Nurses' Knowledge of Pain Assessment and Management

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Vol. 14 No. 3 September 1997 Journal of Pain and Symptom Management 175

Special Article

Nurses' Knowledge of Pain Assessment and Management: How Much Progress Have We Made?

M a r g o McCaffery, MS, RN, FAAN, a n d Betty R. Ferrell, P h D , FAAN

Nursing Consultant (M.M.), Los Angeles, California and Nursing Research (B.t~E ), City of Hope National Medical Center, Duarte, California, USA

Abstract

Uadertreatment of pain and lack of knowledge about pain management have been evident for approximately two decades. Because nurses are often the cornerstone of pain

management, nurses' knowledge in this area is especially important. This paper explores indications of progress in the level of nursing knowledge about basic aspects of pain management. The literature is reviewed and findings from recent (1995) surveys of nurses' knowledge are compared with results of similar surveys conducted beginning in 1988.

Improvements in nurses' knowledge of pain assessment, opioid dosing, and likelihood of addiction seem to have occurred. However, knowledge deficits continue. Fewer than one-half of the nurses surveyed understand that the patient's self report of pain is the single most reliable indicator of pain and that the nurse should increase a previously safe but ineffective dose of opioid. Findings from surveys on addiction reveal that the longer the patient receives opioids the more concerned nurses become about causing addiction.

Nevertheless, results of current knowledge surveys of nurses suggest that educational efforts probably have been beneficial and should continue. To maximize the impact of educational

efforts, content in basic and continuing education courses should be prioritized and critically evaluated for relevance and accuracy, especially content related to addiction.

Early in the education of nurses, responsibility for pain assessment and use of analgesics must be instilled. J Pain S y m p t o m Manage 1997;14:175-188. © U.S. Cancer Pain Relief Committee, 1997.

Key Words

Addiction, assessment, nursing education, nurses' knowledge, opioid dose, pain, physical dependence, surveys, tolerance.

Introduction

U n d e r t r e a t m e n t of pain was d o c u m e n t e d in

Address reprint requests to: Margo McCaffery, MS, RN, FAAN, 8347 Kenyon Ave. Los Angeles, CA 90045.

Accepted for publication: November 25, 1996.

the 1970s a n d was thought to be due in part to lack of education of health-care professionals. 1'2 Consequently, increasingly n u m e r o u s efforts w e r e m a d e o v e r t h e n e x t two d e c a d e s to r e e d u c a t e health-care professionals, culminat- ing in the d e v e l o p m e n t a n d widespread dis- semination o f clinical practice guidelines. ~-5

Published by Elsevier, New York, New York PII S0885-3924(97)00170-X

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176 McCaffery and FerreU Vol. 14 No. 3 September 1997

Despite this, clinical practice has c h a n g e d very little, and improvements in pain m a n a g e m e n t a p p e a r to o c c u r slowly. 6'7

U n d e r t r e a t m e n t o f p a i n persists. As an example, the patient population that has been targeted for improved pain m a n a g e m e n t for the longest period of time is probably terminally ill patients, the focus often being on those with cancer pain. In the early 1970s, principles of palliative care were i n t r o d u c e d into the United States, and the first officially recognized hospices began opening their doors. In 1986, the World Health Organization estimated that application of existing knowledge about analgesic therapy could result in effective m a n a g e m e n t of pain in up to 90% of patients with cancer. 8 Yet, in the 1990s, evidence suggests that approximately one- haft of terminally ill patients needlessly experience moderate to severe pain. A survey con- d u c t e d in 1990-1991 o f 1308 patients with metastatic cancer from 54 cancer treatment locations revealed that of those who h a d pain, 36%

had pain severe enough to impair function, and 42% received inadequate analgesics. 9 Beginning in 1989, a 4-year study of over 9000 terminally ill patients in five teaching hospitals revealed that 50% of conscious patients who died in the hospital experienced moderate to severe pain at least one-haft the time. 1°

Lack of knowledge also persists. T h e results of countless n u m b e r s o f surveys over the last 20 years provide incontrovertible p r o o f that many nurses caring for patients with pain lack a d e q u a t e i n f o r m a t i o n a b o u t pain m a n a g e - m e n t (see below). Many pain specialists and nurses in general practice are b e c o m i n g weary o f these r e p e a t e d a n n o u n c e m e n t s . Is t h e r e any encouraging news? Although nurses' level o f knowledge is inadequate, is there any evi- d e n c e that m o r e nurses practicing today possess i n f o r m a t i o n a b o u t pain m a n a g e m e n t than their counterparts o f 5-7 years ago?

T h e purpose o f this p a p e r is to review the literature o n nurses' knowledge o f pain man- a g e m e n t and to present the findings from cur- r e n t surveys (1995) o f nurses' knowledge of pain assessment, opioid dosing, and likelihood o f addiction. These results will be c o m p a r e d with those of similar surveys of nurses' knowledge c o n d u c t e d beginning in 1988.

Assumptions About Nursing Responsibilities and Required Knowledge

Any study ~ o f nurses' k n o w l e d g e o f pain m a n a g e m e n t is based o n assumptions a b o u t what nurses should know to provide a high quality of care for patients with pain. Nurses tend to spend m o r e time with patients with pain than any o t h e r health team members. It is the nurse who p e r f o r m s many interventions for pain relief or f u r t h e r individualizes for the patient those interventions prescribed or per- f o r m e d by others. It is also the nurse who is most likely to be in a position to evaluate the effectiveness o f the pain m a n a g e m e n t plan and to initiate any necessary changes.

Thus, nursing activities related to pain man- a g e m e n t are n u m e r o u s , a n d c o n s i d e r a b l e knowledge is required. It is, therefore, challenging to identify only a few specific items o f i n f o r m a t i o n that all nurses caring for patients with pain should possess. Two o f the many activities routinely p e r f o r m e d by nurses are assessment o f pain intensity and administration o f opioid analgesics. Based o n c u r r e n t clinical practice guidelines, a-5 some o f the knowledge areas essential to p e r f o r m those tasks can be identified, as follows:

1. Self-report of pain is the single most reliable indicator of pain intensity. Behaviors and vital signs should n o t be used instead o f self report. Nursing assessment o f pain i n t e n s i t y r e q u i r e s , w h e n e v e r possible, teaching the patient how to use a pain rating scale and r e c o r d i n g the pain rating n u m b e r s r e p o r t e d by the patient, s'5 2. W h e n an opioid dose is d e t e r m i n e d to be

safe b u t i n e f f e c t i v e f o r the i n d i v i d u a l p a t i e n t , t h e o p i o i d d o s e s h o u l d b e increased by 25%-50%. 5

3. Addiction caused by using opioids for pain relief is rare, and concerns about causing addiction should not interfere with appropriate administration of opioid analgesics. ^{3 - 5}

Review of Literature

Most surveys o f knowledge a n d attitudes a b o u t pain m a n a g e m e n t have b e e n used at a

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Vol. 14 No. 3 September 1997 Nurses' Knowledge of Pain Assessment and Management 177

single p o i n t in time. Survey items are often d e v e l o p e d by the investigator a n d used in a single study. T h e r e f o r e , it is difficult to identify w h e t h e r o r n o t n u r s e s ' k n o w l e d g e h a s improved. However, there is n o shortage o f studies to show that m a n y nurses in years past have lacked knowledge in the three areas cited above. Following are selected studies that illus- trate these deficiencies.

