Undertreatment of pain and fears of addiction in pediatric chronic pain patients: how do we stop the problem?

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Undertreatment of pain, or oligoanalgesia, is a serious worldwide problem in the pediatric setting (Alexander & Manno, 2003; Lander, 1990; Rupp & Delaney, 2004;

Wolfe et al., 2000) that can lead to patient anger, frustration, depression, low self-worth, anxiety, mistrust, isolation, or even suicide (Fishbain, Goldberg, Rosomoff, & Rosomoff, 1991; Stimmel, 1989; Weissman & Haddox, 1989). In an effort to quell this "public health problem," the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) developed standards that deemed pain assessment to be the "fifth vital sign" and pain treatment to be a patient right.

Marks and Sachar's historic study (1973) first brought light to the problem of poor pain management, implicating the lack of pharmacologic information, misunderstanding about addiction and its prevalence, or even "puritanical counter-reactions" about prescribing a drug that could cause euphoria as some of the root causes. These same problems exist today and are unfortunately compounded by stereotyping based on cause of pain, race, culture, gender, socioeconomic status, age, lack of parental understanding of the pros and cons of pain medication, and lifestyle (Elander, Lusher, Bevan, & Telfer, 2003; Goldfrank & Knopp, 2000; Hostetler, Auinger, & Szilagyi, 2002; Rupp & Delaney, 2004; Stimmel, 1989).

Despite the overwhelming evidence to the contrary, many physicians cite fear of addiction as their primary reason for not prescribing additional opioids when their patient complains of pain (Fishbain, Rosomoff, & Rosomoff, 1992; Friedman, 1990; Lander, 1990; Portenoy, 1990; Rupp & Delaney, 2004; Schnoll & Weaver, 2003). As a result of this opiophobia (Furrow, 2001), many patients up the ante by displaying progressively worsening symptoms in an attempt to get the medication they need to feel relief. They may even resort to extreme behaviors they would have normally considered unconscionable had their pain been adequately controlled (Kirsh, Whitcomb, Donaghy, & Passik, 2002; Porter-Williamson, Heffernan, & von Gunten, 2003). This phenomenon, called pseudoaddiction, was first described in 1989 by Weissman and Haddox (1989) and is often misdiagnosed as a true addiction.