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Knowing How to Play the Game: Hospitalized Substance Abusers’ Strategies for Obtaining Pain Relief
Original Articles Knowing How to Play the Game: Hospitalized Substance Abusers’ Strategies for Obtaining Pain Relief yyy Betty D. Morgan, PhD, APRN-BC
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From the University of Massachusetts Lowell School of Health and Environment, Department of Nursing, Lowell, Massachusetts. Address correspondence and reprint requests to Betty D. Morgan, PhD, APRN-BC, Assistant Professor, University of Massachusetts Lowell School of Health and Environment, Department of Nursing, 3 Solomont Way, Suite 2, Lowell, MA 01854. Email: [email protected] This research was supported by two grants: American Society for Pain Management Nursing Eastern Massachusetts Chapter Research Grant 2002 and American Society for Pain Management Nursing Research Grant 2003. 1524-9042/$32.00 © 2006 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2005.12.003
ABSTRACT:
This study explored hospitalized substance abusers’ perspectives about getting their pain adequately addressed in the hospital setting and their interactions with nurses about pain-management issues. The aim of the study was to generate theory that can contribute to a greater understanding of the problem of pain management with this population. A grounded theory approach was used to interview participants with a substance abuse problem who were hospitalized with a medical/surgical problem. Interviews were conducted using an interview guide; interviews were audiotaped and transcribed. In addition, a focus group of nurses who worked with this population met twice, once midway through the study, and before the final participant interview. The nurses commented on the fit of the developing model according to their experiences of working with the population described. Eighteen participants were interviewed for a total of 20 interviews (two participants were interviewed twice). All participants were polysubstance abusers and had a painful medical/surgical problem for which they were hospitalized. The Model of “Knowing How to Play the Game” was developed on the basis of participants’ descriptions of their experiences and consisted of two core action categories “Feeling Respected/Not Respected” and “ Strategizing to Get Pain Relief.” Participants had many suggestions about nursing actions that were helpful or not helpful in assisting them to obtain pain relief. Nursing practice, education, research, and policy implications were discussed. © 2006 by the American Society for Pain Management Nursing
The problem of inadequate pain management in hospital settings is well documented (Gordon, et al., 2002; McNeil, Sherwood & Stark, 2004; Melzack, 1990; Newshan, 1998; Portenoy, et al., 1997). Up to 40% of patients with cancer do not receive appropriate treatment for pain (Cleeland, et al., 1994; Foley, 2000; Rainone, 2004) and up to 80% of patients with human immunodeficiency Pain Management Nursing, Vol 7, No 1 (March), 2006: pp 31-41
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virus/acquired immunodeficiency syndrome (AIDS) may be undertreated for their pain (Breitbart, et al., 1996; Harding, et al., 2005). Researchers reported in the SUPPORT study (1995) that approximately 40% of severely ill and older patients who died in university hospitals were in moderate to severe pain during the last 3 days of life. Unrelieved pain diminishes quality of life (Ferrell, 1995; Hughes, 2004), further weakens debilitated patients, and causes unnecessary suffering (Gordon, Berry & Dahl, 2000). It can contribute to increased levels of anxiety and depression, and have a significant impact on the coping skills of the family, as well as the patient (Ferrell, Rhiner, Cohen & Grant, 1991). Inadequate pain management also has financial costs resulting from longer hospital stays, frequent readmissions, and increased outpatient and emergency department visits (American Chronic Pain Association, 2003; Freeman, 2004; Grant, Ferrell, Rivera & Lee 1995). The problem of inadequate pain management is compounded when the patient has a problem with, or a history of, substance abuse. Fear of addiction (both provider and patient fear) is a leading barrier to adequate pain management (Paice, Toy, & Schott, 1998). Lack of knowledge among providers about addiction and pain management and stigma around opiate use are also barriers. The undertreatment of pain in this population is compounded by provider knowledge deficits and provider attitudes about substance abusers (Portenoy et al., 1997).
REVIEW OF THE LITERATURE Many authors have addressed the clinical dilemmas of addiction and pain management. The coexistence or the overlap of the issues of pain and addiction has been described as a challenge for professionals (Kemp, 1995). Several authors have provided screening tools and suggestions for screening for addiction in patients with chronic pain (Adams, et al., 2004; Chaball, Erjavec, Jacobson, Mariano & Chaney, 1997; Coambs & Jarry, 1996; Compton, Darakjian & Miotto,1998; Michna, et al., 2004; Miotto, Compton, Ling & Conolly, 1996; Savage, 1993; Sees & Clark, 1993). Other authors have suggested guidelines for dealing with pain in substance abusers (ASPMN, 2003; Compton & Athanasos, 2003; Fishman, Bandman, Edwards & Borsook, 1999; Fishman, et al., 2000; Gitlin, 1999; Passik & Portenoy, 1998; Passik & Theobold, 2000; St. Marie, 1996; Vourakis, 1998). Suggestions have included the need for acceptance of and respect for the patients’ report of pain (Ferrell, 2005; McCaffery & Vourakis, 1992), the use of written contracts with patients about use/abuse of
prescriptions (Vourakis, 1998), and the selection of one provider who will provide the pain prescriptions. Consultation with pain and substance abuse specialists (Vourakis, 1998; Wesson, Ling & Smith, 1993), multidisciplinary team involvement, and primary care services within drug-treatment centers to provide comprehensive care for the patient have been shown to improve care (Currie, Hodgins, Crabtree, Jacobi & Armstrong, 2003; Karasz, et al., 2004; McCaffery & Vourakis, 1992).
RESEARCH ON PAIN MANAGEMENT FOR PEOPLE WITH SUBSTANCE ABUSE PROBLEMS Researchers who have examined the problem of pain management in a population with substance abuse problems have conducted most of their studies on patients with cancer or AIDS. Breitbart, et al. (1997) compared pain report and adequacy of analgesic therapy in patients with AIDS with and without a history of substance abuse. Differences were found in psychologic distress and adequacy of pain treatment, but no difference in pain reports, between the two groups. Patients with substance abuse also had higher levels of depression and psychologic distress, fewer supports, and poorer quality of life, and were significantly more likely to receive inadequate pain medication. Misuse of opioids or aberrant drug-taking behaviors in patients with substance abuse problems have been examined (Adams, et al., 2004; Dunbar & Katz, 1996; Michna, et al., 2004; Passik, et al.2000; Passik & Kirsch, 2005). Researchers reported that those who abused the opioid therapy demonstrated aberrant behavior patterns early in therapy, were polysubstance abusers or used oxycodone (Dunbar & Katz, 1996), and had higher levels of psychosocial distress and poorer functioning (Adams et al., 2004). Passik et al. (2000) found that aberrant drug behavior was seldom reported to staff, but patients acknowledged that they would consider aberrant behavior if pain and symptom management were not adequate. Several teams of researchers examined pain in methadone-maintained opioid abusers (Compton, Charuvastra, Kintaudi & Ling, 2000; Karasz, et al, 2004; Rosenblum, et al., 2003). Those with pain reported more health problems , more psychiatric disturbance, more prescription and nonprescription medication use, and a greater belief that they were undertreated (Jamison, Kauffman & Katz, 2000) The authors concluded that patients on methadone maintenance receive limited pain management. Rosenblum et al. (2003) studied the prevalence and characteristics of chronic pain among patients dependent on a variety of
Hospitalized Substance Abusers’ Strategies for Obtaining Pain Relief
substances in methadone maintenance and residential treatment facilities. They found that chronic, severe pain was prevalent in patients in substance abuse treatment, especially among those on methadone maintenance. They also found that self-medication was a problem, especially for those in “drug-free” programs. Karasz et al. (2004) found that severe pain had major consequences in the lives of patients on methadone maintenance and found that a common concern was that providers demonstrated a lack of concern and an inability to listen to patients. Studies conducted by Kaplan, Slywka, Slagle, and Ries (2000), Martin and Ingles (1965) and Ho and Dole (1979) addressed issues of tolerance, different pain thresholds, and the need for higher doses of pain medication in a substance-abusing population. Newshan (1998) examined pain in hospitalized patients with AIDS. In this phenomenologic study of 11 patients, five themes emerged: “Knowing pain,” “Battling pain,” “Having AIDS,” “Pain’s influence,” and “Being a drug user.” The theme of “Being a drug user” identified negative staff attitudes and participants’ belief that pain medication was withheld because of their substance abuse history. In summary, research examining the issue of pain management in people with substance abuse problems has only been examined over the last decade. Research from the perspective of patients with pain and substance abuse problems is needed to identify problems, strategies to manage the pain, and difficulties that arise in the interactions between patients with these problems, and the health care professionals who care for them.
IMPORTANCE TO NURSING Nurses comprise the largest body of health care workers and routinely provide 24-hour hospital care; therefore, they are in frequent contact with substance abusers seeking health care (Howard & Chung, 2000). Howard, Walker, Walker, and Suchinsky (1997) documented inadequate preparation in substance abuse screening and treatment in nursing programs. Lack of understanding of chemical dependency may affect the quality of nursing care this group of patients receive.
PURPOSE OF THE STUDY The purpose of this study was to identify and explore the experiences of people who have substance abuse problems who sought pain relief during hospitalization for a medical problem. The research questions were: (1) How do participants with substance abuse problems manage painful medical conditions during
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hospitalization? (2) What difficulties do they encounter in getting adequate help with pain while hospitalized? (3) How do participants with substance abuse problems understand their interactions with nurses around issues of pain?
