Educating Patients About Pain Medications
Former US Surgeon General C. Everett Koop, MD, famously said, "Drugs don't work in patients who don't take them." Medications also don't work in, and can even harm, patients who don't take them as intended. In a meta-analysis of research studying medication adherence and treatment outcomes, nonadherence accounted for 33% of hospital admissions for adverse drug events.1 Nonadherence to an analgesic regimen could result in untreated pain or adverse events, which can cause decreased productivity and increased employee absences. Poor provider– patient communication has been identified as a barrier to adherence.
In 1999, the Institute of Medicine urged clinicians to counsel patients on prescribed medications.2,3 Every patient has a story, and so does every drug. After you know the patient's pain story and decide a medication should be part of their treatment plan, it's your job to properly introduce the patient to the medication by sharing the drug's story with the patient. This includes nonprescription and prescription analgesics, non-opioids and opioids, and topical and systemic analgesics (Table 1). An easy way to cover all of the important pieces of information a patient needs is by remembering the elements of any story: Who, What, Why, When, How, and Where (Figure 1).
Patients must be educated regarding information they will find on the medication label as well as information that won't be on the label. First and foremost, a patient needs to know "who," which, for a medication, is the brand and/or generic name. If the patient is prescribed or dispensed a generic version of their medication, often they will be more familiar with the drug's brand name due to direct-to-consumer advertising. Often, the brand name is also easier to pronounce and remember, but phonetic spelling on a patient handout can help a patient remember the generic name (eg, MOR-feen). In the case of acetaminophen, it is important to explain that "acetaminophen," "APAP," "paracetamol," and "Tylenol" are all the same medication so patients know to avoid an overdose situation.
The "what" in a medication's story includes the dosage form and strength prescribed, as well as what the patient can expect from the drug in terms of therapeutic and adverse effects. For an opioid prescription, the patient needs to know they may experience drowsiness and/ or nausea initially, and constipation for the duration of therapy. It would be prudent to explain how to prevent constipation, as well as explain about any medications they will be taking to manage this adverse effect. Therapeutic effects should be explained in terms of reduction in pain scores, as recorded in pain diaries, and improvement in daily functioning. These will vary based on the patient's story. Therapeutic goals go hand in hand with "why" you are giving the patient this particular drug.
Of course, a prescription label will contain your directions for when and how to take the medication. However, going over this information with the patient will reinforce it and often reveal interacting foods or drugs the patient might be taking. In addition, educating the patient on when and how can uncover misunderstandings the patient might have. The patient also needs to know when to follow up with you to monitor the efficacy and safety of their regimen. Part of "how" includes how to take or use the medication including swallowing a tablet or capsule whole versus allowed dosage formulation manipulation (crushing, chewing, etc), application of a transdermal patch, or application of a topical analgesic.
Finally, where is often overlooked, but incredibly important. Drug diversion is an increasing problem; patients must be advised that the medication cabinet isn't the best place for long-term medication stability or short-term security of their medication. Patients on opioid medications are well advised to store their medication as they would their money; in other words, NOT on the kitchen table. In addition to storage, knowledge of proper disposal is critical. Improper disposal of fentanyl patches has resulted in serious illness and death in children who came in contact with them.4 Patients should be advised to fold fentanyl patches in half so the sticky sides meet, and flush them down the toilet. In fact, if your local authorities do not have a take-back prescription drug program, the FDA recommends flushing all controlled substances.5
Another good way to remember all the pieces of information a patient needs to know about their medications is to use the guide provided by the National Council on Patient Information and Education (Table 2). The table features "Questions to Ask About Prescription Medications," and uses extended-release morphine tablets as an example.6
Fears, Myths, and Misconceptions
While providing factual information about analgesics as described above is critically important in achieving therapeutic success, it is equally important to explore patients' health care beliefs and fears or thoughts about analgesics. Another important factor is how the prescriber introduces the use of analgesics to the patient. Reid et al reported that cancer patients found opioid therapy to be a more acceptable option to manage their pain when health care providers displayed confidence in opioid therapy, and adverse effects were well managed.7
Fitzcharles and colleagues evaluated the pain experience of patients with rheumatoid arthritis being managed in a specialty rheumatology practice, specifically evaluating patients' satisfaction with pain control and determining barriers that may affect pain management.8 More than half of the 60 patients surveyed reported three or more barriers to effective pain management. Eighty percent were concerned about analgesic adverse effects, 63% had concerns about taking too many pills, 57% were concerned about drug interactions, 35% had fears of addiction, and 27% felt that analgesic therapy may mask or hide their disease.
More than a decade ago, Ward et al explored patients' concerns about reporting pain and using pain medications, referring to these concerns as "patient-related barriers to pain management."9 After reviewing the literature and conducting a series of studies, the authors summarized into eight categories patients' concerns that prevent accurate reporting of pain and reluctance to take medications: