Editorial: This might hurt … a reflection on pain management in the 21st century


This month, the International Association for the Study of Pain will be holding its 12th World Congress in Glasgow, Scotland. Anaesthesiologists, Pain Specialists, Nurses and other professionals from many health care fields will be gathering to attend presentations about new pain theories, to debate the scientific progress that has been made in the understanding of pain, to discuss pain and generally to spend a week immersed in the field of pain control. In the UK, there are at least two national Pain Conferences every year together with countless regional and local study days. This pattern is reflected globally, I suspect since – as can be seen by this edition of the JCN– pain control and pain management continue to be areas of interest and concern for practitioners across the world. The interesting question, however, is why? Why, when we have greater understanding of the mechanisms of pain across age ranges, do we still fail to implement that understanding? Why, when we have better and more efficient methods of administering pain relief, are patients still waiting unacceptable lengths of time for analgesia? Why, when the advances in pharmacology and pharmacokinetics have lead to increasingly effective analgesics, are patients still being told that there is nothing to be done about their pain? Why is pain still not being assessed adequately and why, if it is assessed, are those assessments not acted upon? Why, when practitioners are aware of the impact that unrelieved pain has on the rehabilitation, recovery and psyche of patients, are we OK with poor pain management? Finally, who can be held to account for this state of affairs?

Traditionally, doctors and nurses have always blamed each other of poor pain management. The nurses complaining that the medics would not prescribe pain relief in sufficient quantities and the doctors complaining that, even when they did prescribe adequately, nurses were reluctant to administer analgesia to full effect. It would be nice if, whilst acknowledging that these attitudes persist in small pockets of practice, it could be confidently stated that all health care practitioners are working together to manage patient pain effectively; nice, but not realistic. Nurses and doctors continue to frustrate adequate pain management by failing to give it the prominence it deserves. To my mind, the reason for this is clear, turning the importance of pain management into glib truisms such as ‘Pain is the fifth vital sign’ and ‘Pain is what the patient says it is and occurs when the patient says it does’ (McCaffery 1983) allows practitioners to sound like they believe pain management is important with out actually acting as if they believe pain management is important. These important statements, designed originally to make health care practitioners think about pain and how they manage and respond to it have become so embedded in the consciousness that they are trotted out with no thought, no critical evaluation and no discernable patient benefit (Dihle et al. 2006).

Some of the responsibility for this can be placed firmly on the shoulders of the educators. They collaborate in the promulgation of such catchphrases but never seem able to link the words up to appropriate and professionally responsible action in the students for whom they are accountable In fairness to both parties, it must be acknowledged that, generally, educators are trying to prepare clinicians to function in high pressure environments and to cope with significant and conflicting demands upon their time. Twycross (2002) noted that nurse education was failing to prepare nurses adequately to manage pain in the clinical area. However, most educators would not condone asking a patient in cardiac arrest to ‘wait an minute’, they would also expect that practitioners would make every effort to aid a patient whose airway was occluded so why, if pain is the fifth vital sign, are educators content to allow it to be disregarded? There is a considerable body of work suggesting that educators play a key role in the socialisation of students, with the values and professional identity of student nurses closely mirroring those of their teacher (see, for example Lewis 1998 and Ohlen & Kerstin 1998). If this is the case it would appear that the willingness to deprioritise pain management is inculcated early in the education process.

Two of the key goals of 21st century health care are self-management, in which patients are encouraged to take more responsibility for their own health and partnership, in which patients and service users are expected to work with the providers of health care to achieve positive outcomes. Therefore, where are the patient voices in this scenario? Surely, if they were truly partners in the health care process they would be demanding adequate pain relief, expecting to have their pain assessed and the findings of that assessment acted upon and, most importantly, expecting to have their reports of pain believed. In the UK in 2006/2007 there were 35,149 written complaints about clinical treatments (The Information Centre for Health and Social Care 2007), it would be interesting to know how many of those centred around or included poor pain management. In the clinical area itself, patients tend to be reasonably acquiescent and reluctant to speak out, often because they have unfounded fears of reprisals if they do; those people that do, such as those with a long history of opioid use (either legal or otherwise), often find themselves penalised for their audacity (Wilson 2008).

One strategy used in the UK to address these issues was the creation of Acute Pain Services. Developed out of a working party report from the Royal College of Surgeons of England and The College of Anaesthetists (1990), small teams of people dedicated to improving pain management in the clinical area sprang up all over the UK. Without doubt, the creation of these teams had a significant and positive impact on the pain experience of patients at the time (Mcdonnell et al. 2003), However, 18 years on, a few specialist pain nurses are wondering aloud whether the main outcome of this initiative has been a de-skilling of clinical staff at the bedside together with an abdication of responsibility by the nursing staff. Anecdotally, a number of specialist pain nurses are telling me that they are often called to ‘problems’ that could be easily solved by consultation between junior medical staff, the nurses and the drug formulary.

I am aware that I am painting an extremely bleak picture. I know there are many practitioners who are passionate about pain relief and who work extremely hard to achieve it. I know that there are nurse educators who are equally zealous when preparing the next generation of practitioners to assess and manage pain. I also know that there are service users, patients and carers who are well informed and vocal about their right to satisfactory pain management both in and out of the hospital setting. However, I think any honest practitioner would agree that there is no good excuse for the poor pain management that is still seen in many affluent and so-called developed health care systems. It is equally clear that the response to this is a complex one than has no quick fix attached to it. Better education, better working relationships, better patient empowerment would all help but there is evidence to suggest that each of these on their own will not make a difference in the long term. To answer my earlier question about who can be held to account for poor state of pain management, it would seem to be the entire process of health care and all the players in it each carry some of the burden of responsibility. If any lasting and clinically meaningful improvements in the field of pain management are to be achieved a full review of the entire process is required, tinkering around with individual elements will not achieve anything.