title: Routines and rituals: a grounded theory of the pain management of drug users in acute care settings.
abstract: OBJECTIVE
  This study reviewed the perceptions and strategies of drug users and nurses with regard to pain management in acute care settings.
  
  
  BACKGROUND
  Drug users present unique challenges in acute care settings with pain management noted to be at best suboptimal, at worst non-existent. Little is known about why and specifically how therapeutic effectiveness is compromised.
  
  
  METHODS
  Qualitative: constructivist grounded theory.
  
  
  METHODS
  A constructivist grounded theory approach incorporating a constant comparative method of data collection and analysis was applied. The data corpus comprised interviews with drug users (n = 11) and five focus groups (n = 22) of nurses and recovering drug users.
  
  
  RESULTS
  Moral relativism as the core category both represents the phenomenon and explains the basic social process. Nurses and drug users struggle with moral relativism when addressing the issue of pain management in the acute care setting. Drug users lay claim to expectations of compassionate care and moralise via narration. Paradoxically, nurses report that the caring ideal and mutuality of caring are diminished. Drug users' individual sensitivities, anxieties and felt stigma in conjunction with opioid-induced hyperalgesia complicate the processes. Nurses' and hospitals' organisational routines challenge drug user rituals and vice versa leading both protagonists to become disaffected. Consequently, key clinical issues such as preventing withdrawal and managing pain are left unaddressed and therapeutic effectiveness is compromised.
  
  
  CONCLUSIONS
  This study provides a robust account of nurses' and drug users' struggle with pain management in the acute care setting. Quick technological fixes such as urine screens, checklists or the transient effects of (cognitive-based) education (or training) are not the answer. This study highlights the need for nurses to engage meaningfully with this perceptibly 'difficult' group of patients.
  
  
  CONCLUSIONS
  The key aspects likely to contribute to problematic interactions with this patient cohort are outlined so that they can be prevented and, or addressed.
authors.affiliation: Nursing and Midwifery Department, University of Stirling, Stirling, Ireland.
authors.forename: May
authors.initials: M
authors.lastname: McCreaddie
authors.forename: Imogen
authors.initials: I
authors.lastname: Lyons
authors.forename: Debbie
authors.initials: D
authors.lastname: Watt
authors.forename: Elspeth
authors.initials: E
authors.lastname: Ewing
authors.forename: Jeanette
authors.initials: J
authors.lastname: Croft
authors.forename: Marion
authors.initials: M
authors.lastname: Smith
authors.forename: Jennifer
authors.initials: J
authors.lastname: Tocher
mesh_terms: D017144:Focus Groups; D006801:Humans; D007407:Interviews as Topic; D010146:Pain / Q000150:complications / Q000188:drug therapy*; D019966:Substance-Related Disorders / Q000150:complications*