There's No Excuse for Pain
Dr J C D Wells Liverpool, UK
Pain has been underestimated and under-treated for hundreds of years. Interestingly, this was not always the case - the physicians of Greece and Rome took pain seriously and used the same medications that we use today. However, in the 18th century we can see the prevailing attitude in Britain and Ireland was to ignore pain, with soldiers and sailors having a leg amputated with nothing more than a draught of alcohol and women being expected to suffer labour uncomplainingly. It was only when Queen Victoria requested anaesthesia for the birth of her child that obstetric analgesia became acceptable. Also, the anaesthetic movement came in then to protect patients from the negative effects of pain during surgery.
Little else happened for the next hundred years in the management of acute, chronic or cancer pain. Then the hospice movement in Britain started to progress ideas about managing cancer pain, and you have already heard how things have developed, and the situation today. Chronic pain started to be taken seriously at the same time and was managed by pioneers such as John Bonica in the USA and Sam Lipton in the UK. However, facilities were poor and the service was always under-funded.
In the '90s, Anaesthetists really began to take a strong interest in the management of acute pain. Acute pain teams have been set up all over the Western world. Management of post-operative pain is still patchy, but certainly better than it was. But what about the management of chronic pain?
There certainly seems no argument that pain has a negative physical and mental effect upon the sufferer. There are also social and behavioural changes which occur and which can lead to chronicity. How sad then that in everyday practice we see doctors and paramedical staff ignoring or belittling a patient's complaints of pain. For instance, every week I get a letter from a doctor who tells me that an elderly patient cannot have medication for his pain because it will "interfere" with the essential drugs that he is having to produce diuresis, lower his blood pressure, stabilise his heart and expand his lungs. What is the point of prolonging life if the patient is in constant pain? Is it ethical to prolong a painful life? It is certainly unethical in my opinion to under-treat people with chronic pain.
A wide variety of treatments are recommended for pain, and perhaps some of the reluctance to treat stems from a lack of clinical evidence. This can be hard to obtain. I would fully concur that it should be obtained but, in the meantime whilst it is being sought, I would decry the nihilistic attitude of those who state that we should do nothing.
The treatments being used need to be constantly appraised, modified and updated. Assessment of the patient, their underlying pathology and their complaint of pain is paramount. When this assessment has been made, treatments can be tailored to the patient's need.
There are many ethical problems in the management of pain. These include the decision to treat, the decision not to treat, the use of treatments which haven't as yet been proven to be effective and the use of drugs, such as epidural steroids and anticonvulsants, for unlicenced indications. However, if modern techniques are assessed as accurately as the Greek and Roman physicians evaluated poppy juice and willow bark 2000 years ago, the lot of the average pain sufferer can be greatly improved.
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