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Substantial material added to address the current social, political, economic, and ethical perspectives related to pain management and prescription drug abuse, including impact on prescribers and patients. Bibliography expanded and updated.

Updated on 2 December 2013. The previous version of this content can be found here.
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Pain

Abstract and Keywords

Pain is a multidimensional, subjective experience that embodies the complex relationship of body, mind, emotions, and spirit. Assessment begins with the patient’s report and is enhanced by diagnostic tools, skilled inquiry and observation of behavioral, physical, cognitive and emotional responses. Pain may be acute, chronic, intermittent, or persistent and can be related to a chronic condition or progressive life-threatening illness—all of which may lead to significant psychological, spiritual, functional, and socioeconomic consequences. The undertreatment of pain is well documented and ubiquitous, especially in vulnerable populations, including the elderly, infants and children, and ethnic minorities. Inadequate management of pain has been the focus of national and international research and policy and relates to many variables, including the controversy and concerns about the use of opioids which are classified as controlled substances. This classification creates a unique environment of legislative, regulatory, and law enforcement scrutiny most recently exacerbated by the public health focus on the abuse of prescription medications. Pain is a clinical, ethical, policy, and advocacy issue. Advocating for state of the art pain management is a shared responsibility of professionals whose ethical codes include social justice, beneficence, and commitment to vulnerable populations.

Keywords: pain, acute, chronic, suffering, delegitimization, undertreatment, public policy, addiction, vulnerable populations, opioids

Definitions

The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience associated with tissue damage or described in terms of such damage (IASP, 1994). Pain may be acute or chronic, persistent and or intermittent, and can be related to a chronic condition or progressive life-threatening illness. Suffering has been defined by Eric Cassell (1991) as an actual or perceived impending threat to the integrity or continued existence of the whole person. Suffering may or may not include physical pain yet both can be intimately intertwined with psychological, spiritual, functional, and socioeconomic aspects of a person’s experience.

Acute pain may be related to injury, a surgical procedure, inflammation, or an unknown cause and generally disappears within an expected period of time as healing occurs. Usually with sudden onset, there are often, but not always, objective physical signs such as hypertension and tachycardia. Chronic pain persists beyond the expected healing time and may last indefinitely, be constant, or intermittent. Examples include pain related to such diseases as arthritis, stroke, diabetes, HIV, or cancer, in which the pain may be associated with the disease or consequent to treatments. Chronic pain may be preceded by an initial injury such as a sprain or be related to an ongoing condition such as arthritis. In some cases, there is no discernible cause or evidence of injury. Rarely associated with signs of nervous system arousal, persons living in chronic pain may not appear to be in pain thus leading inexperienced clinicians and significant others to challenge the credibility of patient reports.

The experience of pain is universal. Under normal conditions pain is a biological warning signal alerting us that something is wrong within the body or that we should cease a hurtful, potentially harmful activity. If one is born without the ability to feel pain, that individual is at high risk of injury and death as they have no signal to alert them to potential damage to their bodies. Clinicians seek to diagnose the underlying physical conditions that cause pain and intervene medically, surgically, and/or pharmacologically. In many instances, organic causes cannot be found with current diagnostic tools, and this lack of concrete data serves as a frustration to clinicians and patients. This is not evidence however that the reported pain is psychological in origin. This inability to discover etiology can create a treatment environment in which the patient and their report of pain are delegitimized and patient credibility is challenged (Ware, 1992).

Pain as an International Human Rights Concern

Pain, as opposed to any other symptom, draws the attention of ethicists, governments, clinicians, and policy experts. Mainstay pharmacologic management of pain involves the use of opioids, referred to as “narcotics” by law enforcement agencies. As with many medications, opioids are potentially abusable. National and international groups have come together in initiatives designed to respond to the challenge of balancing law enforcement concerns with the ethical mandate to treat pain and to diminish the further stigmatization of a class of medications that are essential to effective management. The 2010 World Cancer Leaders Summit held in Shenzhen, China, included the participation of over 170 leaders from the health, government, philanthropic, and corporate sectors. Highlights of the 2010 Summit included the launch of the Global Access to Pain Relief (GAPRI), an initiative focused on furthering target 8 of the World Cancer Declaration, which sets a goal of universal availability of effective pain control. The Human Rights Watch (2011) Report, Global State of Pain Treatment, Access to Medicines and Palliative Care estimates that 1.2 million people die in Sub-Saharan from cancer or HIV/AIDS without adequate pain treatment each year. The World Health Organization (2012) estimates that 6 million people die from cancer each year without sufficient analgesia or often without any treatment of their pain. About half of all end stage AIDS patients suffer from severe pain. Additionally, there are many people with untreated severe pain from injuries (for example, car accidents, victims of war), myocardial infarction, and other chronic conditions.

