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Pain (PDQ®): Supportive care - Health Professional Information [NCI] - Overview

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Barriers to Effective Pain Management

  • Problems related to health care professionals:
    • Inadequate knowledge of pain management.
    • Poor assessment of pain.[5,6,7]
    • Concern about regulation of controlled substances.
    • Fear of patient addiction.[6]
    • Concern about side effects of analgesics.[5]
    • Concern about patients becoming tolerant to analgesics.
  • Problems related to patients:
    • Reluctance to report pain.
    • Concern about distracting physicians from treatment of underlying disease.
    • Fear that pain means disease is worse.
    • Lack of knowledge about principles of basic pain management.[8][Level of evidence: I]
    • Concern about not being a "good" patient.
    • Reluctance to take pain medications.
    • Fear of addiction or of being thought of as an addict. (This fear may be more pronounced in minority patients.)[9]
    • Worries about unmanageable side effects (such as constipation, nausea, or clouding of thought).
    • Concern about becoming tolerant to pain medications.
    • Poor adherence to the prescribed analgesic regimen.[10]
    • Financial barriers.[6]
  • Problems related to the health care system:
    • Low priority given to cancer pain treatment.[5]
    • Inadequate reimbursement for pain assessment and treatment.
    • The most appropriate treatment may not be reimbursed or may be too costly for patients and families.[6]
    • Restrictive regulation of controlled substances.
    • Problems of availability of treatment or access to it.
    • Opioids unavailable in the patient's pharmacy.
    • Unaffordable medication.

Flexibility is the key to managing cancer pain. As patients vary in diagnosis, stage of disease, responses to pain and interventions, and personal preferences, so must pain management. The recommended clinical approach outlined below emphasizes a focus on patient involvement.

  1. Ask about pain regularly. Assess pain and associated symptoms systematically using brief assessment tools. Assessment should include discussion about common symptoms experienced by cancer patients and how each symptom will be treated.[3,4] Asking a patient to identify his or her most troublesome symptom is also of clinical value because the most troublesome symptom is not always the most severe, as demonstrated in a survey of 146 patients in the palliative phase of treatment for lung, gastrointestinal, or breast cancer.[11]
  2. Believe patient and family reports of pain and what relieves the pain. (Caveats include patients with significant psychological/existential distress and patients with cognitive impairment.)[12,13]
  3. Choose pain-control options appropriate for the patient, family, and setting.
  4. Deliver interventions in a timely, logical, coordinated fashion.
  5. Empower patients and their families. Enable patients to control their course as much as possible.
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