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The Global Burden of Pain: The Tip of the Iceberg?

Enright, Angela MB, FRCPC; Goucke, Roger MB, ChB, FFPM, ANZCA

doi: 10.1213/ANE.0000000000001519
Editorials: Editorial

From the *Department of Anesthesia, University of British Columbia, Royal Jubilee Hospital, Victoria, British Columbia, Canada; and School of Medicine and Pharmacology, University of Western Australia, Western Australia, Australia.

Accepted for publication June 20, 2016.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Angela Enright, MB, FRCPC, 2797 Arbutus Rd, Victoria, BC, Canada V8N 5X6. Address e-mail to

“Who, except the gods, can live time through forever without any pain?”


The global burden of pain is large and growing. The International Association for the Study of Pain estimates that 1 in 5 patients experience pain and that 1 in 10 patients are diagnosed with chronic pain every year.1 Pain is the most common reason patients seek medical care.2

Jackson et al,3 in this issue of Anesthesia & Analgesia, have attempted to assess the burden of chronic pain, which does not have a clear etiology, in those individuals living in low- and middle-income countries (LMICs).3 Their meta-analysis confirms the prevalence of unspecified persistent pain to be 34% in the general population in LMICs. This is consistent with the earlier findings of the World Mental Health Survey of 2008, which found a prevalence of persistent pain in LMICs of 41%,4 and that of the study by Elzahaf et al5 who observed it to be 33.9%. There is much heterogeneity in the types of chronic pain reported, including back pain, headache, musculoskeletal pain, and pelvic pain. It is also clear that chronic pain is more prevalent in the elderly and workers.

Not currently explored by Jackson et al3 is the ever-increasing prevalence of chronic pain from known causes such as cancer, injuries, and human immunodeficiency virus infection and acquired immune deficiency syndrome.6 An estimated 25% of the burden of chronic pain results from surgery and trauma; 60% to 70% of patients with advanced cancer and late-stage acquired immune deficiency syndrome experience moderate to severe pain; and 70% of the pain experienced by elderly patients is chronic noncancer pain.7

Claudius, in Shakespeare’s Hamlet, opined, “When sorrows come, they come not single spies but in battalions.” So it is with chronic pain, which is often accompanied by depression, anxiety, anorexia, sleep disturbance, decreased mobility, and a host of social challenges related to family, work, costs, and finances.7,8 The economic burden can certainly be significant for the patient and family, but it is huge for society as a whole. It has been estimated that 1 million working days per year are lost in Denmark because of chronic pain.9 In the United Kingdom, health care costs for back pain are estimated to be 1 billion pounds per annum.10 It is difficult to estimate the economic costs of chronic pain in LMICs, but they must be considerable.

There is universal agreement that chronic pain is inadequately, if not poorly, managed everywhere—but especially in LMICs. The World Health Organization estimates that 80% of people with severe pain do not receive adequate treatment.11 There are many barriers: availability of medications, education of professionals, cultural misconceptions, laws and regulations, and health care system-related issues.6,8,12 Governments do not regard the management of pain as a priority.12 There is competition for scarce health care dollars. Major funding agencies view pain as a symptom of disease rather than a disease in its own right. They are focused on curing the disease and not on treating the accompanying pain.1 Access to opioids is controlled by international agencies which have adopted a law enforcement approach that makes it difficult for countries to obtain sufficient opioids to treat severe acute and cancer pain in their populations.11

So looking to the future, what can be done? Jackson et al3 recommend standardizing pain-related definitions so that more valid and reliable epidemiologic data can be gathered and used to define the extent of the problem. Medical, nursing, and pharmacy schools as well as residency training programs need to improve the education of their students and trainees in the management of pain. Physicians and other clinicians need to adopt a multimodal approach to the treatment of chronic pain, with an emphasis on the use of not only opioids but also adjuvant analgesics (eg, antiepileptic and antidepressant drugs) for chronic noncancer and cancer pain, plus a better understanding of the psychosocial determinants and effects of pain. Governments need to prioritize pain management in their health care initiatives and ensure that a consistent, safe supply of opioids and other analgesics is available for those in need. Finally, international agencies such as the World Health Organization should further acknowledge and promulgate that the assessment and treatment of chronic pain is a basic human right13 and should make it a very high public health priority. Then, perhaps, patients in pain will receive the treatment they deserve.

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Name: Angela Enright, MB, FRCPC.

Contribution: This author helped write the manuscript.

Name: Roger Goucke, MB, ChB, FFPM, ANZCA.

Contribution: This author helped write the manuscript.

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