Where Does It Hurt?
Pain is often undertreated or untreated, sometimes leading to harmful side effects, researchers say
Sept. 28, 2009
Let’s talk about pain.
Dull, sharp, aching, gnawing, stinging, nagging, throbbing, pounding, shooting, stabbing, radiating, searing, tearing, pinching, suffocating, splitting, crushing, wrenching, I-can’t-stand-it-anymore agonizing pain.
The fact is pain is often undertreated in this country and many people suffer unnecessarily, say University of Texas at Austin researchers.
“Many of us don’t know what to expect from pain relievers or how to best advocate for ourselves and our loved ones who have pain,” said Dr. Scott Strassels of the College of Pharmacy.
Untreated or undertreated pain can rob people of the ability to function and can cause depression, irritability, sexual dysfunction and disruptions in sleeping, eating and mobility, according to Strassels and Dr. Eun-Ok Im of the School of Nursing.
Proper treatment can help return people to their lives.
Pain is one of the most common reasons for which individuals visit the doctor. Yet many health care providers do not receive adequate training on how best to care for people with pain, Strassels and Im said, adding that health providers also are often unfamiliar with how best to use the wide array of pain-relieving strategies available.
“The result is unnecessary suffering with myths and misplaced fears about pain and pain relievers being reinforced at all levels of society,” said Strassels, assistant professor in the Division of Pharmacy Practice.
When prescribed appropriately by knowledgeable health care providers and taken as directed, prescription pain medication can make a tremendous difference for people suffering from pain, he added.
Even with all the descriptive and colorful words, it is surprisingly difficult to describe how pain feels because each of us experience pain differently.
In other words, on a 0-to-10 pain scale, one person’s two can be another person’s 10.
Because it is highly subjective, it also is a challenge for the health care provider to evaluate.
“People may have pain even if they are not able to communicate it,” Strassels said. “The subjectivity of pain is part of what makes pain so difficult to treat and explains why it is so important that clinicians accept patients’ reports of pain.”
Strassels was among six pain management experts from the United States and Canada who received Mayday Pain and Society Fellowships last fall. The fellowships provide leaders in pain management with tools and skills to advocate on behalf of better treatment for pain.
Strassels wants people to speak up about pain and says the first step is to begin a national conversation among patients, health care providers and related organizations.
He has been working with Paul Christo, a doctor at Johns Hopkins University School of Medicine, and Bonnie Stevens, who teaches nursing at the University of Toronto, in spreading the word about good pain management.
One such step already is under way. The Joint Commission on Accreditation of Healthcare Organizations has introduced a “Speak Up!”campaign to encourage patients to talk about their pain.
Also, in its “Roadmap for Medical Research,” the National Institutes of Health (NIH) calls for reengineering the way health care providers respond to patients’ pain and other symptoms.
Im, too, believes education about pain management should be a priority for the nation’s health care system. Her research on cancer pain, funded by NIH, has dealt with gender and ethnic differences in cancer pain experience.
“Erroneous assessments and subsequent undertreatment and mistreatment of cancer pain disproportionately affect women and ethnic minorities,” said Im, who holds the La Quinta Motor Inns, Inc. Professorship in nursing. She points out that there have been very few studies on the subject of gender and ethnic difference in cancer pain experiences.
Strassels and Im believe health care providers of all types must be comfortable with pain management tools.
“We actually have good, safe pain medications and not all of them make you feel ‘fuzzy,’” Strassels said. “And, people can have optimal pain management–including use of potent drugs like morphine and codeine–without intolerable adverse effects. But medicines are tools just like anything else.”
Strassels and other pain management specialists worry about those who think pain relievers are a necessary evil at best, and at worst, habit-inducing substances to be avoided at all costs.
Media coverage of high-profile celebrities’ alleged misuse or abuse of prescription medication further increases the stigma faced by legitimate pain patients or increase barriers to these important medications.
“But what many people don’t understand is that pain itself can cause harmful side effects and can affect concentration and mental clarity just as profoundly as any drug,” Strassels said.
“People with pain have a right to timely and appropriate pain care. There is a relatively small percentage of patients who are using drugs inappropriately.”
Strassels has conducted several studies on pain at the end of life and after surgery. He also has been involved with research on other pain reliever interventions like corticosteroid injections and nerve blocks that can be used alone or in combination with pain-relieving medications.
Non-drug treatments, including acupuncture, massage, yoga and meditation also help people with pain.
Total pain relief is desirable but sometimes reducing pain to a tolerable level is more realistic, Strassels said.
Depending on the type of pain, an interdisciplinary approach is often useful, he said, adding that treating pain at its onset is more effective than waiting until it worsens.
Before Strassels came to the university, he worked as a hospital pharmacist and began to see first-hand evidence of poorly treated pain. He remembers a man undergoing lung surgery and how hard it was to get his pain under control.
“Pain management after surgery is particularly vital,” Strassels said. “If a person’s pain is undertreated, he or she is less likely to want to get up and moving. Then, you’re asking for more problems like possibly developing pneumonia or having an increased risk of developing persistent pain.”
Undertreatment of pain also can contribute to higher costs directly by lengthening hospital stays, he said.
There are several factors that contribute to poorly managed post-operative pain. Clinicians’ may have mistaken attitudes and beliefs about adverse effects and addiction. Patients may believe they should not complain about pain, they may be concerned about addiction or believe pain is to be expected and is not treatable. Clinicians’ also may fear legal action for aggressive treatment of pain.
Another barrier to good pain management is that some people do not tell their doctor they have pain because they want to be “good patients.”
“They may not want to bother the doctor with complaints. Or they also may have a fear of what the pain means,” said Strassels. “Does it mean my disease is getting worse, has the cancer come back?”
To improve patient care, Im has developed a computer program to help oncology nurses better manage the pain of their patients.
Her decision-support computer program will assist nurses in dealing effectively with gender and ethnic differences in cancer pain experience based on cancer patients’ own views and experiences.
“Managing cancer pain effectively, economically and responsibly is a growing challenge that can be aided by technologies, ultimately helping oncology nurses make decisions about care,” Im said. “More than 80 percent of cancer patients experience pain during the course of their illness or treatment, but the pain is often undertreated.”
In her research, Im has found strong ethnic differences in cancer pain intensity. Each ethnic group displayed a unique cancer pain experience.
Asian participants, for example, had significantly lower cancer pain scores than those of Hispanic and white participants. African American participants had significantly lower pain scores than Hispanics and whites.
“The low pain scores do not necessarily mean that they rarely experience pain,” said Im. “Rather, they often exhibit stoicism toward pain. Asians, for example, highly value stoicism and many times want to be considered ‘good patients’ by health care providers.”
In addition, misconceptions about powerful pain relievers, including that they shorten life and cause addiction, have been reported to be common among Asians. This also makes them reluctant to manage their pain as does their sense of reported fatalism about cancer pain.
The study showed that Hispanics had the highest functional status, meaning they are functioning in their daily lives better than other ethnic groups. The reason for high functional status among Hispanics is due in part to strong family support, Im said.
All in all, pain is an integral part of being human, Strassels said.
“But fear of side effects is not a good reason to avoid pain-relieving medications,” he said. “Our hope is that people who suffer from pain will come to understand that you don’t have to choose mental clarity or pain relief. You can have both.”
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