The Barriers To Effective Pain Relief

Certain barriers to effective pain relief are so consistently cited in the literature that there would appear to be no genuine dispute about either their existence or their nature. Here are the usual suspects that are rounded up by the advocates of improved pain management practices:

• the failure of clinicians (primarily physicians and nurses) to identify pain relief as a priority in patient care;

• insufficient knowledge among clinicians about the assessment and management of pain;

• clinicians' fear of regulatory scrutiny of the prescribing and administering of opioid analgesics;

• the failure of healthcare institutions and organizations to hold clinicians accountable for effective pain relief.

Other barriers are mentioned with varying degrees of frequency that do not implicate physicians quite so directly, e.g. patient and family concerns about addiction, tolerance, and side effects, absence of certain narcotics from formularies, and reimbursement problems with pain therapies. However, patients and families must look to physicians for accurate information about opioid analgesics, and formulary and reimbursement issues came about long after the other barriers had been recognized and copiously documented.

There is important information in the use of the term "barrier" to explain the phenomenon of undertreated pain. It suggests that, but for the existence of these barriers, physicians would consistently provide optimal pain relief to their patients. Indeed, these barriers are sometimes described as though they were artifacts of nature, as formidable and immutable as a mountain range. The fact of the matter is, of course, that these barriers are the product of cultural beliefs, attitudes, and prejudices. We have created them, and, if necessary or appropriate, we can remove them. The fact that they have been with us for at least the last 50 years suggests that there is something less than a strong consensus and a concerted effort to bring them down. Perhaps, in scrutinizing each more carefully, we can gain some understanding as to why that might be so.27

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