Acello, Barbara MS, RN; Bedard, Marcia PhD; Rickels, Charlotte MFA; Dack, Cheryl Ensom BA
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,
* center educational activities on the myths and facts of pain management,
* have accurate, up-to-date reference pain management material,
* use pain assessment tools and scales and develop competency in using them correctly, and
* work with the client and physician to adjust the dose of the ordered analgesic to meet the client’s needs (Redmond, 1998).
Understanding Pain Management Goals
Many nurses erroneously believe that the goal of pain management is to keep the dose of narcotic analgesics as low as possible. This is not true. The overall patient objective should always be to keep the client as comfortable as possible, therefore improving the quality of life (Strevy, 1998). To accomplish this means providing an effective dosing schedule of the most appropriate pain medication. Often, the proper dose is found in a combination of short-and long-acting narcotic analgesics and adjuvant medications.
If a single drug is used, but is ineffective, the dose may be increased by 25% to 50% until relief is obtained (McCaffery & Ferrell, 1999; Rhiner & Kedziera, 1999). If pain relief is ineffective, gradually increasing the opioid dosage is safe. There is no upper ceiling for dosing of these drugs; increasing the dose of the medication increases pain relief. The resulting side effects of high doses can usually be managed through skilled medical and nursing interventions.
The frail elderly client may require lower doses of narcotic analgesics than younger clients; however, some elderly clients take the same doses as younger adults. The nurse must follow physician’s orders and the state’s nurse practice act when titrating medication. Medication dosage should be individualized to the client’s response, with the goal being adequate pain relief.
Joint Commission Pain Standards: Since 2000, the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) has required healthcare organizations to teach all clients to use a pain rating scale. The agency will agree with a goal for pain management with the client, and work to achieve this goal. To work with opioids safely, agency staff may need additional education working with pain scales, titrating these drugs, and managing side effects and breakthrough pain.
These standards emphasize the patient’s right to pain assessment and management and require the healthcare organization to provide for adequate assessment and treatment of pain. The standards will undoubtedly lead to improvement in pain management skills and understanding on the part of practitioners; however, the most important outcome will be more effective pain control for the patient.
Understanding the Nursing Role
Working with the client and caregiver to relieve severe pain requires excellent assessment skills, client advocacy, empathy, and a creative plan of care. Before beginning therapy, pain management should be discussed in detail making clear the client’s self-assessment and description of the pain as the centerpiece for directing the pain management plan.
Safe use and security of the medication should also be explained and patient responsibilities related to pain management might be stated in contract form and signed by the client to verify agreement. Nurses are responsible for teaching the client and caregivers about pain, its consequences, and pain management strategies. The nurse must have excellent pain management skills to effectively:
* 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.
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.
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.
believe prolonged use of narcotic analgesics inevitably leads to drug addiction.
suspect addiction when a client pleads for stronger pain relief.
suspect addiction when a client taking narcotic analgesics insists the dose is not strong enough.
are more concerned about scrutiny from regulatory agencies than the suffering of your client.
cannot describe the difference between tolerance and addiction related to the use of narcotic analgesics.
believe that all clients taking high doses of narcotic analgesics are addicts.
believe that clients taking several analgesic medications concurrently are drug abusers.
have 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.
consider asking the physician for orders for a placebo if you believe the client is requesting too much pain medication.
deliberately delay giving the medication for as long as possible (assuming a 3-to 4-hour PRN dosing schedule) when a client requests a narcotic analgesic 3 hours from the last dose.
believe the objective of narcotic administration is to provide the lowest dose possible.
What Would You Do?
You discover that Susan, your client’s family caregiver, has been flushing her mother’s morphine down the toilet, and substituting an over-the-counter drug that is similar in appearance. The daughter has been telling you that she has administered the morphine, but the client, Mrs. Harriman, discovered what her daughter was doing, and cries while she relates the story to you.
She tells you that while her daughter was away, she called a friend on the phone and asked her to obtain stronger drugs because her pain was unbearable. You approach the client’s daughter. She says, “It’s bad enough that my mother is dying. I will not have her die a drug addict! She only thinks she needs the medication.”
How will you respond?
What actions will you take to ensure the client receives her narcotic analgesics?
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.
Actions for Overcoming Narcophobia
* Learn all of the facts by reading the studies cited in this article. Education is one of the best ways to change your opinion, and dispel fear.
