Pain is a more terrible lord of mankind than even death itself.
Pain, particularly chronic or persistent pain, has become a significant health care and socioeconomic burden worldwide. We have ample evidence that pain reduces quality of life and has physical, psychological, and environmental impacts not only on the individual but also on society as a whole.1 So why is it neglected?
In the first 2 decades of the 21st century, 5.5 billion people, approximately 80% of the world’s population, live in countries with little or no access to pain management; 4% have moderate access with only 7% having adequate access.2
Every year up to 5.5 million patients with cancer and 1 million with end-stage human immunodeficiency virus/acquired immune deficiency syndrome experience moderate to severe pain.2
Apart from cancer, many other medical conditions cause pain, for example, ischemic heart disease, infections such as zoster and leprosy, renal calculi, and diabetes. When we consider these and the multiple other causes of pain that contribute to the burden, such as labor pain, acute noncancer pain, road trauma, and burns, the prospect for effective pain control remains daunting.
It is estimated that 28% of the global burden of disease may be averted by appropriate surgery and safe anesthesia.3 With the Lancet Commission on Global Surgery calling for a significant expansion of surgical services, postoperative pain management will need to be an increasing focus of our attention.4 Poorly treated postsurgical pain can lead to persistent or chronic pain. It is essential that the increase in surgical procedures is accompanied by appropriate acute pain management.5
INCIDENCE OF PAIN
It has been estimated that globally 1 in 5 adults suffer from pain and that another 1 in 10 adults are diagnosed with chronic pain each year.6 The 4 main causes of pain are cancer, arthritis, surgery and injuries, and spinal problems. A recent systematic review and meta-analysis of the burden of pain (with no clear etiology for the pain) in low- and middle-income countries (LMICs) identified a prevalence of 34%. This is similar to earlier studies of 41% and 33.9%.7,8 These “unclear” pain types included low back pain, headache, musculoskeletal pain, pelvic pain, abdominal pain, and unspecified chronic pain. These conditions are all well recognized but are difficult to treat even in high-income countries.9
With the appropriate use of oral opioids, 80%–90% of cancer pain can be controlled.10 However, progress has been exceptionally slow in delivering opioids to those in need. In 1961, the Single Convention on Narcotic Drugs was adopted by the United Nations specifically to control the use of opioids but also recognized their value in relieving pain and suffering. In the early 1980s, the World Health Organization (WHO) developed draft guidelines that included the WHO ladder. These guidelines had a profound impact on cancer pain management by recommending an approach to treating mild, moderate, and severe cancer pain by the gradual introduction of oral opioids.11 In spite of continuous advocacy by the WHO and bodies such as the Pain and Policy Studies Group in Wisconsin, huge disparities remain across the globe with regard to access to morphine.12 Only 6.7% of the world’s medical opioids are available to LMICs despite these countries having 74% of the world’s deaths from cancer and human immunodeficiency virus.13 A further Lancet Commission Report: “Alleviating the access abyss in palliative care and pain relief - an imperative of universal health coverage,” highlights these incidence figures and further emphasizes the access issues.14
Barriers are many and have been variously classified. At a recent International Association for the Study of Pain (IASP) workshop held in the Philippines, participants classified barriers into those relating to the health care system and its workforce, drug availability, and patients (Table). These barriers occur at multiple sites along the health delivery pathway, at government, hospital, or community level.
The importance of a clear policy on opioid access from central government is paramount but often not seen as a priority due to competing health care issues. The Ministry of Health in Vietnam introduced a balanced policy for palliative care, cancer, and acquired immune deficiency syndrome in 2006. A recent report15 describes the development of a committed stakeholder group that included senior health officials, police, and regulatory personnel along with cancer physicians. Their progress over 7 years demonstrates a 9-fold increase in morphine consumption and an increase from 3 to 15 in the number of hospitals offering palliative care.
