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Release: April 12, 1999

UI study finds many physicians withhold pain medication

IOWA CITY, Iowa -- Many physicians withhold pain medication from patients in emergency situations because of informed consent issues or because the doctors believe the drugs may affect the accuracy of their diagnoses, a University of Iowa survey found.

However, withholding pain medication may actually be a barrier to informed consent and accurate diagnoses, said Mark A. Graber, M.D., associate professor of surgery and family medicine, and the study's principal investigator. The survey's results did not surprise Graber, an emergency room doctor who believes physicians should abandon this unnecessary caution against administering pain medication.

"Current training teaches that we should not use pain medication because it can affect a diagnosis and informed consent," Graber said. "However, current studies suggest that giving pain medication may actually result in fewer unnecessary surgeries. Although decisions about which and how much medication to administer should be done on a case-by-case basis, we should be more generous with pain medication."

The results of Graber's survey appeared in the March issue of the American Journal of Emergency Medicine.

In July 1996, Graber mailed a questionnaire to all 182 general surgeons practicing in Iowa. He wanted to determine their beliefs about the use of analgesics for acute abdominal pain and examine how these beliefs affect prescribing patterns.

Of the 131 respondents, 78 percent considered the ability to obtain informed consent in their decisions to forgo pain medication. The survey also showed that 53 percent thought the amount of pain medication necessary to make patients comfortable would prevent the patients from signing a legally binding informed consent.

Informed consent is an important ethical and legal issue for all physicians. Valid informed consent requires patients act independently without coercion. The individuals must have received appropriate, comprehensible information. At the time of consent, the patients must be able to communicate their decisions.

The informed consent definition raises two questions, Graber said. One, does administering pain medication void patients' informed consent because of a loss of judgment and competence due to mental clouding? Two, recognizing that no physician would purposefully cause patients to suffer, can withholding pain medication (external coercion) or the presence of pain, which may limit the patients' ability to concentrate on and understand doctors' explanation, invalidate informed consent?

To answer the first question, one need only look at other medical experiences, Graber said. There are patients who receive large doses of narcotics, such as individuals with terminal cancer. These people are considered competent to make their own health care decisions.

As for the second question, patients in pain want to relieve that pain, Graber said. Therefore, patients may give hasty consent to surgery or other interventions knowing that once they have, relief will be forthcoming. These treatments may not be in the patients' best interests.

"Pain relief may actually enhance a patient's ability to give informed consent by removing coercive factors," Graber said.

In addition to informed consent, doctors also consider how administering pain medication might affect the accuracy of their diagnoses. Sixty-seven percent of survey respondents indicated that drugs hindered their ability to make accurate diagnoses. Graber disagrees with this majority opinion, pointing out that studies suggest diagnostic accuracy increases with the use of pain medication because it increases sensitivity and specificity of the physical examination.

"Since withholding pain medication may actually be a barrier to informed consent and diagnostic accuracy, these policies should be reconsidered," Graber said.