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Pain Care for a Global Community: Part 2

Ethics and Economics in Intersection
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“Make me a meal and I eat for a day…teach me to forage, harvest, and cook and I shall feed myself always…”

Practicalities of a Core Philosophy of Pain Care

The argument for pain medicine to adopt a strong “…philosophical foundation that allows practical articulation across a diversity of socio-cultural contexts and circumstances” in order to adequately confront and address chronic pain on a worldwide level cannot ignore the implications and obligations entailed by such a core philosophy.1 The tenets of this philosophy do not depict medicine, in general, or pain medicine more specifically, as being articulated in a socio-cultural vacuum. To the contrary, by articulating the need for, and practical ends of a right and good care of pain patients, this philosophy acknowledges particular environmental and cultural contingencies along with the effects and implications of changing economic forces. Without grounding pain care to such a philosophical foundation, we believe that it would be relatively easy to overlook the complexity of variables that influence the provision of medical treatment. In misrepresenting, or not considering these factors, a true appreciation of the hierarchical needs of chronic pain patients nested within (and affected by) various societies and cultures, as well as a validly beneficent response of an internationally-relevant pain medicine, would be unlikely.2

In this essay, we describe the dynamic interplay between patient-specific, political, and economic factors inherent to the socio-cultural environment(s) of various nations, (as applicable to both diagnosis and therapeutics), and opine that these factors must be recognized and engaged in order to plan and implement pain care that is tangible and sustainable in developed, developing, and non-developed nations.3-10 Although a strong scientific and humanistic philosophical foundation is integral to the treatment of chronic pain on a worldwide level, in and by itself this is not sufficient, as real-world execution of medical care is enacted within—and between—the national political infrastructures that can incur economic limitations, burdens, and risks. In this way, any realistic application of a core philosophy and ethic(s) of pain care on a global level must also identify and account for how politico-economic variables influence the calculus of resource-reliance, -provision, -allocation, and -use.

Global Issues in Pain Care

To be sure, this is not only important when considering pain care in developing, or non-developed countries. For example, the inadequacy of chronic pain treatment in the United States has been well-documented, particularly with regard to the inappropriate exercise (i.e. under-use and/or incorrect/excessive use ) of various diagnostic and therapeutic technologies, and a failure to provide integrative treatment approaches that address psycho-social, as well as biological aspects of pain.11-15 Certain racial and ethnic groups, children, and seniors are at particular risk for inadequate chronic pain management given insufficient insurance coverage for, and/or lack of access to those (diagnostic and therapeutic) approaches that could maximize beneficial health outcomes.16-18

Recently, we have argued that the use of technology—while important to diagnosis and treatment of pain—cannot (nor should not) be employed without prudent evaluation of 1) benefit: burden: risk ratios; 2) time- , cost- and outcomes’-effectiveness, and 3) viability in an integrative diagnostic and therapeutic plan that combines objective and subjective dimensions of assessment and care.19,20 Moreover, it is important to consider whether the availability and/or use of such technologies are, in fact sustainable. It has been posed that shortcomings in the treatment of chronic pain in the United States reflect both a shortage of pain practitioners and the relative unavailability of state-of-the-art techniques and technologies provided under the diligent aegis of specialized, multi-disciplinary pain care.21,22

In light of the fact that 1) the economic profile of the United States and other western countries is considerably higher than second- and third-world nations, and 2) deficits in the provision and accessibility of pain therapeutics are notable in, and among, western nations,23,24 we are prompted to question the status of chronic pain care in less-developed countries. It is likely that the extent of chronic pain mirrors the overall quality of healthcare in a particular country. Relatively little is known about chronic pain management in developing nations. While painful musculoskeletal conditions were thought to be more prevalent in developed nations,25 recent studies have indicated that the prevalence of chronic pain is actually higher in non-developed and developing countries than in developed nations.26,27 This is consistent with findings that a high prevalence of chronic pain has been reported in Africa,28 Indonesia,29 Thailand,30 Vietnam,31 Pakistan,32 Oman,33 Lebanon,34 and Nepal.35 It has been suggested that in non-developed and developing countries, the prevalence of chronic pain may reflect hesitance to seek (early and/or continuing) treatment, social stigma associated with pain, and occupational obligations incurred by poverty that mitigate availability, adequacy, and/or continuity of care.36,37 Still, as Brennan and colleagues note, most of the statistics used to illustrate the “problem of pain” and direct pain therapeutics reflect epidemiologic data from “first-world” nations and thereby overlooking, or frankly neglecting, the issues and needs of developing/non-developed countries and this may contribute to a “…global failure to adequately respond to the challenge” of pain.38

“The under-treatment of chronic pain in developing nations is related to factors such as economic instability, conditions of poverty, and lack, and/or incapacity of medical infrastructure.”39

The under-treatment of chronic pain in developing nations is related to factors such as economic instability, conditions of poverty, and lack, and/or incapacity of medical infrastructure.39 Taylor and colleagues note that “… barriers …include poor understanding and lack of education regarding pain…” , given that “…pain management in poor countries must compete for limited resources with other primary health care services, as well as with other social concerns such as food.”40 While pain medicine is recognized as a distinct specialty in most western countries, and chronic pain is ideally treated by a specialist, even in developed nations like the United States, the vast majority of chronic pain is treated by generalists.41 The majority of developing nations have a paucity of physicians and medical resources on the whole and, as a consequence, pain management specialists and the specific diagnostic and therapeutic resources inherent to effective pain practice are, for the most part, direly lacking.42

Last updated on: December 20, 2011
First published on: September 1, 2008