The persistent problem with pain

This article first appeared in The Lancet, 21 April 2001 Editorial There is a tendency among those living in richer countries to think of pain management as a service that is administered by teams of anaesthesiologists, psychologists, and other specialists in major hospitals and referral centres. But in a despatch in this week's Lancet, Martyn Broughton reports on a pain-management programme being run by the humanitarian group Médecins sans Frontières in Sierra Leone. Click for large version of image This image, taken by Harald Henden in 2001 at the MSF camp for amputees in Sierra Leone, was the winner of the Science and Technology First Prize in the 2001 World Press Photo competition. CAPTION: A man and a child embrace in Murray Camp, Freetown, in Sierra Lone. The camp is supported by Médecins Sans Frontières and functions specifically to help amputees. Thousands of civilians have had their limbs cut off by rebel fighters in the course of Sierra Leone's civil war. The camp helps teach victims how to fit artificial limbs and how to be as independent as possible.
One of the patients being treated there is a man, named Kulfar Dabor, who, since his hand was chopped off by machete-wielding terrorists five years ago, has suffered intractable phantom limb pain so debilitating that "the injury has reduced him to the state of a child and for a long time all he wanted to do is die". His story reminds us that pain is universal, afflicting people everywhere, and that skilled pain management services are needed in every community. In the coming years the need for such care is only going to grow. The world's population is aging rapidly--both in the developed and developing world--and with this aging will come an increase in the prevalence of chronic painful conditions that are difficult to treat, such as arthritis and low-back pain, and a rising incidence of cancer. The World Health Organizations' Programme on Cancer Control has estimated, for example, that over the next 20 years the number of people diagnosed with cancer will double to 20 million cases a year. 70% living in the developing world where most cancers will be diagnosed only when the disease is far advanced. If that prediction proves correct, pain management and palliative care will soon become as serious a health concern in developing nations as it has become in developed nations over the past two decades. Fortunately, some progress has been made towards improving pain management worldwide. Guidelines, such as those in the WHO publication Achieving balance in national opioids control policy (2000), are resulting in less restrictive drug laws so that healthcare providers can feel more free to use opioids when medically indicated. Progress on legal reforms has been made in several countries, including China, India, and Mexico. Still change has come slowly and in many nations pain management remains substandard. In developing nations, cost is often a major obstacle, as these countries lack the funds needed to provide the even the most basic health services. But even where money is not a major problem, many barriers to good pain management continue to frustrate reform. First, there is the cultural attitude that prevails in many nations which holds that pain is something to be endured without complaint. It is an attitude that encourages patients to suffer unnecessarily in silence; at the same time it allows their caregivers to ignore this suffering. Second, there is the persistent, irrational fear of opioid addiction that causes many governments to enforce drug-control regulations that are so intimidating or so cumbersome--such as burdensome prescription filling requirements and unrealistic limitations on the amount and duration of prescriptions for powerful analgesic drugs--that doctors and nurses are discouraged or even prevented from providing their patients with effective pain control. Even though addiction is rarely a complication of pain management, it continues to be cited as a major concern by regulators and sometimes by physicians too. Finally, medical education still pays too little attention to pain control so that many doctors feel unprepared to assess and treat difficult pain syndromes. In 1999, to try to address some of these issues, The Lancet published a nine-part series on pain, which included articles on the neurobiology of pain, the management of acute, chronic, and cancer pain, and the use of opioids. Because of continued interest in the articles, we will be posting an updated version of the series on our website (www.thelancet.com). Perhaps making these reviews freely available to everyone will both help to improve the management of pain worldwide and encourage additional research in this increasingly important aspect of medical practice. The Lancet