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The Ethical Duty Assumed by Health Professionals to "Do No Harm"

Updated on May 11, 2014
Properly conduct a pain assessment.
Properly conduct a pain assessment. | Source

Healthcare Workers may Arbitrarily Withhold Pain Medications from Patients who need them

Health care professionals assume an ethical duty to do no harm. However, countless patients suffer in healthcare settings from improper pain assessment and inadequate pain relief. Nurses caring for a patient may not all agree that the patient’s complaints of pain are credible. This can occur when nurses take their own biases into the health care setting. At other times pain assessment is negated because nurses are overwhelmed or too busy.

Pain can be described as an unpleasant sensation that is physically and psychologically debilitating. Pain affects people in different ways. A patient in pain may refuse to eat or refuse to participate in activities. A patient in pain may not want to interact with staff or family members, or may refuse to cooperate with others.

Severe pain may cause feelings of helplessness and anger in patients. Worse, a patient in pain may associate his or her pain with certain staff members. This usually occurs in cases where nurses routinely allow patients to wait long periods for their pain medications, fail to give adequate medication to treat the level of pain, or fail to medicate at routine intervals before break through pain occurs.

Years ago, I worked with a nurse who routinely refused to administer pain medications as needed (PRN) to a patient during hemodialysis (Dialysis) treatments. The patient who belonged to a minority group, had a diagnosis of lower back cancer that caused him severe pain during dialysis. The Patient’s doctor had ordered several PRN medications for the patient that included Percocet,Tylenol and Dilaudid. The Nurse verbalized that she believed that the patient was an addict who liked Dilaudid.

Despite the cancer diagnosis, the nurse insisted that the patient came to the Dialysis department just to get Dilaudid. As such, she refused to give him Dilaudid or even Percocet when he was assigned to her care. When he cried and described his pain as 10/10, she offered Tylenol to him which did not seem to be effective.

On the other hand, this nurse consistently gave Percocet to another patient with whom she shared the same ethnicity. At times, this other patient who also had a PRN order for Percocet, left the treatment area to use the bathroom and returned to find her Percocet at the chair side without requesting it.

I was deeply disturbed by this behavior but was unsure how to handle the situation. I was relatively new to the facility. The staff members and management shared a close bond. I evaluated the patient on several occasions and conversed with his wife and was convinced that the patient’s complaints of pain were genuine.

I reported the problem to the nurse manager.

In hindsight, I wished I had done more to help that patient.

Don't Assume that a Patient is a Drug Seeker

Don't be quick to assume that a patient is`a drug seeker. Get a complete history.
Don't be quick to assume that a patient is`a drug seeker. Get a complete history. | Source
Patients who need stronger medications like morphine for severe pain should not be denied.
Patients who need stronger medications like morphine for severe pain should not be denied. | Source
Don't assume that a patient is stocking prescription drugs.
Don't assume that a patient is stocking prescription drugs. | Source

The Mislabeled Drug Addict

Healthcare staff may unfairly label patients who request pain medications frequently as drug addicts.

Patients receiving narcotic medications may be labeled as being:physically dependent, drug tolerant or drug addicted.

Physical dependence

Physical dependence to a drug is described as a physiological adaptation of the body tissues to the presence of a drug. The body eventually requires continued administration of the drug for normal tissue function.[1] [2]

When a patient who is physically dependent on opiates ceases to use these drugs, the patient experiences withdrawal symptoms. [3] These symptoms include agitation, insomnia, increased tearing, nausea, runny nose, vomiting, abdominal cramping, muscle aches dilated pupils and sweating and other symptoms. [4]

Drug Tolerance

Drug tolerance is defined as the body’s adaptation to a drug such that the continued use of the drug results in decreased pain relief with the same dosage over time. [5] When a patient becomes tolerant to a drug, he or she needs increased amounts of the drug to achieve the same effects.

