ANA’s new position statement on pain management offers guidance

When a federal law permanently expanded medication-assisted treatment (MAT) prescribing authority to NPs and PAs in October 2018 (with five-year limited authority to CNMs, CNSs, and CRNAs), the nursing community celebrated a gain—more tools to fight the opioid crisis. While this move will benefit patients suffering from opioid misuse, nurses face another side of the opioid crisis: helping patients alleviate pain.

Pain continues to be a significant public health problem, reports show, and one that nurses confront daily. Nurses have an ethical responsibility to relieve patients’ pain and the suffering it causes, according to a new position statement grounded in the Code of Ethics for Nurses with Interpretive Statements.

“It’s known that sometimes pain is undertreated because of the fear of addiction,” said Marcia Bosek, DNSc, RN, associate professor in the department of nursing at the University of Vermont and co-author of the position statement. “There are nurses who may be reluctant to administer pain medication due to a bias against people taking opioids.”

To help nurses effectively address pain management concerns, the American Nurses Association (ANA) Board of Directors in February adopted the 2018 position statement, “The Ethical Responsibility to Manage Pain and the Suffering it Causes,” authored by the ANA Center for Ethics and Human Rights Advisory Board. ANA’s 2003 position statement on pain management was retired in 2010.

“The impetus for the new statement was recognition of the ethical challenges of pain management and the stigma associated with patients receiving pain treatment,” said Liz Stokes, JD, MA, RN, director, ANA Center for Ethics and Human Rights.

Bias and moral disengagement

The statement provides guidance for nurses navigating the tension between the duty to manage pain and the duty to avoid harm. Careful discernment is required to limit the ripple effect of underprescribing when opioid use is indicated or overprescribing when nonopioid analgesics and/or nonpharmacologics may be equally effective, the statement asserts.

Possible bias is a challenge. A number of biases may accompany a nurse’s impression of a patient’s need for pain medication; the statement lists, among others, culture, societal influences, economic circumstances, race, geographic location, sexual orientation, and gender expression.

Concerns about medication misuse also can alter a nurses’ perception of a patient. For example, “When encountering a patient with hepatitis C and HIV, a nurse may assume that he or she has a substance use disorder and be inclined to undertreat the pain,” said Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN, director of professional practice at the Hospice and Palliative Nurses Association, an ANA organizational affiliate.

“If the patient has a substance use disorder, you must be more thoughtful about the medications and monitor them closely,” said Dahlin, an ANA Massachusetts member. An addiction specialist or mental health specialist can help the nurse and patient come up with an appropriate pain management plan, Dahlin suggests.

Nurses can be susceptible to moral disengagement, which is the separation of personal and professional values from corresponding action. One mechanism in moral disengagement is displacement of responsibility, the statement notes.

“When we feel a conflict, it’s possible for us to disregard the emotional aspects of a situation and fall back on ‘I’m just following orders,’” said Bosek, an ANA Vermont member.

From an ethical standpoint, nurses must first identify their own biases and then acknowledge and set aside or bracket their biases so they can better understand the patient’s experience, according to the position statement.

But nurses do have a responsibility to evaluate orders— to ensure patient safety. “Nurses, no matter what their practice, have the obligation to be engaged with the patient assessment to consider and recommend appropriate treatment,” Dahlin said.

Respect and education

The new pain management position statement affirms nurses’ ethical obligation to provide respectful, individualized care to all patients experiencing pain regardless of personal characteristics, values, or beliefs. “This kind of care starts with respecting your patient,” Stokes said.

Nurses can demonstrate that respect by giving personalized care. Dahlin explained that some organizations are abandoning pain-rating scales, and instead assessing patients by asking how much their function is impaired and how much time they are spending in bed because of pain. This kind of assessment allows the patient to better articulate pain levels and gives the nurse more insight into how the pain is affecting the patient’s life—and the ability to create a more effective treatment plan.

Patients sometimes are uneasy about their pain management plan—either worried that the medication won’t relieve their pain or concerned they’ll develop an opioid misuse problem. Nurses can teach their patients how to use pain medication effectively and efficiently, and how and when to taper off, Bosek said.

Patient education plays a key role. Dahlin makes sure her patients understand when and why pain medication is needed. “When I’m writing a prescription, I tell the patient that I have done thoughtful dosage calculations to help them be more functional,” she said.

Multimodal treatment and access

Nurses should be able to assess whether nonpharmacologic treatment is appropriate for a patient who is experiencing pain. Bosek recommends that nurses keep up with new modalities through continuing education, journals, and staff development opportunities.

Encouraging patients to try alternative health approaches may be difficult at first. “Be in covenant with your patient,” Bosek said. She suggests asking patients to try an alternate therapy and assuring them that if it doesn’t work, you’ll try something else.

One challenge to suggesting alternative health approaches is access. Dahlin explained that in rural areas, stigma is attached to being prescribed opioids— people are afraid they’ll become addicted. “Maybe long-term physical therapy, massage, or other therapies like yoga could be effective before prescribing opioids,” she said. But many rural areas don’t have these types of providers and insurance is unlikely to cover alternative care. This makes it more difficult to avoid opioids, if that is the goal of the nurse and patient, she said. To better address problems like access to alternative care, the Code states that it is the nurses’ duty to advocate for improved parity in coverage for all effective pain relief modalities.

Nurses can advocate for alternative pain management approaches by speaking up at their organizations. “Nurses can do that through their professional governance, and they can bring it up to their nurse leaders by asking, ‘Do we have those resources available in our institution? Do we have access to holistic care? Are nurses involved in it?’” Bosek suggested. “Let them know you want to learn more.”

— Elizabeth Moore is a writer at ANA.