Pain is the most common reason people seek health care in the U.S. (Ashburn & Lipman, 2004). Yet, unrelieved pain continues as a major public health epidemic. Causes of inadequate pain management have been identified as lack of knowledge by clinicians and the public, lack of priority for pain relief in the healthcare system, confusion between appropriate use and misuse/abuse of medications, negative misinformation about medications for pain, regulatory and legislative concerns, and lack of reimbursement for effective pain assessment and management.
Pain assessment and management is a core competency for health professionals and a basic right for all individuals seeking health care. This mandate was strengthened in 1999 when the Joint Commission on Accreditation of Health Care Organizations (JCAHO) (now the Joint Commission) implemented new standards to address pain and pain management in all healthcare settings accredited by the Joint Commission. Around the same time, the Veterans Health Administration launched a systems-wide effort to improve pain management for their patients. Healthcare practitioners are mandated to ask all patients about pain routinely, assess patients for pain at first point of contact, plan and implement strategies to reduce pain, and re-assess efficacy at routine scheduled intervals. Results of screening and assessment should be documented in a way that facilitates tracking and follow-up.
In acute care settings, pain is often identified as the 5th vital sign. Screening for pain and documentation of pain and pain relief ratings are completed at the same time as other routine vital signs like temperature, pulse and respiratory rate. In 2000, The American Nurses Association (ANA) House of Delegates endorsed the view of pain as the 5th vital sign. Pain is also identified as a quality indicator by the Federal Center for Medicare and Medicaid Services (CMS). Pain is one of CMS’ publicly reported outcomes for long term care facilities, home care agencies, and acute care organizations. Anyone can access this information and compare one facility to another based on their performance on selected indicators.
Whether mandated or not, effective pain assessment and management are key components of quality health care and a basic right for all. However, in spite of published standards and guidelines existing for many years, unrelieved pain remains a significant public health problem. Education alone hasn’t changed practice. Sustained improvements in clinical practice require professional and public education, an organizational commitment to identify standardized pain assessment and management as a priority, and implement policies and procedures to assure consistency, vigilance and competence.
The consequences of poor pain management are numerous:
- Prolonged pain and suffering destroys quality of life.
- Sleep deprivation, anxiety, depression, and other significant effects on daily living and function result from untreated pain.
- Pain causes difficulties with overall enjoyment of life, including work and family relationships.
- Pain causes long term physical and psychological consequences.
- Unrelieved pain in the U.S. costs more than 100 billion dollars annually (Pujol, Katz, & Zacharoff, 2007).
Pain is always subjective. It involves the perception of a sensation as well as a response to the sensation. Pain is always unique to an individual. Self-report, whenever possible, is the “gold standard” for understanding a person’s experience with pain and pain relief. Only the person experiencing pain can know what his or her pain is like. For example, the perception of the individual experiencing postoperative pain may be quite different from the individual experiencing crushing chest pain or from pain caused by cancer. The meaning of pain from childbirth is very different than pain at the end of life. Everyone responds differently, even if pain is similar.
All pain management is based on the individual response of the person with pain. Strategies that work for one person may not work at all for another person with similar pain. Algorithms can help with planning by using recommendations from published standards and guidelines, but individual responses are unpredictable and will vary significantly from person to person. Although many medications and other interventions are available for pain relief, there is no one medication or modality that provides adequate pain relief for all, even if pain is similar. The science of pain transmission and pain management are advancing daily so healthcare providers must remain current about the science and art of pain management and new pain management strategies in order to be able to provide optimal relief for people with pain.
The management of pain is multidisciplinary. Pain itself is multidimensional and requires the expertise of many disciplines to find an effective plan. A collaborative approach is necessary and should include the person with pain, nurses, physicians, physical therapists, psychological counselors, and family members, among others, in order to provide successful pain management. The primary focus of the healthcare team should be to assist the person with pain to establish goals and to achieve his/her goals regarding pain relief. We must thoroughly assess and reassess the patient to ascertain individual beliefs, goals, values, preferences, and practices in order to provide optimal pain management.
Core competencies for healthcare providers include a basic understanding of the pathophysiology of pain and pain transmission, skills for accurate screening and assessment in both verbal and non-verbal/non-responsive individuals, knowledge of pharmacologic and non-pharmacologic interventions for pain relief, advocacy skills, knowledge to educate the patient and his/her family, and the ability to individualize the pain management plan based on each unique set of patient needs.
© 2008 NYSNA, all rights reserved.
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