**3. Challenges to effective pharmacological pain management**

The challenges militating against effective pharmacological pain management strategy are categorized into five, including pain recognition and quantification error, patient factor, practitioner factor, drug factor, and gap between scientific evidence and clinical applications.

## **3.1 Pain recognition and quantification error**

Critical to successful pain intervention is the ability to accurately recognize and quantify pain. Pain is often not given due recognition, underreported and undetected, especially in the nonverbal and patients with communication difficulties or cognitive impairment [33, 34]. In patients who can verbally communicate, pain recognition and quantification rely on the judgment of these individuals in addition to the physiological indicators of pain. On the other hand, the accurate recognition and quantification of pain in nonverbal or cognitively impaired patients is dependent on the practitioner or care provider. Some patients with communication difficulties as seen in intensive care units (ICUs) relay pain using other cues such as signaling with eyes, leg movements, guarding of painful region, and making physical contacts with the practitioner [35]. Hence, these behaviors were incorporated into pain scales for ICU patients under sedation [35]. Practitioners have also employed the use of surrogates and analgesic trials to assess pain [36]. Hence, the successful recognition of pain in these instances lies on the expertise of the practitioner. Additionally, pain recognition and quantification error could result from the patient's inability to express pain even after experiencing a potential painful episode, or from patient not displaying consistent signs of pain.

**49**

*Why Effective Pain Management Remains a Challenge DOI: http://dx.doi.org/10.5772/intechopen.93612*

There are differences in patients' responses to pain and pain management strategies, thus, necessitating the need to understand the peculiarity of each patient experiencing pain. Proper examination of patient history and adequate knowledge of patient information are vital when considering the choice of pain management regimen. Several studies have reported demographics such as age [37–40], sex [38, 41, 40], and cultural differences including ethnicity [39–40, 42–43] in response to pain and these should be borne in mind. Additionally, the patient's response to pain is influenced by previous pain experience [44], nature of injury [37, 38, 45], and presence of underlying conditions which cause sensory impairment or communication difficulties [46]. These potentially complicate pharmacological pain management strategies. Therefore, understanding and treating each patient as unique is crucial for a successful alleviation of pain.

Adequate understanding of pain, its physiology, myths and misconceptions, ethics, recognition, and quantification and management is essential for every pain management personnel. While this is obviously the standard, information in the literature revealed that there are extensive knowledge deficits among most pain practitioners and care providers [47–51]. In hospital settings, provision of pain management relies on trained nurses often following physician's prescriptions [49]. In nonhospital settings such as residential care homes and patients' homes, pain management is performed by the patient or a caregiver in case of morbidity and cognitive impairment. In all these instances, proper knowledge of the pharmacologic agent, its mode of action, duration of the effect, recommended dose, and adverse effects are very important but hardly achieved. Several studies have demonstrated poor pain management strategy practiced by nurses [47–51], which was attributed to

education deficit, errors in pain assessment, and side effects of opioids [47].

administration technique, and inconsistency in timing of administration.

constitute a barrier to effective pain management.

**3.5 Gap between scientific evidence and clinical applications**

The choice of a pharmacologic agent for pain management is influenced by its efficacy and cost, patient response, and practitioner's preference. Different classes of drugs are often combined to maximize pain alleviation. For instance, effective pain management is dependent on the choice of drug, its efficacy, dose, administration technique, adverse effects, time, and consistency of intervention. Pain management is often ineffective because of misuse errors resulting from underdosage, poor

To minimize the complications resulting from the use of a sole analgesic and to achieve balanced analgesia, different classes of agents are combined in a multimodal fashion [52–54]. Though complex, cited advantages include effective and efficient analgesia, and possibly, reduction in doses of one or more individual drugs [54]. However, if misused, they can hinder the effectiveness of analgesics and thus

Even though there exist many scientifically proven analgesic regimens for pain mitigation in the literature [55], effective pain management has not been adequately achieved across treatment settings. It does appear that these evidencebased recommendations are not properly incorporated in clinical practice, thus,

**3.2 Patient factor**

**3.3 Personnel factor**

**3.4 Drug factor**

### **3.2 Patient factor**

*Pain Management - Practices, Novel Therapies and Bioactives*

**2.3 Pain management**

postsurgical pain.

evidence and clinical applications.

**3.1 Pain recognition and quantification error**

transcends into a chronic phase. This does not mean that every acute pain phase will gradually become chronic. However, in the absence of effective pain intervention

Pain is managed using pharmacological and non-pharmacological means. Pharmacological agents used in the management of pain include opioids, nonsteroidal anti-inflammatory drugs, steroidal anti-inflammatory drugs, and local anesthetics [25]. Additionally, tranquilizers, corticosteroids, tricyclic antidepressants and antiepileptic medications (topical capsaicin, mexiletine, and N-methyl-d-aspartate receptor antagonists), serotonin norepinephrine reuptake inhibitors, calcium channel α2-δ ligands, topicals, anticonvulsants, and transdermal substances are included in the pain management regimen as adjuvants to analgesics depending on the type and severity of pain [26–29]. Nonpharmacological management of pain involves the use of suitable housing, bed rest, gentle handling and manipulation (massage, osteopathic and chiropractic), meditative movements (such as Tai Chi and yoga), and diets [30, 31]. Much recent strategies for non-pharmacological pain management were classified into sensory (massage, positioning, acupuncture, hot and cold treatment, progressive muscle relaxation, and transcutaneous electrical nerve stimulation), psychological interventions, and others including music, belief, and spirituality [31, 32]. These non-pharmacological means are thought to play a huge role in relieving

and inability to self-limit acute pain, it is expected to assume this course.