DESIGN A grounded theory approach was used to interview participants who were substance abusers and who had a painful medical condition. Interviews of approximately 30 minutes to 1.5 hours were conducted. A semistructured format was used to explore participants’ experiences of obtaining adequate pain management during a hospitalization. Demographic data were also gathered. The purpose of the interview was twofold: to discover the successes and the barriers to adequate pain management and to understand the participants’ relationships and/or interactions with health care providers (especially nurses) during the process of seeking pain relief. Theory was generated from these data. Inclusion and Exclusion Criteria for the Study Inclusion criteria for the sample were as follows: 18 years of age or older, English-speaking, a medical condition that included acute and/or chronic pain (as reported by the participant), and a documented history of substance abuse. Substance abuse was defined as active problems with substances or a recent history of sobriety (i.e., ⬍5 years). The participants met DSMIV-TR (APA, 2000) criteria for a Substance Abuse Disorder and/or Substance Dependence Disorder. Participants had to be willing to talk, have no evidence of significant dementia, and not be psychotic or intoxicated at the time of the interview. Exclusion criteria were severe, acute mental health problems, such as delirium, dementia, hallucinations, paranoia, delusions, or suicidal or homicidal ideation. The exclusion criteria also included inability to give consent because of mental status impairment. Those who abused only alcohol were also excluded. Participants were not interviewed if they were in severe pain at the time of the interview. Description of the Setting and Sample A sample of 18 participants, 14 men and 4 women, was obtained from an urban public hospital. Sixteen participants were white, and two participants were African-American. Participants’ age ranged from 32 to 60 years. Educational background varied from a seventh grade education to a masters degree, and occupations included being unemployed and blue-collar and professional occupations. The majority of the par-
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TABLE 1. Drugs Used by Participants Drugs of abuse
Number*
Heroin Cocaine Alcohol Benzodiazepines Speed Prescription abuse (use other than as prescribed) Klonopin Opiates Opiates and benzodiazepines Route of use IV Other
16 13 10 3 2 11 5 5 1 17 1
The numbers do not add up to 18 since most participants used several drugs. *Number of participants using drug.
ticipants were hospitalized for an infectious process related to their substance use. One-third of the population were human immunodeficiency virus infected, and 72% had hepatitis C. All participants had more than one medical diagnosis. All 18 participants were polysubstance abusers, with 16 participants using heroin as their drug of choice (Table 1). All participants except one were actively using drugs before hospitalization. Participants had acute, chronic, or both acute and chronic pain. Most participants were not being treated for the current episode of pain before the hospitalization. Interview Procedures After referral from a staff member (who asked for the patients’ permission to make the referral) the potential participant was provided with information about the study and invited to participate in the research. After agreement to participate, an interview was scheduled to take place in a private area or the participants’ hospital room if they were too ill to leave the unit and adequate privacy was able to be maintained. Four interviews were conducted in the participants’ room at their request; this also allowed the researcher to observe some interactions between staff and participant. At the time of the initial interview, informed consent was obtained. All interviews were audiotaped. Demographic data were collected at the end of the interview. The interview was conducted following a semistructured format using an interview guide (Appendix A). A general question was used to begin the discus-
sion about the pain-management experiences of the participant. Over time, as more interviews were conducted and analyzed, in-depth questioning occurred on the basis of previous interview data and as concepts and relationships between concepts emerged from the data. In interviews conducted in the last half of the data-collection period the researcher shared themes from earlier interviews and asked participants to address how these themes were similar to, or different from, their experiences. As the model “Knowing How to Play the Game” was being developed, this was also shared with participants, and their feedback about the model and whether it depicted their experience was solicited. Two participants were interviewed twice, one to accommodate physical exhaustion of the participant and the other to gather more in-depth information. Written notations in the form of field notes were made during the interviews and developed further after the interviews to highlight observations not captured on the audiotape. Two focus groups were conducted with nursing staff (n ⫽ 5) to elicit feedback about the evolving theoretic model from those nurses who regularly worked with the population. The focus group members were expert clinicians who reviewed the developing model. These meetings were held after the thirteenth interview, and a second meeting was held before the final interview. The group members commented on the model and whether it clearly depicted their understanding of the process that occurred between patients and nurses. They made suggestions about the need for a variety of pathways they experienced with patients seeking pain relief. These comments were used in subsequent participant interviews, and participants were asked to comment on variations in the proposed model. The second focus group meeting included four of the original five nurses. Greater understanding and satisfaction with the model were expressed at this meeting. The nurses agreed that the model identifies the key interpersonal processes that they experienced in clinical practice. Data Analysis Preliminary data analysis began after the completion of the first interview. Field notes were developed during and after each interview to capture nonverbal expressions and impressions of the researcher. Each audiotape was transcribed, and the transcription was reviewed with the audiotape to establish its accuracy. Beginning concepts were identified during the first interview analysis. Each subsequent interview was compared with previous interviews for concepts that were grouped into categories; variations and differences in the categories, as they were reported by
Hospitalized Substance Abusers’ Strategies for Obtaining Pain Relief
participants, were also developed. Wimpenny and Gass (2000) described how ongoing analysis of interview data in grounded theory studies leads to the emergence of a tentative theory, which then provides a revised focus for subsequent interviews. Memos were written to track the researchers’ analysis, thoughts, interpretations, questions, and directions for further data collection. Frequent meetings were held with the researchers’ panel of experts to review transcripts of the interviews, categories that were being developed, and further questions to be raised in subsequent interviews. Open coding, or line-by-line coding, as well as axial coding, or the relation of subcategories to categories and development of the properties and dimensions of the categories was conducted throughout the study (Charmaz, 2002; Strauss & Corbin, 1998). Sampling continued until data saturation occurred or no new information was obtained. Theoretic saturation was achieved when no more theoretic variations were found (Strauss & Corbin, 1998). Morse (2001) described trustworthiness as the product of thorough and sensitive data collection and analysis in qualitative research. Morse (2001) described the grounded theorist’s deliberate listing of all data, coding processes, and incremental development of theory, which is verified with data each step of the way as establishing the “groundedness” of the grounded theory (p. 11). Glaser and Strauss (1967), Lincoln and Guba (1985), and Strauss and Corbin (1998) developed criteria for evaluating trustworthiness. The criteria included credibility, transferability, dependability, and confirmability as components of trustworthiness in qualitative research. Credibility means the researchers remain neutral in relation to the data and do what they said they were going to do in the research process (Glaser & Strauss, 1967). The credibility can be evaluated by the detailed descriptions of collection, analysis, and presentation of the data. Transferability or generalizability is a difficult issue in qualitative research because of the small sample size. The ability to state that findings can be applied to another setting are limited by the context of the study and the time of the study (Horsberg, 2003). Descriptions of the setting were provided in the study to aid in assessment of transferability. Dependability provides a way to determine the reliability of the data. The dependability is demonstrated by an audit trail of the research process including all data collected, that is, informed consent forms, interview audiotapes and transcripts, field notes, memos, and notes from meetings with panel of experts and focus groups. Confirmability is the clear demonstration that the findings can be deduced from
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the data. Use of thick descriptive data and maintenance of the audit trail established both confirmability and dependability as described by Glaser and Strauss (1967), Lincoln and Guba (1985), and Strauss and Corbin (1998). Model Development Midway through the data collection model development began that connected data-related categories in terms of conditions. The model was shared with participants during interviews, and as many variations in the model were sought as possible. Development of a diagram to display the model has been described as forcing the researcher to analyze the logic of the relationships (Strauss & Corbin, 1998). Discussion of the model with the focus group of nurses also assisted in the development of the model and analysis of the relationships of the categories, and further refined the questions for the last interviews that were conducted.
THE MODEL: KNOWING HOW TO PLAY THE GAME The participants in this study consistently described a process of analyzing their interactions with staff and then strategizing to get pain relief. The participants’ perceptions of respect by staff were key determinants of what strategy to use when interacting with staff. The core category of the study, Knowing How to Play the Game, encompasses two core action strategies, “Feeling Respected/Not Respected” and “Strategizing to Get Pain Relief.” The conditions that gave rise to this phenomenon included the categories of “Being an Addict,” “Past Experience Seeking Pain Relief,” “Current Pain,” and the perceived attitudes of the staff toward the participants as demonstrated by the category, “Treating Me Like a Junkie,” which constituted the problem in the model. The category “Continuum of Getting Some Relief” and the process of cycling back through the strategizing and interaction with staff categories if there was inadequate pain relief were the consequences of the interaction of the core concepts. The model “Knowing How to Play the Game: Hospitalized Substance Abusers’ Strategies for Obtaining Pain Relief,” displayed in Figure 1, illustrates the theory that emerged and maps the component parts of the model. Contributing Conditions The contributing conditions were the influences on the core categories of “Feeling Respected/Not Respected” and “Strategizing to Get Pain Relief.” “Being An Addict” encompassed the participants’ experiences of being an addict in the world and the health
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________________________________________________________________________ Conditions Problems Core Category Consequences
Knowing How to Play The Game
Current Pain
Continuum of Getting Relief Keeping Me Comfortable
Being An Addict
Treating Me Like A Junkie
Feeling Respected/ Not Respected
Strategizing to Get Pain Relief
Getting Some Relief
Still Looking For Relief Past Experience Seeking Pain Relief
FIGURE 1.
