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Whitelaw S, Bell A, Clark D. The expression of 'policy' in palliative care: A critical review. Health Policy 2022; 126:889-898. [PMID: 35840439 DOI: 10.1016/j.healthpol.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/24/2022] [Accepted: 06/26/2022] [Indexed: 11/30/2022]
Abstract
The importance of 'policy' within palliative care has steadily increased over the past 25 years. Whilst this has been welcomed within the palliative care field and seen as a route to greater recognition, we focus here on a more critical perspective that challenge the effectiveness of a 'policy turn' in palliative care. Applying Bacchi's "What's the Problem Represented to Be?" (WPR) framework to data from a systematic search, we address the research question, "in what ways has 'policy' been articulated in palliative care literature?". The paper describes the construction of 'the problem' context and reflects critically on the robustness and pragmatic utility of such representations. In particular, we identify five elements as prominent and problematic: (1) a lack of empirical evidence that connects policy to practice; (2) the dominance of 'Global North' approaches; (3) the use of a policy narrative based on 'catastrophe' in justifying the need for palliative care; (4) the use of idealistic and aspirational 'calls to action'; and (5) a disengaged and antagonistic orientation to existing health systems. We conclude by suggesting that the efficacy of palliative care policy could be enhanced via greater emphases on 'Global South' perspectives, 'assets-based' approaches and attention to pragmatic implementation.
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Affiliation(s)
- Sandy Whitelaw
- School of Interdisciplinary Studies, University of Glasgow, Dumfries Campus, Dumfries, DG1 4ZL, United Kingdom.
| | - Anthony Bell
- School of Interdisciplinary Studies, University of Glasgow, Dumfries Campus, Dumfries, DG1 4ZL, United Kingdom
| | - David Clark
- School of Interdisciplinary Studies, University of Glasgow, Dumfries Campus, Dumfries, DG1 4ZL, United Kingdom
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Kennedy RE, Hildebrand CJ. Coordinating pain control in newly diagnosed head/neck cancer: From a case report to a multi-disciplinary approach. Journal of Cancer Research and Practice 2018; 5:77-80. [DOI: 10.1016/j.jcrpr.2017.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Qureshi ZP, Haider MR, Rodriguez-Monguio R, Wooten NR, Nikitin RV, Ball S, Barth K, Elk R, Horner R, Bennett C. Opioid Prescription Drug Use and Expenditures in US Outpatient Physician Offices: Evidence from Two Nationally Representative Surveys. Cancer Ther Oncol Int J 2017; 3:555611. [PMID: 28845476 DOI: 10.19080/CTOIJ.2017.03.555611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Opioids are widely prescribed for their analgesic properties. Chronic opioid use is a persistent problem in the US. Nevertheless, little is known about its prescribing and utilization patterns and overall expenditures. OBJECTIVE This study examined secular trends in opioid prescription drug utilization and expenditures, along with factors associated with opioid prescription drug use in US physician offices. METHODS National Ambulatory Medical Care Survey (NAMCS) and Medical Expenditure Panel Survey (MEPS) data (2006-2010), both nationally representative surveys, were used to assess the trend, predictors of opioid prescription among US adults (more than 18 years) and the opioid-associated expenditures as a whole and borne by the patients in outpatient settings. RESULTS Opioid prescription drugs use among US adults in outpatient settings, as a percentage of all prescription drugs, showed a gradual increase since 2006, leveling off in 2010. Opioid prescription drug expenditures showed an upward trend from 2009 after declining over three years. Mean out-of-pocket payments per prescription steadily declined over study period. LIMITATIONS Cross-sectional nature and visit based information of NAMCS do not provide the actual prevalence and the reason for opioid prescription. CONCLUSIONS Given the upward trend in opioid prescription drug utilization and associated expenditures, clinicians may benefit from evidence-based methods of monitoring prescription opioid use to prevent misuse, abuse, and other adverse patient outcomes. FUNDING Drs. Qureshi, Haider, Ball, Horner and Bennett's efforts are partially supported by the University of South Carolina's ASPIRE I. Dr. Wooten's effort is funded by the National Institute on Drug Abuse (K01DA037412).
