Pain Management - Undertreatment

Undertreatment

Undertreatment of pain is common in surgical wards, intensive care units, accident and emergency departments, dentistry, general practice, in the management of all forms of chronic pain including cancer pain, and in end of life care, and is experienced by all age groups from neonates to the elderly.

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

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.

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

Undertreatment in the elderly can be due to a varitey of reasons including the misperception that pain is a normal part of aging, therefore it is unrealistic to expect older adults to be pain free. Other misperceptions 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 are 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.

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 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, 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.

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.