In our astoundingly complex healthcare system, providers are expected to be knowledgeable about pain management across an entire spectrum of diseases and injuries—from temporary discomfort to chronic problems. They are also expected to understand the complex psychological issues related to pain, and to be knowledgeable about diversion of prescription pain medications and drug-seeking behaviors.
Many factors contribute to this difficult picture. The general public may be surprised to learn that pain education and training is far from comprehensive and many clinicians may lack a thorough understanding of the causes and mechanisms of pain. Misinformation about addiction, unnecessarily restrictive drug control regulations and practices, fear of legal sanctions for legitimate medical practice, and the inflated cost of pain treatment complicate this picture. These barriers can be understood not only as a failure to provide essential medicines to relieve suffering but also as human rights abuses (Lohman et al., 2010).
The Institute of Medicine (IOM) estimates that treatment and management of pain costs about $635 billion annually in the United States in direct medical costs and lost productivity (IOM, 2011). Despite these costs—approaching two-thirds of a trillion dollars a year—our failure to enact policies on pain treatment, management, and palliative care, along with the failure to put in place functioning drug supply systems, has hampered the development of consistent pain policies throughout the United States.
Pain Often Undertreated
Despite the amount of money spent each year on the treatment and management of pain, it is nevertheless inadequately treated in vulnerable populations such as children, older adults, and ethnic minorities. Patients with cognitive impairments, cancer patients, and those with active addiction or a history of substance abuse are also undertreated.
Untreated pain has a profound impact on quality of life and can have physical, psychological, social, and economic consequences. Inappropriately managed acute pain can result in immunologic and neural changes, which can progress to chronic pain if untreated. Clinical outcomes of untreated postoperative pain include increased risk of atelectasis, respiratory infection, myocardial ischemia, infarct or cardiac failure, and thromboembolic disease. Common sequelae of untreated chronic pain include decreased mobility, impaired immunity, decreased concentration, anorexia, and sleep disturbances (King & Fraser, 2013).
Surprisingly, undertreatment of pain can be an issue for those with diseases and conditions known to cause pain, such as cancer, HIV, and trauma. Conservative estimates by the World Health Organization (WHO) suggest that 1 million terminal HIV/AIDS patients, 5.5 million cancer patients, and 800,000 trauma patients have little or no access to treatment for moderate to severe pain (King & Fraser, 2013).
Older adults and those of racial and ethnic minorities are at higher risk of being undertreated for pain. Studies have shown that minority patients with pain are more likely to report greater activity limitations, severe pain, and functional impairments compared with non-Hispanic whites. The sources of pain disparities among racial and ethnic minorities are complex and are related to lack of provider education, system-level lack of access to pain medications, and cultural beliefs about pain (Makris et al., 2015).
In the African American population, lower rates of clinician assessment and higher rates of undertreatment have been found in all settings and across all types of pain (IOM, 2011). Similar results have been found among Hispanics, Asian Americans, and Native Americans.
Gender plays a significant role in pain management. A large number of studies indicate that there is gender bias (an unintended and systematic neglect of one gender) in healthcare. Women are more often neglected than men and medically unjustified differences in the availability of examination and treatment of women have been demonstrated with a number of conditions, including coronary heart disease, neck pain, irritable bowel syndrome, tuberculosis, renal transplantation, and HIV treatment (Hammarström et al., 2015). In one study, HIV-infected women with pain were twice as likely to be undertreated as their male counterparts (Lohman et al., 2010).
A Swedish study aimed to understand whether gender plays a role in a patient’s access to pain rehabilitation services. Researchers found that men more often than women were referred to physiotherapy and x-ray independent of self-reported pain intensity, pain activity, and pain localization. Higher scores on self-reported pain did not trigger referral to rehabilitation. In fact, a negative trend was found among women. The higher the scores of pain, the less likely that women were referred to rehabilitation (Hammarström et al., 2015).
Not surprisingly, nursing home residents report inadequate pain control. It is estimated that 45% to 80% of patients in nursing homes have substantial pain that is undertreated. This suggests that when nursing home residents have moderate to severe pain, they have only about a 50% chance of obtaining adequate pain relief.
People may be discouraged from seeking treatment because they lack health insurance or lack a “usual” source of care. Some may not seek out treatment due to distrust of clinicians, low expectations of treatment outcomes, language barriers, and communication difficulties (IOM, 2011).
Global Health and Pain
By any measure, pain is an enormous problem throughout the world. Globally, it has been estimated that 1 in 5 adults suffer from pain and that another 1 in 10 adults are diagnosed with chronic pain each year. The five greatest causes of pain are
- Rheumatoid arthritis
- Surgeries and injuries
- Spinal problems (Goldberg & McGee, 2011)
Clearly, the etiology of pain is a complex, multidisciplinary issue with multiple serious consequences, including depression, inability to work, disrupted social relationships, and suicidal thoughts (Goldberg & McGee, 2011).
In developing countries, traffic collisions, lung cancer, and HIV/AIDS are among the leading causes of mortality. Each is likely to cause pain that is severe, debilitating, and untreated. Conservative estimates by WHO suggest that 800,000 trauma patients, 5.5 million cancer patients, and 1 million terminal HIV/AIDS patients have little or no access to treatment for moderate to severe pain (King & Fraser, 2013).
Worldwide, medications for the treatment of pain are distributed unevenly. Approximately 89% of the total world consumption of morphine occurs in North America and Europe. Low- and middle-income countries consume only 6% of the morphine used worldwide, even though they are home to about half of all cancer patients and more than 90% of HIV-infected patients. Despite the availability of medications, however, inadequate pain management is still prevalent in developed countries (Lohman et al., 2010).