**3. Challenges to effective pharmacological pain management**

The challenges militating against effective pharmacological pain management strategy are categorized into five, including pain recognition and quantification error, patient factor, practitioner factor, drug factor, and gap between scientific

Critical to successful pain intervention is the ability to accurately recognize and quantify pain. Pain is often not given due recognition, underreported and undetected, especially in the nonverbal and patients with communication difficulties or cognitive impairment [33, 34]. In patients who can verbally communicate, pain recognition and quantification rely on the judgment of these individuals in addition to the physiological indicators of pain. On the other hand, the accurate recognition and quantification of pain in nonverbal or cognitively impaired patients is dependent on the practitioner or care provider. Some patients with communication difficulties as seen in intensive care units (ICUs) relay pain using other cues such as signaling with eyes, leg movements, guarding of painful region, and making physical contacts with the practitioner [35]. Hence, these behaviors were incorporated into pain scales for ICU patients under sedation [35]. Practitioners have also employed the use of surrogates and analgesic trials to assess pain [36]. Hence, the successful recognition of pain in these instances lies on the expertise of the practitioner. Additionally, pain recognition and quantification error could result from the patient's inability to express pain even after experiencing a potential painful episode, or from patient not displaying consis-

**48**

tent signs of pain.

There are differences in patients' responses to pain and pain management strategies, thus, necessitating the need to understand the peculiarity of each patient experiencing pain. Proper examination of patient history and adequate knowledge of patient information are vital when considering the choice of pain management regimen. Several studies have reported demographics such as age [37–40], sex [38, 41, 40], and cultural differences including ethnicity [39–40, 42–43] in response to pain and these should be borne in mind. Additionally, the patient's response to pain is influenced by previous pain experience [44], nature of injury [37, 38, 45], and presence of underlying conditions which cause sensory impairment or communication difficulties [46]. These potentially complicate pharmacological pain management strategies. Therefore, understanding and treating each patient as unique is crucial for a successful alleviation of pain.

## **3.3 Personnel factor**

Adequate understanding of pain, its physiology, myths and misconceptions, ethics, recognition, and quantification and management is essential for every pain management personnel. While this is obviously the standard, information in the literature revealed that there are extensive knowledge deficits among most pain practitioners and care providers [47–51]. In hospital settings, provision of pain management relies on trained nurses often following physician's prescriptions [49]. In nonhospital settings such as residential care homes and patients' homes, pain management is performed by the patient or a caregiver in case of morbidity and cognitive impairment. In all these instances, proper knowledge of the pharmacologic agent, its mode of action, duration of the effect, recommended dose, and adverse effects are very important but hardly achieved. Several studies have demonstrated poor pain management strategy practiced by nurses [47–51], which was attributed to education deficit, errors in pain assessment, and side effects of opioids [47].

### **3.4 Drug factor**

The choice of a pharmacologic agent for pain management is influenced by its efficacy and cost, patient response, and practitioner's preference. Different classes of drugs are often combined to maximize pain alleviation. For instance, effective pain management is dependent on the choice of drug, its efficacy, dose, administration technique, adverse effects, time, and consistency of intervention. Pain management is often ineffective because of misuse errors resulting from underdosage, poor administration technique, and inconsistency in timing of administration.

To minimize the complications resulting from the use of a sole analgesic and to achieve balanced analgesia, different classes of agents are combined in a multimodal fashion [52–54]. Though complex, cited advantages include effective and efficient analgesia, and possibly, reduction in doses of one or more individual drugs [54]. However, if misused, they can hinder the effectiveness of analgesics and thus constitute a barrier to effective pain management.

#### **3.5 Gap between scientific evidence and clinical applications**

Even though there exist many scientifically proven analgesic regimens for pain mitigation in the literature [55], effective pain management has not been adequately achieved across treatment settings. It does appear that these evidencebased recommendations are not properly incorporated in clinical practice, thus,

presenting an obvious aperture between these scientific recommendations on pain management strategies and applications in treatment settings. Supporting this claim is the study of Bennetts et al. [56] which demonstrated that the staff of the Australian emergency departments recognized the gap between recommendations and everyday practice-based pain as a barrier to effective pain management. Additionally, the report of Glajchen [57] underscored knowledge gaps as clinician's barrier to effective pain relief. This paucity in the incorporation of evidence-based findings in actual practice may be driven by lack of awareness and knowledge deficits on scientifically proven optimal pain management regimens which are constantly evolving [56, 57], hence, the need to be up-to-date. Therefore, regular training of practitioners through continued education programs and dissemination of current scientific findings in a convenient user-friendly format may help militate this challenge.

Furthermore, the lack of incorporation of scientific findings in treatment settings may also be due to the existence of abundant low-quality scientific evidence which does not meet the required standard to be incorporated into clinical guidelines for pain management [58]. This observation supports the need for high-quality research using refined methods, randomized trials, and efficient research-collaborations. Thus, this has implications for future research.
