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Narcophobia: Part 1: Defining the Problem

CE Article as presented in Home Healthcare Nurse
February 2001
Volume 19, Number 2

Barbara Acello, MS, RN, Marcia Bedard, PhD,
Charlotte Rickels, MFA
, and Cheryl Ensom Dack, BA


 

Narcophobia is a fear that regulatory agencies, healthcare professionals, clients experiencing acute and chronic pain, and their families can share. Our goal was to determine whether clients with severe, chronic pain were adequately medicated and if not, the reasons why. This article, the first of a two-part series, discusses the problem so that hospice and home care nurses can be aware of how their attitudes affect patient care.
 

Are You Narcophobic?
 

Before exploring narcophobia, take this true / false quiz to evaluate your knowledge of pain management and the use of narcotics.
1. Opioid use should be limited to clients in acute pain and malignant pain. T F
2. Addiction is a brain disorder in which the client compulsively seeks drugs and
continues to use them despite their harmful effects. T F
3. Nurses generally administer effective pain relief when given the latitude to adjust the dosage. T F
4. Opioid use is safe and appropriate for clients with chronic, nonmalignant pain. T F
5. Methadone is a safe and effective analgesic. T F
6. Pain is treated adequately in the United States. T F
7. Opioids should be prescribed according to the severity of pain. T F
8. Nurses routinely undermedicate clients who report having pain. T F
9. Morphine is highly addictive. T F
10. Dependence is a physiologic occurrence recognizable in the symptoms of withdrawal when the medication is discontinued. T F
11. Clients with chronic, nonmalignant pain take narcotic analgesics as a way of avoiding life’s problems. T F
12. There is no gender difference in the methods of pain management; men and women are treated equally. T F
13. When caring for clients with chronic pain, analgesia should be administered regularly rather than waiting for pain to emerge. T F
14. Chronic use of narcotic analgesics always causes addiction. T F
15. Dependence on narcotic analgesics is the same as addiction. T F
16. Approximately 60% of all clients with chronic pain become addicted to narcotic analgesics within 6 months. T F
17. The elderly have no more pain than do younger adults. T F
18. The goal of chronic pain management is to keep the client as comfortable as possible, regardless of the dose. T F
19. A placebo is indicated if the nurse believes the client is requesting too much pain medication. T F
20. Clients who need larger or more frequent doses of narcotic analgesics are usually addicted to them. T F

Review the answers and the definitions on the following page. Adequate knowledge related to pain management is essential to overcoming narcophobia. How do you rate?


Barriers to Effective Narcotic Use

The literature describes several barriers to effective use of narcotics:

  • Fear that the client will become addicted.
  • Confusion between physical dependence and addiction.
  • Regulatory oversight and scrutiny of prescribing physicians.
  • Inadequate pain management education among healthcare professionals.
  • Social stigma related to use of narcotic analgesics.
  • Fears and misconceptions about side effects of narcotic analgesics and lack of knowledge regarding side effect management.
  • Failure to adequately assess the client’s pain.
  • Underestimation of the client’s need for narcotic analgesics.
  • Communication problems among healthcare professionals, clients, families, and caregivers.
  • Attitudes related to age, gender, ethnicity.
  • Religious beliefs related to pain and suffering and the use of narcotics.
  • Power struggles between the client and others affecting medication administration.
  • Discrimination, prejudice, and judgmental attitudes.
  • Lack of availability and/or difficulty obtaining narcotic medications.
     

How Do You Rate?
 

1. False. Opioids can be safely used for chronic, nonmalignant pain (McCaffery & Ferrell, 1999).
2. True. Opioid addiction is a psychological dependence in which the client compulsively craves and seeks drugs for effects other than pain relief (McCaffery & Ferrell, 1999; Strevy, 1998).
3. False. Although nursing actions have improved with education, some nurses continue to depend on behavior as an indicator of severe pain. Nurses are less likely to medicate a client who is smiling versus one who is grimacing (McCaffery & Ferrell, 1999).
4. True. In some clients, opioids improve functioning (Zenz et al, 1992); medication for chronic pain is started with NSAIDS and lesser forms of analgesics, and advanced to opioids if pain cannot be controlled by other methods (Strevy, 1998).
5. True. Methadone is an effective analgesic for some types of pain (e.g., neuropathic pain); it has a long duration of action (Rhiner & Kedziera, 1999).
6. False. Pain is undertreated virtually everywhere in the United States (Brownlee & Schrof, 1997).
7. True. Pain is initially managed with over-the-counter analgesics. If ineffective, mild opioids are used. Stronger opioids (e.g., morphine or fentanyl [Duragesic]) are used only for more severe pain that cannot be controlled by other methods (Strevy, 1998).
8. True. Many nurses believe that the goal of pain management is to keep the dose of narcotic analgesics as low as possible. This is not true; the goal is to keep the client as comfortable as possible, improving the quality of his or her life (Strevy, 1998).
9. False. Less than 1% of patients become addicted as a result of taking opioids for pain relief (McCaffery & Ferrell, 1999).
10. True. Dependence means that if the drug is abruptly withdrawn, opioid withdrawal will occur (McCaffery & Ferrell, 1999).
11. False. Many clients in chronic pain can return to a functional existence when adequate narcotic analgesia is provided (Gorman, 1997).
12. False. Researchers are now beginning to study gender differences in pain control; however, it appears that gender biases exist (Perlman, 1999).
13. True. To avoid peaks and valleys (i.e., seesaw effect), regular dosing is best (Strevy, 1998; Mayday, 1996).
14. False. Clients taking narcotic analgesics become physically dependent after several weeks; less than 1% become addicted (McCaffery & Ferrell, 1999).
15. False. Physical and psychological dependence (addiction) are two separate phenomena (Strevy, 1998).
16. False. Less than 1% of all clients with chronic pain become addicted. Physical dependence occurs in as little as 2 to 3 weeks of therapy; however, this is not the same as addiction (McCaffery & Ferrell, 1999; Strevy, 1998).
17. False. The prevalence of pain in individuals who are elderly is known to be twice that of younger adults; estimates of prevalence of pain ranges between 25% and 50%. More than 80% of all elderly clients suffer from painful chronic diseases. (Fulmer, Mion, & Bottrell, 1996).
18. True. The goal of pain management is to keep the client as comfortable as possible, improving his or her quality of life (Strevy, 1998).
19. False. Placebos should be used only in research, when the client is informed in advance and gives consent (Mayday, 1996).
20. False. Tolerance may develop over a prolonged period of time. The client’s disease may have worsened, necessitating a dosage adjustment (Schug et al., 1992).


