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With all our education, training, technology and medications in 2008, there are still many shortcomings in our capacity to make a difference to our patients' burden of pain.

A Definition of Pain:

• Pain is that unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (IASP).

• Pain is divided into acute, chronic and cancer pain.

Regrettably our patients' right to pain relief is often not met. Age, culture, geographics and ethnic origin should not be a barrier to accessing this pain relief. Yet, this is obvious in Brisbane and Australia and, more so, internationally.

The patient in pain is a picture of misery, wracked by anxiety to the point of panic. The patient is reduced to helpless and hopelessness with increasing social isolation and social dependence. The patient becomes an increasing burden with a loss of physical fitness together with friends, sexuality and work. Little wonder there is a loss of the will to live.

The patient in pain can be suffering one or some or all of these feelings:

• Anxious / panic
• Helpless / hopeless
• Isolated / dependent
• Physically deconditioned
• Suffering loss of friends, fitness, sexuality & work
• Vulnerable
• A loss of the will to live.

Areas of shortcomings:

• Neonatal pain
• Paediatric & foetal pain
• Nursing homes – the elderly & dementia
• Acute pain services
• Surgical scars
• Prescribing practices
• Nursing attention
• Opiaphobia
• Access & social justice

In the 1960s, as a registrar, it was the usual practice to circumcise neonates without anaesthesia. In fact, anaesthesia was withheld for neonatal surgery until the 1980s. Even today, pain relief in the children's hospital is an issue. Increasingly, research scientists indicate that foetal pain also requires attention. The large number of nursing homes in our communities is another focus of poor pain practices. Professor Abby has been a longstanding advocate of recognising the pain in the elderly and the demented, an area long neglected.

Nearer to home, the acute pain services in many of our hospitals remain understaffed and overwhelmed by the patient's distress and educational issues with resident doctors and nursing staff who have first contact with these patients. Increasingly, surgeons are relying on anaesthetists to follow up the pain problems of inpatients in the private sector.

Then, on discharge, a surprising number of surgical scars are the site of neuropathic pain. Henrik Kellett, the Danish general surgeon, has documented this, identifying that 10% of hernia scars, 30% of breast wounds, 40% of thoracotomy scars and up to 80% of amputation stumps leave patients with long-term neuropathic pain requiring ongoing relief. Inpatient prescribing habits still remain a little offhand. Morphine, less frequently Pethidine, is offered fourth hourly with little regard to individual differences and responses to these drugs. Then again, often nurses fail to identify that more pain relief is required or fail to provide the prescribed drug. This is partly due to the identified opiaphobia in our younger staff. They are brought up on lectures identifying drug addiction and opioid complications and the patient's pain relief suffers.

Then there are wide variations in geographic access to adequate medications. Australia comes high on the list of having appropriate access to opioid drugs but many countries of the world provide minimal access in their health systems. At the general practitioner level, the heavy demands on their time leave little time to explore the patient's pain management and there are again fears of being labelled an opioid-prescribing practitioner. This again results in inadequate medications and often too much Benzodiazepine and Tramadol when more effective opioids such as Oxycontin are necessary. It seems, at times, that this is to avoid prescribing drugs that might be identified at the Drugs of Dependence Unit.

Lastly, politicians in Queensland do not seem to have the political will to deliver proper pain services to our public patients.

Over the past ten years, the burden of pain has been well documented in international communities and in Australia. There seems to be uniform agreement that the prevalence of chronic, non-cancer pain in international populations is 20%. In Australia, this has been well identified by Fiona Byth and Michael Cousins. But Eriksen, in Denmark, and Nicola Torrance, in England, have had similar results and neuropathic pain was found in 8% of patients. Henrik Kellett has further looked at the epidemiology of pain in post-surgical cases.

Unspoken Thoughts in the Patient's Mind:

• Effects of religion, philosophy & folklore.
• Pain is a spiritual part of the patient’s condition.
• Pain is a punishment.
• Pain is a path to redemption.
• Should be a “good patient” and stoic.
• Avoid drugs until pain severe.
• “I have a high pain threshold.”

The pain patient has many unspoken thought and beliefs that complicate access and management of pain. Over hundreds of years, the Judo-Christian faiths have had a progressive impact on our philosophers and our cultures. Morris (1998) said they "have saturated pain with meaning". Pain has become part of the spiritual life of the patient. In many, it is seen as a punishment. For many of our recognised saints, e.g. St Sebastian, pain was the path to redemption. Hair shirts, self flagellation and the 1200 mile Camino walk across Spain provided a higher place in Heaven. These beliefs and others often provide a barrier in moving the patient along a path to adequate pain relief.

