Pain management in low-resource settings—anesthesiologists advocate for increased access

Increasing the availability of effective pain management in low- to middle-income countries will be an essential part of ongoing efforts to expand global access to safe surgery and anesthesia, according to a special article in the April issue of Anesthesia & Analgesia.

"Pain is a common, widespread problem with some clearly complex barriers that need to be overcome before more effective treatment options can be delivered to our patients across the world," write Roger Goucke, FFPM, of University of Western Australia, Nedland, and Pongparadee Chaudakshetrin, FFPM, of Mahidol University, Bangkok. Their article appears as part of special section devoted to the theme of "Safe Surgery Globally by 2030."

Addressing the Neglected Problem of Pain in Low-Resource Settings

Drs. Goucke and Chaudakshetrin discuss the high burden of uncontrolled pain in low- to middle-income countries. They note that 80 percent of the world population lacks adequate access to pain management, while also experiencing three-fourths of deaths from cancer and HIV. Attention to expanding the availability of effective pain treatments will be an essential part of an ongoing initiative to expand the availability of appropriate surgical services and safe anesthesia around the world.

That effort, called Global Surgery 2030, defines targets for increasing access to surgery worldwide—including an ambitious goal of reaching at least 80 percent coverage of essential surgical and anesthesia services per country by 2030. "It is essential that the increase in surgical procedures is accompanied by appropriate acute pain management," Drs. Goucke and Chaudakshetrin write.

It has been estimated that one in five adults worldwide suffer from pain, while one in ten are diagnosed with chronic pain each year. Although 80 to 90 percent of cancer pain can be controlled with appropriate use of oral opioids, progress has been "exceptionally slow" in delivering opioids to patients in need. Only 6.7 percent of the world's supply of medical opioids is available to low- and middle-income countries.

The authors note a wide range of barriers to improving access to these and other effective medications for controlling pain. These include distribution difficulties, regulatory requirements, staffing issues, and patients' cultural or religious beliefs. Global health, anesthesia, and pain medicine societies have taken the position that access to appropriate pain relief should be a basic human right.

Drs. Goucke and Chaudakshetrin outline some broad strategies that will be essential to making progress toward universal access to pain treatment. These include a commitment to education in multidisciplinary pain medicine, both in medical and nursing schools and for practicing healthcare workers. Once governments have been made aware of the scope and cost of the problem, the world healthcare community must be prepared to respond with information and guidance—including the need to balance regulation and control of opioids and their use in cancer, postoperative, and trauma pain.

Drs. Goucke and Chaudakshetrin conclude: "With our increasing knowledge of the mechanisms of pain and the complex interaction between the social, psychological, environmental and physical components, we must do more to address these issues not only in the low resource setting but also in high income countries."

Increasing access to treatment for cancer and postoperative pain is only part of anesthesia's responsibility for reaching the Global Surgery 2030 goals, according to an editorial by Robert J. McDougall, MD, of University of Melbourne and Angela Enright, MB, of University of British Columbia. Other topics in the special issue include examples of highly successful training programs to address the shortage of anesthesia providers; considerations to help ensure that the expanded availability of surgery is accompanied by efforts to improve and maintain safety in anesthesia; the development and use of standards to measure progress toward global goals; and the special challenges of expanding obstetric care, including cesarean section.

"Lack of access to safe anesthesia and surgery threatens 5 of the 7 billion people who occupy this planet," Drs. McDougall and Enright write. They add that world governments and the anesthesia community have a "moral imperative" to act in increasing the availability of surgery, anesthesia, and pain treatment. "For those 5 billion people in need, it is their human right to expect that we will."