Self-Report of Pain

N u r s e s do n o t always follow t h e s i m p l e guideline o f asking the p a t i e n t a b o u t p a i n a n d accepting the p a t i e n t ' s report. In o n e study c o n d u c t e d in the late 1970s, nurses ( N = 443) r a n k e d the patient's verbal r e p o r t of pain as fifth o n a list o f seven indicators of pain. la In a n o t h e r survey c o n d u c t e d in the late 1980s, 78 n u r s e s w e r e a s k e d h o w t h e y d e t e r m i n e d w h e t h e r a p a t i e n t was e x p e r i e n c i n g pain. 12 Less t h a n 75% r e p o r t e d that they first asked a direct question.

Using vignettes, a survey c o n d u c t e d in 1990 asked nurses ( N = 456) to r e c o r d their assess- m e n t s o f patients' pain intensity. 13 M o r e t h a n o n e - h a l f the nurses s e l e c t e d a p a i n r a t i n g o t h e r t h a n what the p a t i e n t r e p o r t e d . This study along with o t h e r surveys using a similar vignette f o r m a t revealed that factors influencing nurses willingness to accept a n d r e c o r d the p a t i e n t ' s s e l f - r e p o r t o f p a i n i n c l u d e d t h e p a t i e n t ' s behavior, age, vital signs, a n d life- style. 14-a6 For example, nurses were m o s t likely to accept a n d r e c o r d the p a t i e n t ' s pain r e p o r t if the p a t i e n t was grimacing, h a d elevated vital signs, was elderly, or led a traditional life-style.

Increasing the Opioid Dose

In a survey c o n d u c t e d in the late 1970s, nurses ( N = 121) were asked to r e a d f o u r p a t i e n t vignettes a n d select a dose of opioid analgesic. 17 All f o u r p a t i e n t s h a d r e c e i v e d m e p e r i d i n e ( D e m e r o l ® 100 m g intramuscu- larly (IM), all stated that this did n o t com- pletely relieve the pain, a n d all were in severe pain 4 hr after the last dose. No side effects h a d occurred. All patients h a d a physician's o r d e r for m e p e r i d i n e at 50-150 m g every 3 - 4 hr. T h e nurses were asked to select a medication dose for the n e x t injection. T h e c o r r e c t choice for all patients was 150 mg, b u t 36%

chose to r e p e a t the same ineffective dose or to administer a lower dose.

Four surveys using a similar vignette f o r m a t e x a m i n e d h o w nurses' choices o f opioid doses were i n f l u e n c e d by the patient's behavior, vital signs, age, a n d life-style. 13-16 In m o s t of the p a t i e n t situations p r e s e n t e d in the vignettes, roughly 50% or m o r e o f the nurses did n o t increase the dose o f opioid w h e n the previous dose h a d b e e n safe b u t ineffective. Nurses were least likely to administer a h i g h e r dose o f m o r p h i n e to patients who were smiling, h a d low n o r m a l vital signs, were elderly, or h a d a life-style t h a t i n c l u d e d u n e m p l o y m e n t , b e e r drinking, a n d riding a motorcycle.

Addiction

E x a g g e r a t e d fear o f causing addiction by administering opioid analgesics is well docu- m e n t e d . In o n e survey, 66% o f p r a c t i c i n g nurses ( N = 106) a n d 63% of nursing students ( N = 101) believed that m o r e t h a n 10% o f hospitalized patients with organic p a i n b e c o m e addicted, is

In a survey of b o t h house staff ( N = 57) and nurses (N-- 70), a question was asked regarding the probability of a hospitalized patient becom- ing addicted after treatment for 10 days with 100 m g meperidine IM every 4 hr. a9 Only 15.8% of the house staff a n d 11.4% of the nurses selected the correct answer of less than 1%. T h e likeli- h o o d that addiction would occur in 16% or m o r e of patients was selected by 39% of the physicians a n d 48% of the nurses.

In a survey c o n d u c t e d d u r i n g 1988-1989 o f 2459 a t t e n d e e s at p a i n p r o g r a m s , m o s t l y nurses, 43% knew that the incidence o f addiction was 1% or less t h a n 1%. 20 An a l a r m i n g 23% t h o u g h t addiction would o c c u r in 25% or m o r e o f patients receiving opioid analgesics f o r p a i n r e l i e f . D u r i n g t h e f o l l o w i n g 12 m o n t h s (1989-1990), a survey of 1781 nurses using the same survey item revealed that the e x a g g e r a t e d fear that addiction would occur in 25% or m o r e o f patients receiving opioids for p a i n c o n t r o l h a d risen to 30.4%, while t h o s e c o r r e c t l y s e l e c t i n g less t h a n 1%

r e m a i n e d m u c h the same (41.3%). 21 This survey i t e m i n c l u d e d definitions o f addiction, physical d e p e n d e n c e , a n d tolerance a n d asked r e s p o n d e n t s to select < 1 % , 5%, 25%, 50%, 75%, or 100%.

P o o r e r results were o b t a i n e d in two statewide surveys o f nurses that used a t r u e / f a l s e i t e m stating that " t h e incidence of psychologi-

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178 McCaffery and FerreU Vol. 14 No. 3 September 1997

ca1 d e p e n d e n c e as a result o f the legitimate use o f narcotic pain-relieving drugs in patients with c a n c e r is less t h a n o n e in 1,000 patients."

A survey in Wisconsin p u b l i s h e d in 199222 a n d a s u r v e y in N o r t h C a r o l i n a p u b l i s h e d in 199623 revealed essentially n o differences in the nurses' responses. T h e question was correctly answered as true by only 16% a n d 17%

o f nurses in Wisconsin a n d N o r t h Carolina, respectively. In b o t h surveys, this was the m o s t f r e q u e n t l y missed question. However, these surveys did n o t offer a definition o f addiction, physical d e p e n d e n c e , a n d tolerance. Confu- sion a b o u t these t e r m s m a y have increased the n u m b e r of wrong answers.