Get the patient's history of drug use before unfairly labeling him or her an addict.
Get the patient's history of drug use before unfairly labeling him or her an addict. | Source

Drug Addiction

Drug addiction is defined as a constant craving and abuse of a drug for pleasure seeking reasons. [6] It is characterized by lack of control, a compulsion to use the drug, and inability to discontinue the use of the drug despite its harmful effects.[7]

With these definitions in mind, it is unclear how the aforementioned nurse was able to determine that a patient whom she saw three days per week, for approximately 4 hours, was addicted to a drug. The patient’s dialysis treatment was only 3.5 hours long. The drug was ordered once as needed during the dialysis treatment. There was no documentation in the patient’s chart to suggest that the patient was engaging in drug seeking behaviors that were unrelated to his cancer diagnosis. There was no documentation that he craved the drug or asked for more that the one dose per treatment that he was entitled to.

Significantly, a review of the patient's home medications did not reveal that he used Dilaudid at home. The patient had never shown up to dialysis with any symptoms of withdrawal from Dilaudid use.

Dilaudid is a water soluble opiod that is dialyzable. [8] Studies have shown that plasma levels of Dilaudid are reduced by about 60 percent during dialysis treatment.[9] Because Dilaudid is dialyzable, it is recommended that proportionally larger doses of Dilaudid be given at the start of treatment and that additional dosing be done after treatment.[10] This infers that a patient receiving Dilaudid during dialysis is not usually at risk of taking home large amounts of this drug in his or her system even if he came to the healthcare facility just to get it.

Patients should not be labeled drug addicts if they come to healthcare facilities to get pain medicine. Pain is an unpleasant sensation which may cause people with low tolerance to seek pain relief. Pain medications are kept in healthcare facilities. People who prescribe pain medications are found in healthcare facilities. As such, it is logical to associate a healthcare facility with plain relief.

The withholding of the Percocet from the dialysis patient was troubling. Studies have shown that minority patients are disproportionally under-treated for pain in healthcare settings and are more likely to be given non narcotic analgesics as opposed to opiates for pain relief.[11][12]


Cancer Pain

Medication are at times withheld from cancer patients due to fear of addiction. Nurses engaging in this practice should reevaluate their actions. Nurses should treat cancer patients for pain before cancer pain becomes severe and unmanageable.

The recommended clinical approaches to management of cancer pain are as follows:

- Get into the habit of questioning a patient frequently about his or her pain experiences.

- Listen to the patient's and family's perceptions of pain and their expressions of what brings relief.

- Collaborate with the patient and family to choose suitable approaches for pain management.

- Provide timely interventions at set intervals.

- Allow patients in pain to believe that they have some control over pain management.

Be mindful at all times that failure to adhere to analgesic pain regimen also contributes to mismanagement of pain.[13][14]

Support for People with Cancer Pain

Pharmacists may asses knowledge and counsel patients about dispensing medications.
Pharmacists may asses knowledge and counsel patients about dispensing medications. | Source
After proper assessment the doctor writes a prescription for pain medication based on the patient's need for a drug.
After proper assessment the doctor writes a prescription for pain medication based on the patient's need for a drug. | Source

How to Properly Identify Drug seeking behaviors

Caregivers should get a complete history on a patient before deciding how to manage his or her pain, or whether to label a patient as a drug seeker.

The initial phase of the pain assessment includes doing or knowing the following:


* Getting a list of all medications and knowing all relevant diagnoses.

* When was the last dose of a medication administered?

* How long has the patient been taking a particular medication?

* How does the patient respond to a particular medication?


