|Year : 2016 | Volume
| Issue : 1 | Page : 28-32
Pain management: An ignored medical issue
Ranabir Pal1, Swapan Kumar Paul1, Pandurang Vithal Thatkar1, Shrayan Pal2
1 Department of Community Medicine, Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, Andaman and Nicobar Islands, India
2 Department of Medicine, I.D. and B.G. Hospital, Kolkata, West Bengal, India
|Date of Submission||09-Apr-2016|
|Date of Acceptance||04-May-2016|
|Date of Web Publication||2-Jun-2016|
Department of Community Medicine, Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair - 744 104, Andaman and Nicobar Islands
Source of Support: None, Conflict of Interest: None
Background: Pain is reality from womb to tomb as the specific personalized articulated feeling of human beings whether they need respite or not.
Objective: To find an optimum primary care approach to pain management.
Methods: The investigators pursued a sincere effort to unearth an answer to pain management through their internalized clinical experience of managing the commonest presentation of symptoms at their clinics by hundreds of ailing citizens.
Results: Since ancient times, thousands of interventions have been practiced for relief of pain including an array of self-medications and traditional practices. In the era of "Evidence Based Medicine" in this new millennium, all forms of pain managements need scientific evaluation by the application of highest research integrity before they can be adapted as a standard treatment protocol. As the severity of the pain is a grossly subjective, the treatment/drug of choice and/or the methods/dosage should depend on the judgments of objective severity by the health care providers, depending on the objective clinical/ radiological/ pathological/ biochemical criteria and if possible by formulating scoring systems. Rather than managing the pain based on the expressed perception of the severity of pain by the patient as mild, moderate or severe, we have to be innovative in the new paradigm of this nascent pain management scenario.
Conclusions: We have to help the budding doctors to grow up not only as a sensible doctor, but also as a great human being, who will give due attention to pain through a holistic tailor-made approach.
Keywords: Care, management, pain, relief
|How to cite this article:|
Pal R, Paul SK, Thatkar PV, Pal S. Pain management: An ignored medical issue. BLDE Univ J Health Sci 2016;1:28-32
"For the past two days, I had unbearable pain in my legs and back. I became unconscious twice and I felt as if I was going to die. The doctor said that there was no need to medicate my pain that it was just a contusion and that the pain would go away slowly. I was screaming all through the night." - A man describing his stay in a hospital in Andaman and Nicobar Islands sustaining a road traffic injury.
| Prologue|| |
Pain, peace, and happiness are subjective feelings; one cannot imagine life without pain. Although universality of pain is spread to fauna and flora, we are only dealing with pain to human beings. The journey of pain starts when the baby is born - after a prolonged period of pain caused by a human baby makes mother to get a dream during birth. Poor mother suffers with intense pain and it is likely that the baby might also be experiencing some pain during delivery. It is thus empirically evident that in all the living beings, the spectrum of pain stretches from birth to death. In everyday life, we are facing pain of variable intensities, and it has become a paradigm for common man's parlance. Further, pain has different thresholds for different individuals and so, treatments for painful conditions also differ from person to person. Pain is actually a defense mechanism of the body, as without pain a person can hurt himself, without knowing the impending danger. Many diseases can also be assessed by the presence of pain as a surrogate marker in diagnosis and prognosis as after treatment, disappearance or reduction of pain denotes appropriateness of the line of thought by the health-care providers. When a patient approaches the doctor in pain, he is always in a hurry to get relief and for this, he is ready to do anything. 
| Pain is not a Single Entity|| |
Pain is often a symptom in acute and chronic diseases and injuries, so the management of pain depends on the types and sources of pain. Sources of pain may be nociceptive and neuropathic pain. There are various causes of pain, for example, headaches, oropharyngeal pain, visceral pain, peripheral nerve pain, coccydynia, compression fractures, postherpetic neuralgia, myofasciitis, piriformis torticollis, syndrome, lateral epicondylitis, plantar fasciitis, cancer pain, etc. Even after appropriate treatment, if pain is persistent, it is recognized as chronic pain. It has been demonstrated by scientific research that moderate-to-severe persistent pain, which has a series of physical, psychological, and social consequences compromises the quality of life. ,
Suffering caused by the pain is not quantifiable, whereas the physical, psychological, and social consequences of pain can be measured. It has been observed that people with severe pain often live in agony for long periods. Pain may also show social consequences resulting in sleep deprivation among other problems such as inability to work, caring their children and family members, and participating in social activities. Cancer and torture survivors even want to commit suicide to end the pain. 
