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American Pain Society
4700 W Lake Ave
Glenview, IL 60025
June L. Dahl, PhD; Patricia Berry, PhD RN CRNH CS; Karen M. Stevenson, MS RN; Debra B. Gordon, MS RNCS; Sandra Ward, PhD RN FAAN
In August 1997, the Robert Wood Johnson Foundation provided support to the University of Wisconsin-Madison Medical School for a 3-year project whose overall goal is to make pain assessment and treatment an integral part of the nation's healthcare system. That lofty goal will not become a reality in such a short period, but certain key steps will be implemented to initiate processes for change. The areas of emphasis of the project are the following:
Countless studies have described the inadequate assessment and treatment of pain by healthcare professionals. Unrelieved pain is a major--yet avoidable--public health problem. Many healthcare professionals lack the knowledge and skills to manage pain effectively, and they also have inaccurate and exaggerated concerns about addiction, tolerance, respiratory depression, and other opioid-related side effects, which lead them to be extremely cautious about the use of these drugs.
Patients and the general public share these concerns about "strong" pain medicines. In addition, they may view pain as an inevitable part of life, something that "good" patients do not complain about, so they are reluctant to challenge a healthcare provider who says, "There is nothing I can do about your pain."
Unrelieved pain has a number of adverse physiological and psychological consequences, including impaired gastrointestinal and pulmonary function, impaired immune response, insomnia, loss of appetite, inability to walk or move about, anxiety and depression, loss of enjoyment of life, inability to maintain close relationships, feelings of hopelessness and helplessness, and even requests for physician-assisted suicide.
Millions of dollars are spent yearly on unrelieved pain as a consequence of longer hospital stays, rehospitalizations, and visits to outpatient clinics and emergency rooms. Furthermore, many people are unable to work because of their pain; this results not only in lost income but also loss of access to insurance coverage. Therefore, inadequate management of pain and other symptoms not only decreases the quality of life, but also creates a financial burden on the healthcare system and on our society as a whole.
During the past 20 years, many educators, clinicians, and professional organizations have dedicated themselves to improving the management of pain. Unfortunately, recent surveys, which document the inadequacy of pain management, suggest that their efforts have had little impact. For example, data from the Robert Wood Johnson-funded SUPPORT study showed a high incidence of uncontrolled pain (74%- 95%) in very ill and dying adults, despite planned interventions from nurses to encourage physicians to attend to pain control. The authors of the SUPPORT study concluded "more proactive and forceful measures may be needed," to improve the care of seriously ill and dying patients (Support Study Principal Investigators, 1995).
It is precisely those "more proactive and forceful measures" that we intend to initiate, to improve pain management not only in the terminally ill but also in those who experience surgical and trauma-related pain and in those who suffer from cancer and other chronic pain problems that are not immediately life threatening. We believe that every American, regardless of diagnosis, should expect and receive appropriate pain management.
It is our view that traditional patterns of professional practice may be the most intractable barrier to effective pain management. Failure of staff to routinely assess and document pain, a lack of practical treatment protocols, and the often accepted view that pain is an insignificant symptom are factors that continue to impede progress. Healthcare organizations and institutions must address these barriers in their practice settings to ensure that all patients receive quality pain management. The resulting improvements in functional status and quality of life can prevent needless suffering and reduce the financial burden of unrelieved pain on the healthcare system and on society as a whole.
SUPPORT Study Principal Investigators. (1995). A controlled trial to improve care for seriously ill hospitalized patients: A study to understand prognoses and preferences for outcomes and risks of treatment (SUPPORT). Journal of the American Medical Association, 274, 1591.
June Dahl is professor of pharmacology at the University of Wisconsin Medical School in Madison, WI. Patricia Berry and Karen Stevenson are project associates in the department of pharmacology. Debra Gordon is a clinical nurse specialist at the University of Wisconsin Hospital and Clinics. Sandra Ward is associate professor in the School of Nursing at the University of Wisconsin in Madison, WI.