The Problem of Chronic Pain

Severe, unrelieved chronic pain is a problem of epidemic proportions in the United States with chronic pain on average lasting 6 months; millions of people are significantly disabled by it, sometimes permanently. Chronic pain may not respond to conventional medical treatment.

Consider these facts:

  • Approximately one-third of all visits to general practitioners in the United States are for pain (Carroll & Bowsher, 1993).
  • It is estimated that 70 million Americans endure chronic pain that is not related to terminal disease. Each day, 4 million people suffer from cancer pain (McGuire, Yarbro, & Ferrell, 1995).
  • The costs of pain, both personal and monetary, are staggering. Approximately 50 million workdays are lost each year because of pain (Brownlee & Schrof, 1997).
  • The annual cost of chronic pain in America is estimated at 50 billion dollars; this includes lost income, compensation payments, and legal and medical expenses (“Hopkins Q & A,” 1997).
Chronic, severe pain is a debilitating, and often frightening experience. Clients and their families both may fear the pain will worsen and medication will be inadequate to alleviate it. Clients with severe pain experience a wide range of problems including, but not limited to, sleep disturbances, loss of appetite, and behavioral changes. Many nurses have heard clients say they would rather die than live with unremitting pain. Family caregivers experience anxiety and other forms of stress from seeing their loved ones suffer which can be highly frustrating for everyone.

Simply obtaining a physician’s order for a narcotic analgesic can be difficult. Not all doctors are willing to write the triplicate prescriptions required by some states. When a prescription is obtained, having it filled also can present a challenge. Some pharmacies do not stock narcotic analgesics or stock only those most commonly used. The caregiver may have to travel long distances to have a prescription filled; the delays in obtaining necessary medications leave the client to suffer.

Although a proliferation of new medications for chronic pain relief was found in the 1990s, there is an incongruous deficit between the increased availability of new or improved medications and the actual use of these medications by the clients who need them. The failure of the medical community to respond to this problem has become the focus of much-needed attention in both scientific circles and the popular press.


Review of the Literature

In addition to articles published in the scientific literature and the popular press on narcophobia and the mismanagement of severe chronic pain, as well as segments on major network television programs, the Internet is an increasingly rich source on the topic. Pain is untreated or undertreated virtually everywhere in the United States (Brownlee & Schrof, 1997). Numerous studies cite the undertreatment of pain in various settings and client populations (Friedman, 1990; Portenoy, 1990; Shapiro, 1994; Taylor, Ferrell, Grant & Cheyney, 1993; McCaffery & Ferrell, 1994; Pipp, 1997; Schrof, 1997; Gorman, 1997; Gianelli, 1996; Larue, Fontaine, & Colleau, 1997; Redmond, 1998).


Impact of Unrelieved Pain

Studies of persons suffering prolonged unrelieved pain revealed the many pernicious effects on the lives of clients:

  • Clients in pain often endure fatigue, nausea, and loss of appetite (Ferrell, Grant, Padilla, Vemuri, & Rhiner, 1991).
  • Daily activities may be limited, and sleep patterns disrupted, in clients with severe pain (Hitchcock, Ferrell, & McCaffery, 1999; “Hopkins Q & A,” 1997).
  • Clients with severe pain over a prolonged period experience depression, anxiety, and memory loss (Zenz, Strumpf, & Tryba, 1992; Hitchcock et al., 1994; “Hopkins Q & A,” 1997).
  • Many long-term pain sufferers have thoughts of suicide (Hitchcock et al., 1994, Shapiro, 1994; Schrof, 1997; Gorman, 1997; Brownlee & Schrof, 1997; “Hopkins Q & A” 1997).
  • Fifty percent of the participants in one study had considered suicide (Hitchcock et al., 1994).
  • The suicide rate among chronic pain clients is 900% higher than the general population (“Hopkins Q & A,” 1997).

Clients with cancer who received adequate opioids showed improved levels of performance and increased levels of functioning and activity (Zenz et al., 1992). Many clients in chronic pain can return to a functional existence when adequate narcotic analgesia is provided (Gorman, 1997). Improved quality of life is a primary goal as well as a measure of success in pain management (Hitchcock et al., 1994; Ferrell et al., 1991; Pratt, 1994).

Much of the literature indicated that successful pain management improves pain symptoms, physical and psychological welfare, social concerns involving family life, leisure activities, and the ability to maintain employment (Hitchcock et al., 1994; Green & Coyle, 1990; Ferrell et al., 1991; Pratt, 1994; Strevey, 1998; “Hopkins Q & A,” 1997)


Why Is Pain Undertreated?

Fear of Regulatory Oversight
- A leading hypothesis for the undertreatment or mismanagement of chronic pain is that fear of regulatory scrutiny limits the physician’s willingness to adequately prescribe (Redmond, 1998). Additionally, state laws vary widely and create, individualized barriers. State medical boards, even in states with intractable pain laws, monitor prescribing practices related to controlled substances. If the state agency notes large amounts of scheduled drugs being prescribed by a physician, he or she may be called in for review. This may occur whether the drugs are prescribed for one client or for many clients. The monitoring usually applies only to prescriptions written from a doctor’s office.

Although many health professionals are inadequately educated regarding chronic pain and its management, most agree that the primary reason that doctors withhold prescriptions for narcotic analgesics is that the medications are controlled substances that are monitored by the federal Drug Enforcement Agency (DEA) and state medical boards.

Physicians often fear they will lose their license or be censured by regulatory agencies for prescribing narcotics too liberally (Hitchcock et al., 1994; Portenoy, 1990; Green & Coyle, 1990; Schrof, 1997; Gorman, 1997; Gianelli, 1996; Portenoy 1996; Brownlee & Schrof, 1997). Articles in the popular press about physicians having their medical licenses revoked due to prescribing narcotic analgesics for clients with chronic nonmalignant pain (Schrof, 1997; Gorman, 1997) show doctors’ fears are often well founded.

Although investigation by regulatory agencies is far less common in hospice and in other settings where pain is treated related to a terminal illness, fear of regulatory scrutiny is still common. To avoid this scrutiny, some pain specialists admit to undermedicating their clients (Schrof, 1997). Many researchers argue that the government’s “War on Drugs” has made it more difficult for clients in chronic pain to receive adequate analgesia (Friedman, 1990; Ferrell, McCaffery, & Rhiner, 1992; Pipp, 1997).

Excessive regulation of physicians’ prescribing practices has declined as it becomes clear that inappropriate regulation and scrutiny are interfering with caring for clients in pain. Physicians and medical boards are becoming more aware of pain management issues (Portenoy, 1996). Regulatory agencies are beginning to review policies and the American Medical Association (AMA) has drafted a model for state legislation guidelines regarding narcotic medications. The model will protect physicians from prosecution when they prescribe controlled substances using the AMA guidelines (Gianelli, 1996).


Fear of Addiction and Abuse - Social stigma attached to use of narcotic medications is another barrier to adequate pain control (Gorman, 1997). As a result, clients seeking narcotics for legitimate purposes are often viewed suspiciously by physicians, nurses, and pharmacists. In many cases, clients’ families may often consider narcotic analgesics illicit, yet these drugs are often the most effective way to relieve severe pain (Pipp, 1997).

Mild pain is often initially managed with over-the-counter analgesics. If this is ineffective, mild opioids are used often in combination with appropriate adjuvant drugs. Stronger opioids (e.g., morphine or fentanyl [Duragesic]) are used for more severe pain that cannot be controlled by other methods (Strevy, 1998). Research shows that clients with cancer who received treatment with opioids demonstrated improved levels of performance and increased levels of functioning and activity (Zenz et al., 1992).

Narcotics are the drug of choice for relieving severe, intractable chronic pain. While narcotics have a potential for abuse and psychological addiction, studies confirm that abuse and addiction are rare among chronic pain clients (Friedman, 1990; McCafferey & Ferrell, 1999; Portenoy 1990; Schug et al., 1992; Zenz et al., 1998). Unfortunately, it appears that the DEA’s “War on Drugs” has created increased narcophobia among health professionals—as well as some clients and their families—even when the medical need is legitimate.

Increased dosage is not a sign of abuse, although many narcophobic persons equate the two. Among cancer patients, research shows that the disease’s progression may indicate a dosage increase (Schug et al., 1992). With repeated doses over time, narcotics have reduced efficacy that necessitates the need to increase the dose to maintain effective pain relief (Redmond, 1998). Increased dosages and the resulting management of pain may improve quality of life, which is a measure of success in pain management (Hitchcock et al, 1994; Ferrell et al., 1991; Pratt, 1994).


Inadequate Education
- Lack of pain management education regarding the use of narcotic analgesics is clearly one of the major causes for the widespread mismanagement of severe chronic pain. Being uninformed or misinformed, caregivers often experience great anxiety when making decisions concerning when and how to administer analgesic medications (Rhiner & Kedziera, 1999). According to Brownlee and Schrof (1997), only a few medical school residency programs require a course in pain management.

Nursing education is also lacking in the area of pain management. Ferrell and her colleagues (1992) did a content analysis of 14 nursing textbooks published since 1985—including texts on pharmacology—which sheds considerable light on the source of nurses’ misinformation on pain management. Most texts used confusing terminology in their discussion of opioid analgesics and the low incidence of addiction when these drugs are used for pain management. Some texts even promoted the fear of addiction when opioids are used for pain control.

Clearly, such inadequate education of healthcare professionals leads to misconceptions associated with the therapeutic use of narcotics (Ferrell et al., 1992; Pipp, 1997; Redmond, 1998), thus, it is apparent that improvements in the education of healthcare professionals are badly needed and would contribute to an improved understanding of the differences between drug abuse and the legitimate use of narcotic medications for pain (Ferrell et al., 1992).


Attitudinal Barriers - Rhiner and Kedziera (1999) recently described attitudinal barriers to pain management, including denial, and belief that pain is a normal part of the chronic illness or condition. Several common attitudes and beliefs included:

  • one must suffer to be cured;
  • using opioids would upset family members;
  • taking opioid medications sets a bad example for children and others;
  • an increase in pain is associated with the need for uncomfortable, or expensive diagnostic tests; and
  • a fear that the healthcare providers will not focus on the patient’s treatment if the patient complains.

A real concern is that many individuals with chronic illnesses already take several medications and may see opioids as unnecessary. Some individuals attempt to save analgesic medications until the pain is intolerable.

Biases in healthcare on the basis of race/ethnicity, sex, age, cognitive impairment, and socioeconomic class exist and can present problems for clients with severe chronic pain. The bias against persons who are seropositive for HIV are well-documented. Thus, it is important for nurses to be aware of some of the recent findings relative to pain management of certain groups:

  • Clients ages 65 years or older are more likely to be undermedicated than their younger counterparts (McCaffery & Ferrell, 1991; Loeb, 1999).
  • Clients of Hispanic and African American descent are more likely to be undermedicated than Caucasians (“Poor Pain Control,” 1997).
  • Undertreatment of pain in clients with HIV disease is common, with less than half receiving no treatment (Larue, Fontaine, & Colleau, 1997).
  • Women are often undermedicated because research related to pain has been done almost exclusively on men (NIH, 1997, Perlman, 1999).
  • Researchers are now beginning to study gender differences in relation to pain control (Perlman, 1999).
  • Children in pain are often undermedicated (Allender, 1997).
     

Definitions
 

Acute pain: Short-lived pain lasting less than 6 months; usually of moderate to severe intensity. This type of pain usually can be relieved; if not treated, it leads to anxiety (Mayday, 1996).

