Introduction   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).  The recent increase in OxyContin abuse (see Fast Fact #80) and the resulting publicity may increase these fears. Patients may refer to the media (”I don’t want that drug that was in Newsweek”) or familial experience (“My cousin was addicted to OxyContin”).  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 traditionally has had 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).

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’s 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.  Proactively prepare patients about side effects that are transient or treatable such as sedation, nausea, and constipation.

References

1. Cleeland CS.  Clinical cancer: 31. Barriers to the management of cancer pain: the roles of patient and family.  Wis Med J. 1988; 87(11):13-15.
2. Ersek M. Enhancing effective pain management by addressing patient barriers to analgesic use. J Hospice Pall Nursing. 1990; 1(3):87-96.
3. Ward SE, Goldberg N, et al.  Patient-related barriers to management of cancer pain. Pain. 1993; 52(3):319-24.
4. Gunnarsdottir S, et al. Patient-related barriers to pain management: The barriers questionnaire II (BQ-II).  Pain. 2002; 99:385-396.

Version History:  This Fast Fact was originally edited by David E Weissman MD. 2nd Edition was edited by Drew A Rosielle MD and published October 2007; 3rd Edition June 2015. Current version re-copy-edited April 2009.