Factors Affecting Hospital Staff Judgments About Sickle Cell Disease Pain

Judgments about people with pain are influenced by contextual factors that can lead to stigmatization of patients who present in certain ways. Misplaced staff perceptions of addiction may contribute to this, because certain pain behaviors superficially resemble symptoms of analgesic addiction. We used a vignette study to examine hospital staff judgments about patients with genuine symptoms of analgesic addiction and those with pain behaviors that merely resemble those symptoms. Nurses and doctors at hospitals in London, UK, judged the level of pain, the likelihood of addiction, and the analgesic needs of fictitious sickle cell disease patients. The patient descriptions included systematic variations to test the effects of genuine addiction, pain behaviors resembling addiction, and disputes with staff, which all significantly increased estimates of addiction likelihood and significantly decreased estimates of analgesic needs. Participants differentiated genuine addiction from pain behaviors resembling addiction when making judgments about addiction likelihood but not when making judgments about analgesic needs. The treatment by staff of certain pain behaviors as symptoms of analgesic addiction is therefore a likely contributory cause of inadequate or problematic hospital pain management. The findings also show what a complex task it is for hospital staff to make sensitive judgments that incorporate multiple aspects of patients and their pain. There are implications for staff training, patient education, and further research.

APPENDIX: STATEMENTS USED TO CONSTRUCT THE VIGNETTES

No Disputes

• 1. During those frequent hospital admissions his pain is managed without problems or arguments and he gets on well with the hospital staff.

• 2. On his last admission to hospital he got on well with the staff and was a very co-operative patient, even when in severe pain.

• 3. In hospital, she co-operates with all the staff in the management of her pain and her treatment is unproblematic despite being frequently in severe pain.

• 4. When he does go to hospital because of pain there are no problems or arguments with the staff and his treatment goes very smoothly despite being in great pain.

• 5. When she was last in hospital she got on well with the staff, and her pain was managed without arguments or problems.

• 6. She is regarded as a co-operative patient whose pain management is unproblematic in spite of the frequency and severity of her pain.

Disputes

• 1. On the last occasion there was an argument about her pain medication, and she got angry and upset because she thought she was being made to wait too long for pain killers, and screamed at the staff until she got her injections.

• 2. The last time he came to hospital he arrived screaming for painkillers and refusing to answer questions about his pain, saying ``just give me my pain relief now!'' He later made a complaint, saying that nurses had accused him of pretending to be in pain.

• 3. On the last occasion there was a major dispute on the ward that led to her discharge from hospital being brought forward. She had brought some painkilling medication from home into hospital and given some to other patients on the ward, and given some pain killing tablets that were dispensed for her in hospital to friends from the patient support group who had visited her in hospital.

• 4. Recently he had a dispute with the staff in hospital about what painkiller he should have. The doctor wanted to change his medication from pethidine injections to morphine tablets, but he didn't think the tablets were working and wanted to go back to injections. There was an argument between him and the doctor about how his medication should be changed, and he refused to change medication as the doctor wanted him to and told the doctor to get lost.

• 5. There have been arguments in the hospital about her pain because the staff prefer her to have morphine for her pain but she believes she is allergic to morphine and insists on pethidine injections because that is how her pain was treated in the past.

• 6. The last time he was in hospital there was a dispute about the dose of analgesic he was given. He claimed that his dose had been reduced when he was transferred from casualty to the ward, and that the dose of diamorphine he was given on the ward was not enough to control his pain. He had looked at his chart and claimed that the nurse was giving him only half the dose he should have received, and accused her of cutting down the dose without the doctor's permission.

No Problematic Analgesic Use

• 1. He had no problems with them. He never needed larger or more frequent doses, never used more than he intended, and never felt he should cut down or had allowed using painkillers to affect his family or social life.

• 2. There were no problems. She never used more and more tablets or took more than she had meant to, and had never felt that using the pain killers affected her social life or family, or that she should use less pain killers.

• 3. They did not cause any problems. She never had to take more than usual or more than she intended to take, never felt that she should use them less, and never felt that using painkillers affected her family or social life.

• 4. He did not have any problems with them, and never needed to take larger doses to control pain. He had never taken more of them than he should have, had never felt that he ought to use less or give them up, and the tablets did not affect his family or social life.

Pain Behaviors Resembling Addiction

• 1. He needed more and more to control the pain. Sometimes he felt as if his body was missing something when he didn't take them when coming home from hospital after a painful episode. Sometimes he takes more than he should, thinking that the more he takes, the faster the pain will go, and although he has tried to stop using pain killers he finds that the pain means he soon has to go to the doctor for more. When he is in pain and has taken painkillers he often phones to say he won't be able to come to work because he is feeling drowsy.

• 2. She needs to use larger amounts of painkillers to delay or avoid going to hospital when she is in pain. She experiences withdrawal symptoms when the pain subsides and she stops taking them, and she sometimes takes more than she intended to, when the pain does not respond to the tablets. She has tried to reduce how many tablets she takes, but needs them to control the pain, and also has to miss work sometimes because when she is in pain and takes painkillers, the tablets make her drowsy.

• 3. He now needs more of them to control the pain than previously, and sometimes he takes more than he intended when the tablets don't seem to control the pain. He would like to cut down on the painkillers he takes, but has not been able to because of the pain he experiences. He also has to miss work sometimes when he has taken painkillers because they make him less alert even though he takes them only when in pain.

• 4. Sometimes she takes more pain killers than she should, when she is still in pain after taking pain killers, and has tried to give up using pain killers but when the pain returns she finds that nothing else works. She often misses work when she is in pain because the painkillers make her sleepy.

Genuine Symptoms of Addiction

• 1. She experiences withdrawal symptoms unless she increases the amount she takes, and is irritable and restless when she stops taking the tablets. When she is feeling low she sometimes takes more than she should. She wants to reduce the painkillers she uses because sometimes she avoids being with people when she has taken them, even when she is not in pain.

• 2. He has trouble relaxing when he is not in pain if he does not take them. He needs to take more of the tablets than in the past to avoid the agitated feeling he gets when he stops taking them, and sometimes he takes more than he should when he is feeling stressed, and when that happened once he stopped going to work for a short period.

• 3. He needed to take more and more to control the stomach cramps he experiences when withdrawing from pain killers, and was restless and agitated when he stopped taking them, even when not in pain. When feeling stressed he sometimes took more than he intended to, and stayed in and stopped going to work during a period when he was feeling depressed and taking a lot of pain killers. He has tried to cut down the painkillers because he thought he was taking too much and they were making him slow and sluggish.

• 4. She needed more and more to control the withdrawal symptoms that happened when she didn't take them, and could not sleep properly without them, even when not in pain. She has to stop herself from getting carried away and taking too many pain killers when she is trying to make sure that the pain won't come back, and has tried to wean herself off the tablets because she felt she was becoming immune to them. For a while she was taking them because she was feeling low, and stopped going out.