Patients Living with Pain

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What are the barriers to patients’ access to pain treatment? Are there more barriers for elderly patients and children? If so, why? 

A 1999 study, Chronic Pain in America, found that only 1 in 4 of those with pain received adequate treatment. ["Chronic Pain in America," survey conducted for American Pain Society, American Academy of Pain Medicine and Janssen Pharmaceuticals, 1999.] Recently, the under treatment of pain has begun to receive professional scrutiny. Additionally, the national media has drawn focus to the addiction issues that often arise. However, there are still many people forced to live a lower quality of living because of under treatment of their pain.

Jayne Pawasauskas, Pharm.D.:

Patients may not have access to pain treatment for many reasons. One of these may relate to difficulty locating a pain specialist, if needed. Other times, patient-specific financial issues may create barriers to receive medical attention or certain treatments. Patients from different ethnic or cultural societies may find difficulty communicating with certain healthcare providers, thus making pain assessment difficult. In addition, patients with substance abuse histories may be more likely to have their pain undertreated. In the actual healthcare setting, clinicians in a variety of settings are faced with demanding schedules. They often have very little time to spend with each patient, so the quality or quantity of time spent addressing something like pain may vary considerably from one healthcare setting to another.

Elderly patients may be at increased risk for undertreatment of pain, as well. From one perspective, there may be a lower ability to accurately capture the type or amount of pain that an elderly patient is experiencing. This could be due to certain beliefs that elderly patients may have regarding pain. For example, an elderly patient may perceive a certain amount of pain to be unavoidable. Other patients may be fearful of what the presence of pain indicates (i.e. new disease or disease progression, need for more tests or procedures), or be fearful about the types of medications or treatments that may be prescribed to attempt to manage the pain.

Cognitive impairment creates another obstacle to adequate assessment of pain. Although there has been research on assessing pain in the elderly population, the presence of cognitive impairment creates challenges for any health care provider who is attempting to assess a patient’s pain. Lastly, when we finally attempt to manage an elderly patient’s pain with medications, we typically start at lower doses than what we would use for an adult patient. In some cases, the doses remain low and were never titrated upward, thus leading to incomplete analgesic response.

What are the barriers to patients’ access to pain treatment? Are there more barriers for elderly patients and children? If so, why? 

A 1999 study, Chronic Pain in America, found that only 1 in 4 of those with pain received adequate treatment. ["Chronic Pain in America," survey conducted for American Pain Society, American Academy of Pain Medicine and Janssen Pharmaceuticals, 1999.] Recently, the under treatment of pain has begun to receive professional scrutiny. Additionally, the national media has drawn focus to the addiction issues that often arise. However, there are still many people forced to live a lower quality of living because of under treatment of their pain.

Maripat Welz-Bosna, M.S.N.:

Many of the barriers, which exist for chronic pain patients are those associated with individual bias and misinformation related to the use of medications, especially the opioids. For many the primary means for which they receive information is through TV, radio, and magazine articles. If Time magazine prints an article, or if something related to chronic pain is on the cover of Newsweek it must be right. Most of the general public and patients don’t realize that the information received this way is not based on clinical data or research but based on what sells.

As of today I have yet to see a positive article in a national magazine which focuses on the positive changes good pain medicine can have on a patient whether a geriatric patient or pediatric patient. All that the public becomes aware of are the negative issues associated with medication, which is used for chronic pain, and for other illnesses such as depression or pediatric illnesses such as Attention Deficit Disorder.

For chronic pain patients many of the barriers, which exist, are not being able to find a physician willing to prescribe the medications which may help them on a long term bases. In the practice where I presently work most new referrals are patients who have undergone numerous interventional procedures such as blocks or continuous infusions, not to mention multiple surgical interventions that still have pain but the physician has refused to start prescribing medication. We have a patient who we have been seeing for the past 5 years who has bilateral avascular necrosis of the hips. When he was first diagnosed over 10 years ago no orthopedic surgeon would perform bilateral hip replacements due to his young age so his PCP started him on a time released opioid, which provided significant pain relief. After caring for him for over 8 months he then told this patient that “He was uncomfortable writing for the medication on a monthly basis and he would need to find another physician”. The patient was referred to our practice by his orthopedist and has been stable for the past 5 years. He has never had any problems with his medications, we added adjuvant medications to help with neuropathic pain, which had not been addressed, and he has been able to return to work on a part-time bases.