Drug seekers may engage in specific types of behaviors. The following will help you identify common signs of drug seeking behaviors:

  1. Patient describes his pain as being intolerable or severe (10/10) yet has a calm facial expression and no other physical or behavioral signs.
  2. Patient frequently requests a narcotic drug even when the time interval for administration has not approached.
  3. Requesting specific types of narcotic medications even though other types have worked for patient in the past.
  4. Patient requests refills frequently although his prescription is not due for a refill.
  5. Patient knows the names of numerous narcotic medications. (This is not usually a reliable indicator since patients are encouraged to educate themselves about their diagnoses and medications)
  6. Going to different physicians for prescription refills.
  7. Patient constantly ask for an increased dose despite expressing relief from a lower dose.
  8. Several claims that medications were lost, misplaced or stolen.
  9. Your family member expresses pain relief after receiving a placebo.

A patient left in pain may call home to get help.
A patient left in pain may call home to get help. | Source
Caregivers who are busy with numerous responsibilities (eg. acting as preceptors) may not focus on proper patient assessments.
Caregivers who are busy with numerous responsibilities (eg. acting as preceptors) may not focus on proper patient assessments. | Source

Reasons for Negating proper Pain Assessment and Management

Proper pain assessment is often negated when nurses are overwhelmed by numerous responsibilities. A nurse may decide to complete a task that could have waited before responding to a patient’s request for pain medication.

As a former supervisor of nurses, I have counseled nurses who delayed administration of pain medications to patients. In one situation a nurse decided to finish doing the medication pass on other patients before responding to a patient's request for pain medication. The patient complained that she did not want this nurse caring for her and described how she usually suffers whenever she is placed in the care of this caregiver.

In nursing home settings, patients may label certain nurses as bad caregivers and spread the word around. This may cause other patients to be fearful when placed in the care of certain nurses.

A Certified Nurse Assistant(CNA) was reprimanded in one case where he openly referred to a particular side of a ward as the “zone of misery.” The CNA contended that the residents in that area were usually groaning or screaming in pain whenever a particular nurse was on duty.

There have been cases where patients have called home and asked family members to call the facility to complain that their pain was not being attended to. Family members who are forced to call healthcare facilities to seek pain relief on behalf of patients usually develop a negative impression of the healthcare facility and staff members.

During a 6 month period, while working in several acute settings, I observed several Nurses conducting pain assessments by simply asking; “Where does it hurt?” “ On a scale of 0 to 10, with ten being the worst, how would you rate your pain?” On other occasions I have heard; “Where does it hurt? Oh, you have a headache; I’ll get you some Tylenol.” The pain assessment tools in all these acute care settings were obviously more detailed and required proper examination of the patients in order to appropriately manage their pain.

In many cases, Tylenol was frequently the drug of choice, seemingly at the nurse's convenience. The likely explanation is that Tylenol is often kept as stock medication on hospital floors and is easily accessible. Additionally, Tylenol is often a routine part of patients PRN orders.

With Tylenol readily available, a busy nurse does not have to place a call to a doctor who may need to be called several times before he or she responds. With Tylenol available, a busy nurse does not have to follow up with the pharmacy or find staff to retrieve a medication from the pharmacy. Moreover, pharmacy may not have a technician available to immediately deliver a stronger drug.

Moreover, a nurse who administers Tylenol does not have to wait on other staff members to co-sign for a drug, nor does he or she have to worry about with problems with the drug count. According to experts, nurses who give mild analgesics to patients with intractable pain are not engaging in “current evidenced based practice.” [15].

Expecting patients to remain in intolerable pain may violate ethics and the duty to do no harm. [16][17]

Types of Pain and Non Verbal Responses to Pain

Be aware that there are two types of pain. The two types of pain are acute pain and chronic pain.

Patients may become hopeless from unrelieved chronic pain.
Patients may become hopeless from unrelieved chronic pain. | Source

Acute Pain

Acute pain has a rapid onset and usually has a short duration. Acute pain usually disappears after healing of a condition and does not last for more than six months.

