Year : 2016 | Volume
: 30 | Issue : 2 | Page : 83--89
Acute pain services in India: A long and challenging journey ahead
Samina Khaliloddin Khatib1, Sadhana Sudhir Kulkarni2, Syed Shamim Razvi3,
1 Department of Anaesthesiology, Government Medical College, Aurangabad, Maharashtra, India
2 Department of Anesthesiology, Government Cancer Hospital, Aurangabad, Maharashtra, India
3 ?Department of Orthopaedics, M. G. M. Medical College, Aurangabad, Maharashtra, India
Samina Khaliloddin Khatib
Yunus Colony, Near Sabahat Hospital, Roshan Gate, Aurangabad, Maharashtra
Acute post-operative pain and other forms of pain are widely undertreated globally including the Indian hospitals. As a result a large proportion of patients suffer from moderate to severe forms of pain. Undertreated pain can have many negative consequences such as pulmonary complications, acute myocardial ischemic events, delayed wound healing, prolonged hospital stay, etc. In spite of this acute pain continues to be negelected. The solution to poorly managed pain is not just developing newer and sophisticated techniques. But the solution lies in developing a dedicated, round-the-clock service called as acute pain service. This concept has gained world wide acceptance in last two decades and a majority of countries are developing such pain services in the hospitals. Unfortunately in India the field of acute pain medicine is still in its infancy. A very few hospitals have full fledged Acute Pain Services. In this review article we have tried to throw light on the hurdles in developing Acute Pain Services in our country. Also we have suggested a few possible solutions.
|How to cite this article:|
Khatib SK, Kulkarni SS, Razvi SS. Acute pain services in India: A long and challenging journey ahead.Indian J Pain 2016;30:83-89
|How to cite this URL:|
Khatib SK, Kulkarni SS, Razvi SS. Acute pain services in India: A long and challenging journey ahead. Indian J Pain [serial online] 2016 [cited 2018 Jan 19 ];30:83-89
Available from: http://www.indianjpain.org/text.asp?2016/30/2/83/186461
Undertreated pain is a global phenomenon and India is no exception to it. Pain is invariably associated with perioperative period, childbirth, road traffic accidents, natural disasters, war, etc., The incidence of moderate-to-severe pain in the postoperative period has been quoted in a number of studies. A questionnaire survey done by Vijayan et al. in different Asian and African countries revealed that only 30% of the patients in India receive adequate management of pain. This means that an astounding 70% suffer from inadequately managed pain.  Uncontrolled acute pain not only leads to discomfort and suffering, but also causes delayed wound healing, increased risk of cardiovascular and pulmonary complications, decreased gastrointestinal activity, prolonged hospital stay, detrimental effect on the mental health of patients, and risk of chronic persistent pain. ,
From various studies, it has become evident that the solution to inadequate pain relief lies not so much in developing newer techniques but more in the development of a formal organization for better application of existing knowledge and existing techniques.  Such an organization is termed acute pain service (APS) which is dedicated to the management of acute pain in surgical patients, trauma cases, parturients, and other patients with acute pain.  The basic quality criteria for APS are personnel assigned for APS, policies for pain management during night and weekend, written protocol for pain treatment, and regular assessment and documentation of pain scores at least once a day. 
Optimal pain management minimizes disruptions to the smooth flow of patient care and reduces short- and long-term costs of care. Proper implementation of APS will lead to decrease in postoperative morbidity and mortality. This will reduce the health costs, hasten up the postoperative recovery process, and lead to early discharge. The government hospitals in our country which cater to the needs of large proportion of mostly low- and middle-income population are always having a shortage of beds. A large number of patients are kept waiting for a long time for elective surgeries due to shortage of beds and slow discharge process. Early discharge of patients due to improved pain services means that a rapid turnover will occur and more number of beds will be available. Poorly controlled postoperative pain delays patients' recovery process and hence increases the number of days of hospital stay.  Relatively small number of hospital bed capacity and prolonged hospital stay results in the overcrowding of patients and poor quality of care. 
It may be argued that when India is so much burdened with infectious diseases, high child and maternal mortality, and many other health problems, is it really worthwhile to invest in APSs?  The available resources for health care understandably focus on the prevention and treatment of killer diseases. Yet most such conditions are accompanied by unrelieved pain that increases suffering, functional disabilities, and leads to loss of quality of life. These conditions include HIV/AIDS, cancer, tuberculosis, malaria, and other infectious diseases and injuries caused by road traffic accidents, war, torture, and other forms of violence. Therefore, the importance of APS cannot be underestimated. 