In 2010, the International Association for the Study of Pain brought together representatives from their chapters in 64 countries, as well as members from 129 countries to cohere around the issue of unrelieved pain in the world. The Declaration of Montreal furthered a historical discussion related to pain relief as a fundamental human right. The Declaration asserts that pain management is inadequate in most of the world. Recognizing the intrinsic dignity of all persons, they concluded that withholding of pain treatment is profoundly wrong and leads to unnecessary, harmful suffering. The following human rights were delineated:

  • Access to

    • pain management without discrimination

    • acknowledgement of pain and information about how it might be assessed and managed

    • appropriate assessment and treatment by adequately trained professionals

Consequent to these rights are obligations that relate to governments and health care professionals including but not limited to advocacy, competence, and fidelity (IASP, 2010).

The United States Experience: The Conundrum of Pain

Institutional Expectations

In the United States there have been various initiatives designed to meet the challenge of the undertreatment of pain in all populations. Examples include the work of the Joint Commission, an independent, not-for-profit organization that accredits and certifies more than 19,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. In January, 2001, the following pain management standards went into effect for Joint Commission accredited ambulatory care facilities, behavioral health care organizations, critical access hospitals, home care providers, hospitals, office-based surgery practices, and long-term care providers. The standards require organizations to:

  • recognize the right of patients to appropriate assessment and management of pain

  • screen patients for pain during their initial assessment and, when clinically required, during ongoing, periodic reassessments

  • educate patients and their families about pain management.

Included in these standards was the American Pain Society concept of pain as a fifth vital sign (American Pain Society, 1995).

Further pressure for institutional responsiveness came in 2006 when the Centers for Medicare and Medicaid Services began reporting Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, which includes a targeted question about patients’ satisfaction with pain management. The pressures created by this question will increase as the HCAHPS scores become a tool for the federal government to determine incentive payments under the Medicare Hospital Value-Based Purchasing program. At the same time that pain management has become a standard for institutions and practitioners, clinical practice guidelines have evolved to inform practice.

In 2002 and later in 2009 the American Geriatrics Society published Clinical Practice Guidelines—Pharmacological Management of Persistent Pain in Older Persons. The American Pain Society and the American Academy of Pain Medicine (2009) published a clinical practice reference Guideline for the Use of Chronic Opioid Therapy in Chronic Non-cancer Pain, following an extensive evidence review. While the pain care environment has been establishing standards and guidelines for the humane and competent care of persons in pain, there has simultaneously been an evolving public health issue related to the abuse of prescription medications.

Prevalence of Pain Across Age, Gender, Race, and Socioeconomics

The Institute of Medicine Committee (2011), Relieving Pain in America, explores the consequence of pain and suffering reported by 100 million Americans. In addition to the health care costs, which are estimated to be 261–300 billion dollars, there is an additional estimate of 297–336 billion dollars due to lost productivity. While compelling, these statistics do not capture the psychological and social impact on families as they seek to adapt and respond to changing family structures, stressed finances and the many losses implicit in chronic and uncertain illness experiences.

The undertreatment of pain is well documented and poses both a public policy and an ethical challenge. Studies indicate that women, elders, infants and children, those who speak a language different from their clinician, the poor, and other vulnerable populations, including those with psychiatric illness or the disease of addiction, are at increased risk of undertreated pain (Anderson et al., 2000; Bonham, 2001; Green et al., 2003; Green & Hart-Johnson, 2010; Heins et al., 2006; Herr & Garand, 2001; Hoffman & Tarzian, 2001; Lasch, 2002; LeResche, 2011; Reyes-Gibby, Aday, Todd, Cleeland, & Anderson, 2007). A prospective observational study as recent as 2012, involved 3,023 patients with breast, colorectal, lung, or prostate cancer. At initial assessment 2,026 (67%) reported having pain or requiring analgesics. 670 (33%) were receiving inadequate analgesia. Predictors of inadequate analgesia included minority status, a good performance status, receiving treatment at a minority treatment site, and having non-advanced cancer without concurrent treatment (Fisch et al., 2012).