Acute pain varies in intensity and has an identifiable cause such as:

A fracture

Dental work

Labor pain

Sudden blow to the body

Surgery

New wound, laceration or bruise

Anxiety is a non verbal sign of pain.
Anxiety is a non verbal sign of pain. | Source

Non-Verbal Response to Acute Pain

Some non-verbal responses to acute pain are:

Restlessness

Increased respiration

Perspiration

Anxiety

Increased blood pressure

Distress

Dilated pupils

Increased heart rate

Increased blood pressure

Inability to concentrate

Grimacing


Withdrawal is a non-verbal response to chronic pain.
Withdrawal is a non-verbal response to chronic pain. | Source

Chronic Pain

Chronic pain is pain that extends or persists beyond the period of healing and lasts for more than six months. Chronic pain may lack an easily identifiable cause and usually affects physical functioning and daily activities.

Types of chronic pain include:

Rheumatoid arthritis

Cancer pain

Neurogenic pain (e.g., Diabetic Neuropathy)

Lower back pain

Migraine headaches


Non-verbal responses to chronic pain

Some non-verbal responses to chronic pain are:

Normal Blood pressure

Normal heart rate

Normal respiration

Withdrawal

Normal pupils

Hopelessness

Skin is dry

Proper pain assessment will lead to proper diagnosis of diseases

Proper pain assessment will lead to proper diagnosis of diseases.
Proper pain assessment will lead to proper diagnosis of diseases. | Source

Dealing with your Pain and Caregivers Attitudes

Would you minimize the severity of your pain if requesting strong pain relief would cause you to be labeled a drug seeker?

See results

Patient Focused Pain Assessment

Proper pain assessment can be crucial to accurate diagnosis of medical conditions. Proper pain assessment of a headache can help caregivers differentiate between different health conditions. For example, proper pain assessment can help differentiate between a migraine headache and a subarachnoid hemorrhage.

A patient suffering from migraine headache may have symptoms that include throbbing on one side of the head, nausea, vomiting and sensitivity to light and sounds.[18] Routine activities may exacerbate the pain caused by a migraine headache.[19] An untreated migraine headache may last several hours to three days [20].

The characteristics of headaches caused by a subarachnoid bleed are usually a stiff neck, pain with bright light as well as personality changes.[21] The patient might describe his pain as the worst headache ever experienced. The pain is usually located at the back of the head. A patient may complain that the pain started after feeling a popping in the head. [22]

Pain of rapid onset is associated with conditions such as cholecystitis, pancreatitis, intestinal obstruction, diverticulitis, appendicitis, urethral stone, and penetrating gastric or duodenal ulcer.

[23] Pain of gradual onset is commonly associated with neoplasms, chronic inflammatory processes and large bowel obstruction. [24]

Proper assessment of abdominal pain can help nurses differentiate between conditions such as gall bladder pain and appendicitis. Pain caused by a gall bladder disease is characterized by gnawing pain in the right upper abdomen near the rib cage.[25] Pain from gall bladder can also radiate to the upper back. Gall bladder pain may go away but return after ingestion of large amounts of fatty foods. [26] The pain from Appendicitis has a rapid onset. It may start within seconds and steadily increase within minutes. [27]

Appendicitis is characterized by pain that starts around the belly button that progresses to the lower right abdominal area.[28]

As such, a nurse that properly assessed the character, location, duration, aggravating factors, or measures that relieve pain would be able to differentiate between pain caused from gall bladder and pain caused from appendicitis.

An elementary concept of pain management is to treat the patient as the master of his or her pain. Only the patient can shed light on the severity of his or her own pain. A patient's self report of pain is the most accurate and reliable evidence of the existence of pain and its intensity.[29]

The Joint Commission (that accredits healthcare facilities) requires proper pain assessment. The Joint Commission requires that health care facilities have pain assessment tools in place and use them consistently in the evaluation of pain. The Joint Commission does not determine which pain tool should be used as long as one is used.

After pain assessment, nurses must carefully document the patient’s concerns, signs and symptoms of pain so that other caregivers can follow up and make informed decisions on how best to manage the patient’s pain.

