Wednesday, June 27, 2012
Jargon often influences attitudes and impedes communication between healthcare providers and patients, which can impact the quality of pain care. Nowhere is this more apparent than in the use of “narcotics” rather than “opioids” in reference to pain relievers, and the results of a recently reported study comparing patients’ understandings of the two terms were both surprising and disturbing.
In the study — conducted by Lorraine Wallace, PhD, of Ohio State University, and colleagues — a convenience sample of 188 English-speaking women who were visiting a primary care clinic completed a 4-question survey. The women were generally healthy, aged 21 to 45 years, and 81% were Caucasian. Each participant was randomly assigned to either a survey version using the term “opioid” or a second version using “narcotic” as follows [Wallace et al. 2012]:
- What is [an/a opioid/narcotic]?
- Give an example of [an/a opioid/narcotic]?
- Why does someone take [an/a opioid/narcotic]?
- What happens when someone takes [an/a opioid/narcotic] for a long time?
Writing in an advance online edition of the journal Pain Practice, the researchers report that more than half of participants (56%) responded “don’t know” to all 4 questions when “opioid” was used, while just 3% responded “don’t know” to all 4 questions using the term “narcotic” (P < 0.01). Most of the women were unfamiliar with the term opioid (76%) and did not know why someone would take an opioid (69%). Whereas, about two-thirds of respondents were able to give an example of a narcotic (64%) and, surprisingly, most of them specified consequences of long-term narcotic use as being addiction-related (63%).
The researchers observe that, while a vast majority of the women were more familiar with “narcotic,” many also identified negative connotations with this term. Wallace and colleagues also note that their findings were almost identical to an earlier survey among a predominantly male veteran population (N=100), in which 78% expressed fear of adverse outcomes from long-term “narcotic” use, with 66% citing addiction as a consequence [Mangione and Crowley-Matoka, 2008].
Wallace et al. contend that choice of terminology could impact patient care, with “opioid” making treatment seem more medical, while “narcotic” insinuates furtive or adverse underpinnings. However, they also concede that using “opioid” — which is the more accurate medical term to describe these analgesics — without clarification and patient education may only lead to confusion.
COMMENTARY: The two studies, one in women the other in men, were relatively small and included population samples of limited scope, so generalization to the public overall is limited. However, it is important to note that the participants were not illiterate persons — eg, 81% of respondents in the Wallace et al. study had a high school or greater education. And, many of the same misperceptions are also reflected in mass media reports and even among healthcare agencies and professionals who should know better.
We have previously discussed concerns about misuse of the term “narcotic” to represent opioid analgesics in a Pain-Topics e-Briefing [PDF here; pp 5-6] and an UPDATE [here]. Recently, Forrest Tennant, MD, DrPH, has presented similar arguments in an editorial in Practical Pain Management [June 2012, pp 10-11, website here].
Briefly, dictionaries typically define “narcotic” as a drug that in moderate doses dulls the senses, relieves pain, and may induce sleep, but in excess causes stupor, coma, convulsions, or death. Often, narcotic drugs are described as capable of producing addiction. At one time, “narcotic” pertained only to opium or its derivatives, but the term was usurped by government agencies dating back more than a century ago to include cocaine, as well as illicit forms of drugs in the sedative, stimulant, and hallucinogen classes (interestingly, although cannabis, or marijuana, was traditionally demonized it was never included in the narcotic category). Thus, “narcotic” has legal and regulatory implications extending well beyond the medical aspects of these drug classes, particularly opioids.
“Opioids” is an umbrella term that incorporates opiates, which includes drugs derived directly from opium (eg, codeine, morphine), as well as a range of synthetic or semisynthetic morphine-like drugs. Unfortunately, many uninformed writers and speakers often use the term “opiate” when they actually are referring to the broader family of opioids, but this might be viewed as a relatively minor affront.
By far, the greater transgression is using “narcotic” in reference to legitimate, prescribed opioid analgesics. In common lore, and as supported by the above research studies, the term “narcotic” has become strongly associated with both legal and illicit drugs that can be harmful and/or addictive. Thus, the term not only elicits fear among patients, but it also raises a spectre of evil-doing among healthcare professionals who prescribe “narcotic drugs” for these patients.
These perceptions are furthered by news media that refer to “narcotics” in stories of abuse, misuse, addiction, and diversion of prescription opioid analgesics. Worse yet, they often describe these drugs as “narcotic painkillers,” rather than pain relievers, in headline news about overdoses and deaths — fostering a distorted perception of these drugs as being excessively unsafe and lethal. Thus, intentionally or not, news reporters are fueling public fears and outrage against a class of medications that serve vital needs among millions of persons with pain.
Even more inexcusable, in an UPDATE last November 2011 [here], we noted how the U.S. Centers for Disease Control and Prevention (CDC) released a highly biased report for the public on prescription-opioid-related overdoses and deaths in which they featured the term “painkillers” throughout. The disinformation implications of this were seeminly not beyond the agency’s grasp, because in the version of the report for healthcare professionals they switched to using the less inflammatory and more medically correct phrase “opioid pain relievers.”
The automatic association of “narcotics” with addiction also is of concern. Roughly two-thirds of respondents in both studies cited above associated narcotics with addiction — as a consequence of long-term use — compared with only a small minority of those asked about “opioid” effects. While there clearly is a possibility of addiction to opioids developing when they are taken long-term for pain, the incidence rate of the de novo occurrence of addiction in these patients actually is far from being definitively established by the research evidence to date. Most likely, patients fears of “narcotic addiction” being commonplace — a belief that also has been adopted by some healthcare professionals — are an exaggeration driven by sensational news reports, biased government declarations, and poor-quality research evidence.
Yes… language does matter. Whenever we hear during presentations or read articles by healthcare professionals using “narcotic” or “painkiller” in reference to opioid pain relievers, we know that (a) they are from the ‘old school’ and have not kept current on the latest knowledge in the pain field, and/or (b) they have a conscious, or subconscious, bias against these medications as being legitimate and appropriate therapy for moderate-to-severe pain of many types; including acute, cancer, and noncancer pain.
Finally, it must be recognized that these problems are not exclusive to the U.S. The term “narcotic” still lingers at the World Health Organization (WHO) in the names of committees and titles of papers dealing with legitimate opioid agents, and in documents from the International Association for the Study of Pain (IASP), to name just two organizations. In many countries the language surrounding opioid analgesics is pejorative: for example, in Austria patients with pain might be given opioid-prescription forms called Suchgiftrezepte, meaning “addictive poison prescription forms”; in Germany, opioid analgesics are referred to as Betäubungsmittel, which translates as “the means to knock you out” [references here].
> Mangione MP, Crowley-Matoka M. Improving Pain Management Communication: How Patients Understand the Terms “Opioid” and “Narcotic.” J Gen Int Med. 2008;23(9):1336-1338 [abstract here].
> Wallace LS, Keenum AJ, AbdurRaqeeb O, et al. Terminology Matters: Patient Understanding of “Opioids” and “Narcotics”. Pain Practice. 2012(Jun 4); online ahead of print [abstract here].