Access provided by
London Metropolitan University
• To enhance your understanding of the complex issues in relation to managing pain in hospital patients with opioid use disorder
• To recognise the stigma that may be experienced by patients with opioid use disorder
• To consider strategies you could use in your practice to improve pain management in patients with opioid use disorder
This article explores the challenges and barriers to the effective nursing management of pain in patients with a history of opioid use disorder. It also identifies recommendations for improving patient care and possible areas for further research. The author examined the relevant literature, which revealed that patients with opioid use disorder may experience stigmatisation by nurses; such negative attitudes are often in conflict with nurses’ professional and ethical duties. This issue is compounded by a lack of knowledge and understanding of dependence, addiction and withdrawal. It was also identified that patients often recognise the effects of stigma and this can cause resentment, frustration and anxiety, in some cases leading to aggressive or disruptive behaviours that reinforce negative stereotypes of people who use opioids. A breakdown in the nurse-patient relationship can result in suboptimal pain management in this often-marginalised patient group. Therefore, effective pain management relies on a nurse-patient relationship that minimises anxiety, as well as multidisciplinary team collaboration.
Nursing Standard. doi: 10.7748/ns.2021.e11521
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Martinez R (2021) Challenges in the management of pain in hospital patients with opioid use disorder. Nursing Standard. doi: 10.7748/ns.2021.e11521
Published online: 01 February 2021
Opioid prescribing has significantly increased over the past few years across the US and Europe, resulting in an increase in the number of people who are addicted to illicit and/or prescription opioids (Mordecai et al 2018, Faculty of Pain Medicine of the Royal College of Anaesthetists 2020). The European Monitoring Centre for Drug and Drug Addiction (Seyler et al 2017) estimated that there are 1.3 million high-risk opioid users in the EU and Norway. The UK has the highest prevalence of high-risk opioid use in Europe, with more than eight cases per 1,000 population aged 15-64 years (Seyler et al 2017).
While heroin remains the most commonly used illicit opioid in the UK, the proportion of individuals presenting to treatment centres solely using prescription opioids, such as oxycodone hydrochloride, fentanyl or tramadol hydrochloride, is rising (Faculty of Pain Medicine of the Royal College of Anaesthetists 2020). Public Health England (2019) estimated that there were more than 250,000 people misusing opioids in England in 2016-17. Therefore, nurses are likely to encounter patients with opioid use disorder in all areas of practice.
The term ‘opioid use disorder’ is favoured by the Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition (DSM V) (American Psychiatric Association (APA) 2013), whereas the eleventh revision of the International Classification of Diseases (ICD-11) uses the term ‘opioid dependence’ (World Health Organization 2018). The definitions of both terms include physical characteristics such as dependence and tolerance, alongside behavioural and psychological features of addiction. Dependence is defined as the presence of physical withdrawal symptoms when a drug is stopped, whereas tolerance occurs when higher doses are required to achieve a drug’s effects (Faculty of Pain Medicine of the Royal College of Anaesthetists 2020). Patients with opioid use disorder experience an overwhelming desire to continue using opioids despite harmful consequences, and experience challenges in controlling their use at the expense of other activities and obligations (APA 2013). This patient group not only includes those who use illicit opioids such as heroin, but also those who may have developed opioid use disorder as a result of taking prescribed opioids.
This article explores the challenges and barriers to the nursing management of acute or persistent pain in hospital patients with a history of opioid use disorder. It excludes patients with cancer pain and palliative or end of life pain, because of the differences in the pain management approach used in these diagnoses.
• Pain management in patients with opioid use disorder is complex because of their physical and psychosocial needs
• Patients with opioid use disorder have reported feeling stigmatised by nurses and other healthcare professionals in hospital settings
• Patients often recognise nurses’ negative attitudes towards them, which can contribute to anxiety-driven behaviours such as aggression or persistent demands, which may reinforce negative stereotypes of people who misuse opioids
• Optimal pain management relies on an effective nurse-patient relationship, as well as multidisciplinary team collaboration and communication
Nurses in a hospital setting may encounter patients with opioid use disorder who are experiencing acute pain such as surgical pain, or they may be required to manage persistent pain in patients who have subsequently developed opioid use disorder. Pain management in the presence of opioid use disorder is complex not only due to the physical aspects such as increased tolerance to opioids and the risk of withdrawal, but also because of the psychological and behavioural characteristics of addiction.