Addiction: A condition in which the client seeks drugs compulsively; characterized by continued cravings for opioid drugs for purposes unrelated to pain relief (McCaffery & Ferrell, 1999).

Breakthrough pain: A transient flare in pain in clients taking long-acting analgesics; this pain occurs suddenly and is often of moderate to severe intensity (Rhiner & Kedziera, 1999).

Chronic pain: Long-term pain lasting more than 6 months, perhaps for life; varying degrees of intensity, from mild to severe; often more difficult to relieve than acute pain; may cause some depression in addition to pain, frequently accompanied by fatigue and exhaustion (Mayday, 1996).

Dependence: A physical condition in which withdrawal symptoms occur when opioid drugs are abruptly withdrawn; clients taking narcotic analgesics can become dependent after as little as 2 to 4 weeks of regular medication use (McCaffery & Ferrell, 1999).

Malignant pain: Pain caused by cancer; categorized separately from other types of pain because it has characteristics of both acute and chronic pain; degree of intensity may vary, but most often is moderate to severe (Mayday, 1996).

Nonmalignant chronic pain: Pain caused by chronic conditions (e.g., migraines, back problems, arthritis, and post polio syndrome); varying degrees of intensity, from mild to severe. The client may show no outward signs of pain or may deny pain exists; may cause some depression in addition to pain if untreated; frequently accompanied by fatigue and exhaustion (Mayday, 1996).

Opioid: Family of drugs derived from opium, as well as any synthetic narcotic that simulates opium effects; produces opiate-like effects on opiate receptors in the brain, relieving pain. The receptors are the same as those used by the body to produce endorphins, easing pain. The effect of opioids may include sedation or euphoria (Peterson, 1997).

Tolerance: A state in which a larger dose of analgesic medication is needed to control pain; pain exceeds the ability of the prescribed opioid drugs to control it; corrected by increasing the dosage (McCaffery & Ferrell, 1999).


Summary

This literature discusses the devastating effects on physical and mental health and the economic aspects when severe pain is untreated. Unfortunately, measuring the emotional pain that invariably accompanies this condition is impossible. The steady erosion of the quality of life for millions of clients in pain and their families—as they struggle with divorce, poverty, homelessness, despair, and often suicide—is the real tragedy. Severe and relentless pain—unrelieved because of narcophobia—kills the mind, the spirit, and sometimes the body.

Unfortunately, narcophobia is alive and surviving well in nursing practice. Numerous studies and findings noted in the literature as well as in current experiences in clinical practice support the fact that multiple fears and barriers prevent adequate treatment of pain with narcotic analgesics.

What are the solutions to this problem that has such negative impact on the client with severe, intractable pain? Part 2 of this article (appearing in March, HHN) will explore ways you can intervene in the lives of your clients when narcophobia presents a barrier to effective pain management and quality care.
 

What Our Health Professionals Said

As we probed the narcophobia problem further, we decided to question hospice and home health staff to see if their responses mirrored the literature. We questioned 13 individuals: seven hospice nurses, two home health nurses, one social worker, one certified hospice nursing assistant, one hospice administrator (who was a patient with chronic pain), and one hospice volunteer.
 

Survey Results

We surveyed the staff of a medium-sized hospice, and two home health nurses associated with the hospital with which the hospice is affiliated. Respondents included nine RNs, but we also interviewed a social worker, a hospice certified home health aide, a hospice administrative employee who asked to answer the survey as a chronic pain patient, and a hospice volunteer who was also a certified clinical hypnotherapist. We wanted to get as many different perspectives on the problem of narcophobia as possible. An additional interview with the hospice director, an RN, was conducted following the survey to clarify the referral process and policies of the department.
14 total were surveyed as follows:

  • 2 home health nurses
  • 1 hospice social worker
  • 1 hospice home health aide
  • 1 hospice administrative employee
  • 1 hospice volunteer
  • 1 RN hospice director
  • 7 hospice RNs (in addition to the RN director above)

Note: The count is off because the hospice director was dropped from the text, although her results were included in the survey.  Because hospice and home care staff frequently treat patients with pain and coordinate pain management efforts, their perspectives on narcophobia might reflect current practice and actual barriers while providing insight and implications for other nurses confronting similar issues. We also believe that 1. the questions we asked could be helpful for clinical managers and educators to use in working with their staff and 2. the quiz presented earlier in this article could increase staff awareness that narcophobia needs to be addressed.

Questions Asked
 

1. Do you perceive a problem with clients receiving medications for pain, especially narcotic analgesics? (Most [9] of the respondents answered, “yes.” Other answers were “sometimes” [1], “no” [1], and “not a problem in hospice” [1].)

2. If you feel there are areas of concern, please describe them and rank them in order of severity. Barriers similar to the ones identified in the literature were mentioned including:

  • fear of client addiction by physicians, nurses working outside of the hospice environment, caregivers and clients;
  • fear of scrutiny by regulatory agencies;
  • problems in obtaining medication including difficulty securing prescriptions and the costs incurred by the client;
  • inadequate education of physicians, nurses, clients, and caregivers related to narcotics and their appropriate use;
  • fears and misconceptions about the side effects of narcotics;
  • social stigma related to narcotic medication (especially morphine);
  • association of narcotic usage with the terminal stage of disease and/or imminent death;
  • refusal to accept the client’s reported level of pain;
  • communication difficulties, especially between physicians and clients who are not assertive in asking questions and explaining or describing their pain;
  • clients’ religious or cultural beliefs that lead them to believe that they must endure pain; and
  • power struggles between client and caregiver related to medication administration.

 

 


Narcophobia: Part 2: The Solution

CE Article as presented in Home Healthcare Nurse
March 2001
Volume 19, Number 3

In Part 1 of this article, the problems and causes of narcophobia were explored based on an extensive literature search. By building on this increased awareness of how narcophobia affects your practice, this article outlines how you can intervene in the lives of your clients when narcophobia presents a barrier to quality care and adequate pain management.

The results of our literature review and our discussions with practitioners shared in Part 1 have immense implications for clinical nursing practice. This article outlines the many strategies professionals can change in their practice to address narcophobia and use that knowledge to achieve better pain management for all patients.