Every day, ailing people worldwide plead to die because of pain and the only way open to them for relief of pain. In the Netherlands, more than 80% of euthanasia is reported to be cancer cases mostly with pain. 
In pain management, trusts develop in care seekers by continuous assessment of caregivers regarding sincerity and updated knowledge. One must keep in mind that effective management of pain can only be achieved through sincere assessment, diagnosis and action plan designed to decrease pain, improve function, and positively impact the quality of life. Further, advanced research is sure to strengthen protocol-based clinical pain management. 
In day-to-day life, pain arises from body parts such as head, neck, throat, abdomen, back nerves, chest, joints as well as from diabetes, cancers, fractures and complex regional pain syndromes, disk herniation, osteoporosis, postsurgery, and shingles among other ailments. Depending on the cause, pain management can be simple or complex and will require a wide variety of skills and techniques to treat the pain, which include comprehensive medication, nerve block, radiofrequency rhizotomy, epidural injections, provocative discography, vertebral augmentation, spinal cord stimulation, infusion therapy, exercise, psychological support, stress management, relaxation therapy, acupuncture, and community-based rehabilitation with scopes for further development in each mode of intervention through research.
In India, in the primary health-care setup, the most common over-the-counter (OTC) drugs are analgesics. However, it is already mentioned earlier in the article that there is a need to give a holistic approach for pain management as it is well known that all the analgesics constrict the afferent arterioles of glomerulus inside human kidneys and may result in renal injuries/chronic renal diseases, leading to renal failure in the near or distant future. It is astonishing that no doctors tell this to their patients and so, indiscriminate use of analgesics are continued, even for trivial pains. Undue benefit is also taken by the so-called qualified and unqualified health-care providers ("?quacks"), who prescribe new and newer brands and old molecules in the so-called new combinations in fascinating names, which are not only causing damage to the kidneys, but also putting undue pressure on their pockets. 
| Pain Relief: We Need Tailor-made Approach|| |
Treatment options for pain are medications, therapies, and body-mind techniques. For any pain management program, the role of physical therapist is very important as he/she can tailor the right exercise regimen, which slowly builds tolerance and reduces pain. Further, meditation, relaxation techniques, transcutaneous electrical nerve stimulation therapy, visual imagery, for example, biofeedback, which teaches control over muscle tension, heart rate, and heat and cold therapy manipulation can be advised. Starting from the Charaka and Sushruta days, empathy has been the driving force to strive for treating pain. Conventional medical education invariably misses the profound associations of interpersonal relations as part of the success of treatment of pain, which is often psychosocial in origin. During pain, people move from pillar to post from traditional healers through private medical practitioners to even a super-specialist of modern medicine, for relief from pain, without consideration even for their financial capabilities. Incidentally updating of knowledge among health-care providers is not commonplace in our country. ,
Majority of the patients approaching the health-care providers come with pain and demand immediate relief; it is a usual practice of the health-care providers to somehow dispose the patient without giving due importance to situational analysis of the trail of events that led to the painful condition. This leads to chronicity of the pain and further blurring of diagnosis and subsequent frustration regarding the surety of relief from pain. This may also cause missed diagnosis of major disease, where pain is surrogate marker, for example, brain tumors often present with morning headache, which may be marked as sleep disturbance or tension headache. In this modern era, where analgesic medications are in abundance, even as OTC drugs, traditional analgesics are not always effective in all painful conditions; common nonsteroidal anti-inflammatory agents are notorious for renal injury. In addition, there is no surety for efficacy of newer medications too and this has to be evaluated with advance research. Also, the health-care providers must show courage not to be allured by undue offers from pharmaceuticals to accept vague superiority of one molecule over other without scientific evidence. A special mention is required that there is a dire need for newer molecules with precise mode of action with relatively lesser "adverse drug reaction" (ADR) for improved patient compliance for painful conditions, particularly neurological in origin. , The role of the patients and their families in the irrational uses of drugs is not that uncommon worldwide, and India is no exception, especially in rural areas.  The World Health Organization (WHO) pain relief guidelines for modern pain management originally developed for treating cancer pain has since been applied successfully to HIV/AIDS-related pain. 
