Undertreatment of pain is the absence of pain management therapy for a person in pain when treatment is indicated.
Consensus in evidence-based medicine and the recommendations of medical specialty organizations establish the guidelines which determine the treatment for pain which health care providers ought to offer. For various social reasons, persons in pain may not seek or may not be able to access treatment for their pain. At the same time, health care providers may not provide the treatment which authorities recommend.
History In 1961 the Single Convention on Narcotic Drugs established that certain drugs are "indispensable for the relief of pain and suffering" and that states should make them available to people who need them.
In 2009, a WHO report noted that accessing treatment for pain was difficult for many people in many places in the world for a range of reasons.
In 2010 the Commission on Narcotic Drugs and adopted a resolution on access to pain treatments. 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. In 2011 the International Narcotics Control Board published a supplement to its annual report which highlighted the issue as a concern to be addressed. Classification When pain is a symptom of a disease, then treatment may focus on addressing the cause of the disease. 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.
In other cases, the pain itself might need its own treatment plan. Palliative care could be used to address the pain as its own priority. Palliative care might be used either with or alongside any treatment for an underlying condition.
Signs and symptoms 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.
Causes 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.Brennan F., Carr D.B., Cousins M., Pain Management: A Fundamental Human Right, Pain Medicine, V. 105, N. 1, July 2007. 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 overprescribing (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.* Human Rights Watch, "Please, do not make us suffer any more..." Access to Pain Treatment as a Human Right, March 2009 Oregon State University (2010, January 5). Pain management failing as fears of prescription drug abuse rise. ScienceDaily. Retrieved January 5, 2010, from https://www.sciencedaily.com/releases/2010/01/100104151929.htm A complicated history of politics also influences practices in the treatment of pain. This includes cultural, societal, religious, and political attitudes. These factors often disadvantage certain groups, such as the above populations, in seeking treatment for pain.
Undertreatment of pain may also be caused by biases among healthcare practitioners. These biases are both gender and race-based, meaning they are compounded for women of color. Gender based biases include the belief that women are overdramatic and emotional, so they exaggerate any pain they feel. For racial biases, there's a common belief that people of color experience less pain overall than white people. The intersection of gender and racial biases regarding pain leads to the unique "Strong Black Woman" stereotype in which Black women are perceived to both experience less pain than white women while also overexaggerating any pain that they do feel.
Affected populations Undertreatment of pain is common and is experienced by all age groups, from neonates to the elderly.*
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 globally, including around four million cancer patients and 0.8 million HIV/AIDS patients, suffer from lack of pain relief as part of their end-of-life treatment.Human Rights Watch, "Please, do not make us suffer any more..." Access to Pain Treatment as a Human Right, March 2009 Yet the medications to treat pain are cheap, safe, effective, and generally straightforward to administer, and international law obliges countries to make adequate pain medications available.
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.*
Pain, particularly chronic pain, is understood via a constellation of factors, specifically pathopsychology, cognitive, affective, behavioral and sociocultural factors. As such, the adequate treatment of pain requires a multidisciplinary approach that accounts for how chronic pain is experienced differently among patients of differing cultures and ethnicities.
Some pain patients are made invisible through the limited representation of people of color in clinical research, the marketing of analgesics, and biases among healthcare practitioners leading their pain to be ignored. While decades of pain research have neither produced a clear and consistent pattern of sex difference in human pain tolerance, nor substantiated "fantastical" claims about racialized pain tolerance, biases within the medical sphere persist in ways which disenfranchise minoritized patients causing the undertreatment of pain.
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.
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. Compared to Caucasian patients, African American and Hispanic patients are particularly at risk for being undertreated for pain. 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. 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. A study examining over 1300 non-minority and minority patients discovered that those at facilities with principally minority patients were three times more likely to be undermedicated than patients treated in non-minority 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. Minority patients, when compared to non-minority patients, were not as likely to be appropriately evaluated for their pain and reported less pain relief. 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.
Sickle cell disease
Around 100,000 Americans are affected by sickle cell disease (SCD), the majority of whom are of African or Hispanic descent, and half of the adults with SCD don't survive past their early-40s. A characteristic feature of SCD is pain crises, or episodes of pain, which can vary in frequency and severity among individuals; sickle cell pain can be a sign of a lack of oxygen delivery to vital organs (vaso-occlusive crisis), which can lead to organ damage and death. Pain itself can exacerbate the severity of the disease as it causes blood vessels to constrict and further prevents proper oxygen circulation in the body.
Disparities in access to treatment and quality of care affect those with SCD, particularly treatment for pain relief. Sickle cell patients often face delayed care in emergency rooms, with patients at one hospital found to have 60% longer wait times to get pain medication compared to those with less severe symptoms of pain. Inadequate training of doctors and nurses to treat SCD is another contributing factor to undertreated pain in this population of patients: medical schools often offer very little sickle cell education, resulting in physicians who don't know how to properly care for sickle cell patients. In a survey of 3,000 family physicians, only 20% claimed they felt confident in treating the disease, meaning many cannot provide appropriate routine care for individuals with SCD. Furthermore, access to specialists and SCD treatment centers is difficult for many patients. Health insurance policies may prevent patients from seeing the specialists equipped to deliver quality care for SCD, and hematologists and treatment centers who specialize in SCD are scarce in general, adding a further barrier for patients to find care within an accessible distance.