The nursing management of pain is based on McCaffery’s (1968) principle that ‘pain is whatever the experiencing person says it is, existing when the experiencing person says it does’. However, when a patient has a history of opioid use disorder, the evidence suggests that their pain is often managed inadequately in hospital, and that their requests for pain relief may be met with mistrust and suspicion by nurses and other healthcare professionals (McCreaddie et al 2010, Krokmyrdal and Andenæs 2015, Paschkis and Potter 2015).
Pain is a subjective and emotional experience that can be intensified by anxiety, distress or fear (International Association for the Study of Pain 2017). Being in pain can cause low mood, irritability, a reduction in sleep, mobility and appetite, and can impair healing (Faculty of Pain Medicine of the Royal College of Anaesthetists 2020). While most analgesic prescribing is a medical responsibility, with the exception of some nurse specialists and other non-medical prescribers, nurses have a crucial role in the assessment of pain and its escalation, and in the appropriate and timely administration of prescribed analgesics.
The author examined the literature on the perceptions of nurses and patients in general adult hospital wards, identifying four main areas related to pain management in patients with opioid use disorder: stigma; lack of knowledge and education; nurse-patient relationships; and multidisciplinary team relationships.
An individual can be said to be stigmatised when they possess a characteristic that causes them to be discredited by society (Goffman 1963). There is strong evidence that patients with opioid use disorder are often stigmatised by nurses. Neville and Roan (2014) found that most nurses expressed negative attitudes, describing patients who misuse drugs as manipulative, needy and drug-seeking.
Similar views were expressed by nurses in a study by Morgan (2014); one nurse described feelings of guilt as she struggled with her negative reactions. Neville and Roan (2014) also identified that staff often experienced conflicts between their professional and ethical duties and their negative feelings towards these patients, with Monks et al (2013) finding that this caused dissonance for nurses. Furthermore, Morley et al (2020) found that managing a patient’s pain alongside their opioid addiction caused ethical uncertainty for some nurse participants, who wanted to act in the best interests of their patients but were unsure how to proceed.
Mistrust was a common theme in the literature. Nurses used terms such as ‘blagging’ and felt suspicious of requests for pain relief, which were often interpreted as drug-seeking (Morgan 2014, Morley et al 2015). Krokmyrdal and Andenæs (2015) found that 62% of nurses believed that patients with opioid use disorder exaggerated their pain.
McCreaddie et al (2010) analysed nurse and patient perspectives, which revealed that patients with opioid use disorder felt they were entitled to non-judgemental compassionate care, and recognised when they were treated differently from other patients. Similarly, Monks et al (2013) found that patients recognised negativity and intolerance from nurses, which sometimes led to confrontational behaviour, and subsequently reinforced negative stereotypes of people who misuse drugs. This suggests that stigma may fuel negative behaviour, resulting in a self-perpetuating cycle in which nurse-patient relationships may become characterised by hostility, mutual mistrust and tension.
A lack of knowledge has been frequently identified as a barrier to managing pain in patients with opioid use disorder. For example, Monks et al (2013) reported that nurses often did not feel confident in managing the needs of these patients, with Morley et al (2015) suggesting that financial pressures had led to a lack of time for teaching and continuing professional development. Krokmyrdal and Andenæs (2015) found that while 80% of nurses felt they were able to recognise pain, 54% felt unable to evaluate the degree of pain and 88% reported that they did not have sufficient knowledge about pain treatment in patients with opioid addiction. Furthermore, McCreaddie et al (2010) and Monks et al (2013) found that nurses lacked confidence in recognising and managing drug withdrawal, and that substance misuse was seen as being outside the remit of adult nursing. This issue was also discussed by Neville and Roan (2014), who found that many nurses considered substance misuse to be a specialist field, so they felt unprepared and that they lacked the necessary knowledge and education to provide effective care for this patient group.
Morley et al (2015) reported that nurses experienced issues with recognising and responding to the complex psychosocial needs of patients with opioid use disorder, although most nurses acknowledged the need for holistic individualised care. Only one participant in their study, a specialist pain nurse, recognised the issue of opioid-induced hyperalgesia, where pain is experienced with a greater intensity as a result of opioid use (Dever 2017). McCreaddie et al (2010) and Krokmyrdal and Andenæs (2015) also found that many nurses were unaware that an increased sensitivity to pain is a potential consequence of opioid addiction.