Access to oral morphine should not be difficult. Immediate release morphine is cheap to manufacture. The regulations of the International Narcotics Control Board, while still complex, allow countries to import medicinal morphine. The International Narcotics Control Board requires estimates of opioid requirements 1 or 2 years in advance—this remains a challenging procedure in resource poor countries. Country-specific restrictions, including concern about abuse and dependence, are a major factor in limiting access to opioids and other controlled medicines. Difficulty distributing to regional centers can be problematic. Regulatory requirements restrict the prescription of opioids without a special licence, and special prescription pads are often required. These may be in short supply, and in some countries, these must be purchased from government agencies by the practitioners using them. Limits to dispensed quantities for rural and remote patients add to the excess burden.
Health care workers can also be hindered by their own barriers: often overworked (eg, only 1 registered nurse for a ward of 60 patients) with insufficient and inadequately trained colleagues, attitudinal concerns, and lack of education.16 The myths and misunderstandings about opioid use (opioid phobia) among health care workers must be continually countered17–19 by reiterating the overwhelming expert opinion that most patients, when appropriately prescribed opioids for cancer pain, do not develop overt signs of addiction.13,20,21
Patient beliefs, not surprisingly, act as barriers. It is well known that patients may not volunteer to their health care worker that they have pain unless directly asked (the doctor may not be interested or have the knowledge to treat pain or the patient wants the doctor to focus on their disease and cure the cancer).22,23 Health care workers may be seen as “all knowing” and therefore should not have to ask questions of their patients, a frequently heard barrier in Australian Aboriginal communities.
In communities where religious beliefs are powerful, it is important to understand how these beliefs may affect an individual’s response to pain and suffering. Many communities may identify a spiritual cause for their pain, such as pain being a test from God or a punishment for some past misdemeanour. Irrespective of the biological cause, we have seen patients reluctant to take oral opioids because of their beliefs. Comments such as “pain may be my passport to heaven” or “this pain is God’s will - which I must bear” are not uncommon.
Spiritual and religious beliefs are clearly beneficial in some cultures and communities. Belief in a happy afterlife, rebirth, or being skilled in Buddhist or Hindu practice is particularly valuable. Acceptance of suffering and karma as part of living and being able to practice detachment or mindfulness may be of significant benefit if there are no opioids to ease cancer-related pain.24,25
ADDRESSING THE PROBLEM
Can human rights principles be used to persuade governments to address this neglected area of inadequate pain relief in LMICs? A number of authors have drawn our attention to pain, suffering, and ethics that led the IASP to initiate the Global Pain Day in 2004, “the relief of pain should be a human right.”26 This initial Global Pain Day was cosponsored by the WHO and the European Federation of International Association of Pain Chapters (EFIC). Further advocacy from the IASP followed with the International Pain Summit and the Declaration of Montreal in 2010. Here the summit declared that access to pain management is a fundamental human right.27
Raising awareness about the prevalence of pain in LMICs is part of the solution and one aim of the global health section of this journal. The IASP and the World Federation of Societies of Anaesthesiologists (WFSA) are also active advocates here.28,29
Promoting the concept that access to appropriate pain relief should be a basic human right, and continuous advocacy for this on the global stage, is also essential. The place for advocacy by the international pain organizations and the world medical bodies such as the WHO and the World Medical Assembly, together with the United Nations, has recently been reviewed.30
The recent pain and palliative care Lancet Commission Report draws our attention to the serious health-related suffering experienced by individuals requiring palliative care and pain relief and proposes an affordable essential package of medicines and equipment to remedy access to care.14
As a noncommunicable disease, the problem posed by unrecognized and untreated pain and its prevalence, including its psychological and social aspects, must make pain a public health priority demanding6 universal access to treatment.31
With regard to education, multidisciplinary pain medicine is seldom taught in medical or nursing schools at undergraduate level, despite a curriculum having been made available through the IASP for many years.32–34 Undergraduate curricula are often in constant states of flux and development and, unless pain clinicians lobby medical school curriculum development officers to include components related to pain medicine, there will be little progress in addressing the multiple myths about pain and opioid use.1
Education for practicing health care workers is also not readily available. There are a number of projects now under way that attempt to address these educational barriers. The WFSA and IASP have been providing fellowships to attend up to 1 year in a Regional Training Centre. The Bangkok Regional Centre started pain medicine training in 2008 and since then has trained 19 participants, who have returned to their home countries throughout Asia. The program consists of training in a multidisciplinary pain service with experience in practical problem-based learning that can be applied to their clinical work.
