Barriers to Effective Pain Management

In this 2007 article, Dr Eloise Carr provides an in-depth discussion of the numerous barriers that have contributed to acute pain after surgery persisting as a significant problem. Despite the fact that this article is 14 years old, these barriers continue to exist to one degree or another. These barriers include:

- patient barriers

- inadequate knowledge of healthcare professionals

- organisational practices which impede the administration of analgesics and non-

pharmacological interventions

- lack of assessment

Let's jump right into a description of the barriers present and provide some of my insights as to how to overcome these barriers.

Patient Barriers

Anxiety and pain - high levels of anxiety are know to influence the level of pain. Patients often have low expectations about pain relief.

-->what you can do

- make preoperative visits / have conversations with patients; these serve to set

realistic expectations regarding pain management and functioning and can allow

the patient to share their concerns. This is an important step in validating their

feelings and expressing your interest and commitment to manage pain in

a safe and effective manner.

Patients may not report their pain for a number of reasons

- thinking the healthcare professional is the authority on their pain

- distracting the surgeon from his or her job in treating the problem

- a fear of injections

- worried about being 'unpopular'

- thinking that pain isn't harmful and can be endured

--> what you can do

- encourage the patient to speak about their pain particularly if they feel it is

interfering with their ability to be mobile

-- Not mentioned in the article; my own thought...

Some patients may expect to not have any pain. If a provider does not intentionally discuss pain that might be experienced as a result of a procedure, it might lead the patient to believe they will not experience any pain. Pain is an emotional experience and has several confounders. Pain often signals to the patient that 'something went wrong' when that might not be the case at all.

--> what you can do

- ask the patient 'what did your doctor tell you to expect after this procedure /

with this medical condition regarding pain?

- say, 'some pain is expected and that is normal. We will do everything we can

to safely minimize pain while getting you to return to being functional.'

Professional Barriers

Assessing pain - 'we may not see (realize) that routine actions may elicit intense pain and discomfort for many patients' (who are intubated / sedated) and cannot verbalize.

- turning

- wound drain removal

- tracheal suctioning

- femoral catheter removal

- placement of CVC

- changing of non-burn wound dressings

Also, it is challenging to assess pain in patients who are unable to communicate and observational scores in these patients commonly underestimate the intensity of their pain experienced.

--> what you can do

- use validated pain scales for children and non-communicative individuals; ask

their caregivers how they demonstrate pain. Caregivers often provide valuable

insights in this regard.

- consider the intensity of the procedure or intervention and let that be a guide

to beginning your pain management plan (check out my PreEmpt Pain app for

more information for a practical guide)

WHO Pain Management Ladder

Treatment based on expected intensity of pain.

Pain education - 'While knowledge levels have improved, the actual practice or management showed less improvement'.

In other words 'recommendations from research regarding best practice for pain management are not consistently applied for several years'.

Improvement in education surrounding pain management starts with improving the relationships with the nursing providers who spend a great deal of time with the patient and best understand how pain may impede the patient from increasing their mobility, taking deep breaths, or resting comfortably.

Dr Carr ponders why education has failed to equip healthcare professionals with good knowledge about pain management.

- variability in duration of pain management education varies widely between

medical schools; however, medical students receive an average of 16 hours over the

duration of their training dedicated to pain management. Veterinary students

receive nearly 90 hours of training.

--> What you can do

- take responsibility for learning the basics of effective pain management and

engage your patients in brief conversations about how they feel their pain is

being managed. Lending a sympathetic ear and taking the time to understand

can have a positive impact on many factors improving pain.

Be a pain management advocate.

- there is a mismatch between need and activity / educational opportunities with

regard to pain management.

--> What you can do

- Set the intention to champion for effective pain management in the

perioperative setting

Sometimes effectively managing pain early in the post-operative course

has a significant impact on quality of life and healing days and weeks

down the road.

Organisational Barriers

Lack of accountability - it is safe to say that, if no one individual or entity is accountable for pain management, no significant attention will be dedicated to improving the pain management experience. Dr Carr prompts us to ask ourselves the following questions:

- Who is accountable for pain management in your practice?

- the surgeon?

- the anesthesiologist?

- the acute pain team?

- the residents?

It is often difficult to determine who is accountable and this can change during the patient's hospital course.

--> What you can do

- Take every opportunity to look for the simple things you can do to

improve the patient's comfort. There are plenty of non-pharmacologic

strategies that are easy to implement and can make a significant

improvement in the patient experience.

- Check in with other services to determine their goals for the patient.

If they wish for the patient to be more mobile, perhaps a change in the

medication regimen will improve pain and will prompt increased mobility.

That's a win for everyone.

Local policies - even in the setting of accountability for pain management and identification of a patient with pain, local policies often prevent the timely delivery of optimal pain management. These policies are often rooted in safety but may result in delay in proper treatment to a patient. Although pain management is rarely a medical emergency (patients don't often succumb solely due to pain) this does not mean that there should be a delay in providing care. This might involve assuring that PRN medications are available to patients (so the pharmacy can be aware of the need).

--> What you can do

- Be present and show up to reassure the patient and support nursing

personnel that you wish to help in every way possible. The patient knowing that

they are not alone in their pain struggle will comfort them to some degree.

Poorly managed breakthrough pain can have sequelae in the long term, even if

not evident immediately. While we do need to assure that we prescribe

medications judiciously, we need to remain calm and decide if the pain

experience is out of scope for what you as the provider expected.

- could there be something acutely progressing of a medical nature that is

driving the pain?

- have the first-line and non-pharmacologic agents been optimized?

- does the patient have a pre-existing chronic pain condition? A pre-

existing daily pain score of 6 may not be improved after a surgical

procedure unless the pain was directly related to the medical process

requiring surgery.

Find out more by checking out my PreEmpt Pain app that provides medical providers with the tools to make a pain management plan.

Log in or become a member of this site for the opportunity to beta-test the app.

Can you identify specific barriers to your institution or location of practice?

Would you feel comfortable being more vocal and an advocate for your patients?

What can you do today to make an intention to be a good pain advocate?

Who can you identify in your practice that you can partner with to accomplish equitable pain management for all?

We'd love to have you share your thoughts in our forum.