To i d e n t i f y f a c t o r s t h a t m i g h t i n c r e a s e nurses' c o n c e r n s a b o u t addiction o c c u r r i n g as a result o f opioid use for p a i n relief, o t h e r questions were a d d e d to surveys distributed f r o m 1992 to 1 9 9 3 . 24 T h e s e q u e s t i o n s e x p l o r e d w h e t h e r or n o t n u r s e s ' c o n c e r n s a b o u t a d d i c t i o n w e r e i n f l u e n c e d by t h e patient's age ( u n d e r 12 years, 13-30 years, a n d over 30 years), length o f time on opioids (1-3 days, 14-30 days, a n d 3 - 6 m o n t h s ) , specific opioid used (codeine or m o r p h i n e ) , a n d the cause Of a c h r o n i c pain c o n d i t i o n lasting 2 years (cancer or n o n m a l i g n a n t ) . Survey resuhs ( N = 656) revealed that the m a j o r factor causing i n c r e a s e d c o n c e r n a b o u t a d d i c t i o n was length o f time on opioids, with 4 0 % o f the r e s p o n d e n t s believing that the likelihood of a d d i c t i o n was 25% o r g r e a t e r in p a t i e n t s receiving opioids for 3 - 6 months.

Comparison of Similar Surveys of Nurses' Knowledge: Past and Present

Over the past decade, the authors have pre- s e n t e d n u m e r o u s e d u c a t i o n a l p r o g r a m s to nurses o n various aspects o f p a i n m a n a g e - ment. T h e s e experiences also p r o v i d e d o p p o r - tunities to survey n u r s e s ' k n o w l e d g e of the subject. While s o m e o f the knowledge surveys c h a n g e d over time to reflect changes in nursing practice a n d to a c c o m m o d a t e new r e c o m - m e n d a t i o n s for p a i n m a n a g e m e n t , s o m e o f the surveys r e m a i n e d similar e n o u g h to allow c o m p a r i s o n of the results over time.

Specifically, s o m e surveys o n addiction, con- d u c t e d b e g i n n i n g in 1988, are similar to ones c o n d u c t e d in 1995. O t h e r surveys a b o u t assess- m e n t a n d use o f analgesics, c o n d u c t e d in

1990, are also similar to ones c o n d u c t e d in 1995. Descriptions a n d results of these 1995 surveys are presented, a n d t h e n the findings are c o m p a r e d with c o m p a r a b l e surveys con- d u c t e d several years earlier.

1995 Surveys of Nurses' Knowledge

All surveys were distributed as a pretest to nurses a t t e n d i n g pain c o n f e r e n c e s a n d were c o m p l e t e d by participants p r i o r to any c o n t e n t p r e s e n t e d on pain. C o n s e n t to participate in the survey was i m p l i e d by r e t u r n o f the com- pleted survey.

Description of Nurses Surveyed

For the survey o f assessment a n d choice o f opioid dose, data were collected f r o m Febru- ary to May o f 1995 in nine locations in the U n i t e d States, across the three regions (western, midwestern, a n d eastern). Over 900 surveys were c o m p l e t e d . F r o m these, 150 surveys were r a n d o m l y selected f r o m each of the three regions to m a t c h the n u m b e r o f nurses in the original survey ( N = 456) c o m p l e t e d in 1990, yielding a total o f 450 surveys. In this group, the highest level o f e d u c a t i o n was associate d e g r e e f o r 28.4%, d i p l o m a f o r 18.4%, a n d bachelors d e g r e e for 38.0%. T h e average n u m - b e r of years o f e x p e r i e n c e was 16.1 years, a n d average age was 41.9 years. Most nurses practiced in hospital settings (55.8%) or in hospice (26%). T h e m o s t c o m m o n areas o f clinical practice were m e d i c a l / s u r g i c a l (53.1%) a n d o n c o l o g y (19.1%).

For the addiction survey, data were collected f r o m May to J u n e of 1995, for a total of 537 surveys. Conferences were held in eight cities in seven states (two states in both the western a n d midwestern regions a n d three states in the eastern region). In this group of nurses, the highest level o f e d u c a t i o n was associate d e g r e e f o r 21.8%, d i p l o m a f o r 17.3%, a n d b a c h e l o r s degree for 42.1%. T h e average n u m b e r of years of experience was 15.4 years, and average age was 40.7 years. Most nurses practiced in hospital settings (78.6%). T h e most c o m m o n areas of clinical practice were medical/surgical (50.1%) and oncology (17%).

Description of Survey Questionnaires

T h e survey questionnaires c h a n g e d slightly over the years. T h e final surveys are p r e s e n t e d in A p p e n d i c e s 1 a n d 2.

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Surveys on assessment and choice of opioid dose.

T h e original vignette survey related to pain assessment and choice o f opioid dose was con- d u c t e d during 1990.1~ This survey used a 0-5 pain rating scale and the IM route o f administration, whereas the 1995 survey uses 0-10 and the intravenous (IV) route o f administration.

In 1990, 0-5 s e e m e d to be m o r e c o m m o n l y used than O-10, and most nurses were m o r e familiar with IM administration than IV. Fur- ther, the original survey did n o t state the goal o f pain m a n a g e m e n t , whereas the c u r r e n t survey states that a pain rating o f 2 has b e e n established as the goal. Results o f the survey used in 1995 (Appendix 1) are r e p o r t e d h e r e for the first time.

Addiction surveys. B e g i n n i n g in 1988, t h e authors distributed a variety o f surveys that i n c l u d e d o n e general question a b o u t addiction that was almost identical to the present survey question 1. In all surveys, a definition of addiction that distinguished it f r o m physical d e p e n d e n c e a n d t o l e r a n c e p r e c e d e d t h e addiction question(s). T h e definition used for surveys c o n d u c t e d from 1988 to 19932°'21'25 was t a k e n from a p h a r m a c o l o g y text c u r r e n t d u r i n g that time: 26 " N a r c o t i c / o p i o i d addiction is defined as psychological d e p e n d e n c e a c c o m p a n i e d by overwhelming c o n c e r n with o b t a i n i n g a n d using n a r c o t i c s f o r psychic effect, n o t for medical reasons. It may o c c u r with or without the physiological changes o f t o l e r a n c e to analgesia a n d physical d e p e n - d e n c e . "

T h e definitions used in the 1993 survey 24 and in the present 1995 survey (Appendix 2) were f r o m the American Pain Society b o o k l e t 4 and were stated as follows: " N a r c o t i c / o p i o i d addiction, or psychological d e p e n d e n c e , is a p a t t e r n o f compulsive d r u g use characterized by a c o n t i n u e d craving for an opioid and the n e e d to use the opioid for effects o t h e r than pain relief. Physical d e p e n d e n c e a n d tolerance are not addiction. Tolerance to opioid analgesia means that a larger dose o f opioid analgesic is r e q u i r e d to maintain the original effect. Physical d e p e n d e n c e o n o p i o i d s is revealed in patients taking c h r o n i c opioids when the a b r u p t discontinuation o f an opioid or the administration o f an opioid antagonist p r o d u c e s an a b s t i n e n c e s y n d r o m e (with- drawal) ."

