Pain Control Literature Research Paper

Literature Research and PICO Question

Pain control is a number one priority in the patient satisfaction scores for the Emergency Departments. With patient satisfaction survey scores driving how healthcare is being performed many physicians feel pressured to prescribe to customer satisfaction instead of medical necessity. (Zgierska, Miller, Rabago, &, 2013) Prescribing opioids in this manner has caused an epidemic of opioid dependence. The deaths from narcotics are superseding the deaths from suicide and motor vehicle accidents. (Manchikanti et al., 2012) The government is now monitoring prescriptions of opioid prescribing and more patients are coming to the Emergency Department (ED) due to the need for pain control and due to opioid addiction. Physicians are looking for a non-opioid pain relief. Ketamine has started to appear in the emergency room for an alternative route for opioid abusers Pain Control Literature Research Paper.

Alternative uses for non-opioid pain relief in the emergency rooms have incorporate low doses ketamine (LDK) to assist with acute pain, chronic pain, and refractory pain. Adverse effects to ketamine results in dizziness, nausea, vomiting, mild hallucinations or agitation. (Pourmand, Mazer-Amirshahi, Royall, Alhawas, & Shesser, 2017) There are different types of psychological factors that can have detrimental effects on patients being given ketamine for pain control. According to Bokor and Anderson, “ketamine can alter numerous functions in the brain including color perception, memory, attention, cognition, reaction time, and sense of time can produce psychological addiction” (Boker & Anderson, 2014) Ketamine is a scheduled class III drug which potentiates the likely increase for abuse and addiction. (American Addiction Centers, 2018). Knowledge of the side effects and levels of abuse the patient can develop from ketamine are concerning for another rising type of addiction to start in the medical field. Currently ketamine is a recreational drug on the streets known as the “date rape drug”. (American Addiction Centers, 2018) The rationale to utilize ketamine instead of opioids is in need of recurring research to ensure safe prescribing for patients.

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PICO

In developing my clinical question, I utilized the formula of patient, intervention, comparison, and outcome. I then was able to develop the question, Is Ketamine a safe effective alternative to pain relief in the Emergency Department for opioid abusers? The patient criteria of the question involve the group of opioid abuser. The problem is the need for an alternate non-opioid pain management for patients who have history of opioid abuse. The alternative needs to be a safe alternative to pain management and not just a cover up or another drug to start an addiction. The intervention is giving low doses of ketamine for pain management to opioid abusers. The comparison component is substituting opioids for low-dose ketamine. The outcome component is highly important, are we managing patients pain safely or is being prescribed ketamine fueling another type of addiction.

Questions

Deciding on the five questions I have developed involved understanding the reasoning, safety, and effects of giving ketamine. Patient safety is the number one priority. One correlation I perceived is are we going to be seeing more people returning to the ED for ketamine? Is this going to be another type of addiction for opioid abuser? To understand and research the problem I have developed these five questions:

What is the mechanism of action for ketamine to provide pain relief?
What are side effects of ketamine?
Is ketamine addictive?
Should ketamine be given on a patient’s own pain scale rating?
When should ketamine be contraindicated?
Question one was developed with needing to know knowledge on how ketamine provides pain relief in the body. This can be beneficial in knowing how the drug will affect the patient. Question two is needing to be researched for patient safety. Side effects can be synergistic to other diagnosis’s the patient may have. Question three is beneficial in understanding ketamine addiction could be a prevalence for patients with opioid abuse to also become addicted to ketamine. Question 4 rational includes understanding the pain scale and when to give ketamine is being given for pain. Should this be a common substitute for acute pain? Should there be other factors to patient reaction when deciding when to give ketamine besides patient’s pain scale rating. Drug abusers will tell you they have a pain of 10 to try and ensure having opioids prescribed to them. Question 5 is indicative to understanding if it is safe or not safe to given in situations when patients present with multiple diagnosis including history of addiction Pain Control Literature Research Paper.

Keywords

Keywords are important in researching the best evidence reviews and practice for developing an outcome to your PICO question. Keywords that I chose to utilize for my database search includes; low dose ketamine, opioid abuse, pain management, adverse effects, drug seekers, analgesia, addiction, acute pain, emergency department, and subdissociative dose ketamine. The keyword chosen correlates to the significance of the PICOT question. The low dose ketamine and subdissociative dose ketamine is the dosage that would be given to patients who need acute pain management. Opioid abuse, drug seekers, and addiction are pertinent words to understand the reasoning for the need of an alternate solution to opioids. Pain management, analgesia, acute pain is the types of pain or synonyms for the research of pain management in the Emergency Department for opioid abusers. The keyword Emergency Department is important in understanding the location and setting where the patient is being given ketamine. Knowledge of adverse effects of ketamine can play an important role in understanding if the medication is safe to give in an ED setting.

Knowledge of ketamine can further inquire on the safety with administration of ketamine. Correlating side effects, adverse effects, and mechanism of action will allow for a base understanding of the scientific purpose for treating pain with ketamine. Further investigation and research needs to be applied in relevance to the later effects of using this type of drug for pain control.