The Status of Acute Pain Medicine in India
After Ready et al. first started an APS in 1988 in Seattle, United States, there was a slow and steady rise in such services in all parts of the world.  In our country also, there were efforts to establish APSs in many tertiary hospitals in the form of duty anesthetists looking after pain management and nurse-based, anesthetist supervised teams. In addition, attempts were made to give specialized pain services to patients with comorbid conditions and those undergoing supramajor surgeries, etc., However, the first APS with fully dedicated pain teams and round-the-clock service was started in the Tata Memorial Hospital, Mumbai, in 2002. A search of literature shows that, till date, only two medical centers from India (the second being the Indian Spinal Injury Centre, New Delhi) comprising APS have published papers regarding their experience and functioning. ,,
In a national survey, Jain et al., observed that there are 68 functioning APS centers in our country, out of which only 3 have a dedicated pain team at night, 20 have no training programs, and 34 have no written protocols.  Of these, 45 APS units are managed by anesthesiologists and rest by surgeons and nurses. In addition, in the majority of these centers, pain is not routinely measured/documented. Therefore, the quality of services provided by these units is also questionable.  There are many other groups of patients who are undertreated for pain. One of the important groups is patients in emergency rooms. Trauma is a hidden epidemic in developing countries and it is among the top ten leading causes of death and ongoing morbidity as described by the WHO.  Studies show that only half of the patients in the emergency department receive any analgesia at all and of those who receive any analgesia, 80% were still left with moderate-to-severe residual pain. 
Thus, the field of acute pain medicine is still in its infancy in our country and we have a long way to go in terms of development, and the prevailing circumstances show that this is very essential to provide quality care to the masses. Hence, what are the hurdles in developing the essential service? A search of literature shows many research articles about the barriers that come in the way of implementing pain services. However, there are very few studies in the Indian setups regarding this. Our challenge was to interpret the available research in the Indian context.
The International Association for the Study of Pain (IASP) 2010-2011 report points to the gaps in the quality of pain care delivery.  The problems related to health-care professionals, patients, and the health-care system are discussed in this report. The problems related to health-care professionals have been cited as inadequate knowledge and attitudes, "clinical inertia" - slowness to update individual practice in light of evolving evidence, opiophobia, exaggerated concerns about the side effects of pain treatment, etc. The problems related to patients have been cited as - lack of awareness of the importance of pain control, mistaken ideas, tendency to be satisfied with inadequate pain control, especially when health-care professionals are perceived as supportive, undue fear of side effects of pain medications, etc., The problems related to the health-care system are reported as low priority to pain education, low value accorded to patient preferences, inadequate infrastructure, practice restrictions on nurses, inadequate funding, etc.
Somewhat similar observations have been made by many other authors. ,,,,,,, According to Powell and Davies,  APS development and improvement could also be impeded by intra- and inter-professional boundaries. Heirarchies lead to independent working and to the members of the same professions competing for patients, resources, and influence. Health professionals may resist change in their role and use a range of strategies to defend the existing professionals' boundaries. Resistance from nursing profession to adopting new tasks around postoperative pain management could have appeared from a sense of professional and individual weakness. The adverse impact of professional boundaries has also been reported by Middleton. 
In the national survey of APSs in India by Jain et al, a majority of anesthesiologists have agreed to have the following hurdles in starting/implementing pain services - lack of manpower and initiative, busy hospital environment, and inappropriate attitudes and inadequate knowledge of health professionals. Despite the known fact of the importance of optimal pain management, the pain services are not well developed. The possible hurdles could be as follows.
Lack of high priority for pain management
The hospital administration does not give priority to APS services because of many reasons, as there is no national/state policy, the hospital administration is less likely to be concerned with pain management. The hospital administration is burdened with other problems mainly concerning basic facilities, management of manpower, etc. The administrators may be unaware about the importance of pain management and the adverse effects of inadequately managed pain. These problems can be effectively dealt with if the Government of India makes a national policy for pain, as is available for many other disease conditions and health problems. Till date, there is no national or state policy for acute pain management in our country except for the state of Kerala which has a policy for pain and palliative care, but it caters mostly to the needs of chronic pain patients.  Analgesia is not a priority because of more importance being given to other health problems.  The WHO recommends that all countries should establish a national palliative care and pain treatment.  However, no steps have been taken in this direction. Since pain and palliative care is not a priority for the government, it leads to a lack of adequate education and training of health-care workers. The government will be convinced in this matter if systematic research is done in this area so as to throw light on the severity of the problem. There is a great paucity of research in acute pain in the Indian setup. If more such studies are taken up, it may be possible to persuade the government to make a pain policy. The associations of anesthesiologists and surgeons must take the problem seriously and take steps in the right direction. While this may take some time, the local administration in all the hospitals needs to be convinced about the severity of the problem and start improving the local hospital practices in pain management.
