Optimizing control of pain from severe burns: a literature review.

The importance of assessing and treating pain was made salient recently when the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2000) declared that pain should be regarded as the fifth vital sign. Yet, the literature suggests that problems with undertreatment of pain have only improved modestly. In the 1970s and 1980s, scathing editorials were published by such journals as the Lancet and New England Journal of Medicine chastising physicians for undertreating this problem (Angell, 1982; Freed, 1976), and this was supported by a number of studies (Anand & Hickey, 1987; Eland & Anderson, 1977; Perry, Heidrich, & Ramos, 1981). Melzack (1990) argued in a Scientific American review that the problem persisted, in spite of unwarranted fears about addiction to morphine when used for pain control, and cited compelling evidence for this, such as children frequently receiving major surgery, including limb amputation, with no medication for relief of their postoperative pain. More recent writings suggest that undertreatment of pain is still a significant problem in a variety of clinical settings (Breitbart et al., 1996; Carr & Thomas, 1997; Ducharme, 2000; Engel, Kartin, & Jensen, 2002; Katz, 2002), including the extremes of age (Banos, Ruiz, & Guardiola, 2001; Feldt & Oh, 2000) and patients with cancer (FrankStromborg & Christensen, 2001). The persistence of inadequate treatment is the result of educational factors (e.g., subtherapeutic dosing, lack of documentation of analgesic effect) as well as psychological factors; e.g., pain is subjective, regarded as a “symptom” and not a “disease,” and often cannot be targeted by “magic bullets” (Ducharme, 2000; Jacob & Puntillo, 2000; Resnik, Rehm, & Minard, 2001). Although increased attention to pain assessment and pain management has occurred in recent years, observations that inadequate acute pain management contributes to poor functional outcomes in settings such as burns (Ptacek, Patterson, Montgomery, Ordonez, & Heimbach, 1995) American Journal of Clinical Hypnosis 47:1, July 2004 Copyright 2004 by the American Society of Clinical Hypnosis