Why is pain treatment a human rights issue?
Although adequate pain treatment is a basic human right, the vast majority of the world population suffering from severe pain have no access to adequate pain treatment. According to an estimate of the World Health Organization (WHO) in 2012, 5.5 billion people live in countries with no or insufficient access to treatment for moderate to severe pain and 83 per cent of the world’s population have no or inadequate access to treatment for moderate to severe pain. This means that tens of millions of people, including around 5.5 million terminal cancer patients and 1 million end-stage AIDS patients, suffer from moderate to severe pain each year without treatment.
Little awareness
Lack of (access to) adequate pain medication has been a condition in which health professionals have been working for many decades. However, there was little awareness of the fact that absence of access to pain treatment is also a grave violation of human rights. A major change in this perception was the 2009 report of Manfred Novak, the then Special Rapporteur on Torture and and other cruel, inhuman and degrading treatment or punishment to the Human Rights Council. He wrote: “the de facto denial of access to pain relief, if it causes severe pain and suffering, constitutes cruel, inhuman or degrading treatment or punishment.”
Besides many other reasons such as poor training, poor logistics and stigma about pain and opioids, the main structural obstacle to access to adequate pain medication is the “war on drugs” that dominates the functioning of International Narcotic Control Board (INCB), which oversees not only the control of illicit drugs but is also responsible for the provision and distribution of opioids.
Paradigm shift
The report of the Special Rapporteur and subsequent other reports that emphasize the human rights basis of access to adequate pain treatment, have caused a major paradigm shift in the perception of health professionals.
One of these reports is “Please do not make us suffer anymore”. Access to pain treatment as a human right, published by Human Rights Watch (HRW) in 2009. The extensive research done by Diederik Lohman and his colleagues at HRW exposed painfully the worldwide absence of access to adequate pain treatment and its underlying mechanisms. As they wrote:
“The poor availability of pain treatment is both perplexing and inexcusable. Pain causes terrible suffering yet the medications to treat it are cheap, safe, effective and generally straightforward to administer. Furthermore, international law obliges countries to make adequate pain medications available. Over the last twenty years, the WHO and the International Narcotics Control Board (INCB), the body that monitors the implementation of the UN drug conventions, have repeatedly reminded states of their obligation. But little progress has been made in many countries.”
A year later, an article appeared in BMC Medicine, entitled Access to Pain Treatment as a Human Right (2010; 8:8). The authors, Diederik Lohman, Rebecca Schleifer and Joseph Amon, wrote:
“According to international human rights law, countries have to provide pain treatment medications as part of their core obligations under the right to health; failure to take reasonable steps to ensure that people who suffer pain have access to adequate pain treatment may result in the violation of the obligation to protect against cruel, inhuman and degrading treatment.”
in 2010, the International Association for the Study of Pain (IASP) adopted the Declaration of Montreal, which affirms:
- The right of all people to have access to pain management without discrimination.
- The right of people in pain to acknowledgment of their pain and to be informed about how it can be assessed and managed.
- The right of all people with pain to have access to appropriate assessment and treatment of the pain by adequately trained health professionals.
Resolution World Medical Association
In January 2011, IFHHRO hosted a conference in the Netherlands where international bodies of health professionals (such as the World Medical Association and the International Council of Nurses), human rights organizations (such as Human Rights Watch) and pain and palliative care organizations (such as the IASP) discussed the implementation of the right to access to adequate pain treatment.
As a result of this conference, IFHHRO formulated a Position Statement on Access to Pain Treatment.
The conference submitted a concept resolution to the World Medical Association, which adopted this resolution at its 62nd General Assembly in Montevideo, Uruguay, in October 2011. Key elements in the WMA resolution are:
- Pain treatment should be accessible for all people without discrimination.
- Physicians and other health professionals have an ethical duty to offer proper clinical assessments to patients with pain and to offer appropriate.
- Instruction on pain management, including clinical training lectures and practical cases, should be included in mandatory curricula and continuing education for physicians and other health professionals.
- Governments should provide the necessary resources for the development and implementation of a national pain treatment plan, including a responsive monitoring mechanism and process for receiving complaints when pain is inadequately treated.
What are the relevant sources?
The human rights basis of the right to adequate pain treatment is fomulated in a variety of human rights intruments, some of which are:
- The International Convenant on Economic, Social and Cultural Rights (ICESCR) provides a legally binding human rights framework on the Right to the Highest Attainable Standard of Health (Article 12).
- General Comment No. 14 of the International Convenant on Economic, Social and Cultural Rights (2000) provides detailed rights-based steps for the implementation of the Right to Health, including the Essential Medicines List of the WHO.
- The International Convenant on Civil and Political Rights (ICCPR) protects the right to life, freedom from torture and cruel, inhuman and degrading treatment and punishment, further elaborated in
- The International Convention Against Torture (CAT). Notably, since the reports of the Special Rapporteurs have made the CAT applicable to access to pain treatment, these documents are of crucial importance.
