A Painful Dilemma
A 47-year-old woman with end-stage renal disease due to polycystic kidney disease was admitted with fever. She was taking propoxyphene or hydrocodone at home for pain. She has had multiple admissions associated with electrolyte abnormalities due to nonadherence with her outpatient dialysis schedule. Because her permanent arteriovenous (AV) graft normally used for dialysis was clotted and unusable, the patient had been receiving dialysis via a temporary catheter placed in her left femoral vein.
Given that her new presentation included fever, blood cultures were drawn, ultimately growing yeast. An echocardiogram revealed a large tricuspid valve vegetation. The patient's temporary dialysis catheter in her left femoral vein was removed and a new one placed in the right femoral vein. The unused clotted AV graft in the left arm remained in place, and the patient was transferred to a tertiary hospital for consideration of surgery for fungal endocarditis.
The case management department reviewed this case. Their assessment was that the patient's nonadherence to dialysis led to clotting of her permanent AV graft, which necessitated use of temporary femoral vein access. Femoral intravenous catheters are associated with significantly increased risk of infection, including fungal infection, when compared with the use of permanent AV grafts. Moreover, the case management department felt that her nonadherence to dialysis was encouraged by the primary physician's prescription of opiates.
Although this patient was believed to be addicted to narcotics, she was never formally diagnosed with an addiction. Her providers suspected that she often intentionally skipped dialysis sessions, became uremic or volume overloaded, then presented to the emergency department for treatment and admission to the hospital. After admission, her primary physician would usually order intravenous (IV) hydromorphone (Dilaudid) to be given for "body pain." The patient would ask the nurses to "push the hydromorphone fast" and flush after the medication (saying that the previous nurse would push it fast) and ask for dose escalation. When a substance abuse evaluation was recommended to the patient, she repeatedly declined it.
In the case above, a patient's nonadherence to dialysis and receipt of pain treatment with IV opiates led to problems with vascular access and ultimately to a bloodstream infection. Although the dominant clinical problem facing this patient was fungal endocarditis (a disease with a high morbidity and mortality), this commentary focuses on the appropriate management of chronic pain in dialysis patients.
Chronic pain is common in dialysis patients; approximately 50% experience chronic pain, with 82% reporting this pain as moderate or severe in intensity.(1) Given the high prevalence of chronic pain, effective pain management is integral to quality dialysis care. This case is somewhat atypical, in that the patient received analgesics for recognized chronic pain. Chronic pain in dialysis patients is often unrecognized and undertreated (2); 72% to 84% of dialysis patients with significant pain have no analgesic prescribed.(3-5) The percentage of dialysis patients in North America using any analgesic is estimated at 24%.(3) Less than 15% are prescribed opioids, and even acetaminophen use is low at 6%. This case, however, does illustrate many of the complexities regarding optimal treatment of chronic pain in dialysis patients.
While this patient could have pain due to polycystic kidney disease or diffuse arthralgias or myalgias commonly experienced by many dialysis patients, it is unclear whether the etiology or nature of her pain was investigated. Dialysis patients frequently experience more than one type of pain: nociceptive, somatic, visceral, and neuropathic. Neuropathic pain is particularly common in dialysis patients, and identifying this type of pain results in the appropriate use of adjuvant analgesics such as anticonvulsants or antidepressants, potentially avoiding or limiting the use of opioids. While opioids may provide effective analgesia, they may exacerbate symptoms already prevalent in dialysis patients such as cognitive impairment, sleepiness, nausea, vomiting, anorexia, and pruritus. Ongoing reassessment of the effect of chronic opioid use on both symptom burden and functional status is essential and does not appear to have been undertaken for this patient.