A study by Green et al. (2003) reported that pain complaints of ethnically diverse populations were handled less aggressively by physicians. Disparities were reflected in perception of pain, assessment and treatment across settings. Reasons for disparities are complex, involving many factors such as patient or provider communication, attitudes, physician and patient decision making, as well as systems issues such as the lack of access to experts, to medication, and to the multidimensional treatments that are the essence of comprehensive pain management. Racial and ethnic differences between doctor and patient affect communication on both sides. Consequent to the initiatives in the 1990s, prescribing for patients coming to the emergency department increased, but differences in opioid prescribing by race and ethnicity did not diminish (Pletcher, Kertesz, Kohn, & Gonzales, 2008). A study published in 2010 of pain management in the emergency department added additional richness to this conversation. The authors investigated the association between effectiveness of pain management and the race of patients and providers. While nonwhite patients arrived with significantly higher pain scores, they were less likely to receive opioids in the emergency department. Nonwhite physicians were more likely to achieve clinically significant reductions in reported pain scores. Of further interest was the finding, as opposed to previous studies, that ethnic concordance between patient and physician did not predict this primary outcome (Heins, Homel, Safdar, & Todd, 2010).

The data surrounding ethnic, racial and socio-economic disparities in the management of pain are compelling and profoundly troubling, infused with ethical, moral, and public policy challenges. Equally compelling is the inquiry related to undertreatment of pain related to gender that goes beyond social, cultural, and emotional factors to consider gender associated differences in the pharmacodynamics and pharmacokinetics of opioid responsiveness. Gender has been associated with differences in pain prevalence, perception, coping, and pain reporting. Beginning in the 1980s researchers noted gender differences. For example, Faherty and Grier (1984) studied the administration of pain medication after abdominal surgery and found that physicians prescribed less pain medication for women than for men ages 55 or older. Additionally nurses administered less pain medication to women than to men ages 25–54 years. In 1994, a study of 1,308 outpatients found that women with metastatic cancer were significantly more likely than men with the same diagnosis to receive inadequate pain medications (Cleeland et al., 1994). Pain reports in woman are often discounted as psychogenic or emotional, thereby delegitimizing the report as well as the patient (Hoffman & Tarzian, 2001; LeResche, 2011; Ware, 1992).

According to the Department of Health and Human Services Report, the following self-reported data captured from a National Health Interview Survey (2009) in the United States provide some additional perspectives on the relationship of race and ethnicity, age, gender, culture and pain.

  • Women were twice as likely to experience migraines or severe headaches or pain in the jaw or face than men.

  • The percentage of persons experiencing migraines or severe headaches was inversely related to age. Twenty percent of adults aged 18–44 years experienced a migraine or severe headache in the 3 months prior to the interview compared with 15 percent of adults aged 45–64, 7 percent of adults aged 65–74, and 6 percent of adults aged 75 and over.

  • Adults aged 18–44 years were less likely to have experienced pain in the lower back during the 3 months prior to the interview compared with older adults. When results are considered by single race without regard to ethnicity, Asian adults were less likely to have pain in the lower back compared to white adults, black adults, and American Indian, or Alaska Native (AIAN) adults.

  • Adults with a bachelor’s degree or higher were less likely to have migraine headaches, neck pain, lower back pain, or pain in the face or jaw, compared to adults who did not graduate from high school.

  • Adults in poor and near poor families were more likely to experience migraine headaches, neck pain, lower back pain, or pain in the face or jaw in the 3 months before the interview than were adults in families that were not poor.

Prescription Drug Abuse: Public Health, Political, and Economic Context

While many have asserted the undertreatment of pain as a public health issue, this discussion is now juxtaposed with a public health issue that involves the abuse of prescription medications, many of which are mainstay medications for the treatment of pain. Opioids have long been the focus of regulatory and law enforcement agencies. Opioids can be effective in treating many pain conditions. When used for acute pain they have been shown to diminish the sensory aspect of pain and ameliorate associated emotional distress. Some documented adverse effects are the potential for drowsiness, mental confusion or cloudiness, constipation, nausea, and respiratory depression with overdose. Opioids are potentially abusable drugs and some patients will misuse them, engage in more serious abuse, and a small proportion have the potential to develop a true addiction with craving, compulsive use, loss of control, and use despite harm. Short-term use that is medically managed properly rarely leads to addiction. Longer term use can lead to physical dependence, which means that patients may experience withdrawal symptoms if they suddenly reduce or stop taking their medications. Physical dependence on opioids is expected and the effects are not apparent unless the drug dose is lowered suddenly or an antagonist drug is given that should be avoided. When taken improperly, such as even a single large dose, opioid use may lead to respiratory depression and death.

The practice of clinicians who prescribe controlled substances can be the focus of law enforcement agencies such as the Drug Enforcement Agency (DEA) or boards such as the Office of Professional Medical Conduct (OPMC) who are responsible for investigating and adjudicating complaints against physicians, physician assistants, and specialist assistants. At times, prescribing behaviors become the center of malpractice cases and criminal litigation stemming from both the undertreatment of pain and from situations where prescribers are charged with criminal offenses when medications are implicated either in diversion or a patient’s death. Regardless of the eventual outcome of these actions and the guilt or innocence of these prescribers, these litigations have a profound impact on both attitudes of clinicians and their prescribing practices which is often referred to as the “chilling effect.”