L e n g t h o f time o n opioids was f o u n d to increase nurses' concerns a b o u t d e v e l o p m e n t o f addiction in patients receiving opioids for pain relief. 24 Because the likelihood o f physical d e p e n d e n c e a n d tolerance increases with length o f time o n opioids, the survey was further modified in the present 1995 survey to include questions a b o u t physical d e p e n d e n c e and tolerance.

Responses to 1 9 9 5 Surveys

Surveys on assessment and choice of opioid dose.

T h e case vignettes state that both patients rated their pain as 8 out of 10. Thus, a pain rating of 8 should have been recorded for both patients.

The results are presented in Table 1. For the smiling patient, only 73.8% recorded 8, but for the grimacing patient 87.1% recorded 8. Thus, nurses were more likely to accept the report of pain from the grimacing patient than from the smiling patient.

Not too surprisingly, the nurses were also m o r e likely to increase the m o r p h i n e dose for t h e g r i m a c i n g p a t i e n t . B o t h p a t i e n t s h a d received m o r p h i n e 2 mg IV 2 hr ago, half- hourly pain ratings h a d r a n g e d from 6 to 8 out o f 10, and n o clinically significant side effects such as sedation h a d occurred. T h e pain rating goal was 2. Nurses were given a choice o f administering n o m o r p h i n e or 1 mg, 2 mg, or 3 mg IV. M o r p h i n e 3 m g IV was the c o r r e c t choice for b o t h patients. However, only 51.5%

o f the nurses would increase the dose for the smiling patient, whereas 71.3% would increase the dose for the grimacing patient (Table 1).

U n d e r t r e a t m e n t o f pain was m o r e likely for the smiling patient, with 26.7% administering either n o m o r p h i n e or 1 mg, one-half the dose that was ineffective previously. For the grimacing patient, only 9.6% took this action. A com- parable n u m b e r o f respondents administered the previously ineffective dose of 2 mg to b o t h p a t i e n t s , 2 1 . 8 % f o r t h e s m i l i n g p a t i e n t ; 19.15% for the grimacing patient.

Addiction surveys. Responses to the survey items r e l a t e d to addiction, physical d e p e n - dence, and tolerance are p r e s e n t e d in Table 2.

In answer to the question a b o u t the overall likelihood o f addiction occurring in patients who receive opioids for pain relief, 62.7%

chose the c o r r e c t answer of less than 1% of patients, and 13.3% showed an exaggerated fear

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180 McCaffery and FerreU ... Vol. 14 No. 3 September 1997

Table 1

Nurses' Assessment and Choice of Opioid Dose: 1995 (N ⁼ 450)

Smiling patient Grimacing patient

N % N %

Assessment of pain

0 9 2.0 0 0.0

1 11 2.4 1 O.2

2 18 4.0 1 0.2

3 25 5.6 1 0.2

4 17 3.8 5 1.1

5 24 5.3 5 1.1

6 13 2.9 10 2.2

7 1 0.2 14 3.1

8* 332 73.8 392 87.1

9 0 0.0 13 2.9

10 0 0.0 8 1.8

Choice of opioid dose

No m o r p h i n e 45 10.0 9 2.0

1 mg 1V now 75 16.7 34 7.6

2 mg IV now 98 21.8 86 19.1

*3 mg IV now 231 51.5 321 71.3

IV, intravenous.

*Correct answer.

of causing addiction by selecting answers rang- ing from 25% to 100% of patients who receive opioids for pain relief. For patients receiving opioids for 1-3 days, even more nurses, 86.4%, correctly estimated the likelihood of addiction as less than 1%, and only 3.8% thought that 25%

or more of patients would b e c o m e addicted.

However, when the question focused on patients who receive opioids for pain relief for 3-6 months, only 24.1% of the nurses correctly identified the likelihood of addiction occm'ring as less than 1%, and 34.8% had an exaggerated fear that addiction would occur in 25% or more

• of patients.

Regarding the likelihood of clinically signifi- c a n t t o l e r a n c e o c c u r r i n g in p a t i e n t s w h o receive opioids for 1-3 days, 86.4% o f the

nurses knew it was less than 1%, and 80.2%

knew that the likelihood o f clinically significant physical d e p e n d e n c e was less than 1%.

A l t h o u g h clinically significant t o l e r a n c e or physical d e p e n d e n c e d o n o t o c c u r in all p a t i e n t s r e c e i v i n g o p i o i d s c h r o n i c a l l y , it should be e x p e c t e d in all patients who receive opioids for 1 m o n t h or longer. 4 Consequently, in answer to the questions a b o u t the likeli- h o o d o f clinically significant physical depen- d e n c e o r t o l e r a n c e d e v e l o p i n g in patients after 3-6 m o n t h s o f opioid use, answers o f 75% o r 100% w e r e ' a c c e p t e d as c o r r e c t . Regarding physical d e p e n d e n c e , only 14.2%

r e c o g n i z e d that this s h o u l d be assumed in most or all patients, at least 75% up to 100%.

Likewise very few nurses (15.6%) recognized Table 2

Nurses' Knowledge of the Likelihood of Addiction, Tolerance, and Physical Dependence Occurring in Patients Receiving Opioids for Pain Relief (N = 537)

When opioids/narcotics are used for pain relief in the following situations:

What percent of patients are likely to

develop N(%) < 1 % 5% 25% 50% 75% 100%

Addiction

M1 p~tients--overall 335 (62.7) *

Patients who received opioids 1-3 days 459(86.4)*

Patients who received opioids 3-6 months 128(24.1)*

Tolerance

Patients who received opioids 3-6 months 23(4.3) Physical dependence

Patients who received opioids 3-6 months 59(11.1)

128(24.0) 53(9.9) 14(2.6) 3(0.6) 1(0.2) 52(9.8) 12(2.3) 5(0.9) 3(0.6) 0(0.0) 219(41.2) 101(19.0) 50(9.4) 29(5.5) 5(0.9) 104(19.5) 31(5.8) 12(2.3) 2(0.4) 0(0.0) 159(29.9) 157(29.6) 109(20.5) 57(10.7)* 26(4.9)*

76(14.3 18(3.4) 9(1.7) 2(0.4) 0(0.0)

175(32.8) 131(24.6) 92(17.3) 55(10.3)* 21(3.9)*

*Correct answer.

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Table 3

Pain Assessment and Opioid Dose: 5 Years Later

Data collected: 1990 Data collected: 1995

N = 456 N = 450

N % N %

Nurses who accepted self-report o f pain Smiling patient

Grimacing patient Both patients

Nurses who increased an ineffective dose o f m o r p h i n e Smiling patient

Grimacing patient Both patients

Nurses who correctly answered all questions for b o t h patients

182 40.7 332 73.8

322 71.6 392 87.1

<40.7 ~ 324 72.0

148 32.8 231 51.5

245 54.0 321 71.3

<32.8 a 226 50.2

<32.8 ~ 211 46.8

°Estimates; data not available to make calculations.

