It seems that politicians, government agencies, and law enforcement simply don’t see this, though they’d quickly change their minds if it were their own flesh in agony.
The concept of access to pain management as a human right has gained increasing currency in recent years. Commencing as individual advocacy, it was later embraced by the disciplines of pain medicine and palliative care and by mainstream human rights organizations.
Today, United Nations and regional human rights bodies have accepted the concept and incorporated it into key human rights reports, reviews, and standards.
We review the foundations in law of this right and the obligations that flow from it to governments. We analyze the nature and content of the obligation in the context of acute, chronic nonmalignant and cancer pain.
Finally, we examine this right in light of the twin crises of inadequate access to pain management and the opioid crisis in the United States and other nations.
Since the 1990s, the notion of access to pain management as a human right has gained significant currency as both legal and public health experts have sought to unpack its dimensions, implications, and limitations.
We examine the foundation of the concept of access to pain management as a human right and its implications for medicine.
We argue that certain obligations flow from this right for governments to fulfill. We analyze the extent and nature of this obligation in the contexts of acute, chronic noncancer and cancer pain and the specific context of the current opioid crisis in the United States and other nations.
The global burden of pain is very significant. The management of pain requires a broad and multidisciplinary approach that addresses its physical, psychosocial, and spiritual dimensions.
Treatment approaches vary depending on the type and nature of pain.
This directly contradicts the reasons behind policies of opioid restrictions that are expected to govern all pain care instead of treating each patient individually.
Opioids have a pivotal role in the management of moderate to severe acute and cancer pain. In CNCP, their role is more limited although required in certain circumstances.
Despite the prevalence of pain and its impact on quality of life, undertreatment remains a major problem.
The opioid crisis in the United States has resulted in restrictions with regard to legitimate access to opioid medication and inadequate pain control for patients.
The Right to Pain Management
The ethical responsibility of clinicians to manage pain is well understood and a basic element of ethical codes.
Really? Neither doctors, nor government agencies, nor politicians, nor law enforcement consider pain worthy of any consideration at all – that’s a huge part of our problem.
- the American Medical Association states that “Physicians have an obligation to relieve pain and suffering,” and
- the World Health Assembly resolved that “[I]t is an ethical duty of health care professionals to alleviate pain and suffering.”
In response to the major gaps in treatment, pain and palliative care professional associations went further and made a series of declarations asserting that pain management and palliative care are basic human rights. (A summary of those statements is presented in BOX 1 below).
Although there may be a moral obligation to manage pain, is there a basis for a right to treatment of pain in human rights law?
Human rights are entitlements and freedoms that all human beings hold, regardless of nationality, ethnicity, gender, or religion.
Internationally, human rights are founded on recognition of the inherent dignity of the human person and expressed in international human rights conventions.
Internationally, the foundations for the assertion of pain management and human rights lie in
- the international right to health;
- the right to be free from cruel, inhuman, and degrading treatment; and
- the principles of dignity, nondiscrimination, and equality.
The relevant sources are summarized in the Appendix (available as a supplement to the online version of this article at http://www.ajph.org).
The principal articulation of the international right to health is Article 12 of the International Covenant on Economic, Social and Cultural Rights. The covenant does not contain an express right of access to pain management. Nevertheless, pain management forms part of health care and, as such, falls within the overall right to health.
The committee identified a number of “core obligations” that countries must fulfill, irrespective of their resources. They include obligations
- to ensure access to health facilities, goods, and services on a nondiscriminatory basis,
- to provide essential medicines as defined by the WHO, and
- to adopt and implement a national public health strategy.
The committee also enumerated obligations “of comparable priority,” which include providing education and access to health information to the community and “appropriate training for health personnel.” These requirements mean that countries should fulfill each of these elements in terms of pain management.
It is important to distinguish the right to pain management
- under human rights law, where obligations rest on governments, and
- under medical ethics, where obligations rest on individual clinicians.
Those sets of obligations converge to the extent that governments have a responsibility (as part of the right to health) to ensure the adequacy of medical education, and (as part of their fulfillment of the quality of health care) they have within their power the licensing of physicians.
In addition to the right to health, there are statements by senior UN human rights officials that the failure to ensure access to controlled medicines for the relief of pain and suffering threatens the protection of persons from cruel, inhuman, and degrading treatment.
Chronic Noncancer Pain and Human Rights
Much has been written about the human rights dimensions of pain management in the context of acute and cancer pain and, more generally, palliative care.
several core obligations related to CNCP management still flow from international human rights norms.
- Firstly, as CNCP is a major contributor to the global burden of years of life disabled, all countries must develop and implement a strategy that responds to this health need.
- Secondly, medications that are included on the WHO’s Essential Medication list, including nonsteroidal anti-inflammatory drugs, muscle relaxants, antidepressants, and opioid analgesics that are frequently used in the management of CNCP, must be available and accessible to all patients who need them
- Finally, countries must ensure that health care providers receive adequate training in the management of CNCP.
In light of the current opioid crisis in the United States, it is important to point out that the right to pain management does not imply an automatic right to opioid medications.
In fact, the right to health requires “quality” of services in terms of skills and expertise in addition to availability, accessibility, and acceptability.
Those skills and expertise require a conscientious assessment of pain and development of a treatment plan, guided by the best evidence available, but that plan does not include providing opioids on demand.
In CNCP syndromes, however, opioids may play a more circumscribed role.
The right to access pain treatment means that physicians should be able to make the clinical determination of the best treatment options—without inappropriate government interference—and patients should have access to them, including opioids.
The Interface of Human Rights and the Opioid Crisis
Globally, there are four strikingly different challenges with opioids.
- The first is access. The vast majority of the world’s population lives in countries with limited or negligible access to morphine for medical purposes.
- The second is that pain management often requires the use of controlled medications. Thus, drug control policies and practices must ensure adequate access to these substances.
- The third is a rise in opioid-related deaths, with a complex etiology predominantly driven by polypharmacy, heroin, and synthetic fentanyl.
- The fourth is the restriction, directly or indirectly, of pain management in patients with genuine needs.
All are pressing issues. If one of these is embraced as the singular challenge and the others are ignored, great harm is likely to flow. Governments, regulatory authorities, clinicians, and society should focus on all issues simultaneously.
One of the dangers of a highly regulatory response to the opioid crisis is an arbitrary restriction of access of opioids to patients who genuinely require them, which may constitute a violation of human rights.
Governments must ensure that clinicians are adequately trained in both pain medicine and management of drug dependence. Currently, there are significant deficits in their training in both disciplines.
Without training, myths persist.
I’m truly shocked at how much of the media myth our doctors believe.
A right to pain management mandates a conscientious and rational approach to the management of pain that may or may not include opioids.
A rights-based discourse significantly expands the emphasis from medical to legal obligations under national and international law.
Equally, vigilance regarding opioid diversion and abuse and appropriate, evidence-based management of drug dependence remains vital.
Striking that balance challenges all involved to ensure that access to effective pain management is a reality