The patient who watches the clock and requests their pain medication at the top of hour. The patient who always rates their pain a “10” out of 10. The patient who requests a specific narcotic like Dilaudid. Some nurses might view such behavior as red flags and will label those patients as potential “drug seekers”—but pain management experts like Bobbie Norris, BSN, RN, CNRN, BC-RN, a pain resource nurse at Johns Hopkins Department of Neurology and Neurosurgery in Maryland, says nurses who jump to those conclusions are often wrong and do a disservice to their patients.
The patient specifically asking for Dilaudid, for instance, isn’t necessarily an addict. In fact, a patient returning to the hospital for his umpteenth surgery most likely is an expert on what medications work best for him. “Just because a patient knows what works for them, that doesn’t mean they’re drug-seeking,” says Norris.
Susan McMillan, PhD, ARNP, FAAN, a nursing professor at the University of South Florida who has researched pain in oncology patients, echoes Norris’ concerns. “Nurses today are very concerned about drug-seeking,” she says, recalling a study in which nurses were asked what made them decide if a patient was “drug-seeking,” as opposed to suffering. “Their answers were: ‘If their pain was unrelieved, if it’s overwhelming, or if they ask too frequently,’” says McMillan, though in reality, each of those behaviors is an indicator that a patient’s pain is not being well managed.
Indeed, if Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores are an effective measurement, patients are not getting enough pain relief during their hospital stays. According to HCAHPS patient survey data, only 71% of those surveyed said their pain was “always” well controlled in 2014-2015. Other studies, meanwhile, show that pain is often undertreated in pediatric patients, in older adults in long-term care, and among certain minority populations.
Experts believe the highly publicized global epidemic of opiod abuse is likely contributing to the conundrum. Nurses and other members of the health care team may worry about patient addiction and tolerance. Patients, too, often worry about addiction and side effects. As a consequence, some are reluctant to take pain medications or even report their pain.
Unrelieved pain, however, can cause serious problems and ultimately jeopardize an individual’s recovery from surgery or illness. Patients with poorly controlled pain are less likely to walk around and breath deeply, increasing their risk for atelectasis and other complications of immobility. Not addressing a patient’s pain also opens a nurse up to legal liability.
Experts say that nurses can better serve their patients by following these five strategies:
1. Believe Your Patient
Margo McCaffrey transformed the nursing profession’s approach to pain management when she declared in 1968 that pain is “whatever the experiencing person says it is, existing whenever he says it does.” While that’s the prevailing philosophy nurses learn in school, it doesn’t always carry over into clinical practice. “Nurses will say to me, ‘They can’t be in this much pain. Their blood pressure’s not up. They’re not tachycardic, they’re not tachypneic,’” says Norris. In fact, patients who’ve suffered from chronic pain for many years often show no objective systemic signs of distress because their central nervous system has “autoregulated.” While the risk of addiction is a valid concern, it does not negate the RN’s responsibility to accept the patient’s report of pain and respond to it with compassion and prompt intervention.
2. Better Monitoring
Measuring pain is an integral part of managing it. That’s why the VA developed an initiative in the 1990s to promote pain as the “fifth vital sign.” The concept of measuring pain as a vital sign—along with heart rate and blood pressure—was intended to get health care professionals in the habit of routinely screening, assessing, and documenting pain levels. One area where nurses continue to struggle, though, is with pain reassessment post-intervention. While every hospital has its own policies about when to reassess pain, ideally pain should be reevaluated at around the time it takes for a drug to reach its peak effect: that’s about 15 to 20 minutes after an IV bolus of morphine, and 60 to 90 minutes after an oral narcotic. Close monitoring also allows the RN to keep an eye on a patient’s sedation level and respiratory status and make any necessary adjustments to the patient’s treatment plan—and that should ease the anxiety of the RN who is worried about overmedicating their patient.
3. Expanding Therapies
Multimodal pharmacology is the optimal approach to managing pain. This means patients do better if they receive a combination of pain medications targeting different pain pathways, such as a narcotic pain reliever that directly decreases transmission of pain signals to the brain—and an NSAID to reduce swelling and inflammation at the site of injury. Drugs aren’t the only way to combat pain. Sandra Siedlecki, PhD, RN, CNS, a senior nurse scientist at Cleveland Clinic, has found that music therapy can be an effective tool to reduce chronic pain, which is notoriously difficult to treat. In fact, when patients suffering from chronic neck, back, and arm pain listened to an hour of music each day, their pain dropped by about 21% according to Siedlecki’s study published in the Journal of Advanced Nursing. A number of hospitals, including Johns Hopkins, have also introduced “Pain Control and Comfort” menus offering patients ‘a la carte’ therapies, ranging from warm packs and icepacks, to handheld fans, repositioning, stress balls, and handheld massagers. While many of the items on the menu have always been available, presenting them in this format gives the patients a feeling of “empowerment,” says Suzanne Nesbit, PharmD, CPE, a clinical pharmacy specialist and pain management research associate at Johns Hopkins.
4. A Tailored Approach
Patients don’t just differ in how they feel pain—they also differ in their response to pain medications. For example, studies have shown that approximately one-third of patients with cancer-related pain don’t respond well to morphine and develop intolerable adverse effects or fail to get any significant pain relief. Researchers, however, are beginning to unravel some of the mysteries of pain and providing scientific explanations for idiosyncrasies in drug response. Genetic variability in the cytochrome P450 (CYP450) system, the enzyme system in the liver that breaks down medications, can dramatically influence how well a drug works. If a CYP450 enzyme metabolizes a medication too quickly, for instance, the patient might require a higher dose for effective pain relief. If the patient’s CYP450 system is sluggish, they might require a smaller dose, otherwise toxicity can occur. Age, gender, and lifestyle can also impact drug response. In the future, hospitals will use genetic testing to help personally tailor pain treatment regimens for patients. Until then, nurses will have to rely on their assessment skills and clinical judgment to implement pain interventions adapted to each patient’s needs.
5. Examine Bias
Research has shown that ethnic minorities are routinely and systemically undertreated for pain when compared to white patients. One study by researchers at Emory University found that 43% of African American patients presenting at an Atlanta emergency department with long bone fractures received no pain medications. By contrast, only 26% of white patients with the same injuries “went untreated for pain.” A 2015 study published in JAMA Pediatrics found that black children with appendicitis were 20% less likely than white children to receive painkillers in the ED. A 2016 study by the University of Virginia on the topic attributed the disparate treatment to erroneous beliefs about biological differences among the two races. Awareness and acknowledgment that such bias exists is a first step to rooting out unconscious bias. The Joint Commission also recommends health care providers perform “teach back,” utilize educational and training techniques to “de-bias” care, and “assiduously” practice evidence-based medicine.