Pain relief: a universal human right

Abstract

1 Introduction Humanitarian aspects of pain relief have been the subject of editorials in this journal (Janeti and Liebeskind, 1994; Liebeskind and Melzack, 1987) and the writings of one of the present authors (Cousins, 1999, 2000; Cousins and Bridenbaugh, 1980; Cousins and Phillips, 1986) and others (James, 1993; Somerville, 1994). Yet the gap between deepening knowledge about pain and clinically inadequate treatment is widening—in aggregate, fewer than 50% of patients with acute, chronic or cancer pain receive adequate relief. Nonetheless, a consensus is now emerging that failure to treat pain appropriately is substandard medicine with adverse outcomes, is unethical, and is susceptible to both legal and professional action. This consensus has culminated in the concept of ‘Pain Relief: a Universal Human Right’, which is the theme of a joint International Association for the Study of Pain (IASP) European Federation of IASP Chapters (EFIC) ‘Global Day Against Pain’ to be launched for the first time with the World Health Organisation (WHO) in Geneva, October 11th, 2004. 2 Disease burden of severe pain Acute pain is a major challenge worldwide. Chronic pain poses a massive disease burden affecting an estimated 20% of adults rising to 50% of the older age population (Blyth et al., 2001; Crombie et al., 1999; Harstall and Ospina, 2003; Verhaak et al., 1998). Cancer pain affects 70% of the 10 million cancer patients diagnosed annually—doubling by 2020 (Goudas et al., 2001). In hundreds of millions of patients suffering HIV/AIDS, 60–100% will experience pain during their illness (Breitbart et al., 1996). 3 Adverse outcomes of unrelieved pain Severe unrelieved pain increases morbidity and even mortality in the settings of acute, chronic and cancer pain (Cleeland et al., 1996; Cousins, 1999; Siddall and Cousins, 2004). Chronic pain must be regarded as a diseaseentity because of the constellation of physical, psychological and environmental changes produced by pain per se (Cousins, 1999; EFIC, 2001; Siddall and Cousins, 2004). Social and economic costs fall on individuals, families and communities: absenteeism and reduced effectiveness (‘presenteeism’); costs of health care; loss of income; nonproductivity at home; workers compensation and welfare payments. In the USA total annual costs of chronic pain are estimated at US$100 billion, not to speak of tremendous human suffering there and globally. 4 Reasons for inadequate pain relief 4.1 Attitudes of health care professionals Misconceptions or ignorance among health care professionals regarding pain and its treatment include: concern about opioid tolerance, dependence and addiction; inappropriate anxieties about opioid use and related side effects (Bennett and Carr, 2002); a belief that analgesia makes diagnosis difficult; and a belief that opioid dose should relate to disease severity rather than pain intensity. 4.2 Cultural and societal attitudes Mirroring, if not determining the attitudes of clinicians, are often the erroneous attitudes of society at large (Morris, 1991, 1998; Papper, 1995). These include: the inevitability of pain; under reporting of pain due to stoicism; waiting until pain is severe before using opioids; the wish to be a ‘good’ patient. Such beliefs are cross-cultural. Societal attitudes to pain relief are influenced by prevailing concepts of pain and its significance to the individual and to society (Procacci and Maresca, 1984). In early societies pain was linked to evil spirits or demons in the body. Later, and still today in some cultures, pain was punishment (poena=punishment in Latin). Some societies, or their members belittle or mock patients—for example, with headache or back pain. Powerful myths (and their proponents) persist and spread with the ease of an epidemic—without the need for logic or evidence (Carr, 1996). Such myths include the often dysfunctional attitudes of healthcare workers noted above, and also that: pain is necessary and beneficial; undertreated pain has negligible adverse effects on treatment outcomes or costs. Combating such myths is difficult. Government-endorsed clinical practice guidelines do not necessarily change attitudes and practices—and do not spread with the ease of myths! The efforts of thought leaders have had more impact. These pain champions include: John Bonica, founder of IASP and promoter of many clinical, research and educational initiatives; one US congressman (Senator Orrin Hatch) and a small group of US clinicians and scientists who spearheaded the pain assessment and treatment initiative of the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), and the Decade of Pain Research and Treatment, proclaimed by US Congress. 4.3 Religious attitudes Religion, philosophy and folklore have ‘saturated pain with meaning’ (Morris, 1998). In many faiths the presence of pain has been incorporated into the very spiritual dimension of the human condition striving to achieve transcendence.