Recognizing Pain Management as a Human Right: A First Step
Scott M. Fishman, MD
From the Division of Pain Medicine, Department of Anesthesiology and Pain Medicine, University of California, Davis School of Medicine, Sacramento, California.
Address correspondence and reprint requests to Scott M. Fishman, MD, Division of Pain Medicine, Department of Anesthesiology and Pain Medicine, University of California, Davis School of Medicine, Sacramento, CA. Address e-mail to email@example.com.
Pain management as a human right is a moral imperative that will help medicine return to its humanist roots. Acknowledging this right is a crucial step in reversing the public health crisis of under-treated pain. However, simply recognizing pain relief as a human right without making the changes necessary to provide appropriate treatment for patients in pain will only foster an illusion of care that can fuel unrealistic expectations and discontent among physicians and patients.
Although elusive in the past, a standard of care for pain treatment is now evolving, complete with the understanding that treating pain is neither an absolute science nor risk free. Where some clinicians may have felt that avoiding pain care altogether is the safest recourse, cases that have successfully brought charges of elder abuse against physicians for under-treating pain would suggest otherwise (1). Moreover, on the opposite extreme, recent federal regulations and prosecutions have blurred the lines between excessive use of controlled substances for analgesia on the one hand and criminal activity on the other (2,3).
Ironically, despite widespread support for improved pain control, United States physicians are experiencing pressures that may drive them to under-treat pain. Much of this is backlash from the escalating public health crisis of prescription drug abuse. Such abuse is a serious social crisis, and one that requires effective actions, but these actions do not have to undermine access to appropriate pain management. And, although punishing physicians who fraudulently prescribe controlled substances is absolutely necessary to protect society, high-profile cases of physicians who prescribe large amounts of opioids for chronic pain, that are taken from the realm of medical board action to formal criminal prosecution, coupled with shifts in Drug Enforcement Administration policies on controlled substance prescribing, have raised concerns among law-abiding physicians that they may encounter trouble even for appropriate prescribing (3). Regardless of great efforts to reverse this trend, physicians who legitimately prescribe opioids for pain may still feel “damned if they do and damned if they don't.” It seems as though we have simultaneously raised consciousness of the need for pain control and increased the risks to physicians of being part of the solution. If this dilemma is not resolved, advancing the cause of pain management as a fundamental human right may, in part, serve to polarize the medical community.
One would think that establishing pain management as a fundamental human right would coincide with organized medicine making pain management a high priority. Unfortunately, the absence of such a priority is clear at almost every level of health care delivery. For instance, although pain is the single most common reason why patients seek medical care, there is neither an institute within the National Institutes of Health that is focused primarily on pain relief nor adequate funding for research grants relating to pain care.
Education is also a fundamental component of our medical system, but there is no systematic approach to teaching pain management at any level of training. The lack of appropriate integration of pain management into medical education has led to recent legal and regulatory mandates to bring such education to medical students and physicians (4). Unfortunately, these external mandates too often result in fragmented approaches to pain education, with each specialty offering its own approach without integrating the multidisciplinary complexity of pain and its treatment into a comprehensive curriculum.
Recent statistics suggest that although pain is overwhelmingly prevalent, pain specialists remain a scarce resource (5,6). Because pain relief is within the purview of all clinical disciplines, Pain Medicine has evolved as a multispecialty field that is largely practiced as a subspecialty with no single most appropriate parent discipline (4). Thus pain medicine is an orphan within major medicine, fragmented by competing disciplines that would adopt it and unable to gain the recognition necessary to affect systemic change. How the specialty of Pain Medicine is positioned for continued development and integration throughout health care will greatly impact how medicine will meet its obligation to understand and treat pain.
Brennan et al. (7) have made a compelling case for pain management as a fundamental human right. But achieving the appropriate social and medical change that will make pain management a fundamental component of health care is the next great challenge. Without major changes in medical education, research, and clinical care, medicine appears ill prepared to address the far-reaching needs of patients in pain and is potentially poised to continue to incur more regulations and laws that will mandate this care. As clinicians continue to feel that they walk a tightrope when it comes to treating pain, advancing pain care as a basic human right will hopefully induce medicine to re-evaluate how it supports the delivery of pain management at the primary care level, and how it positions the discipline of Pain Medicine as a medical specialty. Society at large will also be faced with reconsidering some of its own conflicting priorities that have given rise to policies, legislation, and litigation that have unintended chilling effects on those who treat patients in pain.
NEWSHAWK Joy Davies