Despite the consensus that lack of knowledge was a barrier to optimal pain management in patients with opioid use disorder, there were differing perspectives on the sources of nursing knowledge and on how this issue should be addressed. Monks et al (2013) emphasised the importance of non-professional sources of knowledge, since nurses who were identified as having expertise in this area often had personal experiences that enabled them to empathise with these patients. They suggested involving people who misuse drugs in educational initiatives to promote compassion and to motivate nurses to enhance their knowledge. Morgan (2014) also identified lack of compassion as a barrier to knowledge and understanding. Krokmyrdal and Andenæs (2015) found colleagues to be an important source of knowledge, whereas traditional sources such as specialist courses and research literature were only minor contributors. They suggested that planned and structured peer coaching could have positive effects.
Managing pain in patients with opioid use disorder requires a skilled pain assessment that considers their vital signs, demeanour and mood, alongside patient report and knowledge of the physiology of pain and its pharmacological management. The evidence indicates that traditional sources of information may be only part of the solution to address nurses’ lack of knowledge, and that improving the quality of practice-based learning and experiences may be more beneficial.
As discussed previously, relationships between nurses and patients with opioid use disorder may be defined by mistrust and hostility. Nurses have reported feeling exploited, whereas patients have described having to negotiate for pain relief. In one study by McCreaddie et al (2010), one patient participant explained that a lack of sympathy from nurses led to feelings of worthlessness, and the authors suggested that the unfamiliar environment of the hospital ward and its structured routines disempowers patients who misuse drugs and contributes to anxiety. They found that the immediate concerns of these patients relate to preventing pain and withdrawal, but that nurses do not always recognise these concerns as a priority.
Monks et al (2013) agreed that fear of unsupported withdrawal was the primary concern for patients, who may use strategies such as persistence to ensure their needs are met. However, this persistence was often interpreted by nurses as ‘being a nuisance’ or ‘drug-seeking’ and they responded with detachment and avoidance. The frustration and anxiety this caused for patients sometimes resulted in a confrontational mode of communication, reinforcing the negative perceptions of patients who misuse drugs as aggressive, needy and unpredictable.
McCreaddie et al (2010) suggested that the patient response to frustration and unmet needs may be self-discharge or non-compliance. Morley et al (2015) also discussed ‘non-compliant’ patients – for example, those who disregard medical advice or refuse to conform to expected behavioural norms – who were often seen as occupying valuable beds. In Neville and Roan’s (2014) study, nurses expressed frustration at the time and effort that they spent caring for patients who would frequently return to hospital in the same situation. McCreaddie et al (2010) observed that nurses rely on successful therapeutic interventions to enhance their job satisfaction and self-worth. Therefore, they have the expectation that patients will engage in care. This evidence suggests that when patients with opioid use disorder are ‘non-compliant’, the reciprocal relationship breaks down, which can lead to reduced job satisfaction for nurses and, subsequently, frustration. The anxiety and tension that result from the breakdown in the nurse-patient relationship has the potential to affect the patient’s experience of pain and reduce the therapeutic effectiveness of nursing interventions.
In Morley et al’s (2015) study, nurses discussed differences between nursing and medical management, with some stating doctors were concerned with trying to ‘fix’ patients and not so focused on managing pain. These nurses thought that some patients required further analgesics, but felt limited by what the doctor was prepared to prescribe, a sentiment also identified by Morgan (2014). Furthermore, Morley et al (2015) discussed the differing approaches between addiction specialists, who focus on risk management and have an increased awareness of the potential for manipulation, and pain management approaches, in which assessment is based on patient report. Nurses reported feeling that they had to balance these two specialties and this resulted in a barrier to pain management. The authors suggested joint pain management plans and improved multidisciplinary team communication to overcome this issue (Morley et al 2015).
To manage ethical uncertainty, Neville and Roan (2014) recommended care based on collegial consensus with other members of the multidisciplinary team. Nurses have an essential role in advocating for patients and in ‘forming a bridge’ between other healthcare professionals.
There is strong and consistent evidence that stigma is a major barrier to optimal pain management in patients with opioid use disorder (Faculty of Pain Medicine of the Royal College of Anaesthetists 2020). While some nurses appear to perceive opioid use disorder as a disease that warrants compassion and treatment, other nurses view it as a lifestyle choice and in some cases, as a crime (Coluzzi et al 2017). This finding reveals that stigma may determine whether patients with opioid use disorder are perceived as being deserving of care. It also demonstrates the extent to which opioid use disorder is stigmatised.