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Epstein JB, Wilkie DJ, Fischer DJ, Kim YO, Villines D. Neuropathic and nociceptive pain in head and neck cancer patients receiving radiation therapy. Head Neck Oncol 2009; 1:26. [PMID: 19594943 PMCID: PMC2717963 DOI: 10.1186/1758-3284-1-26] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Accepted: 07/14/2009] [Indexed: 12/23/2022]
Abstract
BACKGROUND Pain is common in head and neck cancer (HNC) patients and may be attributed to the malignancy and/or cancer treatment. Pain mechanisms and patient report of pain in HNC are expected to include both nociceptive and neuropathic components. The purpose of this study was to assess the trajectory of orofacial and other pain during and following treatment, using patient reports of neuropathic pain and nociceptive pain and pain impact. METHODS 124 consecutive HNC patients receiving radiation therapy (RT) (95 men, 29 women; mean age: 54.7 +/- 12.3 years) participated in a patient-reported outcome (PRO) assessment. Patients completed the McGill Pain Questionnaire three times during therapy and 3 months following study entry. RESULTS The majority of patients related their pain to the tumor and/or cancer treatment. Whereas 59% reported their pain to be less severe than they expected, 29% were not satisfied with their level of pain despite pain management during cancer therapy. Worst pain was 3.0 +/- 1.3 on a 0- to 5-point verbal descriptor scale. Pain intensity was present at entry, highest at 2-week follow-up, declining towards the end of treatment and persisting at 3-month follow-up. The most common neuropathic pain descriptors chosen were aching (20%) and burning (27%); nociceptive words chosen were dull (22%), sore (32%), tender (35%), and throbbing (23%), and affective/evaluative descriptors were tiring (25%) and annoying (41%). 57% of patients reported continuous pain, and combined continuous and intermittent pain was reported by 79% of patients. DISCUSSION This study provides evidence that patients with HNC experience nociceptive and neuropathic pain during RT despite ongoing pain management. The affective and evaluative descriptors chosen for head and neck pain indicate considerable impact on quality of life even with low to moderate levels of pain intensity. These findings suggest that clinicians should consider contemporary management for both nociceptive and neuropathic pain in head and neck cancer patients.
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Affiliation(s)
- Joel B Epstein
- University of Illinois Cancer Center, University of Illinois, Chicago, USA
- University of Illinois College of Dentistry, University of Illinois, Chicago, USA
- Univerity of Illinois College of Medicine, University of Illinois, Chicago, USA
| | - Diana J Wilkie
- University of Illinois Cancer Center, University of Illinois, Chicago, USA
- University of Illinois College of Nursing, University of Illinois, Chicago, USA
| | - Dena J Fischer
- University of Illinois College of Dentistry, University of Illinois, Chicago, USA
| | - Young-Ok Kim
- University of Illinois College of Nursing, University of Illinois, Chicago, USA
| | - Dana Villines
- University of Illinois College of Dentistry, University of Illinois, Chicago, USA
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El‐Aneed A, Alaghehbandan R, Gladney N, Collins K, Macdonald D, Fischer B. Prescription drug abuse and methods of diversion: The potential role of a pharmacy network. Journal of Substance Use 2009. [DOI: 10.1080/14659890802446087] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Cancer-associated pain is extremely common and is associated with significant physical and psychological suffering. Unfortunately, pain associated with cancer or its treatment is frequently under-treated, probably due to several factors, including phobia of opioids, under-reporting by patients, and under-diagnosis by healthcare workers. The most common etiology of cancer pain is local tumor invasion (primary or metastatic), involving inflammatory and neuropathic mechanisms; these have been reviewed in Part I. As malignant disease advances, pain usually becomes more frequent and more intense. Additional expressions of orofacial cancer pain include distant tumor effects, involving paraneoplastic mechanisms. Pain secondary to cancer therapy varies with the treatment modalities used: Chemo-radiotherapy protocols are typically associated with painful mucositis and neurotoxicity. Surgical therapies often result in nerve and tissue damage, leading, in the long term, to myofascial and neuropathic pain syndromes. In the present article, we review the clinical presentation of cancer-associated orofacial pain at various stages: initial diagnosis, during therapy (chemo-, radiotherapy, surgery), and in the post-therapy period. As a presenting symptom of orofacial cancer, pain is often of low intensity and diagnostically unreliable. Diagnosis, treatment, and prevention of pain in cancer require knowledge of the presenting characteristics, factors, and mechanisms involved.
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Affiliation(s)
- J B Epstein
- Department of Oral Medicine and Diagnostic Sciences, MC-838, College of Dentistry, 801 S. Paulina St., Chicago, IL 60612, USA.
