Perception of pain treatment: views and ground reality

Huma Saleem, Asma Ashraf Khan, Muhammad Faisal
Author affiliation:
  1. Huma Saleem, Consultant Anesthetist, Shaukat Khanum Memorial Cancer Hospital & Research Center, Lahore, Pakistan.
  2. Asma Ashraf Khan, Consultant Anesthetist, Shaukat Khanum Memorial Cancer Hospital & Research Center, Lahore, Pakistan.
  3. Muhammad Faisal, Resident Anesthesia, Shaukat Khanum Memorial Cancer Hospital & Research Center, Lahore, Pakistan.
Correspondence: Dr. Huma Saleem, E-mail: humasaleem@skm.org.pk; Phone: +92 42 35905000

 

ABSTRACT
 

Pain has been associated with the mankind right from the very beginning, and the struggle to conquer pain is also as old as the human history. The pain, the human understanding of pain and the pain management, also have evolved in different phases with the passage of time. Perhaps, more awareness and perception of pain is one of the factors leading to an ever-increasing burden of pain patients on the healthcare perception. Pain medicine is now recognized as a sole specialty, with multiple sun-specializations. This editorial highlight different aspects of pain management and training in this rapidly evolving specialty.

Key words: Chronic Pain; Neuralgia; Neuropathies; Pain; Pain Management

Citation: Saleem H, Khan AA, Faisal M. Perception of pain treatment: views and ground reality. Anaesth. pain intensive care 2023;27(3):291−293; DOI: 10.35975/apic.v27i3.2235

Received: April 26, 2023; Accepted: May 05, 2023

Pain is defined as sensory or emotional discomfort associated with actual or potential tissue injuy.1,2 There is huge global burden of pain and it is increasing day by day. Pain is the most prevailing symptom to get medical care.3 Mechanism of pain is poorly understood and has multiple etiologies. Out of these inflammatory process, neuropathic, ongoing ischemia, compression effect of mass and spiritual beliefs are just a few to mention.4
Pain can be acute or chronic. Pain that last less than three months comes under acute etiology. Reasons can be surgery, trauma or burn. On the other hand, pain that last more than 3 months is chronic pain.5 Vast number of diseases including neuropathies, cancer diseases, psychiatric illnesses, neuralgia, AIDS and sometime idiopathic, results in chronic pain. Untreated or under treated acute pain results in chronic pain.6 The International Association for the Study of Pain quantify that 1 in 5 patients have pain and 1 in 10 are being diagnosed with chronic pain.3 Roughly 25% of chronic pain is associated with surgery, 60% with trauma and 70% of patients with advanced stage malignancies. 70% of pain in geriatric population is non-cancer chronic pain.7,8 There is a famous saying “When sorrow’s come, they come not single spies but in battalions.” Same is the case with chronic pain which is often accompanied by sleep disturbance, anxiety, depression, anorexia, immobility, work problem and financial burden.7 The financial challenge is significant for patient and family but it is enormous for a country as a whole. Approximately 1 million working days are being lost every year in Denmark because of chronic pain. In United Kingdom only, back pain costs 1 billion pounds per annum.3 The estimate of financial burden in low middle-income countries like Pakistan is difficult to calculate.

Declaration of Montreal states that access to pain management is a fundamental human right.9 Pain treatment varies according to its severity. Using a step ladder approach for pain management, NSAIDs are used for mild pain, NSAIDs and weak opioids for moderate pain while, strong opioids for severe pain. Now, with recent advancement in medical sciences, interventional procedures like regional analgesia are being offered. Despite these, unrelieved pain is very common amongst patients. This pain which is left untreated and under treated is the cause of patient dissatisfaction and lack of trust in the treating system.10 There is significant association of analgesics prescribed and adequacy of pain control. The analgesics that provide adequate analgesia to some patients may have no effect on others. Treatment failure can be viewed under multiple aspects.

The most extensively researched avenue is the difference in the metabolism of Codeine Sulphate. This drug is widely employed in the treatment of moderate to severe intensity pain. It can confer good analgesia in patient population which have extensive CYP2D6 activity and account for 77–92% of population. On the other hand, there is a sizeable population percentage (5–10%) which are poor metabolizers and thus the drug will not be metabolized to its active form morphine. Thus, the pain control will be inadequate in this population subset and may be deemed as treatment failure.11
Majeed et al. revealed inadequate analgesia in patients resulted in moderate to severe pain which is 19% and 75% respectively. This was found to the result of inadequate prescription of analgesics.4 Delay in pain assessment and treatment initiation was identified as the major contributor to failure in pain control.

Pain is currently being treated under primary treating specialty. They focus more on treating disease rather than accompanying pain which can potentially lead to under treatment and poor pain control. Vuong et al. showed the prevalence of under treated pain among 33.3% patients.10
Noncompliance with prescribed medications can count for another reason towards treatment failure. Noncompliance can be due patient related factors, physician discretion and country’s socioeconomic policies. Patient factors are carelessness in taking medicine, poor buying capacity to get medications, or patients quit taking medications as dictated by spiritual beliefs.

Even if patient is compliant with medicines, non-availability is a major deterrent in their effective usage.10,12 Medicines that are being considered as mainstay of pain treatment in many conditions including cancer pain such morphine, fentanyl or oxycodone have legitimate barriers for access.

Clinical training of the undergraduate doctors regarding the treatment of pain is not optimal.13 This causes the clinicians to feel unprepared for the treatment of pain especially the complex presentations of pain.14 These barriers can lead to failure to implement treatment plan and appropriate health care provision. Now, pain medicine departments and palliative Care facilities are being developed.

In Future, by taking certain initiatives towards appropriate pain management much can be achieved in improving patient care and the trust of the stakeholders in healthcare provision system. There is need to improve the training regarding the management of pain at the undergraduate and postgraduate levels. This can be done by adopting curricula and strategies suggested by the governing societies to build the capacity for system. All stakeholders should be involved in the designing of policies and systems to help in the provision of the basic Human Right -Access to Pain Management to all people without discrimination.

 

Conflict of interest
None declared by the authors.

 

Authors’ contribution
HSD: Concept, write-up research

AAK: Review of literature

DMF:  Write-up research, Final drafting of manuscript

 

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