By the time he reached the half-way point in treatment he was beyond miserable.  He was taking Extra-Strength Tylenol around the clock and finally decided he needed something stronger to control his discomfort. He started to take the BTP medications regularly, though it was with a great deal of reluctance. I kept encouraging him to take the pain medications more frequently, reminding him that our strategy was to take “the lowest effective dose” and explaining repeatedly that the word effective was more important than the word lowest.  Though he was taking the medication regularly, I believed he was undermedicated based on his wincing when he spoke and on his dysphagia and odynophagia. However, it was progress of sorts that he took anything and I continued to chip away at his resistance.

Once he started taking the BTP medication, he established a regimen of 4 to 5 doses per day. We offered him a Fentanyl patch to address his baseline pain.  I went through the strategy of long-acting and short-acting pain medication and he nodded as he listened to my explanation.  He took the new prescription and said the same thing he said when we gave him the previous prescription: “I’ll fill it, but I am only going to use it if I have to.”  When he came in for his treatment 3 days later, he told me, “I finally put the patch on yesterday. You were right, I feel better.” Which made me feel better.

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But there was more to it.  “Let me tell you a story,” he said.  As a college freshman, he experienced a severe bout of pneumonia with a hacking cough that made it difficult to sleep. He was prescribed codeine , which helped with the cough. He ended up taking it for several weeks. When his pneumonia cleared and his coughing improved he stopped the codeine abruptly.  “That’s when it got really bad for me.” He described 4 to 5 days of withdrawal-like symptoms. He concluded t hat he had “become addicted to it.” Even worse, he was certain he was an addict and any further exposure to opioids would reveal that. With the onset of radiation therapy and subsequent discomfort he agreed to take the pain medication only when his pain exceeded his anxiety about addiction. 

Before he was given the prescription for BTP medication, I discussed with him the difference between addiction, dependence, and tolerance. I had reviewed with him that our goal was to get through the treatment and to use the pain medication to facilitate that. But I had missed something critical. I had nudged him along the path, and indeed he had listened to me when I explained what addiction looked like compared to what we were doing, but he had not shared his story about codeine until later, afraid perhaps to reveal a past he believed meant something different than what it did.

There are many tools for assessing pain. But with Mr Brown it was not an issue of measuring his pain.  Good assessment and even good education were only going to get me where I wanted to be if we first understood our starting point.  “Tell me more about your concerns with taking pain medication.” I had included that question in my initial assessment and he had explained some of his concerns, but it wasn’t until later that he shared his experience taking codeine.  Assessment includes more than the starting and ending point. Going back to the idea of an app for driving directions, some of the apps include another feature: they take into consideration traffic and weather conditions, both of which can change as you drive. For Mr Brown, his past experience influenced his willingness to take pain medication even though his pain was high. I needed to tweak my pain assessment “app.” Successful navigation needs to include those other conditions that may impede progress.

Mr Brown had a big story. I needed to hear his story in order to integrate it into my teaching.  There is an old nursing adage: “tincture of time.”  For Mr. Brown, a certain amount of time needed to pass before he was ready to tell his story.  Understanding his past experience with codeine and his incorrect interpretation of its meaning helped me adjust my patient teaching.  Pain assessment is an ongoing assessment that changes and adjusts to the circumstances. Mr Brown continued to undermedicate, which was what fit for him, yet he did come to understand his own barriers. As did I.

Ann Brady is the symptom management care coordinator at the Cancer Center, Huntington Hospital, Pasadena, California.