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Weissman DE. Pain management and the bogeyman. J Palliat Med 2005; 3:381-2. [PMID: 15859686 DOI: 10.1089/jpm.2000.3.4.381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
OBJECTIVES To determine the frequency of media reports of controlled substance diversion. DESIGN Quantitative search of news articles from LexisNexis Academic, using search strings related to four different types of controlled substance diversion. SETTING Not applicable. PATIENTS OR PARTICIPANTS Not applicable. MAIN OUTCOME MEASURES Number of media reports about diversion of controlled substances at the prescriber or dispenser levels, through pharmacy robberies or thefts, and through hijackings or robberies of shipments. RESULTS Media reports of controlled substance diversion indicate that theft and loss are important problems and that inappropriate prescribing and dispensing are substantial problems as well. Leaks of controlled substances from the closed system of distribution seem to be increasing as rapidly through theft and loss as through inappropriate prescribing and dispensing. During the five biennia between 1993 and 2002, these percentage increases in media reports were observed for the different types of diversion: 200% for prescribers; 350% for dispensers; 133% for pharmacy robberies and thefts; and 1,800% for thefts from shipping channels. CONCLUSION A balanced approach to the prevention of controlled substance diversion, aimed at reducing illicit acquisition of drugs from theft and loss as well as from prescribing and dispensing, may produce the greatest success without adversely affecting the quality of patient care.
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Affiliation(s)
- David B Brushwood
- Department of Pharmacy Health Care Administration, College of Pharmacy, University of Florida, Gainesville 32610-0496, USA.
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Abstract
Pain is one of the most commonly experienced and feared symptoms of advanced cancer. Most cancer patients experience pain, usually of moderate to severe intensity, and most also have a number of distinct pains. The most common type of pain is related to bone metastases. Neuropathic pain occurs in one-third of patients, alone, or as a mix of nociceptive and neuropathic pain. The failure to manage pain properly is due to several factors. In developing countries, it is likely to be related to geography and limited resources. Legal restrictions also present barriers. In developed countries, failure to manage pain properly is usually related to a "disease" rather than a "symptom" model of care, which minimizes symptom management. Other factors include lack of physician education and failure to follow existing guidelines. Patients fear addiction, drug tolerance, and side effects. Despite adequate resources, pain is still undertreated.
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Affiliation(s)
- Mellar P Davis
- The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Abstract
PURPOSE/OBJECTIVES To obtain information about the knowledge and attitudes of Utah nurses concerning cancer pain management. DESIGN Descriptive study. SETTING Nurses in Utah. SAMPLE 44 oncology nurses and 303 nononcology nurses completed the study. METHODS Ferrell's Nurses' Knowledge and Attitudes Survey Regarding Pain was given to oncology and nononcology nurses to compare knowledge and attitudes about treating cancer pain. MAIN RESEARCH VARIABLES Knowledge and attitudes regarding cancer pain. FINDINGS Attitudes of oncology nurses were more in line with recommended practices (principles) of cancer pain management than those of nononcology nurses. Oncology nurses had a better understanding of recommended practices (principles) of cancer pain management than nononcology nurses but still struggled with understanding the pharmacology of medications used to manage cancer pain. CONCLUSIONS Nurses do not use evidence-based practice in pain management consistently. Continuing education regarding cancer pain management remains important for oncology and nononcology nurses. IMPLICATIONS FOR NURSING Adoption of evidence-based practice requires ongoing education of nurses and support from nursing colleagues, nursing administration, and associated healthcare providers. Data from this study can be used to design a curriculum involving content about cancer pain management. All members of the healthcare team should be supported in practicing the correct principles of cancer pain management in actual practice.
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Affiliation(s)
- Patricia Rushton
- College of Nursing, Brigham Young University, Salt Lake City, UT, USA.
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Abstract
Persistent pain is a frequently occurring condition with significant economic, clinical, and humanistic implications, for both individuals and society. Current literature, however, points to unresolved issues with regard to its identification, assessment, diagnosis, and treatment, and a number of suggestions have been made for improving the quality of care for pain sufferers. Because persistent pain shares many of the salient features of other chronic conditions such as diabetes and congestive heart failure, it is reasonable to believe that the adoption of a coordinated approach to care management could substantially improve the quality of care. Several strategies--including identification, appropriate referral, education, and planning--can and should be implemented to offer comprehensive, individualized treatment alternatives that are not currently available and that improve patient outcomes, including quality of life.