For geriatric patients many of the same barriers exist related to not being able to find physicians willing to prescribe for these patients, and also the stereotype that “pain comes with old-age”. Often these patients just assume pain is a part of growing old and don’t mention how they feel to their PCP. Many of these patients have depression which has also gone undiagnosed or is a result of their pain and loss of function, which then makes them less likely to go out or to be assertive in their medical care. When these patients are evaluated and treated by a pain medicine physician, they can have significant positive outcomes both related to their pain and depression.

What are the barriers to patients’ access to pain treatment? Are there more barriers for elderly patients and children? If so, why? 

A 1999 study, Chronic Pain in America, found that only 1 in 4 of those with pain received adequate treatment. ["Chronic Pain in America," survey conducted for American Pain Society, American Academy of Pain Medicine and Janssen Pharmaceuticals, 1999.] Recently, the under treatment of pain has begun to receive professional scrutiny. Additionally, the national media has drawn focus to the addiction issues that often arise. However, there are still many people forced to live a lower quality of living because of under treatment of their pain.

Robert Kerns, Ph.D.:

Access to appropriate pain treatment remains a significant problem. Numerous barriers to access can be cited that cut across patient, provider, healthcare system, and policy domains. Barriers to appropriate pain care are present across all age ranges and socio-economic status, but scientific data suggest that some groups may be more vulnerable to undermanagement of pain than others.

In our culture, complaining about pain is viewed as a sign of weakness. We frequently use the phrases, “no pain, no gain”, “put up and shut up”, and so forth. So, one critically important barrier to overcome is the person’s hesitancy to inform their provider about pain. Combined with a sense that complaining about pain may “turn off” the provider or distract him or her from “more important” health problems, fears about the use of pain medication, and low expectations about the ability to control pain are all patient related barriers to appropriate pain treatment.

Among providers, a lack of formal education about pain assessment and management and an associated lack of clinical skills are critically important barriers that need to be addressed. Despite the recent increase in attention to pain management in healthcare settings, few medical and nursing schools provide formal courses or even elective seminars on pain management. This means that in many parts of the country there are no pain management specialists available. Many primary care providers and other specialists lack the competencies to assess and manage pain effectively. As with many patients, providers may also have irrational and ill-informed fears about the use of pain medications, including fears about threats to their licenses associated with the prescribing of controlled medications for pain. Finally, many providers view pain management as of secondary importance relative to other medical conditions, and therefore fail to make pain assessment and management a priority in their plans of care.

Healthcare system administrators often fail to provide the necessary resources for effective pain management. Again, pain management is simply not viewed as a high priority during a time of efforts to control healthcare costs and shrinking budgets. Similarly, health insurance companies often place restrictions on access to specialty pain care. Paradoxically, despite strong and growing support for the effectiveness of multidisciplinary pain programs, insurance companies commonly fail to offer reimbursement for such programs to their members.

As noted above, although problems with access to appropriate pain care is widespread, certain populations are particularly vulnerable. Children, particularly infants, and the elderly are among the groups where disparities in access to effective pain care have been observed. Equally concerning is the observation that women, relative to men, and most minority populations are more likely to have their pain undermanaged, particularly in terms of the use of opioid medications.

What are the barriers to patients’ access to pain treatment? Are there more barriers for elderly patients and children? If so, why? 

A 1999 study, Chronic Pain in America, found that only 1 in 4 of those with pain received adequate treatment. ["Chronic Pain in America," survey conducted for American Pain Society, American Academy of Pain Medicine and Janssen Pharmaceuticals, 1999.] Recently, the under treatment of pain has begun to receive professional scrutiny. Additionally, the national media has drawn focus to the addiction issues that often arise. However, there are still many people forced to live a lower quality of living because of under treatment of their pain.

Charles Argoff, M.D:

There are at least several major barriers to patients’ access to pain treatment. First, many patients are still not aware of the existence of the subspecialty of pain medicine and therefore of the available therapies for symptom control. All too often, certainly depending upon the community, "pain management" to a patient may be either the use of solely chiropractic care or acupuncture. However, this leads into another obstacle- many health care providers still view "pain" as an annoying symptom that whiny patients describe as opposed to acknowledging that chronic pain most often represents a complex disease that needs to be assessed and treated as such - no different than chronic diabetes or chronic heart disease. Patients do not need to justify their angina or hyperglycemia; patients should not have to justify their pain in a manner that may inhibit many from bringing it up in the first place.

Proper pain assessment is critical to the proper diagnosis and management of patients with any type of pain problem. The elderly and children may have particular difficulty either due to cognitive decline or due to age appropriate language development issues with conventional pain assessment tools. The use of the “faces” scale for pain assessment for example, is one attempt to help with proper pain assessment in these populations.