Data from 1990 reprinted with permission from reference 13.

t h a t t o l e r a n c e s h o u l d be e x p e c t e d in all patients, at least 75% or m o r e o f patients, after 3-6 m o n t h s of opioid administration. In fact, in patients receiving opioids for 3-6 months, 43.9% b e l i e v e d t h a t physical d e p e n d e n c e would o c c u r in only 5% or fewer patients a n d 34.2% believed that tolerance would o c c u r in 5% or fewer patients. Thus, nurses underesti- mated the likelihood o f clinically significant tolerance and physical d e p e n d e n c e .

To examine the extent to which nurses con- fused the likelihood of addiction with the likeli- h o o d of physical d e p e n d e n c e or tolerance in patients receiving opioids f o r 3 - 6 m o n t h s , answers of less than 1% and answers of 25% or more can be compared for each condition. The likelihood that fewer than 1% of patients would develop addiction, tolerance, or physical dependence was selected by 24.1%, 4.3%~ and 11.1%, respectively. The likelihood that 25% or more of patients would develop addiction, tolerance, or physical d e p e n d e n c e was selected by 34.4%, 65.7%, and 56.1%, respectively. Thus, beliefs about the likelihood of addiction are not compa- rable to beliefs about the likelihood of tolerance and physical dependence, suggesting that nurses are not necessarily confusing these terms with addiction.

Comparison of Past and Present Survey Findings

C o m p a r e d with surveys c o n d u c t e d five years ago, nurses' willingness to r e c o r d the patient's pain rating as their assessment o f the patient's pain has improved (Table 3). Recording the smiling patient's numerical rating o f severe

pain increased from 40.7% in 1990 to 73.8%

in 1995. Acceptance o f the grimacing patient's r e p o r t o f pain was fairly high in the 1990 survey, 71.6%, and increased f u r t h e r to 87.1% 5 years later. In 1990, fewer than 40.7% o f the n u r s e s a c c e p t e d t h e p a i n r a t i n g o f b o t h patients, b u t in 1995, 72.0% accepted the pain rating o f b o t h patients.

Nurses' willingness to increase a safe but ineffective dose o f m o r p h i n e by 50% has also i m p r o v e d (Table 3). In 1990 o n l y 32.8%

increased the m o r p h i n e dose for the smiling patient, but in 1995 this increased to 51.5% o f the nurses. More nurses were also willing to increase the m o r p h i n e dose for the grimacing patient, increasing f r o m 54.0% in 1990 to 71.3% in 1995. Nurses' willing to increase the dose for b o t h patients increased f r o m less than 32.8% in 1990 to 50.2% in 1995.

T h e n u m b e r o f n u r s e s w h o c o r r e c t l y assessed and treated the pain in b o t h patients did n o t change greatly. Nurses who correctly r e c o r d e d the pain rating a n d increased the opioid dose for b o t h patients rose from less than 32.8% in 1990 to only 46.8% in 1995.

Answers to the general question c o n c e r n i n g t h e l i k e l i h o o d o f a d d i c t i o n o c c u r r i n g in patients receiving opioids for pain relief show fairly steady i m p r o v e m e n t from 1988 t h r o u g h 1995 (Table 4). Nurses selecting the c o r r e c t answer o f less than 1% likelihood o f addiction increased f r o m 43.0% to 62.7%. Exaggerated fears o f addiction, that is, belief that addiction w o u l d o c c u r in 25% or m o r e o f p a t i e n t s increased slightly but t h e n declined. Overall, nurses with e x a g g e r a t e d fears o f a d d i c t i o n decreased f r o m 23.0% in 1988 to 13.3% in

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182 McCaffery and Ferrell Vol. 14 No. 3 September 1997

1995. T h e largest gains in knowledge a b o u t a d d i c t i o n r e l a t e d to p a i n c o n t r o l o c c u r r e d between 1992 a n d 1995.

Discussion

I m p o r t a n t l i m i t a t i o n s exist in u s i n g t h e above survey findings to identify educational needs o f the general p o p u l a t i o n of practicing nurses or to c o n f i r m any progress in the education of nurses a b o u t pain m a n a g e m e n t . N o t only were there changes in the surveys t h e m - selves, b u t there is also a p r o b l e m o f sample bias. As a whole the nurses surveyed p r o b a b l y are n o t r e p r e s e n t a t i v e o f p r a c t i c i n g nurses.

Nurses who attend p r o g r a m s o n p a i n are likely to be m o r e motivated to learn a b o u t p a i n t h a n their c o u n t e r p a r t s who did n o t a t t e n d a n d are likely to have already studied the subject.

Further, nurses a t t e n d i n g p a i n p r o g r a m s today, c o m p a r e d with 5 - 7 years ago, are likely to have a h i g h e r level o f interest a n d motiva- tion. Today's nurses m a y be sent to p r o g r a m s on pain by institutions interested in i m p r o v i n g p a i n m a n a g e m e n t t h r o u g h i n t e r d i s c i p l i n a r y p a i n c o m m i t t e e s . Nurses are o f t e n actively i n v o l v e d in t h e s e e f f o r t s . T h u s , a p p a r e n t i m p r o v e m e n t in n u r s e s ' k n o w l e d g e m a y be d u e in p a r t to s a m p l e b i a s r a t h e r t h a n progress in education.

Nevertheless, nursing knowledge seems to have improved in the three areas examined in these surveys. Over 5 years, 1990--1995, the percent of nurses correctly responding to survey questions about assessment a n d titration upward of opioid dose has increased, with the greatest increase occurring in the percent of nurses willing to record the pain rating given by the smiling patient. Because the survey item on nursing assessment o f pain was identical in both surveys (except for the switch f r o m a 0-5 to a 0-10 pain rating scale) i m p r o v e m e n t in this area would a p p e a r to be due primarily to education. T h e i m p r o v e m e n t in p e r c e n t o f n u r s e s w h o increased the opioid dose is close to a 20%

increase (17.3% and 18.7%). However, this find- ing may be a result n o t only of education but also of a c h a n g e in the survey item. T h e 1995 survey stated that the pain rating goal was 2 out of 10 for b o t h patients. T h e 1990 survey did n o t state a goal. W h e n results of the 1990 survey were discussed with nurses they often explained that their reason for not administering anything

or for not increasing the opioid dose was that the patient did not ask for it. T h e addition of the pain m a n a g e m e n t goal to the 1995 survey was in r e s p o n s e to this a p p a r e n t m i s u n d e r s t a n d i n g a b o u t the nurses role in a d m i n i s t e r i n g "as n e e d e d " analgesics. Including the goal of pain m a n a g e m e n t may have favorably influenced the nurses to increase the opioid dose, accounting for some of the i m p r o v e m e n t noted in the current survey.

Findings related to the vignette surveys are encouraging. Still, m u c h remains to be done.

