Running head: POST-OPERATIVE PAIN MANAGEMENT IN OPIOID TOLERANCE

Post-Operative Pain Management in Opioid Tolerant Patients: An Exploration of Nurses

Perceptions

By, Navjot Deol

Dominican University of California
Dr. Luanne Linnard-Palmer
Professor Debbie Daunt
NURS 4998
May 01, 2015

POST-OPERATIVE PAIN MANAGEMENT IN OPIOID TOLERANCE

Abstract
Pain is a common physiologic response that is often seen in patients in the acute care
setting and managed by nurses. Managing this acute pain can become more compounded in
patients with severe pain after undergoing a surgical intervention. Additionally, patients with a
history of opioid use for chronic pain conditions experience more pain in the post-operative
period and resolve their pain more slowly. These patients have developed a tolerance to opioids,
which are commonly given post-operatively. Delayed pain relief can have several negative
impacts such as delayed wound healing and longer hospital stays. Therefore, the purpose of this
research study is to gain insight to nurses perspectives of assessments, interventions, and
barriers to managing post-operative pain in opioid-tolerant adult patients. This allows for a
deeper understanding of these areas in order to improve the outcomes for these patients.

POST-OPERATIVE PAIN MANAGEMENT IN OPIOID TOLERANCE

Acknowledgments
This author would like to thank her family, friends, and instructors for their continuous
support and encouragement. This research paper was made possible through the guidance and
dedication of Dr. Luanne Linnard-Palmer and Professor Debbie Daunt, nursing faculty members
at Dominican University of California.

POST-OPERATIVE PAIN MANAGEMENT IN OPIOID TOLERANCE

Introduction
In nursing, pain is known as the 5th vital sign and is a common reason people seek
medical care. Thus, pain assessments and interventions should be a priority nursing focus.
However, management of pain becomes more complex in certain populations. For instance, after
undergoing a surgical procedure, most patients have acute, intense pain in the immediate postoperative period. This pain can be compounded in those patients that use opioid medications for
management of a pre-existing condition. As a result of opioid use, these patients tend to have a
higher tolerance for the pain medications that are given for the post-operative pain. Therefore,
managing this acute post-operative pain poses a challenge for the patient and healthcare team. An
important step towards improving these patients pain levels and comfort is identifying the
nurses perspectives of barriers to its management.
Background
Several pre-existing conditions warrant the need for opioid use to manage the
accompanying moderate to severe pain. These include but are not limited to chronic lower back
pain, migraines, arthritis, neuropathy, musculoskeletal injuries, and cancers. However, chronic
opioid use can lead to tolerance. According to the World Health Organizations (2011) Ensuring
balance in national policies on controlled substances, tolerance is when increased doses of the
psychoactive substance are required in order to achieve effects originally produced by lower
doses (p. 7). When these opioid-tolerant individuals experience severe acute pain that is
typically managed by opioids, such as after a surgery, these medications become less effective at
managing their pain. Therefore, chronic opioid use needs to be assessed for in order to provide
alternative methods of pain management for these patients.

POST-OPERATIVE PAIN MANAGEMENT IN OPIOID TOLERANCE

Purpose Statement
The aim of this research study is to gain insight to nurses perspectives of assessments,
interventions, and barriers to managing post-operative pain in opioid-tolerant adult patients.
Literature Review
Introduction
Several research studies have been conducted to better understand nurses experiences
with post-operative pain management in general. A smaller number of studies focused on
managing post-operative pain in the at-risk group of patients with opioid tolerance. No current
studies were found that looked specifically at the experiences of nurses in these situations,
despite the fact that nurses are at the forefront of pain management. This author searched through
several of Dominican University of Californias online library databases including CINAHL,
PsycInfo, PubMed, and Science Direct. A review of the literature concluded that understanding
nurses experiences of the assessment, interventions, and barriers to pain management provides
the foundation for future interventions to improve patient outcomes.
Pain Assessment
Pain is the subjective experience of the patient. Thus, most studies concluded that the
most reliable indicator of a patients pain was their self-report (Richard & Hubbert, 2007; Francis
& Fitzpatrick, 2013). Richards and Hubberts (2007) qualitative study focused on the learning
how expert nurses assessed, managed, and cared for patients with post-operative pain. Based on
their interview with three nurses, an important part of their assessment of pain was considering
the whole person. Although behavioral and physiological indicators complement the nurses pain

