Pain management in the acute and long-term care facility faces many boundaries: provider bias

and ignorance, insurance companies, and its' own subjective nature. McCaffery states, "Pain is whatever
the experiencing person says it is, existing whenever the experiencing person says it does." The ethical
obligation to appropriately treat pain does not cease to exist simply because it is subjective.
Pain begins and ends with the person experiencing it. Pain is both a stressor on the body and a
sign of other stressors regardless of its initial etiology. Several factors affect how a person perceives and
responds to pain making each person's pain unique to them. The complication of undertreated pain,
however, is a universal experience. "The potential for depression and anxiety often occurs with
mismanaged pain." (Glowacki, 2015, p. 34). For true management of pain, the patient must be allowed
full autonomy and information to make decisions about their care.
The bias and ignorance of health care providers play a major role in the mismanagement of pain.
Per Glowacki (2015, p. 37) only 80-90% of physicians have formal training in prescribing controlled
substances due, partially, to the fact that only 5 of the 133 medical schools in the US have required
courses on pain management. She goes on to say (2015, p. 37) that there are only 1672 registered nurses
were certified in pain relief. This may be why many providers withhold pain medication due to concerns
for patient safety and the perceived dangerous side effects of the medication. Biases plays a well
documented role in pain management and is why "Persons in minority groups have been shown to receive
less pain medication than their white counterparts in emergency rooms, post-operatively, and in labor."
(Bernhofer, 2012, p. 2)
Another player in the undertreatment of pain is insurance companies. Insurance companies
operate from a business model that is vastly different from the ethical model that health care professionals
are sworn to. "Instead, these companies tend to perceive pain as a financial perturbation and inadequately
treat it in the cheapest possible manner." (Schatman, 2011, p. 417) ). Health insurance companies use a
system of refusal to reimburse clinicians, claim denial, and requiring preauthorizations, to delay treating
pain despite current evidence that a delay for as little as two weeks greatly increases the chance of longterm chronic disability.
There are many options for appropriate, evidence-based, pain management. The first we should
consider is to education for the patient, the provider and the insurance companies. Educating patients in
regards to their condition, the etiology of their pain and their pain management options allows them to
practice full autonomy over their condition. When given proper pain education surgical patients required
less narcotics and were discharged sooner than patients that did not have pain education. (Glowacki,
2015, p.35) Acute care patients that were provided with PCA had more effective analgesia (Bernhofer,
2012, p. 1) Insurance companies often deny claims for an interdisciplinary approach to chronic pain
preferring to reimburse long-term opiod use. Schatman states that this is due to a lack of understanding
about the efficacy of non-opiod treatments for pain such as physical or cognitive behavior therapy.
(Schatman, 2011, p.417) An optimal fix for this lack of education would be to employ physicians who
are experienced in pain management to write policies for treatment.
Health care providers need to become more comfortable giving opiods for pain and more
experienced in the multimodal approach to pain management. Adjuvant pharmacological therapies have
proven to work best when used synergistically with an opiod and this is a practice that primary care
physicians, internalists and hospitalists as well as nursing professionals need to become familiar with to

effectively manage pain. Mercy Hospital in Buffalo trialed an interdisciplinary team of a clinical nurse
specialist, the nurse manager, a pharmacist and a primary registered nurse that did daily pain rounds on
the patients on two of their med-surg floors. The daily pain rounds, as well as patient education, improved
patient outcome, patient satisfaction and pain management. (Glowacki,, 2012, p. 38-39)
The bias that health care providers have, whether subconscious or conscious, can be addressed by
asking the four questions that Bernhofer posits: Are the patientss preferences in pain treatment
(autonomy) given the highest priority? Does the patient benefit (beneficence) from my pain treatment
decisions? What can I do to decrease harm (nonmalficence) when deciding on a pain treatment regimen?
Did I do my best to protect the most vulnerable patient, treating his /her pain in the best possible way with
respect and without discrimination?
While it is unlikely that every patient can be free of pain, pain should be treated like other
medical conditions. Hypertension in one patient can be controlled with a beta blocker but another patient
requires a beta blocker, a diuretic and an ace inhibitor. Asthmatics arent accused of being drug seekers. A
band-aid does not fix all hemorrhaging. The health care industry, knowing the physiological and
psychological toll that pain has a person, has an ethical obligation to treat pain as aggressively as it treats
every other condition and the first step in doing so is education about how to treat pain.