Use a Pain Assessment Scale with pictures for patients who are unable to speak

Source

Pain Assessment Questionnaire

Try to be involved in your care or the care of family members so that you can help determine if pain is being properly managed in a healthcare setting. This is a pain assessment questionnaire that you can use at home before getting medical help for a loved one:

  1. Location: Where is the pain located on your body and where does it radiate? Location of pain may help to determine types of diagnosis such as gall bladder problems or kidney stones.
  2. Quality: Describe the quality of your pain? Quality is described by words such as dull, sharp, burning, aching, throbbing, pressing, gnawing, cramping, aching, burning, constant or intermittent.
  3. Trigger: What triggered the pain or what were you doing when the pain started?This will help to determine whether any special activity triggered the pain. If your pain started suddenly or has been ongoing, then a determination can be made as to whether there is chronic or acute pain.
  4. Time: How long has the pain lasted? Has it stopped since it started?
  5. Severity: What is the severity of the pain? Use a 0 to 10 pain scale. 0=no pain;1-3=mild pain; 4-6=moderate pain; 7-10=severe pain. If the patient is unable to speak use a pain scale with pictures such as the Wong-Baker Faces (WBF)pain rating scale. Each face on the WBF has a number for pain severity identification.
  6. Provocation: What provokes or worsens the pain? Does a movement or particular activity makes the pain worse?

Be empathetic and manage pain appropriately.
Be empathetic and manage pain appropriately. | Source

Pain Management

Get involved in your care and the care of family members. You should learn the name of commonly used pain medications and the standard dosages. I have added a table that shows commonly prescribed pain medication and the usual adult dosages. The adjustments for renal or liver diseases are not included.

Commonly used pain mediation and standard dosages

Mild to Moderate Pain
Dosages and Frequencies
Moderate to Severe Pain
Dosages and frequencies
Tylenol
325-650 mg by mouth as needed every 4 hrs. Maximum dose 4gm per day
Morphine
5-20mg Intramuscularly or subcutaneously every 4hr PRN; By mouth 10-30 mg every 4hours as needed
Aspirin
325-650 my by mouth every 4 hrs as needed. Maximum dose 4gm day
Fentanyl transdermal
25-100mcg/hr-change patch every 72 hours. Apply to new site on torso
Ibuprofen
200-400mg by mouth every 4-6 hrs as needed, not to exceed 3.2gm day
Oxymorphone
Intramuscularly or subcutaneously 1.0-1.5mg every 4 to 6hrs as needed; Intravenously 0.5mg every 4-6 hrs as needed
Naproxen
550mg, then 275 mg every 6-8hrs as needed, not to exceed 1375 mg
Hydromorphone
1-6mg by Mouth every 4-6 hours as needed; 2-4mg Intramuscularly subcutaneously or Intravenously every 4-6hs as needed; Geriatric 1-2mg by mouth every 4-6 as needed
Indocin
Acute arthritic pain 50 mg three times daily by mouth, then dose reduced
Oxycodone
10-30mg by mouth every 4-6hrs as needed
Tramadol
50-200mg by mouth every 4-6hrs as needed, not to exceed 400mg
Methadone
2.5 to 10 mg by mouth as needed, subcutaneously or intramuscularly every 3-4hrs
Pain can become intolerable if not properly managed
Pain can become intolerable if not properly managed | Source

Reassess Pain and Respond Appropriately

Nurses must reassess pain after pharmacological or non pharmacological intervention in accordance. This is a requirement of the Joint Commission.[30] Reassessment focuses on whether the patient’s goal of pain relief has been met. [31] Relief brought about from oral medications should be reassessed within an hour after administration of these medications.[32] Relief from parenteral medications should be reassessed within 15 to 30 minutes. [33]

During the 6 month period discussed above, many patients who were given pain medications were rarely reassessed.