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Affiliation(s)
- Christine W Hartmann
- Office of Health Policy and Clinical Outcomes, Thomas Jefferson University, 1015 Walnut Street, Philadelphia, PA 19107, USA.
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Abstract
BACKGROUND Although opioids are commonly used to treat chronic neuropathic pain, there are limited data to guide their use. Few controlled trials have been performed, and many types of neuropathic pain remain unstudied. METHODS Adults with neuropathic pain that was refractory to treatment were randomly assigned to receive either high-strength (0.75-mg) or low-strength (0.15-mg) capsules of the potent mu-opioid agonist levorphanol for eight weeks under double-blind conditions. Intake was titrated by the patient to a maximum of 21 capsules of either strength per day. Outcome measures included the intensity of pain as recorded in a diary, the degree of pain relief, quality of life, psychological and cognitive function, the number of capsules taken daily, and blood levorphanol levels. RESULTS Among the 81 patients exposed to the study drug, high-strength levorphanol capsules reduced pain by 36 percent, as compared with a 21 percent reduction in pain in the low-strength group (P=0.02). On average, patients in the high-strength group took 11.9 capsules per day (8.9 mg per day) and patients in the low-strength group took close to the 21 allowed (18.3 capsules per day; 2.7 mg per day). Affective distress and interference with functioning were reduced, and sleep was improved, but there were no differences between the high-strength group and the low-strength group in terms of these variables. Noncompletion of the study was primarily due to side effects of the opioid. Patients with central pain after stroke were the least likely to report benefit. CONCLUSIONS The reduction in the intensity of neuropathic pain was significantly greater during treatment with higher doses of opioids than with lower doses. Higher doses produced more side effects without significant additional benefit in terms of other outcome measures.
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Affiliation(s)
- Michael C Rowbotham
- Pain Clinical Research Center, Department of Neurology, University of California, San Francisco, School of Medicine, San Francisco, USA
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Mendenhall M. Psychosocial aspects of pain management: a conceptual framework for social workers on pain management teams. Soc Work Health Care 2003; 36:35-51. [PMID: 12836779 DOI: 10.1300/j010v36n04_03] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
To have a significant impact in the arena of pain management, social workers must be able to articulate social work values and concepts clearly, productively, and compellingly as assets in overcoming identified barriers to pain relief. A literature review concerning vulnerable populations, identified barriers, and related social policies explores alternative perspectives that social workers can bring to a multi-disciplinary team's efforts to improve the delivery of pain management technology. The article offers a beginning framework for discussions about the profession's potential contributions. The goal of these discussions is to contribute to encouraging a more pronounced involvement of social workers in pain management issues.
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Abstract
There is general agreement that the “principle of balance” should guide controlled substance policy and regulation in the United States. Although the diversion of controlled substances from medical to nonmedical purposes is a significant public health problem, overly aggressive controlled substance regulation has been shown to have an unintended deterrent effect on appropriate controlled substance use, including pain management with opioid analgesics. The promotion of effective pain management and the reduction of substance abuse are equally important regulatory objectives. Neither regulatory objective need be sacrificed to achieve the other. Rather, the two objectives must be balanced with each other to assure that necessary pain management is encouraged while drug abuse is curtailed.Approximately 75 million people in the United States suffer from severe pain. Fifty million of these suffer chronic pain, and 25 million suffer acute pain from trauma or surgery. Pain is not merely an uncomfortable symptom.
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Abstract
Pain management is evolving as critics clamor for improvement in patient care. Progress, however, is surprisingly slow, the result of continued uncertainty by providers as to appropriate opioid use, fear of criminal prosecution, and lack of institutional attention to pain management. Progress, however, is also evident, with accreditors paying more attention to pain management, the implementation of team approaches in some hospitals, and the recognition by physicians and other providers that pain, just as any clinical problem, needs to be treated in an effective manner.
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Affiliation(s)
- Barry R Furrow
- Health Law Institute, Widener University School of Law, 4601 Concord Pike, PO Box 7474, Wilmington, DE 19803-0474, USA.
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Affiliation(s)
- June L Dahl
- University of Wisconsin-Madison Medical School, Madison, WI 53706, USA
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Abstract
Studies tell us that most people fear a protracted, painful death; unfortunately, this is what many experience. Palliative nursing care seeks to change this. This new series challenges nurses to think differently about caring for people when cure isn't possible.
