Pain Management and Public Health: Introduction to the Special Section

Three critical issues surround contemporary pain management and public health. First is the assessment of pain management needs and evidence-based interventions on an individual and population basis. Second is the tragic crisis of opioid use disorder in the United States and other developed countries. Third is the fragmented response to the opioid crisis, which has resulted in some undertreatment of severe pain and essential pain medications becoming unavailable, even as overdose deaths involving opioids continue to increase. This special section of AJPH on pain management (pp. 30–72) focuses primarily on the first issue, pain management assessment and intervention, but it does so in light of the other two crucial and related issues. The primary purpose of the special section is to document why pain, especially managing it, should be a high priority for public health policy, research, and practice.

The authors of the articles, commentaries, and editorials in the special section describe how pain, its treatment with opioids, and the consequences, both intended and unintended, of policies addressing it have evolved in the past 30 years. They document the evidence, and gaps in evidence, showing that pain may be effectively treated. They also identify challenges in creating policies that respond to the suffering and burden that pain imposes on patients and their loved ones, clinicians and caregivers, regulators, and society. Some articles provide an international perspective, including the argument that preventing pain and increasing access to pain care provided by qualified personnel is a human right. Overall, the articles support the view that a public health approach to pain management is essential to ensure that pain management receives appropriate attention and population-wide adoption.

US POLICY

Gross and Gordon, in “Strengths and Weaknesses of Current US Policy to Address Pain” (p. 66), review the current state of US policy. As the authors document, this is a moving target, because state and federal policies are evolving rapidly and often disjointedly. Although the National Pain Strategy and Federal Pain Research Strategy are important initiatives, the authors argue that additional funding for research is needed to better understand, prevent, and manage unintended consequences of policies to address the opioid crisis while seeking new treatments for pain and better models of pain care.

EVIDENCE

In their commentary, “Evidence-Based Pain Management: Building on the Foundations of Cochrane Systematic Reviews” (p. 46), Aldington and Eccleston provide an overview of the history and current status of evidence-based medicine for the prevention and treatment of acute, chronic noncancer and cancer-related pain as developed in the Cochrane Pain, Palliative and Supportive Care Review Group. The Cochrane Library is an important global resource that, the authors argue, should be more widely disseminated and integrated with decision support. They also identify limitations in the quality of some pain-related evidence.

In “Quantifying the Adequacy of Opioid Analgesic Consumption Globally: An Updated Method and Early Findings” (p. 52), Scholten et al. address the challenge of examining surfeits or shortfalls in global legal consumption of opioids and present their updated method to estimate optimal target goals for national opioid consumption. From a global health and World Health Organization perspective, disparities in what is available in the developed world versus the developing world are striking, raising important questions of social justice.

In “The Socioeconomic Burden of Pain From War: A Case Study of Transformation” (p. 41), Gallagher and Sandbrink examine the pain burden that war places on the health and well-being of combatants, civilians, and societies. From the context of the US Veterans Health Administration (VHA) Stepped Care Model of Pain Management and a VHA system-wide approach to education, training, and networking, they document national, system-level responses to the challenge of caring for pain after war. They contend that “[s]ocieties are encouraged to develop their health care system's capacity to effectively respond to the victims of warfare” (p. 41).

Carr and Schatman, in their editorial, “Cannabis for Chronic Pain: Not Ready for Prime Time” (p. 50), assess the evidence for the use of cannabinoids for pain and find it unpersuasive, especially when weighing the benefits against short- and long-term side effects. The authors caution against hasty adoption of this simple approach to the challenge of treating pain and urge careful consideration of possible unintended consequences of widespread use of cannabinoids for pain.

INTERNATIONAL

In “Solving the Global Crisis in Access to Pain Relief: Lessons from Individual Countries’ Responses” (p. 58), the Lancet Commission on Global Access to Palliative Care and Pain Relief extends its previous work on quantitating the burden of “serious health-related suffering.” By addressing palliative care along with pain relief, the authors convey the complexity of treating pain across spectra of symptom severity and life-limiting or terminal conditions. They also summarize relevant lessons learned from the US opioid crisis.

In “The Global Burden of Musculoskeletal Pain” (p. 35), Blyth et al. describe the global burden of low back pain and the documented shortfall between that burden and global policy responses. Calling attention to the increased prevalence of musculoskeletal pain with advancing age, they offer an integrated policy and research agenda that includes the introduction of new pain-related codes in the ICD-11 (International Classification of Disease, 11th edition). They recognize that the failure to capture data on pain may lead to underestimating its prevalence and impact.

HUMAN RIGHTS

Brennan et al., in “Access to Pain Management as a Human Right” (p. 61), survey the evidence on access to pain management from a social justice perspective. They explore how the obligation to manage pain is affected by the type of pain and the dilemma created by harmful, inappropriate opioid use in the United States and other nations. They assert that access to appropriate pain management should be considered a human right.

CONCLUSIONS

In their concluding commentary, Bonnie et al. (p. 31) discuss the articles in this special section in light of their 2017 report on opioid use by the National Academies of Sciences, Engineering, and Medicine.¹

Although the opioid crisis in North America and elsewhere is dominating current pain management policy, pain has been and will certainly continue to be a widespread and often unavoidable aspect of the human experience. Efforts to enhance access to opioids, particularly for cancer-related pain and end of life care, are urgently needed in low-resource countries. Most importantly, the dogmatism and politicization that has characterized many decisions in the recent history of pain control and opioid analgesia must be replaced by humility, compassion, and willingness to align the needs of multiple stakeholders in the interest of public health.