Barriers to Acute Pain Management

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By Palanisamy Vijayanand

Despite substantial advances in pain research in recent decades, inadequate acute pain control is still more the rule than the exception. 2010-2011 has been declared as the Global Year against Acute Pain by International Association for Study of Pain (IASP) – the leading professional forum for science, practice, and education in the field of pain, headquartered at Seattle, Washington, USA. The campaign focuses on education for health care professional and government leaders as well as public awareness to help lessen the gap between existing knowledge and technology for acute pain control and current pain management practice.

Korula A special interest of Prof. Mary Korula, based at  Christian Medical College, Vellore, is Acute Pain management. She has held many posts – Executive Committee Member, Indian Society for Study of Pain (ISSP); Editorial board of the Indian Journal of Pain; Vice- President of Indian Society for Study of Pain 2005; External Expert – WHO normative guidelines in Pain management – Delphi study Geneva 2007; and Member of the Task Force of IASP for the Global Year of Acute Pain (October 2010-2011).

So, we have found the right person. Read on to find if we have asked her the right questions.

We all understand that acute pain should be optimally treated, if anything, from a humanitarian perspective. There could be certain other advantages too?
Definitely, and there is ample scientific evidence for it.

  • An obvious one I needn’t elaborate is that adequate pain control improves an individual’s quality of life and his/her satisfaction with care.
  • Managing pain optimally reduces the risk of many complications. For instance, there is a reduced incidence of blood clots forming in the veins (DVT).
  • It permits earlier discharge, and hence quality time with family, early return to work and so on.
  • Good pain control facilitates recovery through multiple mechanisms. Our body, for example, goes through a lot of biological upheavals following an operation or an injury. It is called the “stress response.” Too much or too little of this response means bad news. Pain increases this response, which puts inordinate stress on our vital organs like heart, lungs and kidneys. Adequate pain control keeps it at just about the right level to speed up our recovery.
  • Clinical resource management is another buzz word. In simple terms, minimize disruptions to the smooth flow of patient care. Unclogging the system means cost savings, and that matters a lot in a healthcare system such as ours.

A simple pain killer swallowed down with a bit of belief in its ability should do, surely?!
It’s as simple and as complicated as that. Science attests to the efficacy of multiple classes of medications and their modes of delivery. By mode of delivery, I mean that a pain killer could be delivered by an injection into the blood vessel (intravenous), muscle (intramuscular) or close to a nerve (regional anesthesia). There are also patches and nasal sprays available. Not just medicines, Evidence also points to the importance of individualized care and consideration of the clinical context – which resource could be utilized efficiently, when all is not rosy. Apart from that, there are plenty of non-drug techniques which come in handy for relieving pain.

You should note, however, that abundant evidence also indicates widespread under-assessment and under-treatment of acute pain.

What do you think are the problem areas to be addressed in managing acute pain in India?
Gaps in the quality of pain care exist everywhere including India. Three issues broadly.

  • Problems related to health care professionals
  • Problems related to patients
  • Problems related to the health care system.

Firstly, the issue with health care professionals. As doctors, what we know should be done and what we actually do is very different. There are gaps, many gaps, big gaps, between science and practice. The reasons are many. There are many barriers when we attempt to close down that gap.

Over-zealous treatments following a rigid protocol based approach do not help either. For example, population based studies do not always tell us the complete story if we do not take into account individual patient differences, patient preferences, the clinical and the cultural context. That’s not all. We should also not forget the long-standing, prevalent myths about acute pain and its control.

Sure, doctors are to be blamed as much as anyone else. What is it that acts as a stumbling block or a barrier, for the doctors to deliver quality care to patients in pain?
Many things!

  • Out-of-date or inadequate attitudes and knowledge, is one. I am surprised to still find that post-operative pain control is denied on the premise that it interferes with prompt recognition of surgical complications. Not acceptable. Again, the general acceptance that surgery has to be associated with pain prevails among doctors, and patients who speak up about pain are “fussy” – is the attitude some take.
  • Clinical inertia” i.e., slowness to update individual practice in light of evolving evidence.
  • Inadequate staffing of an acute pain service, resulting in ad hoc efforts oriented toward treating pain rather than preventing it systematically.
  • Incomplete, sporadic, or non-standard pain assessment.
  • Opiophobia or fear of using stronger pain killers like morphine in situations which warrant it.
  • Exaggerated concerns about the side effects of pain treatment. The typical ones touted are the risk of addiction and depression of breathing. Not as rare as hen’s teeth, but with proper systems in place these complications are few and far between.

We see the occasional well-informed patient discussing treatment options with us, and that is rare. For most part they are resigned to accept what the healthcare system offers. Why is it so?
We are sculpted from the same stone as the society we live in. Out-of-date or mistaken ideas which I have just mentioned exists among patients too. See, we aren’t very different from the society.

A prevalent belief among patients is that “nice” patients do not complain about pain or do not show suffering. The decision to speak one’s mind or suffer cannot be that difficult. Again patients as a group are easy to please when they perceive their doctors as supportive and caring. This is a woefully inadequate replacement to good pain control. There are other issues too like, reluctance to take pain medications because of side effects (nausea & vomiting) and other consequences (addiction), and a lack of awareness of the importance of pain control. It cannot be emphasised strongly enough that inadequate pain control leads to persistent pain problems in later life.

These issues are world wide but there seems to be more awareness in developed countries. In most parts of even developed India, optimal management of pain has always taken a back-seat.

We all agree that the Indian Healthcare system is far from ideal. What are problem areas when it comes to delivering good pain management?
Many again.

  • Low priority has been accorded to pain control education for health professionals. ISSP has taken the lead in proposing pain education in the MBBS curriculum.
  • Low value is accorded to patient preferences. This is endemic in India.
  • Regulatory impediments to controlled substance use. We have made great strides in India due to the tireless efforts of doctors passionate about treating pain.
  • From a financial perspective, income derived from pain treatment is often inadequate to sustain a viable enterprise. Then there is the cost-shifting to patients by insurers.
  • Inadequate infrastructure, including knowledgeable personnel to deliver medications and other interventions such as patient-controlled analgesia or cognitive-behavioural techniques.
  • Practice restrictions, such as regulations that permit nurses to administer injections only intramuscularly or subcutaneously and not intravenously.
  • There is just not enough research on the long-term consequences of untreated or inadequately treated pain coming out of India.
  • Relative to the burden of acute pain, the funding for basic and clinical research are disproportionately low.

I suppose it has to be a combined effort from all concerned to address these issues. There is still a long way to go.

 

Dr. Palanisamy Vijayanand

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FCARCSI, DPainMed (RCSI), MSc (Pain), FFPMCAI, FFPMANZCA | Hyderabad, India

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