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]

Affected Populations

Undertreatment of pain is common,[7] and is experienced by all age groups, from neonates to the elderly.[8] 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.[9]

In addition, there are multiple demographics, namely elders, non-white racial minorities, and women, which suffer from undertreatment at disproportionate rates relative to their younger, non-Hispanic white male peers.[10][11][12]

Age

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.[10][13]

However, as a result of two recent cases in California 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.

Race

Literature examining the medical field indicates disparities in pain care for racial and ethnic minorities.[11] Compared to Caucasian patients, African American and Hispanic patients are particularly at risk for undertreatment of pain.[11] There are a variety of conditions for which African Americans and other racial and ethnic minorities experience continuous undertreatment, including cancer pain, acute postoperative pain, chest pain, acute pain, and chronic low back pain.[11] Research demonstrates that even when controlling for age, gender, and pain intensity, racial and ethnic minorities are frequently subjected to insufficient treatment for acute and chronic pain when compared to non-Hispanic whites.[14] A study examining over 1300 nonminority and minority patients discovered that patients at facilities that had principally minority patients, were three times more likely to be undermedicated than patients treated in nonminority facilities. Furthermore, a follow-up study that investigated pain treatment in minority patients with recurrent or metastatic cancer found that 74% of Latinx and 59% of African American patients experiencing pain were not given the adequate analgesics.[15] Minority patients, when compared to nonminority patients, were not as likely to be appropriately evaluated for their pain and reported less pain relief.[15] Although the prescription of opioid analgesics in response to pain-related visits grew from 1993 to 2005, disparities in prescribing to racial and ethnic minorities persisted. White patients experiencing pain were considerably more likely to be prescribed an opioid analgesic when compared to Black, Hispanic or Asian patients. Specifically, 40% of white patients were prescribed opioid analgesics in 2005, while only 32% of nonwhite patients experiencing pain were prescribed them.[15]

Gender

There are disparities in the quality of healthcare between sexes and genders, and because pain is one of the most common reasons for people to seek healthcare, there are disparities in the treatment of pain.[16] Research show that there are biological differences in the experience of pain both along biological sex lines and along gender identity lines.[17] There is also evidence to support that social expectations about the expression of pain can dictate patient and doctor responses, linking the treatment of pain to social stereotypes.[17] However, historically, women have been underrepresented in clinical studies, meaning that their experience of pain and their reaction to various medications is less understood.[18] Additionally, chronic pain, and conditions of chronic pain, are more common in women, but the rates of chronic pain and the differences in experience between men and women are not well documented.[16] Chronic pain in women may also be attributed to reproductive issues or mental health, even when these are not causes.[17]

Causes

This phenomenon can be associated with a multitude of causes. Firstly, the biomedical model of disease, focused on pathophysiology rather than quality of life, reinforces entrenched attitudes that marginalize pain management as a priority.[19] Other reasons may have to do with inadequate training, personal biases or fear of prescription drug abuse. For example, physicians may 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.[20] A complicated history of politics also influences practices in the treatment of pain.[21] This includes cultural, societal, religious, and political attitudes. These factors often disadvantage certain groups, such as the above populations, in seeking treatment for pain.

Social, cultural, and political factors

Under treatment of pain may also be cause by biases among healthcare practitioners.[22]

The United States

In the U.S., historical and ongoing racism against nonwhites has lead to the undertreatment of pain for minorities. Research review by the National Academy of Medicine has recorded persistent qualitative discrepancies between the medical care provided to racial minorities. In its publication Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, researchers cite cultural barriers, distrust of the healthcare system by racial minorities, and racial stereotyping. In the case of cultural barriers, physicians and their patients may lack the tools to communicate effectively because of language barriers and other differences.[23] Many minority individuals may not trust their doctors due to past and current unethical medical practices, such as experiments performed on slaves, the Tuskegee Syphilis Study, and the forced sterilization of Native American women, African Americans, and potentially, current immigrants in ICE detention centers.[24][25][26] They therefore avoid care or do not fully participate in treatment plans.[23] Furthermore, healthcare providers, who are typically white, may also empathize more with patients of their own race than with others.

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.[19]

History

In 1961 the Single Convention on Narcotic Drugs established that certain drugs are "indispensible [sic] 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][27]

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]

