The national debate on the proper use of opioids continues to build as the high prevalence of addiction and overdoses fuel the continuing attention to this “public health crisis.”1
Much of the anti-opioid rhetoric regarding the “opioid epidemic” implies that pain is a nuisance that really doesn’t require treatment. Instead of making the focus one of achieving good pain relief, far too much attention has been directed solely at the risks of opioid prescribing and how we must provide naloxone on every street corner where an opioid might be sold.
If Ever There Was a Need for a Call to Action, It Is Now
According to the Institute of Medicine (IOM), an estimated 100 million Americans suffer from pain—more than diabetes, heart disease, and cancer combined.2
What we need now is a proper discussion about the immense risks of untreated pain. Simply put, untreated severe and chronic pain are not only forms of torture but put patients on the road to death.3 We have known for ages that untreated moderate to severe pain, whether slowly or rapidly, may lead to hyperlipidemia, hypertension, tachycardia, adrenal exhaustion, cardiovascular collapse, and at times to suicide.3
All of the finger-pointing, blaming, and hand-wringing has escalated to a feverish pitch along with a lot of head-scratching. How about an earnest effort to come up with a viable solution? Clearly, a better approach is needed.
In the search for answers, I’d like to call immediate attention to the General Assembly of the United Nations (UN), which is on record as having declared that “untreated pain is tantamount to torture or cruel, inhuman or degrading treatment or punishment”.4 If only our legislators and government agency leaders would read the “Report of the Special Rapporteur on Torture and Other Cruel Degrading Treatment or Punishment”4before acting to diminish patients’ access to needed pain medicines.
Following the UN report, Human Rights Watch weighed in, stating that “the poor availability of pain treatment is both perplexing and inexcusable”.5
Given the urgent need for a reasonable and responsible approach to pain care, every pain practitioner and all pain patients should become familiar with these reports, which make a case for profound governmental failures; but that’s not enough.
The time has come to demand that every pain treatment critic in the United States government, the insurance industry, members of the press, religious leaders, and anyone else for that matter who is addressing this subject seek solutions that do more than tie the hands of credentialed medical professionals who are treating patients with chronic pain. As well, there is a need to distinguish between addiction, abuse, and a medically confirmed need for opioid treatment in forming future programs.
Know the Facts Before Withholding Pain Care
The UN report laid out the reality of suffering with pain and presented recommendations that need more widespread dissemination.4 In particular, people who use drugs are not necessarily addicts or substances abusers, as many are simply patients who developed a medical condition that has left them unable to function without adequate treatment for severe, chronic, or intractable pain.2,6
In addressing marginalized groups, the UN report offered the following:4
- “People who use drugs are a highly stigmatized and criminalized population whose experience of healthcare is often one of humiliation, punishment, and cruelty.”
- “Actions by healthcare workers and police often deprive individuals of their civil rights and access to medical care.”
- “By denying effective drug treatment, State drug policies intentionally subject a large group of people to severe physical pain, suffering, and humiliation.”
- “Persons with disabilities are particularly affected by forced medical interventions and continue to be exposed to non-consensual medical practices” (A/63/175, para 40).
In conclusion, the report states that: “The right to an adequate standard of health care (‘right to health’) determines the States’ obligations towards persons suffering from illness…In that fashion, attention to the torture framework ensures that system inadequacies, lack of resources or services will not justify ill-treatment.
Although resource constraints may justify only partial fulfillment of some aspects of the right to health, a State cannot justify its non-compliance with core obligations, such as the absolute prohibition of torture, under any circumstances. (Committee on Economic, Social and Cultural Rights, general comment No. 14).”
Aiming to protect people with pain conditions, UN Special Rapporteur Juan E. Mendez recommended the following:4
“Safeguard free and informed consent on an equal basis for all individuals without any exception, through a legal framework and judicial and administrative mechanisms, including through policies and practices to protect against abuses.
Adopt policies and protocols that uphold autonomy, self-determination and human dignity. Ensure that information on health is fully available, acceptable, accessible and of good quality; and that it is imparted and comprehended by means of supportive and protective measures such as a wide range of community-based services and supports (A/64/272, para 93).”
To work against denial of pain relief, Juan E. Mendez recommended that all states:4
- “Adopt a human rights-based approach to drug control as a matter of priority to prevent the continuing violations of rights stemming from the current approaches to curtailing supply and demand (A/65/255, para. 48). Ensure that national drug control laws recognize the indispensable nature of narcotic and psychotropic drugs for the relief of pain and suffering; review national legislation and administrative procedures to guarantee adequate availability of those medicines for legitimate medical uses;
- Ensure full access to palliative care and overcome current regulatory, educational and attitudinal obstacles that restrict availability to essential palliative care medications, especially oral morphine. States should devise and implement policies that promote widespread understanding about the therapeutic usefulness of controlled substances and their rational use;
- Develop and integrate palliative care into the public health system by including it in all national health plans and policies, curricula and training programmes and developing the necessary standards, guidelines, and clinical protocols.”
