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Enablers and Barriers to Effective Pain Assessment and Management


Pain can be defined as unpleasant sensory and poignant experience related to definite or possible tissue damage (American Pain Society, 2008, P.2). Pain can be classified as nociceptive, acute or chronic pain. Nociceptive pain results from the arousal of specialized receptors or neuropathic caused by impairment of the peripheral or central nervous system (Hager & Brockopp, 2007, p.7-8).

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Chronic pain can further be classified as malignant, nonmalignant or neuropathic (either malignant or nonmalignant). Drug treatment to a large extent depends on the type of chronic pain condition (Burgess, Crowley-Matoka & Phelan, 2008, p. 1853; Hager & Brockopp, 2007, p.7-8).

Stages of Pain Treatment

Treatment of painful conditions generally follows several distinct stages. The first one deals with Pain Intensity and this encompasses the eradication of the painful sensation. This is followed by Pain Unpleasantness which focuses on treating the reaction according to the different individuals as the way pain is handled is unique in different people. The third stage focuses on Pain Suffering and this revolves around peoples’ perception of the condition they are suffering. The fourth and final stage which is known as Pain Behavior focuses on the various behavioral expressions that people with painful conditions exhibit (MacLellan, 2006, p.3). Right through the assessment and treatment of pain conditions whether in the emergency rooms or in the premise of urgent care physician, the primary care physician is the one who manages the acute stage of treatment. Generally, primary care physician starts with conservative care and, in many cases, patients recover as anticipated (Fosnocht & Swanson, 2007, 791-792; Hager & Brockopp, 2007, p.9).

During the early stages of pain treatment, psychosocial factors are also taken into account. Nevertheless, there are some exceptional cases linked to poor pain treatment outcomes that include anxiety, depression, hypochondriasis as well as somatization. These necessitate that physicians acquaint themselves with their patients’ emotional status before they embark on treating the painful conditions. This is usually considered in a case where after sustaining serious injuries, a patient appears to extremely depressed, demands high level of opioids, snubs examination or is totally non-compliant (Price, Fogh & Glynn, 2007, p.12)This kind of behavioral characteristic is very limited in patients with acute painful condition. Such conditions depict the onset of a bio-psychosocial pain disorder which is multidimensional (Fosnocht & Swanson, 2007, p.791-792).

The transitional phase also known as the sub-acute phase which refers to the healing and repair of the painful condition usually occurs between one to six months. refers to the healing and repair of the painful condition Some experts in the field of medicine posit that bio-psychosocial pain disorder take place in diverse forms with distinct natural history (Price, Fogh & Glynn, 2007, p.12). Natural history in this case refers to the situation where a medical condition becomes increasingly entangled with psychosocial complications. Considering this school of thought, one of the signs of bio-psychosocial pain disorder is the developments in the sub-acute phase that deviates from the anticipated path of recovery (Burgess, Crowley-Matoka & Phelan, 2008, p. 1853; Hager & Brockopp, 2007, p.7-8).

When a severe pain lasts for more than four weeks and there is no concrete explanation to explain this, the pain is said to be developing into a bio-psychosocial pain disorder. Beyond acute stage, it has been observed that the initial sign of chronic pain is when pain surprisingly starts to spread to other parts of the body, even when there is no medical explanation for this. In the chronic stage of pain, the whole bio-psychosocial scale is often observed (Breuer, et al., 2006, p.245-246). As stated earlier, the bio-psychosocial pain disorders occur in different forms that may either be social, emotional, and behavioral or thought related. When dealing with the treatment of painful conditions, it is important to first of all determine if the pain has a physical or a psychological origin (Fosnocht & Swanson, 2007, p.791-792).

Patients with persistent and dynamic painful condition often contend with the fact that they are socially disabled. As a result, they start developing depression. The distress associated with persistent and dynamic pain condition worsens patients’ pain and suffering. Patients who suffer from acute pain and have psychological dysfunctional tendencies generally end up having chronic pain (Dumas & Ramadurai, 2009, p. 197-198). Psychological dysfunctions normally affect compliance and hamper with the results. In addition, other psychological risk factors such as being preoccupied, intolerant to pain, self perception of disability, focus on compensation among others, increases the risk o developing bio-psychological pain disorder (Safdar, Heins & Homel, 2009, p. 365; Disorbio, Bruns & Barolat, 2006, p.4-5).