POST-OPERATIVE PAIN MANAGEMENT IN OPIOID TOLERANCE

assessment, a patients statement is the most dependable indicator of their pain (Richards &
Hubbert, 2007, p. 21).
Many studies noted discrepancies between the patients and nurses scoring of pain levels.
Ene et al. (2008) studied the discrepancies in pain scoring between the nurses and the patients.
This study showed the need for more accurate assessments to improve patient outcomes. They
concluded that nurses relied more on personal judgments of their patients condition than on
assessment tools to manage postoperative pain. Diizel et al. (2013) looked at the differences in
post-operative pain assessments between nurses and patients and found that contrary to other
studies, there was no statistically significant difference between both assessments. These results
were partly attributed to the well-equipped educational hospital this study was conducted at and
the education level of the nurses.
Pain Assessment During Opioid Tolerance
Chapman et al. (2011) observed the pain ratings of postoperative patients with chronic
pain. They compared the ratings of those using opioid therapy for management of their chronic
pain to those who did not (n=55). They found that chronic pain patients with opioid use had
higher initial pain levels postoperatively, but they resolved their pain at the same, slow rate as
other chronic as other chronic pain patients. They concluded that more innovative and aggressive
pain management protocols need to be directed at this vulnerable patient population.
Similarly, Patanwala et al. (2008) also compared pain scores of post-operative patients
with or without opioid tolerance (n=29). In addition to this, they also looked at the opioid
requirements, sedation scores, and any adverse effects in both groups. They found that opioidtolerant patients had higher pain ratings during the first 24 hours after being discharged from the
PACU and required more opioids during their stay in the PACU. The findings of higher pain

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ratings in opioid-tolerant patients were consistent with those of Chapman et al. (2011). They did
not find any significant differences in the sedation scores or adverse effects experienced by both
groups. Both studies (Patanwala et al., 2008; Chapman et al., 2011) suggested using a more
aggressive pain management approach post-operatively in patients with opioid tolerance.
Pain Relief Interventions
Chung & Lui (2003) surveyed patients to examine their level of pain and satisfaction with
their postoperative pain management. Patients reported high satisfaction with pain relief despite
the reports of moderate pain. This could be a result of the patients expectation to experience pain
after surgery and thus not expect much pain relief. Less than half the patients indicated that their
healthcare team showed concern for providing pain relief. This indicated a need for more
professional education on pain relief.
The independent art of nursing was another theme that emerged. This is the nurses
ability to act independently. The nurses often offered other interventions to complement the
medications such as repositioning, dimming the lights, and decreasing external stimuli
(Richards & Hubbert, 2007, p. 21). However, not all nurses recognize the extent of their role in
pain management. The nurses limited authority was cited as a perceived barrier to pain
management by nurses in Rejeh et al.s (2009) study.
Barriers to Pain Control
Accepting what the patient says was a theme that emerged when the nurses were asked
about any challenges to pain management (Richards & Hubbert, 2007). These expert nurses were
able to recognize and put aside their biases and accept the patients perception of pain. Rejeh et
al. (2009) interviewed 26 nurses to understand their perceptions of barriers to postoperative pain
management and found four themes throughout the interviews. According to the participants, a

POST-OPERATIVE PAIN MANAGEMENT IN OPIOID TOLERANCE

lack of educational preparation, nurses limited authority, limited nurse-patient relationship, and
disturbances in pain management interventions were considered important barriers to
postoperative pain management (Rejeh et al., 2009, p. 277). Most educational programs these
nurses experienced focused on the pharmacological interventions rather that the patients views,
cultural considerations, assessment tools, and non-pharmacological interventions. They noted
that pain management is traditionally seen as a physicians responsibility and the nurses role
gets overlooked. They also experienced having limited time to spend with the patient to develop
a good nurse-patient relationship. Another barrier was the nurses work load which resulted in the
delaying of pain relief interventions.
Francis and Fitzpatrick (2013) surveyed nurses about their knowledge of pain assessment
and management with a mean score of 69.3%. This indicated that nurses need to be more
knowledgeable about pain management. They also noted that their patient participants
experienced a moderate level of pain, which further stresses the need for more education for
nurses about pain. Ene et. al (2008) found that although the nurses had more theoretical
knowledge about pain management, it was not successfully implemented in their clinical
practices.
Improving Patient Outcomes
Consequences of unmanaged pain in the post-operative period include impaired
respirations, immobility, subsequent venous thrombosis, delayed recovery, delayed discharge,
and hospital readmission (Richards & Hubbert, 2007, p. 19). Therefore, pain must be managed to
improve patient outcomes. Abdalrahim et al. (2011) assessed nurses knowledge and attitudes
about pain before and after the implementation of a postoperative pain management program.
Before the program, nurses showed a lack of knowledge about pain based on their answers to a

