|Year : 2016 | Volume
| Issue : 2 | Page : 80-82
Recognition of pain as a specialty in India
Varun Singla1, Yatindra Kumar Batra2
1 Department of Anaesthesia, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Anaesthesia, Max Super Speciality Hospital, Mohali, Punjab, India
|Date of Web Publication||18-Jul-2016|
1st Floor, A Block, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Chronic pain problem is one of the most common symptoms for which a patient visits a primary health-care practitioner in India. Pain management is a rapidly growing specialty of medicine concerned with the prevention of pain, and the evaluation, treatment, and rehabilitation of persons in pain. Pain as a specialty has grown enormously in the last decade and is being recognized at the national level by the government, medical fraternity, and community at large. The time has come for the formation of a uniform, high-quality, standardized, multidisciplinary pain education, and training framework which would include health-care providers from the grass root level to the specialized pain consultants.
Keywords: India, pain education and training, specialty
|How to cite this article:|
Singla V, Batra YK. Recognition of pain as a specialty in India. Indian J Pain 2016;30:80-2
| Introduction|| |
India with 20% of the loss of global disability-adjusted life years (DALYs) has one of the highest disease burdens in the world, and noncommunicable diseases are gaining the upper hand over communicable diseases as leading cause of morbidity and mortality in India.  Chronic pain has been viewed as an epidemic and if preventive and curative measures are delayed, it may emerge as an entity with high DALYs, social burden, and economic decline. At present, health care situation in India is dismal with total expenditure on health as a percentage of gross domestic products being 4% (2013) and general government expenditure on health as a percentage of total health expenditure being <50% (32.2%), which shows government's attitude toward health care. This is reflected by the amount of money paid by patient toward health care, out-of-pocket expenditure as a percentage of total expenditure on health is 58.2%.  The percentage of the person below the poverty line in 2011-2012 has been estimated as 25.7% in rural areas, 13.7% in urban areas, and 21.9% for the country as a whole, and the percentage of people insured in India (2014) is 17%. , These people cannot access medical care from costly private institutions and pain clinics are present only in few tertiary centers leaving a wide lacuna of accessibility at the local level.  Moreover, socioeconomic differences are prevalent in India with more social value being given to male and young leading to less health coverage of females and geriatric population.  Chronic pain problem, with a point prevalence of 13%, is one of the most common symptoms for which a patient visits a primary health-care practitioner in India.  It is likely to grow as the population ages with better preventive and curative medicine and thus the need for qualified professional pain specialists.  Currently, India has the world's largest youth population and for the economy to soar and society to progress, the country needs to invest in their health and education. 
India is a complex and dynamic country with a rich and varied traditional culture. In ancient times, pain was managed mainly with the use of herbs and spices, such as opium.  Ayurveda, a type of complementary and alternative medicine, has historical roots in the Indian subcontinent.  Yoga well-known for its healing effects on body originated in prevedic times in India and was introduced to the Western world.  Pain management techniques and medications have grown widely all over the world in recent times with subsequent growth of the specialty.
Pain management is a rapidly growing specialty of medicine concerned with the prevention of pain, and the evaluation, treatment, and rehabilitation of persons in pain.  It meets the unmet need of existing medical specialties, requiring specialized knowledge and skills to diagnose, and manage complex entity such as chronic pain. Late John J. Bonica's vision and pursuit for the management of pain led to the development of pain as a specialty. It has evolved into a multidisciplinary outlook toward pain scenario, with its roots growing deeper in the medical field and branches spreading over to involve other specialties. First multidisciplinary pain clinic was created by Dr. Bonica in 1978 in the United States of America, and the culture spread over the whole of the world with pain clinics starting to flourish in India too. He also founded the International Association for the Study of Pain (IASP) in 1973 that has since then played a pivotal role in pain education and research worldwide. 
