Acello, Barbara MS, RN; Bedard, Marcia PhD; Rickels, Charlotte MFA; Dack, Cheryl Ensom 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.
Opioid use should be limited to clients in acute pain and malignant pain.T□F□
Addiction is a brain disorder in which the client compulsively seeks drugs and continues to use them despite their harmful effects.T□F□
Nurses 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□
Pain is treated adequately in the United States.T□F□
Opioids should be prescribed according to the severity of pain.T□F□
Nurses routinely undermedicate clients who report having pain.T□F□
Morphine is highly addictive.T□F□
Dependence is a physiologic occurrence recognizable in the symptoms of withdrawal when the medication is discontinued.T□F□
Clients with 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□
When caring 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□
Dependence on narcotic analgesics is the same as addiction.T□F□
Approximately 60% of all clients with chronic pain become addicted to narcotic analgesics within 6 months.T□F□
The elderly 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□
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.
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).
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).
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).
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.
How Do You Rate?
False. Opioids can be safely used for chronic, nonmalignant pain (McCaffery & Ferrell, 1999).
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).
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).
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).
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).
False. Pain is undertreated virtually everywhere in the United States (Brownlee & Schrof, 1997).
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).
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).
False. Less than 1% of patients become addicted as a result of taking opioids for pain relief (McCaffery & Ferrell, 1999).
True. Dependence means that if the drug is abruptly withdrawn, opioid withdrawal will occur (McCaffery & Ferrell, 1999).
False. Many clients in chronic pain can return to a functional existence when adequate narcotic analgesia is provided (Gorman, 1997).
False. Researchers are now beginning to study gender differences in pain control; however, it appears that gender biases exist (Perlman, 1999).
True. To avoid peaks and valleys (i.e., seesaw effect), regular dosing is best (Strevy, 1998; Mayday, 1996).
False. Clients taking narcotic analgesics become physically dependent after several weeks; less than 1% become addicted (McCaffery & Ferrell, 1999).
False. Physical and psychological dependence (addiction) are two separate phenomena (Strevy, 1998).
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).
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).
True. The goal of pain management is to keep the client as comfortable as possible, improving his or her quality of life (Strevy, 1998).
False. Placebos should be used only in research, when the client is informed in advance and gives consent (Mayday, 1996).
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).
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).
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.
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.
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 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.
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