These unspoken thoughts often cause the patient to reject any thought of taking opioids. There are feelings of failure and worries about addiction, dependence and tolerance.

Attitudes of health professionals:

• Concern about opioid tolerance dependence and addiction.
• Concern about opioid side effects.
• Beliefs that analgesia makes diagnosis difficult.
• Dose of opioid should relate to disease severity rather than pain intensity.
• Use drug not identified by Drugs of Dependence Unit.

Among our own medical practitioners there are growing fears about addiction, dependence and tolerance if they commence patients on strong opioids. There are some who believe that such drugs will interfere with the ability to make a diagnosis. How often does the patient present saying they have stopped taking their narcotics before a consultation. There are those concerned that opioids will have overwhelming side effects and others who feel the dose should be related to the severity of the illness and not the severity of the pain.

A history of change:

• Hippocratic Oath (5th Century BC).
• Declaration of Geneva (1948 – Last revision 2004).
• The Georgetown Mantra.
• The United Nations Declaration of Human Rights (1948).
• “All persons are equal in dignity and have the right to life, liberty and security.”

With the foundation of the Hippocratic Oath, policies on pain management have been spreading at a national and international level since the Second World War. First there was the Declaration of Geneva, mainly targeted towards prisoners and captives, and this was last reviewed in 2004. Then the Georgetown Mantra, proposed by Beauchamp and Childress in Georgetown, emphasised the place of beneficence, non-malevolence, patient autonomy and social justice; Justice being a fair and equitable and appropriate distribution in society of privilege, benefit and security.

The United Nations Declaration of Human Rights in 1948 further advanced these principles.

Policy Statements:

• World Health Organisation (2007)
• USA – JCAHO Initiatives
• International Association for the Study of Pain
• European Federation on IASP Chapters
• Australian & New Zealand College of Anaesthetists

More recently, policy statements have come from the World Health Organisation (2007) and the United State of America Joint Commission on Accreditation of Hospital Organisations. The International Association for the Study of Pain has driven the issue to the point that the United States recognised this decade as the "Decade of Pain Management and Research". The European Federation of IASP Chapters has also laid down principles, and our own Australian & New Zealand College of Anaesthetists Faculty of Pain Medicine has promulgated a Policy Statement.

ANZCA Faculty of Pain Medicine:

1. The right to be believed - recognising that pain is a personal experience and that there is a great variability among people in their response to different situations causing pain.
2. The right to appropriate assessment and management of pain - patients and their families have a key role in working with health care teams to develop realistic goals for pain management.
3. The right to have results of assessment regularly recorded - in a way that assists in adjusting treatment to achieve effective ongoing relief.
4. The right to be cared for by health professionals with training and experience in managing pain - and who maintain such competencies by all necessary means. Where such competencies are unavailable, the patient should be referred.
5. The right to appropriate effective pain management strategies - these need to be supported by appropriate policies and procedures.
6. The right to education about effective pain management - for the patient's particular problems.
7. The right to appropriate planning for pain management after discharge from hospital.

In summary, it was Albert Schweitzer who noted that:

Conclusion:

• Pain relief should be a priority in healthcare.

• Social justice demands universal access.

• Initiatives in Medicine, Law, Ethics and General Community.

• Need for better communication among disciplines.

• Must improve advocacy.

In conclusion, there is an urgent need for all levels of our medical system to recognise that pain relief is a priority in healthcare delivery. Today, in 2008, at levels of our individual practice, our hospitals, our city, our state and our international community, there are great variations in access to pain management for the young, the old, the geographically isolated, some cultures and some ethnic groups. Opioids, for example, are in generous supply in Australia but our own community has access far out of proportion to those in countries such as New Guinea, Africa and Asia.

We can advance our initiatives with better effective policies in Medicine, Law, Ethics and the General Community. To do this, we need to have far better communications between all disciplines. We need to have a political will to change.

Basic Human Rights:

• Relief of sever unrelenting pain
• Freedom from hunger and thirst
• Peace without political or other persecution
• Freedom of speech, press, religion, assembly, mobility
• Unpolluted food, water and air.