especially prone to chronic pain, veterans, those of lower socioeconomic status, and former athletes. Patients with cancer are very likely to experience inadequately controlled pain.
The prevalence of pain varies somewhat between ethnic groups in the United States. Although pain thresholds (minimum detectable pain) are similar across ethnic groups, Caucasians generally demonstrate higher experimental pain tolerance than do African Americans, Hispanic, and Asian populations, the reasons are unknown (Kim et al. 2017). Important disparities in access to care and impacts on clinical decision‐making influence outcomes. These factors generally contribute to higher levels of untreated pain in minority populations (Campbell and Edwards 2012). There is no evidence that people of color experience less pain and proper pain assessment is essential for all patients.
Low socioeconomic status has a negative impact on pain outcomes and predicts a higher prevalence of pain in a population. Many factors may contribute to this especially physical work demands for patients with lower educational attainment and poor access to prompt and effective healthcare. For example, pharmacies located zip codes with lower incomes are less likely to stock opioid medications meaning that patients with cancer and other serious pain‐associated conditions cannot obtain WHO essential medications in their own neighborhoods (Green et al. 2005).
There are important, somewhat subtle, differences between how men and women respond to noxious stimuli in the laboratory, but similarities abound. In general, men and women respond to pain similarly and the differences between men and women are dwarfed by the interindividual variability in pain sensitivity that we don't yet have explanations for. Nonetheless women on average experience more pain than men. There are important sex differences in the prevalence in pain–associated conditions: migraines are much more prevalent in females and cluster headaches much more prevalent in males. There are also sex‐specific pain conditions such as dysmenorrhea, endometriosis, and testicular torsion.
Pain is an important cause of work‐related disability and being engaged in litigation or a workman's compensation claim has a negative impact on pain outcomes. Patients may not be conscious of secondary gain however pain persists when there is a matter pending legal resolution.
Finally, access to care is a major cause of persistent suffering. Over‐reliance on opioids has led to a backlash against assessing pain. In the U.S., opioids cause more overdose deaths than any other medication, in other countries, it is impossible to access opioids when clearly appropriate (Figure 4.2). Access to essential medicines, especially opioids is severely restricted in most countries globally so that countries with highest rates of opioid utilization report per capita consumption of 10 000 times more opioids than countries with the lowest rates. WHO estimates that 4.8 million people with cancer die in pain each year without medicine. Globally, millions are dying without relief from pain, there is a pain management crisis of epic proportions.
Figure 4.2 Access to pain‐relieving medication varies widely with location. This figure demonstrates that high‐resource countries have much higher opioid consumption that low‐resource countries.
Source: Berterame et al. (2016). © 2016, Elsevier.
References
1 Berterame, S., Erthal, J., Thomas, J. et al. (2016). Use of and barriers to access to opioid analgesics: a worldwide, regional, and national study. The Lancet 387 (10028): 1644–1656. http://www.thelancet.com/cms/attachment/2053462746/2060237771/gr2_lrg.jpg.
2 Campbell, C.M. and Edwards, R.R. (2012). Ethnic differences in pain and pain management. Pain Management 2 (3): 219–230.
3 Green, C.R., Ndao‐Brumblay, S.K., West, B., and Washington, T. (2005). Differences in prescription opioid analgesic availability: comparing minority and white pharmacies across Michigan. Journal of Pain 6 (10): 689–699. https://doi.org/10.1016/j.jpain.2005.06.002. PMID: 16202962.
4 Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies Press.
5 Kim, H., Yang, G.S., Greenspan, J.D. et al. (2017). Racial and ethnic differences in experimental pain sensitivity: systematic review and meta‐analysis. Pain 158: 194–211.
6 Murphy, K., Han, J.L., Yang, S. et al. (2017). Prevalence of specific types of pain diagnoses in a sample of United States adults. Pain Physician 20: E257–E268.
7 Stovner, L.J., Hagen, K., Jensen, R. et al. (2007). The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 27: 193–210.
5 Pain and ethical practice: How do we resolve dilemmas in pain care?
Modern healthcare ethics stands on four pillars: beneficence, non‐maleficence, autonomy, and distributive justice (Beauchamp and Childress 2013; Figures 5.1 and 5.2). Beyond this, an exemplary career in pain‐competent healthcare is guided by high levels of compassion, interpersonal insight, resilience, and self‐regulation. Every day in pain care, these ideals are tested and tempered. As noted by Giordano (2006) “there is a core philosophy of medicine that reflects the intellectual and moral quality of the healing relationship”. The same is true in nursing, pharmacy, dentistry, physical therapy, social work, clinical psychology, and all health professions. Pain‐focused care is rich and fulfilling when actuating the ethical virtues through compassionate connections with patients and others in a joint effort to relieve pain.
Figure 5.1 Healthcare ethics rests on the “four pillars.”
Figure 5.2 Each of the four pillars has distinctive aspects that shape ethical decision‐making.
Beneficence
Pain care presents frequent opportunities to practice beneficence. In pain care, the overarching goal is the relief of pain, but parallel goals include the improvement of function and quality of life. In restoring the patient's confidence in their ability to manage chronic pain or in alleviating acute pain, there is tremendous beneficence. By learning pain care, whether studying a drug dose, route, and potential interactions; in exploring the mechanisms of focal pain, or in learning how to support patients emotionally, we gain an opportunity to help people in the most direct manner: applying our clinical
