Healthcare Professionals' Perspective
Lack of Knowledge of Opioid Pharmacological Effects

False notions of addiction in pain management results from clinicians’ ignorance of opioids’ pharmacological effects for intractable pain. It’s true that decades of studies have supported the use of opioids for intractable pain, yet most clinicians today still do not prescribe and distribute the appropriate analgesics to match their patients’ severity of pain.¹² Healthcare providers continue to undertreat intractable pain patients because they learn pain management through customary prescribing behavior, which in turn creates an atmosphere for inappropriate prescribing and undertreatment of pain in different populations.

Customary prescribing behavior

Physicians continue to undertreat pain patients due to a cyclical phenomenon known as customary prescribing behavior.⁸ Customary behavior is behavior that is perpetuated by community thought as opposed to individual outcomes. This behavior is passed down from physicians to medical school graduates as graduates enter training in hospitals. Medical school graduates accept the prescribing patterns that they learn in training hospitals because they do not receive formal pain management training in their medical school curricula.

The house staff who train medical school graduates believe that they treat pain via the "bedside experience." However, if this were true, they would not continuously ignore two outcome variables that could help them treat their patients’ pain adequately—their consistent failure to treat pain and the fact that they have rarely seen patients become addicts.⁸ Customary prescribing behavior creates a situation in which clinicians ignore the results of their inadequately treating pain and, instead, focus on treating patients as physicians before them have done.¹³

PRN prescribing patterns

Another reason that clinicians inadequately relieve pain is their continued support of PRN (pro re nata, or as needed) prescribing. PRN was once thought to be effective in relieving patients’ pain because PRN requires patients to receive pain medication when they absolutely need it therefore avoiding "addiction." PRN prescribing is no longer thought to be effective for analgesia because:

• PRN requires patients to experience unnecessary pain before receiving relief ^4,14
• clinicians tend to label patients as addicts because patients continuously ask or even beg for pain relief ⁷
• once the dose is finally given, the pain could be so severe that the medication does not treat it, and a higher dose becomes necessary. If higher doses are not given gradually, side effects, such as mental clouding and nausea usually result ^7,14

In fact, PRN prescriptions are contraindicated for pain relief because the roller coaster incidence of pain does not minimize tolerance and addiction but actually exaggerates them.^4,15

Undertreatment in different populations

Children, elderly, and minorities tend to receive lesser relief of pain than the rest of the population. The reasoning is not founded upon discrimination, but a belief system that: children don’t feel pain like adults ^7,16; the elderly are believed to feel less pain than they had before and don’t report their pain like younger patients ^7,16; and minorities are treated in a customary behavior founded on the thought that minorities are at a greater risk of addiction.¹⁷

The truth is everyone, despite age or ethnicity, feels pain. The difference between the levels of pain felt does not result from age or ethnicity but from disease progression.⁴ Therefore, no boundaries should be set for appropriate levels of pain management based on anything except reported pain levels experienced by each, individual patient. Also, it is the responsibility of each patient to report their pain to their healthcare provider in order to receive adequate amounts of pain treatment.