Fewer t h a n o n e - h a l f (46.8%) o f the nurses d e m o n s t r a t e a grasp o f b o t h of the two basic principles o f accepting the patient's self-report o f p a i n a n d i n c r e a s i n g safe b u t ineffective o p i o i d doses by 2 5 % - 5 0 % . In o t h e r words, f e w e r t h a n o n e - h a l f t h e s e n u r s e s w o u l d a p p r o a c h the care o f the p a t i e n t with pain by r e g a r d i n g the patient's self-report o f p a i n as the single m o s t reliable indicator of p a i n a n d by p r o c e e d i n g to increase an opioid dose that was safe b u t ineffective.

O v e r a 7-year p e r i o d , 1988-1995, f e w e r nurses r e s p o n d i n g to the surveys have unwar- r a n t e d c o n c e r n s a b o u t addiction o c c u r r i n g as a result o f o p i o i d use. Presently, 62.7% o f nurses correctly identify that overall less t h a n 1% o f patients who receive opioids for pain relief will develop addiction, a n d only 13.3%

e r r o n e o u s l y believe that addiction will o c c u r in 25% or m o r e o f patients. Unfortunately, nurses responses to patients receiving opioids for 3 - 6 m o n t h s reveals a m u c h h i g h e r level of c o n c e r n a b o u t addiction. Nurses clearly associate addiction with length of time o n opioids, a n d this does n o t a p p e a r to be solely a result o f confusion a b o u t differences b e t w e e n physical d e p e n d e n c e , t o l e r a n c e , a n d a d d i c t i o n . T h e s e terms were d e f i n e d in the surveys that p r o d u c e d the findings p r e s e n t e d in Tables 2 a n d 4. Nurses gave quite different answers to the questions a b o u t the likelihood o f addiction, physical d e p e n d e n c e , or tolerance occurring in patients who receive opioids for 3 - 6 m o n t h s . H i g h e r p e r c e n t a g e s o f n u r s e s e x p e c t e d tolerance a n d physical d e p e n d e n c e to o c c u r t h a n e x p e c t e d addiction to occur.

T h e results o f studies that do n o t include definitions of addiction, physical d e p e n d e n c e , a n d tolerance r e p o r t m u c h lower p e r c e n t a g e s (16% a n d 17%) of nurses knowing that the likelihood o f addiction is rare. 22'23 T h e r e f o r e ,

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Table 4

Nurses' Knowledge of Likelihood of Addiction Occurring as a Result o f U s i n g Opioids for Pain Reliefi 1988-1995 Data collected: Data collected: Data collecmd: Data collected: Data collected:

1988-1989 a 1989-1990 b 1992 c 1992-1993 d 1995

N = 2296 e N = 20632 N = 150 N = 656 N = 537 Likelihood of addiction

occurring in all patients who receive opioids for

pain relief: N % N % N % N % N %

Nurses who correctly 988 43.0 853

identified chance o f addiction in patients as

< 1 %

Nurses who h a d an 528 23.0 649 exaggerated fear o f

addiction occuring in 25% or m o r e o f patients

41.3 66 43.4 325 49.5 334 62.7

30.4 44 28.9 101 15.4 71 13.3

°Data reprinted with permission from reference 20.

~Data reprinted with permission from reference 21.

ff)ata reprinted with permission from reference 25.

dData reprinted with permission from reference 24.

eN adjusted to number responding to question; not all survey

it appears that d e f n i n g the terms improves the likelihood o f c o r r e c t answers a b o u t addiction, but does n o t allay all the concerns nurses may have. Interestingly, few nurses realized that b o t h tolerance and physical d e p e n d e n c e should be e x p e c t e d in all patients who receive opioids for 3-6 months.

Although we prefer to assume that education has caused the improvements in nurses' knowledge about pain control, it is important to note that, in addition to sample bias and changes in the surveys over time, simple survey exposure may have played a large role. For t h e past few years, the vignette survey has been used by many hospitals throughout the United States to assess staff k n o w l e d g e , a n d t h e s u r v e y was also included in a widely viewed video tape. To many, it became affectionately known as the "Andy/

Bob" survey. T h e addiction question (specifically question 1) has also been used in numer- ous surveys. Possibly some of the improvement in nurses answers is merely a result of having been told the answers to the questions and may neither reflect an understanding of the concepts nor be typical of what nurses actually do in clinical practice.

W h e t h e r or not the survey findings provide evidence that improvements have o c c u r r e d in nurses' knowledge o f pain m a n a g e m e n t , it is a p p a r e n t that serious problems c o n t i n u e to exist. Disagreement between the health-care professional a n d the p a t i e n t r e g a r d i n g the patient's pain intensity is one o f the most sig-

respondents answered all questions.

nificant p r e d i c t o r s o f i n a d e q u a t e analgesic therapy. 9 At a very m i n i m u m , nurses caring for patients with pain should appreciate that the only scientific tool for m e a s u r i n g pain intensity is the patient's r e p o r t using a pain rating scale. Apparently, nurses c o n t i n u e to h a r b o r many misconceptions that cause them to d o u b t patients' r e p o r t s o f pain. Nurses n e e d clarification o f the fact that no research has shown that the patient's behavior, vital signs, or life-style is a better indicator o f pain intensity than the patient's self-report.

Further, although nurses may r e c o r d what the patient says, they do n o t necessarily feel obligated to act u p o n it. Nurses' willingness to increase a safe b u t ineffective dose of mor- p h i n e may be m o r e related to their personal attitude a b o u t the patient's r e p o r t o f pain than to their knowledge of the safety of this action. In the 1995 survey, only 51.5% of the nurses increased the opioid dose for the smiling patient b u t 71.3%, almost 20% more, took this action for the grimacing patient. Thus, there were approximately 20% who felt it was safe to increase the dose but did not do so for the smiling patient. In fact, 71.8% r e c o r d e d the smiling patient's r e p o r t o f pain, but only 50.5% increased the opioid dose, suggesting that they may n o t have truly a c c e p t e d the patient's pain rating.

Continued c o n c e r n about addiction occurring as a result o f opioid use poses a major obstacle to appropriate opioid therapy. A variety

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184 McCaffery and Ferrell Vol. 14 No. 3 September 1997

of studies have revealed the detrimental conse- quences of irrational concerns about addiction.

For example, a study o f 85 family caregivers of patients with cancer pain revealed that caregivers had considerable fear of addiction in spite of b e i n g told t h a t it s h o u l d n o t b e a m a j o r c o n c e r n Y -29 They felt it was their responsibility to try to avoid addiction by limiting the a m o u n t of medication used. A survey of 270 patients with cancer revealed that their reluctance to r e p o r t pain a n d to use analgesics resulted in p o o r pain relief a n d was often due to concerns about addiction, s°

A m i n i m u m e x p e c t a t i o n o f all nurses who administer opioids to patients for p a i n relief is that fear o f causing addiction should n e v e r c o m p r o m i s e their willingness to a d m i n i s t e r effective doses of opioid. In addition, nurses s h o u l d b e proactive in discussing a d d i c t i o n with p a t i e n t s a n d t h e i r f a m i l i e s . R o u t i n e a d m i n i s t r a t i o n o f an a b b r e v i a t e d version o f the barriers questionnaire d e v e l o p e d by Gor- d o n a n d Ward 31 is a simple m e t h o d o f identi- fying p a t i e n t ' s c o n c e r n s a b o u t addiction a n d o t h e r aspects of opioid use such as tolerance.