Lack of resources, funds, and manpower
As the pain services are to be implemented as round-the-clock service, a dedicated staff needs to be appointed. All these require extra funds which are difficult to obtain unless the local administration and in case of government hospitals, the government policy makers are convinced. Getting funds for APS is a major problem unless the cost-effectiveness is proved. Hence, again the need of systematic research is stressed. The cost of drugs and equipment is also a major hindrance in low-resource settings. In a study by De Lima et al, it was observed that the cost of the opioids relative to income is higher in developing countries as compared to developed countries (median cost as a percentage of gross national income per capita per month was 36% for developing countries and only 3% for the developed countries.). 
To overcome the financial hurdles, many low cost models have been developed such as the nurse-based services.  A study by Gould et al.  has shown that even low cost techniques such as educating the nurses, developing protocol for intramuscular opioid administration, encouraging surgeons to infiltrate the wound with local anesthetics and educating the patients can be very effective in controlling pain and improving patient satisfaction. Dr. Rao has advocated a holistic approach to acute pain management in which nonpharmacological approaches such as herbal medicine, hypnosis, meditation, transcutaneous electrical nerve stimulation (TENS), acupuncture, complimentary/alternative medicine, and patient education can be used as an adjuvant to the main methods of pain relief.  Similarly, Upp et al, have also suggested the multimodal therapy with a focus on acupuncture, TENS therapy, etc., to minimize the incidence of acute tolerance to opioids and hyperalgesia when they are used as primary analgesics.  The WHO Federation of Societies of Anesthesiologists has produced a modified ladder for acute pain.  Starting with the strong parenteral opioids, ketamine and/or local anesthetics, there is then a step down to oral opioids and finally to nonsteroidal anti-inflammatory drugs and paracetamol on its own. The ladder will be helpful in utilizing drugs effectively in low-resource settings and will also act as a guide for effective pain education in all the health-care professionals. 
Getting funds for APS is a major problem unless the cost-effectiveness is proved. A study by Stadler et al. shows that the APS has an overall positive result for the health-care system by improving the postoperative morbidity and pain and hence, it was found to be cost-effective.  An APS service can be integrated with other rehabilitative or critical outreach services to increase the cost-effectiveness and outcomes. 
Lack of support during weekends and emergency hours
To surmount this problem, a dedicated acute pain team, which works in rotation as round-the-clock service, can be appointed. Having a separate team is also advantageous because they will be solely responsible and accountable for their work. However, having a separate pain team is not a cost-effective option in a low-resource setting. In such situation, a few members of the anesthesia department can work in rotation to provide pain services.  During emergency hours, one or two members of the emergency team can be appointed solely for managing pain services. 
Poor attitudes and lack of pain education in health-care professionals
A solid foundation of knowledge and a positive attitude toward pain management are a must for every health-care professional including the nurses. However, there are many lacunae and inadequacies in pain education for medical students, nurses, and advanced trainees leading to poor understanding about pain assessment and multimodal treatment approach for pain.  The current status of pain education in India is grimmer than that in developed countries.  There are hardly any data on pain management and education at undergraduate level.  Same is the scenario in nursing education. , Many studies show that health-care professionals have knowledge deficit, inconsistent responses in many areas related to pain management such as pain assessment, nonpharmacological intervention to relieve pain, the difference between acute and chronic pain, and anatomy and physiology of pain. ,,,,,
The situation can be improved if pain education is incorporated in both undergraduate and postgraduate curricula of medical as well as nursing education. Continuing education programs should lay great stress on pain management. Loeser has suggested that "no one should receive a medical degree without learning core knowledge about both acute and chronic pain, including cancer pain and nonmalignant pain."  The IASP Global Year against Acute Pain Factsheet number 6  states that acute pain management should be an obligatory part of treatment in all medical and nursing schools. It should be taught to medical administrators and must be addressed by establishing national strategies and framework involving all those dealing with pain at scientific and practical levels.
