessed 23 May 2017].

Perrino, P.J., Colucci, S.V., Apseloff, G. and Harris, S.C., 2013. Pharmacokinetics, tolerability, and safety of intranasal administration of reformulated OxyContin® tablets compared with original OxyContin® tablets in healthy adults. Clinical drug investigation, 33(6), pp.441-449.

Principles Of Opioid Management.  2017. SymptomGuidelines [online] Available at: https://www.fraserhealth.ca/media/16FHSymptomGuidelinesOpioid.pdf [Accessed 23 May 2017].

Sun, E.C., Darnall, B.D., Baker, L.C. and Mackey, S., 2016. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Internal Medicine, 176(9), pp.1286-1293.

Thompson, N., 2016. Anti-discriminatory practice: Equality, diversity and social justice. Palgrave Macmillan.

Yalcin, N.G., Choong, C.K. and Eizenberg, N., 2013. Anatomy and pathophysiology of the pleura and pleural space. Thoracic surgery clinics, 23(1), pp.1-10.