Barrier: Fear of Addiction

Nursing Approaches

  • Clarify the terms addiction, physical dependence, and tolerance (see below).
  • Explain that addiction is uncommon in older adults taking opioids for pain.
  • Assess the older adults history of substance abuse using a direct, nonjudgmental approach.

Barrier: Fear of Tolerance

Nursing Approaches

  • Clarify the terms addiction, physical dependence, and tolerance (see below).

  • Explain that tolerance is a normal physiologic response in people on chronic opioid therapy. Developing tolerance does not mean that the older adult is addicted.

  • If tolerance does develop, the older adult medication may need to be changed. For example, morphine can be used instead of oxycodone or vise-versa.

  • Explain that there is no upper dosage limit for opioids such as morphine, oxycodone and hydromorphone. Therefore, opioids can be safely titrated under the supervision of the physician or nurse practitioner without causing damage to the kidney or liver.

  • Discuss that tolerance develops more slowly to the analgesic effects of opioids than to many side effects such as sedation and respiratory depression.

Barrier: Concerns about Side Effects

Nursing Approaches

  • Teach methods to prevent and to treat common side effects.

  • Emphasize that many side effects such as sedation and nausea often decrease with time.

  • Explain that different medications have unique side effect profiles and that other pain medications can be tried to minimize specific side effects.

  • Incorporate nondrug pain therapies into the treatment plan to minimize the dose of medication needed to control pain.

Barrier: Desire to be Stoic

Nursing Approaches

  • Explain that while stoicism often is a valued behavior in our culture, failing to report pain can result in undertreatment and severe, unrelieved pain.

  • Teach staff resident and family that unrelieved pain can lead to other problems, e.g., loss of sleep, depression, impaired immune response.

  • Explore meaning of the disease and spiritual/cultural beliefs.

Barrier: Desire to Be a "Good Patient"

Nursing Approaches

  • Explore factors such as culture, age, and gender that influence resident-provider communication. For example, an older person may not feel comfortable discussing concerns with a very young health care provider. Address these issues openly and assure the resident that their concerns will be taken seriously and are important to the health care team.

  • Explain that older adults are partners in their care and that the partnership works when there is open communication between the older adult and provider.

  • Emphasize to older adults their responsibilities in ensuring optimal pain treatment—one responsibility is keeping the provider informed about pain.

  • Approach the older adult in a sincere, unhurried manner.

Barrier: Ineffective Medication

Nursing Approaches

  • Teach that there are multiple options within each category of medication (e.g., opioid, NSAIDs) and another medication from the same category may provide better relief.

  • Emphasize that finding the best treatment regimen often requires periods of trial and error.

  • Incorporate non-drug approaches in the treatment plan.

Barrier: Dealing with the Older Adult's and/or Family's Belief that Pain is Inevitable and Untreatable

Nursing Approaches

  • Explain that pain is not a natural and unavoidable condition in old age.

  • Explain that there are many effective medications and nondrug therapies for pain.

  • Explain that establishing an optimal therapeutic regimen can require a period of trial and error.

  • Emphasize that many side effects can be prevented or controlled.

Barrier: Fear of Distracting the Physician from Treating the Disease

Nursing Approaches

  • Explain that reporting pain is important in treating both the disease and the symptoms.

  • Emphasize that older adults have a right to have their disease and their symptoms treated.

Barrier: Concern that Pain Signifies Disease Progression (for example, cancer)

Nursing Approaches

  • Explain that increased pain or analgesic needs may reflect tolerance to the medication and not that their disease is progressing.

  • Emphasize that new pain may come from a non-life threatening source, e.g., muscle strain, UTI.

  • When necessary, incorporate pharmacologic and non-drug therapies to manage anxiety.

  • Ensure that the older adult and family have current, accurate, and comprehensive information about disease and prognosis.

  • Provide psychological support; refer to social worker, psychologist, or chaplain as appropriate.

  • Discuss older adult’s and family goals for care in light of disease progression and resident prognosis.

Barrier: Fear of Injections

Nursing Approaches

  • Explain that in the nursing home, the most common route of administration for pain medicines is the oral route.

  • Emphasize that even if the oral route is not possible, transdermal or indwelling parenteral routes can be used rather than injections.

Definitions of Addiction, Physical Dependence, and Tolerance (adapted from reference 2)

Addiction: a chronic neuro-biologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

 

Physical Dependence: a state of adaptation manifested by a withdrawal syndrome that is specific to the class of drug or medication; in other words, withdrawal to anti-depressant therapy or long-term corticosteroid treatment has different symptoms than opioid withdrawal. Withdrawal can occur when the drug is stopped suddenly, the drug dose is reduced abruptly, changes in metabolism and other factors cause decreased blood level of the drug, and/or an antagonist (for example, naloxone) is administered.

 

Tolerance: a state of adaptation in which exposure to a drug induces changes that result in a decrease of one or more of the drug's effects over time.

 

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Reference

  1. Ersek M. Enhancing effective pain management by addressing patient barriers to analgesic use. Journal of Hospice and Palliative Nursing. 1999(1): 87-96.
  2. Savage, S., et al. Definitions Related to the Use of Opioids for the Treatment of Pain: A consensus document from the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine.  American Pain Society Advocacy and Policy. 2001.