Strategies for Addressing Narcophobia

Education

The lack of education on pain management is at the core of narcophobia. To address this problem, healthcare professionals administering analgesics and teaching clients and families need to:

  • be competent in completing a thorough pain assessment,
  • center educational activities on the myths and facts of pain management,
  • have accurate, up-to-date reference pain management material,
  • use pain assessment tools and scales and develop competency in using them correctly, and
  • work with the client and physician to adjust the dose of the ordered analgesic to meet the client’s needs (Redmond, 1998).
     

Understanding Pain Management Goals

Many nurses erroneously believe that the goal of pain management is to keep the dose of narcotic analgesics as low as possible. This is not true. The overall patient objective should always be to keep the client as comfortable as possible, therefore improving the quality of life (Strevy, 1998). To accomplish this means providing an effective dosing schedule of the most appropriate pain medication. Often, the proper dose is found in a combination of short- and long-acting narcotic analgesics and adjuvant medications.

If a single drug is used, but is ineffective, the dose may be increased by 25% to 50% until relief is obtained (McCaffery & Ferrell, 1999; Rhiner & Kedziera, 1999). If pain relief is ineffective, gradually increasing the opioid dosage is safe. There is no upper ceiling for dosing of these drugs; increasing the dose of the medication increases pain relief. The resulting side effects of high doses can usually be managed through skilled medical and nursing interventions.

The frail elderly client may require lower doses of narcotic analgesics than younger clients; however, some elderly clients take the same doses as younger adults. The nurse must follow physician’s orders and the state’s nurse practice act when titrating medication. Medication dosage should be individualized to the client’s response, with the goal being adequate pain relief.

Joint Commission Pain Standards: Since 2000, the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) has required healthcare organizations to teach all clients to use a pain rating scale. The agency will agree with a goal for pain management with the client, and work to achieve this goal. To work with opioids safely, agency staff may need additional education working with pain scales, titrating these drugs, and managing side effects and breakthrough pain.

These standards emphasize the patient’s right to pain assessment and management and require the healthcare organization to provide for adequate assessment and treatment of pain. The standards will undoubtedly lead to improvement in pain management skills and understanding on the part of practitioners; however, the most important outcome will be more effective pain control for the patient.


Understanding the Nursing Role

Working with the client and caregiver to relieve severe pain requires excellent assessment skills, client advocacy, empathy, and a creative plan of care. Before beginning therapy, pain management should be discussed in detail making clear the client’s self-assessment and description of the pain as the centerpiece for directing the pain management plan.

Safe use and security of the medication should also be explained and patient responsibilities related to pain management might be stated in contract form and signed by the client to verify agreement. Nurses are responsible for teaching the client and caregivers about pain, its consequences, and pain management strategies. The nurse must have excellent pain management skills to effectively:


You Might Be Narcophobic if You:

 

1. were taught in nursing school, or believe that, narcotic analgesics are always addictive, and should be used only with dying patients in the most severe pain at the end of life.
2. believe prolonged use of narcotic analgesics inevitably leads to drug addiction.
3. suspect addiction when a client pleads for stronger pain relief.
4. suspect addiction when a client taking narcotic analgesics insists the dose is not strong enough.
5. are more concerned about scrutiny from regulatory agencies than the suffering of your client.
6. cannot describe the difference between tolerance and addiction related to the use of narcotic analgesics.
7. believe that all clients taking high doses of narcotic analgesics are addicts.
8. believe that clients taking several analgesic
medications concurrently are drug abusers.
9. have deliberately withheld narcotic analgesics from clients because you thought they were unnecessary.
10. are afraid to give high doses of narcotic analgesics to clients and you routinely administer the lowest possible dose.
11. consider asking the physician for orders for a placebo if you believe the client is requesting too much pain medication.
12. deliberately delay giving the medication for as long as possible (assuming a 3- to 4-hour PRN dosing schedule) when a client requests a narcotic analgesic 3 hours from the last dose.
13. believe the objective of narcotic administration is to provide the lowest dose possible
  • complete a head-to-toe physical assessment;

  • facilitate the client’s description of his or her pain location and intensity;
  • attempt to determine the source of the client’s pain using physical assessment data; consult with the physician related to the cause and type of pain;
  • discuss the pain with the client and determine client’s willingness to take analgesic medications, especially if narcotics are needed;
  • work with the client to determine the appropriate scale or methodology for describing the pain;
  • evaluate the need for analgesia, then act as the liaison with the physician to obtain an order for an effective medication that is appropriate for the type of pain, using the World Health Organization Analgesic Ladder and standard measurement tools;
  • allay the client’s and caregivers’ fears about using analgesic medication;
  • perform various teaching activities to the patient and caregiver including but not limited to:
  • information about the prescribed medication,
  • the administration of the drug(s) and its (their) effectiveness,
  • how to monitor for and manage side effects,
  • how to institute a bowel management program when opioids are used,
  • how to titrate the dosage, within prescribed limits as ordered for adequate pain relief, and
  • how to manage breakthrough pain.
  • reassess the client’s pain at each visit and determine when pain is out of control;
  • reassess the client’s side effects and the results of the bowel management program at each visit; and
  • offer suggestions for nonpharmacological methods of pain management.


Use of Alternative Therapies

Pain relief may also be enhanced by providing analgesic medication in combination with adjunctive nonpharmacological techniques such as massage, accupressure, vibration, distraction, biofeedback, transcutaneous electrical nerve stimulation (TENS), guided imagery, and relaxation.

What Would You Do?

You discover that Susan, your client’s family caregiver, has been flushing her mother’s morphine down the toilet, and substituting an over-the-counter drug that is similar in appearance. The daughter has been telling you that she has administered the morphine, but the client, Mrs. Harriman, discovered what her daughter was doing, and cries while she relates the story to you.

She tells you that while her daughter was away, she called a friend on the phone and asked her to obtain stronger drugs because her pain was unbearable. You approach the client’s daughter. She says, “It’s bad enough that my mother is dying. I will not have her die a drug addict! She only thinks she needs the medication.”

How will you respond?

What actions will you take to ensure the client receives her narcotic analgesics?

