| Pamphlet | News and Events |
Bedroom Talk |
Articles of Interest
| Links |
Narcophobia: Part 1: Defining the Problem
CE Article as presented in Home
Volume 19, Number 2
Barbara Acello, MS,
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
exploring narcophobia, take this true / false quiz to evaluate
your knowledge of pain management and the use of narcotics.
should be limited to clients in acute pain and malignant pain. T
Addiction is a
brain disorder in which the client compulsively seeks drugs and
continues to use them despite their harmful effects. T F
generally administer effective pain relief when given the
latitude to adjust the dosage. T F
Opioid use is
safe and appropriate for clients with chronic, nonmalignant
pain. T F
Methadone is a
safe and effective analgesic. T F
treated adequately in the United States. T F
be prescribed according to the severity of pain. T F
routinely undermedicate clients who report having pain. T F
highly addictive. T F
a physiologic occurrence recognizable in the symptoms of
withdrawal when the medication is discontinued. T F
chronic, nonmalignant pain take narcotic analgesics as a way of
avoiding life’s problems. T F
There is no
gender difference in the methods of pain management; men and
women are treated equally. T F
for clients with chronic pain, analgesia should be administered
regularly rather than waiting for pain to emerge. T F
Chronic use of
narcotic analgesics always causes addiction. T F
narcotic analgesics is the same as addiction. T F
60% of all clients with chronic pain become addicted to narcotic
analgesics within 6 months. T F
have no more pain than do younger adults. T F
The goal of
chronic pain management is to keep the client as comfortable as
possible, regardless of the dose. T F
A placebo is
indicated if the nurse believes the client is requesting too
much pain medication. T F
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?
Effective Narcotic Use
describes several barriers to effective use of narcotics:
- Fear that the
client will become addicted.
between physical dependence and addiction.
oversight and scrutiny of prescribing physicians.
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.
problems among healthcare professionals, clients, families, and
related to age, gender, ethnicity.
beliefs related to pain and suffering and the use of narcotics.
struggles between the client and others affecting medication
Discrimination, prejudice, and judgmental attitudes.
- Lack of
availability and/or difficulty obtaining narcotic medications.
How Do You Rate?
Opioids can be safely used for chronic, nonmalignant pain (McCaffery
& Ferrell, 1999).
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).
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).
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,
Methadone is an effective analgesic for some types of pain
(e.g., neuropathic pain); it has a long duration of action (Rhiner
& Kedziera, 1999).
Pain is undertreated virtually everywhere in the United States
(Brownlee & Schrof, 1997).
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).
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).
Less than 1% of patients become addicted as a result of taking
opioids for pain relief (McCaffery & Ferrell, 1999).
Dependence means that if the drug is abruptly withdrawn, opioid
withdrawal will occur (McCaffery & Ferrell, 1999).
in chronic pain can return to a functional existence when
adequate narcotic analgesia is provided (Gorman, 1997).
Researchers are now beginning to study gender differences in
pain control; however, it appears that gender biases exist (Perlman,
To avoid peaks and valleys (i.e., seesaw effect), regular dosing
is best (Strevy, 1998; Mayday, 1996).
Clients taking narcotic analgesics become physically dependent
after several weeks; less than 1% become addicted (McCaffery &
Physical and psychological dependence (addiction) are two
separate phenomena (Strevy, 1998).
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).
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, &
The goal of
pain management is to keep the client as comfortable as
possible, improving his or her quality of life (Strevy, 1998).
Placebos should be used only in research, when the client is
informed in advance and gives consent (Mayday, 1996).
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
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.
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.
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 &
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).
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.
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
Review of the
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).
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).
may be limited, and sleep patterns disrupted, in clients with severe
pain (Hitchcock, Ferrell, & McCaffery, 1999; “Hopkins Q & A,” 1997).
severe pain over a prolonged period experience depression, anxiety,
and memory loss (Zenz, Strumpf, & Tryba, 1992; Hitchcock et al.,
1994; “Hopkins Q & A,” 1997).
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
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,
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
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.
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.
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.
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,
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,
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).
- 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.
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.
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).
- 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
- one must suffer
to be cured;
would upset family members;
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.
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).
Hispanic and African American descent are more likely to be
undermedicated than Caucasians (“Poor Pain Control,” 1997).
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).
now beginning to study gender differences in relation to pain
control (Perlman, 1999).