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Abstract
Physicians' concerns about regulatory scrutiny and the possibility of unwarranted investigation by regulatory agencies negatively affect their prescribing of opioid analgesics to treat pain. Indeed, some state medical boards have rejected prescribing practices that are considered acceptable by today's standards. This article describes a ten-year program of research, education, and policy development implemented by the Pain & Policy Studies Group aimed at updating and clarifying state medical board policies on the use of opioid analgesics to treat pain, including cancer and chronic noncancer pain. Following surveys of medical board members and educational workshops, state medical board policies began an initial period of change, drawing on guidelines from other states, particularly in California. The next phase of policy development was marked by the introduction of Model Guidelines by the Federation of State Medical Boards of the U.S. The Model Guidelines address professional standards for the appropriate prescribing of opioid analgesics for pain management, as well as physicians' fears of regulatory scrutiny. Although most state medical boards have adopted regulations, guidelines, or policy statements relating to controlled substances and pain management, to date ten boards have adopted the Model Guidelines, while ten more have adopted the Model Guidelines in part. Further actions are recommended so that state medical boards can address inadequate pain management and physician concerns about regulatory scrutiny.
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Chapman CR, Lande SD, McCarberg BH, Nash DB. Pain Control in Healthcare Organizations: Developing Effective Disease Management Programs. ACTA ACUST UNITED AC 2001. [DOI: 10.1089/10935070152596016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | | | - David B. Nash
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Affiliation(s)
- R Kanner
- Albert Einstein College of Medicine and Department of Neurology, Long Island Jewish Medical Center, New Hyde Park, New York, USA.
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Abstract
Physicians report that concern about regulatory investigation negatively influences their prescribing of opioid analgesics. The views of medical regulators about the legality of prescribing controlled substances for pain management were studied in 1991. However, little is known about whether these views have changed in light of increased emphasis on pain management and educational programs for state medical boards. Two studies that examined this issue are described. In Study 1, a 1997 survey of state medical board members was compared to results obtained in 1991 to evaluate differences in knowledge and perceptions about opioid analgesics. Important changes were observed over time, particularly regarding characteristics of "addiction" and the legality of prolonged prescribing of opioids. For Study 2, a longitudinal survey was conducted of medical board members who participated in five workshops about pain management and regulatory policy. Results revealed significant and sustained changes in attitudes about the incidence of iatrogenic addiction when using opioids to treat pain, the analgesic and side-effect properties of opioids, and the perceived legality of prescribing opioids. Recommendations for reducing concerns about regulatory scrutiny are presented, including the need for a more intensive education program, increasing the rate of adoption of new state medical board policies, and improving communication between regulators and clinicians.
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Affiliation(s)
- A M Gilson
- Pain & Policy Studies Group, Comprehensive Cancer Center, University of Wisconsin, Madison, WI 53705, USA
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Abstract
Pain is undertreated in the American health-care system at all levels: physician offices, hospitals, long-term care facilities. The result is needless suffering for patients, complications that cause further injury or death, and added costs in treatment overall. The health-care system's failure to respond to patient pain needs corrective action. Excuses for such shortcomings are simply not acceptable any longer.Physicians have long been accused of poor pain management for their patient. The term “opiophobia” has been coined to describe this remarkable clinical aversion to the proper use of opioids to control pain. If the professional mandate of the health-care professional is to relieve suffering, then physicians are falling far short of their obligations by accepting myths about the use of opioids in the face of evidence to the contrary.
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Abstract
OBJECTIVES To see how often families in Oregon reported moderate to severe pain in dying patients in late 1998 compared with late 1997. DESIGN A systematic random sample of death certificates was used to identify family members of decedents who died in a hospital setting between October 1 and December 31, 1998. A structured telephone interview was used to obtain data. PARTICIPANTS Family members of 103 decedents (who died in hospitals 2 to 4 months before data collection) were identified with the use of death certificates. RESULTS In late 1998, 56 family members (54%) reported that their loved one experienced moderate to severe pain in the last week of life. CONCLUSIONS Family reports of moderate to severe pain in dying hospitalized Oregonians remain high. The influence of environmental factors on pain management may have implications for practice and policy nationwide.
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Affiliation(s)
- S W Tolle
- Center for Ethics in Health Care, School of Medicine Oregon Health Sciences University, Portland 97201-3098, USA.
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