Pain Mangement Journals
JLME Volume 33:4, 2005
JLME Volume 31:1, 2003
JLME Volume 29:1, 2001
JLME Volume 26:4, 1998
JLME Volume 24:4, 1996
JLME Volume 29: 1 2001
Executive Summary
Read the full articles of this issue here in Acrobat(.pdf) format 
Symposium Articles
Introduction: Relieving
Unnecessary, Treatable Pain for the Sake of Human Dignity
Sandra H. Johnson 
(11k)
The Girl Who Cried Pain:
A Bias Against Women in the Treatment of Pain
Diane E. Hoffmann and Anita J. Tarzian (83k)
Pain strikes women more frequently and at more intense levels than it
does men. Yet health-care providers seem less inclined to take women's
complaints of pain seriously: Even though women are more likely to seek
treatment for their pain than men, they are less likely to receive it.
These findings raise important questions surrounding the biological origins
of pain, socialized gender differences related to pain, and possible
gender bias in the treatment of pain.
In general, women report more severe levels of pain, more frequent incidences
of pain, and pain of longer duration than men. Women are more likely
than men to report migraines and chronic tension headaches, facial pain,
musculoskeletal pain, and pain associated with osteoarthritis, rheumatoid
arthritis, and fibromyalgia. Women are also more likely to develop a
chronic pain syndrome after experiencing trauma.
Why does this happen? Because so many different stimuli cause pain, it
is difficult to determine whether gender-based differences in how people
experience and perceive pain are biological or psychosocial in nature.
One modern approach is to acknowledge pain as a product of both biological
and psychological factors.
Possible biological factors in pain experience and perception include:
o the influence of reproductive hormones;
o dissimilarities between men and women in the activation of stress-induced
analgesia, which is the body's natural way of relieving pain caused by
stressful situations; and
o sex-based differences in the brain and central nervous system.
In addition, research into psychological factors influencing pain show
that men and women differ in how they attribute meaning to their experiences
with pain. For example, women tend to describe their pain within the
context of how it affects their personal relationships and ability to
perform child-care duties. Men, on the other hand, are more likely to
wait to attend to pain until it threatens to interfere with their work
duties. Their pain reports generally amount to objective descriptions
of physical symptoms or functional limitations, without reference to
their effect on personal relationships.
These differences in cognitive appraisal — or meaning-making — in
turn affect how men and women respond to pain. For example, women tend
to view seeking health care for their pain as a positive step that reflects
their ability to handle their problems; men are more apt to seek health
care out of fear that the problem is beyond their ability to solve.
Men and women also display different mechanisms for coping with pain.
Women express their feelings, seek social support, and look for ways
to take their mind off pain. They also respond more positively to taking
medications or consulting a health-care provider than do men, who tend
to take a more stoic approach to pain that involves accepting their situation
and engaging in exercise.
Culture and socialization may also account for differences in how men
and women perceive and report pain. For example, research has found that
baby boys are actually more emotionally expressive than baby girls, but
that boys' emotional expressiveness diminishes substantially by the time
they are five or six years old. Men have reported that they feel obliged
to maintain a stoic composure in response to pain, while women feel freer
to express their emotions and seek social support when they are in pain.
Considering that women report greater and more frequent pain than men,
and are more likely to seek health care for their pain than men, it would
seem to follow that women receive more treatment for pain. That is not
the case. Women appear less likely to receive pain medications than men
and more likely to receive sedatives for their pain. Among patients complaining
of chest pain, women are less likely than men to be admitted to the hospital.
Women also appear to face more barriers when trying to obtain specialty
care: They are more likely to be referred by a specialist for treatment
of chronic pain at a pain clinic, compared with men, who are more likely
to be directly referred by a general practitioner.
In general, women tend to receive less aggressive treatment for pain
in their early encounters with health-care providers. Although men are
slower than women to seek medical care for their pain, there is no evidence
that men are in need of more aggressive care than women when they do
seek pain treatment.
These observations suggest that health-care providers regard women's
complaints of pain with more skepticism than they do men's. Women, it
seems, have to "prove" that they are as sick as men in order to receive
the same level of pain treatment.
It is difficult to say what accounts for these differences in perception
and behavior among health-care providers, although there are many theories.
Some health-care providers may believe that women have a higher natural
capacity to endure pain that stems from their biological role in childbirth.
