Pain: a complex phenomenon
Pain is a common problem and there is now a major shift in the understanding of pain from being just ‘a sensory experience‘ to being a complex phenomenon. There is thus a lot to teach and learn in order to enhance effective pain control globally. While acute pain is associated with tissue injury and can be protective, chronic pain is more challenging and it is no longer considered a symptom but a disease in itself. The process of pain transmission and perception has been better elucidated through research over the last two decades: involving pain processing through nociceptive primary afferents, several mediators, spinal cord relays, ascending and descending pathways to connections in the brain including those for emotional and stress reactions which accompany pain. In addition are the complex processes of peripheral and central sensitization, wind-up and neuroplasticity in pain modulation. There are also psychological, social, cultural, genetic and spiritual factors to consider. Hence, it is not surprising that each individual reacts to pain in a different way and many patients remain unsatisfied with the way their pain is treated.
Advancement in pain assessment methods, investigations, treatment and continued pain research abound in several volumes of journals, books and websites all in an effort to relieve pain. Guidelines from different organizations and movements are available on principles of effective pain management including acute, chronic, cancer pain, neuropathic and nocciceptive types of pain. Unfortunately, the vast majority of patients in less developed areas of the world have derived only little benefit from these developments. Even in developed countries, a large-scale computer-assisted telephone survey in 15 European countries and Israel revealed that one-third of the chronic pain sufferers were currently not being treated Citation[1]. Thus, despite all the research and available pain management programs, patients still experience inadequate pain relief for various pain problems.
Why is it difficult to improve the situation?
Among the reasons often mentioned as barriers to optimal pain management are:
▪ Lack of public awareness that pain can be effectively managed to reduce suffering.
▪ Inadequate knowledge of healthcare professionals about the complex features of pain, analgesic pharmacology and safe use of opioids.
▪ Poor attitude of healthcare professionals, fears and misconceptions about opioid analgesics (opiophobia).
All of these issues can be addressed and improved through appropriately targeted and comprehensive education since, in its technical sense, education is the process by which society deliberately transmits its accumulated knowledge, skills, and values from one generation to another. Pain education can be targeted through the public, the patients and healthcare professionals.
Public education
Public awareness and education are two key strategies for improving pain management. Topics to be addressed should include pain in general, myths and misconceptions, pain conditions that affect specific patient populations and how to seek effective pain management. Targets would include the public, policy makers, administrators, drug regulators and advocacy groups. Events should be organized to achieve wide coverage through community outreach, including local newspapers, radio, television and the internet, which has become an important international electronic network and mass medium for individuals, including those in developing countries seeking information on most topics. Although a public awareness effort is being propagated through such organizations as the American Pain Foundation September pain awareness month and the International Association for the Study of Pain Global Year Against Pain activities Citation[101,102], it should become a regular agenda on every national health promotion strategy.
Patient & family education
Patients and their family members often have uncertainties about pain and require education and information about what to expect, communication about their pain and available therapies for pain relief. Effective preoperative education for example can help to reduce anxiety, decrease use of pain medications, promote early discharge from hospital and increase patient satisfaction Citation[2]. Videos or DVDs help to reduce time required by professionals to teach as information is presented in a standardized yet engaging manner, allowing face-to-face contact to be individualized. Such intervention was found to reduce anxiety, improve pain management in cancer patients and patient satisfaction following surgery Citation[3,4]. Also, an intensive pain education program given by nurses lowered pain intensity levels in cancer patients and increased their knowledge of pain Citation[5]. Children too, especially the older ones have the right to information about painful conditions and procedures including how much pain and what will be done to make it better. It is also imperative to ensure that parents must be well informed in a manner that they can easily understand so that they can take rational decisions on behalf of their children.
Health professionals
Pain education for health professionals at all levels has been repeatedly identified as an important step toward more effective pain management practices in both developed and developing countries. Despite evidence that well-designed pain curricula can significantly improve pain knowledge and beliefs of health professional and students, reports of pain content in prelicensure (prequalifying, preregistration) curricula are minimal Citation[6,7]. A curriculum review that includes pain education modules and incorporation of interprofessional education will lead to significant changes in students‘ pain knowledge and beliefs. When such students qualify as professionals, they will be able to appreciate patients need for adequate pain assessment, effective treatment, audit and continuing education of staff members. Developing countries still lag behind in such strategies but the International Association for the Study of Pain, through its chapters in developing countries, has been active in promoting pain education by funding workshops, seminars, conferences and regional pain centers and a pain management camp.
Education of patients regarding the aims and associated risks of pain therapy is an essential part of pain control. Education of health professionals improves their knowledge about ‘total pain‘ management, reduces myths and misconceptions and can lead to an increased interest in pain research especially in the developing world. This is an area where more investment is required and more collaboration between advanced and less advanced pain centers.
Financial & competing interests disclosure
The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
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▪ Websites
- American Pain Foundation www.APFActionNetwork.org
- International Association for the Study of Pain www.iasp-pain.org