Achieving balance in national opioids control policy recommends pain medications and analgesics and its administration as per the severity of the pain. For mild-to-moderate pain, basic pain relievers and a weak opioid, such as codeine is recommended and for moderate-to-severe pain, opioids, such as morphine is recommended. For managing cancer pain, opioids are "absolutely necessary." The pain relief ladder recommends various adjuvant drugs to increase the effectiveness of analgesics or counter their side effects, including laxatives, anti-convulsants, and anti-depressants. 
| Socioeconomy of Analgesics|| |
Cost of medication of pain management and palliative services is the most important hurdle, particularly in low- and middle-income countries. The states have the responsibility to ensure that opioids are available at a reasonable price that is affordable for patients. In addition, restrictions imposed if any must not hinder easy access to opioids for pain management. Distance is another impediment as many patients stay far from pharmacies or health centers, causing considerable burden due to repeated travel expense and difficulty of travel for people who are ill. It also causes burden on already overworked health-care workers in many countries. Many countries have relaxed the length of time for which oral morphine can be prescribed at once, for example, Romania (from 3 to 30 days), France (from 7 to 28 days), Peru (from 1 to 14 days), Mexico (from 5 to 30 days), and Colombia (from 10 to 30 days). 
It is mandatory to boost hands-on knowledge of health workers on symptom management of pain. In addition, there must be a multicenter study to assess the status of current pain management barriers against it. 
| Research in Pain|| |
A wide-ranging body of research on pharmaceutical management with strong ethical as well as legal binding can provide relief at the right time and right place to billions of suffering human population by the right authority. Ethics in medical research in pain should confer Helsinki declaration. Every academic institute should be acquainted in the ethical course of researches. There is a need for population-based interventions with robust samples and multi-centric studies.
Although we know that women are half of the population of the world, still in the new millennium, the participation of women in clinical trials had been undervalued. Role of genetics of feminine gender with hormonal blueprint in pathogenesis and salutogenesis of pain is yet to be studied thoroughly. ,, Similarly, the outcome data of noninclusion of elderly population get delimited regarding external validity.  The low income among minority groups is linked to an increase in morbidity, mortality, and disability, as a result of exposure to increased social and environmental risk factors. , Last but not the least, we need to explore innovative analgesic protocols with reduced use of drugs, namely, hypnoanesthesia-proven beneficial in dental pain, labor pain, and even neurosurgery. What we need is the transparent user-friendly clinical practice guidelines with rigorous health service research in India as, along with the renal complications, cardiovascular and other complications of analgesics are also gradually being reported in increasing number. Hence, regular monitoring of ADRs of analgesics in community-based research in relation to OTC sales is the call of the day.
| Access to Pain Management: A Human Right|| |
The WHO in 2008 estimated that though the medications to treat pain are cheap, safe, effective, and generally straightforward to administer about 80% of the world population, they have either no or insufficient access. The WHO has also observed that every year, tens of millions of people including four million cancer patients and nearly 1 million end-stage HIV/AIDS patients suffer from pain without treatment. Being an essential medicine, the states must ensure the availability of morphine, the mainstay medication for the treatment of moderate-to-severe pain, failure to make access to essential pain medication, will result in a violation of the right to health and in some cases, failure to ensure patients' access to treatment for severe pain will also give rise to a violation of the prohibition of cruel, inhuman, and degrading treatment. They must develop policies on pain management and palliative care; introduce instruction for health-care professionals, including those already practicing; and reform regulations that impede the accessibility of pain medications. ,
There exists a vast gap between pain treatment requirements and what is delivered, but most important among them is that only few governments have put in place the effective supply and distribution systems for morphine with no pain management and palliative care policies or guidelines for practitioners. Instead, they have excessively strict drug control regulations that unnecessarily impede access to morphine or establish excessive penalties for mishandling it. As a result, there will be fear that medical morphine may be diverted for illicit purposes and this will hamper access to pain treatment. 
