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December 6, 2000

Improving the Practice of Pain Management

Author Affiliations

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Copyright 2000 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2000American Medical AssociationThis is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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JAMA. 2000;284(21):2785. doi:10.1001/jama.284.21.2785-JMS1206-3-1

Studies carried out during the last 25 years have documented the undertreatment of both acute and chronic pain.1,2 Unrelieved pain has profound physiological and psychological consequences that result in significant costs to patients and families, to the health care system, and to society as a whole. Undertreatment persists despite the availability of drugs and other therapies to manage pain effectively. Unfortunately, a variety of barriers impede the application of appropriate treatments with the result that patients suffer needlessly.3,4

Physicians have often been blamed for the problem. Indeed, studies have shown that physicians may fail to assess pain, and they may prescribe inappropriate drugs at inadequate doses and at incorrect dosing intervals. If pain management requires the use of opioids, physicians may feel that the risks of overtreatment outweigh the risks associated with undertreatment. They may be reluctant to prescribe for lack of knowledge of the basic pharmacology of the drugs and for fear of regulatory scrutiny and adverse effects—especially tolerance, addiction, and respiratory depression.1,2,5

The fact that physicians may lack the knowledge and skills to manage pain has led to many educational interventions to change practice. The results of such efforts are clear: education is important, but insufficient to effect a change in practice.6 Traditional educational approaches such as continuing medical education (CME) activities have not led physicians to improve how they manage pain or other medical problems.7,8 The numerous clinical practice guidelines that summarize the best available evidence on which to base treatment decisions have also had limited impact.9

But perhaps physicians should not be solely responsible for pain management. Inadequate pain management is a systems issue. Good pain management takes time, because each patient represents an individual therapeutic experiment requiring individual titration of analgesics. Even if physicians have the correct knowledge and the right attitudes, they are often overwhelmed with the need to deliver complex care for the treatment of disease, particularly with new payment systems placing constraints on their resources.

One solution is to change the system so that physicians feel comfortable with sharing responsibility for managing pain with other health care professionals. The new pain assessment and management standards from the Joint Commission on Accredidation of Healthcare Organizations (JCAHO) will be a great stimulus to such efforts.10 These standards require accredited health care facilities to recognize the right of patients to appropriate assessment and management of pain; to assess pain in all patients; to record the assessment in a way that facilitates regular reassessment and follow-up; to educate patients, families, and providers; to establish policies that support appropriate prescription or ordering of pain medicines; to include patient needs for symptom control in discharge planning; and to collect data to monitor the appropriateness and effectiveness of pain management.

These standards will facilitate the development of specific policies and procedures to guide the assessment and management of pain at various points in patients' care. The administrative "rules" that emerge as accredited facilities work to implement the standards will restructure physicians' work environment. It will be critical for physicians to become engaged in the development of these rules. The standards will also facilitate change from the bottom up by empowering patients and families to request more effective pain control.

In an unprecedented action, the Oregon Board of Medical Examiners recently sanctioned a physician who failed to provide adequate pain relief for his patients.11 Earlier the Board had adopted a statement that urged the use of effective pain control for all patients irrespective of the etiology of their pain and said it would consider clearly documented undertreatment of pain to be a violation equal to overtreatment.12

One would hope that worries about undertreatment or overtreatment would not dominate the practice of pain management. Physicians should instead base treatment decisions on the scientific and medical evidence that is available from many sources. It is time for physicians, nurses, pharmacists, other health care professionals, system administrators, and regulators to come together to ensure improved function and good quality of life for all persons in pain.

Carr  DBJacox  AK  et al.  Acute Pain Management: Operative or Medical Procedures and Trauma. Clinical Practice Guideline, No. 1. Rockville, Md: Agency for Health Care Policy and Research; 1992. AHCPR publication 92-0032.
Jacox  AKCarr  DBPayne  R  et al.  Management of Cancer Pain. Clinical Practice Guideline, No. 9. Rockville, Md: Agency for Health Care Policy and Research; 1994. AHCPR publication 94-0592.
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Drayer  RAHenderson  JReindenberg  M Barriers to better pain control in hospitalized patients. J Pain Symptom Manage. 1999;17434- 440Article
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Max  M Improving outcomes of analgesic treatment: is education enough? Ann Intern Med. 1990;113885- 889Article
Weissman  DE Cancer pain education for physicians in practice: establishing a new paradigm. J Pain Symptom Manage. 1996;12364- 371Article
Davis  DThomson O'Brien  MAFreemantle  N  et al.  Impact of formal continuing medical education. JAMA. 1999;282867- 874Article
Stross  JK Guidelines have their limits. Ann Intern Med. 1999;131304- 305Article
Joint Commission on Accredidation of HealthCare Organizations (JCAHO), Not Available Available at: Accessed October 1, 2000.
Not Available, Oregon disciplines doctor for undertreating pain. Available at: Accessed August 31, 1999.
Pain & Policy Studies Group (2000), A guide to evaluation. Achieving balance in federal and state pain policy. Available at: Accessed October 7, 2000.