Concerns related to substance abuse and addictions infuse the treatment environment in which clinicians, patients, and families interface. Research, education, and expert analysis of data are essential to replace myths and misconceptions and to foster the skills necessary to both assess and treat pain and to recognize and secure treatment when there is evidence of abuse. In addition to the safety concerns for those who abuse, the economic costs related to lost productivity, medical care, and criminal justice processes consequent to the abuse of prescription medications add considerably to the financial impact delineated in The Institute of Medicine Committee (2011), Relieving Pain in America (Birnbaum et al., 2011; Strassels, 2009).

According to the National Institute on Drug Abuse (NIDA, 2011), prescription drug abuse is defined as the “use of a medication without a prescription, in a way other than as prescribed, or for the experience or feelings elicited.” Multiple national reports and statistics reveal that non-medical use of prescription medications is a growing trend in the United States, leading to an increase in death overdose and substance abuse treatment needs for those who develop an addiction (Centers for Disease Control and Prevention [CDC], 2011; NIDA, 2011; Substance Abuse and Mental Health Services Administration [SAMHSA] 2011). The following data have energized institutions and health care professionals to propose and assert solutions to stem the rise of prescription drug abuse. The challenge is to include balanced and thoughtful analysis before policies are enacted to insure that the care of persons who live with pain is not compromised medically or ethically.

The SAMHSA 2010 National Survey on Drug Use and Health found

  • In 2010, non-medical use of prescription drugs among youths (12–17) and young adults (18–25) was the second most prevalent illicit drug use category, behind marijuana, and pain relievers are the most commonly misused.

  • A high majority of people who use prescription drugs non-medically obtain these drugs from a friend or relative, most often for free. These friends or relatives most often obtained the drugs from just one doctor.

  • In 2010, the average age of first non-medical use of pain relievers was 21 years (SAMHSA, 2011).

The CDC document Vital Signs: Overdoses of Prescription Opioid Pain Relievers (CDC, 2011) reports

  • Currently, more overdose deaths are attributed to opioid pain relievers than heroin and cocaine combined.

  • In 2010, about 12 million Americans (age 12 or older) reported non-medical use of prescription pain medications in the past year.

  • Prescription pain medication overdoses caused the death of nearly 15,000 people in the United States in 2008; more than 3 times the 4,000 people who died in 1999.

  • Nearly half a million emergency department visits in 2009 were due to people misusing or abusing prescription pain medications.

The following data, from the CDC, while not well understood, capture differences based in gender, socioeconomics, and ethnicity.

  • More men than women die of overdoses from prescription pain medications.

  • Middle-aged adults have the highest fatal overdose rates.

  • People in rural counties are about two times as likely to overdose on prescription pain medications as people in big cities.

  • Whites and American Indian or Alaska Natives are more likely to overdose on prescription pain medications.

  • About 1 in 10 American Indian or Alaska Natives age 12 or older used prescription pain medications for non-medical reasons in the past year, compared to 1 in 20 whites and 1 in 30 blacks (CDC, 2011).

The Office of National Drug Control Policy (ONDCP) reports

  • From 1998 to 2008, the proportion of all substance abuse treatment admissions age 12 or older who reported any pain reliever abuse increased more than fourfold (SAMSHA, 2010).

  • Department of Defense (2008) survey indicates that one in nine active-duty service members (11 percent) reported past-month prescription drug misuse.

  • Substance abuse treatment admissions for individuals age 50 or older nearly doubled from 1992 to 2008, climbing from 6.6 percent of all admissions to 12.2 percent. The percentage of primary admissions for prescription drug abuse among older individuals increased from 0.7 percent to 3.5 percent over the same time period (SAMSHA, 2009).

Actions and Impacts: Policy and Ethical Challenges

The above statistics are driving initiatives in many venues—medical, legal, regulatory, industry, legislative, and advocacy. At times the word “epidemic” is used to describe the increase in prescription drug abuse. Just as the use of the word “narcotics” colors the attitudes and care of patients who require opioids so does the term epidemic have the potential to create an environment of fear and crises in which actions and reactions may precipitate unintended consequences. For example, the doctor–patient relationship, which has historically been based in confidentiality, trust, and fidelity, is increasingly the focus of government, insurance, and law enforcement. Treatment plans may be adapted, not consequent to the influence of good science, but rather consequent to institutional and agency mandates, insurance policies and in some instances the fear of regulatory or law enforcement scrutiny. As persons in pain seek care, an important ethical question is whether law enforcement and public health is being privileged over the care of patients and the values of medicine. The following are a sampling of actions and reactions that warrant thoughtful consideration and scrutiny as they have the potential to create benefit as well as harm and are infused with clinical and ethical considerations.