Response

Talk to the daughter, and educate her about narcophobia. Refer her to books, or give her copies of current literature on narcotic analgesics. Help her to work through her problems related to her mother’s illness and the need for analgesics. You may wish to include you agency’s social worker in the case or other community or organization resource. If withholding prescribed medication is considered abuse under your state’s reporting laws, consider tactfully informing the daughter that she is breaking the law; however, do not do this without first consulting a supervisor.

Ask the client if her friend, or another trusted individual, is available to oversee the analgesic medications. Another consideration may be to explain the situation to the physician and request a medication such as oxycodone that the caregiver might be willing to administer because many people react to the stigma related to morphine but are comfortable giving other medications. Use of a transdermal patch that is applied every 72 hours might be an appropriate (but more costly) alternative if the client’s pain is fairly stable and the caregiver agrees to leave it in place.
 


Nursing comfort measures such as reassurance, repositioning, eliminating bright lights and loud noise, providing a comfortable and relaxing environment, and applying heat and cold therapy may also be helpful. Approaches should be appropriate for the client’s situation and receptivity to alternative therapies and interventions. Along with the evaluation of medication effectiveness, the results of these approaches should occur at each visit and the care plan should be adjusted accordingly.

The benefits of exercise on the client’s cardiovascular system, combined with improved joint mobility, may also minimize or reduce pain; however, exercise may be contraindicated in some clients. The client should check with the physician before beginning an exercise program.


Comprehensively Evaluating the Client’s Pain

Pain is personal and subjective. Culture, ethnicity, language barriers, and many other factors may affect the client’s ability to express that he or she is experiencing pain. Some clients are very stoic, and may seem comfortable; however, avoid assuming that they are not in pain. Some clients exhibit signs of pain with body language and facial expressions while others may cry loudly.

The nurse should not make assumptions based solely on such observations. Determining the client’s level of pain based on his or her behavior is a major problem. A study by McCafferey and Ferrell (1999) concluded that nurses were less likely to document pain and administer analgesia if the client who complained of severe pain was smiling. Nurses must learn to accept reports of pain and act on them, irrespective of the client’s behavior (McCaffery & Ferrell; Redmond, 1998).
 

Actions for Overcoming Narcophobia
 

  • Learn all of the facts by reading the studies cited in this article. Education is one of the best ways to change your opinion, and dispel fear.
  • Talk to colleagues who have worked in a hospice setting or pain management clinic about your concerns.
  • Ask a physician who specializes in pain management to describe some of the clients he or she sees in practice, and how they are managed.
  • Speak with nurses who work in oncology about pain management in clients with cancer, and how pain affects the quality of life.
  • Attend a seminar or inservice on using narcotic analgesics for pain management.
  • Attend a seminar on how to assess pain and the use of pain scales. Consider establishing a pain goal for each client, teaching him or her the use of the pain scale, and utilizing the scale to assess effectiveness of medications.
  • Order some of the excellent materials from the Mayday Pain Resource Center, 1500 E. Duarte Road, Duarte, CA 91010, (616) 359-8111, ext. 3829, and visit their Web site: http://mayday.coh.org
  • Use the Agency for Healthcare Policy Research and Quality (U.S. Department of Health and Human Services) to educate yourself and your patients. Publications include both patient and clinicians’ guides to managing cancer pain.
     
  • Talk to clients with nonmalignant pain who are successfully managed on narcotic analgesics about their experience with these drugs. Ask them how proper pain management has affected their quality of life.
  • Participate or lurk (internet-speak for eavesdropping) on one of the many on-line discussion groups or listservs where chronic pain clients share their anguish in attempting to obtain narcotic analgesics so they can return to work, parent their children, and have a lives again.
  • Organize weekly or monthly brown-bag lunch meetings at your agency and share pain management strategies with each other by discussing some of your most difficult cases.
  • Join or start a weekly or monthly reading and discussion group with three or four of your colleagues. Take turns selecting a new article on pain management that everyone reads, then discuss its implications for nursing practice at the next meeting.
  • Ask the medical librarian at the largest hospital in your area to meet with the nursing staff at your agency to discuss pain management resources and library services (e.g., performing literature searches). Ask the librarian to notify you when a new book or article on pain management is received in the library.
  • Imagine yourself in the client’s position—it could happen at any time—and ask yourself what you would want a nurse to do for you.


Listening to the Patient’s Description of Pain

The client’s self-report is the single most accurate indicator of pain intensity (McCaffery & Ferrell, 1999). Pulse, respirations, blood pressure, and other physical parameters also provide useful information; however, the client can have normal vital signs despite severe pain (McCaffery & Ferrell). The nurse should not depend on the client’s facial expression or body language to guide pain management. Reports of severe pain require action regardless of the client’s appearance.


Controlling the Client’s Pain

Chronic pain should be anticipated and the client should receive medications on an individualized schedule rather than an as-needed basis. Long-acting medications allow for dosing only every 8 to 12 hours giving the client greater freedom. Clients or caregivers may be anxious about administering analgesic medications due to fear of overdosing. When the pain is appropriately managed and the dosage stabilized, frequent medication adjustments will be unnecessary. Teaching resources, written instructions, and describing scenarios in which medication should be used to control breakthrough pain may be useful.

Some clients find it useful to keep a dairy using a pain scale to document pain on a daily basis and recording the medication taken, its effectiveness, and any side effects (Rhiner & Kedziera, 1999). The nurse can review the diary at each visit using the information to develop a current assessment and contact the physician about adjusting the care plan if needed.


Dealing With Breakthrough Pain

Despite receiving regular analgesic medication, many clients experience breakthrough pain—an acute pain that occurs spontaneously. It may be triggered by activity and is best managed with short-acting opioids. Work with the client to manage the pain, using medication and adjunctive measures, or teach the client to modify his or her lifestyle, as appropriate. Scheduling adjustments may need to accommodate the need to take medications with food, time spent commuting, and other factors. Long-acting medications may need adjusting if episodes of breakthrough pain occur frequently.