Despite the clear consensus that pain treatment medications should be available, according to the WHO, approximately, 80% of the world population has either no or insufficient access to treatment for moderate-to-severe pain and millions of people around the world.  Countries also have an obligation to implement palliative care services, which must have "priority status within public health and disease control programs." The policy makers of all the countries must ensure a policy and regulatory framework, develop a plan for point-of-care services, and take all steps to execute the plan. Failure to attach adequate priority in developing palliative services within health-care services will violate the right to health. 
There are many publications regarding the nonavailability of pain treatment all over the world. The WHO, the International Narcotics Control Board (INCB), health-care providers, and scholars have deliberated about the failure of many governments to take realistic steps to improve access to pain medication and palliative services. But even today, conditions are the same. Many countries are not submitting the exact requirement for controlled substances as per the UN drug conventions to the INCB, some are simply reproducing the same requirement each year, regardless of demographic changes. ,
| Recommendations|| |
The pain treatment gap around the globe is a human rights crisis that needs to be addressed immediately. We need to establish a working group on pain management and palliative care services. There should be a working group including health-care providers, health officials, drug regulators, nongovernmental providers of palliative care, and academics, and a holistic plan of action. National human rights commissions or ombudsman offices need to investigate hindrance to the availability of pain management and palliative care services.
| Ensuring an Effective Supply System|| |
States must submit estimates for the requirement of controlled medications (opioid) to the INCB and prepare a proper procurement, transportation, and stocking regulations, which should be able to prevent potential abuse including oral morphine and other controlled pain medications in national lists of essential medicines.
| Ensuring Instruction for Health-care Workers|| |
Ensure adequate instruction for health-care providers - doctors, nurses, and pharmacists, at both undergraduate and postgraduate level. Basic pain management lessons should also be accessible to those previously practicing as part of continuing medical education.
| Reforming Drug Regulations|| |
We need to review the existing drug control regulations to assess whether they unnecessarily impede the accessibility of pain medications. There is an immediate need of the health-care providers to actively participate in this review and if necessary, regulations regarding access should have to be amended. The declared recommendations of the WHO and health-care providers should strengthen the foundation of amended drug control regulations.
To find a solution to the universal problem, we need to appeal to the global policy makers to ensure cost-effective drugs to the ailing population. They should set determined and quantifiable goals to considerably improve the right to use to these medicines globally over the coming years. We also hope to demand to the WHO, UNAIDS, and the donor community to boost up availability of drugs to the last man on the road by actively encouraging countries to undertake comprehensive steps to improve access to analgesics, for which support to be extended to those working in this field, including collaborative effort to get the WHO Access to Controlled Medications Programme. UNAIDS have to work with governments to identify and remove obstacles to the availability and accessibility of pain management and palliative care services.
Our plea to the global human rights community will be that they should customarily tell again and again to remind all the countries of their obligations under human rights law to ensure adequate availability of pain medications. The agenda of the human rights groups should include embracing pain relief and palliative management, also by reporting to the UN treaty bodies, provide information to the UN Special Rapporteurs on the highest attainable level of health, and on torture, cruel, inhuman, and degrading treatment and punishment to the Human Rights Council.
To sum up, as the "healer, teacher, and preacher," the health-care providers have the historical role to ensure the superior role of one protocol over another in pain relief as well as safety. At that moment, a doctor is expected to see the individual with utmost empathy, feelings, and greatness, as historically, doctors are respected across the communities as next to the God. But, one have to keep in mind that doctors can never guarantee "cure;" still in painful conditions, the health-care providers are expected to guarantee "care" as the learned friend for the uncountable dependent mass reaching them in their most distressed situation. Pain is an individualized feeling for each individual, for which common protocol medication does not become effective on all conditions and exasperated individuals move from doctor-to-doctor in search of solution to their "pain." In this situation, the so-called "Jhola Chhap Doctors" come into merrymaking by luring these patients with magical reliefs in their own inimitable way.