Recommendations for Nursing Education

Based on the findings o f these a n d o t h e r surveys a n d the a u t h o r s ' e x p e r i e n c e s with nursing e d u c a t i o n over the past 10 years, the following r e c o m m e n d a t i o n s are m a d e . First, because educational efforts directed at nurses s e e m to have c o n t r i b u t e d to i m p r o v i n g their knowledge a b o u t pain m a n a g e m e n t , there is j u s t i f i c a t i o n f o r t h e c o n t i n u a t i o n o f t h e s e efforts. As a whole, it a p p e a r s that the longer nurses are e x p o s e d to c o r r e c t i n f o r m a t i o n a b o u t p a i n m a n a g e m e n t , t h e b e t t e r t h e i r knowledge level becomes. For e x a m p l e , nurses f r o m countries with the longest e x p o s u r e to palliative care (Australia, Canada, a n d U n i t e d States) t e n d to have a h i g h e r level o f knowl- e d g e a b o u t c a n c e r p a i n r e l i e f t h a n nurses f r o m c o u n t i e s in which palliative care has b e e n m o r e r e c e n t l y i n t r o d u c e d J a p a n a n d Spain) .25 While knowledge itself is n o t e n o u g h to g u a r a n t e e i m p r o v e m e n t in p a t i e n t care, it is the first step. In the absence o f c o r r e c t infor- mation, p a t i e n t care is unlikely to improve.

Second, to maximize the i m p a c t of educational courses a b o u t pain m a n a g e m e n t , the

c o n t e n t o f b o t h c o n t i n u i n g e d u c a t i o n offer- ings a n d basic nursing p r o g r a m s needs to be e x a m i n e d critically for relevance a n d accuracy.

Nursing textbooks t e n d to contain inaccurate a n d irrelevant i n f o r m a t i o n a b o u t p a i n man- a g e m e n t , 32 nursing p r o g r a m s devote very little time to the topic o f pain, 3~'~4 a n d n u r s i n g faculty are often m i s i n f o r m e d . 34 Suggestions for pain m a n a g e m e n t c o n t e n t in the c u r r i c u l u m o f schools o f nursing have b e e n d e v e l o p e d by the Wisconsin Cancer Pain Initiative 35 a n d the I n t e r n a t i o n a l A s s o c i a t i o n f o r t h e Study o f Pain. ~6 Because pain is a rapidly developing science, clinical practice guidelines f r o m the Agency for H e a l t h Care Policy a n d Research ~5 a n d t h e A m e r i c a n P a i n Society 4 p r o b a b l y should be relied u p o n in b o t h basic a n d continuing e d u c a t i o n courses to provide c u r r e n t a n d accurate i n f o r m a t i o n .

In r e s p o n s e to the n e e d to i m p r o v e pain c o n t e n t in the c u r r i c u l u m o f nursing schools, a study is in progress at City o f H o p e National Medical C e n t e r to assess the i m p a c t o f a 3-day course to e d u c a t e the educator. Competitively selected nurse educators f r o m different under- g r a d u a t e schools across the U n i t e d States are participating.

Because educational resources, such as time a n d money, are limited, the a m o u n t o f time d e v o t e d to various pain topics m u s t be evaluated carefully. W h a t does the b e g i n n i n g level nurse n e e d to k n o w to provide an acceptable level of care f o r the p a t i e n t with pain? Setting priorities is challenging b u t necessary. N u m e r - ous studies have implicated i n a d e q u a t e assess- m e n t a n d use of analgesics as the reasons for p a t i e n t s s u f f e r i n g p a i n n e e d l e s s l y . T h u s , knowledge of cultural differences in response to pain a n d the i m p a c t o f various psychological factors such as anxiety are i m p o r t a n t b u t p r o b a b l y are n o t as essential as knowledge that the b e s t scientific tool f o r m e a s u r i n g p a i n intensity is the p a t i e n t ' s self-report using a pain rating scale. While knowledge o f the neu- rophysiology o f pain ultimately improves use o f analgesics, the first step is knowing the principles related to adjusting analgesic doses a n d intervals b e t w e e n doses. I f instructional time is limited, how m u c h o f it should be allocated to n o n d r u g pain relief m e t h o d s , such as relax- ation? While n o n d r u g p a i n t r e a t m e n t s cer- tainly have value, n o studies to d a t e have attributed i n a d e q u a t e m a n a g e m e n t o f acute

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pain or c a n c e r pain to a failure to use non- d r u g p a i n treatments.

T h i r d , e d u c a t i o n a b o u t s u b s t a n c e a b u s e s h o u l d be critically a p p r a i s e d . Pain c o n t r o l a n d addiction are f r e q u e n t l y c o n f u s e d with d e t r i m e n t a l c o n s e q u e n c e s f o r b o t h patients with p a i n a n d patients w h o have substance abuse problems. An alliance b e t w e e n nurses in p a i n m a n a g e m e n t a n d t h o s e in a d d i c t i o n s would b e n e f i t b o t h nurses a n d patients. Unfor- tunately, very few n u r s i n g textbooks incorpo- rate a c c u r a t e i n f o r m a t i o n a b o u t a d d i c t i o n resulting f r o m use of opioid analgesics. In a review o f 14 f r e q u e n t l y u s e d n u r s i n g textbooks, p u b l i s h e d b e t w e e n 1985 a n d 1992, an analysis of c o n t e n t revealed that only o n e text- b o o k correctly stated the definition o f opioid addiction a n d its likelihood following the use o f o p i o i d a n a l g e s i c s f o r p a i n c o n t r o l . 32 Although substance abuse is a m a j o r health- care p r o b l e m , studies suggest that, like pain, m o s t nurses receive very litde e d u c a t i o n a b o u t addiction in their basic n u r s i n g p r o g r a m s . A national survey in 1987 revealed that schools o f n u r s i n g p r o v i d e d a p p r o x i m a t e l y 15 h r o f instruction o n substance abuse. 37 In 1994, a similar study of schools o f n u r s i n g in Iowa con- c l u d e d that the average h o u r s o f classroom instruction was 5 a n d the average h o u r s o f additional clinical instruction was 9.38 hr. a8

If nurses do n o t u n d e r s t a n d what addiction is a n d what causes it, they will n o t be able to develop c o n f i d e n c e that opioid use for pain c o n t r o l is n o t a m a j o r cause o f addiction.

