Chronic Pain: Treatment Barriers and Strategies for Clinical Practice

Myra Glajchen, DSW, Institute for Education and Research in Pain and Palliative Care (MG), Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York.

J Am Board Fam Med. 2001;14(3) 

In This Article

Barriers to Effective Pain Management

In a recent study of 805 chronic pain sufferers, it was reported that more than 50% found it necessary to change physicians in their quest for pain relief. Specific reasons for changing physicians included lack of physicians' willingness to treat the pain aggressively, failure to take the pain seriously, and lack of knowledge about pain management.[3] In a study of 1,308 outpatients with metastatic cancer,[11] 67% (871) of the patients reported that they had pain or had taken analgesic drugs daily during the week preceding the study, and 36% (475) had pain severe enough to impair their ability to function. Forty-two percent of those with pain were not given adequate analgesic therapy. A discrepancy between patient and physician in judging the severity of the patient's pain was predictive of inadequate pain management. One third of practitioners reported that they would wait until the patient had less than 6 months to live before starting the maximal tolerated analgesia for severe pain.

Although opioid use in the treatment of chronic cancer pain has gained increasing acceptance worldwide, the debate continues regarding the use of these analgesics in the treatment of chronic non-malignant pain.[2,12,13] A recent review concludes that the reluctance to use opioids for noncancer pain treatment has resulted in ineffective relief for a large group of patients. Several researchers have found physician resistance to treating chronic non-malignant pain with opioids. Regulatory concerns, beliefs about the inevitability of tolerance, concern about long-term safety and durability of response -- all combine to reduce the willingness of primary care physicians to prescribe opioids for chronic nonmalignant pain.[14]

Gaps in knowledge, negative attitudes toward prescribing opioids, inadequate assessment skills, and timidity in prescribing are barriers that clinicians can unwittingly bring to clinical encounters with patients.[15,16] The problem might begin with the low priority given to pain treatment in medical schools and residency training programs. When asked about their training in pain management, 88% of physicians reported that their medical school education in pain management was poor, and 73% reported that residency training was fair or poor.[15,17] In a study of physician attitudes and practice, Von Roenn and associates[15] asked physicians to describe barriers to pain relief in their practice settings. The 897 physicians who completed the survey were members of the Eastern Cooperative Oncology Group, and all had patient care responsibilities. Approximately three fourths of the physicians (76%) cited their own sense of low competence in patient assessment as the major barrier to effective pain management. Reluctance to prescribe opioids was cited by 61% of the respondents as the second most important barrier.[15] These clinician-related barriers have been borne out by subsequent research, and they tend to be compounded in the treatment of nonmalignant pain.[12]

Patient-related barriers include communication, psychological, and attitudinal issues. In a sample survey of cancer patients receiving services from an outpatient social service agency, patients who reported communication problems with their physicians had significantly worse pain than those who did not.[18] Several psychological factors can influence pain assessment and treatment, such as anxiety, distress, depression, anger, and dementia, all of which can complicate assessment by masking symptoms. Ward and colleagues[19] measured the extent to which patients' attitudes toward pain and opioids pose barriers to treatment. Fear of addiction, tolerance, and side effects were described by patients as their most important concerns. Fatalism and the desire to please the clinician were also cited by a majority of respondents. Some patients expressed the belief that pain was inevitable, indicating that they did not expect medication to relieve their pain. In addition, patients associated pain with worsening disease. Such concerns can result in patients' reluctance to report pain or comply with a regimen that involves opioid medication.

The health care system itself can pose barriers to effective pain relief in the form of practical constraints. The lack of a neighborhood pharmacy, the lack of transportation to the physician or pharmacy, an absence of high doses of opioids at the pharmacy, and the lack of a home caregiver to assist with administering drugs pose major obstacles to pain treatment. Changes in reimbursement policies impose barriers, especially for older patients whose Medicare benefits do not pay the costs of outpatient prescription drugs.[20] In addition, patients and care-givers might confront increasing co-payments, outof-pocket expenses, limits on the number of prescriptions filled per month, and limits on refills. Finally, fear of regulatory scrutiny for prescribing controlled substances has been shown to discourage physicians from prescribing opioids of sufficient strength for the patient's pain, especially for chronic nonmalignant pain.[11] Such fears can result in the selection of less effective analgesics and, ultimately, undertreatment of the patient's pain.

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