Aim: To determine the extent to which nurses are able to correctly identify drugs as narcotics and to ascertain their perception of the addiction potential of opiates when used for pain management. Methods: A questionnaire was administered to 86 nurses who attended palliative care workshops in India. Findings: Only morphine (95%), heroin (71%) and codeine (75%) were correctly identified as narcotics by the majority of participants. Imipramine (34%), diazepam (20%) and phenobarbitone (39%) were wrongly classified as narcotics by many nurses. Dextropropoxyphene (11%), pentazocine (21%), buprenorphine (15%) were correctly classified as narcotics by fewer than half the participants. Only 14% knew that that the frequency of psychological dependence due to use of morphine for cancer pain was less than 1%.
Keywords: narcotics, dependence, cancer pain, palliative care, and nurse education.
A lack of knowledge about common pharmacological agents used in pain control, and exaggerated fears about the likelihood of psychological dependence lead to poor pain management in clinical practice. Studies have demonstrated that many health professionals have a poor understanding about pain assessment and treatment.
Cohen's (1980) questionnaire survey of 121 nurses also revealed that nurses had inadequate knowledge about use of opioid analgesic drugs and were overly concerned about the possibility of opioid addiction. When asked to estimate the number of persons with pain who become addicted as a result of being treated with narcotic drugs in the hospital, only 31.5% of the nurses correctly thought it was 1% or less. 13% of this sample estimated the chance of addiction at 26% or greater.
A survey was carried out by Weis et al (1983) among house staff and nurses involved with postoperative care to assess their knowledge of analgesics and their attitudes toward postoperative analgesic care. Only one-fifth of the respondents prescribed adequate analgesics for complete pain relief. There were some misconceptions about adding other drugs to narcotic analgesics, as well as fear of the addictive properties of these narcotics. The incidence of addiction after use of opioid drugs for pain relief was correctly identified as <1% by only 15.8% of physicians and 11.4% of nurses.
McCaffrey et al (1990) analyzed data obtained from workshops on pain to determine the nursing knowledge of pharmacological management of pain. Results indicated that nurses lack knowledge in classification of opioids with correct responses ranging from 23 to 98% across seven analgesic drugs. Less than 25% of nurses correctly identified the frequency of psychological dependence.
These above studies indicate that nurses and other health professionals have inaccurate knowledge about common pharmacological agents used in pain control, and they have exaggerated fears about the likelihood of psychological dependence on opioids as a result of the use of narcotics for pain control. This study was conducted to understand the perception and knowledge of nurses about narcotics in Indian setting.
The data was collected from pretest surveys during two workshops conducted by the author (SKC). The participants had varying years of experience in nursing, and oncology. These workshops were conducted in the year 1999 and 2000. These were conducted at two large cancer centers in South India.
The procedure used by the workshop leader was to distribute the questionnaire at the beginning of the session and to tabulate the results during the day to share the results with the attendees. Consent for using the findings for further teaching and reporting in a journal was obtained from the participants. The tool, included two sections. The first section assessed knowledge of drug classification by asking the subjects to identify ten drugs as narcotic or nonnarcotic. Subjects were given choices of "narcotic", "nonnarcotic", and "don't know". The drugs listed were cocaine, codeine, heroin, morphine, Fortwin (pentazocine), Proxyvon (dextropropoxyphere), Tidigesic (buprenorphine), imipramine, calmpose (diazepam), and luminol (phenobarbitone).
The second section was a single item assessing knowledge of narcotic addiction. Subjects were asked to identify the frequency (by percent) of addiction in patients treated with narcotic drugs for pain. Ten possible choices were given ranging from <1% to 100%. A definition of the term "narcotic addiction" was included on the tool. It was defined as the behavioral pattern of drug use, characterized by overwhelming involvement with the use of drug, the securing of its supply, and a high tendency to relapse after withdrawal. It is not used interchangeably with physical dependence (Jaffe 1985). Data was analyzed using the statistical package SPSS tenth version.
There were a total of eighty-six respondents. (N=86). All participants were female. The median age was 31. The median number of years of experience in nursing was 9 years. The median duration of experience with cancer patients was 2 years. [Table - 1]
The results of the narcotic classification questionnaire are presented in [Table - 2]. Correct answers for individual drugs ranged from 95% for morphine to 17% for cocaine. The majority of participants correctly identified only morphine, heroin and codeine as narcotics. Imipramine, phenobarbitone and diazepam were wrongly judged as narcotic by 40%, 45% and 23% of nurses respectively. Fewer than half the participants correctly classified dextropropoxyphene, pentazocine, and buprenorphine as narcotics.
None of the participants could give all correct responses. Seven nurses gave 8 or 9 correct answers and 52 gave four to six correct responses. 19 had fewer than four correct answers [Table - 3]. An attempt was made to examine the association between the correct scorers and years of experience in nursing. It was found that nurses who had fewer years of experience had better knowledge about narcotic substances, as compared to those who had more than ten years of experience. This difference was found to be statistically significant (p < 0.05) [Table - 4].
Knowledge about the frequency of drug addiction is presented in [Table - 5]. Only 14% of nurses correctly identified the frequency of addiction among cancer patients on opiates as <1%. 32% of the nurses thought the frequency of addiction was more than 50%.
Nurses are integral to palliative care delivery and it is important that they have a clear understanding of the nature of the drugs prescribed. In our study nurses had a poor knowledge about the classification of narcotic drugs and about the low potential of addiction in patients using opiates for pain relief. Similarly, McCaffrey et al (1990) found in pain management workshops that many nurses had inadequate knowledge about the pharmacological management of pain. When asked to classify analgesics, the percentage of correct responses for seven drugs ranged from 17% for cocaine 95% for morphine.
On examining the association between the knowledge about narcotics and years of experience in nursing, it was found that nurses who had fewer years of experience had better knowledge, as compared to those who had more than ten years of experience. This implies that those trained recently have a better knowledge about narcotic drugs rather than those trained more than ten years back. This trend is positive, and it is hoped that present nursing training would give more attention to cancer pain and use of morphine for pain relief.
Confusion regarding opioid analgesics probably results from multiple factors. The term narcotic has been used to refer to morphine related strong analgesics. The media often refer to all substances of abuse as 'narcotic' drugs and some health professionals also use the term loosely.
Less than a quarter of the nurses in McCaffery's study correctly identified the frequency of psychological dependence. Marks and Sachar (1973) reported that only 60% of physicians correctly identified the chance of addiction from use of narcotic drugs for pain relief as <1%. 16% thought that addiction occurred in between 1 and 5% of patients; and 22% thought the incidence of addiction was greater than 6%. Chart review of 37 patients in their hospital showed that physicians underprescribed analgesics and nurses compounded the problem by administering less opioid medication than was prescribed. Concern about iatrogenic addiction was probably a significant factor in the under use of analgesics.
In India, legal and administrative obstacles to the use of opioids drugs for pain control can easily convey the message that such drugs are better avoided. The present study indicates that many nurses have fears about patients developing psychological dependence on opioid drugs. Consequently nurses may fail to play an active role in titrating opioids and in administering analgesics for breakthrough pain. If this is to improve, it is imperative that staff and student nurses in India have adequate opportunities to learn about the properties of commonly used analgesics, and the scientific use of opioids for pain management.
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]