y Knowing how to play the game: hospitalized substance abusers’ strategies for obtaining pain relief.
care setting. Although participants self-identified as addicts, they went beyond accepting the societal label of “addict.” The meaning of “Being an Addict” included descriptions and consequences of their drug use, descriptions of perceived stigma, comments about their credibility (as judged by others), their coping skills, the hierarchical structure among addicts, and experience with methadone treatment. The condition “Past Experience Seeking Pain Relief” included participants’ descriptions of their past experience with pain and with health care professionals in a variety of settings. All participants described past negative experiences. These past experiences color expectations of pain relief and interaction with staff in the current setting. The condition “Current Pain” included both acute and chronic pain experienced by all participants and affected not only the participants’ experience of pain but also the staff assessment of their pain (i.e., some pain was considered more legitimate or severe, such as pancreatic pain). Larry described personal history, which was similar to that of many study participants: It’s probably more from my childhood experiences or something. It just started. I had a real rough childhood growing up and ah, you know, it was extremely traumatic and I mean as soon as I found drugs, it was just like I fell in love. It was booze and then grass and then every pill you could name every day, you know, I’d do like 3 times what everybody else was doing. I mean I just wanted to get obliterated. . .smoking angel dust, I mean by the time I probably took my first drink, I think, 12, and by the time I was 13, I was eating any drug I could get my hands on. Yeah, like I said, I had a pretty rough childhood, you know. I think I was probably, trying to, you know, using
it for more like a mood stabilizer, whatever, just to get out of my body.
Problem “Treating Me Like a Junkie” was the problem in the model and described the participants’ thoughts about staff reactions to them as substance abusers. Responses in this category varied from positive to negative, with all participants identifying at least one negative response from staff. Staff responses included both verbal and nonverbal expressions and/or behaviors. Participants evaluated the meaning of these responses, and the title, “Treating Me Like a Junkie,” epitomized the disdain and lack of respect that many participants described. John stated: I’ve had nurses in hospitals tell me you’re just looking for drugs and a place to sleep. . . Tell me that I’m using the system. They say you don’t look like you’re in much pain. . . I’ve gotten pretty harsh responses a few times. . . They say, you don’t like it, there’s the door. . . .
Gary said: You can tell when someone believes in you and you can tell when someone is pegging you, you can tell by the way they look at you. I know, they have their doubts. . .you see doubts all over their face. . .drug addict, you know. . .wants drugs.
Core Category: Knowing How to Play the Game This core category encompasses both “Feeling Respected/Not Respected” and “Strategizing to Get Pain Relief.” “Feeling Respected/Not Respected” described the participants’ perceptions of the judgments that staff made about them, based on verbal comments and
Hospitalized Substance Abusers’ Strategies for Obtaining Pain Relief
nonverbal behaviors of staff. Participants described an almost immediate ability to judge whether staff was treating them with respect. Carl stated: I (feel) totally disrespected. They’ll look at you and make a face. They’ll talk about you and you can hear them. . . The ones that just push you away, they can’t be bothered, they don’t have the time for you. . . They’re too high faluttin’. They can’t be bothered with you. . . ‘because I caused this myself’ as she told me.
John said: “Some get real mad and tell you right out ‘you’re lying’. . . ‘you’re trying to con everybody for more drugs.’” Additional factors that affected “Feeling Respected/Not Respected” include racial and ethnic differences and beliefs. Although there was not much diversity in the study population, there was tremendous diversity among the staff in the study setting, and this was mentioned repeatedly in the interviews. Gender and class differences, language differences, power differential between staff and participants, and staff knowledge about pain and addiction were discussed by participants and contributed to a perceived respect or lack of respect. “Strategizing to Get Pain Relief” was a behavior discussed by all participants and took place whether or not they felt respected by staff. The participants viewed strategizing as the best way to obtain pain relief. Strategies were of two types: presentation strategies and self-management strategies. The effectiveness of the strategies varied. Mary described a selfmanagement strategy: I’m biting my tongue. I don’t bother them (nurses). I only bother them for my pain medicine and that’s it. . .I try to be nice. I always say thank you, please, you know. . . .
Waiting for long periods of time for “prn” medications was discussed by many participants. This was described as a time when they needed to use a presentation strategy to get their medication in a more timely manner. Most participants described at least one example of waiting for a long period of time to receive medication they had requested, and often attributed the wait to the fact that they were addicts. Bob described an ineffective presentation strategy: “I feel like if I make waves, they’re just going to make me wait even longer (for medications).” Shelley said: “ What sense would it be to be pushy? You know, you don’t really get anything. It doesn’t get you anywhere. It gets you a bad name in the hospital.” Consequences The “Continuum of Getting Some Relief” was the consequence of the model and had three levels of pain relief: “Keeping Me Comfortable,” “Getting Some Re-
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Successful Strategizing
Collaboration
Feeling Respected
Going Back to the Drawing Board
Challenging the system
Not Feeling Respected Antagonism
Unsuccessful Strategizing
FIGURE 2. y Response types based on feeling respected/ not feeling respected/strategizing to get pain relief.
lief,” and “Still Looking for Relief.” Participants described all three levels and gave descriptions of pain relief, and the need for better pain relief. Jim stated: It doesn’t erase the pain completely, but it puts me down to maybe a 5, 6 from an 8, 9 (on a scale from 0-10, with 0 being no pain and 10 being worst pain). . . I can tolerate the rest of the pain. . . I’d kind of like to have more (pain medicine) but you know, if they don’t want to give it to me, they don’t want to give it to me.
All participants were asked a final question at the end of the interview about what they would recommend to staff when providing pain relief for addicts in pain. Mary responded: When we’re in pain, we’re in pain. . .just like if there’s a good reason for us to be in pain, give us the medication and leave us alone. We’re in pain. . . Stop being so rude. Have a heart. If it was their kids or their mother or father or sister or brothers, they would have a heart then, you know. Treat us the way they would treat their families.
Response Types Based on Level of Feeling Respected/Not Feeling Respected/Strategizing to Get Pain Relief Figure 2 illustrates the four types of responses based on participants’ perception of Feeling Respected/Not Respected by staff and the success or lack of success of their Strategizing to Get Pain Relief. “Collaboration” occurred when the participant felt respected by providers and was able to develop successful strategies to get pain relief. “Challenging the System” was the result of the interaction between Not Feeling Respected and eventual Successful Strategizing to Get Pain Relief. Multiple attempts at getting pain relief involved getting others to intervene for them, taking additional drugs while hospitalized (described from past hospitalizations), or convincing staff that they needed more medication. “Going Back to the Drawing Board” was the result of the interaction between Feeling Respected and Un-
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successful Strategizing to Get Pain Relief. Participants knew that not all medications would work for their pain and were able to tolerate this if they could tell the health care workers that it was not working and felt that another solution would be attempted. Some participants clearly described that the fact that the staff listened and/or believed them provided some relief in and of itself. “Antagonism” was the result of Not Feeling Respected and Unsuccessful Strategizing to Get Pain Relief. Participants felt they received no respect and little to no pain relief and had no way to cope with this problem. Multiple attempts to cope with health care providers who would not listen or respond to their requests contributed to high levels of frustration, and resulted in arguments, threatening behaviors, seeking drugs from other sources, and signing out of the hospital against medical advice.
DISCUSSION In this study, the participants described strategies they used to get pain needs met and difficulties they encountered getting their pain acknowledged and treated. They also identified a perceived lack of respect from staff for them as human beings, believing that their needs, fears, feelings, and pain went unacknowledged. Nonpharmacologic interventions and complementary alternative therapies are often used in the treatment of pain; however, only three participants in the study mentioned any of these interventions or thought they were useful. The importance of realistic goal-setting for achievable pain relief, and use of nonpharmacologic interventions may be important factors that staff need to incorporate in the care of all patients with pain, but particularly those with a substance abuse problem. Identification of staff’s lack of knowledge about both pain management and addictions was described by many participants. Participants validated this lack of knowledge through discussions with staff. Negative attitudes toward substance abusers by nursing staff have been described in the literature (Howard & Chung, 2000) and were also an issue in this study. In the focus group, staff actually described how difficult this population was to deal with and the need for staff to pay attention to their own reactions when intervening with patients. Countertransference reactions of staff who work with substance abusers have been described (Forest, 2002). Many professionals feel inadequate when dealing with patients with addiction who are in pain and are often reluctant to treat this population. Fagerhaugh and Strauss (1977) identified the nature of the organization as an important factor in affecting the interactions between staff and patients in
pain. Corley and Goren (1998) challenged nurses to eliminate behaviors that do not contribute to desired patient outcomes and suggested that “no professional behaviors persist without tacit or overt peer group or institutional support” (p. 103). Study participants expected negative reactions from health care providers on the basis of their past experiences. In society today, substance abusers are often vilified and punished or incarcerated, rather than treated. Some of the nursing responses to participants seemed to indicate an adoption of a punitive attitude toward participants. Corley and Goren (1998) state that nurse behaviors often mirror the predominant values of society. One of the nurses from the focus group stated: “The nursing profession is a very ruleladen profession and you’re dealing with your ultimate rule breakers (substance abusers).” Knowing How to Play the Game, therefore, could be seen as a necessary strategy for substance abusers to achieve respect and/or treatment for their pain in the hospital setting. In summary, participants in the study described their interactions with staff, their perceptions of staff members’ respect or lack of respect toward them, and their development of strategies to get pain relief. This study provides an explanatory model for the problem of inadequate pain management that is troublesome to both nurses and patients in the hospital setting. Implications for Clinical Practice and Research This research is a first step in understanding how substance abusers in pain view their need to interact with staff and strategize to get pain relief in the hospital setting. The model needs further testing in other settings, with women, and more diverse ethnic/racial groups. Because setting and institutional norms are so important to the delivery of pain management (Fagerhaugh & Strauss, 1977), research in diverse settings is indicated. Researchers have found that behavior change by staff who manage patient’s pain is minimal unless accompanied by an institutional policy change (Gordon, Berry, & Dahl, 2000; Clarke et al., 1996; Titler et al., 1994). Identification of policies and practices in environments that support nurses in the delivery of respectful, competent pain management will help other institutions develop appropriate programs. The theoretic model indicates that patients with pain and substance abuse need clinicians who are respectful and educated about pain management and substance abuse. Awareness of the impact of stigmatization and staffs’ own reactions to “difficult populations” is vital. Nurses often need, but do not receive, support in dealing with their reaction to patients. Use of advanced practice nurses as consultants is one way to deliver expert patient care, provide role models for
Hospitalized Substance Abusers’ Strategies for Obtaining Pain Relief
staff nurses, focus on the nurse–patient relationship, and provide education and support for staff as they increase their understanding of management of patients with complex disorders. Educational programs in schools of nursing on the undergraduate and graduate levels need to expand the current content on pain management and substance abuse. Finally, psychiatric nursing and the importance of the nurse–patient relationship, respect for all humans, and the emotional challenges that patients face when hospitalized may not be fully appreciated when the knowledge to develop these skills are integrated into the general nursing curriculum. The skills learned
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in psychiatric nursing courses and clinical settings, the importance of the nurse–patient relationship, and acquisition of the knowledge and the skills to develop and maintain effective nurse–patient relationships should play a more prominent role in nursing education as nurses care for complex patient problems in hospital settings. Acknowledgments The author acknowledges the help and support of Dr. June Andrews Horowitz, PhD, APRN-BC, FAAN; Dr. Margaret H. Kearney, PhD, RNC, FAAN; and Dr. Paul M. Arnstein, RN, PhD, FNP-C.
REFERENCES Adams, L. L., Gatchell, R. J., Robinson, R. C., Polatin, P., Gajraj, N., Descher, M., et al. (2004). Development of a self-report screening instrument for assessing potential opioid medication misuse in chronic pain patients. Journal of Pain and Symptom Management, 27(5), 440-459. American Chronic Pain Association. (2003). APCA: Medications and chronic pain. Supplement 2003. pp. 1-38. Retrieved from www.theacpa.org/resources/ ACPAdrugsupplement2003.pdf. Retrieved January 13, 2004. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th Ed.-TR). Washington, DC: American Psychiatric Association. American Society of Pain Management Nurses. (2003). ASPMN position statement: pain management in patients with addictive disease. Pensacola, FL: American Society of Pain Management Nurses. Breitbart, W., McDonald, M. V., Rosenfeld, B., Passik, S., Hewitt, D., Thaler, H., et al. (1996). Pain in ambulatory AIDS patients. I. Pain characteristics and medical correlates. Pain, 68, 315-321. Breitbart, W., Rosenfeld, B., Passik, S., Kaim, M., FunestiEsch, J., & Stein, K. (1997). A comparison of pain report and adequacy of analgesic therapy in ambulatory AIDS patients with and without a history of substance abuse. Pain, 72,235-243. Chabal, C., Erjavec, M. K., Jacobson, L., Mariano, A., & Chaney, E. (1997). Prescription opiate abuse in chronic pain patients. The Clinical Journal of Pain, 13(2), 150155. Charmaz, K. (2002). Qualitative interviewing and grounded theory analysis. In Gubrium, J.F. & Holstein, J.A. (Eds.). Handbook of interview research: context and method. 675-694 Thousand Oaks, CA: Sage Publications, Inc. Clarke, E. B., French, B., Bilodeau, M. L. Capasso, V. C., Edwards, A., & Empoliti, J. (1996). Pain management knowledge, attitudes and clinical practice: the impact of nurses’ characteristics and education. Journal of Pain and Symptom Management, 11(1), 18-31. Cleeland, C. S., Gonin, R., Hatfield, A. K., Edmonson, J.H., Blum, R. H., Stewart, J. A., et al. (1994). Pain and its treatment in outpatients with metastatic cancer: the East-
ern Cooperative Oncology group’s outpatient study. New England Journal of Medicine, 330(9), 592-596. Coambs, R. B., & Jarry, J. L. (1996). The SISAP; a new screening instrument for identifying potential opioid abusers in the management of chronic nonmalignant pain in general medical practice. Pain Research Management, 1(3), 155-162. Compton, P., & Athanasos, P. (2003). Chronic pain, substance abuse and addiction. Nursing Clinics of North America, 38, 525-537. Compton, P., Darakjian, J., & Miotto, K. (1998). Screening for addiction in patients with chronic pain and “problematic” substance use: evaluation of a pilot assessment tool. Journal of Pain and Symptom Management, 16(6), 355-363. Compton, P., Charuvastra, C., Kintaudi, K., & Ling, W. (2000). Pain responses in methadone-maintained opioid abusers. Journal of Pain and Symptom Management, 20(4), 237-245. Corley, M. C., & Goren, S. (1998). The dark side of nursing: impact of stigmatizing responses on patients. Scholarly Inquiry for Nursing Practice, 12(2), 99-122. Currie, S. R., Hodgins, D. C., Crabtree, A., Jacobi, J., & Armstrong, S. (2003). Outcome from integrated pain management treatment for recovering substance abusers. The Journal of Pain, 4(2), 91-100. Dunbar, S. A., & Katz, N. P. (1996). Chronic opioid therapy for nonmalignant pain in patients with a history of substance abuse: report of 20 cases. Journal of Pain and Symptom Management, 11(3), 163-171. Fagerhaugh, S. Y., & Strauss, A. (1977). Politics of Pain Management: Staff Patient Interaction.Menlo Park, CA: Addison-Wesley Publishing Company. Ferrell, B. (2005). Ethical perspectives on pain and suffering. Pain Management Nursing 6(3), 83-90. Ferrell, B. R., Rhiner, M., Cohen, M. Z., & Grant, M. (1991). Pain as a metaphor for illness: I. impact of cancer pain on family caregivers. Oncology Nursing Forum, 18, 1303. Ferrell, B. R. (1995). The impact of pain on quality of life: a decade of research. Nursing Clinics of North America, 30(4), 609-624.
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Fishman, S. M., Bandman, T. B., Edwards, A., & Borsook, D. (1999). The opioid contract in the management of chronic pain. Journal of Pain and Symptom Management, 18(1), 27-37. Fishman, S. M., Wilsey, B., Yang, J., Reisfield, G. M., Bandman, T. B., & Barsook, D. (2000). Adherence monitoring and drug surveillance in chronic opioid therapy. Journal of Pain and Symptom Management, 20(4), 293-307. Foley, K. M. (2000). Controlling cancer pain. Hospital Practice, 35, 101-108, 11-112. Forest, G. G. (2002). Countertransference in chemical dependency counseling. Binghamton, NY: The Haworth Press. Freeman, S. M. (2004). The relationship of opioid treatment in chronic pain conditions: Implications on brain reward response. Journal of Addictions Nursing, 15, 3-10. Gitlin, M. C. (1999). Contracts for opioid administration for the management of chronic pain: a reappraisal. Journal of Pain and Symptom Management, 18(1), 6-8. Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: strategies for qualitative research. Chicago: Aldine, Atherton. Gordon, D. B., Berry, P. H., & Dahl, J. L. (2000). JCAHO’s new focus on pain: implications for hospice and palliative care nurses. Journal of Hospice and Palliative Care Nursing, 2(4), 135-142. Gordon, D. B., Pellino, T. A., Maiskowski, C., McNeill, J. A., Paice, J. A., & Laferriere, D. (2002). 10-year review of quality improvement monitoring in pain management: recommendations for standardized outcome measures. Pain Management Nursing, 3(4), 116-130. Grant, M., Ferrell, B. R., Rivera, L. M., & Lee, J. (1995). Unscheduled admissions for uncontrolled symptoms: a healthcare challenge for nurses. Nursing Clinics of North America, 30, 673-682. Harding, R., Easterbrook, P., Higginson, I. J., Karus, D., Raveis, V. H., & Marconi, K. (2005). Access and equity in HIV/AIDS palliative care: a review of the evidence and responses. Palliative Medicine, 19(3), 251-258. Ho, A., & Dole, U. (1979). Pain perception in drug-free and methadone-maintained human ex-addicts. Social Experiments in Biological Medicine, 162, 392-395. Horsberg, D. (2003). Evaluation of qualitative research: Methodological issues. Journal of Clinical Nursing, 12(2), 307-312. Howard, M. O., & Chung, S. S. (2000). Nurses’ attitudes toward substance misusers. I: surveys. Substance Use and Misuse, 35(3), 347-365. Howard, M. O., & Chung, S. S. (2000). Nurses’ attitudes toward substance misusers. II: experiments and studies comparing nurses to other groups. Substance Use and Misuse, 35(4), 503-532. Howard, M. O., Walker, R. D., Walker, P. S., & Suchinsky, R.T. (1997). Alcohol and drug education in schools of nursing. Journal of Alcohol and Drug Education, 42(3), 54-80. Hughes, A. (2004). Symptom management in HIV-infected patients. Journal of Association of Nurses in AIDS Care, 15(5 Suppl.), 7S-13S. Jamison, R. N., Kauffman, J., & Katz, N. P. (2000). Characteristics of methadone maintenance patients with chronic pain. Journal of Pain and Symptom Management, 19(1), 53-62.
