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Fast Fact and Concept #83: Why patients do not take their opioids

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Title: Fast Fact and Concept #83: Why patients do not take their opioids

Author(s): Robert Arnold, MD

Patients have many of the same misconceptions regarding opioids that health care providers have. This Fast Fact discusses common reasons that patients do not take prescribed opioids, thus resulting in unnecessary pain and suffering.

Fear of Addiction Patients are very afraid of "becoming hooked"; they confuse physical dependence with psychological dependence (addiction). As a result, patients try to limit their intake and often wait until the pain is severe before using opioids.

Fear of Tolerance Patients often worry about taking pain medicine "too early" in their disease course. They believe that if the pain gets worse they will have already taken the "best" medicine and thus have severe pain during the dying process. A related belief is that if they take the medicine on a regular basis, their body will "get used to it" and thus the pain medicine will no longer be effective.

Opioid Toxicity Patients are concerned about opioid side effects, especially mental impairment, nausea and constipation.

Pain as a symptom Patients may believe that treating the symptom rather than the cause of the pain (e.g. cancer) is a bad idea. They worry that this may ?mask? the disease?s progression so that future medical decisions are not made in a timely manner.

The Good Patient Patients frequently don't want to "worry" the doctor or "bother" him or her with complaints. Particularly with pain, they may feel their report of pain is a criticism. Patients may believe that "good" patients do not complain about pain or ask for more medicine. Our society has a very ambivalent view towards pain and pain treatment, believing that it is better if patients are "strong", minimizing their symptoms. (see Fast Fact #78, Cultural aspects of pain management)

The Meaning of Pain Patients may view their pain as a punishment for past bad deeds, or view the pain experience as an opportunity for growth or personal redemption. When present, such beliefs lead patients not to discuss their pain with their health care team and to defer using analgesics.

Patient Assessment Tips

Patients want to please their doctor, thus asking, "Are you taking your medicine?" is likely to result in the patient saying "yes". To better understand the patient's beliefs regarding pain medicine and how they are taking their medicine one should:

  1. Use non-judgmental phrasing. Tell me exactly how you take your pain medicine?. Often it is easier for patients to tell you that they are not taking the medicine the way they were prescribed if you acknowledge how hard it is to take the medicine; It must be really hard to take all these pills. How often, in the last week, have you found that you forget one or two?
  2. Normalize the patient concerns. Some patients worry that if they take the pain medications, they will become addicted. Do you have this worry??
  3. Explicitly ask about their health beliefs regarding opioids. Ask what they know about morphine or whether they have any family members who have taken morphine and what the experience was like.
  4. Ask about side effects at every visit in the same way that you ask about pain. Moreover, ask about whether the patient notices any other changes that s/he believes might be caused by the opioids.

References

Cleeland, C. S. (1988). "Clinical cancer: 31. Barriers to the management of cancer pain: the roles of patient and family." Wis Med J 87(11): 13-5.

Ersek, M. (1999). "Enhancing effective pain management by addressing patient barriers to analgesic use." JHPN 1(3): 8796.

Ward, S. E., N. Goldberg, et al. (1993). "Patient-related barriers to management of cancer pain." Pain 52(3): 319-24.

Gunnarsdottir, S. et al (2002). Patient-related barriers to pain management: The barriers questionnaire II (BQ-II). Pain, 99, 385-396.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Fast Facts and Concepts #83 . Why patients do not take their opioids. Arnold R. February 2003. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 2/2003

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)
Training: Fellows, 1st/2nd Year Medical Students, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Clergy/Chaplains, General Public, Graduate Students, Lawyers, Patients/Families, Nurses, Social Workers

ACGME Competencies: Interpersonal and Communication Skills, Medical Knowledge, Patient Care

Keyword(s): Addiction, Chronic non-malignant pain, Controlled substance regulations, Pain, Pain assessment, Pain treatment


The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).