There appears to be a consensus in the literature that a lack of knowledge of opioid use disorder is a barrier to effective pain management. However, various types of knowledge are necessary in the complex task of managing pain in this patient group. Paschkis and Potter (2015) suggested that how quickly and effectively pain is treated depends largely on the nurse’s knowledge and skills. In addition, Quinlan and Cox (2017) emphasised the importance of establishing an atmosphere of trust and understanding with this patient group. Liberto and Fornili (2013) proposed that a lack of knowledge underlies the stigmatisation of patients with opioid use disorder; however, an alternative view is that stigma leads to a lack of knowledge. Morgan (2014) supported this view, claiming that a lack of compassion is a barrier to knowledge, since it may mean that nurses are less motivated to enhance their understanding.
Morley et al (2015) identified differing management approaches between professional specialties as a barrier to pain management. Like Neville and Roan (2014), they call for closer multidisciplinary teamworking and collegial consensus to manage ethical uncertainty and to formulate expert care. Morley et al (2015) also suggested that there is a need to move away from the traditional paternalistic model of care in which the patient is a passive recipient. They emphasised the importance of recognising the patient’s right to go against the advice of healthcare professionals and of developing genuine partnerships with these patients.
Paschkis and Potter (2015) suggested that the distress experienced by patients with opioid use disorder is exacerbated by having little control over their pain relief. The power imbalance between patients and nurses can be a source of frustration and anxiety that leads to disruptive behaviours and suboptimal pain management. Quinlan and Cox (2017) asserted that effective pain management is based on supportive non-judgemental partnerships that minimise these patients’ anxiety.
This examination of the literature revealed that patients who habitually use opioids, whether illicit or prescribed, may be subjected to stigma by nurses and other healthcare professionals. Their stigmatisation means that nurses may be less motivated to improve their knowledge of opioid use disorder on an individual and professional level. Patients often recognise the effects of stigma and are disadvantaged by the power imbalance of the nurse-patient relationship. This tends to cause anxiety and frustration, which can worsen the experience of pain and lead to disruptive behaviour that reinforces negative stereotypes of people who misuse drugs (Monks et al 2013). The breakdown in their relationships with nurses is a definitive barrier to effective pain management. Figure 1 summarises the barriers to effective pain management in patients with opioid use disorder, demonstrating how these barriers interact with one another.
Several recommendations and implications for practice have been identified in the literature to improve pain management in hospital patients with opioid use disorder. These include: developing individualised care and genuine partnerships; improving knowledge; improving experiential learning; and ensuring collaborative care planning and effective communication.
The complexity of pain management in patients with opioid use disorder means that individualised care is essential to form effective working partnerships based on trust and respect. To do this, nurses need to demonstrate empathy and, in the words of Monks et al (2013), ‘see the person in the patient’. Future initiatives should focus on fostering compassion and promoting genuine partnerships. Including patient narratives as part of nurse education on the topic may be useful in encouraging an empathetic approach and enhancing nurses’ understanding of the challenges and anxieties experienced by these patients during a hospital stay.
The evidence consistently indicates that there are issues relating to stigma and lack of knowledge of opioid use disorder (Morgan 2014, Neville and Roan 2014, Faculty of Pain Medicine of the Royal College of Anaesthetists 2020). Future research should focus on investigating the most effective way to deliver educational initiatives that challenge misconceptions and suboptimal practice, and on fostering closer, increasingly collaborative multidisciplinary team relationships that aim to resolve ethical uncertainty.
In addition, all nurses who are involved in managing pain in patients who are dependent on opioids need sufficient knowledge of the pharmacodynamics of analgesics so that they can understand and participate in prescribing decisions and ensure the optimal use of these medicines. The updated Nursing and Midwifery Council (2018) standards for education and training reflect the increased need for pharmacological knowledge for nurses at the point of registration. Hospitals need to ensure that all nurses are provided with adequate training and information to ensure their knowledge and skills up to date.
Krokmyrdal and Andenæs (2015) emphasised the importance of experiential learning. They suggested that nurses’ competence could be characterised as experience-based rather than evidence-based, indicating that improving the quality of workplace experiences is important to improve standards of care for patients with opioid use disorder. Liberto and Fornili (2013) proposed that, when caring for these patients, specialist pain nurses could be recruited as leaders who disseminate educational material and act as role models by reflecting the values and ethics set out by the 6 Cs of nursing – care, compassion, competence, communication, courage and commitment (Department of Health and NHS Commissioning Board 2012). It is possible that the increasing number of nurse prescribers and specialist nurses may present further opportunities for bedside and ward-based nurse education, since every interaction provides a potentially teachable moment.