Children in pain
are often undermedicated (Allender, 1997).
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).
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).
flare in pain in clients taking long-acting analgesics; this
pain occurs suddenly and is often of moderate to severe
intensity (Rhiner & Kedziera, 1999).
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).
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).
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
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).
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).
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 &
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.
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
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
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
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:
home health aide
1 RN 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
1. Do you perceive a problem with clients
receiving medications for pain, especially narcotic analgesics?
(Most  of the respondents answered, “yes.” Other answers were
“sometimes” , “no” , and “not a problem in hospice” .)
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
client addiction by physicians, nurses working outside of the
hospice environment, caregivers and clients;
scrutiny by regulatory agencies;
obtaining medication including difficulty securing
prescriptions and the costs incurred by the client;
education of physicians, nurses, clients, and caregivers
related to narcotics and their appropriate use;
misconceptions about the side effects of narcotics;
stigma related to narcotic medication (especially morphine);
of narcotic usage with the terminal stage of disease and/or
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;
religious or cultural beliefs that lead them to believe that
they must endure pain; and
struggles between client and caregiver related to medication
Narcophobia: Part 2:
CE Article as presented in Home
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
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,
educational activities on the myths and facts of pain management,
up-to-date reference pain management material,
assessment tools and scales and develop competency in using them
work with the
client and physician to adjust the dose of the ordered analgesic to
meet the client’s needs (Redmond, 1998).
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 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.
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.
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:
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.
prolonged use of narcotic analgesics inevitably leads to drug
addiction when a client pleads for stronger pain relief.
addiction when a client taking narcotic analgesics insists the
dose is not strong enough.
concerned about scrutiny from regulatory agencies than the
suffering of your client.
describe the difference between tolerance and addiction related
to the use of narcotic analgesics.
all clients taking high doses of narcotic analgesics are
clients taking several analgesic
medications concurrently are drug abusers.
deliberately withheld narcotic analgesics from clients because
you thought they were unnecessary.
are afraid to
give high doses of narcotic analgesics to clients and you
routinely administer the lowest possible dose.
asking the physician for orders for a placebo if you believe the
client is requesting too much pain medication.
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.
objective of narcotic administration is to provide the lowest
Use of Alternative
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?
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 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.”
actions will you take to ensure the client receives her narcotic
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.
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.
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
Speak with nurses who work in oncology about pain management
in clients with cancer, and how pain affects the quality of
Attend a seminar or inservice on using narcotic analgesics for
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
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
Imagine yourself in the client’s position—it could happen at
any time—and ask yourself what you would want a nurse to do
Listening to the
Patient’s Description of Pain
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.
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
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.
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
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?
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
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.
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.
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
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?
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?
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).
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,
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
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).
(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
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,
Hopkins Q & A:
Dealing with pain. (1997). InteliHEALTH News. Retrieved
September 24, 1997 from the World Wide Web:
Fontaine, A., & Colleau, S. M. (1997). Underestimation and
undertreatment of pain in HIV disease. British Medical Journal,
Loeb, J. L. (1999).
Pain management in long-term care. American Journal of Nursing,
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,
McGuire D., Yarbro,
C. H., & Ferrell, B. R. (1995). Cancer Pain Management. Boston:
Jones and Bartlett Publishers.
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:
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,
Pratt, R. B.
(1994). Pharmacotherapy for cancer pain: An anaesthesiologist’s
viewpoint. Annals of the Academy of Medicine of Singapore, 23,
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:
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),
Zenz, M., Strumpf,
M., & Tryba, M. (1992). Long-term oral opioid therapy in patients with
chronic nonmalignant pain. Journal of Pain and Symptom Management,
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:
Fulmer, T., Mion,
L. C., & Bottrell, M. M. (1996). Pain management protocol. Geriatric
Nursing, 17(5), 222–226, 239.
(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.
Organization. (1997). Hospice fact sheet. Retrieved November 16, 1997
from the World Wide Web:
Hospice facts &
figures. (1997). Before I die (Web site). PBS Online. Retrieved
November 15, 1997 from the World Wide Web:
(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),
(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.
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.
Health Research Group. (1996). Questionable doctors: A public citizen
health research group report. Washington, DC: Author.
Organization. (1997). The basics of hospice. Retrieved November 16,
1997 from the World Wide Web:
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.