Undertreatment of pain

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]

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]

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]

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.

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]

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]