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between groups of patients who did or did not receive ketorolac for management of postoperative pain.135 Inappropriate or exaggerated concerns and inadequate or inaccurate clinical knowledge also limit clinicians’ abilities to appropriately manage pain.139,141,144 Concerns often relate to aspects of pharmacologic treatment such as regulatory scrutiny, analgesic side effects, and iatrogenic addiction (see I.E.5). Problems with clinical knowledge include inadequate understanding of pharmacology and misconceptions about pain (Table 6). 3. Patient and Family Barriers Whereas poor clinician-patient communication may reflect deficits in the clinician’s skills, certain patient characteristics (e.g., age, language, cognitive abilities, coexisting physical or psychological illness, cultural traditions) may impair a patient’s ability to communicate.13 Alternatively, patients may be reluctant to report pain to clinicians due to low expectations of obtaining relief, stoicism, fears, or concerns about what the pain means (e.g., worsening disease, death), analgesic side effects, or addiction.141 In a recent survey of terminally ill patients, whereas half experienced moderate to severe pain, only 30% wanted additional pain treatment.121 Reasons the patients offered for declining additional therapy included fear of addiction, dislike of mental or physical drug side effects, and not wanting to take more pills or injections. Other patient and family factors that contribute to the undertreatment of pain include financial barriers (e.g., lack of health insurance, high cost of certain medications) and even poor adherence to treatment regimens.14,141 Limited data suggest that patients do not always take analgesics as prescribed.148-150 In addition, some patients with chronic pain do not seek medical attention. A recent survey of individuals with CNCP suggested that, while most chronic pain sufferers have visited a doctor at some point, almost 40% are not currently under the care of a physician.14 Difficulty in locating a clinician who could effectively manage their pain was a commonly cited reason. 4. Legal and Societal Barriers Legal and societal issues also contribute to the undertreatment of pain. The former include restrictive laws or regulations about the prescribing of controlled substances as well as confusion about the appropriate role of opioids in pain treatment.141,151 Societal issues that contribute to the undertreatment of pain include drug abuse programs and erroneous beliefs about tolerance, physical dependence, and addiction (see I.E.5). For example, some clinicians incorrectly assume that exposure to an addictive drug usually results in addiction. 5. Tolerance, Physical Dependence, and Addiction a. Definitions Many medications, including opioids, play important roles in pain management. However, concerns about their potential misuse and misunderstanding of the nature and risk of addiction limit their appropriate use.152 Disparate definitions of tolerance, physical dependence, and addiction contribute to this problem. Therefore, the American Society of Addiction Medicine (ASAM), the American Academy of Pain 16 Pain: Current Understanding of Assessment, Management, and Treatments Section I: Background and Significance Table 6. Common Misconceptions About Pain The incorrect beliefs that: • Physical or behavioral signs of pain (e.g., abnormal vital signs, grimacing, limping) are more reliable indicators of pain than patient self-report. • Elderly or cognitively impaired patients cannot use pain intensity rating scales. • Pain does not exist in the absence of physical or behavioral signs or detectable tissue damage. • Pain without an obvious physical cause, or that is more severe than expected based on findings, is usually psychogenic. • Comparable stimuli produce the same level of pain in all individuals (i.e., a uniform pain threshold exists). • Prior experience with pain teaches a person to be more tolerant of pain. • Analgesics should be withheld until the cause of the pain is established. • Noncancer pain is not as severe as cancer pain. • Patients who are knowledgeable about pain medications, are frequent emergency department patrons, or have been taking opioids for a long time are necessarily addicts or “drug seekers.” • Use of opioids in patients with pain will cause them to become addicted. • Patients who respond to a placebo drug are malingering. • Neonates, infants, and young children have decreased pain sensation. Sources: References 13 and 140. Medicine (AAPM), and the American Pain Society (APS) recently recommended use of the following definitions:152 ■ Tolerance: “Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time.” ■ Physical Dependence: “Physical dependence is a state of adaptation that often includes tolerance and is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.” ■ Addiction: “Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm,
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