As trials proceed for “torture”, we wonder how far culpability extends for known allowance of human suffering. What is the difference between torture and a severe constant pain state?
Brennan and others from Australia have asked in Anesth Analg. 2007 Jul;105(1):205-21. whether pain management is a fundamental human right. Certainly, the World Health Organization recognizes hunger as justifying emergency measurs, but there is a way to go yet in recognizing the really severe pain states as justifying humanitarian action.
We are taking a careful look at the treatment of those in prisons, and of course there is no prison like a body of pain. Can conditions be improved?
The concept of pain management as a human right began its momentum with the 2004 European Federation of the International Association for the Study of Pain (IASP) and the World Health Organization-in a sponsored event named, “Global Day Against Pain,” Some of the authors were invited to contribute topics and materials for that event.
Pain management as a human right uses worldwide medical, ethical, and legal trends. It considers the moral issues of pain treatment in three areas:
1) Acute pain
2) Cancer pain and Chronic noncancer pain (central pain falls here)
3) “adverse physical and psychological effects and social and economic costs of untreated pain.”
The group concluded that focusing on pathophysiology rather than on the quality of life, “reinforces entrenched attitudes that marginalize pain management as a priority”. Do we really care if someone had an SCI,a stroke, MS, syrinx, or whatever before we decide to help. For that matter, ordinary musculoskeletal pain can ruin lives as well, not to mention the ravages of central nerve injury pain.
The group recommends:
1)”framing pain management as an ethical issue; promoting pain management as a legal right, providing constitutional guarantees and statutory regulations that span negligence law, criminal law, and elder abuse”
2)”categorizing failure to provide pain management as professional misconduct”
3)issuing guidelines and standards of practice by professional bodies
4) increasing the role of the World Health Organization is discussed, particularly with respect to opioid availability for pain management
This last goal may run into loggerheads with the various federal and state agencies which sometimes fail to take into account legitimate research showing benefit from various substances. It also may cut back on prosecutots eager for an easy and devastating blow against doctors who administer opiates.
The opiate issue is not of much importance in central pain since they do not stop central pain, function primarily as sedatives, and a very long pain state like CP virtually guarantees everyone who attempts it long term may acquire a dependency.
What is really needed of course is funding for basic research so we can quit worrying about the opiate mess. It is very, very ominous that as the July 4 Newsweek reported, pain clinics are shutting down all over the country. After all, who wants to lose their medical license! There has to be better communication on this topic. We don’t want criminals to be the only source for pain meds and we don’t want patients attempting to treat themselves. However, if we put pain doctors at high risk of arrest, we may be violating civil rights. It is certainly a topic that must be discussed further.
A step in the right direction would be for the federal regulators to republish guidelines for pain managament which can be used as a benchmark for acceptable care; ie a safe harbor to treating severe pain. Many SCI patients have large amounts of musculoskeletal pain and here opiates can play a role. For central pain, we need something better, more money, and more caring about those who languish in prisons of pain, with no rights, no representation, and no objective tribunal.
This is not to detract from the difficult role of brave law enforcement officers who attempt to control the drug trade. They are dealing with the most violent and dangerous criminals. We pay them tribute. However, a distinction must be made in the way pain clinics and pain doctors are approached. Maybe a few more warnings and a few less swarms of agents in clinics. The recent moral of the Mike Nifong story is that reputations can be demolished in just a few moments of comment. Some of the information about arrested pain doctors is not only troublesome, it verges on being blind injustice. That is why specific guidelines are needed. In our country, we call vague laws unconstitutional. Medically speaking, we cannot afford to have vague laws for opiate use.