* Talk to colleagues who have worked in a hospice setting or pain management clinic about your concerns.
* Ask a physician who specializes in pain management to describe some of the clients he or she sees in practice, and how they are managed.
* Speak with nurses who work in oncology about pain management in clients with cancer, and how pain affects the quality of life.
* Attend a seminar or inservice on using narcotic analgesics for pain management.
* Attend a seminar on how to assess pain and the use of pain scales. Consider establishing a pain goal for each client, teaching him or her the use of the pain scale, and utilizing the scale to assess effectiveness of medications.
* Order some of the excellent materials from the Mayday Pain Resource Center, 1500 E. Duarte Road, Duarte, CA 91010, (616) 359-8111, ext. 3829, and visit their Web site: http://mayday.coh.org
* Use the Agency for Healthcare Policy Research and Quality (U.S. Department of Health and Human Services) to educate yourself and your patients. Publications include both patient and clinicians’ guides to managing cancer pain.
* Talk to clients with nonmalignant pain who are successfully managed on narcotic analgesics about their experience with these drugs. Ask them how proper pain management has affected their quality of life.
* Participate or lurk (internet-speak for eavesdropping) on one of the many on-line discussion groups or listservs where chronic pain clients share their anguish in attempting to obtain narcotic analgesics so they can return to work, parent their children, and have a lives again.
* Organize weekly or monthly brown-bag lunch meetings at your agency and share pain management strategies with each other by discussing some of your most difficult cases.
* Join or start a weekly or monthly reading and discussion group with three or four of your colleagues. Take turns selecting a new article on pain management that everyone reads, then discuss its implications for nursing practice at the next meeting.
* Ask the medical librarian at the largest hospital in your area to meet with the nursing staff at your agency to discuss pain management resources and library services (e.g., performing literature searches). Ask the librarian to notify you when a new book or article on pain management is received in the library.
* Imagine yourself in the client’s position—it could happen at any time—and ask yourself what you would want a nurse to do for you.
What Would You Do?
David is a 29-year-old client who has had multiple back surgeries resulting from an automobile accident 12 years ago. The injured area has a great deal of scar tissue, and David is in severe, chronic pain. He describes the pain as an “excruciating, stabbing, lingering, nerve pain.” The doctors have advised him that nothing more can be done medically, and he will probably be on narcotic analgesics for the rest of his life.
David takes 100 mg. of methadone daily for pain relief. He has an additional prescription for 10 mg. of methadone BID PRN for breakthrough pain. You are reporting off to another nurse about the clients in your caseload before going on vacation. When you report the client’s analgesic medications, the nurse states that the client must be a drug addict.
How will you respond?
Use this opportunity to teach the nurse about management of nonmalignant pain. Your colleague may not know that methadone is a very effective analgesic in the treatment of chronic neuropathic pain.
Share current journal articles about the appropriateness of methadone in treating specific pain syndromes and other pain management information, as well as definitions and information on dependence and addiction.
What Would You Do?
An elderly client with metastatic breast cancer has an order for morphine, 15 mg. to 30 mg. PO every 3 to 4 hours PRN for pain relief. She confides that she is fearful of taking morphine.
Despite a careful explanation, she continues to tell you she is afraid, but agrees to try the drug. When you return, the client admits that she “just couldn’t” take the morphine.
She also admits to being in “terrible pain.” How will you ensure this client receives adequate pain relief?
Reassure the client that her pain can be managed through appropriately prescribed medications. Repeat your explanation of the use of morphine for pain management and review the physician’s orders for the medication. Try to determine what she fears and address these fears with information. Use teaching sheets, videos, or other resources directed toward clients with similar questions and concerns (many pharmaceutical companies have produced excellent resources directed toward the patient).
Telling the client that many people take morphine regularly for pain relief may be effective. If you have cared for other elderly women using morphine, give examples, maintaining confidentiality. If on-call services are available, inform the client that she can contact a healthcare professional immediately should she experience any untoward effects. Advising the client that the morphine dose is relatively low may alleviate some fears. Consider a switch to time-release morphine or oxycodone; the pills are small and can be taken every 12 hours so that the client is not as aware of the need for a narcotic.
© 2001 Lippincott Williams & Wilkins, Inc.