Kaplan, R., Slywka, J., Slagle, S., & Ries, K. (2000). A titrated morphine analgesic regimen comparing substance users and non-users with AIDS-related pain. Journal of Pain and Symptom Management, 19(40), 265-273. Karasz, A., Zallman, L., Berg, K., Gourevitch, M. Selwyn, P., & Arnstein, A. (2004). The experience of chronic severe pain in patients undergoing methadone maintenance treatment. Journal of Pain and Symptom Management, 28(5), 517-525. Kemp, W. C. (1995). Substance abuse and chronic pain: a challenge for nursing. Addictions Nursing, 7(20), 32-35. Lincoln, Y., & Guba, E. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage Publications. Martin, J. E., & Inglis, J. (1965). Pain tolerance and addiction. British Journal of Social and Clinical Psychology, 4, 224-229. McCaffery, M., & Vourakis, C. (1992). Assessment and relief of pain in chemically dependent patients. Orthopaedic Nursing, 11(2), 13-27. McNeill, J. A., Sherwood, G. D., & Stark, P. L. (2004). The hidden error of mismanaged pain: a systems approach. Journal of Pain and Symptom Management 28(1), 47-58. Melzack, R. (1990). The tragedy of needless pain. Scientific American, 262(2), 27-33. Miotto, K., Compton, P., Ling, W., & Conolly, M. (1996). Diagnosing addictive disease in chronic pain patients. Psychosomatics, 37(3), 223-235. Michna, E., Ross, E. L., Hynes, W. L., Nedeljkovic, S. S., Soumekh, S., Janfaza, D., et al. (2004). Predicting aberrant drug behavior in patients treated for chronic pain: Importance of abuse history. Journal of Pain and Symptom Management, 28(3), 250-258. Morse, J. M. (2001). Situating grounded theory within qualitative inquiry. In Schrieber, R. & Stern, P.S. (Eds.). Using grounded theory in nursing. 1-16 New York: Springer Publishing Company. Newshan, G. (1998). Is anybody listening? A phenomenological study of pain in hospitalized persons with AIDS. Journal of the Association of Nurses In AIDS Care, 9(2), 57-67. Paice, J. A., Toy, C., & Shott, S. (1998). Barriers to cancer pain relief: fear of tolerance and addiction. Journal of Pain and Symptom Management, 16(1), 1-9. Passik, S., & Portenoy, R. K. (1998). Substance abuse issues in palliative care. In A. (Ed.) (Berger, 1998). Principles and practices of supportive oncology. 513-533 Philadelphia: Lippincott-Raven Publishers. Passik, S. D., Kirsh, K. L., McDonald, M. V., Ahn, S., Russak, S. M., Martin, L., et al. (2000). A pilot survey of aberrant drug-taking attitudes and behaviors in samples of cancer and AIDS patients. Journal of Pain and Symptom Management, 9(4), 274-286. Passik, S. D., & Theobald, D. E. (2000). Managing addiction in advanced cancer patients: why bother? Journal of Pain and Symptom Management, 19(3), 229-234. Passik, S., & Kirsh, K. L. (2002). Pain clinicians’ ranking of aberrant drug-taking. Journal of Pain and Palliative Care Pharmacotherapy, 16(4), 39-49. Passik, S., & Kirsch, K. L. (2005). Managing pain in patients with aberrant drug-taking taking behaviors. Journal of Supportive Oncology, 3(1), 83-86.
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Portenoy, R. K., Dole, V., Herman, J., Lowinson, J., Rice, C., Segal, S., et al. (1997). Commentary. Journal of the American Medical Association, 278(7), 592-593. Rainone, F. (2004). Treating adult cancer pain in primary care. Journal of American Board of Family Practice, 17(Suppl), S48-S56. Rosenblum, A., Joseph, H., Fong, C., Kipnis, S., Cleeland, C., & Portenoy, R. K. (2003). Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities. Journal of the American Medical Association, 289(18), 2370-2378. Savage, S. R. (1993). Addiction in the treatment of pain: significance, recognition, and management. Journal of Pain and Symptom Management, 8(5), 265-278. Sees, K. L., & Clark, W. (1993). Opioid use in the treatment of chronic pain: assessment of addiction. Journal of Pain and Symptom Management, 8(5), 257-264. Strauss, A., & Corbin, J. (1998). Basics of qualitative research: techniques and procedures for developing grounded theory. Thousand Oaks, CA: Sage Publications, Inc. St. Marie, B. (1996). Chemical abuse and pain management. Journal of Intravenous Nursing, 19(50), 247-255. The SUPPORT Principle Investigators. (1995/sb:dateA controlled trial to improve care for seriously ill patients. Journal of the American Medical Association, 277,]?15911598. Titler, M. G., Moss, L., Greiner, J., Alpen M., Jones G., Olson K., et al. (1994). Research utilization in critical care: an exemplar. Clinical Issues, 5,124-132. Vourakis, C. (1998). Substance abuse concerns in the treatment of pain. Nursing Clinics of North America, 33(1), 47-60. Wesson, D. R., Ling, W., & Smith, D. E. (1993). Prescription of opioids for treatment of pain in patients with ad-
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dictive disease. Journal of Pain and Symptom Management, 8(5), 289-296. Wimpenny, P., & Gass, J. (2000). Interviewing in phenomenology and grounded theory: is there a difference? Journal of Advanced Nursing, 31(6), 1485-1492.
APPENDIX A Interview Schedule Broad Beginning Question I am interested in finding out how people with problems with substance abuse get pain relief while they are in the hospital. Can you tell me what this experience has been like for you? Probes: 1. Tell me about an episode of pain. 2. How have the nurses responded to your pain? 3. What has it been like to live with this pain? How have you managed or coped with it? 4. What other kinds of distress (other than the pain) has the pain caused? 5. How have the nurses responded to your distress? 6. What has helped to relieve your pain? 7. How do you think your problem with substance abuse has affected your experience with pain and the treatment you’ve received? Closing Questions: Is there anything else you would like to add that would help me to better understand your pain? Are there things that you have learned that you would like to tell staff who are working with other people in pain?
y
From the University of Massachusetts Lowell School of Health and Environment, Department of Nursing, Lowell, Massachusetts. Address correspondence and reprint requests to Betty D. Morgan, PhD, APRN-BC, Assistant Professor, University of Massachusetts Lowell School of Health and Environment, Department of Nursing, 3 Solomont Way, Suite 2, Lowell, MA 01854. Email: [email protected] This research was supported by two grants: American Society for Pain Management Nursing Eastern Massachusetts Chapter Research Grant 2002 and American Society for Pain Management Nursing Research Grant 2003. 1524-9042/$32.00 © 2006 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2005.12.003
ABSTRACT:
This study explored hospitalized substance abusers’ perspectives about getting their pain adequately addressed in the hospital setting and their interactions with nurses about pain-management issues. The aim of the study was to generate theory that can contribute to a greater understanding of the problem of pain management with this population. A grounded theory approach was used to interview participants with a substance abuse problem who were hospitalized with a medical/surgical problem. Interviews were conducted using an interview guide; interviews were audiotaped and transcribed. In addition, a focus group of nurses who worked with this population met twice, once midway through the study, and before the final participant interview. The nurses commented on the fit of the developing model according to their experiences of working with the population described. Eighteen participants were interviewed for a total of 20 interviews (two participants were interviewed twice). All participants were polysubstance abusers and had a painful medical/surgical problem for which they were hospitalized. The Model of “Knowing How to Play the Game” was developed on the basis of participants’ descriptions of their experiences and consisted of two core action categories “Feeling Respected/Not Respected” and “ Strategizing to Get Pain Relief.” Participants had many suggestions about nursing actions that were helpful or not helpful in assisting them to obtain pain relief. Nursing practice, education, research, and policy implications were discussed. © 2006 by the American Society for Pain Management Nursing
The problem of inadequate pain management in hospital settings is well documented (Gordon, et al., 2002; McNeil, Sherwood & Stark, 2004; Melzack, 1990; Newshan, 1998; Portenoy, et al., 1997). Up to 40% of patients with cancer do not receive appropriate treatment for pain (Cleeland, et al., 1994; Foley, 2000; Rainone, 2004) and up to 80% of patients with human immunodeficiency Pain Management Nursing, Vol 7, No 1 (March), 2006: pp 31-41
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virus/acquired immunodeficiency syndrome (AIDS) may be undertreated for their pain (Breitbart, et al., 1996; Harding, et al., 2005). Researchers reported in the SUPPORT study (1995) that approximately 40% of severely ill and older patients who died in university hospitals were in moderate to severe pain during the last 3 days of life. Unrelieved pain diminishes quality of life (Ferrell, 1995; Hughes, 2004), further weakens debilitated patients, and causes unnecessary suffering (Gordon, Berry & Dahl, 2000). It can contribute to increased levels of anxiety and depression, and have a significant impact on the coping skills of the family, as well as the patient (Ferrell, Rhiner, Cohen & Grant, 1991). Inadequate pain management also has financial costs resulting from longer hospital stays, frequent readmissions, and increased outpatient and emergency department visits (American Chronic Pain Association, 2003; Freeman, 2004; Grant, Ferrell, Rivera & Lee 1995). The problem of inadequate pain management is compounded when the patient has a problem with, or a history of, substance abuse. Fear of addiction (both provider and patient fear) is a leading barrier to adequate pain management (Paice, Toy, & Schott, 1998). Lack of knowledge among providers about addiction and pain management and stigma around opiate use are also barriers. The undertreatment of pain in this population is compounded by provider knowledge deficits and provider attitudes about substance abusers (Portenoy et al., 1997).
