Pain is a far-reaching phenomenon, present in all of our lives, whether it be the daily pain of hunger, the pain of loss, of bereavement, or following trauma, a heart attack or long-term disease, even terminal cancer. Untreated pain is a great burden – to individuals who suffer emotionally and are predisposed to further complications through immobility, to their families who witness this suffering and support their relatives, and to society funding health and social care.
The theme for Worldwide Hospice and Palliative Care Day 2016 is ‘Living and dying in pain: it doesn’t have to happen’. The Worldwide Hospice Palliative Care Alliance (WHPCA) organises this annual day as, ‘a unified day of action to celebrate and support hospice and palliative care around the world’, and this year’s events will take place on and around 8 October.
At first sight this theme might seem incontestable but I would like to explain some of my thoughts around this and why I fear it will not achieve its desired aim.
I have particular interest in this topic – working as an NHS consultant in anaesthesia and pain medicine, I treat patients in pain every day of my working life. I am also a social science PhD student looking at the practice of pain management in India.
By chance, at the time of writing this blog I am in Hong Kong attending the World Congress of Anesthesiologists, and as I write I can see across the picturesque Victoria Harbour, the site of the Opium Wars of the 19th Century. The wars, which needless to say resulted in multiple casualties, were fought between China and Britain and led to the ceding of Hong Kong to the British.
Modern opium wars
It could be that the impetus for the announced theme of World Hospice and Palliative Care Day has arisen out of two 21st Century opium or more correctly, opioid (the term used for the modern pharmaceutically-manufactured opium) battles:
Barely a week seems to pass without high-profile media stories, usually from North America, describing the ‘War on Drugs’.
They speak of an escalating death toll caused by the abuse of opioid drugs, of frequent casualties, lethal overdoses and catastrophic levels of violent crime. The US government has pledged to tackle this overwhelming catastrophe. A significant part of this described problematic use is ascribed to an increase in the prescription of opioid drugs legitimately by the medical profession for medical purposes.
The argument goes that rising problematic use follows these prescribing trends, either for the individuals who have been prescribed the drugs or when the drugs find their way into the illicit market.
Doctors themselves are so concerned about this phenomenon, that the American Medical Association has debated the notion that clinicians stop routinely asking all patients whether they are in pain, believing that the very act of asking may be driving the high prescribing rates.
This opioid war, with its heavy casualty list, does not appear to show any significant signs of abating.
And at the same time another battle is being waged.
Access to opioids
It is vital to understand that these very same opioids are in fact medicines (as opposed to drugs of abuse) used by the medical profession to relieve severe pain. Pain such as that following trauma or major surgery, or for patients suffering in the terminal stages of diseases such as cancer. This second, devastating war is being played out, primarily in low and middle-income countries, where opioid medications are frequently not available at all.
Much of the impetus to address this lack of access to opioids has come from the palliative care community where many individuals are campaigning tirelessly to redress this balance. Again, the tales are multiple, with horrific stories of patients resorting to committing suicide due to a lack of access to these potentially life-changing medications.
The reasons for the lack of access are multiple but a significant factor are the complex legal and bureaucratic procedures in place partly fuelled by the war against illicit use – the first war I have described here. Doctors, patients, policy makers and wider society are fearful of recreating a similar situation, with increased prescribing and a rise in crime and death rates. The efforts of the palliative care community calling for increased access to these medicines have been immense and are on going, but progress has, sadly, been limited.
Personally I think there is hope for some resolution or at least a chance of peace-talks, but I would argue that the key to this process is a more nuanced understanding of this complex situation, which is so often desperately oversimplified.
Pain, in three categories
Within the field of western medicine we often classify pain into three different types. These categories are somewhat artificial and for each individual patient there is often considerable overlap between the three groups. However, I think that understanding these differences goes some way to help us see why the modern-day opioid wars continue.
The first category is acute pain – this is short-lived pain, such as that following trauma or surgery, an infection or a heart attack. These pains are typically amenable to medical treatment, frequently responding to opioid medications, which are by definition used for a short period of time.
Secondly, there is the pain of terminal disease – pain due to any condition, often cancer, that is likely to lead relatively quickly to the patient’s death. Again patients with these pains frequently respond very well to opioid medications – receiving incredible relief from suffering at the end of their lives. It is important to understand here that although these pains are not ‘acute’ in the sense that they are not short-lived, due to the very fact that the patient has terminal disease, their period of treatment with any medication is typically not more than weeks or months.
The third and final category is termed chronic non-malignant pain. These patients may have pain from a wide variety of conditions such as arthritis, spinal cord injury, lower back pain, amputation, pancreatitis or fibromyalgia. Chronic pain does not abate with time, but neither is the sufferer likely to die imminently from their disease. In contrast to the other categories I have described, the treatments available within western medicine are frustratingly ineffective at curing these pain conditions. This is not for want of trying, of patients and their families, and the medical and scientific communities. Most hospitals in the UK have a chronic pain service, where patients are helped to manage their pain – this terminology is important – sadly we can only manage it, we very rarely cure it. We try injections, infusions, complementary medicine, psychology and physiotherapy. Frequently we do help to manage it but not to cure it. And, most crucially, opioids are helpful to very few patients.
A global challenge
We, the medical profession and society as a whole, find this difficult. We don’t like to hear that medicine does not have all the answers and we don’t like to admit to failure. But I think it is vital that we are realistic about this, honest to ourselves as well as to patients. This is important for many reasons – most pertinently to prevent us from doing more harm (causing collateral damage) both to patients and to wider society through the escalation of or continued prescribing of treatments that are ineffective. This will often include opioids. We also need to ensure that research explores new avenues that may yield more effective treatments.
Finally, during my work overseas I am frequently reminded of the allure of western medicine in so-called ‘developing’ countries. When western medicine is translated for use in other environments we have a particular responsibility to be very clear about the limitations of our knowledge.
Danger of oversimplification
To return to the statement ‘Living and Dying in Pain: it doesn’t have to happen’, I think this is simply untrue in our current world. Assuming we have a basic humanitarian desire for it to be so, a pain-free world is currently not attainable.
Whilst I totally agree it is vitally important that we improve access to opioid medications for those patients suffering the pain of terminal disease or short-term pain conditions, I think one of the causes of the lack of access at a global level is an oversimplification of the debate. Stating that pain ‘doesn’t have to happen’, will unrealistically raise the hopes of patients and society, and it could stifle the impetus to create badly needed innovative research.
But most pertinently of all, if one of the contributing factors in the war against drug abuse in North America has been a rise in unnecessary prescribing of opioid medicines then I would argue that this could be made worse by the declaration that pain ‘doesn’t have to happen’. It could drive an inappropriate escalation of ineffective treatments which could create further problematic use and fuel a spiral of fear, leading to a further reduction in access for those who are most in need.
Lives in both of the 21st Century opioid wars are being devastated and lost on a daily basis. I am not for one moment claiming that any solutions to these complex issues will come about easily, but I am calling for a more nuanced debate.
We, the medical profession, have to be honest with ourselves and the public, about the limitations of medicine as practised in the West, otherwise we will never move towards the peaceful resolution we all are striving to achieve.
As the ancient Greeks taught us ‘Truth is the first casualty of war.’
Dr Clare Roques