Reassessment of pain is paramount in the case where a patient who sustained a fall is admitted to the emergency room with a headache. A nurse should be concerned if a patient rates his headache as 5 out of 10 upon admission that worsens to a 10 within an hour. If the patient is now complaining of positional headache and tightness to his head characterized by dizziness, slurred speech, short term memory loss and blurred vision this should be immediately communicated to the physician. The physician needs to be informed of unrelived pain with adverse symptoms so that he or she may decide whether a CT scan or MRI needs to be done.

A nurse may create liability for herself if she simply gives Tylenol for such type of pain and fails to thoroughly assess and reassess the patient who later develops complications.

Proper pain management requires empathy. A nurse showing empathy steps back to acknowledge the patient. He or she then recognizes the patient’s suffering from the patient’s own perspective. Nurses at times may tell a patient that they know how the patient feels. Most nurses know that this is not true. A caregiver rarely knows exactly how a patient in pain feels. Patients experiencing severe pain are nonetheless dependent on nurses to help them achieve pain relief.

Conclusion

The ethical duty to do no harm can be satisfied by proper pain management. An elementary concept of pain management is to accept pain as whatever and wherever the patient says it is. Listen to patients and document thoroughly.

Always reassess patients after pharmacological or non pharmacological intervention. A rule of thumb is to treat the patient in pain the way you would want to be treated.

Cecile D. Portilla, RN, BSN, CLNC

Tips


  • Patients should be medicated before pain gets unmanageable
  • Pain is where ever and whatever that patient says that it is
  • Always use a pain scale to rate the patient's pain
  • 0-3=mild pain; 4-6=moderate pain; 7-10=severe pain
  • Reassess patients after administration of pain medications


References

[1] Gordon, Debra B. et als. Improving Reassessment and Documentation of Pain Management. The Joint Commission Journal on Quality and Patient Safety. Vol 34. Number 9. (September 2008)

[2] Id.

[3] Perry, Anne Griffin and Potter, Patricia A. Clinical Nursing Skills techniques, Missouri, Mosby 7th Ed. 2006.

[4] Id.

[5] Sherman R. Abdominal Pain. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 86. Available from: http://www.ncbi.nlm.nih.gov/books/NBK412/

[6] Id.

[7] University of Maryland Medical Center. [Internet]. Gall Stones and Gallbladder Disease. [Last reviewed 8/26/2012]. Available from: http://umm.edu/health/medical/reports/articles/gallstones-and-gallbladder-disease

[8] Id.

[9] Sherman R. Abdominal Pain. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 86. Available from: http://www.ncbi.nlm.nih.gov/books/NBK412/

[10] Medlineplus [internet]. Bethesda (MD): National Library of Medicine (US): Subarachnoid Hemorrhage. Available from: http://www.nlm.nih.gov/medlineplus/ency/article/000701.htm.

[11] Herr KA, Garand L. Assessment and measurement of pain in older adults. Clin Geriatr Med. 2001 August; 17(3): 457–78. [PMC free article] [PubMed]

[12] Donna D. Ignatavicius, et. M. Linda Workman & Mary A. Mishler . Medical Surgical Nursing: Chronic Pain (2nd ed). Philadelphia: W. B. Saunders (1995)

[13] Mayo Clinic Staff. Drug Addiction. [Internet]. [Place Unknown]: Mayo Clinic; C.1998-2013. Available from: http://www.mayoclinic.com/health/drug-addiction/DS00183n.d.

[14] Johnson, Sarah J. Opiod Safety in Patients with Renal or Hepatic Dysfunction. [Internet] Glenview (IL). Pain Treatment Topics. [Updated Nov 30, 2007]. Available at: http://pain-topics.org/pdf/Opioids-Renal-Hepatic-Dysfunction.pdf

[15] Id.

[16] Id.

[17] Anderson, K. O., Richman, S. P., Hurley, J., Palos, G., Valero, V., Mendoza, T. R., Gning, I. and Cleeland, C. S. (2002), Cancer pain management among underserved minority outpatients. Cancer, 94: 2295–2304. doi: 10.1002/cncr.10414

[18] NIH: National Cancer Institute. Pain® PDQ. [Internet]. Bethesda, MD: National Cancer Institute. Available from: http://cancer.gov/cancertopics/pdq/supportivecare/pain/HealthProfessional. Accessed 01/12/2013.

[19] Id.

[20] Miaskowski C, Dodd MJ, West C, et al.: Lack of adherence with the analgesic regimen: a significant barrier to effective cancer pain management. J Clin Oncol 19 (23): 4275-9, 2001. [PubMed Abstract]

[21] Perry, Anne Griffin and Potter, Patricia A. Clinical Nursing Skills techniques, 7th ed. Missouri: Mosby 2006

[22] Bernhofer, E., (October 25, 2011) "Ethics and Pain Management in Hospitalized Patients" OJIN: The Online Journal of Issues in Nursing Vol. 17 No. 1.

[23] Fink R. Pain assessment: the cornerstone to optimal pain management. Proc (Bayl Univ Med Cent) 2000 Jul;13(3):236–9. http://europepmc.org/abstract/MED/16389388. [PMC free article] [PubMed]

[24] U.S. Food and Drug Administration: News and events [Internet]. FDA approves Botox to Treat Chronic Migraine. [cited 2010, October 15] Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm229782.htm.

[25] Cleveland Clinic.[Internet]. Diseases and Conditions: Migraine Headaches. Available from: http://my.clevelandclinic.org/disorders/migraine_headache/hic_migraine_headaches.aspx.

[26] Id.

[27] Medline Plus. [Internet]. Bethesda (MD): National Library of Medicine.(US): Subarachnoid Hemorrhage. Medline Plus Available from. http://www.nlm.nih.gov/medlineplus/ency/article/000701.htm.

[28] Id.

[29] Sophie M. Colleau, PhD & David E. Joranson, MSW., Fear of Addiction: Confronting a barrier to cancer Pain Relief. WHO Pain and Palliative Care Communication Medium. Cancer Pain Release. Vol 11, No 3 (1998). Available at: http://www.whocancerpain.wisc.edu/?q=node/244. Accessed 01/14/2013.

[30] Donna D. Ignatavicius, M. Linda Workman & Mary A. Mishler, Medical Surgical Nursing: Chronic Pain. 2nd ed. Philadelphia, W.B. Saunders, ( 1995)

[31] Id.

[32] A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; ©1997-2013; Opiate Withdrawal . [Updated 1/23/2012] Available from: http://www.nlm.nih.gov/medlineplus/ency/article/000949.htm

[33] American Academy of Pain Medicine: The Physician’s Voice In Pain Medicine. [Internet]. Glenview (IL): American society of Addiction Medicine (2001); Use of Opiods for the Treatment of Chronic Pain: Tolerance. Available from: http://www.painmed.org/search.aspx?f=80&s=what%20is%20drug%20tolerance


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    • cam8510 profile image

      Chris Mills 3 years ago from St. Louis, MO until the end of June, 2017

      This is an excellent article not only for nurses in healthcare facilities but also for families and patients. I appreciate your documentation of sources as well.

    • cecileportilla profile image
      Author

      Cecile Portilla 3 years ago from West Orange, New Jersey

      Thank you cam8510 for reading this article! I hope that the information that I presented is helpful to many.

    • ubanichijioke profile image

      Alexander Thandi Ubani 3 years ago from Lagos

      a very useful article. It is essential that rules are followed without any trace of prejudice or impartiality. I am glad your article spoke my mind. Good one!

    • cecileportilla profile image
      Author

      Cecile Portilla 3 years ago from West Orange, New Jersey

      Thank you for stopping by this hub! I agree, all patients should treated fairly.

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