Chapter 4

“For all the happiness

Mankind can gain;

Is not in pleasure,

But in rest from pain.”

John Dryden (1631–1701)

Relief of pain is one of the great objectives of medicine. Pain is the most common symptom reported to physicians; more than 80% of all patients who see physicians do so because of pain. It has been a predominant concern of humankind since the beginning of recorded history. Chronic pain affects hundreds of millions of people worldwide, altering their physical and emotional functioning, decreasing their quality of life, and impairing the ability to work. It affects general health, psychological health, and social and economic well-being. Patients in chronic pain use health services up to five times more frequently than the rest of the population. The cost of unrelieved chronic pain in the United States is more than $50 billion per year (more than$80 billion per year if lost wages from work are counted) and in the age of steady cost-cutting in a managed care environment, we can no longer afford it. More than 550 million workdays are lost every year because of chronic pain. Yet 40% of all cancer patients, 50% of nursing home patients, 55% of postoperative patients, and 70% of patients with acquired immunodeficiency syndrome (AIDS) have unrelieved or inadequately relieved pain.

In October 2000, the 106th U.S. Congress passed HR 3244, which was then signed into law. Title VI, Sec. 1603, provides for the “Decade of Pain Control and Research,” to begin January 2001. It follows the “Decade of the Brain” and is only the second congressionally declared, medically related decade. Pain is now designated as a public health problem of national significance. Beginning in 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) implemented new standards to assess and treat pain. To qualify for accreditation, all facilities, including rehabilitation centers, outpatient surgical centers, hospitals, and nursing homes, must recognize the right of patients to appropriate assessment and management of pain. All health care facilities must identify pain in patients during initial assessment and, where required, during ongoing periodic assessments and must educate patients and their families about pain management.

The word pain is derived from the Latin poena, meaning punishment. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”1 This definition may appear somewhat convoluted, but it clearly states that pain is subjective. It is both a physiologic sensation and an emotional reaction to that sensation. Viewed from an evolutionary prospective, pain is perceived as a threat or damage to one’s biological integrity and has three components: sensory-discriminative, motivational-affective, and cognitive-evaluative.

The concepts of pain and suffering are frequently mixed and sometimes confused in the dialogue between patient and physician, ...

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