Nurses will n o t be able to distinguish b e t w e e n medical a n d n o n m e d i c a l uses o f opioids. Dis- cussion o f opioids for pain control p r o b a b l y s h o u l d include the following: definitions o f a d d i c t i o n , t o l e r a n c e , a n d p h y s i c a l d e p e n d e n c e ; characteristics o f the disease o f addiction; a n d risk factors associated with the d e v e l o p m e n t o f addiction. Because o f society's legitimate c o n c e r n a b o u t substance abuse a n d the fact t h a t legal actions are o f t e n t a k e n against p e r s o n s who abuse substances, health- care professionals n e e d h e l p in focusing on addiction as a health-care issue r a t h e r t h a n a legal or m o r a l one. T h a t is, addiction is a b a d disease, b u t addicts are n o t b a d people.

F o u r t h a n d finally, responsibility f o r p a i n m a n a g e m e n t m u s t be instilled in nurses early in their basic educational p r o g r a m . U n f o r t u - nately, in a study o f baccalaureate n u r s i n g stu-

dents in their final course, only 13% t h o u g h t t h a t c a n c e r p a i n m a n a g e m e n t s h o u l d b e i n c l u d e d in their n u r s i n g curriculum. 39

S o m e nurses r e s p o n d i n g to the vignette survey in which they were asked to select the n e x t dose o f m o r p h i n e n o t only said that they were n o t taught that dose titration was their responsibility b u t also said that they t h o u g h t the physician knew a n d should prescribe the exact dose a n d intervals b e t w e e n doses for the specific patient. T h e s e c o m m e n t s a n d others illus- trate that nurses s e e m largely unaware o f the great interindividual variability in r e s p o n s e to opioids. Nurses s e e m to assume that physicians know the analgesic r e q u i r e m e n t s of patients in advance of their prescribing them, a n d nurses do n o t a p p e a r to e m b r a c e their vital role in the titration o f opioid doses.

To i m p r o v e p a i n m a n a g e m e n t , it is essential that nurses recognize that they are often the c o r n e r s t o n e o f the t e a m a p p r o a c h a n d that they have direct responsibilities related to pain assessment a n d tailoring o f opioid analgesics.

Education m u s t p r e p a r e t h e m with the knowledge r e q u i r e d to execute these tasks. Because nurses are m o r e often p r e s e n t with patients with pain t h a n are o t h e r health t e a m m e m - bers, it is t h r o u g h nurses that m o s t patients have the greatest o p p o r t u n i t y to b e n e f i t f r o m an interdisciplinary a p p r o a c h a n d receive a high quality o f pain m a n a g e m e n t . Nurses m u s t be e n c o u r a g e d to e x p a n d t h e i r k n o w l e d g e a n d be h e l d a c c o u n t a b l e for assuming their responsibilities for pain m a n a g e m e n t .

References

1. Charap AD. The knowledge, attitudes, and experience of medical personnel treating pain in the terminally ill. Mt Sinai J Med 1978;45:561-580.

2. Marks RM, Sachar EJ. Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med 1973;78:173-181.

3. Agency for Health Care Policy and Research.

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Appendix 1

Survey: Assessment and Use of Analgesics

"Andrew--Robert"

Professional discipline: Highest education: Practice setting: Clinical area:

[] Nursing [] Student [] Hospital [] Medical

[] Pharmacy [] LPN [] Home/community [] Postop/Surg

[] Medicine [] AD [] Hospice [] Oncology

[] Physical therapy [] Diploma [] Office [] Orthopedics

[] Social work [] Bachelors [] Other, Specify: [] Pediatrics

[] Other, Specify: D Masters [] ICU/CCU

[] Doctorate [] Other, Specify:

G e n d e r [] F e m a l e [] Male

_ _ Years e x p e r i e n c e as h e a l t h professional.

Directions" Please select o n e answer f o r e a c h question.

P a t i e n t A: A n d r e w is 25 years old, a n d this is his first day following a b d o m i n a l surgery. As y o u e n t e r his r o o m , h e smiles at y o u a n d c o n t i n u e s talking a n d j o k i n g with his visitor. Your assessment reveals the following i n f o r m a t i o n : BP = 1 2 0 / 8 0 ; H R = 80; R = 18; o n a scale o f 0 - 1 0 (0 = n o p a i n / d i s c o m f o r t , 10 = worst p a i n / d i s c o m f o r t ) he rates his p a i n as 8.

1. O n t h e p a t i e n t ' s r e c o r d y o u m u s t m a r k his p a i n o n t h e scale below. Circle the n u m b e r t h a t rep- resents y o u r assessment o f A n d r e w ' s pain.

0 1 2 3 4 5 6 7 8 9 10

N o p a i n / d i s c o m f o r t Worst p a i n / d i s c o m f o r t

2. Your assessment, above, is m a d e 2 h r after he received m o r p h i n e 2 m g IV. H a l f - h o u r l y pain ratings following t h e i n j e c t i o n r a n g e d f r o m 6 to 8 a n d h e h a d n o clinically significant r e s p i r a t o r y d e p r e s s i o n , sedation, o r o t h e r u n t o w a r d side effects. H e has i d e n t i f i e d 2 as an a c c e p t a b l e level o f p a i n relief. His physician's o r d e r f o r analgesia is " m o r p h i n e IV 1 - 3 m g qlh P R N p a i n relief" C h e c k the a c t i o n y o u will take at this time:

[] a) A d m i n i s t e r n o m o r p h i n e at this time.

[] b) A d m i n i s t e r m o r p h i n e 1 m g IV now.

[] c) A d m i n i s t e r m o r p h i n e 2 m g IV now.

[] d) A d m i n i s t e r m o r p h i n e 3 m g IV now.

Patient B: R o b e r t is 25 years old, a n d this is his first day following a b d o m i n a l surgery. As y o u e n t e r his r o o m , h e is lying quietly in b e d a n d g r i m a c e s as h e t u r n s in bed. Your assessment reveals the following i n f o r m a t i o n : BP = 1 2 0 / 8 0 ; H R = 80; R = 18; o n a scale o f 0 - 1 0 (0 = n o p a i n / d i s c o m f o r t , 10 = worst p a i n / d i s c o m f o r t ) h e rates his p a i n as 8.

1. O n t h e p a t i e n t ' s r e c o r d y o u m u s t m a r k his p a i n o n t h e scale below. Circle the n u m b e r t h a t rep- resents y o u r assessment o f R o b e r t ' s pain:

0 1 2 3 4 5 6 7 8 9 10

N o p a i n / d i s c o m f o r t Worst p a i n / d i s c o m f o r t

2. Your assessment, above, is m a d e 2 h r after he received m o r p h i n e 2 m g IV. Half-hourly pain ratings following the injection r a n g e d f r o m 6 to 8 a n d he h a d n o clinically significant respiratory depression, sedation, or o t h e r u n t o w a r d side effects. H e has identified 2 as an acceptable level o f pain relief. His physician's o r d e r for analgesia is " m o r p h i n e IV 1-3 m g qlh P R N pain relief" C h e c k the action y o u will take at this time: