Legal and ethical barriers to pain management
A combination of patient, health system, and clinician-related barriers continues to impede access to optimal pain management in the U.S., where 46% of ambulatory cancer patients with pain do not receive treatment adequate to meet WHO standards, despite the many alternatives available. Women, minorities, and patients over 70 are at greater risk than others for inadequate pain control.

Legal and ethical barriers to pain control may be divided into patient, professional, and social factors, as summarized in the table below. Overcoming these barriers requires adherence to four principles: 1) respect for patient autonomy; 2) the willingness to do good for patients; 3) the commitment to avoiding harm to the patients; 4) justice — equal treatment for all patients.

Pain that is unrelieved may create a desire for death — while there is no correlation between morphine dose and death. According to Richard Payne, MD, failure to control pain that can be controlled is "a fundamental breach of human rights." It is a moral imperative that physicians work to relieve pain.

Fortunately, there are many ongoing efforts to support patients' right to pain relief:

The new standards for institutions from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)
The VA initiative — Pain is "the fifth vial sign"
Trend to lawsuits or loss of accreditation/license to practice for undertreatment of pain

(Society of Surgical Oncology. 2000 Annual Cancer Symposium, Symposia Highlights, p. 8.)

Types of barriers to pain management
Barrier type:
Specific barriers

Patient factors:
Patient fear of discussing pain:
Fear of being labeled a complainer
Fear that treatment will be discontinued
Fear that pain discussion will divert physician's attention from the underlying disease
Fear of taking pain medicine, especially opioids

Professional factors (physicians, nurses, etc.):
Poor pain assessment skills
Concern about drug side effects
Exaggerated fear of addiction
Fear of regulatory sanction

Health System factors:
Unavailability of some drugs for some patients
Cost of care
Inadequate physician reimbursement for pain management and palliative care

(Society of Surgical Oncology. 2000 Annual Cancer Symposium, Symposia Highlights, p 8.)