Empowering the Client

Pain can often be overpowering, resulting in feelings of powerlessness that engenders hopelessness and helplessness. Many individuals with chronic illness and pain want to become experts in their own care. Teaching effective pain management and working in a partnership toward a shared goal empowers the client and caregivers, giving them control and enabling them to normalize their lives.
 

What Would You Do?

David is a 29-year-old client who has had multiple back surgeries resulting from an automobile accident 12 years ago. The injured area has a great deal of scar tissue, and David is in severe, chronic pain. He describes the pain as an “excruciating, stabbing, lingering, nerve pain.” The doctors have advised him that nothing more can be done medically, and he will probably be on narcotic analgesics for the rest of his life.

David takes 100 mg. of methadone daily for pain relief. He has an additional prescription for 10 mg. of methadone BID PRN for breakthrough pain. You are reporting off to another nurse about the clients in your caseload before going on vacation. When you report the client’s analgesic medications, the nurse states that the client must be a drug addict.

How will you respond?
 

Response

Use this opportunity to teach the nurse about management of nonmalignant pain. Your colleague may not know that methadone is a very effective analgesic in the treatment of chronic neuropathic pain.

Share current journal articles about the appropriateness of methadone in treating specific pain syndromes and other pain management information, as well as definitions and information on dependence and addiction.

 


Conclusion

The good news is that through adequate education and skill development, narcophobia in nursing can become a fear of the past. Clients and their families can enjoy the benefits of adequate pain management and enhanced quality of life. Educating others about the realities of narcophobia, as well as the myths and facts of pain management, is an important nursing responsibility. Making a commitment to providing adequate pain relief to assigned clients is equally important. For a nurse in the home care setting, overcoming the obstacles to effective management of severe pain can be challenging.

Understanding the problems and solutions related to narcophobia enables the nurse to work effectively within the system to ensure that the client’s needs are met. Providing support and reassurance that pain can be controlled is an important intervention. Advocating for the client and collaborating with the physician is essential to obtaining effective pain relief.

The two articles presented on narcophobia will assist you in exploring your own fears and, through appropriate education, to overcome false beliefs and attitudes. You are now ready to collaborate with clients, families, and physicians to ensure appropriate and adequate pain management for those suffering with chronic pain.
 

What Would You Do?

An elderly client with metastatic breast cancer has an order for morphine, 15 mg. to 30 mg. PO every 3 to 4 hours PRN for pain relief. She confides that she is fearful of taking morphine.

Despite a careful explanation, she continues to tell you she is afraid, but agrees to try the drug. When you return, the client admits that she “just couldn’t” take the morphine.

She also admits to being in “terrible pain.” How will you ensure this client receives adequate pain relief?

 

Response

Reassure the client that her pain can be managed through appropriately prescribed medications. Repeat your explanation of the use of morphine for pain management and review the physician’s orders for the medication. Try to determine what she fears and address these fears with information. Use teaching sheets, videos, or other resources directed toward clients with similar questions and concerns (many pharmaceutical companies have produced excellent resources directed toward the patient).

Telling the client that many people take morphine regularly for pain relief may be effective. If you have cared for other elderly women using morphine, give examples, maintaining confidentiality. If on-call services are available, inform the client that she can contact a healthcare professional immediately should she experience any untoward effects. Advising the client that the morphine dose is relatively low may alleviate some fears. Consider a switch to time-release morphine or oxycodone; the pills are small and can be taken every 12 hours so that the client is not as aware of the need for a narcotic.


Barbara Acello, MS, RN, is an independent nurse consultant and owner of Innovations in Health Care in Denton and El Paso, TX.
Marcia Bedard, PhD, is a Professor Emeritus for California State University, Fresno, where Charlotte Rickels, MFA, is a lecturer in the English Department.
Cheryl Ensom Dack, BA, is a Copy Writer for Gottschalk’s, Inc. (Editor’s note: At the time the article was written, Cheryl and Charlotte were students).
 


References

Allender, M. (1997). Studies refute misconceptions about pain. Nursing in Pediatrics, (fall/winter), 21.

Brownlee, S., & Schrof, J. M. (1997, March 17). The quality of mercy: Effective pain treatments already exist. Why aren’t doctors using them? U.S. News and World Report, 54–67.

Carroll, D., & Bowsher, D., (Eds.). (1993). Pain Management and Nursing Care. Oxford: Butterworth Heinemann.

Ferrell, B., Grant, M., Padilla, G., Vemuri, S., & Rhiner, M. (1991). The experience of pain and perceptions of quality of life: Validation of a conceptual model. The Hospice Journal, 7, 9–24.

Ferrell, B. R., McCaffery, M., & Rhiner, M. (1992). Pain and addiction: An urgent need for change in nursing education. Journal of Pain and Symptom Management, 7, 117–124.

Friedman, D. P. (1990). Perspectives on the medical use of drugs of abuse. (1990). Journal of Pain and Symptom Management, 5, S2–S5.

Gianelli, D. M. (1996). Medical boards, legislatures expand view of pain control. American Medical News. Retrieved November 11, 1996 from the World Wide Web: http://www.ama-assn.org/sci-pubs/amanews/pick/pick1111.htm.

Gorman, C. (1997, April 28) The case for morphine: If nothing is better for pain than narcotics, why don’t more doctors prescribe them? Time, 14–17.

Green, J., & Coyle, M. (1990, September). Methadone use in the control of nonmalignant chronic pain. Physician Assistant, 84–92.

Hitchcock, L. S., Ferrell, B. R., & McCaffery, M. (1994). The experience of chronic nonmalignant pain. Journal of Pain and Symptom Management, 9, 312–318.

Hopkins Q & A: Dealing with pain. (1997). InteliHEALTH News. Retrieved September 24, 1997 from the World Wide Web: http://www.intelihealth.com/IH/ihtIH/EMIHCOOO/21899/21899.html.

Larue, F., Fontaine, A., & Colleau, S. M. (1997). Underestimation and undertreatment of pain in HIV disease. British Medical Journal, 314, 23–28.

Loeb, J. L. (1999). Pain management in long-term care. American Journal of Nursing, 99(2), 48–52.

McCaffery, M., & Ferrell, B. R. (1991). Patient age: Does it affect your pain-control decisions? Nursing 91, 21, 44–48.

McCaffery, M., & Ferrell, B. R. (1994). Understanding opioids and addiction. Nursing 94, 24, 56–59.

McCaffery, M., & Ferrell, B. R. (1999). Opioids and pain management. Nursing 99, 29, 48–52.

McGuire D., Yarbro, C. H., & Ferrell, B. R. (1995). Cancer Pain Management. Boston: Jones and Bartlett Publishers.

National Institute of Health (NIH). 1997. Summary of the capitol hill breakfast briefing on pain management sponsored by the honorable Tom Harkin (1997, May 7). National Institute of Nursing Research.(Online).

Perlman, D. (1996, October 30). Gender gap in efficacy of pain pills: One type works for women study finds. San Francisco Chronicle, p. 1.

Pipp, T. L. (1997, August). Conquering pain: Many doctors are reluctant to prescribe narcotics to relieve patients’ suffering. The Detroit News. Retrieved August 1, 1997 from the World Wide Web: http://detnews.com/1997/accent/9708/01/index.htm

Poor pain control in minority cancer patients. (1997). InteliHEALTH News.(online).

Portenoy, R. K. (1990) Chronic opioid therapy in nonmalignant pain. Journal of Pain and Symptom Management, 5, S46–S62.

Portenoy, R. K. (1996). Opioid therapy for chronic nonmalignant pain: A review of the critical issues. Journal of Pain and Symptom Management, 11, 203–217.

Pratt, R. B. (1994). Pharmacotherapy for cancer pain: An anaesthesiologist’s viewpoint. Annals of the Academy of Medicine of Singapore, 23, 598–609.

Redmond, K. (1998). Barriers to the effective management of pain. International Journal of Palliative Nursing 4, 6.

Retrieved June 27, 1999 from the World Wide Web: http://www.markallengroup.com/ijpn/bmanp.htm

Rhiner, M., & Kedziera, P. (1999). Managing breakthrough pain: A new approach. American Journal of Nursing, 99(33), S3–S14.

Schrof, J. M. (1997, March 17). Caught in pain’s vicious cycle: He helped his patients—and lost his license. U. S. World and News Report, 64.

Shapiro, R. S. (1994). Liability issues in the management of pain. Journal of Pain and Symptom Management, 9, 146–152.

Schug, S. A., Zech, D., Grond, S., Jung, H., Meuser,T., & Stobbe, B. (1992). A long-term survey of morphine in cancer pain patients. Journal of Pain and Symptom Management, 7, 259–266.

Strevy, S. R. (1998). Myths and facts about pain. RN, 62, 42–45.

Taylor, E. J., Ferrell, B. R., Grant, M. & Cheyney, L. (1993). Managing cancer pain at home: The decisions and ethical conflicts of patients, family caregivers, and homecare nurses. Oncology Nursing Forum, 20(6), 919–927.

Zenz, M., Strumpf, M., & Tryba, M. (1992). Long-term oral opioid therapy in patients with chronic nonmalignant pain. Journal of Pain and Symptom Management, 7, 69–77.

 

Suggested Reading

Bedard, M. (1998). Bankruptcies of the heart: Secondary losses from disabling chronic pain. The Syndrome Sentinel, 1(4), 3–5.

Canine, C. (1997, March). Pain, profit, and sweet relief. Worth, 79–82, 151–158.
Do I have to die in pain? (1997, November) Before I die (Web site). PBS Online. Retrieved November 15, 1997 from the World Wide Web:
http://www.pbs.org/wnet/bid/program.html

Fulmer, T., Mion, L. C., & Bottrell, M. M. (1996). Pain management protocol. Geriatric Nursing, 17(5), 222–226, 239.

Hellinghausen, M. (1998, April 14). Aging Painlessly. HealthWeek, 2, 4, 9.

Hitchcock, L. S. (1993). Attitudes of chronic pain sufferers regarding access to opioid medications: Results of 1993 survey of NCPOA members. National Chronic Pain Outreach Association, Inc.

National Hospice Organization. (1997). Hospice fact sheet. Retrieved November 16, 1997 from the World Wide Web: http://nhpco.org/

Hospice facts & figures. (1997). Before I die (Web site). PBS Online. Retrieved November 15, 1997 from the World Wide Web: http://www.pbs.org/wnet/bid/program.html.

Kedziera, P. (1998). The two faces of pain. RN, 98, 45–46.

Loeb, J. (1999). Pain management in long-term care. American Journal of Nursing, 99(2), 48–52.

Mayday Foundation. (1996). Care of the patient with pain: A pain management curriculum for skilled nursing facilities. Duarte, CA: Author.

Max, M., Cleary, J., Ferrell, B., Foley, K., Payne, R., & Shapiro, B. (1997). Treatment of pain at the end of life: A position statement from the American Pain Society. Glenview, IL: American Pain Society.

Medical guidelines for determining prognosis in selected non-cancer diseases. (1996). Standards and Accreditation Committee Medical Guidelines Task Force. Arlington, VA: National Hospice Organization.

Mostowy, D. E. (1996). An application of Transcutaneous electrical nerve stimulation to control pain in the elderly. Gerontological Nursing. 22(2), 36–37.

Pasero, C. L., & McCaffery, M. (1997). Pain control: Are opioids right for nonmalignant pain? American Journal of Nursing, 97(6), 20, 22.

Peterson, A. M. (1997). Analgesics. RN, 97(4), 45–50.

Public Citizen’s Health Research Group. (1996). Questionable doctors: A public citizen health research group report. Washington, DC: Author.

National Hospice Organization. (1997). The basics of hospice. Retrieved November 16, 1997 from the World Wide Web: http://www.pbs.org/wnet/bid/program.html.

Todd, C. (1998, February 16). Pain in the elderly, part 1: Assessing a complex population. HealthWeek, 2, 18–19.

Todd, C. (1998, March 16). Pain in the elderly, part 2: Management strategies. HealthWeek, 2, 28–29.

U.S. Department of Health and Human Services. (1994, March). Managing cancer pain: Patient guide. Washington, DC: Author.

 


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