To find the solution to a pain-free world, we need a multipronged action by the health-care providers. The first and the foremost are to arrange advance researches by doctors in the field of pain management. In this regard, one has to emphasize that all researches must include empathy component, then only, one will be able to provide satisfaction to the persons with pain.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pal R. To be or not to be: Altruism needed for our progeny. Int J User Driven Healthc 2013;3:71-3.
Brennan F, Carr DB, Cousins M. Pain management: A fundamental human right. Anesth Analg 2007;105:205-21.
Daut RL, Cleeland CS, Flanery RC. Development of the Wisconsin Brief Pain Questionnaire to assess pain in cancer and other diseases. Pain 1983;17:197-210.
Jha MK, Pal R, Bhattacharrya P, Oberoi SS, Garg A. Euthanasia: The Indian scenario, post 07/03/2011. J Punjab Acad Forensic Med Toxicol 2012;12:43-7.
Pal R, Paul SK. Research in pain management. Editorial. J Recent Adv Pain 2016;2: 1-3.
Roy SK, Roy SK, Bagchi S, Bajpayee A, Pal R, Biswas R. Study of KAP of the private medical practitioners about national disease control programmes. Indian J Public Health 2005;49:256-7.
Pal R, Mohanta PK, Sarker G, Rustagi N, Ghosh A. Traditional healers and evidenced based medicine. Am J Public Health Res 2015;3:194-8.
Pal R. Rational use of drugs. J Neurosci Rural Pract 2011;2:123-4.
Ahmad A, Patel I, Mohanta GP, Balkrishnan R. Evaluation of Self Medication Practices in Rural Area of Town Sahaswan at Northern India. Ann Med Health Sci Res 2014; 4(Suppl 2):S73-S78.
O′Neill JF, Selwyn PA, Schietinger H. A Clinical Guide to Supportive and Palliative Care for HIV/AIDS. Washington, DC: Health Resources and Services Administration; 2003.
Adams V; Worldwide Palliative Care Alliance. Access to pain relief: An essential human right. A report for World Hospice and Palliative Care Day 2007. Help the hospices for the Worldwide Palliative Care Alliance. J Pain Palliat Care Pharmacother 2008;22:101-29.
Okuyama T, Wang XS, Akechi T, Mendoza TR, Hosaka T, Cleeland CS, et al.
Adequacy of cancer pain management in a Japanese Cancer Hospital. Jpn J Clin Oncol 2004;34:37-42.
Gear RW, Gordon NC, Heller PH, Paul S, Miaskowski C, Levine JD. Gender difference in analgesic response to the kappa-opioid pentazocine. Neurosci Lett 1996;205:207-9.
Sarton E, Olofsen E, Romberg R, den Hartigh J, Kest B, Nieuwenhuijs D, et al.
Sex differences in morphine analgesia: An experimental study in healthy volunteers. Anesthesiology 2000;93:1245-54.
Britton A, McKee M, Black N, McPherson K, Sanderson C, Bain C. Threats to applicability of randomised trials: Exclusions and selective participation. J Health Serv Res Policy 1999;4:112-21.
Lillie-Blanton M, Laveist T. Race/ethnicity, the social environment, and health. Soc Sci Med 1996;43:83-91.
Keitt SK, Wagner CR, Tong C, Marts SA. Understanding the biology of sex and gender differences: Using subgroup analysis and statistical design to detect sex differences in clinical trials. MedGenMed 2003;5:39.
"Please, do not Make us Suffer any More" Access to Pain Treatment as a Human Right. Human Rights Watch; 2009. Available from: https://www.hrw.org/report/2009/03/03/please-do-not-make-us-suffer-any-more/access-pain- treatment-human-right. [Last cited on 2016 Mar 30].
Lohman D, Schleifer R, Amon JJ. Access to pain treatment as a human right. BMC Med 2010;8:8.
International Narcotics Control Board, Report of the International Narcotic Control Board for 2008, United Nations; 2014.
WHO. National Cancer Control Programme: Policies and Managerial Guidelines. Geneva: WHO; 2002. p. 86.
World Health Assembly, Resolution WHA 58.22 on Cancer Prevention and Control (Ninth Plenary Meeting, 25 May 2005 - Committee B, Third Report). Available from: . [Last cited on 2016 Mar 30].