To the Editor:
We appreciate the thoughtful comments embodied in the four editorials on our article (1). Because our review is congruent with every governmental and professional white paper on the benefits of appropriate pain management, we are not surprised that three of the editorials were strongly supportive. White and Kehlet (2), however (4), give the impression that our article focused upon the relief of pain by opioids as a fundamental human right. The title of our article and its content make it clear that this is not the case. Only one line of the article’s abstract and <15% of its text are devoted to the use of opioids for pain management. Nevertheless the level of opioid administration is universally used as a marker to indicate whether pain management is being given an appropriate priority. In particular, Figure 1 in the editorial by Scholten et al. (3) of the World Health Organization employs per capita opioid consumption as a measure of the quality of pain management in various countries throughout the world.
The current article (1) and prior publications of two of the authors (4–6) make it clear that we regard persistent pain as a multifaceted problem requiring a multimodal approach to management.
For most of the world’s population and in many settings, opioids offer a unique combination of low cost and great effectiveness. The World Health Organization, the other editorialists, and the leading professional and governmental bodies cited in our article share this view. A recent article by Sykes (7), declared that “morphine kills the pain, not the patient.” and observed that “professional and public anxieties about the effects of morphine continue to hinder adequate access to analgesia.” He summarized abundant, highly credible data from various countries that “found no significant difference in survival according to either absolute morphine dose or change in morphine dose” and noted further evidence that “underprescribing of opioids remains a major barrier to effective pain control.” Relevant to our review (1)and the White-Kehlet response (2), he continued that “if ineffective pain management is still an issue in high-income countries, it is nearly universal in low-income countries where access to morphine is limited or absent, but where most people dying of cancer or AIDS reside.” He concluded that opioiphobia, fueled by rhetoric favoring expensive alternatives accessible only in the developed countries, would result in the world’s poor getting nothing.
Can any agreement be reached between our article and the White/-Kehlet editorial (2)? We believe so. These shared conclusions include:
- Physicians require education about all aspects of pain management, including the safe use of opioids.
- Opioids are not the only agents for management of pain, but they should be available as one method of treatment.
- Opioids should be prescribed and used in a manner that is reasonable and appropriate, according to the needs and responses (including side effects) of each individual.
This balanced approach is what our patients need, expect and deserve from us.
Frank Brennan, MBBS, DCH. Dip Obs, FRACP, FAChPM, FACLM, LLB
Daniel B. Carr, MD, FABPM, FFPMANZCA (Hon)
Michael Cousins, MBBS, MD, DSc, FANZA, FFPMANZCA, FAChPM, (RACP)
Pain Management Research Institute
University of Sydney at Royal North Shore Hospital
St. Leonards, NSW Australia
1. Brennan F, Carr DB, Cousins MJ. Pain Management: a fundamental human right. Anesth Analg 2007;105:205–21
2. White PF, Kehlet H. Improving pain management: are we jumping from the frying pan into the fire? Anesth Analg 2007;105:10–12
3. Scholten W, Nygren-Krug H, Zucker H. The World Health Organization paves the way for action to free people from the shackles of pain. Anesth Analg 2007;105: 1–4
4. Siddall PJ, Cousins MJ. Persistent pain as a disease entity: implications for clinical management. Anesth Analg 2004;99:510–20
5. Walker SM, Goudas LC, Cousins MJ, Carr DB. Combination spinal analgesic chemotherapy: a systematic review. Anesth Analg 2002;95:674–715
6. Cousins MJ, Bridenbaugh PO, eds. Neural blockade in clinical anesthesia and management of pain. 3rd ed. Philadelphia: Lippincott-Raven, 1998
7. Sykes NP. Morphine kills the pain, not the patient. Lancet 2007;369:1325–26