References

American Addiction Centers. (2018). Can ketamine be abused and cause withdrawal? Retrieved from https://americanaddictioncenters.org/ketamine-abuse/

Boker, G., & Anderson, P. (2014, March 20). Ketamine: An update on its abuse. J Pharm Pract, 27(6), 582-586. http://dx.doi.org/10.1177/0897190014525754

Manchikanti, L., Helm, S., Fellows, B., Janata, J. W., Pampati, V., Grider, J. S., & Boswell, M. V. (2012, July). Opioid epidemic in the united states. Pain Physician, 15, ES9-ES38. Retrieved from http://www.painphysicianjournal.com/current/pdf?article=MTcwNA==&journal=68

Pourmand, A., Mazer-Amirshahi, M., Royall, C., Alhawas, R., & Shesser, R. (2017, March 2). Am J Emerg Med. Low dose ketamine use in the emergency department, a new direction in pain management, 35(6), 918-921. http://dx.doi.org/10.1016/j.ajem.2017.03.005

Zgierska, S., Miller, M., & Rabago, D. (2013, February 25). Patient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA, 307(13), 1377-1378. http://dx.doi.org/10.1001/jama.2012.419

Literature Review: Ketamine as a viable alternative for opioids

The program is intended to determine if ketamine would be a viable alternative pain management strategy to address the pain needs of opioid abusers. To address this concern, the program identified five questions to explain the reasoning, safety, and effects of ketamine use. The first question is, what is the mechanism of action for ketamine to provide pain relief? Answering this question is beneficial to knowing how the drug will affect the patient. The second question is, what are the side effects of ketamine? Answering this question would improve the patients’ safety. The third question is, is ketamine addictive? Answering this question is beneficial to knowing if ketamine exhibits addiction patterns and if this could be of relevance to persons already addicted to opioids. The fourth question is, should ketamine be given on a patient’s own pain scale rating? Answering this question aids in developing a realistic scale for interpreting pain. The final question is, when should ketamine be contraindicated? Answering this question is beneficial to understanding the safety of using ketamine when other demographic factors come into play to include history of addiction. These five questions have been condensed into the PICO question as: “among opioid abusers in the emergency department (P), can ketamine act as an effective alternative pain medication (I) versus other pain medication (C) reduce the incidence and intensity of pain (O)?” To address the PICO question, a preliminary literature review was conducted using six journal articles and the results presented Pain Control Literature Research Paper.

Fan et al. (2017) mentions that effective pain management must begin with the patient who must be involved in the whole process. In this case, the patient must be able to offer a true measure of the pain level and comply with the medication requirements before effective pain management can be achieved. Bokor and Anderson (2014) notes that although ketamine is an effective pain reliever, it is subject to abuse. Additionally, it alters brain function to include time, reaction, cognition, attention, memory and color perception. Besides that, chronic use is accompanied by toxicity in the gastrointestinal and urinary tracts. The article concludes that ketamine should be used with caution. Manchikanti et al. (2012) is clear that there is extensive opioid abuse in the US, which is resultant of inappropriate prescribing patterns linked to knowledge deficiencies, safety perceptions, and inadequate pain assessment associated with under-treatment. Pourmand et al. (2017) is categorical when noting that opioid analgesics are accompanied with addiction and abuse problems. Ketamine presents a viable alternative since it is a non-opioid analgesic whose action is similar to opioids, and is both safe and effective. Aleksandra, Miller, and Rabago (2012) mention that opioids abuse is linked to efforts to apply patient-centered approach that allows patients to have greater input into their care. That is because it would promote opioids prescription. American Addiction Centers (2018) notes that addiction to prescription medication is not a novel concept. Rather, it is a common concept that needs to be actively addressed through deliberate actions that can be address through the use of less addictive medication with comparable medication.

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Although the reviewed literature show that there is high potential for opioid pain medication to be abuse and even turn addictive with ketamine presenting a viable non-addictive alternative, some of the information is not based on primary data and clinical trials thus questioning their clinical significance. Other limitations present in these studies include absence of active comparators or placebo, and subjectivity of pain assessment tools whose accuracies are questionable. As such, conducting a clinical trial using patients in the emergency room that compares opioid analgesics against ketamine (non-opioid medication) would determine performance in terms of effectiveness, and addiction. It is evident that the proof offered in the six articles presents strong support for the use of ketamine to replace opioids.

References

American Addiction Centers (2018). Can ketamine be abused and cause withdrawal? Retrieved from https://americanaddictioncenters.org/ketamine-abuse/

Bokor, G. & Anderson, P. (2014). Ketamine: An update on its abuse. J Pharm Pract, 27(6), 582-586. doi: 10.1177/0897190014525754

Fan, Z, Lin, J., Li, X., Chen, X. & Huang, X. (2017). The effect of pain self-management based on pain control diary on breakthrough pain. Journal of Clinical Oncology, 3(15), 10107. doi: 10.1200/JCO.2017.35.15_suppl.10107

Manchikanti, L., Helm, S., Fellows, B., Janata, J. W., Pampati, V., Grider, J. S. & Boswell, M. V. (2012). Opioid epidemic in the United States. Pain Physician, 15, ES9-ES38. Retrieved from http://www.painphysicianjournal.com/current/pdf?article=MTcwNA==&journal=68

Pourmand, A., Mazer-Amirshahi, M., Royall, C., Alhawas, R. & Shesser, R. (2017). Low dose ketamine use in the emergency department, a new direction in pain management. Am J Emerg Med., 35(6), 918-921. doi: 10.1016/j.ajem.2017.03.005

Zgierska, S., Miller, M. & Rabago, D. (2013). Patient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA, 307(13), 1377-1378. doi: 10.1001/jama.2012.419 Pain Control Literature Research Paper.

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