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Cardiovascular Increased heart rate Unstable angina (chest pain) Increased vascular resistance Myocardial infarction (heart attack) Increased blood pressure Deep vein thrombosis (blood clot) Increased myocardial oxygen demand Hypercoagulation Respiratory Decreased air flow due to involuntary Atelectasis (reflex muscle spasm) and voluntary Pneumonia (“splinting”) mechanisms that limit respiratory effort Gastrointestinal Decreased rate of gastric emptying Delayed gastric emptying, constipation, Decreased intestinal motility anorexia, ileusa Musculoskeletal Muscle spasm Immobility Impaired muscle mobility and function Weakness Fatigue Immune Impaired immune function Infection Genitourinary Abnormal release of hormones that affect Decreased urine output urine output, fluid volume, and electrolyte balance Hypertension (fluid retention) Electrolyte disturbances Sources: References 13 and 23. aMechanical, dynamic, or adynamic obstruction of bowel often manifests as colicky pain, distension, vomiting, and absence of the passage of stool. ACTH: adrenocorticotrophic hormone. ence health care.15 Left unchecked, these symptoms can contribute to more serious consequences. In one study, about half of the patients with CNCP reported that they had considered suicide despite the availability of resources and coping strategies.105 c. Financial consequences Pain costs Americans an estimated $100 billion each year.4,133 Patients, families, health care organizations, and society bear this financial burden. Patients with chronic pain are five times as likely as those without chronic pain to use health care services.15 In addition, medical complications associated with inadequately controlled acute pain can increase length of stay, rehospitalization rates, and outpatient visits.135 Results from some studies (e.g., Burke et al.h,135) suggest that adequate management of acute (postoperative) pain can reduce length of stay and costs. Pain is also costly in terms of lost productivity and income. It is a leading cause of medically related work absenteeism and results in more than 50 million lost work days per year in the United States.2,136 About 25% of the population in industrialized nations suffers from chronic pain of sufficient severity that they miss days of work.137 Individuals with chronic pain often face long-term or permanent unemployment or underemployment. E. B ARRIERS TO THE A PPROPRIATE A SSESSMENT AND M ANAGEMENT OF PAIN The undertreatment of pain reflects barriers to both assessment and management. These barriers can be broadly categorized as those attributable to the health care system, clinicians, patients and families, laws and regulations, and society.134,138-139 Collectively, these barriers contribute to a failure to assess pain, to accept the patient’s self-report of pain, and/or to take appropriate action.140 1. Barriers Within the Health Care System Systems barriers to pain assessment and management include an absence of clearly articulated practice standards and failure of the system to make pain relief a priority.134,141-142 For example, some health care organizations fail to adopt a standard pain assessment tool or to provide staff with sufficient time and/or chart space for documenting pain-related information.134 Others fail to provide clinicians with practical tools and training to improve pain management such as CPGs, algorithms, protocols, and computer help screens. However, the greatest systems barrier to appropriate pain management is a lack of accountability for pain management practices. Institutions and health care organizations must implement means of holding clinicians accountable for adequate pain assessment and management (e.g., chart audits of pain documentation, pain competencies in staff orientation and performance evaluations, formal reviews for critical incidents) to ensure effective pain management.134 Recent changes in the health care system (e.g., growth of managed care, shift from inpatient to outpatient treatment settings, new reimbursement policies) also have introduced barriers to pain management. Patient care is more fragmented; thus, the risk of poor coordination of care across treatment settings is increased.141,143 The use of gatekeepers and formularies by managed care organizations may impede access to pain specialists, comprehensive pain management facilities, and certain analgesic therapies.141,143 In addition, inconsistent reimbursement policies for pain treatment, or concern that aggressive treatment will increase costs, can lead to inadequate treatment of pain.144 2. Health Care Professional Barriers Clinicians’ attitudes, beliefs, and behaviors contribute to the undertreatment of pain. For example, some clinicians do not view pain relief as important and/or do not want to “waste time” assessing pain.141 Others refuse to accept that the patient’s self-report is the most reliable indicator of pain. Studies have shown that lack of assessment, underassessment, and a disparity between the clinician’s and the patient’s ratings of pain intensity are major causes of inadequately controlled pain (e.g., Donovan et al.,107 Drayer et al.,114 Grossman et al.,145 Gu and Belgrade,111 Paice et al.,146 Von Roenn et al.147). National Pharmaceutical Council 15 Section I: Background and Significance hBurke et al. compared resource utilization and costs
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