Pain Management – Barriers and Misconceptions with Opioid Use
One of the tragedies of modern healthcare is that although efficacious opioid analgesics are available for the management of pain, some clinicians are reluctant to prescribe these medications based on barriers and misperceptions that adversely affect the quality of patient care. To gain some fresh insights in this area, this paper provides a review of the relevant literature to identify and describe common opioid misconceptions and the reasons why they exist. A critical discussion concerning the specific impact of opioids on the accuracy of pain assessment, decisions regarding the use of analgesics (including opioids) and the timely and necessary involvement of other members of the multidisciplinary team is followed by factual evidence from both the course readings as well as wider research to dispel each misconception about opioids. Finally, this paper outlines a plan, strategies and resources for education that could be used in the day-to-day dealings with both clients and colleagues in order to change attitudes and help minimize the impact of these misconceptions. A summary of the research concerning opioid barriers and misperceptions is presented in the conclusion together other important findings.
Review and Analysis
Pain is the most common complaint among patients presenting in primary care settings today (McCaffrey, Frock and Garguilo 2003). Indeed, according to Hunter (2000), “Pain is an experience that is common to most people, occurs in all areas of health care, and is the major reason for people to seek medical care” (379). The experience of pain, though, is highly subjective and frequently varies from person to person, even when the same pain-inducing stimuli are present and people can even experience significantly different types and intensities of pain from the same pain-inducing conditions at different times (Eccleston 2001). The conventional focus of pain-related examinations has been on biological factors; however, psychological (Eccleston 2001), cultural and emotional factors can also play an important role in how pain is manifested in different people (McCaffrey et al. 2003). Therefore, clinicians must take a broad array of factors into account in formulating pain management interventions. In this regard, Eccleston (2001) reports that, “Improvement in pain management can often be brought about by very simple, if subtle, changes in clinical practice” (144).
There are a number of common misperceptions about opioid use that introduce psychological barriers to their effective use. For example, Turk and Gatchel (2002) emphasize that, “Patients may experience a number of problems in getting professional help with their pain. They need to receive information about the signs and symptoms that indicate that the pain is out of control and requires urgent attention” (507). The research to date, though, also indicates that people tend to respond to pain management differently in the same ways as well, making the formulation of efficacious pain management protocols that remain responsive over time a particularly challenging enterprise (Eccleston 2001). Although effective pain management protocols, including the use of opioids, exist for a wide range of medical conditions, many patients remain under- or misinformed concerning appropriate levels of opioid use. For example, Block, Kremer and Fernandez (1999) emphasize that, “Patients and potential patients possess misinformation about the controllability of pain and maintain misconceptions regarding the use and morbidity associated with routine opioid therapy” (p. 505).
In addition, many patients in need of pain management may be reluctant to request opioid treatments based on their perceptions of patient compliance and desire to accommodate healthcare providers’ advice. In this regard, Block and his associates add that, “Pain treatment patients maintain dysfunctional attitudes pertaining to the conduct of a ‘good patient’ who suffers and the effect of requests for pain treatment. Clearly, educational efforts are necessary to alter these maladaptive perceptions” (1999, p. 505). This point is also made by Aranda, Yatesp, Nash, Skerman and McCarthy (2003) who emphasize, “Attitudes towards the opioids used to treat cancer pain are also known to play a significant role in cancer patients’ reluctance to acknowledge pain and to adhere to recommended pain relief strategies” (337).
Patient attitudes are also adversely affected by misperceptions concerning the use of opioids and their subsequent options as their condition progresses. In this regard, Aranda and his associates conclude that, “In addition, concerns about side-effects, with being a good patient and beliefs that using morphine too early will limit options at the end of life all play a role in reducing the potential effectiveness of pain management” (337). Some patients may be reluctant to comply with pain management protocols based on their views about the role of pain in preventing further injuries. For instance, Block et al. report that, “Patients often develop misconceptions about pain management techniques that can interfere with adherence. For example, patients commonly are reluctant to engage in exercise for fear that it will exacerbate pain intensity and/or provoke further injury” (103). Other researchers have also identified significant misperceptions among cancer pain patients concerning medication use that adversely affected their compliance (Block et al. 1999).
