1. O'MALLEY, PATRICIA PhD, RN, CCRN, CNS, Column Editor

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Research evidence suggests that an epidemic of unrelieved pain continues to haunt the healthcare system. Despite standards and recommendations for best practices from the American Medical Association, Agency for Health Care Policy and Research, American Nurses Association, and the World Health Organization, the undertreatment of pain persists for patients experiencing trauma, postoperative, chronic, cancer, and end-of-life pain.1,2 Hospitalized patients fear pain more than any other aspect of illness and although the anger associated with illness passes with time, the anger with the healthcare provider's response to pain does not.3,4 Unrelieved pain fractures personal autonomy, increases perceived vulnerability, and undermines the dignity of human person.1


The lack of objective, quantifiable measures of pain character and intensity as well as relief negatively affects practice and research. Pain is subjective, private, highly variable, and may or may not be expressed.2,5 Psychologic, social, and cultural influences help explain the wide variation observed in pain tolerance and expression. Furthermore, persons experiencing pain are also processing additional sensory, cognitive, and emotional information, which significantly affect perceived pain and responses.5


How can it be that pain is undertreated considering available pharmacologic agents and extensive evidence regarding their benefits? There is a variety of forces-each of which the Clinical Nurse Specialist (CNS) should consider when responding to the patient experiencing pain.


First, much of the pain experience is lost in the research literature. Focus on prediction and control in experimental designs with the purpose of developing objective measures of pain with measurable outcomes is usually overcome by the infinite elements of the pain experience.6 Qualitative designs may be more helpful in examining pain and may provide more valuable information on pain and how the relationship with the healthcare provider attenuates pain. Furthermore, qualitative designs could help refine the language used to describe pain and capture the subjective and personal nature of pain that seems never fully captured in quantitative designs.1,6 In summary, the healthcare community still does not know pain. However, the patient does.


The CNS's ability as well as willingness to detect pain and trust the patient's report of pain also may account for the undertreatment of pain. Exclusive focus on diagnosis and cure rather than managing symptoms underlies hidden bias that pain is less serious than the disease itself.5 Furthermore, the suffering associated with pain increases when explicitly or implicitly the patient is accused of weak character, medication seeking, or exhibiting poor will power.1 Rather than asking "can the pain really be that bad?", the CNS should adopt the bioethical principal of personal autonomy as a guide for practice. This is best expressed by the principal that pain is whatever the patient says it is and exists whenever the patient says it does.7,8 Only then can the nursing assessment of discomfort and relief become a bias-free process that supports the moral authority of the nurse to seek and trust the patient's report of pain.1


Another hidden force supporting the undertreatment of pain are the fears of regulatory scrutiny in prescribing opioids which translates into tolerance for poor care. Undertreatment of pain appears to keep the provider in safe legal territory. However, increasingly, courts are defining undertreatment of pain as abuse, negligence, malpractice, and professional misconduct.1,7,9 Nursing has an ethical, moral, and legal obligation to act to relieve pain under the ethic of beneficence.9 Furthermore, prescribing less than effective analgesics related to fear of regulatory scrutiny is nearly equivalent to inflicting pain.10 The truth is that there are increasingly more actions taken to discipline providers for inadequate treatment of pain rather than discipline for use of excessive doses.11 Fears of addiction, tolerance, dependence, and adverse effects are the result of myth and misinformation. Despite the evidence that as pain intensity increases, the opioid dose necessary for relief increases and that tolerance to respiratory side effects increases concomitantly, many patients continue to receive inadequate medication to relieve pain.1,10


Certainly, patient choices affect pain relief. Patients who believe that suffering is virtuous, that pain is a necessary element of cure, and concerns for side effects may result in patients being reluctant to provide information to the CNS are critical for assessment and appropriate intervention.5 Providing patients with accurate information regarding pain and treatment within the nurse-patient relationship can help patients seek, trust, and accept prescribed interventions to relieve their pain.10


Best practices suggest that management of pain is more effective using a multidisciplinary approach.10 Creating an organizational climate that supports the nurse in their ethical obligation to relieve pain can also be helpful. The CNS can be a powerful force in providing evidence-based information to dispel the myth of opioid respiratory depression when using opioids to treat pain. Furthermore, fostering the belief that nurses can radically change the experience of pain, reduce suffering, and that nurses have a clear moral mandate to do so should be taught in the patient's room, the classroom, the staff meeting, and practice rounds.1,7


Healthcare providers are increasingly being held accountable for the undertreatment of pain in the courts. Perhaps it is time for healthcare providers to hold each other accountable as well through peer review. Federal and state regulations do negatively affect the legitimate use of controlled substances by prescribers.1,5 However, in light of this discussion, healthcare providers cannot ethically use restrictive regulations as an excuse to provide less than effective doses of medication for pain. Perhaps it is time to take the evidence back to the bench and the conference room and challenge the regulatory policies that hinder legitimate use of narcotics that promotes the undertreatment of pain. Finally, providing information based on the current evidence and national standards to patients, families, colleagues, student nurses, novice nurses, experienced nurses, and other healthcare providers would be additional places to begin to end the undertreatment of pain.




1. Blacksher E. Hearing from pain: using ethics to reframe, prevent and resolve the problem of unrelieved pain. Pain Med. 2001;2(2):169-175. [Context Link]


2. Pierce SF, Dalton JA, Duffey M. The nurse's ethical obligation to relieve pain: actualizing the moral mandate. J Nurs Law. 2001;7(4):19-29. [Context Link]


3. Elshamy M. Needs of patients and caregivers at end of life. Insights from recent research. Innov Breast Cancer Care.1998;4(1):13-17. [Context Link]


4. Frank AW. The pedagogy of suffering. Theory Psychol. 1992;2(4):467-485. [Context Link]


5. Resnik DB, Rehm M, Minard RB. The undertreatment of pain: scientific, clinical, cultural and philosophical factors. Med Health Care Philos. 2001;4:277-288. [Context Link]


6. Malloy DC, Hadjistavropoulos T. The problem of pain management among persons with dementia, personhood and the ontology of relationships. Nurs Philos. 2004;5(2):147-159. [Context Link]


7. LaDuke S. Ethical issues in pain management. Crit Care Clin N Am. 2002;14:165-170. [Context Link]


8. McCaffery M. Nursing practice theories related to bodily pain and man-environment interaction. Los Angeles: UCLA Students Store; 1968. [Context Link]


9. Swenson CJ. Ethical issues in pain management. Semin Oncol. 2002;18(2):135-142. [Context Link]


10. Clark PA. Ethical implications of pain management, can a formalized policy help? Health Prog. July-Aug 2002:19-28. [Context Link]


11. Frank-Stromborg M, Christensen A. A serious look at the undertreatment of pain: part 1. Clin J Oncol Nurs. 2001;5(5):1-2. [Context Link]