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Chronic pains can results into social conflicts within the patient’s surrounding. For instance, conflict may arise in the work place as results of the injured person preferring to perform light duties only or at home due to incapacity to help in the domestic duties. Chronic pains also cause tensions in the hospital owing to non compliancy with the treatment regime. Conflicts in the hospital are likely to take place when the patient has unrealistic expectation or is prone to conflict with hospital authority (Fosnocht & Swanson, 2007, p.793; Safdar, Heins & Homel, 2009, p. 365).

Patients with chronic pains can receive treatment in different settings. They may continue receiving treatment from the primary care physician or may hire a private physician specialized in pain (Hager & Brockopp, 2007, p.10). Patients can also see numerous non physician medical experts on the same case. Whatever the setting, it is significant for the patient to make sure that assessment of the wide range of possible complications is done (Hager & Brockopp, 2007, p.7-8; McNeill, Reynolds & Ney, 2007, p.1122).

Barriers of pain assessment and management of chronic pain

Barriers that prohibits emergency department physicians from proper assessment and management of pain include ethnic or racial bias, sex or gender bias, age bias, insufficient knowledge, and formal training in chronic pain management, opiophobia, environment in the emergency department, and the culture in the emergency department (Deandrea, 2008, p.1986). Extensive research reports have revealed that ethnic and racial factors are major forces in drafting guidelines and policies towards pain management in the emergency departments. Patients from the minority groups in some instances have been reported to be under-assessed and treated for their painful conditions. Majority of these data originated from the study of adult patients presenting the emergency department with painful conditions, but some exists in the pediatric population (Lee, 2006, p.121).

Age bias exists in the provision of sufficient analgesia in the emergency department among different age groups. Research study conducted for American Osteopathic Association established that elderly patients received more analgesia compared to their younger counterparts. The study also found out that elderly patients had a more prolonged waiting time for delivery of the pain medications, thus were under dosed (Deandrea, 2008, p.1987). The study also found that under reporting by the elderly patients, typical expression of pain among the elderly, need for enhanced appreciation of the pharmacokinetic and pharmacodynamic changes connected to ageing, and false impression about the tolerance and obsession to opioids, were the major barriers of pain assessment on the elderly persons (Deandrea, 2008, p.1987; Deer et al., 2007, p. 25).

Gender associated analgesia is another factor that adversely affects pain assessment and management. Gender physiology and pharmacogenomics have established the effects of gender bias on receiving appropriate analgesia in the emergency departments. Studies have found that women receive more analgesia than men (Bijur, 2008, p.589). The difference was also noted in the rate of pain assessment and the quantity of intravenous analgesics. Another barrier to pain assessment and management is the inadequacy of knowledge and training among the emergency physicians. The probable cause of this includes lack of proper curriculum of pain management in medical schools, reluctance of the established physicians to apply new knowledge, and preconceived opinion towards the use of opioid analgesics in the emergency department (Todd, Ducharme & Choiniere, 2007, P. 460-461; Bijur, 2008, 589, p.590).

Opiophobia is the intolerance against the use and prescription of opioid analgesics among the physicians. This results in patients being denied proper analgesics or receives them in insufficient dosage thus leave emergency rooms in pain and without prescriptions for the same. The medical ethics requires that primary care physicians or medical experts specializing in pain management to do anything in their power to alleviate human suffering caused by acute pain (Australian Government Department of Health and Ageing, 2006, p.2)

Last but not the least, environment and culture in the emergency department is also a barrier to pain assessment and management. This usually occurs when conflicts arises between the patients and the hospital staff or patients and their family. Conflicts between the patients and the emergency staff usually arise when the patient has no medical insurance policy, intolerance to pain among patients waiting to be served (Woo et al., 2007). This causes frustration among these patients to an extent that even the theoretical possibility of well-timed, efficient, and sufficient pain management becomes unrealistic (Deer et al., 2007, p. 26). Additionally, stereotyping and prejudice among the physicians and lack of trust and satisfaction among the patients, when combined, can form a dreadful barrier to successful pain assessment and management (Todd, Ducharme & Choiniere, 2007, P. 460-461).