Regional centers with funding from the WFSA and IASP also offer up to 8 short- and long-term pain management fellowships in South America, South Africa, and India.35
Once awareness of the size and cost of the problem comes to the attention of governments, we need to be ready with some solutions. Education for health care undergraduates and professionals is poor, as is information available to the general community or indeed patients themselves. There are a number of sources of good educational and informational material readily available.36 Community education can be offered through newspapers, television, and patient handouts at hospitals and medical facilities (including community schools). The challenge for access to oral opioids requires us to educate governments and regulators about the need for balance between regulation and control of these powerful yet cheap drugs and their use in cancer, acute perioperative, and trauma pain.37 Governments must also support the pharmaceutical industry to deliver low-cost, immediate relief oral morphine for cancer pain management.38
In 2010, a 1-day interactive educational program covering the recognition, assessment, and management of pain was developed. The program is called Essential Pain Management and uses case-based discussions relevant to the types of pain commonly seen in particular areas. This 1-day program can be combined with a Teach the Teacher course that promotes local ownership and propagation of the program. Since 2010, Essential Pain Management has been run in 47 LMICs, and recently, a condensed 4-hour course is being used in a number of Australian, New Zealand, and British medical schools.39
In 2011, the IASP started a further educational initiative in the form of interdisciplinary pain management camps. These are run in conjunction with the biennial congress of the Association of South East Asian Pain Societies. They have been held in Bangkok, Singapore, Manila, and Yangon. The camps offer short, real-life, interactive, group sharing experiences and are combined with a didactic lecture course.
Pain is a common, widespread problem with some clearly complex barriers that need to be overcome before more effective treatment options can be delivered to our patients across the world. The way forward is for us to maintain strong advocacy at all government levels and to focus on education, primarily at the undergraduate level for medical, nursing, and allied health students but also for established health care providers.
With our increasing knowledge of the mechanisms of pain and the complex interaction between the social, psychological, environmental, and physical components, we must do more to address these issues not only in the low-resource setting but also in high-income countries.
Name: C. Roger Goucke, FFPMANZCA.
Contribution: This author helped design the article and write the manuscript.
Conflicts of Interest: C. R. Goucke is an author of the Essential Pain Management Programme, and he is the lead author.
Name: Pongparadee Chaudakshetrin, FFPMANZCA (Hon).
Contribution: This author helped design the article, review and edit the manuscript, and contribute references.
Conflicts of Interest: P. Chaudakshetrin is a previous Director of the Bangkok Regional Pain Medicine Training Programme.
This manuscript was handled by: Angela Enright, MB, FRCPC.
1. Sessle B. Unrelieved pain: a crisis. Pain Res Manag. 2011;16:416–420.
2. Seya MJ, Gelders SF, Achara OU, Milani B, Scholten WK. A first comparison between the consumption of and the need for opioid analgesics at country, regional, and global levels. J Pain Palliat Care Pharmacother. 2011;25:6–18.
3. Walters JL, Jackson T, Byrne D, McQueen K. Postsurgical pain in low- and middle-income countries. Br J Anaesth. 2016;116:153–155.
4. Meara JG, Leather AJ, Hagander L, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–624.
5. Lavand’homme P. Transition from acute to chronic pain after surgery. Pain. 2017;158(suppl 1):S50–S54.
6. Goldberg DS, McGee SJ. Pain as a global public health priority. BMC Public Health. 2011;11:770.
7. Tsang A, Von Korff M, Lee S, et al. Common chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders. J Pain. 2008;9:883–891.
8. Elzahaf RA, Tashani OA, Unsworth BA, Johnson MI. The prevalence of chronic pain with an analysis of countries with a human development index less than 0.9: a systematic review without meta-analysis. Curr Med Res Opin. 2012;28:1221–1229.
9. Jackson T, Thomas S, Stabile V, Shotwell M, Han X, McQueen K. A systematic review and meta-analysis of the global burden of chronic pain without clear etiology in low- and middle-income countries: trends in heterogeneous data and a proposal for new assessment methods. Anesth Analg. 2016;123:739–748.
10. Wiffen PJ, Wee B, Moore RA. Oral morphine for cancer pain. Cochrane Database Syst Rev. 2016;4:CD003868.
11. Lohman D, Schleifer R, Amon JJ. Access to pain treatment as a human right. BMC Med. 2010;8:8.
12. Cleary JF, Husain A, Maurer M. Increasing worldwide access to medical opioids. Lancet. 2016;387:1597–1599.
14. Knaul FM, Farmer PE, Krakauer EL, et al. Lancet Commission on Palliative Care and Pain Relief Study Group. Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report. Lancet. 2017 October 11 [Epub ahead of print].
15. Krakauer EL, Nguyen TP, Husain SA, et al. Toward safe accessibility of opioid pain medicines in Vietnam and other developing countries: a balanced policy method. J Pain Symptom Manage. 2015;49:916–922.
16. Zhang Q, Yu C, Feng S, et al. Physicians’ practice, attitudes toward, and knowledge of cancer pain management in China. Pain Med. 2015;16:2195–2203.
17. Flemming K. The use of morphine to treat cancer-related pain: a synthesis of quantitative and qualitative research. J Pain Symptom Manage. 2010;39:139–154.
18. Grant M, Ugalde A, Vafiadis P, Philip J. Exploring the myths of morphine in cancer: views of the general practice population. Support Care Cancer. 2015;23:483–489.
19. Colak D, Oguz A, Yazilitas D, Imamoglu IG, Altinbas M. Morphine: patient knowledge and attitudes in the central Anatolia part of Turkey. Asian Pac J Cancer Prev. 2014;15:4983–4988.
20. Carlson CL. Effectiveness of the World Health Organization cancer pain relief guidelines: an integrative review. J Pain Res. 2016;9:515–534.
22. Cohen E, Botti M, Hanna B, Leach S, Boyd S, Robbins J. Pain beliefs and pain management of oncology patients. Cancer Nurs. 2008;31:E1–E8.
23. Daher M. Cultural beliefs and values in cancer patients. Ann Oncol. 2012;23(suppl 3):66–69.
24. Whitman SM. Pain and suffering as viewed by the Hindu religion. J Pain. 2007;8:607–613.
25. Yodchai K, Dunning T, Savage S, Hutchinson AM, Oumtanee A. How do Thai patients receiving haemodialysis cope with pain? J Ren Care. 2014;40:205–215.
26. Brennan F. Palliative care as an international human right. J Pain Symptom Manage. 2007;33:494–499.
30. Brennan F, Carr D, Cousins M. Access to pain management–still very much a human right. Pain Med. 2016;17:1785–1789.
31. Gilson AM, Maurer MA, Ryan KM, Skemp-Brown M, Husain A, Cleary JF. Ensuring patient access to essential medicines while minimizing harmful use: a revised World Health Organization tool to improve national drug control policy. J Pain Palliat Care Pharmacother. 2011;25:246–251.
32. Watt-Watson J, McGillion M, Hunter J, et al. A survey of prelicensure pain curricula in health science faculties in Canadian universities. Pain Res Manag. 2009;14:439–444.
33. Bair MJ. Learning from our learners: implications for pain management education in medical schools. Pain Med. 2011;12:1139–1141.
34. Briggs EV, Battelli D, Gordon D, et al. Current pain education within undergraduate medical studies across Europe: Advancing the Provision of Pain Education and Learning (APPEAL) study. BMJ Open. 2015;5:e006984.
37. Alford DP. Opioid prescribing for chronic pain—achieving the right balance through education. N Engl J Med. 2016;374:301–303.
38. Setiabudy R, Irawan C, Sudoyo AW. Opioid use in cancer pain management in Indonesia: a call for attention. Acta Med Indones. 2015;47:244–250.