OVERCOMING THE BARRIERS OF EFFECTIVE PAIN MANAGEMENT

 

The commonest reason for seeking health care is PAIN. Almost every patient who visits the hospital today complains of some level of pain and yet, majority of patients do not receive adequate pain relief.
Overcoming The Barriers of Effective Pain Management

 

Whereas more than 80% of patients who undergo surgical procedures experience acute postoperative pain, only less than half of this group of patients report adequate postoperative pain relief (that is over 50% reports of inadequate pain management).
Pain is considered as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. It’s not an exclusively physiological experience but also has spiritual, emotional and psychosocial dimensions.
Pain experiences could be Acute, Chronic or Breakthrough in nature.  Acute Pains are usually of recent onset and commonly associated with a specific injury whereas Chronic Pains are constant or intermittent pain that persists beyond the expected healing time. A Breakthrough Pain is an acute exacerbation of pain that breaks through an existing analgesic regime.
For adequate pain relief, pain management interventions must be able to match or balance patient’s level of pain (as reported by the patient not as assumed by the health professional). However, in most cases, such do not happen. More people in pain report of inadequate pain relief.
The major pitfalls in pain management are Under-estimation of patient level of pain and Under-dosing of pain management interventions. Assessment of pain plays a very significant role in pain management. It forms the baseline on which health professionals gauge their interventions. In fact, the whole concept of pain management heavily depends on proper assessment.
However, due to the subjective bias involved in pain assessment, the fear of ‘overestimation’ and subsequently ‘doing too much’ (i.e. over dosing of interventions) deters most clinicians from deploying the right tools in proportionate levels to tackle pain.
Other factors such as Clinician’s level of experience and knowledge, communication difficulties and cultural differences also contribute to the concept of under-estimation and under-dosing. (More light will be thrown on this in latter paragraphs)
Pain management barriers are both Clinician Centered and Client Centered. Both the clinician and client contribute hugely to the effective pain management call and thus lack of proper coordination between the two, can negatively affects pain relief.

CLINICIAN CENTERED BARRIERS

Clinician level of experience and information on pain and pain management, his believes, fears and cultural background have a major impact on pain management. Clinicians may have incomplete or inaccurate information about pain and pain assessment, use of opioids in pain management and the interplay of other variables in effective pain management.
Different cultures treat pain differently. Whereas some may admonish their members to be pain tolerant, others may do otherwise. For instance, among some Ghanaian cultures women are taught to be tolerant of both labour and postpartum pains and that being able to endure, no matter the severity, makes you a ‘real (strong) woman.’At times, those who give birth via caesarean section are seen as weak. A midwife with such a cultural background may be reluctant to intervene a postpartum pain. 
Also, there are a lot of myths believed by many clinicians that wrongly guides them in the pain management call. Some of these myths have been there for ages and thus, have been accepted by a vast number of clinicians as true; yet their detrimental effects have not change. Till today, many clinicians believe that patient often exaggerate their level of pain. Instead of tagging a pain as ‘exaggerated’, it will be right on the side of the clinician to explore different pain assessment tools to probe further. 
Pain is whatever the person says it is, existing whenever the person says it does.People who complain of pain are in pain and are thus seeking for one thing, ‘Pain Relief’. Clinicians must accept the patient’s report of pain.
Also, the idea that “people in pain demonstrate or show that they have pain –i.e. pain can be seen in the patient’s behaviour” is always not the case. Many individuals may be unwilling to show or express their pain no matter how high it may be; probably due personal or previous experiences or cultural exposure. Among the Akans (a tribe in Ghana), there is a popular adage that is literally translated as “Men don’t shed tears”. This adage means that men are not to show signs of pain no matter the severity. According to the Akans, a real man must be one who is able to endure pain. A client exposed to such a background may not express his pain no matter how high it may be.
Other myths common among clinicians involved in pain management are
  • ·         Too much pain medication frequently constitutes substance abuse, causes addiction, will result in respiratory depression or will hasten death;
  • ·         Pain should be treated, not prevented;
  • ·         People in pain always report their pain to their health care provider;
  • ·         Generally a patient cannot be relieved of all pain;
  • ·         Some pain is good so that the patient’s symptoms are not masked;
  • ·         Newborn infants do not have pain; and,
  • ·         It is expected that the elderly, especially the frail elderly, always have some pain.

 

CLIENT CENTERED BARRIERS

Client centered barriers are usually associated with communication pitfalls. Since pain assessment is primarily through self-reporting, difficulty in communicating level of pain increases the patient’s risk for under-treatment.
Populations at high risk include infants and children, the elderly, patients with cognitive dysfunction, patients with emotional or mental illness and patients who speak a different language other than that of the clinician.
Other populations identified by the literature as also being at risk include
·         Patient who are from a cultural tradition different from that of the clinician
·         Patients with chronic pain,
·         Patients with neuropathic pain,
·         Substance abusers
·         Minority populations
·         Women
·         The homeless
·         Patients with terminal illnesses
Conclusion
Inadequately controlled pain negatively impacts numerous aspects of patient health. It affects quality of life of patient, function, and functional recovery of the patient. In surgery, it increases the risk of post-surgical complications and the risk of persistent postsurgical pain. It may also increase the risk of developing chronic pain.
No amount of pain is normal or bearable, no matter how subtle it is. Pain is unpleasant and uncomfortable experience. No one enjoys pain and must therefore be treated aptly with a sense of urgency. It is avoidable and must therefore be prevented. Remember, a pain free life is achievable.
What Out For Effective Pain Management

Written By Prince Assandoh-Mensah (RN, BSN- CHN, Clinical Nurse)

REFERENCES

American Pain Society.(2016) Guidelines on the management of post-operative pain. The Journal of Pain, Vol 17, No 2 (February), 2016: pp 131-157 retrieved on 18th October, 2017 from http://www.jpain.org/article/S1526-5900(15)00995-5/fulltext 
Human Right Watch.(2016). Global State of Pain Treatment, Access to Palliative Care as a Human Right.retrieved  on 20th October, 2017 from https://www.hrw.org/sites/default/files/reports/hhr0511W.pdf 
Maryland Board of Nursing. Pain Management Nursing Role/Core Competency A Guide for Nurses. http://www.painpolicy.wisc.edu/sites/www.painpolicy.wisc.edu/files/MD_nursing.pdf 

Hinkle, J. L. (2014). Brunner &Suddarth’s textbook of medical-surgical nursing (Edition 13.). Philadelphia: Wolters Kluwer Health/Lippincott

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