In addition, the fact that women have better as well as more coping mechanisms
to deal with pain than men may work against them — leading health-care
providers to believe that they are better able to put up with pain and
less in need of treatment. Another possible factor has to do with the
subjective nature of pain: Providers may discount women's reports of
pain as emotional or psychogenic in origin and therefore not real.
This article recommends steps to help correct these discrepancies in
pain treatment. Medical school curricula should address ways of improving
physician-patient communication concerning pain management, so that physicians-in-training
learn to better elicit and respond to their patients' feelings. In additional,
the Joint Commission on the Accreditation of Healthcare Organizations,
which recently established pain management standards for health-care
providers, should address the current bias in pain treatment of women.
Finally, institutional ethics committees can educate health-care providers
and encourage them to treat women more fairly and appropriately when
they complain of pain. These measures will help assure that all patients
with pain are treated equally effectively.
Pain Management and Provider
Liability: No More Excuses
Barry R. Furrow (137k)
The threat of medical malpractice potentially provides a strong incentive
for health-care practitioners to improve their treatment of pain. Yet,
thus far, few malpractice suits have been filed for the mismanagement
of pain. The author examines the reasons that malpractice law has not
been applied to the negligent treatment of pain, and outlines rapid changes
that are converging to make such lawsuits an effective deterrent to pain
mismanagement.
Malpractice law has seldom been applied to claims of pain mismanagement
for a variety of reasons. First, until recently, the medical profession
has lacked a standard for the treatment of pain. Since medically accepted
standards of care provide the key basis to evaluate claims of medical
malpractice, this lack of any standard has been a chief obstacle to pain
malpractice suits.
Second, most medical malpractice lawsuits are filed in reaction to a
tangible harm, such as a poorly conducted procedure or misdiagnosis that
leads to further injury or death. In these cases, the attendant pain
is considered as part of the damages. But if a procedure is properly
executed and the attendant pain not treated, the pain itself has not
been considered malpractice. Rather, pain has been viewed as subjective
and worth ignoring. Neither medical practitioners nor the law has recognized
pain as a separate, compensable injury.
However, in response to a growing outcry for the improvement of patient
care, health-care providers have begun to rethink their treatment of
pain, and a medical standard has begun to emerge. The biggest single
change has been new guidelines by the Joint Commission on Accreditation
of Healthcare Organizations. As a basis for accreditation, the revised
guidelines mandate that hospitals treat pain as a "fifth vital sign" (along
with temperature, pulse, respiration, and blood pressure).
Furthermore, a number of medical associations have established and promulgated
standards of care for pain management. These include the Agency for Healthcare
Research and Quality, the American Pain Society, and the American Society
of Anesthesiologists. Physicians and patients can now readily find these
clinical practice guidelines through the Internet. The crystallization
of a medical standard for the evaluation and treatment of pain makes
malpractice claims more feasible, while also weakening the perception
of pain as merely a subjective experience.
In the context of these changes, the article reviews tort rules and case
law in medical malpractice that can be applied to the mismanagement of
pain. The heart of any malpractice case is proof that the defendant failed
to meet the standard of care. Emerging standards of care encompass a
right to relief from pain. Although a physician may argue in his defense
that he was not trained in proper pain management and that it is customary
for physicians to undertreat pain, this argument can be countered. Evidence
of good practice may override the defense of customary practice if what
is customary is the result of ignorance and inertia.
Tort rules give voice to patients who have been patronized, ignored,
manipulated, or cruelly treated by doctors and institutions. All these
behaviors can manifest themselves in the mistreatment of pain. For example,
established tort principles require a treating physician who is incapable
of properly treating his patient to refer the patient to a specialist.
In the emerging field of pain management, specialists provide a range
of services beyond the experience of many primary care physicians. Therefore,
physicians who cannot or do not want to manage their patients' pain have
a duty to refer and refusal to do so is unethical. Connected to the duty
to refer is the doctrine of informed consent, which requires physicians
to disclose alternative methods of accepted treatment, their risks, consequences,
and probability of success.
Some cases provide precedent for patients to sue for pain mistreatment
based on negligent or intentional infliction of mental distress. To watch
a loved one's unrelieved suffering because of a lack of proper pain management
can also inflict emotional distress on the family as bystanders.
Patients also have legal recourse when institutions fail to manage pain,
a common occurrence in many hospitals and nursing homes. Post-operative
pain and end-of-life care often neglect the relief of pain and suffering.
Rather than just the individual physician, the system of care — including
managed care organizations — may be at fault for failing to address
the problem.
Physicians' obligation to relieve suffering is articulated in the modified
Hippocratic Oath, the Code of Ethics of the American Medical Association,
and the statements of medical leaders. Nonetheless, medical practice
and medical school curricula have been slow to incorporate all that is
known about pain management. The threat of medical malpractice for pain
mistreatment can speed the alleviation of suffering and prompt institutional
reforms in the treatment of pain.
Race, Ethnicity, and Pain
Treatment: Striving to Understand the Causes and Solutions to the Disparities
in Pain Treatment
Vence L. Bonham (679k)
Race and ethnicity cast a large shadow over pain treatment. Research
demonstrates that blacks and Hispanics are less likely than whites to
receive effective pain treatment — a finding that holds true across
health-care settings, including hospital emergency rooms, inpatient services,
outpatient clinics, and nursing homes.
One study, for example, found that Hispanic emergency room patients with
long bone fractures were more than twice as likely as their white counterparts
to receive no analgesic to relieve their pain. Yet a companion study
concluded that patient ethnicity was not a factor in physicians' ability
to assess the severity of their patients' pain. This finding further
begs the question of why their treatment decisions differed so sharply
for white versus Hispanic patients.
In another study of emergency room patients, whites were significantly
more likely than blacks to receive analgesics (74 percent versus 57 percent),
despite similar records of pain complaints in their medical records.
These findings suggest that patient race and ethnicity affect physician
decision-making independent of clinical criteria.
Other research has shown that facility type influences how patients from
racial and ethnic minorities are treated for pain as well. For example,
cancer patients who received treatment at outpatient clinics that primarily
served blacks and Hispanics were three times more likely to be undermedicated
with analgesics than patients treated in other settings. Yet in another
study, in a community hospital with a diverse and predominantly Hispanic
patient population, Hispanic patients received pain treatment on a par
with that of whites and were not likely to be undermedicated for pain.
Patient race and ethnicity are not the only factors affecting pain treatment
and they may not be the most significant factors. One study found physicians'
impressions of patient pain to be the only significant predictors of
pain treatment; race and ethnicity were not significant influences.
Still, disparities in pain treatment based on race and ethnicity are
a common theme in the pain research literature. But there is little hard
evidence to explain why these disparities exist. Possible explanations
include racism and bias on the part of health-care providers, language
and cultural barriers that impede patient-physician communication, socio-economic
factors that adversely affect minority patients, and gaps in physicians'
understanding of how to accurately assess pain. Until research sheds
more light on these issues, it will be difficult to design effective
strategies for eliminating racial and ethnic disparities in pain treatment.
From Confrontation
to Collaboration: Collegial Accountability and the Expanding Role of
Pharmacists in the Management of Chronic Pain
David B. Brushwood (626k)
The modern day pharmacist's role is expanding beyond the image of sentry
of the pharmaceutical supply, filling prescriptions with accuracy and
appropriateness, to the duty of caring for patients through their course
of treatment in collaboration with physicians. This team approach will
strongly benefit patients in chronic pain who use medications frequently
and need to know that both the physician and the pharmacist are clear
and aware of their particular treatment plan.
While traditional care often pits pharmacist against physician — particularly
in the prescribing and dispensing of controlled substances such as morphine — a
new age of "pharmaceutical care" encourages the use of a simple written
contract between physician and pharmacist to solve conflicts, while creating
joint responsibility for patients. Empirical evidence supports this type
of collaboration as an effective way to improve therapeutic outcomes,
reduce health-care costs, and relieve human suffering. Indeed, pharmacists
are already managing medications for diabetes, asthma, hyperlipidemia,
and anticoagulation therapy.
The author concludes that a written contract and a form of care called
collaborative drug therapy management, already in practice in many states,
would be particularly beneficial for the management of chronic pain.
However, authorized collaborative practices that include management of
chronic pain are not widespread. The author suggests that new collaboration
between doctor and pharmacist could benefit patients in pain who have
traditionally been undertreated or not treated for their pain at all.