In their small pilot study on dementia care, Leah et al (2017) found that shifting the focus from classroom-based education to structured experiential learning improved person-centred care. They delivered a combination of short films and simulated scenarios, followed by debriefs and small group discussions facilitated by clinical nurse specialists, to a multidisciplinary group. Although Leah et al (2017) found that this form of training was resource-heavy and required considerable planning, the process of active reflection was found to promote person-centred care and was effective from a multidisciplinary team perspective. Using case studies followed by small group discussions could provide opportunities for nurses to work with other healthcare professionals – such as prescribers, pharmacists and specialist nurses – to share knowledge and enhance their skills in managing pain in patients with opioid use disorder.
It has been suggested that differing management approaches between specialties can be a barrier to pain management (Neville and Roan 2014, Morley et al 2015). Effective care planning requires input from various healthcare professionals, including GPs, substance misuse teams, key workers, pain specialists, mental health services, doctors, pharmacists and nurses.
Opioids Aware (Faculty of Pain Medicine of the Royal College of Anaesthetists 2020) is a valuable resource that provides information relating to the management of patients with opioid use disorder. It recommends close liaison between healthcare professionals and a well-planned pain management strategy that is communicated effectively between staff in hospital and community services. A structured approach should include the identification of opioid use disorder on admission, comprehensive assessment and history taking, and a pain management plan that is developed in partnership with the patient. This plan should include the patient’s requirements for analgesia and for the prevention of withdrawal, since the patient will gain no analgesic benefit from opioid substitution therapies.
Prescribed doses of analgesics should take account of the individual’s level of tolerance, and multimodal analgesia may be beneficial in minimising the need for additional opioids to manage acute pain. For patients who are recovering from opioid use disorder, non-opioid interventions should be used where possible. There is a risk of relapse associated with opioid use and undertreated pain. The patient should be at the centre of decisions about their analgesia and their wishes should be respected. Discharge planning should also be considered, with a clear plan for dose tapering as acute pain subsides. Box 1 details some of the recommendations for effective pain management in patients with opioid use disorder.
• Undertake thorough pain assessments based on patient report, but take account of vital signs, body language, patient demeanour and the potential for hyperalgesia. Consider the nature of the pain, for example whether it is acute, chronic, post-surgical, neuropathic or nociceptive
• Optimise the use of non-opioid analgesics such as intravenous paracetamol and non-steroidal anti-inflammatory drugs or gabapentinoids, as appropriate
• Recognise symptoms of withdrawal such as piloerection, rhinorrhoea, perspiration, yawning, agitation, abdominal cramps, tremor and dilation of the pupils. Escalate and ensure that opioid substitution therapy is prescribed if necessary
• Take time to get to know the patient and acknowledge their concerns in relation to their hospital admission, particularly those regarding their drug use. The nurse should be aware of stigmatisation in themselves and their colleagues, and understand its effects on the patient. Aim to establish a relationship with the patient based on open communication and respect
• Involve relevant specialties in the patient’s care, for example the pain team, substance misuse or mental health services. Find out if the patient is known to community services, keep them updated and coordinate discharge planning to reduce the risk of relapse
Pain management in patients with a history of opioid use disorder is complex, and therefore requires a skilled pain assessment and a well communicated management plan based on multidisciplinary team consensus. There is strong evidence in the literature that patients with opioid use disorder experience stigmatisation by nurses; such negative attitudes are often in conflict with nurses’ professional and ethical duties, causing dissonance and detachment. This is compounded by a lack of knowledge and understanding about dependence, addiction and withdrawal.
Patients frequently report feeling misunderstood, and often recognise the effects of stigma, which may lead to feelings of resentment and frustration. This frustration, along with fear of pain and withdrawal, can worsen the patient’s experience of pain and may lead to anxiety-driven behaviours such as aggression or persistent demands, which reinforce negative perceptions about patients with opioid use disorder as disruptive or manipulative and needy. A breakdown in the nurse-patient relationship can lead to suboptimal pain management in this complex and vulnerable patient group. Future research and education should focus on promoting compassionate person-centred care and enhancing multidisciplinary team collaboration.
02 October 2024 / Vol 39 issue 10
Promoting quality of life for patients with myeloma
This article aims to provide nurses with an update of best...
An assessment of the value of music therapy for haemato-oncology patients
The aim of this service evaluation was to assess the value...
Assessing the benefits of social prescribing
Social prescribing provides GPs and other healthcare...
Use of olaparib in BRCA mutation-positive ovarian cancer
Nurses should understand the role and purpose of the new...
Introduction of a pain assessment tool in a cancer centre: an action research approach
The aim of this research project was to develop and pilot a...