POST-OPERATIVE PAIN MANAGEMENT IN OPIOID TOLERANCE

questionnaire. After the program, these nurses showed a better understanding about the nature of
pain and had more positive attitudes towards pain management. Thus, educational programs can
improve the delivery of safe practice and ensure achievement of patients outcomes
(Abdalrahim et al., 2011). Expert nurses with five or more years of experience in surgical nursing
all expressed pride in their ability to positively affect patient outcomes through their pain
management skills (Richards & Hubbert, 2007).
Dykstra (2012) looked at the implementation of an evidence-based practice model to pain
management in opioid-tolerant patients at a hospital and found that the need for more compliance
among health care professionals in order to effectively implement this protocol. The model
emphasized continuing patients home pain medications, providing missing doses of opioids, and
adding non-opioid analgesics, consulting with pain services, and discussing the pain treatment
plan with the patient. Based on the aforementioned previously conducted research, this pilot
study will explore the following:
1. What are the perspectives of adult acute-care nurses on assessments of post-operative
pain for patients with opioid tolerance?
2. What are the perspectives of adult acute-care nurses on pain relief interventions of postoperative pain for patients with opioid tolerance?
3. What are the perspectives of adult acute-care nurses on identified barriers of postoperative pain management for patients with opioid tolerance?
4. What are some ways of improving patient outcomes post-operatively for patients with
opioid tolerance?
5. What clinical resources or practice protocols do adult acute-care nurses have to manage
post-operative pain for patients with opioid tolerance?
Theoretical Framework

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In order to better understand the acute pain these patients experience, it is important to
understand the physiology of their chronic pain. Ronald Melzack and Patrick Wall developed the
gate control theory of pain in the 1960s (Deardoff, n.d.). This theory provides a framework for
understanding the mechanisms of chronic pain. When a pain signal is received in a nerve, it
travels up the spinal cord to the brain. In the spinal cord, there are nerve gates that selectively
open or close and alter ones perception of the painful stimuli. Many factors can open these
gates and cause more pain or close these gates and reduce the perception of pain. Factors that can
open these gates and cause more pain perception include injury, inactivity, long-term opioid use,
depression, and stress. These are all relevant to a degree in the hospitalized adult patient postoperatively with a history of chronic pain and opioid use.
Factors that can close these gates and reduce the perception of pain include short-term
pain medication use, distractions, stress and depression management, and increasing activities.
These pain messages can also be overridden by stimulating fibers that are faster at reaching these
gates. Management of type of pain, in theory, can be done by stimulating those fibers that are
faster at reaching the nerve gates with interventions such as massage, heat, cold, and
transcutaneous nerve stimulation. The gate control theory of pain provides a foundation to
understanding the mechanisms and management strategies of chronic pain.
Methods
A pilot exploratory survey was conducted among adult acute-care registered nurses that
are current members of Sigma Theta Taus Rho Alpha Chapter at Dominican University of
California. Convenience sampling was used until saturation was reached. The target sample size
was 30 out of the approximately 380 current members. Inclusion criteria included experience
working with one or more patients whom the nurse considered opioid-tolerant. Also, membership

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in Sigma Theta Taus Rho Alpha Chapter was required in order to receive the survey. Exclusion
criteria included not having experience working with one or more patients whom the nurse
considered opioid-tolerant as well as not being a member of the aforementioned Chapter.
Step by step procedures
1. Created survey tool.
2. Validated tool with two Ph.D. prepared nursing faculty at Dominican University of
California for construct and content validity.
3. Gain approval from the Institutional Review Board at Dominican University of
California.
4. Contacted Rho Alpha President for permission to conduct survey.
5. Distributed survey at a Rho Alpha meeting.
6. Sent out survey to all Rho Alpha members via email.
7. Analyzed results of survey.
8. Synthesized significance of results and implications for nursing for discussion.
9. Created a presentation of the research paper.
10. Presented research paper to Honors Director, faculty advisors, and other attendants on
April 10, 2015.
Measures/ Instruments
See appendix A and B.

