Emergency Medicine: Barriers to Effective Pain Management

Entrenched beliefs and practices that interfere with optimal pain treatment abound and often are attributed to the following three origins: the patient, the health-care team, and the health-care system. Among the most common obstacles to overcome are a failure to assess and acknowledge the existence of pain, outdated prescribing habits, inadequate quality improvement monitoring, and a lack of accountability for unsatisfactory outcomes related to poorly managed pain. Clinician-related barriers, including knowledge deficits regarding pain assessment and management principles, personal and cultural bias, and communication difficulties between the patient and the health-care team, contribute considerably to suboptimal pain management in the hospital.

Structured Approaches to Pain Management in the ICU

Table 1

Evidence of Pain Management Barriers in Acute Care Settings

Barrier	Description
Knowledge and other deficits	inadequate pain assessment knowledge
	Failure to accept pain as an inevitable part of the disease process and considering pain as an important stimulus for coughing and deep breathing
	Lack of a standardized objective pain assessment for patients who are critically ill and noncommunicative
	Available pain assessments generate single pain score that lacks meaning in relation to treatment goals
	Lack of knowledge related to the pharmacological effects of opioids and nonopioid analgesics.
	Physicians' reluctance to prescribe appropriate and adequate analgesics; nurses administer less than prescribed opioid analgesics because of fears of respiratory depression, sedation, and addiction
	Decision process about pain intervention challenged by the need to optimize patients' hemodynamic and respiratory conditions, to collaborate with medical plan of care, and to act according to patient and family preferences.
	Analgesic interventions influenced by patients' behavioral cues or physiological status despite presence of self-reported pain.
	Inappropriate analgesic prescription by physicians and reluctance to use adjuvant therapy to manage pain
	Inflexible analgesic schedule and minimal use of nonpharmacologic interventions
Personal and cultural bias	Stereotyping or bias based on patients' demographic characteristics
	Preconceived notion about a patient's pain in relation to the type of surgery, number of days after surgery, ventilatory status, and the patient's pattern of analgesic use
	Nurse willingness to spend maximum time and energy to care for patients with cancer and AIDS who are in pain but less willing to spend maximum time and energy to care for patients who attempt suicide or abuse drugs
	Medical-surgical nurses indicating that they would give fewer analgesics to patients who were engaging in socially unacceptable behavior at the time of injury.
	Physicians who treat pain in women and minorities less aggressively than other populations.
	Men and younger cardiac surgery patients receive more analgesics than women or older patients.
	African American patients less likely to receive analgesics than white patients in emergency departments .
Communication difficulties	Communication difficulties identified as the number-one barrier to pain management in older surgical patients.
	Issues with caring for minority patients, including language barriers, lack of pain measurement tools in various languages, and missing patient cues of pain because of unfamiliarity with minority patients' pain expressions and behavioral responses.
	Disagreement between physicians and nurses on pain management plan.
	Miscommunication between physicians and nurses when evaluating the patient's pain .

Source: CHEST June 2009 vol. 135 no.6 1665-1672