  • Prescription Monitoring Programs (PMPs) are currently statewide and collect data on the prescribing and dispensing medications with potential for abuse. The goal of PMPs is to identify patients who may be abusing or receiving medications from many doctors. They may also identify clinicians who might possibly be engaged in inappropriate prescribing. Preliminary research and data seem to suggest that these programs benefit law enforcement and may have an impact on opioid and misuse trends (Reifler et al., 2012). A finding by Wang and Christo (2009) that PMPs decreased the overall sales and supply of prescriptions medications may represent a benefit or harm if patients who would be helped by medication have not received them. Because PMPs do not assess patient outcomes, their impacts on individuals who live with chronic pain go undiscovered. Additionally, providing patient data to a central data base accessible by law enforcement raises question about protecting patient confidentiality and the fidelity implicit in the doctor patient relationship.

  • Risk Evaluation and Mitigation Strategies (REMS) are mandates promulgated by the United States Food and Drug Administration (FDA) designed to reduce risk and improve safe use. In July 2012, the FDA approved a risk evaluation and mitigation strategy (REMS) for extended-release (ER) and long-acting (LA) opioid medication as part of a multi-agency Federal effort to address the growing problem of prescription drug abuse and misuse. These REMS require companies to create training for prescribers, update medication guides and patient counseling documents, and establish a process for assessment and auditing. The intent of REMS is to improve safe use, while providing access for patients in pain. Slevin and Ashburn (2011) found that half of the primary care physicians surveyed would comply with further training and other REMS requirements, but a large group of physicians stated they would not prescribe opioids under the new REMS requirements thus potentially limiting access for patients.

  • Insurance companies influence pain management as they dictate reimbursement rates and often control treatments by limiting doses and requiring prior approvals for medications. While the CDC views their influence as effective in reducing inappropriate prescribing and patients’ attempts to obtain opioid medications from multiple providers, other experts view their role as impeding proper pain treatment and therefore compromising patient care (Schatman, 2012). Insurers are not bound by the same ethical standards as physicians and while they are limiting and controlling access to pharmacology, many insurance companies do not reimburse for multidisciplinary treatments that are essential to state of the art pain management. Thus for many patients pharmacology is the only treatment actually available to them.

The current climate related to prescription drug abuse has created an extremely sensitive environment for physicians and medical teams treating pain. Many practitioners have integrated urine toxicology, treatment agreements, and pill counts into their treatment plan as concurrent research and surveys seek to determine both the effectiveness and the impact of these practices on patient care. While some see these as tools to be used universally to enhance, informed consent, safety, and adherence, others view these strategies as paternalistic, stigmatizing, and symbolic of an implicit message of mistrust and thereby a threat to the integrity of the physician patient relationship (Payne et al., 2010). Prescribers are faced with a conundrum. They are charged with the task of properly and safely treating people in pain, working to maintain a relationship of trust within an environment of practice infused with worry about the risk of abuse and diversion. The legal and regulatory lens through which their prescribing behaviors are viewed combined with efforts to increase patient satisfaction with their pain management creates a complex practice context for clinicians, patients and families.

These combined factors have contributed to providers’ documented discomfort and frustration with the clinical work of managing pain, especially for chronic pain and outside of a palliative or hospice setting. Concerns about regulatory scrutiny are present for many. Additionally providers may be fearful of contributing to abuse and addiction and treating pain in the setting of such complicating factors as co-morbid psychiatric conditions and current or history of substance abuse. Improved physician training, guidelines on treating pain and assessing risks for abuse as well as an interdisciplinary approach that emphasizes comprehensive patient assessments are necessary to create plans of care that meet the multidimensional needs of patients and reinforce the safety of prescribers and patient. Enhanced and ongoing communication between regulators and prescribers may also mitigate some of these fears (Gilson, Maurer, & Joranson, 2007; Keller et al., 2012; Manchikanti, 2007; Olsen & Daumit, 2004; Spitz et al., 2011).