Validity
The survey tool was reviewed and validated by two Ph.D. prepared nursing faculty at
Dominican University of California for construct and content validity. Both faculty felt that the
survey tool contained appropriate demographic questions, likert-type scale questions, and openended questions. The survey tool was in alignment with the researchers research questions and
purpose.
Statistical Analysis

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Descriptive statistics were used in the analysis of the results of the survey. They were
used to summarize the demographic characteristics of participants and their responses to the
likert-scale questions. The number of responses for each category from strongly agree to strongly
disagree were totaled for each question and represented as a percentage. Numerical responses to
questions as the length of time as a nurse were averaged. This was then used to compare and
further analyze the results.
Quantitative Results
16 members of Sigma Theta Tau, Rho Alpha Chapter responded to the survey.
Demographic data for each respondent was collected and analyzed as shown in Figure 1.
Although this data represented a small sample size of 16 nurses, there was a wide age range
represented from 20 to 58 years old with an average age of 34. 62% of respondents were
Caucasian, 19% were Hispanic, and 19% were Asian. 100% of the participants were female. On
average, these nurses had 12.5 years of experience. The question asking about their current work
setting had the option to select all choices that applied to their answer. Thus, 81% worked in a
hospital, 25% in an academic position, 6% in a clinic, and 6% in conducting research. 44% were
employeed full time as nurses, whereas 56% were students with some clinical experience.
Since 7 participants were experienced nurses and 9 participants were students, the
responses from these two groups were further analyzed and compared to observe any statistical
differences. On average, these participants responded that they considered 13% of the patients
they cared for in the last year to be opioid tolerant. When both groups were compared, the
average for experienced nurses was 12% and the average for student nurses was 13%, which held
no statistical significance. Data was also collected on a participants responses from strongly
agree to strongly disagree with three statements. 56% of nurses strongly agreed and 44% of

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nurses agreed that a patients statement of pain is the most important inficator of their pain. There
was no statistical difference between the two groups in response to this statement since 100% of
nurses either strongly agreed or agreed to this statement.
Of all participants, 56% of nurses strongly agreed, 38% agreed, and 6% were neutral to
using non-pharmacological interventions to manage pain. From the group of experienced nurses,
71% strongly agreed and 29% agreed to this statement. In comparison, 44% of student nurses
strongly agreed, 44% agreed, and 12% were neutral to using non-pharmacological measures of
pain management. When all participants were asked if they felt adequately prepared through
their education and within their scope of practice to manage post-operative pain, 19% strongly
agreed, 44% agreed, 25% were neutral, and 12% disagreed. This question received the widest
range of responses. Among the group of student nurses, 12% strongly agreed, 33% agreed, 33%
were neutral, and 22% disagreed. In comparison, 29% of experienced nurses strongly agreed,
57% agreed, and 14% were neutral. None of the experienced nurses in this study disagreed with
the statement that they felt adequately prepared to manage post-operative pain in opioid tolerant
patients through their education and scope of practice, whereas 22% of student nurses disagreed
with this statement.
Open-ended Question Results
Participants were asked five open-ended questions to gain a deeper understanding of their
experiences and perspectives of post-operative pain management. Participants were asked to
define opioid tolerance. One experienced nurse defined opioid tolerance as when a patient
requires larger amounts of opioid in order to obtain pain relief. Similarly, a student nurse stated
that it is the opposite of opioid nave, able to tolerate/resist opioids at higher levels/doses than
average. Nurses also identified many common barriers to managing this type of pain. Several

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nurses identified a fear of respiratory depression as a barrier. One stated, the border between
adequate pain relief and over sedation can be quite narrow in these patients and they must be
monitored more closely. Generally, nurses tend to under-medicate these patients.
Another common barrier was a lack of knowledge, of both alternative methods to pain
management and of the patients tolerance level. A lack of communication was also cited as a
key barrier. Other barriers included cultural and language considerations. Some nurses stated that
some patients were fearful of addiction or of being labeled as an addict if they asked for more
pain medications. Nurses also noted their time management and workload as a barrier to getting
pain medications to these patients in time in order to provide effective pain relief before the pain
escaladed. Their own judgments and biases about a patients level of pain was also identified as a
barrier.
Participants also identified several ways to improve patient outcomes for post-operative
patients with opioid tolerance. One nurse suggested the use of a pain specialty team. Several
suggested using non-pharmacological intervention and alternating between opioid and nonopioid medications. Others suggests getting the patient more involved in their plan of care and
having a pain management plan in place before surgery. Nurses were also asked to identify what
clinical resources they had to manage post-operative pain in this specific patient population.
Seven respondents stated they did not know of any clinical resources that were available to
address this need. Some stated resources such as pain consultants, palliative care teams, pain
control specialists, other nurses, and non-pharmacological interventions. Nurses were also asked
to identify what practice protocols were in place at their facilities to manage this type of pain.
Fourteen out of the sixteen respondents stated that they did not know of any practice protocols
that were in place. The remaining two listed the use of a pain specialist and non-pharmacological

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interventions as practice protocols. However, no formal practice protocols were identified at their
facilities.
Discussion
Based on the results of this study, it becomes evident that further education and practice
protocols need to be in place in order to effectively manage post-operative pain in opioid tolerant
patients. While all participants strongly agreed or agreed that a patients statement of pain is the
most important indicator of their pain, they also cited a nurses judgments of a patients pain as a
barrier in their pain management. It is important for nursing education to emphasize the
importance of the role of the nurse in assessing and managing pain. One important aspect of
assessing pain is understanding that pain is a subjective experience that is individual to every
person and thus, cannot be subjected to bias by nurses and other healthcare professionals.
Part of managing pain is understanding and utilizing non-pharmacological pain
management interventions. There was a disparity noted in the use of non-pharmacological pain
management techniques between student nurses and experienced nurses. Experienced nurses felt
more strongly about using these techniques whereas 12% of student nurses were neutral to its
use. Nurses need to feel adequately prepared to manage pain and have access to tools to manage
more complex forms of pain. However, 55% of student nurses felt neutral or disagreed with the
statement that they were adequately prepared to manage post-operative pain in opioid tolerant
patients. In comparison, 14% of experienced nurses were neutral to this statement and none
disagreed with it. This disparity can be partly attributed to a lack of experience for those student
nurses. Student nurses as well as experienced nurses need to feel more adequately prepared to
manage pain in order to improve patient outcomes. This suggests a need to evaluate nursing
education programs to identify the sources and possible solutions to this gap in curriculum.

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Almost all participants were able to define opioid tolerance in a way that was congruent
with the World Health Organizations definition of opioid tolerance. Nurses were also able to
identify using non-opioid medications, non-pharmacological interventions, involving pain
specialists, and planning for these interventions pre-operatively as some of the ways to improve
patient outcomes. This demonstrated that the nurses had an understanding of the topic of opioid
tolerance and ways to manage pain. Nurses also showed an understanding of barriers to
managing post-operative pain in these patients.
However, the results of this study revealed that nurses lacked the proper guidance to
manage this pain. This was due to a lack of identifiable clinical resources and practice protocols.
Although pain specialist were available at some of their facilities, one nurse noted that it could
take a while for the specialist to get to the patient. Therefore, nurses need additional resources to
be available in order to provide effective pain relief to opioid-tolerant patients and create better
patient outcomes. Practice protocols also need to be in place to manage this specialized patient
population, which the nurses in this research study perceive to be 12% of their patient
population. Elements of such protocols could include to continue a patients home pain
medications, provide missing doses of opioids, adding non-opioid medications, consulting with
pain services, and discussing the pain treatment plan with the patient prior to surgery. An alert
could also be placed on their chart so that all healthcare providers are aware of the patients
needs in regards to pain management. This would allow for a multidisciplinary approach with a
collaboration between the nurses, physicians, and the patient and their family. Overall, these
results suggest a lack of educational preparedness, clinical resources, and practice protocols that
would empower nurses to effectively manage post-operative pain in opioid tolerant patients.
Limitations

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These results may contain gender bias since only female nurses responded to the survey
and are thus disproportionately represented in these results. Convenience sampling was used to
obtain this sample of nurses from Sigma Theta Tau, Rho Alpha Chapter. This may have also
resulted in some bias in the results. Furthermore, the small sample size of sixteen limits the
application of these results to a larger population of nurses.
Implications for Future Research
These limitations lead to implications for further research to obtain a larger and more
randomized sample size in order to eliminate gender bias and allow the results to represent a
greater population. Further research should also explore the differences in the experiences and
perspectives of nurses from different specialties. This would give a better understanding of how
this issue pertains to various specialties as well as their unique methods for improving patient
outcomes. Gathering data from the perspectives of other healthcare providers would also be
useful to get a multidisciplinary angle on this issue. It would also be important to gain insight
into the experiences of these opioid-tolerant patients during their post-operative period. This
would lead to a better understanding of how to develop and implement practice protocols that are
most effective at managing this pain for this specific patient population.
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