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surveys indicated that routine orders for as-needed intramuscular (IM) injections of opioids failed to relieve pain in about half of all postoperative patients (e.g., Marks and Sachar,106 Donovan et al.,107 Oden108). This finding prompted recommendations including the scheduled administration of pain medications via other routes. A national survey of perioperative pain in hospitalized patients recently assessed adherence to these and other (American Society of Anesthesiologists) CPGs.109 Although overall guideline adherence was excellent, frequent IM administration of opioids and infrequent use of nonpharmacologic pain management methods were important exceptions. Results of other 1990s studies (e.g., Abbott et al.,110 Gu and Belgrade,111 Ward and Gordon,112 Warfield and Kahn,113 Drayer et al.114) contribute to concerns about the management of acute pain. In one study of pain management in hospitalized patients, 61% of the 217 patients interviewed reported pain ratings of 7 to 10 (on a scale from 0 for no pain and 10 for the worst imaginable pain) within the preceding 24 hours.112 Forty-nine percent reported a current pain level between 4 and 10, and this was after analgesic administration in 20%. A study of the adequacy of analgesia in an urban emergency department produced some disturbing results. Hispanic patients with long-bone fractures were half as likely as non-Hispanic white patients to receive pain medication.115 A 1998 survey of a random cross-section of U.S. households suggests that CNCP also is undertreated.14 Of 805 adults interviewed, 70% reported sufficient control of moderate pain. However, this percentage decreased to 51% in patients with severe pain and to 39% in those with very severe pain. Results from a 2001 survey suggest that most individuals with severe CNCP still do not have their pain under control.14 Of those who do, it took almost half of them a year to achieve adequate pain control.14 Undertreatment of cancer pain also is well documented. A landmark study involved 1308 cancer outpatients at 54 treatment sites.116 Approximately two-thirds (67%) of the patients interviewed reported pain sufficient to require daily analgesics, and 36% reported that the pain limited their ability to function. However, only 42% of those with pain reported receiving sufficient pain relief. Data from more recent studies (e.g., Zhukovsky et al.,117 Cleeland et al.,118 Anderson et al.,119 Wolf et al.,120 Weiss et al.121) suggest that pain associated with terminal illnesses, including cancer, is still undertreated. Elderly, female, minority, and pediatric patients National Pharmaceutical Council 13 Section I: Background and Significance are at greatest risk for inadequate management of cancer pain.120,122 3. What Are the Consequences and Costs of Undertreatment of Pain? a. Physiological consequences As discussed in Section I.C.1, acute tissue injury triggers physiological “stress” responses intended to protect the body. Yet these responses can have adverse effects if allowed to persist unchecked. Table 5 summarizes some of the adverse physiological consequences of inadequately controlled postinjury and postoperative pain (e.g., pneumonia, blood clots, infection, shock). Very young, very old, and frail patients are at greatest risk for such complications.13 In one study of neonates who underwent cardiac surgery, patients who received “light” versus “deep” anesthesia and postoperative analgesia had higher mortality rates.123 Another key adverse effect of poorly controlled acute pain is progression to chronic pain.124-125 Some chronic neuropathic pain (e.g., postmastectomy pain, postthoracotomy pain, phantom limb pain) results, in part, from a lack of aggressive pain management and/or early rehabilitation following surgery.126-127 Inadequate control of pain associated with acute herpes zoster (shingles) may increase the likelihood of subsequent postherpetic neuralgia.128 One study showed that pain levels in patients hospitalized for serious conditions (e.g., chronic obstructive pulmonary disease, liver failure, cancer) determined future pain levels.129 Undertreated pain early in life is associated with pain later in life.130-131 b. Quality of life Inadequate control of pain interferes with the pain sufferer’s ability to carry out activities of daily living (e.g., work, relationships, hobbies, sex).14 It also has adverse psychological consequences. Patients with inadequately managed pain may experience anxiety, fear, anger, depression, or cognitive dysfunction,15 and family members report varying levels of helplessness, frustration, and “heartbreak.”132 These consequences are especially likely to occur in patients with chronic pain. These individuals report impairments on multiple measures of physical, social, and psychological well-being, and many experience psychological symptoms (e.g., depression, anxiety) that adversely influ14 Pain: Current Understanding of Assessment, Management, and Treatments Section I: Background and Significance Table 5. Examples of Physiological Consequences of Unrelieved Pain Functional Domain Stress Responses to Pain Examples of Clinical Manifestations Endocrine/metabolic Altered release of multiple hormones (e.g., Weight loss ACTH, cortisol, catecholamines, insulin) with Fever associated metabolic disturbances Increased respiratory and heart rate Shock
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