Pain Management

January 20, 2017 | Healthcare Risk, Quality, & Safety Guidance

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​​Every year, millions of Americans experience acute and chronic pain, although estimates on the exact number vary. For example, in 2011, the Institute of Medicine (now the National Academy of Medicine) found that about 100 million American adults are affected by chronic pain, costing about $635 billion per year in medical treatment and lost productivity (IOM). In contrast, the National Institutes of Health found this number to be significantly lower, estimating that about 25.3 million American adults—approximately 11.2% of the population—suffered from daily chronic pain, with an additional 23.4 million (10.3% of the population) suffering from "a lot of pain," based on an analysis of three month​s of data in the Functioning and Disability Supplement of the 2012 National Health Interview Survey (Nahin). Yet another estimate, analyzing data from 2010, puts the number of American adults experiencing chronic pain (defined as "persistent pain") at 39.4 million per year (Kennedy et al.)  Regardless of the exact number, the fact remains that many Americans suffer from chronic pain; left unmanaged, that pain can have significant negative impact on individuals' quality of life.

Healthcare providers are often concerned about the adverse legal and medical consequences arising from the improper administration of narcotics and pain medications, including opioids (e.g., fentanyl, hydromorphone, morphine, oxycodone, oxymorphone). Most individuals in need of pain relief go to their primary care provider for treatment, while others seek treatment for pain in the emergency department (ED). In such settings, the patient is responsible for following his or her treatment regimen at home, and providers may hesitate to prescribe certain controlled substances because of concerns about their addictive properties, as well as fears that the patient will abuse the substances or divert them for sale.

In the hospital setting, physicians often order a patient's pain medications on a pro re nata (PRN) basis (i.e., "as needed"), instructing nurses and other care providers to administer the medication only when the patient needs it, with guidelines for the frequency of administration and for administration based on the patient's level of pain. Often, patients with pain may have orders for two or more medications for pain relief, requiring the nurse or care provider to determine which prescription is most appropriate for each episode of pain, based on the pain scale prescribed by the physician. Providers in the hospital setting may hesitate to provide medication because of fears of oversedation from the medication.

Physicians and healthcare providers have always had an ethical duty to provide effective pain relief, but pain management is now increasingly recognized as a medical standard of care. Care providers concerned with the adverse effects of prescribing pain medication generally focus on effects that can occur when excessive amounts of pain killers are given. Indeed, opioid overdose is a major public health problem across all healthcare settings in the United States, with the number of deaths involving prescription opioid analgesics tripling to 19,000 per year between 2001 and 2014 (SAMHSA). According to the U.S. Department of Health and Human Services (HHS), prescription opioid–related deaths are considered to be one of the leading preventable public health problems in the United States. (ODPHP)

Because the consequences of undermedicating are less detrimental than those of overmedicating, providers or caregivers who prescribe or administer medications may tend to err on the side of safety—with the result that patients suffer needlessly. To ensure quality patient care, patients in pain must receive appropriate relief in an environment where it can be given safely. Fear of liability for creating addiction is usually...

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