REVIEW OF THE LITERATURE Many authors have addressed the clinical dilemmas of addiction and pain management. The coexistence or the overlap of the issues of pain and addiction has been described as a challenge for professionals (Kemp, 1995). Several authors have provided screening tools and suggestions for screening for addiction in patients with chronic pain (Adams, et al., 2004; Chaball, Erjavec, Jacobson, Mariano & Chaney, 1997; Coambs & Jarry, 1996; Compton, Darakjian & Miotto,1998; Michna, et al., 2004; Miotto, Compton, Ling & Conolly, 1996; Savage, 1993; Sees & Clark, 1993). Other authors have suggested guidelines for dealing with pain in substance abusers (ASPMN, 2003; Compton & Athanasos, 2003; Fishman, Bandman, Edwards & Borsook, 1999; Fishman, et al., 2000; Gitlin, 1999; Passik & Portenoy, 1998; Passik & Theobold, 2000; St. Marie, 1996; Vourakis, 1998). Suggestions have included the need for acceptance of and respect for the patients’ report of pain (Ferrell, 2005; McCaffery & Vourakis, 1992), the use of written contracts with patients about use/abuse of
prescriptions (Vourakis, 1998), and the selection of one provider who will provide the pain prescriptions. Consultation with pain and substance abuse specialists (Vourakis, 1998; Wesson, Ling & Smith, 1993), multidisciplinary team involvement, and primary care services within drug-treatment centers to provide comprehensive care for the patient have been shown to improve care (Currie, Hodgins, Crabtree, Jacobi & Armstrong, 2003; Karasz, et al., 2004; McCaffery & Vourakis, 1992).
RESEARCH ON PAIN MANAGEMENT FOR PEOPLE WITH SUBSTANCE ABUSE PROBLEMS Researchers who have examined the problem of pain management in a population with substance abuse problems have conducted most of their studies on patients with cancer or AIDS. Breitbart, et al. (1997) compared pain report and adequacy of analgesic therapy in patients with AIDS with and without a history of substance abuse. Differences were found in psychologic distress and adequacy of pain treatment, but no difference in pain reports, between the two groups. Patients with substance abuse also had higher levels of depression and psychologic distress, fewer supports, and poorer quality of life, and were significantly more likely to receive inadequate pain medication. Misuse of opioids or aberrant drug-taking behaviors in patients with substance abuse problems have been examined (Adams, et al., 2004; Dunbar & Katz, 1996; Michna, et al., 2004; Passik, et al.2000; Passik & Kirsch, 2005). Researchers reported that those who abused the opioid therapy demonstrated aberrant behavior patterns early in therapy, were polysubstance abusers or used oxycodone (Dunbar & Katz, 1996), and had higher levels of psychosocial distress and poorer functioning (Adams et al., 2004). Passik et al. (2000) found that aberrant drug behavior was seldom reported to staff, but patients acknowledged that they would consider aberrant behavior if pain and symptom management were not adequate. Several teams of researchers examined pain in methadone-maintained opioid abusers (Compton, Charuvastra, Kintaudi & Ling, 2000; Karasz, et al, 2004; Rosenblum, et al., 2003). Those with pain reported more health problems , more psychiatric disturbance, more prescription and nonprescription medication use, and a greater belief that they were undertreated (Jamison, Kauffman & Katz, 2000) The authors concluded that patients on methadone maintenance receive limited pain management. Rosenblum et al. (2003) studied the prevalence and characteristics of chronic pain among patients dependent on a variety of
Hospitalized Substance Abusers’ Strategies for Obtaining Pain Relief
substances in methadone maintenance and residential treatment facilities. They found that chronic, severe pain was prevalent in patients in substance abuse treatment, especially among those on methadone maintenance. They also found that self-medication was a problem, especially for those in “drug-free” programs. Karasz et al. (2004) found that severe pain had major consequences in the lives of patients on methadone maintenance and found that a common concern was that providers demonstrated a lack of concern and an inability to listen to patients. Studies conducted by Kaplan, Slywka, Slagle, and Ries (2000), Martin and Ingles (1965) and Ho and Dole (1979) addressed issues of tolerance, different pain thresholds, and the need for higher doses of pain medication in a substance-abusing population. Newshan (1998) examined pain in hospitalized patients with AIDS. In this phenomenologic study of 11 patients, five themes emerged: “Knowing pain,” “Battling pain,” “Having AIDS,” “Pain’s influence,” and “Being a drug user.” The theme of “Being a drug user” identified negative staff attitudes and participants’ belief that pain medication was withheld because of their substance abuse history. In summary, research examining the issue of pain management in people with substance abuse problems has only been examined over the last decade. Research from the perspective of patients with pain and substance abuse problems is needed to identify problems, strategies to manage the pain, and difficulties that arise in the interactions between patients with these problems, and the health care professionals who care for them.
IMPORTANCE TO NURSING Nurses comprise the largest body of health care workers and routinely provide 24-hour hospital care; therefore, they are in frequent contact with substance abusers seeking health care (Howard & Chung, 2000). Howard, Walker, Walker, and Suchinsky (1997) documented inadequate preparation in substance abuse screening and treatment in nursing programs. Lack of understanding of chemical dependency may affect the quality of nursing care this group of patients receive.
PURPOSE OF THE STUDY The purpose of this study was to identify and explore the experiences of people who have substance abuse problems who sought pain relief during hospitalization for a medical problem. The research questions were: (1) How do participants with substance abuse problems manage painful medical conditions during
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hospitalization? (2) What difficulties do they encounter in getting adequate help with pain while hospitalized? (3) How do participants with substance abuse problems understand their interactions with nurses around issues of pain?
DESIGN A grounded theory approach was used to interview participants who were substance abusers and who had a painful medical condition. Interviews of approximately 30 minutes to 1.5 hours were conducted. A semistructured format was used to explore participants’ experiences of obtaining adequate pain management during a hospitalization. Demographic data were also gathered. The purpose of the interview was twofold: to discover the successes and the barriers to adequate pain management and to understand the participants’ relationships and/or interactions with health care providers (especially nurses) during the process of seeking pain relief. Theory was generated from these data. Inclusion and Exclusion Criteria for the Study Inclusion criteria for the sample were as follows: 18 years of age or older, English-speaking, a medical condition that included acute and/or chronic pain (as reported by the participant), and a documented history of substance abuse. Substance abuse was defined as active problems with substances or a recent history of sobriety (i.e., ⬍5 years). The participants met DSMIV-TR (APA, 2000) criteria for a Substance Abuse Disorder and/or Substance Dependence Disorder. Participants had to be willing to talk, have no evidence of significant dementia, and not be psychotic or intoxicated at the time of the interview. Exclusion criteria were severe, acute mental health problems, such as delirium, dementia, hallucinations, paranoia, delusions, or suicidal or homicidal ideation. The exclusion criteria also included inability to give consent because of mental status impairment. Those who abused only alcohol were also excluded. Participants were not interviewed if they were in severe pain at the time of the interview. Description of the Setting and Sample A sample of 18 participants, 14 men and 4 women, was obtained from an urban public hospital. Sixteen participants were white, and two participants were African-American. Participants’ age ranged from 32 to 60 years. Educational background varied from a seventh grade education to a masters degree, and occupations included being unemployed and blue-collar and professional occupations. The majority of the par-
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TABLE 1. Drugs Used by Participants Drugs of abuse
Number*
Heroin Cocaine Alcohol Benzodiazepines Speed Prescription abuse (use other than as prescribed) Klonopin Opiates Opiates and benzodiazepines Route of use IV Other
16 13 10 3 2 11 5 5 1 17 1
The numbers do not add up to 18 since most participants used several drugs. *Number of participants using drug.
ticipants were hospitalized for an infectious process related to their substance use. One-third of the population were human immunodeficiency virus infected, and 72% had hepatitis C. All participants had more than one medical diagnosis. All 18 participants were polysubstance abusers, with 16 participants using heroin as their drug of choice (Table 1). All participants except one were actively using drugs before hospitalization. Participants had acute, chronic, or both acute and chronic pain. Most participants were not being treated for the current episode of pain before the hospitalization. Interview Procedures After referral from a staff member (who asked for the patients’ permission to make the referral) the potential participant was provided with information about the study and invited to participate in the research. After agreement to participate, an interview was scheduled to take place in a private area or the participants’ hospital room if they were too ill to leave the unit and adequate privacy was able to be maintained. Four interviews were conducted in the participants’ room at their request; this also allowed the researcher to observe some interactions between staff and participant. At the time of the initial interview, informed consent was obtained. All interviews were audiotaped. Demographic data were collected at the end of the interview. The interview was conducted following a semistructured format using an interview guide (Appendix A). A general question was used to begin the discus-
sion about the pain-management experiences of the participant. Over time, as more interviews were conducted and analyzed, in-depth questioning occurred on the basis of previous interview data and as concepts and relationships between concepts emerged from the data. In interviews conducted in the last half of the data-collection period the researcher shared themes from earlier interviews and asked participants to address how these themes were similar to, or different from, their experiences. As the model “Knowing How to Play the Game” was being developed, this was also shared with participants, and their feedback about the model and whether it depicted their experience was solicited. Two participants were interviewed twice, one to accommodate physical exhaustion of the participant and the other to gather more in-depth information. Written notations in the form of field notes were made during the interviews and developed further after the interviews to highlight observations not captured on the audiotape. Two focus groups were conducted with nursing staff (n ⫽ 5) to elicit feedback about the evolving theoretic model from those nurses who regularly worked with the population. The focus group members were expert clinicians who reviewed the developing model. These meetings were held after the thirteenth interview, and a second meeting was held before the final interview. The group members commented on the model and whether it clearly depicted their understanding of the process that occurred between patients and nurses. They made suggestions about the need for a variety of pathways they experienced with patients seeking pain relief. These comments were used in subsequent participant interviews, and participants were asked to comment on variations in the proposed model. The second focus group meeting included four of the original five nurses. Greater understanding and satisfaction with the model were expressed at this meeting. The nurses agreed that the model identifies the key interpersonal processes that they experienced in clinical practice. Data Analysis Preliminary data analysis began after the completion of the first interview. Field notes were developed during and after each interview to capture nonverbal expressions and impressions of the researcher. Each audiotape was transcribed, and the transcription was reviewed with the audiotape to establish its accuracy. Beginning concepts were identified during the first interview analysis. Each subsequent interview was compared with previous interviews for concepts that were grouped into categories; variations and differences in the categories, as they were reported by
Hospitalized Substance Abusers’ Strategies for Obtaining Pain Relief
participants, were also developed. Wimpenny and Gass (2000) described how ongoing analysis of interview data in grounded theory studies leads to the emergence of a tentative theory, which then provides a revised focus for subsequent interviews. Memos were written to track the researchers’ analysis, thoughts, interpretations, questions, and directions for further data collection. Frequent meetings were held with the researchers’ panel of experts to review transcripts of the interviews, categories that were being developed, and further questions to be raised in subsequent interviews. Open coding, or line-by-line coding, as well as axial coding, or the relation of subcategories to categories and development of the properties and dimensions of the categories was conducted throughout the study (Charmaz, 2002; Strauss & Corbin, 1998). Sampling continued until data saturation occurred or no new information was obtained. Theoretic saturation was achieved when no more theoretic variations were found (Strauss & Corbin, 1998). Morse (2001) described trustworthiness as the product of thorough and sensitive data collection and analysis in qualitative research. Morse (2001) described the grounded theorist’s deliberate listing of all data, coding processes, and incremental development of theory, which is verified with data each step of the way as establishing the “groundedness” of the grounded theory (p. 11). Glaser and Strauss (1967), Lincoln and Guba (1985), and Strauss and Corbin (1998) developed criteria for evaluating trustworthiness. The criteria included credibility, transferability, dependability, and confirmability as components of trustworthiness in qualitative research. Credibility means the researchers remain neutral in relation to the data and do what they said they were going to do in the research process (Glaser & Strauss, 1967). The credibility can be evaluated by the detailed descriptions of collection, analysis, and presentation of the data. Transferability or generalizability is a difficult issue in qualitative research because of the small sample size. The ability to state that findings can be applied to another setting are limited by the context of the study and the time of the study (Horsberg, 2003). Descriptions of the setting were provided in the study to aid in assessment of transferability. Dependability provides a way to determine the reliability of the data. The dependability is demonstrated by an audit trail of the research process including all data collected, that is, informed consent forms, interview audiotapes and transcripts, field notes, memos, and notes from meetings with panel of experts and focus groups. Confirmability is the clear demonstration that the findings can be deduced from
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the data. Use of thick descriptive data and maintenance of the audit trail established both confirmability and dependability as described by Glaser and Strauss (1967), Lincoln and Guba (1985), and Strauss and Corbin (1998). Model Development Midway through the data collection model development began that connected data-related categories in terms of conditions. The model was shared with participants during interviews, and as many variations in the model were sought as possible. Development of a diagram to display the model has been described as forcing the researcher to analyze the logic of the relationships (Strauss & Corbin, 1998). Discussion of the model with the focus group of nurses also assisted in the development of the model and analysis of the relationships of the categories, and further refined the questions for the last interviews that were conducted.
THE MODEL: KNOWING HOW TO PLAY THE GAME The participants in this study consistently described a process of analyzing their interactions with staff and then strategizing to get pain relief. The participants’ perceptions of respect by staff were key determinants of what strategy to use when interacting with staff. The core category of the study, Knowing How to Play the Game, encompasses two core action strategies, “Feeling Respected/Not Respected” and “Strategizing to Get Pain Relief.” The conditions that gave rise to this phenomenon included the categories of “Being an Addict,” “Past Experience Seeking Pain Relief,” “Current Pain,” and the perceived attitudes of the staff toward the participants as demonstrated by the category, “Treating Me Like a Junkie,” which constituted the problem in the model. The category “Continuum of Getting Some Relief” and the process of cycling back through the strategizing and interaction with staff categories if there was inadequate pain relief were the consequences of the interaction of the core concepts. The model “Knowing How to Play the Game: Hospitalized Substance Abusers’ Strategies for Obtaining Pain Relief,” displayed in Figure 1, illustrates the theory that emerged and maps the component parts of the model. Contributing Conditions The contributing conditions were the influences on the core categories of “Feeling Respected/Not Respected” and “Strategizing to Get Pain Relief.” “Being An Addict” encompassed the participants’ experiences of being an addict in the world and the health
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________________________________________________________________________ Conditions Problems Core Category Consequences
Knowing How to Play The Game
Current Pain
Continuum of Getting Relief Keeping Me Comfortable
Being An Addict
Treating Me Like A Junkie
Feeling Respected/ Not Respected
Strategizing to Get Pain Relief
Getting Some Relief
Still Looking For Relief Past Experience Seeking Pain Relief
FIGURE 1.
y Knowing how to play the game: hospitalized substance abusers’ strategies for obtaining pain relief.
care setting. Although participants self-identified as addicts, they went beyond accepting the societal label of “addict.” The meaning of “Being an Addict” included descriptions and consequences of their drug use, descriptions of perceived stigma, comments about their credibility (as judged by others), their coping skills, the hierarchical structure among addicts, and experience with methadone treatment. The condition “Past Experience Seeking Pain Relief” included participants’ descriptions of their past experience with pain and with health care professionals in a variety of settings. All participants described past negative experiences. These past experiences color expectations of pain relief and interaction with staff in the current setting. The condition “Current Pain” included both acute and chronic pain experienced by all participants and affected not only the participants’ experience of pain but also the staff assessment of their pain (i.e., some pain was considered more legitimate or severe, such as pancreatic pain). Larry described personal history, which was similar to that of many study participants: It’s probably more from my childhood experiences or something. It just started. I had a real rough childhood growing up and ah, you know, it was extremely traumatic and I mean as soon as I found drugs, it was just like I fell in love. It was booze and then grass and then every pill you could name every day, you know, I’d do like 3 times what everybody else was doing. I mean I just wanted to get obliterated. . .smoking angel dust, I mean by the time I probably took my first drink, I think, 12, and by the time I was 13, I was eating any drug I could get my hands on. Yeah, like I said, I had a pretty rough childhood, you know. I think I was probably, trying to, you know, using
it for more like a mood stabilizer, whatever, just to get out of my body.
Problem “Treating Me Like a Junkie” was the problem in the model and described the participants’ thoughts about staff reactions to them as substance abusers. Responses in this category varied from positive to negative, with all participants identifying at least one negative response from staff. Staff responses included both verbal and nonverbal expressions and/or behaviors. Participants evaluated the meaning of these responses, and the title, “Treating Me Like a Junkie,” epitomized the disdain and lack of respect that many participants described. John stated: I’ve had nurses in hospitals tell me you’re just looking for drugs and a place to sleep. . . Tell me that I’m using the system. They say you don’t look like you’re in much pain. . . I’ve gotten pretty harsh responses a few times. . . They say, you don’t like it, there’s the door. . . .
Gary said: You can tell when someone believes in you and you can tell when someone is pegging you, you can tell by the way they look at you. I know, they have their doubts. . .you see doubts all over their face. . .drug addict, you know. . .wants drugs.
Core Category: Knowing How to Play the Game This core category encompasses both “Feeling Respected/Not Respected” and “Strategizing to Get Pain Relief.” “Feeling Respected/Not Respected” described the participants’ perceptions of the judgments that staff made about them, based on verbal comments and
Hospitalized Substance Abusers’ Strategies for Obtaining Pain Relief
nonverbal behaviors of staff. Participants described an almost immediate ability to judge whether staff was treating them with respect. Carl stated: I (feel) totally disrespected. They’ll look at you and make a face. They’ll talk about you and you can hear them. . . The ones that just push you away, they can’t be bothered, they don’t have the time for you. . . They’re too high faluttin’. They can’t be bothered with you. . . ‘because I caused this myself’ as she told me.
