Most Americans believe that a key role of medicine to relieve suffering whenever possible. Yet other, less easily articulated beliefs often conflict with this aim. The result is needless suffering. Every day, people die in severe, often agonizing pain despite the availability of medications and other therapies to reduce and even eliminate pain. Fewer than half of cancer patients get adequate pain relief, according to data from the American Cancer Society(ACS). A study cited in the 2001 Oncology Nursing Update indicates that patients with advanced cancer face a 90 percent chance of experiencing a painful death. Robert C. Young, president of the Fox Chase Cancer Center and president-elect of the ACS, said, "The undertreatment of pain is a significant public health problem in our country."
The problem is certainly not a lack of scientific knowledge about how to relieve pain, nor is it a lack of pain medications and therapies. According to the ACS, "with current information and careful attention to the use of drugs and other pain-relief techniques, the majority of individuals with cancer pain can indeed find relief."
Why then, are so many people suffering needlessly? In its treatment guidelines for cancer pain, the National Comprehensive Cancer Network (NCCN) lists four obstacles to pain relief : fear of addiction, fear of side effects, inadequate knowledge on the part of doctors and nurses, and legal obstacles. Widespread fear of the hazards of narcotics and a cultural belief in the virtue of suffering have created a climate in which it is hard to get adequate pain relief to those who need it-and hard to convince patients that such relief is acceptable. The first issue that pain-relief advocates would like to see put to rest is the problem with narcotics. The "just say no" approach to narcotics has no place in the treatment of chronic pain. Pain experts are very clear on this point: The use of opioids for the relief of chronic pain rarely, if ever, leads to addiction. When asked about the possibility of patients becoming addicted to their pain medications, Bill Lamers, M.D., a pain researcher and hospice pioneer, puts it simply, "you just don't see it happen."
Side effects, however, are another matter, though not an insurmountable problem. Betty Ferrell, Ph.D. R.N., pain researcher at City of Hope Cancer Center in Los Angeles, California, explained, "We are always trying to achieve a balance between pain and side effects [such as nausea, constipation, and drowsiness]. You can achieve zero pain, but not without unpleasant side effects. You can, however, get very close to zero. With proper care and attention, pain can be kept in the 0-3 range on the pain scale [mild pain]." Pain experts can achieve a balance of mild pain and tolerable side effects. This is not a one-time calculation. As circumstances change, so will pain. "Pain management is an ongoing process of adjusting and responding as the pain changes," Ferrell said. "It really is something of an art."
If pain management is an art, it is best practiced as a collaborative one. Health care providers cannot know how much pain a patient is in if the patient doesn't tell them. Proper assessment is essential for pain management and for that, the patient's input is essential. "Patients should never suffer in silence," Ferrell said. "They must let their caregivers know what they are feeling."
Organizations such as the Oncology Nursing Service, the American Geriatrics Society, the American Academy of Pain Medicine and a variety of advocacy groups have been working hard to educate the health care community and the public about the realities of pain management. Their efforts are beginning to pay off. Just last year, the Joint Commission on Accreditation of Healthcare Organizations enacted new standards and procedures for assessing and treating pain.
In some cases, litigation has proven to be effective in addressing failures of pain management. In June, a California jury convicted an internist of elder abuse for having failed to treat a patient's pain-a failure that ensured that patient's miserable death. The jury awarded the patient's family $1.5 million. (For details, see the May/June 2001 Exchange and visit Comapssion in Dying.
Advocates for better pain management have a long way to go and a great many misconceptions to overcome if pain relief is to become readily available to all who need it. But the climate is changing, if slowly. "This is an issue we all need to think about," said Ferrell. "And we shouldn't wait until we or our loved ones are in this situation. Odds are that we'll all be there one day."
Avery Hurt is a free-lance medical and science writer based in Birmingham, Alabama.
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