|Year : 2013 | Volume
| Issue : 1 | Page : 4-6
Pain management in a government hospital: The present scenario
Dipasri Bhattacharya1, Sujata Ghosh2
1 Department of Anaesthesiology, Critical Care and Pain, R.G. Kar Medical College, Kolkata, India
2 Department of Anaesthesiology, National Medical College, Kolkata, India
|Date of Web Publication||10-Jul-2013|
Department of Anaesthesiology, Critical Care and Pain, R. G. Kar Medical College, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bhattacharya D, Ghosh S. Pain management in a government hospital: The present scenario. Indian J Pain 2013;27:4-6
Since the first demonstration of ether anesthesia for the alleviation of surgical pain, algology has walked a long way from the Ether Dome. It is a common consensus that Pain Medicine and Intervention have achieved an impetus and are rearing to go. However, is it really so? India is a country where 29.18% of the population live below the poverty line. The population consists of laborers, farmers, menial workers, and people from different walks of life, and they are certainly not free from pain. Their only access to medical help is the government hospital - Primary, Secondary, and Tertiary. For them Private and Corporate hospitals, with an extremely high cost of treatment is out of reach. This acute lack of access to Pain Clinics leads to a considerable loss of man-hours. A large number of patients suffering from complicated diseases like cancer often have to go through unbearable pain as the government-run hospitals do not have the proper pain management system. The injections that are used to give relief from such pain are expensive. Even in the private hospitals there is no uniform rate for pain management treatment. The cost of the treatment varies from one private hospital to another. Chronic pain affects as many as one in five people causing not only significant costs to the individuals, families, and carers, but also to the healthcare systems. ,
Chronic pain has a profound impact on people's lives, affecting work, relationships, and normal daily life. , It reduces the quality of life almost more than any other condition; 31.16% state that their pain is so bad that they sometimes want to die; 65% of the sufferers report difficulty in sleeping, and 49% suffer from depression. Disability is common. People with chronic pain are seven times more likely to quit their jobs due to ill health than the general population. Overall, 19% of the people with chronic pain eventually lose their jobs. ,
There are also national and regional guidelines that focus on particular types of pain and local protocols, such as Diagnosing and Managing Neuropathic Pain: Guidance for the Primary Care Team. The National Institute for Health and Care Excellence (NICE) has developed guidelines on neuropathic pain and low back pain, in May 2009. This is certainly a step in the right direction. A recent UK report found that services in Primary Care were unequal and inconsistent and suffered from insufficient funding. ,,
Pain Clinics in Government Hospitals are few and are present only in some sporadic tertiary centers scattered in different parts of each state. In spite of stipulations put down by the Medical Council of India, effectively functioning Pain Clinics in Government hospitals are few, the offending causes being lack of infrastructure and manpower. The Medical Council of India has already stressed on the importance of setting up the system in state-run hospitals so that the poor patients can avail of the treatment at a cheap rate.
Although effective pain management interventions and programs exist, provision of these services is inconsistent and chronic pain is not given the priority it requires, in view of the extent of its burden on individuals and society. This is in part due to a shortage of pain clinics not only in India, but also in different parts of the world, like UK.  Health Minister Earl Howe of UK, recently stated that the government would promote the development of the best practice pathways for chronic pain, with providers being rewarded for quality of care. He said a pain score should be one of the clinical indicators considered, and the NICE guidance for all patients assessed on admittance to hospital should be followed with uniformity. ,,
In June 2008, The Welsh Assembly published service development and commissioning directives for chronic non-malignant pain, to help remodel the services, to improve the management of chronic pain.  It set out to refocus services and improve the use of resources to meet the local needs with clear care pathways, supported by timely assessment and accurate diagnosis. It also called for the integrated delivery of high quality services by multidisciplinary and multi-agency teams to become a standard feature of care.
According to one report only 30% of the pain clinics collect outcome data. A lack of data demonstrating the effectiveness of services is a significant barrier to maintaining and improving the existing services and commissioning new ones. Most people with pain will benefit from an integrated approach that addresses different aspects of their pain simultaneously. 
The Pain Proposal has been initiated to achieve a consensus on the impact of chronic pain across Europe, to highlight the need for immediate action to address current failings in its management and to share good practice examples, to demonstrate how effectively pain management can be achieved. The initiative has brought together a group of experts in chronic pain from across Europe, to share their knowledge, experience, and best practice from the individual countries, to help in recommending the best way forward. 
The Indian scenario is yet not so definitive, but there are some definite changes in the right direction. In Mellapuram and Wayanad, in Kerala, Palliative and Pain medicine is now being organized by the local self-government, to provide affordable and sustainable primary level services.  Almost 700 other villages have followed this model. Kerala is the first state to have declared the Pain and Palliative Care Policy, in 2008. It makes provision for professional training, doctors, and support staff, including supply of morphine to Government hospitals.
Recognition of public intervention, willingness to work along with the private Sector and the NGOs remains the cornerstone of the policy.
The Maharashtra minister of Health and Family Welfare has rightly pointed out that the public and the private sectors must work in tandem. A cost-effective workable public health model must be made as also mobilization of resources - human, material, and financials - is to be done. 
In recent times, Guwahati arranged a state level workshop for government officials of both the Health and Family Welfare Department as well as the Excise Department, to develop awareness of pain. 
However, awareness is still lacking. According to Dr. Ashoke Kumar Saxena, of Teg Bahadur Hospital of Delhi - 'The concept of Pain Management is yet to make inroads into the minds of many medical persons'.
The Primary issues that still need to be addressed are - the management of chronic pain in the healthcare system is still inefficient, often involving inappropriate referrals and delays in diagnosis. There is no coordinated strategy for pain management, resulting in a fragmented approach. Pain management should be approached and treated according to individual needs, in a coordinated manner. National Health Service (NHS) tariffs and International Classification of Diseases (ICD) codes that help to measure healthcare costs are required to demonstrate the large scale of the problem and to enable resources to be reallocated and used more efficiently. ,
Chronic pain is not well understood and people are not well equipped to seek assistance or proactively manage their own pain. Public awareness of chronic pain, centers for treatment, and patient organizations for information and support are a dire necessity. , There is poor understanding among those affected by pain of how to manage and describe their pain. Information is to be given to people with pain to empower them to take a more proactive role in the management of their own pain. , Care remains fragmented, and training in chronic pain assessment and management inadequate. The result is patchy services, inefficient use of resources, and limited understanding and evidence of improved outcomes.
Successful examples of service redesign show that significant extra resources are not necessary to remove inefficiencies and improve outcomes. The answer lies in reconfiguring services to provide a better outcome - focused, multidisciplinary care, tailored to the needs of the individual patient. This requires clear patient pathways, easily navigable management guidelines and appropriate training. 
A new government focused on stripping out inefficiencies and improving patient outcomes presents a major opportunity for change. By simply reallocating resources the government could make a huge impact on the NHS, the economy, and the patient load.
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