John said: “Some get real mad and tell you right out ‘you’re lying’. . . ‘you’re trying to con everybody for more drugs.’” Additional factors that affected “Feeling Respected/Not Respected” include racial and ethnic differences and beliefs. Although there was not much diversity in the study population, there was tremendous diversity among the staff in the study setting, and this was mentioned repeatedly in the interviews. Gender and class differences, language differences, power differential between staff and participants, and staff knowledge about pain and addiction were discussed by participants and contributed to a perceived respect or lack of respect. “Strategizing to Get Pain Relief” was a behavior discussed by all participants and took place whether or not they felt respected by staff. The participants viewed strategizing as the best way to obtain pain relief. Strategies were of two types: presentation strategies and self-management strategies. The effectiveness of the strategies varied. Mary described a selfmanagement strategy: I’m biting my tongue. I don’t bother them (nurses). I only bother them for my pain medicine and that’s it. . .I try to be nice. I always say thank you, please, you know. . . .
Waiting for long periods of time for “prn” medications was discussed by many participants. This was described as a time when they needed to use a presentation strategy to get their medication in a more timely manner. Most participants described at least one example of waiting for a long period of time to receive medication they had requested, and often attributed the wait to the fact that they were addicts. Bob described an ineffective presentation strategy: “I feel like if I make waves, they’re just going to make me wait even longer (for medications).” Shelley said: “ What sense would it be to be pushy? You know, you don’t really get anything. It doesn’t get you anywhere. It gets you a bad name in the hospital.” Consequences The “Continuum of Getting Some Relief” was the consequence of the model and had three levels of pain relief: “Keeping Me Comfortable,” “Getting Some Re-
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Successful Strategizing
Collaboration
Feeling Respected
Going Back to the Drawing Board
Challenging the system
Not Feeling Respected Antagonism
Unsuccessful Strategizing
FIGURE 2. y Response types based on feeling respected/ not feeling respected/strategizing to get pain relief.
lief,” and “Still Looking for Relief.” Participants described all three levels and gave descriptions of pain relief, and the need for better pain relief. Jim stated: It doesn’t erase the pain completely, but it puts me down to maybe a 5, 6 from an 8, 9 (on a scale from 0-10, with 0 being no pain and 10 being worst pain). . . I can tolerate the rest of the pain. . . I’d kind of like to have more (pain medicine) but you know, if they don’t want to give it to me, they don’t want to give it to me.
All participants were asked a final question at the end of the interview about what they would recommend to staff when providing pain relief for addicts in pain. Mary responded: When we’re in pain, we’re in pain. . .just like if there’s a good reason for us to be in pain, give us the medication and leave us alone. We’re in pain. . . Stop being so rude. Have a heart. If it was their kids or their mother or father or sister or brothers, they would have a heart then, you know. Treat us the way they would treat their families.
Response Types Based on Level of Feeling Respected/Not Feeling Respected/Strategizing to Get Pain Relief Figure 2 illustrates the four types of responses based on participants’ perception of Feeling Respected/Not Respected by staff and the success or lack of success of their Strategizing to Get Pain Relief. “Collaboration” occurred when the participant felt respected by providers and was able to develop successful strategies to get pain relief. “Challenging the System” was the result of the interaction between Not Feeling Respected and eventual Successful Strategizing to Get Pain Relief. Multiple attempts at getting pain relief involved getting others to intervene for them, taking additional drugs while hospitalized (described from past hospitalizations), or convincing staff that they needed more medication. “Going Back to the Drawing Board” was the result of the interaction between Feeling Respected and Un-
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successful Strategizing to Get Pain Relief. Participants knew that not all medications would work for their pain and were able to tolerate this if they could tell the health care workers that it was not working and felt that another solution would be attempted. Some participants clearly described that the fact that the staff listened and/or believed them provided some relief in and of itself. “Antagonism” was the result of Not Feeling Respected and Unsuccessful Strategizing to Get Pain Relief. Participants felt they received no respect and little to no pain relief and had no way to cope with this problem. Multiple attempts to cope with health care providers who would not listen or respond to their requests contributed to high levels of frustration, and resulted in arguments, threatening behaviors, seeking drugs from other sources, and signing out of the hospital against medical advice.
DISCUSSION In this study, the participants described strategies they used to get pain needs met and difficulties they encountered getting their pain acknowledged and treated. They also identified a perceived lack of respect from staff for them as human beings, believing that their needs, fears, feelings, and pain went unacknowledged. Nonpharmacologic interventions and complementary alternative therapies are often used in the treatment of pain; however, only three participants in the study mentioned any of these interventions or thought they were useful. The importance of realistic goal-setting for achievable pain relief, and use of nonpharmacologic interventions may be important factors that staff need to incorporate in the care of all patients with pain, but particularly those with a substance abuse problem. Identification of staff’s lack of knowledge about both pain management and addictions was described by many participants. Participants validated this lack of knowledge through discussions with staff. Negative attitudes toward substance abusers by nursing staff have been described in the literature (Howard & Chung, 2000) and were also an issue in this study. In the focus group, staff actually described how difficult this population was to deal with and the need for staff to pay attention to their own reactions when intervening with patients. Countertransference reactions of staff who work with substance abusers have been described (Forest, 2002). Many professionals feel inadequate when dealing with patients with addiction who are in pain and are often reluctant to treat this population. Fagerhaugh and Strauss (1977) identified the nature of the organization as an important factor in affecting the interactions between staff and patients in
pain. Corley and Goren (1998) challenged nurses to eliminate behaviors that do not contribute to desired patient outcomes and suggested that “no professional behaviors persist without tacit or overt peer group or institutional support” (p. 103). Study participants expected negative reactions from health care providers on the basis of their past experiences. In society today, substance abusers are often vilified and punished or incarcerated, rather than treated. Some of the nursing responses to participants seemed to indicate an adoption of a punitive attitude toward participants. Corley and Goren (1998) state that nurse behaviors often mirror the predominant values of society. One of the nurses from the focus group stated: “The nursing profession is a very ruleladen profession and you’re dealing with your ultimate rule breakers (substance abusers).” Knowing How to Play the Game, therefore, could be seen as a necessary strategy for substance abusers to achieve respect and/or treatment for their pain in the hospital setting. In summary, participants in the study described their interactions with staff, their perceptions of staff members’ respect or lack of respect toward them, and their development of strategies to get pain relief. This study provides an explanatory model for the problem of inadequate pain management that is troublesome to both nurses and patients in the hospital setting. Implications for Clinical Practice and Research This research is a first step in understanding how substance abusers in pain view their need to interact with staff and strategize to get pain relief in the hospital setting. The model needs further testing in other settings, with women, and more diverse ethnic/racial groups. Because setting and institutional norms are so important to the delivery of pain management (Fagerhaugh & Strauss, 1977), research in diverse settings is indicated. Researchers have found that behavior change by staff who manage patient’s pain is minimal unless accompanied by an institutional policy change (Gordon, Berry, & Dahl, 2000; Clarke et al., 1996; Titler et al., 1994). Identification of policies and practices in environments that support nurses in the delivery of respectful, competent pain management will help other institutions develop appropriate programs. The theoretic model indicates that patients with pain and substance abuse need clinicians who are respectful and educated about pain management and substance abuse. Awareness of the impact of stigmatization and staffs’ own reactions to “difficult populations” is vital. Nurses often need, but do not receive, support in dealing with their reaction to patients. Use of advanced practice nurses as consultants is one way to deliver expert patient care, provide role models for
Hospitalized Substance Abusers’ Strategies for Obtaining Pain Relief
staff nurses, focus on the nurse–patient relationship, and provide education and support for staff as they increase their understanding of management of patients with complex disorders. Educational programs in schools of nursing on the undergraduate and graduate levels need to expand the current content on pain management and substance abuse. Finally, psychiatric nursing and the importance of the nurse–patient relationship, respect for all humans, and the emotional challenges that patients face when hospitalized may not be fully appreciated when the knowledge to develop these skills are integrated into the general nursing curriculum. The skills learned
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in psychiatric nursing courses and clinical settings, the importance of the nurse–patient relationship, and acquisition of the knowledge and the skills to develop and maintain effective nurse–patient relationships should play a more prominent role in nursing education as nurses care for complex patient problems in hospital settings. Acknowledgments The author acknowledges the help and support of Dr. June Andrews Horowitz, PhD, APRN-BC, FAAN; Dr. Margaret H. Kearney, PhD, RNC, FAAN; and Dr. Paul M. Arnstein, RN, PhD, FNP-C.
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APPENDIX A Interview Schedule Broad Beginning Question I am interested in finding out how people with problems with substance abuse get pain relief while they are in the hospital. Can you tell me what this experience has been like for you? Probes: 1. Tell me about an episode of pain. 2. How have the nurses responded to your pain? 3. What has it been like to live with this pain? How have you managed or coped with it? 4. What other kinds of distress (other than the pain) has the pain caused? 5. How have the nurses responded to your distress? 6. What has helped to relieve your pain? 7. How do you think your problem with substance abuse has affected your experience with pain and the treatment you’ve received? Closing Questions: Is there anything else you would like to add that would help me to better understand your pain? Are there things that you have learned that you would like to tell staff who are working with other people in pain?