- The Single Convention on Narcotic Drugs (1961) and subsequent conventions of the International Narcotics Control Board are the basis of regulation of “illicit” drugs including opioids, which are crucial in adequate pain treatment.
What are the relevant issues related to pain treatment?
Control of “illicit” drugs
The alarming lack of access to adequate pain treatment prompted the former Special Rapporteur on the Right to Health, Anand Grover, and the former Special Rapporteur on Torture, Manfred Nowak, to send a letter to the INCB calling for fundamental changes in the policies of the INCB aimed at ensuring access to essential medicines (including opioids), and reviewing national and international regulations impeding the adequate provision of controlled medicines.
In another report, Grover recommended the adoption of a new regulatory system similar to that of the Framework Convention on Tobacco Control. “Grover is calling for a far more humanistic approach to drug control; with his call for decriminalization and de-penalization, he has also called for a far greater effort to be made in the areas of treatment and social care for those affected by illicit drugs.”
Who prescribes?
A shortage of physicians in resource-constrained countries prevents adequate provision of opiods to cancer patients and others in severe pain. Human Rights Watch states in its report “Please do not make us suffer anymore”:
“While medical doctors in many countries can prescribe morphine by virtue of their professional license, this is not the case for nurses. This is a considerable problem in many middle and low income countries around the world where there are few medical doctors. For example, in Malawi there is only one doctor per 100,000 people. In 2004, Uganda introduced nurse-based prescribing of oral morphine. According to its amended regulations nurses with a certificate in specialized palliative care are permitted to prescribe and supply certain types of opioid analgesics, including oral morphine. Prior to 2004, many people in rural Uganda—where there is one physician per 50,000 people—did not have realistic access to medications for moderate to severe pain. INCB praised Uganda for this important step”.
Task shifting including prescribing by others than physicians has also become a policy of the World Medical Association.
Prejudices
Prejudices against morphine and other opioids cause widespread barriers to adequate and timely prescribing and using opioids. Dr. Mary Cardosa, a Malaysian consultant anaesthesiologist and pain specialist and former President of the Malaysian Medical Association, said in 2013:
“These patients require palliative care, a health service that can restore or maintain their quality of life and allows them to live with dignity. Despite this great need, palliative care services remain sparse in much of the world. Apart from having national policies on pain and palliative care, efforts must include education of the public and of healthcare professionals, in order to overcome barriers to effective pain management and palliative care.
Among the big challenges are the prejudices and fears of healthcare professionals regarding the use of morphine which is the mainstay of pain relief in patients with acute pain as well as those with advanced cancer and other painful conditions. Morphine provides cheap and effective analgesia to such patients but is often not accessible because of legal barriers or, worse still, because of healthcare professionals’ fear of addiction and side effects as well as lack of knowledge on the appropriate prescription of morphine and morphine-like substances for pain relief in these patients.”
What can health workers do?
Health workers can play a pivotal role in the implementation of the right to access to adequate pain treatment. Very practical examples of action are initiatives of “painfree cities” such as Münster, a project of Jürgen Osterbrink.
Use of human rights instruments
Health workers, preferably collectively, such as in their professional organizations, can report absent or insufficient access to adequate pain treatment tot their government, but also – if domestically without result – to supervising committees of UN Conventions, such as the Committee on Economic, Social and Cultural Rights and the Committee Against Torture. Special Rapporteurs too can be approached. In the IFHHRO action guide Steps for Change suggestions are given for policies.
It should be kept in mind that in the implementation of the Right to Health, accountability mehanisms play an important role. This means that health professionals can hold their government (and agencies) accountable for the implementation of the availability of essential medicines including opioids.
A call for a national pain plan (separately or as a chapter in the national health plan) is also appropriate.
Adequate education and training
Health professionals should be educated and trained adequately in pain treatment and palliative care in its full content. Very often pain treatment and palliative care have no place (yet) in the core curriculum of medical and nursing schools.
The resolution of the World Medical Association is very explicit in this respect: “Instruction on pain management, including clinical training lectures and practical cases, should be included in mandatory curricula and continuing education for physicians and other health professionals. Such education should include evidence-based therapies effective for pain, both pharmacological and non-pharmacological. Education about opioid therapy for pain should include the benefits and risks of the therapy. Safety concerns regarding opioid therapy should be emphasized to allow the use of adequate doses of analgesia while mitigating detrimental effects of the therapy. Training should also include recognition of pain in those who may not be able to adequately express their pain, including children, and cognitively impaired and mentally challenged individuals.”
Complaint mechanism
A very noteworthy extra in the resolution of the WMA is the recommentation of having a complaint mechanism in place: “Each government should provide the necessary resources for the development and implementation of a national pain treatment plan, including a responsive monitoring mechanism and process for receiving complaints when pain is inadequately treated.”
Health workers and institutions can play a pivotal role in establishing such a complaint mechanism.