The Indian Society for Study of Pain (ISSP) has also taken efforts by forming a task force in 2009 to outline the course content for pain management of different durations. The ISSP has also formed a committee to identify training ventures and award a fellowship of 1 year duration. Few private centers regularly conduct short courses and workshops. A postdoctoral certificate course of one year duration and recognized by Medical Council of India(MCI) is started at the Banaras Hindu University, Varanasi (since 2008) and the Sanjay Gandhi Institute of Postgraduate Medical Sciences, Lucknow (since 2010). A 3-year M.D. in Palliative Medicine has also been started in the Tata Memorial Center, Mumbai, in 2012, and it is approved by MCI. This is just the beginning and India has still a long way to go in training in pain medicine. 
At an international level, the knowledge of professionals can be increased by encouraging links between developed and developing countries, for example, by linking anesthesia departments, which will promote sharing of ideas and problems, exchange visits of personnel, and may even help with the supply of essential drugs and equipment.  Refresher courses, development of local protocols, motivation of staff to assess and treat pain, stressing the observation of pain intensity as a basic observation or the 5 th vital sign, etc., should be promoted. 
Patients' attitudes and perception about pain
Many patients expect that pain is inevitable after surgery and that there is nothing much that can be done about it. Such attitudes characterized by low expectations of postoperative pain relief encourage the persistence of poor standards for analgesia. A number of studies show that patients are satisfied even though they suffer from moderate-to-severe pain and had to wait for a relatively long time for pain medication. ,,,,,
Patient education is the solution to this problem. Widespread public education should be started so that a public demand is created for the pain services and also a legislative recognition is secured for the importance of pain management.  The usefulness of this strategy is proved in the surveys carried out in France.  Hospitalized patients and those on surgery list can be counseled by distributing pamphlets containing the information. The ward nurses and junior doctors can easily counsel them about this problem.
Difficulty in procuring opioids
Opioids are the main drugs required for effective pain management. However, they are difficult to obtain because of strict regulatory laws based on fear of misuse and diversion of opioids. These strict regulations are a major barrier to acute pain management.  In 1985, Narcotic Drugs and Psychotropic Substances Act was developed which had a negative effect on the availability of morphine in India for medical purposes (requirement of morphine fell by 97%). 
Besides availability, there are problems regarding the attitudes and use of potent opioids in medical professionals and patients, especially undue fear of addiction leading to inadequate use of opioids for pain treatment. ,, The WHO has recommended that the countries should establish a national drug policy that ensures the availability of essential medicines including morphine. ,,,
Lack of knowledge about the economic implications of acute pain service
There is an undue fear in hospital administration that APS implementation will increase health costs and that increase in patients' bills will lead to a negative publicity of the hospital. Many institutions are reluctant to start a separate APS unit because they feel that it will only increase the hospital expenditure with no additional benefit. This apprehension is mainly because of lack of research in this area in the Indian setup. Financial considerations of APS are very important and are largely responsible for the slow adoption of APS.  Many studies ,,, from other countries show that implementation of APS leads to reduced expenditure because of reduced stay in recovery areas and Intensive Care Unit, reduced nursing time, reduced postoperative complications and hospital stay. Further savings could result from the reduced treatment of postoperative complications.
There is conflicting evidence on the effectiveness of APS for directly reducing the length of hospital stay. Lee has suggested some measures such as using regional anesthesia techniques, identifying patients who would benefit from APS intervention before hospital admission, incorporating APS care into fast-track programs, using the procedure-specific and evidence-based pain management practices, etc., which will reduce costs and improve hospital efficiency with implications for APS provision.  The most cost-effective way to implement an APS will vary among hospitals because of local variations in culture and personnel.
Another less discussed aspect of the APS is whether these services should be charged separately or not. In our opinion, charging APS services may have several advantages such as increased awareness and demand among patients for pain management, an incentive and accountability of health-care professionals, and creation of fund for the development of pain services. There can be a debate whether separate charging will be fair to the patients, but in the long run, optimal pain management will bring down the morbidity and health costs, promote savings in the patient's hospital bill and increase in the patient satisfaction. However, further research needs to be done about how separate charging affects the attitudes of health-care professionals and patients.
Cost should not be a hindrance in implementing APS. Even simple measures such as education of health staff regarding monitoring and taking regular pain scores, development of protocol for giving analgesic drugs and infiltration of wound with local analgesics lead to considerable improvement in pain relief and patient satisfaction.  The APS if implemented properly along with rehabilitative programs, leads to cost reduction in the long run.
Thus, APS can be successfully implemented even in low-resource settings. For this, a change in the attitude of health-care professionals and patients is very important. All health-care providers need to be sensitive to the humanitarian aspect of pain and the right of every human to have pain relief. The very basic cause for which every health professional works, i.e., to relieve the pain and misery of humanity will thus be achieved.
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Conflicts of interest
There are no conflicts of interest.
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