Undertreatment of pain

Undertreatment of pain is the absence of pain management therapy for a person in pain when treatment is indicated.

Consensus in evidence-based medicine and the recommendations of medical specialty organizations establish the guidelines which determine the treatment for pain which health care providers ought to offer.^[1] For various social reasons, persons in pain may not seek or may not be able to access treatment for their pain.^[1] At the same time, health care providers may not provide the treatment which authorities recommend.^[1]

Classification

When pain is a symptom of a disease, then treatment may focus on addressing the cause of the disease.^[2] Because of the hope that treatment which ends the disease would eliminate the pain, sometimes pain management is not recognized as a priority in favor of efforts to address an underlying cause of the pain.^[2]

In other cases, the pain itself might need its own treatment plan.^[2] Palliative care could be used to address the pain as its own priority.^[2] Palliative care might be used either with or alongside any treatment for an underlying condition.^[2]

Signs

Some organizations advise that health care providers treat pain whenever it is present. The perspective is that when a person complains of serious pain, then that person is in need of treatment.

Various publications offer guidance on recognizing pain and advising when a person with pain needs additional treatment.^[3][4][5][6]

Causes

Reasons for deficiencies in pain management include cultural, societal, religious, and political attitudes. Moreover, the biomedical model of disease, focused on pathophysiology rather than quality of life, reinforces entrenched attitudes that marginalize pain management as a priority.^[7] Other reasons may have to do with inadequate training, personal biases or fear of prescription drug abuse.

Prevention and screening

Current strategies for improvement in pain management include framing it as an ethical issue; promoting pain management as a legal right; providing constitutional guarantees and statutory regulations that span negligence law, criminal law, and elder abuse; defining pain management as a fundamental human right; categorizing failure to provide pain management as professional misconduct, and issuing guidelines and standards of practice by professional bodies.^[7]

Epidemiology

Undertreatment of pain is common,^[8] and is experienced by all age groups from neonates to the elderly.^[9]

Global incidence

In September 2008, the World Health Organization (WHO) estimated that approximately 80 percent of the world population has either no or insufficient access to treatment for moderate to severe pain. Every year tens of millions of people around the world, including around four million cancer patients and 0.8 million HIV/AIDS patients at the end of their lives suffer from such pain without treatment. Yet the medications to treat pain are cheap, safe, effective, generally straightforward to administer, and international law obliges countries to make adequate pain medications available.^[10]

United States

In the United States, women and Hispanic and African Americans are more likely to be undertreated.^[11]

History

In 1961 the Single Convention on Narcotic Drugs established that certain drugs are "indispensible for the relief of pain and suffering" and that states should make them available to people who need them.^[1]

In 2009, a World Health Organization report noted that accessing treatment for pain was difficult for many people in many places in the world for a range of reasons.^[1][12]

In 2010 the Commission on Narcotic Drugs and adopted a resolution on access to pain treatments.^[1] Also in 2010 the United Nations Office on Drugs and Crime published a feature explaining the problem of lack of access to pain treatment and expressing interest in the topic.^[1] In 2011 the International Narcotics Control Board published a supplement to its annual report which highlighted the issue as a concern to be addressed.^[1]

Society and culture

There is a complicated history of politics which influences practice in the treatment of pain.^[13]

Undertreatment may be due to physicians' fear of being accused of over-prescribing (see for instance the case of Dr William Hurwitz), despite the relative rarity of prosecutions, or physicians' poor understanding of the health risks attached to opioid prescription^[14] As a result of two recent cases in California though, where physicians who failed to provide adequate pain relief were successfully sued for elder abuse,^[15] the North American medical and health care communities appear to be undergoing a shift in perspective. The California Medical Board publicly reprimanded the physician in the second case; the federal Center for Medicare and Medicaid Services has declared a willingness to charge with fraud health care providers who accept payment for providing adequate pain relief while failing to do so; and clinical practice guidelines and standards are evolving into clear, unambiguous statements on acceptable pain management, so health care providers, in California at least, can no longer avoid culpability by claiming that poor or no pain relief meets community standards.^[16]

Special populations

Undertreatment in the elderly can be due to a variety of reasons including the misconception that pain is a normal part of aging, therefore it is unrealistic to expect older adults to be pain free. Other misconceptions surrounding pain and older adults are that older adults have decreased pain sensitivity, especially if they have a cognitive dysfunction such as dementia and that opioids should not be administered to older adults as they are too dangerous. However, with appropriate assessment and careful administration and monitoring older adults can have to same level of pain management as any other population of care.^[17][18]

References