India has lagged behind the global trend in population health-care coverage and aspires for universal health coverage. The public health system of India is a three tier system with primary health-care center forming the first contact point between community and healthcare, community health-care center and tertiary-care center form the first referral and the ultimate referral unit. About 0.8 million of health-care providers are trained in alternative forms of medicine compared to 0.7 million trained in modern medicine.  This vast human resource remains to be utilized and can serve to strengthen the pillars of pain management at the ground level with strong referral units consisting of pain physician. Private practitioners have an important role to play in the strengthening of health-care pillars of India as they provide 80% of outpatient and 60% of inpatient care in India.  Moreover, nongovernment organizations can help by raising awareness of chronic pain and its management and lend emotional, moral, and economic support to patients.
Lack of awareness of chronic pain as a disease is prevalent not only in general population but also among medical fraternity.  Human rights watch in 2011 report emphasized on the need of pain and palliative care education as a standard part of the undergraduate medical curriculum and postgraduate training in specialties routinely dealing with pain and palliative care patients.  In the United States, American Board of Pain Medicine and American Board of Anesthesiology are the two organizations responsible for credentialing pain physicians. Furthermore, the World Institute of Pain offers Fellow of Interventional Pain Practice certification to pain physicians all over the world.  The situation in India is grim with pain and palliative care education availability in undergraduate medical curriculum and postgraduate training in palliative care sparse. There are many practicing pain physicians who have obtained training and experience by stopgap means, self-education, and "hit and trial" method. One year fellowship and certificate courses in pain medicine have been launched in the government sector, namely Banaras Hindu University and Sanjay Gandhi Post Graduate Institute of Medical Sciences since 2008 and 2010, respectively. MD course in palliative medicine is available at Tata Memorial Centre, Mumbai, with academic session started from 2012 after recognition from Medical Council of India (MCI).  Recently, All India Institute of Medical Sciences has started MD course in palliative medicine and DM course in oncoanesthesia and palliative care from January 2016 session with specialized training in pain management and palliative care at the Institute Rotary Cancer Hospital, New Delhi.  In India, MCI and National Board of Examination are two statutory bodies responsible for regulating medical education. MCI has been notified to take necessary steps for recognition of Post doctoral certificate course (PDCC) and DM in pain medicine in government institutes, but there is no affirmative response yet. Moreover, Indian Association of Palliative Care (IAPC) and Indian Society for Study of Pain (ISSP) have written to MCI and IAPC has been successfully able to incorporate some 5-10 lectures on palliative issues in MBBS course. We are on the right path and hope that medical education centers follow with the growth of pain and palliative care education and research all over the country.
ISSP is keen on the issue of standardized pain education and training. It provides IASP and ISSP sponsored fellowship in pain with a 1 month training period in one of the ten approved training centers located at different parts of the country.  It envisions formation of Indian Academy of Pain to propagate quality oriented pain medicine education and practice all over the country. It has been proposed to impart training to selected candidates over an 18 months period in selected regional centers of various states and successful candidates will be awarded fellowship named Fellow of Academy of Pain Medicine.  Various societies and organizations, both government and private, play an instrumental part in physician, nurse, and community education by organizing seminars, workshops, and conferences.
With the advent of technology and World Wide Web came new opportunities for learning and dissemination of knowledge from one corner of the world to the other. Online education and certification are new to India although many universities in the Western world offer online courses on varied subjects and is considered equivalent to on-campus education and training. Long distance virtual classes would be of great benefit to people who have difficulty in leaving the residing place or job.
Pain education and training in India has been limited mainly to people with experience in anesthesia (DA, MD, or equivalent degree). In our view, pain management cannot be limited as a subspecialty of anesthesiology because it has moved from postoperative pain management to chronic cancer and noncancer pain. It would be justified to rank pain medicine as a super specialty with its subspecialties being divided into acute pain, chronic pain (excluding spine), chronic spinal pain, and cancer pain. We need to broaden the eligibility criteria with the involvement of other medical specialties such as orthopedics, neurosurgery, neurology, psychology, physical medicine, and rehabilitation so that wide knowledge can be harnessed and multidisciplinary pain education, training, and research can be established.
Pain as a specialty has grown enormously in the last decade and is being recognized at the national level by the government, medical fraternity, and community at large. The time has come for the formation of a uniform, high-quality, standardized, multidisciplinary pain education, and training framework which would include health-care providers from the grass root level to the specialized pain consultants.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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