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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.
 

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.
   

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).

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).

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).
   

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.
 

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).
   

• 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.

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).
 

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.
 

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.
 

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).
 

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