Social Work – Potential Roles and Interventions

Pain has become a focus of specialty medical care, research, and technology; neurochemical and neurologic mechanisms have been identified that point to the synergistic influence of physiology, emotion, cognition, and behavior (Baliki & Apkarian, 2007; Geha et al., 2008). Historically, treatment of pain has been the responsibility of physicians, nurses, and psychologists. As we examine the multidimensional nature of pain and the current policy challenges, it is clear that social work’s commitment to advocacy, vulnerable populations and to relieving suffering places pain clearly within the province of the profession’s role and responsibility. The current political and policy concerns create an environment in which social work clinicians have no choice but to integrate learning about pain, its treatment, and the differences between competent and effective pain management, abuse, and addiction. The abuse of prescription medications has raised pain to the level of national dialogue in communities, government, and medical settings, and this dialogue is infused with ethical questions.

A bio-psychosocial spiritual approach has evolved to reflect the complex interface of sensory, affective, behavioral, social, economic, spiritual, and cognitive factors often embodied in pain whether chronic or related to life-threatening illness (Turk, Monarch, & Williams, 2002). Culture infuses many aspects of the pain experience and factors such as gender, genetics, age, socioeconomic class, and race have been identified as variables that can influence the expression of pain, access to care, and response to medications (Anderson et al., 2000; Anderson, Green, & Payne, 2009; Bonham, 2001; Green & Hart-Johnson, 2010; Hoffman & Tarzian, 2001; Lasch, 2002; LeResche, 2011). Consequently each of these aspects becomes a focus of inquiry, understanding and potential intervention. Pain management is a clinical area that invites social work participation in advocacy, public policy and clinical work.

Assessment of the subjective nature of pain begins with the person’s report which is complemented by diagnostic studies, observed or described behaviors, coping styles, and function. There are numerous pain intensity scales and assessment tools that can be adjusted to age, language, and cognitive ability and are useful for documenting outcome of treatments (http://prc.coh.org/pain_assessment.asp). There are functional and psychological tests that can enhance understanding of the multiple dimensions of pain and its effect on self-image, function, mood, and family relationships. Associations between pain, anxiety, depression, psychiatric vulnerability, stress, and trauma mandate comprehensive assessment to identify the multidimensional variables that influence the pain experience for both the patient and the family, responses of clinicians, and ultimately inform appropriate interventions. Multidimensional pain management may include medications, surgical approaches, biofeedback, rehabilitation, integrative therapies, family education and counseling, and psychosocial and cognitive-behavioral interventions. This combined approach is designed to impact the relationship of body, mind, and spirit and reflects recognition that pain and suffering often require an acknowledgement and integration of loss and a deliberate focus on restoring or creating new sources of meaning.

Pain is often accompanied by job loss, change in social and family role, disturbance in routine activities of daily living, limits on activities and sleep disruption (Karoly & Ruehlman, 2007). Social workers can help to identify resources, remove or address barriers to care, and teach skills to mediate the effects of these life changes. Social workers can apply their expertise in assessing an individual’s history, culture, learned beliefs, and coping styles and strategies to help people in pain learn how to redefine their self-concept within the context of their individual cultures and with the goal of continued engagement in life. There is empirical evidence that people who believe they can maintain control and function despite a chronic pain condition experience less depression, enhanced function, and integration in life tasks. Skilled social work clinicians can address maladaptive pain beliefs such as catastrophizing through cognitive and educational interventions, and assist patients through individual or group interventions to reduce fear-based avoidance, enhance control, and adopt a more accepting outlook, which has been associated with less pain, disability, depression, pain-related anxiety, and better work status (Gatchel, Peng, Peters, Fuchs, Turk, 2007; Jensen, Turner, & Romano, 2001; Karoly & Ruehlman, 2007; McCracken & Eccleston, 2003; McCracken, Vowles, & Gauntlett-Gilbert, 2007; West, Stewart, Foster, & Usher, 2012).

Social work interventions may be family focused. The literature indicates that many patients and their families fear addiction to pain medications, and this fear has been exacerbated by the increase in prescription medication abuse. (Katz & Barkin, 2008; Rhiner & von Gunten, 2010; Simone, Vapiwala, Hampshire, & Metz, 2008). Psycho-education and risk assessment of medication abuse or misuse are essential skills to assist colleagues, patients and families to replace fears with clinical data and a treatment plan designed to enhance benefit and minimize harm. Patients who suffer in pain and are identified as being at increased risk of inappropriate use of opioid mediations require skilled assessment and interventions. For these patients, when a trial of opioid treatment is deemed appropriate, a structured care plan to insure safety is essential and might include engaging the patient’s support system and treatment protocols involving opioid screening tools, urine toxicology and formal patient physician agreements within a setting of open and direct communication (Chou et al., 2009; Miotto, Kaufman, Kong, Jun, & Schwartz, 2012; Sehgal, Manchikanti, & Smith, 2012).