New federal and state regulations have catalyzed the expanding responsibilities
of pharmacists in patient care. Pharmacists' legal responsibilities have
been expanding since 1990, when most states implemented a federal standard
contained in the Omnibus Budget Reconciliation Act of 1990. The Act required
pharmacists to screen for drug duplication, drug-drug interactions, incorrect
dosage or duration of drug treatment, allergic reactions, and clinical
abuse/misuse. Once a problem is identified, the pharmacist contacts the
prescribing physician. More recently, most states are authorizing collaborative
drug therapy management so that pharmacists can order and interpret laboratory
tests, modify drug dosage, and initiate new drug therapy under a plan
approved by the patient's physician. To date, these types of collaborations
are found mostly within hospitals and other institutions, but are also
extending into drug stores and other independent practices.
This collaborative effort could have a significant affect on the treatment
of patients who are prescribed controlled substances such as opioids.
Traditionally, physicians and pharmacists have had a confrontational relationship
because of stringent regulatory controls over these substances (policies-on-paper)
and pharmacists' sometimes unjustified fear of disciplinary action (policies-in-practice).
Even today, some pharmacists will not carry particular medications that
are highly valued on the black market. Other pharmacists question the
overuse of opioids by the physicians who prescribe them. Just as physicians
continue their reluctance to prescribe adequate medications for chronic
pain, pharmacists are similarly reluctant to dispense high doses of opioid
medications.
Replacing this relationship of confrontation, a collaborative agreement
would place the responsibility for patient outcomes in the hands of both
physician and pharmacist. Together they would determine the appropriate
pain management therapy for each patient, based on objective clinical
practice guidelines. The pharmacist's written consult (and explanation
of it later, should there be a challenge presented to the therapy) would
reinforce the validity of the physician's choice of aggressive pain management.
Pain management is an area of specialization that is ripe for this physician-pharmacist
collaboration, with the patient as the beneficiary. State regulations
will need to be adopted to address pain management through collaborative
arrangements. Federal and state regulators will then be in a position
to recognize a "safe harbor" for those medial practices that authorize
the use of large quantities of abusable drugs, but do so only within
a collaborative relationship based on objective criteria.
Ethics Commentary, Court Decisions, and Advertisements
Currents in Contemporary
Ethics
T. Howard Stone (35k)
In what is clearly an important development related to research integrity
and the protection of human research subjects, the U.S. government has
instituted two new training requirements as a condition of receiving
federal financial support. First, the National Institutes of Health (NIH)
is requiring, as a condition of funding, that key research personnel
involved in human subject research complete education "in the protection
of human subjects." Evidence that key personnel have completed this training
must be provided in NIH grant applications or contract proposals.
The NIH education policy will eventually be superseded by a more broadly
applicable instructional policy for the "responsible conduct of research," which
will be promulgated by the Department of Health and Human Service's Office
of Research Integrity and the Public Health Service (PHS). The instructional
policy will apply to all persons engaged in any research or research
training with PHS support. Presently, the only version of the policy
is in draft form. The final version of the policy was, according to schedule,
announced in November 2000, following a period of public comment on the
draft version. However, the newly installed Bush administration suspended
the final version in February, responding to criticisms that the public
comment period wasn't widely known and the final version of the policy
didn't respond to the few comments that were made. A review and public
comment period is now underway, with a final version of the policy anticipated
shortly.
Heightened concern over research integrity and human subject protection — as
well as the related public policy response of requiring PHS-supported
researchers to undergo responsible research training — is a welcome
development that is long overdue. In 1998, several well-publicized reports
and congressional testimony were released indicating, in part, that researchers
and those who were responsible for research review and oversight were
inadequately trained on matters pertaining to research integrity or human
subject protection. A follow-up report that was recently published found
that extremely little has been done to correct these and other deficiencies.
The new training requirements, coming well over two years since the findings
of deficiencies, are a belated attempt to address a deceptively simple
problem: educating researchers and those responsible for research oversight
about research integrity and protecting human subjects. As is common
with many of the federal regulations pertaining to research, however,
both the interim NIH education policy and the PHS draft policy appear
too ambiguous and ambivalent to solve this problem. A review of the two
policies indicates that much more should be done to improve the substantive
training requirements and enhance this important development in our nation's
research enterprise.
Recent Developments in Health
Law (78k)
American Journal of Law & Medicine
Harvard Law & Health Care Society
The student authors examine recent developments in antitrust, bioethics,
the Emergency Medical Treatment and Labor Act, evidence, insurance, malpractice,
medical practice, pharmaceuticals, and research guidelines.
