Three Lessons Pain Management Teaches Us About Patient Adherence
(This article was first published in the Journal of Patient Compliance; see page 12.)
Pain medication is an anomaly in patient adherence. Here the concern is with taking too much and not often enough, which is the usual problem faced in getting patients to take their medication.
A common reason why patients seek medical advice is because they are in pain. When treating a patient for pain, particularly with opioids, physicians often wrestle with the dilemma that the treatment, while relieving pain, may result in the patient becoming addicted or overusing a powerful, opiate medication.
This concern is justified. According to the Centers for Disease Control and Prevention in the United States, the number of deaths related to opioid analgesics and other drugs and substances is rising. From 1999 to 2007, the number of US poisoning deaths involving any opioid analgesic (e.g., oxycodone, methadone, or hydrocodone) more than tripled, from 4041 to 14,459, or 36% of the 40,059 total poisoning deaths in 2007. In 1999, opioid analgesics were involved in 20% of the 19,741 poisoning deaths. During 1999–2007, the number of poisoning deaths involving specified drugs other than opioid analgesics increased from 9262 to 12,790, and the number involving non-specified drugs increased from 3608 to 8947.
Moreover, recently, The Joint Commission (an independent, not-for-profit organisation that accredits and certifies more than 19,000 health care organisations and programmes in the US) recently warned about the safe use of opioids. The Joint Commission cautions, “While opioid use is generally safe for most patients, opioid analgesics may be associated with adverse events, the most serious effect being respiratory depression, which is generally preceded by sedation.”
Here are three lessons patients in pain teach us about better patient adherence.
#1 — Following a Prescription is Not the Final Answer
Taken as prescribed, opioids can be used to manage pain safely and effectively. However, a single extra dose (even if physician prescribed) can cause severe respiratory depression and death.
Take the case of 18-year old Amanda Abbiehl. She was connected to a patient-controlled analgesia (PCA) pump to manage her pain. As Patricia Iyer, MSN, RN, explains in her article on PCA pumps, “Patient Controlled Analgesia (PCA) pumps were developed to address the problem of undermedication. They are used to permit the patient to self-administer small doses of narcotics (usually Morphine, Dilaudid, Demerol, or Fentanyl) into the blood or spinal fluid at frequent intervals. PCA pumps are commonly used after surgery to provide a more effective method of pain control than periodic injections of narcotics. This method of pain control has been found to result in less pain and earlier discharge from the hospital.”
However, when Amanda Abbiehl’s parents kissed her goodnight on July 16, 2010, they never imagined it would be for the last time. She had been admitted to an Indiana hospital the day before with a painful case of strep throat. It ought to have been a fairly routine case. Instead, she died hours later. As the Daily Mail in a recent article asked, “Did self-dosing pain pump kill beautiful girl, 18, when she was in the hospital for Strep Throat?”
According to Dr Frank Overdyk (Executive Director for Research, North American Partners in Anesthesiology, and Professor of Anesthesiology at Hofstra University School of Medicine) “PCA pumps provide optimum patient controlled analgesia and high patient satisfaction, yet despite their built-in safety mechanisms, can result in dangerous levels of over-sedation and respiratory depression. These pumps are safest in tandem with continuous electronic monitoring, a combination of pulse oximetry and/or capnography. We need to avoid unrecognised, critical respiratory depression, which can cause tragedies like that of Amanda Abbiehl.”
Amanda Abbiehl died, and yet she was following what her doctor prescribed. Her death is a stark reminder that following a prescription is not the final answer.
#2 — Consider Non-Medicated Alternatives
According to the Institute of Medicine (IOM), in the United States, every year about 100 million adult Americans experience chronic pain, a condition that costs that country between $560 and $635 billion.
The IOM report calls on healthcare providers, insurers, and the public to understand that although pain is universal, it is experienced uniquely by each person, and care –which often requires a combination of therapies and coping techniques — must be tailored.
An example of how combination therapy may be beneficial is illustrated in a recent study on chronic back pain published in the Annals of Internal Medicine. This research concluded, “Massage therapy may be effective for treatment of chronic back pain, with benefits lasting at least six months. No clinically meaningful difference between relaxation and structural massage was observed in terms of relieving disability or symptoms.”
The study involved 401 persons 20 to 65 years of age with non-specific chronic low back pain, who were told to undergo one of three therapies, namely the structural massage, relaxation massage, or usual care on a random basis. The massage treatment was given for an hour on a weekly basis up to 10 weeks.
Daniel C. Cherkin, PhD, a senior investigator at Group Health Research Institute and the study’s trial leader, concluded, “We found that massage helps people with back pain to function even after six months. Better function means they are more able to work, take care of themselves, and be active. This is important because chronic back pain is among the most common reasons people see doctors and alternative practitioners, including massage therapists. It’s also a common cause of disability, absenteeism, and ‘presenteeism,’ when people are at work but can’t perform well.”
Two patients (not related to this study) wrote about their experiences incorporating massage for their chronic back pain (identities have been removed for confidentiality; typos and misspelling included):
“I get severe muscle spasms in my back and neck and deep tissue massage helps relax the muscles and helps the pain for a day or more.”
“I go for regular massage, I have degenerative disk disease as well as severe arthritis and fibromyalgia. I agree that it’s not right for everyone, however, a good therapist will always check in with you and ask if the pressure is ok, and tell you to tell them if it is painful. If you have bone, vertebra or nerve damage a very gentle massage can be relaxing. I use to do massage and there are several different modalities, not just sweedish or deep muscle. Of course check with your doctor first, even trepidation (gentle rocking motions) can be very relaxing to someone in pain. I swear by my massage, and my massage gal is worth her weight in gold a million times over!”
Patients should be aware of non-medicated alternatives, which when used could help achieve the same goal for which the medication was prescribed.
#3 — Find the Motivating Factor
Pain is a common condition that all patients don’t want. The motivation to get rid of pain is high with patients.
Professors Aparna Labroo from the University of Chicago and Jesper Nielsen from the University of Arizona describe what motivates people: “Our natural inclination is to avoid — or try to avoid — anything immediately aversive even though it may be beneficial for us in the long term.”
Finding the motivating factor is the key to successful patient adherence. Dr Melissa Hunt, a licensed clinical psychologist and the Associate Director of Clinical Training in the Department of Psychology at the University of Pennsylvania, one of the top-ranked clinical training programmes in the United States, explains:
Patient factors constitute the main reasons for lack of adherence to medication. Many revolve around faulty beliefs, associations and assumptions that patients hold. Most can be corrected with interventions from trusted patient sources that provide accurate information targeted at actual patient beliefs, reframe negative appraisals, and acknowledge and address the “disadvantages” of the medication from the patients’ perspective.
Below is an example illustrative of Dr Hunt’s principles of finding the patient’s motivating factors for a glaucoma patient, who has weighed the pros and cons of taking medication in favour of non-adherence:
Understanding the motivation of patients for taking or not taking their medication is critical for the success of any recommended treatment. Particularly for asymptomatic diseases, the condition must be as “real” as pain for treatments to be adhered to. Says Dr Hunt:
Patients are generally not stupid, lazy or intentionally self-destructive. But, they can be misinformed, they can have misperceptions, and they can often underestimate both the benefits of the medication and the risks of the illness, and they can overestimate the disadvantages of taking the medication and the benefits of remaining untreated. Patients across a wide range of diseases and disorders often share a collection of faulty or distorted beliefs about medication. Identifying and understanding the psychological barriers to adherence and the motivations for being adherent, and then delivering corrective and reinforcing messages and information through a trusted source are a powerful tool for improving adherence.
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