Chronic pain can have a profound impact on the family system, including shifts in roles, altered communication patterns, increased stress and financial burden, and impact on sexuality and intimate relationships. Working clinically within the larger family system or individually, social workers can create a safe space to explore the sensitive and personal topics that may influence family dynamics and patients’ experiences of pain such as sexuality and spirituality, validating their essential importance in the lives of patients and families.

A small number of social workers have expertise in this specialty area. The subjective nature and multidimensional aspects implicit in the pain experience reflect the basic social work values of “starting where the client is” and a “person in environment approach.” This synergism invites social work participation in this rich and challenging field. Clinicians, researchers, educators, and policy advocates have expertise, both as generalist and specialist practitioners, to improve the care of persons with pain whether through direct treatment or enhancing the political, socioeconomic, cultural, and ethical environment in which treatment is provided.

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                            Geha, P. Y., Baliki, M. N., Harden, R. N., Bauer, W. R., Parrish, T. B., & Apkarian, A. V. (2008). The brain in chronic CRPS pain: Abnormal gray-white matter interactions in emotional and autonomic regions. Neuron, 60(4), 570–581.Find this resource:

                              Gilson, A. M., Maurer, M. A., & Joranson, D. E. (2007). State medical board members’ beliefs about pain, addiction, and diversion and abuse: A changing regulatory environment. Journal of Pain 8(9), 682–691.Find this resource:

                                Green, C. R., Anderson, K. O., Baker, T. A., Campbell, L. C., Decker, S., Fillingim, R. B., et al. (2003). The unequal burden of pain: Confronting racial and ethnic disparities in pain. Pain Medicine, 4(3), 277–294.Find this resource:

                                  Green, C. R., & Hart-Johnson, T. (2010). The adequacy of chronic pain management prior to presenting at a tertiary care pain center: The role of patient socio-demographic characteristics. Journal of Pain, 11(8), 746–754.Find this resource:

                                    Heins, J. K., Heins, A., Grammas, M., Costello, M., Huang, K., & Mishra, S. (2006). Disparities in analgesia and opioid prescribing practices for patients with musculoskeletal pain in the emergency department. Journal of Emergency Nursing, 32(3), 219–224.Find this resource:

                                      Heins, A., Homel, P., Safdar, B., & Todd, K. (2010). Physician race/ethnicity predicts successful emergency department analgesia. Journal of Pain, 11(7), 692–697.Find this resource:

                                        Herr, K. A., & Garand, L. (2001). Assessment and measurement of pain in older adults. Clinics in Geriatric Medicine, 17, 457–478.Find this resource:

                                          Hoffman, D. E., & Tarzian, A. J. (2001). The girl who cried pain: A bias against women in the treatment of pain. Journal of Law, Medicine & Ethics, 29, 13–27.Find this resource:

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                                            Institute of Medicine Committee on Advancing Pain Research, Care, and Education. (2011). Relieving pain in American: A blueprint for transforming prevention, care, education, and research. Washington, DC: The National Academies Press.Find this resource:

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                                                International Association for the Study of Pain (IASP). (2002). Culture and pain. Pain: Clinical Updates, 10(5). Retrieved from http://www.iasp-pain.org/AM/AMTemplate.cfm?Section=Home&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=7578&SECTION=HomeFind this resource:

                                                  International Association for the Study of Pain (IASP). (2010). Declaration of Montreal. Access to pain management. Retrieved from http://www.iasp-pain.org/PainSummit/DeclarationOfMontreal.pdf

                                                  Jensen, M. P., Turner, J. A., & Romano, J. M. (2001). Changes in beliefs, catastrophizing, and coping are associated with improvement in multidisciplinary pain treatment. Journal of Consulting and Clinical Psychology, 69(4), 655–662.Find this resource:

                                                    Karoly, P., & Ruehlman, L. S. (2007). Psychosocial aspects of pain-related life task interference: An exploratory analysis in a general population sample. Pain Medicine, 8(7), 563–572.Find this resource:

                                                      Katz, W. A., & Barkin, R. L. (2008). Dilemmas in chronic/persistent pain management. American Journal of Therapeutics, 15(3), 256–264.Find this resource:

                                                        Keller, C. E., Ashrafioun, L., Neumann, A. M., Van Klein, J., Fox, C. H., & Blondell, R. D. (2012). Practices, perceptions, and concerns of primary care physicians about opioid dependence associated with the treatment of chronic pain. Substance Abuse, 33(2), 108–113.Find this resource:

                                                          Lasch, K. E. (2002). Culture and pain. International Association for the Study of Pain. Pain: Clinical Updates, X(5). Retrieved from http://www.iasp-pain.org/AM/AMTemplate.cfm?Section=Home&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=7578&SECTION=HomeFind this resource:

                                                            LeResche, L. (2011). Defining gender disparities in pain management. Clinical Orthopaedics and Related Research, 469(7), 1871–1877.Find this resource:

                                                              Manchikanti, L. (2007). National drug control policy and prescription drug abuse: Facts and fallacies. Pain Physician, 10(3), 399–424.Find this resource:

                                                                McCracken, L. M., & Eccleston, C. (2003). Coping or acceptance: What to do about chronic pain? Pain, 105(1–2), 197–204.Find this resource:

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                                                                      Pletcher, M. J., Kertesz, S. G., Kohn, M. A., & Gonzales, R. (2008). Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. Journal of the American Medical Association, 299(1), 70–78.Find this resource:

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                                                                        Olsen, Y., & Daumit, G. L. (2004). Opioid prescribing for chronic nonmalignant pain in primary care: Challenges and solutions. Advances in Psychosomatic Medicine, 25, 138–150.Find this resource:

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                                                                            Reifler, L. M., Droz, D., Bailey, J. E., Schnoll, S. H., Fant, R., Dart, R. C., et al. (2012). Do prescription monitoring programs impact state trends in opioid abuse/misuse? Pain Medicine, 13(3), 434–442.Find this resource:

                                                                              Reyes-Gibby, C. C., Aday, L. A., Todd, K. H., Cleeland, C. S., & Anderson, K. O. (2007). Pain in aging community-dwelling adults in the United States: Non-Hispanic whites, non-Hispanic blacks, and Hispanics. Journal of Pain, 8(1), 75–84.Find this resource:

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                                                                                  Schatman, M. E. (2012). The role of the health insurance industry in perpetuating suboptimal pain management. Pain Medicine, 12(3), 415–426.Find this resource:

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                                                                                                Turk, D. C., Monarch, E. S., & Williams, A. D. (2002). Cancer patients in pain: Considerations for assessing the whole person. Hematology/Oncology Clinics of North America, 16, 511–525.Find this resource:

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                                                                                                  Wang, J., & Christo, P. J. (2009). The influence of prescription monitoring programs on chronic pain management. Pain Physician, 12(3), 507–515.Find this resource:

                                                                                                    Ware, J. (1992). Suffering & the social construction of illness: The delegitimation of illness experience in chronic fatigue syndrome. Medical Anthropology Quarterly, 4, 347–361.Find this resource:

                                                                                                      West, C., Stewart, L., Foster, K., & Usher, K. (2012). The meaning of resilience to persons living with chronic pain: An interpretive qualitative inquiry. Journal of Clinical Nursing, 21(9–10), 1284–1292.Find this resource:

                                                                                                        World Health Organization. (2012). Briefing note—Access to controlled medications programme. Retrieved from http://www.who.int/medicines/areas/quality_safety/ACMP_BrNote_Genrl_EN_Apr2012.pdf

                                                                                                        Further Reading

                                                                                                        American Academy of Pain Medicine. AAPM facts and figures on pain. Retrieved from http://www.painmed.org/patientcenter/facts_on_pain.aspx

                                                                                                        Bray, R. M., Pemberton, M. R., Hourani, L. L., Witt, M., Rae Olmsted, K. L., Brown, J. M., et al. (2009). Department of Defense survey of health related behaviors among active duty military personnel. Retrieved from http://www.fedprac.com/PDF/028050001s.pdf

                                                                                                        Center for Health Law Studies, St. Louis University American Society of Law, Medicine and Ethics: http://slu.edu/school-of-law-home/centers-of-excellence/center-for-health-law-studies/health-law-resources

                                                                                                        City of Hope, Pain and Palliative Care Resource Center: http://prc.coh.org

                                                                                                        Department of Pain Medicine and Palliative Care, Beth Israel Medical Center: http://stoppain.org

                                                                                                        Federation of State Medical Boards of the United States, Inc. (2004). Model policy for the use of controlled substances for the treatment of pain. Retrieved from http://www.fsmb.org/pdf/2004_grpol_controlled_substances.pdf

                                                                                                        International Association for the Study of Pain: http://www.iasp-pain.org/AM/Template.cfm?Section=Publications&Template=/CM/HTMLDisplay.cfm&ContentID=2307

                                                                                                        Johnson, S. H. (2001). Relieving unnecessary, treatable pain for the sake of human dignity. Journal of Law, Medicine & Ethics, 29, 11–12.Find this resource:

                                                                                                          Robinson, C. L. (2007). Relieving pain in the elderly. Health Progress, 88(1), 48–53.Find this resource: