In 1931, medical missionary Dr. Albert Schweitzer wrote, “Pain is a more terrible lord of mankind than even death itself.” In recent years, there has been a growing recognition in the healthcare community of the devastating impact pain can have on people.

Pain is no longer considered simply a secondary condition that will go away when the primary condition has been successfully treated. Rather, pain is now viewed as “the fifth vital sign,” the management of which needs to be a priority in medical treatment plans.

Unfortunately, studies reveal disturbing inadequacies in pain assessment and treatment strategies. Consider the following:

• According to the journal Pain, a randomsample study of 454 medical-surgical inpatients found that 79% experienced pain while hospitalized, and 58% of those patients reported pain that was “horrible” or “excruciating.”
• A study of seriously ill hospitalized patients found that of the 50% who complained of pain, one-sixth experienced extremely severe pain at least half the time, according to The Journal of Law, Medicine & Ethics.

These are just two examples from an enormous amount of research conducted on pain. A variety of studies have resulted in one consistent finding: A significant percentage of patients are needlessly suffering from pain.

Physician reluctance to treat pain aggressively because of regulatory scrutiny and addiction concerns is pervasive and well-documented. Other barriers to effective pain-relief practices include a lack of pain management knowledge and training, erroneous belief systems and ethnic/racial/age/gender biases.

Studies show that special patient populations—for instance, the elderly, children, women, minorities and individuals with comorbidities—are at appreciably greater risk of pain because of the above-noted factors.

As patient expectations regarding effective pain relief continue to rise, physicians will be held increasingly accountable for their attitudes and actions in the pain control arena.

Liability for inadequate pain management stems from the intersection of a patient’s experience of suffering (as well as the family’s experience of the patient’s suffering) and the physician’s motivation to help. The encounter between the two sides can be highly charged due to competing pressures.

The patient and family—aware that the physician has a variety of interventions available—demand relief, frequently with a sense of urgency and frustration. As noted, many physicians have their own considerations regarding pain management.

Chronic Pain
Chronic pain disables more people than cancer or heart disease. It affects a person’s ability to work, participate in family and social activities, and do the other things that make life satisfying. It is debilitating and demoralizing; indeed, many chronic pain patients consider suicide as a way to escape their plight.

Despite available pain-relief technology, approximately 40% of chronic pain sufferers cannot find adequate relief. In a 1999 article titled “Chronic Pain in America: Roadblocks to Relief,” the president of the American Pain Society stated, “Many Americans with chronic pain are suffering too much for too long and need more aggressive treatment.”

Palliative Care
Sometimes nothing more can be done to save patients, and physicians have the difficult task of telling them they’re terminal. This does not mean, however, that the physicians cannot and should not help them in other ways. Indeed, not providing appropriate end-of-life care—including pain management—is inconsistent with the proper practice of medicine and can be illegal. High-quality palliative care for the terminally ill is available, and one way it can be provided is through hospice care. Hospice is a highly useful tool for physicians, one they will increasingly need to employ as the baby boomer generation ages and the demand for palliative care increases correspondingly.

Special Populations
As already stated, a number of special populations are at greater risk of suffering severe pain. This is particularly an issue for the elderly, who make up the fastest growing segment of the nation’s population.

In the year 2000, the U.S. population of adults aged 65-84 was just over 30 million; by 2050, that figure will more than double. The population of adults 85 and over was 4.2 million in 2000; by 2050, it will more than quadruple to an estimated 21 million.

For physicians, treating frail elderly patients will become an almost ordinary occurrence—and given the vagaries of age, many of them will require extraordinary care when it comes to the treatment of pain.

Pain management in the elderly can be very complex. As human beings age, the heart pumps more slowly, lung capacity is reduced and lean body mass shrinks. Frailty alone makes it more difficult to treat pain, because it is harder to pinpoint exact dosages. It is also harder to predict possible side effects.

To help all patients who suffer from severe pain and to reduce potential liability risk, healthcare providers are urged to examine and correct any deficits in their pain management practices. Upcoming Medigram articles will closely examine a variety of issues involved in pain management and will suggest some best-practice solutions.