The Medical and Medicolegal Implications of the Undertreatment of Pain

Pain is the commonest reason for a patient to visit their doctor, with around 25% of adults suffering from chronic pain at any one time, a figure that rises to around 50% in the over-65s. Advances in our understanding of pain have allowed the diagnosis and treatment of conditions that were previously ignored, such as fibromyalgia. However, inadequate pain management can still be found in many different clinical settings, including terminal illness, cancer, emergency care, post-operatively and in connection with chronic pain conditions. This lack of treatment occurs for many reasons but the consequences for the patient can be far-reaching. 

Many doctors place great faith in objective tests and measurements. Pain is a very subjective experience, which varies from patient to patient, and this does not fit in well with the traditional scientific approach to health and disease. Therefore, pain is often viewed as a less important issue than a physical symptom, such as an abnormal scan or a high temperature. This often leads to pain management being given less importance in treatment plans than other concerns, such as prolonging life and restoring good health. Furthermore, some pain conditions have no obvious cause, so some healthcare providers have a tendency to dismiss such conditions as the result of psychological distress or deliberate deceit. However, a causal basis should not be a requirement for acceptance of the reality of a condition: for many years, the causes of epilepsy were not understood but the condition was still recognised. 

For many cases of moderate to severe pain, opioid drugs are the first-line treatment. However, worries about abuse and addiction often shape policies on their prescription. These have increased since instances of OxyContin misuse became common in the USA. Many doctors are also concerned about the development of tolerance to opioids, which they fear may lead to dose escalation and dependence. Side-effects, such as constipation, may also be a concern. Well-publicised prosecutions of doctors for inappropriate opioid prescription have resulted in the misconception that such cases are common, when this is not actually true. It has also led healthcare professionals to face legal and regulatory pressures to restrict the use of some drugs, particularly opioids, in the treatment of pain. This has resulted in inconsistencies between educational efforts to encourage the appropriate prescribing of pain medications and the threat of prosecution for those who do so. 

Patient factors also have an important role to play in the undertreatment of pain. Concerns about the probable or possible side-effects of medication can decrease adherence to treatment plans. Some patients may also be reluctant to admit that their pain is getting worse, as they fear a life-changing diagnosis or deterioration in their condition. 

Undertreatment of pain, especially in chronic conditions, can lead to patient suffering. Inadequately treated pain after surgery increases the heart rate and systemic vascular resistance and increases the patient’s risk of myocardial ischemia, stroke, bleeding and other complications. Untreated acute pain may lead to neuronal alterations, such as central sensitisation, with the pain eventually becoming chronic. Chronic pain is associated with numerous negative effects. It can interfere with daily activities, impair sleep, limit the patient’s ability to work and enjoy social relationships, and lead to psychological symptoms, such as anxiety, depression, or anger. Chronic pain also places a great burden, which is often hidden, onto caregivers, and this can be both economic and emotional. Untreated pain may also infringe the autonomy of patients in determining their own care.

Therefore, inadequate treatment of pain may actually constitute negligence on the part of the doctor. Failure to document a patient’s history of pain, to consider all treatment options, or to consult a pain expert for intractable cases may leave a practitioner open to accusations of not taking reasonable care and could lead to litigation. An increasing number of statutory bodies agree with this view, although where the boundaries of reasonable behaviour currently lie is not always obvious. As cases are decided, the picture should become clearer.  

The development of tools to assess pain objectively would improve its management, although it will always remain a subjective experience. Adopting a multi-disciplinary approach to pain treatment is more likely to result in a successful outcome, but this may require considerable education and patient compliance, which may be difficult to achieve. Statutory regulations that protect doctors from liability after administering pain relief, provided that treatment is given with the consent of the patient and with the intention of relieving pain and not shortening the patient’s life, would also help to remove barriers to effective pain management. 

As medical developments have provided better methods of controlling pain, so attitudes to it have changed, to the extent that some organisations now regard pain as the ‘fifth vital sign’. Undertreatment of pain is now viewed as unethical and patients are less prepared to accept untreated pain. Often, if a condition cannot be cured, pain may be the only aspect of it that can be effectively managed. However, better treatment of pain will require changes to medical philosophy and education, as well as new legislation. 

Further reading:

Brennan, F., Carr, D.B., Cousins, M. Pain management: A fundamental human right. Anesthesia and Analgesia 105, 205-221 (2007). https://doi.org/10.1213/01.ane.0000268145.52345.55

Resnik, D.B., Rehm, M. The undertreatment of pain: Scientific, clinical, cultural, and philosophical factors. Med Health Care Philos 4, 277–288 (2001). https://doi.org/10.1023/A:1012057403159