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Enablers of effective assessment and management of chronic pains

Pain assessment and management has been made easier by numerous breaks through in the field of medicine. In case of cancer patients, the use of opioids and adjuvant drugs has helped them to relieve pain (Deer et al., 2007, p.300-301). Opioid therapy is usually initiated when the use of other medications such as acetaminophen or NSAIDs (Non-steroidal anti-inflammatory drugs) are no longer effective. Opioids generate analgesia by binding to definite opioid receptors in the brain or spinal cord. Opioids therapies are also relevant for pain control in patients with other advanced diseases and are effective for the treatment of most types of pain. Opioids include morphine sulfate, hydromorphone, oxycodone among others (Payne, Seymour & Ingleton, 2008, p.10).

Somatic pain which is another type of nociceptive pain may result from metastatic diseases of the bone in the cancer patients. This kind of pain is responsive to opioids, but using additional three-stage therapeutic approach improves treatment. NSAIDs are the main treatment of somatic pain (Therapeutic Guidelines, 2007). They inhibit cyclooxygenase, which stimulates conversion of arachidonic acid to prostaglandins and leukotrienes. NSAIDS do not trigger opioid receptors and therefore, can be used safely with opioids (Old & Swagerty, 2007, p.6-7; Payne, Seymour & Ingleton, 2008, p.10).

When Patients do not respond to NSAIDS, corticosteroids can be used. The normal initial dose of prednisone is 20 mg b.i.d in small doses. Corticosteroids can also be used as adjuvant therapy if the patient has allergy to NSAIDs.Patients with bone metastasis who do not improve despite using opioids, NSAIDs or corticosteroids are normally referred to radiation oncologists for further evaluation (Australian Government Department of Health and Ageing, 2006, p.2-3).

Pain among elderly suffering from dementia

Uninhibited pain considerably reduces the level of functioning, both physically and psychologically; eventually, this causes depression, minimal activities, sleeplessness, and deprived quality of life. Therefore, physicians specialized in treating pain, must do everything to control/treat pain so as to promote good quality life (Payne, Seymour & Ingleton, 2008, p.10).

Elderly persons with dementia do not understand the causes of pain in their body and are not willing to participate in activities that can help to alleviate pain, including physical therapy. Due to this, elderly patients with dementia normally become more incapacitated and experiences severe pain. Mismanagement of pain among these patients may even come at a time when patient’s comfort is the optimal objective (Payne, Seymour & Ingleton, 2008, p.10). Assessment and management challenges arise because patients suffering from this condition are not able to express their pain sufficiently, ask for medication, or safely use controlled analgesia pumps for personal medication (Payne, Seymour & Ingleton, 2008, p.11). The role of healthcare physicians in assessing and managing pain in elderly is critically significant owing to high prevalence rates of pain and numerous elements of pain (World Health Organization, 2005).

Advanced practice nursing (APN) plays a significant position in testing and treating pain. This involves application of advanced range of practical, theoretical, and research oriented knowledge to phenomena witnessed by patients within a specific clinical area nursing. All the clinical areas of nursing have incorporated pain management in their program. The fundamental elements of Advanced Clinical Nursing include guidance, consultancy, teamwork, research, principled decision making, and experimental leadership (Old & Swagerty, 2007, p.6-7; Hwang et al., 2006, p. 271).

Acute Care Nursing Practitioner (ACPN) is a branch of APN which is focused on critically sick patients in acute care. Its core proficiency comprises assessment and managing of diseases, disease avoidance, and general improvement of health. ACNP is patient is patient –centered, thus bed side present and manages acute phenomena in patient care. Therefore, ACNP is one of the greatest tool is pain assessment and management in the modern day nursing (Old & Swagerty, 2007, p.6-7).