Hemodialysis patients require careful selection of analgesics. Active opioid metabolites are excreted by the kidney, accumulate in patients with kidney failure, and may lead to opioid toxicity. The opioids prescribed for this patient are highly inappropriate. Specifically, propoxyphene is contraindicated, and hydrocodone is not recommended in kidney failure. The appropriate management of chronic pain in kidney failure and the evidence to support the use of particular analgesics (6-8) have led to the development of clinical algorithms based on an adapted World Health Organization Analgesic Ladder.(9)
One of the major barriers to effective pain management for both patients and providers is the fear of opioid addiction.(10) Although short-term opioid treatment for acute pain is associated with negligible addiction rates (0.03% to 5%) (11), the prevalence may be as high as 20% in patients receiving opioids for chronic pain.(10,12) However, the recent increase in use and abuse of opioids is predominantly in young adults aged 18 to 25.(10) There are no data suggesting similarly high rates of abuse or addiction in chronically ill populations such as dialysis patients. Rather, dialysis patients have a low use of opioids relative to the extremely high prevalence of pain.(5) Studies of older patients attending specialty clinics found addiction rates of 1% to 3%.(13) In contrast to the current case, opioid addiction is not a common cause of nonadherence in dialysis patients.
That being said, cases of opioid abuse may occur occasionally in dialysis patients. Aberrant drug-taking behaviors—such as loss of control over use, continued use despite knowledge of harmful consequences, compulsion to use, and craving—may be clues to drug addiction. Unfortunately, diagnosing addiction in dialysis patients is limited by the inability to perform urine drug screening in most patients and a lack of data as to which aberrant behaviors best predict drug abuse. Dialysis patients typically experience chronic pain in the context of multiple, debilitating symptoms such as anorexia, fatigue, nausea, insomnia, anxiety, and depression as well as end-of-life issues, all of which may interfere with psychosocial and physical coping strategies. Aberrant behavior may be precipitated by untreated pain (not the case here), depression, anxiety (no documentation of this having been assessed in the current case), and maladaptive coping strategies to living with a chronic, life-limiting illness.(14,15) A major difference between dialysis patients with chronic pain and those with addiction is that patients who are not addicted do not seek a psychoactive effect from their drugs. However, this case illustrates several behaviors that are highly suspicious for addiction. These include poor adherence to her dialysis treatment schedule to manipulate hospital admissions, refusal to submit to a substance abuse evaluation, demands for IV opioid administration, and seemingly inappropriate demands for escalating doses of opioids. Processes for prescribing and managing opioid treatment can be implemented in dialysis units to mitigate these issues.
Dialysis patients are usually seen in a multidisciplinary setting up to three times a week. It should be made clear to outpatients that their nephrologist(s) will coordinate their pain management and opioid prescribing, and that this approach will be carried over to hospital admissions (excepting indications necessitating a short-term change to the opioid prescription such as a surgical intervention). The oral route should be used whenever possible. Although dialysis patients have convenient IV access, it should generally not be used routinely for opioid administration, with the exception of acutely ill patients with problems like vomiting, end-of-life weakness, or bowel obstruction. This patient was inappropriately given IV opioids, not only when admitted to hospital, but also while receiving dialysis. In this case, a reasonable approach in the emergency department would have been not prescribing opioids and referring the patient back to the primary or nephrology care team.
Despite the challenge of managing chronic pain in dialysis patients, physicians are expected to have the knowledge, seek out information, or consult appropriately. Fears of opioid addiction cannot limit adequate pain management. Physicians who are uncomfortable treating chronic pain in dialysis patients should seek out appropriate consultation and continuing professional development opportunities. Limited clinical competence and scope of practice should never result in refusal to treat chronic pain or patients who are perceived to be otherwise difficult.(16) In this case, insufficient physician knowledge of appropriate analgesic use for dialysis patients was a primary problem.
- All dialysis patients should be routinely screened for chronic pain, which is common and often severe.
- Clinical algorithms are available for optimal management of chronic pain in kidney failure.
- In dialysis patients with chronic pain, underuse of analgesics, including opioids, is a greater problem than opioid addiction. Dialysis patients are more likely to require hospital admissions for inadequately controlled pain than for inappropriate drug seeking.
- Patients prescribed opioids need to be monitored for signs of substance abuse.
- Patients' frequent visits to dialysis units provide an opportunity to coordinate opioid use. Despite availability of IV access in these patients, the oral route should be used whenever possible.
Sara N. Davison, MD, MHSc Assistant Professor of Nephrology University of Alberta Department of Medicine
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