Here is an article written by a nurse who specializes in pain management:

It's a pain
By Roberta B. Abrams, RNC, MA, LCCE, for HealthLeaders.com

Healthcare today is a study in disparities. There are many areas of disparity between what we are able to do, and what we actually do. There are widening disparities between what we know and what we do. There are vast disparities between what patients need and what they receive.
Nowhere is this more obvious than in the area of pain management. Let's take a closer look at the realities, the etiologies, and the sequelae of these phenomena from A Nurse's Viewpoint.Margo McCaffery, RN, MS, FAAN, a renowned clinician who focuses her career on pain management, in her book Pain: Clinical Manual describes the current state of pain management. She states:

"If you or a loved one has surgery or cancer that causes pain of moderate to severe intensity, a 50% chance exists that you or your loved one will unnecessarily suffer this pain about 50% of the time. Current survey data show that this is a conservative prediction."
As healthcare providers, we have made significant strides in our knowledge about pain. Unfortunately, this knowledge has not consistently led to improved pain management for patients. In 1992, the Agency for Health Care Policy and Research (AHCPR) stated that healthcare providers have a responsibility for caring for the patients' pain and that this "begins with the affirmation that patients should have access to the best level of pain relief that may safely be provided." We currently have the knowledge and resources to provide appropriate pain relief to about 90% of pain sufferers, but that knowledge and those resources do not translate into practice.
The obstacles to dealing appropriately with patients' pain emanate from three areas: the healthcare system, healthcare providers, and patients.

Obstacles in pain management that belong to the healthcare system revolve around three factors: lack of accountability, fragmentation of care, and lack of timely availability for medications.

Improvement of pain management delivery systems should begin with the recognition that treatment of the patient's pain is a priority in caring for the patient. In 1968, McCaffery told us that: "Pain is whatever the experiencing person says it is, existing whenever he/she says it does." There still exist a number of healthcare providers who either do not believe or do not accept that statement, believing instead that the providers are more adroit at assessing pain than the patient who is experiencing it.

There continue to exist healthcare systems that do not hold their clinicians accountable for assessing and relieving pain. Reviews of medical records display a pattern in which patients do not have routine assessments for pain.

Fragmentation of care is an all-too-frequent result of the plethora of caregivers responsible for care of complex patients. If the oncologist is responsible for chemotherapeutic agents, the surgeon responsible for removal of the malignant lesion, and the endocrinologist responsible for the patient's diabetes, then who is responsible for the patient? Hopefully, there are two providers who coordinate the care: the professional nurse (who is the care manager) and the primary care provider. Either or both of these people should coordinate the creation of a multidisciplinary plan of care (care map/clinical pathway) that includes regular assessment and management of pain.

The clinical experts in pain management speak of pain as the "fifth vital sign." We need to assess pain with the same frequency and attention that we devote to the patient's blood pressure, temperature, pulse, and respiratory activity. The American Pain Society suggests that pain assessments should be included and documented on the same form as those other vital signs. This would make pain more visible and increase awareness of the needs for pain management.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has established new standards whose purpose is to make pain assessment and management a priority for our healthcare delivery systems. The standards refer to patients in hospitals, home care agencies, outpatient clinics, extended care facilities, and behavioral health facilities. These places are called upon to:

Recognize the right of all patients to assessment and management of pain
Provide mechanisms for regular pain assessments for all patients
Record those assessments in a manner facilitating prevention and alleviation of pain
Evaluate the competency of all clinical staff to assess and treat pain
Educate all clinical staff in pain assessment and treatment techniques
Develop and implement policies and procedures for prescribing and administering of pain medications
Teach patients and their families about the relevance of appropriate and effective pain management
Include needs of patients for pain and symptom management in clinical paths and discharge plans
Provide for data collection related to the appropriateness and efficacy of pain management
Hopefully, as these standards are implemented and surveyed, the system responses will improve, and pain prevention and treatment will become a standard of care.
Lack of timely availability for medication is a not-infrequent problem for the patient who is at home. Retail pharmacies, for a variety of reasons, often do not carry a full array of agents needed for pain alleviation. Many pharmacies also have defined hours of operation, a situation that is worsening due to the shortage of pharmacists. For the patient whose pain requires modification of the pharmacotherapeutic regimen, there needs to be a list of places that carry the needed medications and where they are available at other than usual business hours.