Assessment and management of pain usually witnesses numerous obstacles. Elderly people often believe that pain is part and parcel of the ageing process and it is not significant to the health care practitioner. In addition, elderly persons have fears linked to pain; there fear is that pain associated with advanced illness, can results into excessive testing and addiction to medication (Shega,, 2006, p. 254). Cognitive weakness is an obstacle to pain management in itself because of not much self reporting and increased problems in assessment (Shega,, 2006, p. 5; Payne, Seymour & Ingleton, 2008, p.10).

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Another barrier is insufficient knowledge by physicians specialized in treating particularly when prescribing opioids. Underestimation of pain levels by practitioners normally results to insufficient treatment regimes (Pines & Hollander, 2008, p. 1-2). Inadequate knowledge applies to both pharmaceutical and non-pharmaceutical interventions. Most physicians are not aware of the non-pharmacologic interventions that can be mixed with pharmacologic procedures to improve pain control. Some fear legal repercussions or possible adverse effects of prescribing these treatment regimes. In addition, they fear further mental damage of elderly from opioid treatment (Old & Swagerty, 2007, p.6-7; Pines & Hollander, 2008, p. 1-2).

Health care systems create numerous obstacles to both the clients and medical practitioners. Healthcare department normally budgets less money for pain research. Lack of enough funds for research and proper policies usually results to stiff regulation by medical agencies causing fear among the practitioners (Old & Swagerty, 2007, p.8, p.240; American Pain Foundation 2009, p. 3-4).

Pain assessment and management is a very complex phenomenon. Hypothetical support for the process of pain treatment is well elaborated in Jean Watson’s caring theory (Watson, 2008, p.3). This theory emphasizes on the importance of the relationship between the patient and the medical practitioners. Transpersonal caring relationship is like a spiritual link which creates in-depth awareness. Recognition of the patient’s pain by the medical practitioner helps in proper assessment and management of pain thus promotes comfort (Shega,, 2006, p. 5; Old & Swagerty, 2007, p.9).

Besides transpersonal caring relationships, Watson’s theory also focuses on caring moment and core competencies (Shega,, 2006, p. 5). Caring moment refers to the event when the medical practitioner and the patient share experiences, views and thoughts, leading into an enormous caring occasion beyond the operation itself. This also results into a mutual connection between the physician and the patient, beyond the normal interaction. Such kind of interaction creates new opportunities for future prospects (Burgess, Crowley-Matoka & Phelan, 2008, p. 1853). The core competencies include human altruistic values, instilling faith and hope, cultivating sensitivity to self and other, developing trust, promoting and accepting positive/negative feelings, systematic use of scientific procedures, promoting transpersonal teaching-learning, providing bio-psychosocial support, offering assistance and allowing for existential phenomenological dimensions. In addition to pharmacological interventions, Watson theory provides effective method of assessing and managing pain in clients with eventual terminal condition (Shega,, 2006, p. 6-7; Hwang et al., 2006, p. 271; Watson, 2008, p.2-3).

Breuer, et al., (2006) came up with Pain Assessment in Advanced Dementia (PAINAB) scale to enhance pain assessment in patients with modest to superior dementia who are not able to comprehend concept of scale or incapable of verbal communication. This instrument is convenient, reliable and quantifies pain for appropriate handling. The main objective of these tools is to provide simple, precise tool that uses ordinary scale 0-10 to patients who are not able to communicate. Other pain assessment tools include Face, Legs, Activity, Cry, Consolability Scale (FLACC) and Discomfort Scale for Dementia of the Alzheimer Type (DS-DAT) of which PAINAD was developed (Payne, Seymour & Ingleton, 2008, p.10).


Emergency rooms are normally crowded by patients with traumatic and non-traumatic pain conditions. Physicians in charge are bound by moral and medical ethics to relieve these patients with all means possible of any possible pain they are experiencing. Pain assessment and treatment is a continuous process that is effectively managed through a multifaceted approach, integrating both pharmacological and non-pharmacological interventions. Old people who happen to suffer from dementia need special evaluation technique due to loss of mental capacity and inability to respond to tests. The most suitable tool to use in such patients is the PAINAD scale which is particularly meant for the impaired and is easy to use. PAINAD means Pain Assessment in Advanced Dementia and was developed by Warden et al., 2003, to assess pain in elderly dementia patients.


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