References
  1. Human Rights Watch (2 June 2011), Global State of Pain Treatment: Access to Medicines and Palliative Care, Human Rights Watch, retrieved 28 July 2016
  2. King, Nicholas B.; Fraser, Veronique (2013). "Untreated Pain, Narcotics Regulation, and Global Health Ideologies". PLOS Medicine. 10 (4): e1001411. doi:10.1371/journal.pmed.1001411. ISSN 1549-1676. PMC 3614505. PMID 23565063.
  3. International Pain Summit of the In (24 March 2011). "Declaration of Montréal: Declaration That Access to Pain Management Is a Fundamental Human Right". Journal of Pain & Palliative Care Pharmacotherapy. 25 (1): 29–31. doi:10.3109/15360288.2010.547560. PMID 21426215.
  4. Fishman, Scott M. (July 2007). "Recognizing Pain Management as a Human Right: A First Step". Anesthesia & Analgesia. 105 (1): 8–9. CiteSeerX 10.1.1.558.6197. doi:10.1213/01.ane.0000267526.37663.41. PMID 17578943.
  5. Lipman, Arthur G. (17 August 2009). "Pain as a Human Right". Journal of Pain & Palliative Care Pharmacotherapy. 19 (3): 85–100. doi:10.1080/j354v19n03_16.
  6. Lohman, Diederik; Schleifer, Rebecca; Amon, Joseph J (20 January 2010). "Access to pain treatment as a human right". BMC Medicine. 8 (1): 8. doi:10.1186/1741-7015-8-8. PMC 2823656. PMID 20089155.
  9. Human Rights Watch, "Please, do not make us suffer any more..." Access to Pain Treatment as a Human Right, March 2009
  10. Blomqvist, K (2003). "Older people in persistent pain: Nursing and paramedical staff perceptions and pain management". Journal of Advanced Nursing. 4 (6): 575–584. doi:10.1046/j.1365-2648.2003.02569.x. PMID 12622866.
  11. Green, Carmen R.; Anderson, Karen O.; Baker, Tamara A.; Campbell, Lisa C.; Decker, Sheila; Fillingim, Roger B.; Kaloukalani, Donna A.; Lasch, Kathyrn E.; Myers, Cynthia; Tait, Raymond C.; Todd, Knox H. (2003-09-01). "The Unequal Burden of Pain: Confronting Racial and Ethnic Disparities in Pain". Pain Medicine. 4 (3): 277–294. doi:10.1046/j.1526-4637.2003.03034.x. ISSN 1526-2375.
  13. Coker, E; Papaioannou, A.; Kaasalainen, S.; Dolovich, L.; Turpie, I.; Taniguchi, A. (2010). "Nurses' perceived barriers to optimal pain management in older adults on acute medical units". Applied Nursing Research. 23 (3): 139–146. doi:10.1016/j.apnr.2008.07.003. PMID 20643323.
  14. Mossey, Jana M. (July 2011). "Defining racial and ethnic disparities in pain management". Clinical Orthopaedics and Related Research. 469 (7): 1859–1870. doi:10.1007/s11999-011-1770-9. ISSN 1528-1132. PMC 3111792. PMID 21249483.
  15. Anderson, Karen O.; Green, Carmen R.; Payne, Richard (December 2009). "Racial and ethnic disparities in pain: causes and consequences of unequal care". The Journal of Pain. 10 (12): 1187–1204. doi:10.1016/j.jpain.2009.10.002. ISSN 1528-8447. PMID 19944378.
  16. Hampton, Sharon B.; Cavalier, James; Langford, Rae (December 2015). "The Influence of Race and Gender on Pain Management: A Systematic Literature Review". Pain Management Nursing. 16 (6): 968–977. doi:10.1016/j.pmn.2015.06.009. ISSN 1532-8635. PMID 26697821.
  17. Tsui, Siu Lun; Chen, Phoon Ping; Ng, Kwok Fu Jacobus (2010). Pain medicine: a multidisciplinary approach. ISBN 978-988-220-623-6. OCLC 709890951.
  18. Liu, Katherine A.; Mager, Natalie A. Dipietro (2016). "Women's involvement in clinical trials: historical perspective and future implications". Pharmacy Practice. 14 (1). doi:10.18549/PharmPract.2016.01.708. ISSN 1885-642X. PMC 4800017. PMID 27011778.
  19. Brennan F., Carr D.B., Cousins M., Pain Management: A Fundamental Human Right, Pain Medicine, V. 105, N. 1, July 2007.
  21. Anderson, T. (11 August 2010). "The politics of pain". BMJ. 341 (aug11 2): c3800. doi:10.1136/bmj.c3800. PMID 20702554.
  22. Hampton, Sharon B.; Cavalier, James; Langford, Rae (December 2015). "The Influence of Race and Gender on Pain Management: A Systematic Literature Review". Pain Management Nursing. 16 (6): 968–977. doi:10.1016/j.pmn.2015.06.009. ISSN 1532-8635. PMID 26697821.
  23. Read "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care" at NAP.edu.
  24. "The 'Father of Modern Gynecology' Performed Shocking Experiments on Slaves - HISTORY". www.history.com. Retrieved 2020-10-17.
  25. "Black Genocide | American Experience | PBS". www.pbs.org. Retrieved 2020-10-17.
  26. "ICE, A Whistleblower And Forced Sterilization : 1A". NPR.org. Retrieved 2020-10-17.
  27. Medicines Access and Rational Use (February 2009), Access to Controlled Medications Programme - Improving access to medications controlled under international drug conventions (PDF), Department of Essential Medicines and Pharmaceutical Policies Health Systems and Services, World Health Organization, retrieved 28 July 2016
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