Many of the psychological barriers to effective opioid use among both patients and clinicians are based on previous experiences with a few drug-seeking patients that affect the perceptions among clinicians that others are likewise over-reporting the severity of their pain. According to Turk and Gatchel (2005), “Fear of dependence on the part of the oncologist and the patient can lead to inadequate doses of analgesics” (507). Although some cancer patients do in fact develop increased tolerances to opioids over time, there is scant evidence to support their conclusion that these pain sufferers have become psychologically dependent in the classic definition of drug dependence. In this regard, Turk and Gatchel emphasize that:
Doctors and nurses are often afraid of colluding with what they perceive as the excessive demands of the small number of patients who have a history of drug dependence. In the management of drug-dependent patients who do not have cancer, the setting of and adherence to strict boundaries are widely regarded as essential to successful treatment. In the case of patients with cancer, this situation can result in undermedication. (507)
Therefore, although patients have a fundamental responsibility to communicate their pain management needs to their healthcare providers and/or caregivers, it is reasonable to conclude that many people who are in severe pain may be reluctant to be assertive regarding their needs in the presence of an authoritative clinician who may likewise be ill-informed about effective pain management methods. In fact, many clinicians may simply be unaware of the broad array of pain treatment modalities available, and educational efforts are needed to help provide healthcare providers with current information concerning best practices with pharmacological, mind-body and other multidisciplinary interventions (McCaffrey et al. 2003). In this regard, Tucker (2004) emphasizes that healthcare providers have been successfully sued for their failures to provide adequate levels of pain management. These lawsuits were based on the needless suffering that was experienced by patients given the ready availability of efficacious opioids, a failure that was due in large part to their lack of knowledge concerning pain management protocols including appropriate dosage levels (Tucker 2004). Clearly, there is a delicate balancing act involved in the provision of adequate pain management for critically ill patients, but the overarching factor is the ethical dimension that is involved. For instance, according to Turk and Gatchel (2002), “Other things being equal, adequate pain control is preferable to inadequate pain control, and inadequately controlled pain can be seen as intrinsically wrong in that it causes unnecessary suffering, with no obvious benefit to the sufferer” (507). While there may be justifiable concerns over long-term opioid use, Turk and Gatchel (2002) insist that the provision of adequate pain control should be the goal of all healthcare providers. In this regard, Turk and Gatchel conclude that, “Withholding drugs to lower the risk of later dependence is not necessarily always the right thing to do, because the decision depends on a careful consideration of the pros and cons of withholding vs. granting adequate pain control” (507). These are important issues rather than mere shades of correctness. According to Tucker (2000), “A person can and does experience ‘harm’ as a result of ineffective pain management practices by health care providers. The term harm encompasses not only physical and emotional harm but also that which results from persons not having their legitimate interests met, to the detriment of their well-being” (380).
Likewise, another potential barrier to the provision of adequate pain relief is based on the misperceptions and practices of healthcare providers involved in pain management (Block et al., 1999). This point is also made by Baker (2005) who reports that many patients may engage in behaviors that are entirely normal for people suffering from chronic pain but which may be misinterpreted by clinicians who are accustomed to drug-seeking behaviors. According to Baker, “Behaviours that we loosely term ‘abnormal’ are expected outcomes of central sensitization to a painful stimulus. The stimulus may be long gone but the circuitry remains, for a reason not yet discovered” (emphasis author’s) (70-71). Similarly, a study by Vortherms and Ward (1992) found that almost half (42%) of the 790 nurses surveyed regarding their perceptions of barriers to the provision of adequate treatment of cancer pain reported that they believed cancer patients over-reported the severity of their pain and just over half (56%) were able to identify appropriate practice management guidelines for analgesics. Moreover, fully three-quarters of the surveyed nurses reported that the lack of adequate assessment of cancer pain was a significant barrier to effective pain management, and almost as many (72%) reported a lack of clinician knowledge as representing yet another significant barrier to effective pain management (Vorthern and Ward 1992). Given the complexity of the pain experience, helping caregivers provide appropriate levels of pain management is particularly challenging. Many caregivers may be reluctant to provide adequate levels of opioids for pain management in the home based on fears of addiction, levels of tolerance, potential side effects of the drugs and whether increased opioid treatment reflecting disease progression (Aranda et al. 2003). Although the sample used in their study was relatively small (n=75), Aranda et al. (2003) conclude that, “The increasing role of the family in managing the patient’s pain in the home environment and a recognition that family beliefs and attitudes will influence the success of their role adds to the growing call for intervention development that includes the family caregiver as a target of such work” (342). Taken together, these issues indicate that day-to-day dealings with pain patients and colleagues tasked with the provision of effective opioid-based pain management protocols must be based on factual realities rather than preconceptions that can result in unnecessary suffering and litigious outcomes.
The research showed that although the experience of pain is virtually universal, the effective management of pain is complicated by a number of barriers, including psychological barriers among both pain patients and healthcare providers alike. These psychological barriers were shown to include misperceptions concerning the need for opioid analgesics from the outset, and extended across the board to include significant differences in how pain is experienced by different people at different times. Clinicians may be reluctant to provide adequate levels of pain management for fear of patients becoming addicted to or dependent on opioids, and some patients may be reluctant to communicate their need for additional pain relief for fear of being perceived as a drug addict or an incompliant patient. In the final analysis, each patient is unique and will experience pain differently. The task of the healthcare provider is to accurately assess the level of pain and provide clinical interventions that are founded on evidence-based practices rather than personal misperceptions that may cause unnecessary suffering.
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