A growing international consensus urges change in several areas - including increased availability of controlled medications such as opioids - toward the goal of recognizing effective treatment for pain as a fundamental human right, according to a special article in the July issue of Anesthesia & Analgesia, the official publication of the International Anesthesia Research Society and published by Lippincott Williams & Wilkins.
Dr. Frank Brennan of Calvary Hospital in Kogarah, N.S.W., Australia and colleagues summarize the medical, legal, and ethical arguments for transforming access to pain management into a global human right. They write, "Medicine is at an inflection point, at which a coherent international consensus is emerging: the unreasonable failure to treat pain is poor medicine, unethical practice, and is an abrogation of a fundamental right."
Inadequate pain treatment is an entrenched problem around the world, related to cultural, societal, religious, and political factors—including, the authors believe, the acceptance of torture. Poorly controlled pain has many and potentially serious adverse effects, both physical and psychological, as well as "massive social and economic costs to society," Dr. Brennan and coauthors write. Cancer pain is a special concern, with up to 70 percent of cancer patients experiencing severe pain caused by their disease or its treatment.
Contributors to inadequate management of pain from cancer and other causes include "opiophobia and opioignorance": fear and ignorance of the strong pain medications classified as opioids—morphine and related drugs. For physicians, a lack of training in the proper use of opioids is compounded by rare but highly publicized cases in which doctors are prosecuted for opioid prescribing.
The authors outline the "complex and overlapping" reasons for delay in recognizing the ethical and legal importance of pain management. Although pain relief is clearly a core value of medical ethics, the legal foundation for a right to pain management is less clear. Frustrated with the slow pace of change, many pain medicine professionals are promoting legislative solutions. Some governments, notably including Australia and the state of California, have passed statutes explicitly defining the right to adequate pain management, protecting medical practitioners who treat pain in terminally ill patients, or introducing requirements for pain management and education.
Laws related to medical negligence, elder abuse, and public interest litigation all have ramifications for promoting adequate pain treatment, as do standards for pain management developed by professional organizations. Other approaches look to international law, including the United Nations (UN) covenants regarding human rights.
Since pain is an international problem, the World Health Organization (WHO), as the UN's supreme health agency, is likely to play a critical role in any solution. The WHO's previous efforts in the areas of cancer pain relief and palliative care have had a major impact on pain treatment around the world. Building on these successes, the WHO is spearheading efforts toward deregulating the availability of medical opioids and making these powerful pain-reducing drugs more affordable for poor countries.
Dr. Brennan and colleagues call on the UN to consider declaring an International Year of Pain Management, and on the WHO and other international bodies to create a single organization unifying all aspects of obligation on national governments in the area of pain control. "Much work and continuing vigilance will be required to make the transition from asserting that pain management is a fundamental human right, to a future in which appropriate pain management is a global reality," the authors conclude.
An accompanying editorial, Willem Scholten, PharmD, MPA, and colleagues at the WHO summarize their organization's role in "freeing people from the shackles of pain." A centerpiece of the WHO's efforts is its Access to Controlled Medications Program (ACMP). The ACMP seeks to remove barriers to appropriate use of controlled medications through legislative and administrative initiatives, education for health care and law enforcement professionals, improved understanding of international drug control treaties, and measures to ensure a steady supply of controlled medications at controlled prices. "The human suffering due to lack of pain relief is an affront to human dignity," Dr. Sholten and colleagues write. "WHO, through its ACMP, will support governments in the realization of their obligation under the right to 'the enjoyment of the highest attainable standard of health.'”