Inadequate Pain Care Is a Worldwide Concern
In 2012, the World Health Organization (WHO) estimated that 5.5 billion people were living in countries with low or no access to controlled medicines and had no or insufficient access to treatment for moderate to severe pain.7 Since 2004, the WHO has supported efforts to recognize pain as a real issue, deserving of attention.
Eighty-three percent of the world population has either no or inadequate access to treatment for moderate to severe pain. Tens of millions of people, including those with terminal cancer and end-stage, acquired immune deficiency syndrome (AIDS), suffer from moderate to severe pain each year without sufficient treatment for their chronic, unrelenting pain.7
Many countries fail when it comes to assuring an adequate supply of pain medications for their citizens. In particular, low- and middle-income countries account for 6% of morphine use worldwide despite accounting for half of all cancer patients and 95% of all patients with newly diagnosed human immunodeficiency virus infection.8,9
Thirty-two countries in Africa alone, for example, have almost no morphine available. In France, a study found that doctors underestimated pain in over half of their AIDS patients.10 In India, more than half of the country’s regional cancer centers do not have morphine or doctors trained in using it. This is despite the fact that 70% or more of their patients have advanced cancer and are likely to require pain treatment.
While relatively inexpensive, highly effective medications such as morphine and other opioids have proven essential for the relief of pain and suffering, these types of medications are virtually unavailable in more than 150 countries.
The issue remains equally compelling closer to home. Surprisingly, the UN report states that over a third of patients in the United States are not adequately treated.4
A Better Approach to Pain Is a US Imperative
It’s time that we openly acknowledge that we are in a most profound and serious battle over the most basic of human rights—the relief of pain and suffering. Let’s call it what it is. Many entities want to deprive patients who are suffering from moderate to severe pain their human right to adequate pain treatment.
These same opioid epidemic-defenders would not admit publicly or to themselves that by withholding access to all available pharmacotherapies, they are in effect promoting torture, cruelty, or degrading treatment.
In my opinion, the problem with our failed approach to pain care stems from a narrow view of pain that misses the point. Withholding all means of pain treatment goes against the view advocated by the UN, WHO, and Human Rights Watch.
It is past due for each and every one of us, including our pain patients and their families, to use our voices to tell all concerned parties that we support the UN view that untreated pain is tantamount to torture, and is cruel, inhuman, or degrading punishment. We need a more medically informed approach to treating people with severe, chronic, intractable pain.
This was originally published by Practical Pain Management
- The Kiplinger Letter. Forecasts for executives and investors. Washington, DC; The Kiplinger Washington Editors. 94(37): 2017.
- Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research.Washington, DC: National Academies Press, 2011.
- Tennant F. The physiologic effects of pain on the endocrine system. Pain Ther. 2013;2(2):75-88.
- United Nations General Assembly. Report of the Special Rapporteur on torture and other cruel, inhuman, or degrading treatment or punishment, Juan E. Mendez. New York, New York; Human Rights Council. 2013:51-56. Available at: www.ohchr.org/Documents/HRBodies/HRCouncil/RegularSession/Session22/A.HRC.22.53_English.pdf. Accessed September 25, 2017.
- Human Rights Watch. Access to pain treatment as a human right. Unbearable Pain—India’s obligation to ensure palliative care. 2009. Available at: www.hrw.org/report/2009/10/28/unbearable-pain/indias-obligation-ensure-palliative-care.
- Anon J, Lohwan D. Denial of pain treatment and the prohibition of torture, cruel, inhuman or degrading treatment or punishment. Interights Bulletin 2011;16(4):172.
- WHO press release. World Health Organization supports global effort to relieve chronic pain. October 11, 2004. Available at: www.who.int/mediacentre/news/releases/2004/pr70/en/. Accessed September 25, 2017.
- Lohman D, Schleifer R, Amon JJ. Access to pain treatment as a human right. BMC Medicine. 2010;8:8. Available at: https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-8-8. Accessed September 25, 2017.
- Scholten WK. Access to opioid analgesics: Essential for quality cancer care. Geneva, Switzerland; World Health Organization, 2013. Available at: http://apps.who.int/medicinedocs/documents/s20982en/s20982en.pdf. Accessed September 25, 2017.
- Larue F, Fontaine A, Colleau SM. Underestimation and undertreatment of pain in HIV disease: multicentre study. BMJ .1997;314:23. Available at: www.bmj.com/content/314/7073/23. Accessed September 25, 2017.