There exist a number of barriers to appropriate patient pain management that are appropriately ascribed to healthcare providers.

There is a defined need for education of the broad array of healthcare providers in the multiple modalities for pain management. Examination of the curricula of both medical and nursing programs documents a dearth of information about pain management. McCaffery tells us that a review of nursing textbooks revealed "inaccurate, confusing, and often irrelevant information about pain, particularly addiction to opioid analgesics." Nursing faculty had comparable deficits in their knowledge base. Years in clinical practice reveal to me that the same is true of practicing physicians, medical students, and medical texts.

This situation is improving. Programs in continuing education, many of them designed for multiple healthcare disciplines, are being offered in most areas. Current professional journals provide articles focusing on pain assessment and treatment. (The American Journal of Nursing has a regular column.) In 1997, researchers at the City of Hope National Medical Center, in Duarte, Calif., initiated a multi-year project, supported by the Robert Wood Johnson Foundation, designed to ameliorate nursing education related to end of life care and pain management. The Cancer Pain Role Model Courses involve teams of nurses, pharmacists, and physicians in preparation for better pain management.

Patient and family obstacles are issues that can and should be overcome by educational interventions.

Many patients and their families are unaware that their pain can be treated. Too many individuals suffer for extended periods of time with chronic pain believing that pain is "something with which you just have to live." Others endure needless pain because of the costs involved for the drugs and/or procedures that will relieve their pain. Still more patients, especially those with cancer pain, may under-report their pain to avoid recognition of the disease's progression. For patients being treated with narcotic analgesics, there is a specious fear of addiction, and of opioid toxicity with possibility of confusion and/or personality changes. Finally, patients and families may be unaware of methods of accessing requisite therapies.

There are several different iterations of a Patient Bill of Rights related to pain management which are being circulated as part of a series of programs designed to help patients and their families deal appropriately with pain. One readily available comes from the American Pain Foundation, based in Baltimore. It states:

"As a person with pain, you have:

The right to have your report of pain taken seriously and to be treated with dignity and respect by doctors, nurses, pharmacists, and other healthcare professionals
The right to have your pain thoroughly assessed and promptly treated
The right to be informed by your doctor about what may be causing your pain, possible treatments, and the benefits, risks, and costs of each
The right to participate actively in decisions about how to manage your pain
The right to have your pain reassessed regularly and your treatment adjusted if your pain has not been eased
The right to be referred to a pain specialist if your pain persists
The right to get clear and prompt answers to your questions, take time to make decisions, and refuse a particular type of treatment if you choose."
The reasons for ameliorating systems and educating both care providers and consumers about pain range from the altruistic to the pragmatic.

As care providers, we need to be knowledgeable about pain assessment and treatment simply because it's the right thing to do. Those of us who are nurses and doctors have promised to care for and about our patients, and to do no harm to those in our care. Pain is harmful. McCaffery cites studies that prove that pain may "inhibit the immune system and even enhance tumor growth." Patients who have undergone cardiovascular surgery and who experience markedly intense pain are more likely to experience atelectasis than their properly cared for peers. A study of patients with non-malignant chronic pain reports that 50% of patients involved had contemplated suicide. Can we honestly say we have cared for our patients if we have not cared for their pain?

Then there are the pragmatic issues. Failure to adequately care for the patient's pain is expensive. The patient in pain has difficulty in learning that which s/he needs to know. The patient in pain has difficulty in participating in care regimens. There are numerous studies that document that patients whose pain is appropriately managed have shorter hospital stays and better outcomes than those who do not have their pain controlled. High-risk surgical patients who experienced epidural anesthesia and analgesia had a 50% reduction in the rate of complications, earlier transfers from intensive care units, and shorter hospital stays, yielding a savings of $10,000 per patient for their surgical experience.

Improving pain management for the patient at home usually results in fewer and briefer hospital admissions. McCaffery cites a study of cancer patients at City of Hope where nursing interventions yielding improvement in cancer pain management reduced admissions and decreased the cost of care by more than 50% in a twelve-month period.

Once again, the cogent question. What is being done in your facility to deal with the issue of pain? Are there appropriate educational interventions to prepare the care providers? Are you providing your patients with the knowledge needed to participate meaningfully in their own care? Are you listening - really listening - to those patients in their assessments of their needs, including those related to pain? What improvements are needed? When will they be done?