Chronic pain: It is time to act….

Pain has always taken a back seat when it comes to prioritizing the resources for prevention and management as it never emerged as an important cause of mortality, which has been a major emphasis for policymaking. However, the recent global burden of disease data has provided with a fertile discussion platform on the basis of disability and nonfatal health loss caused due to pain globally and in low-and middle-income countries (LMICs). It is time that chronic pain must be considered as a public health problem and appropriate steps taken to mitigate this health burden. “For all the happiness mankind can gain, Is not in pleasure, but in rest from pain.” –John Dryden.[1] It has been 16 years since in 2004, “Pain management as a fundamental human right” was adopted as a central theme by the International Association for the Study of Pain and global health community stated that “failure to treat pain is viewed worldwide as poor medicine, unethical practice, and an abrogation of a fundamental human right.”[2] However, epidemiological studies have only revealed a consistently increasing burden of chronic pain.[345] Till late 19th century, we were still dwelling on “Biomedical model” of pain, starting from Rene Descartes' concept of “pain as an exclusive process” in 17th century to “Specificity theory of pain” by Maximilian Von Frey and “Pattern theory of pain” by Goldschneider, both in 1894.[6] Even the modern “Bio-psycho-social theory” of pain is not new, its roots date back to Melzack and Wall's “Gate control theory” of pain in the 1960s and “Neuromatrix Model” of pain proposed by Melzack in 1999.[6] Chronic pain is indeed a complex phenomenon. It is time that we stop viewing chronic pain as merely an accompanying symptom. It is a disease entity in its own right and has even received its due taxonomical place in the International Classification of Diseases 11, which has been presented in the World Health Assembly in May 2019 and will come into effect on January 1, 2022.[6] Chronic pain is multifaceted, dynamic, and difficult to measure; hence, the estimates of chronic pain prevalence globally have always been approximate and yet alarming.[7] As the global burden of disease has shifted focus from mortality alone to years lived with disability (YLDs), low back pain, and migraine have remained as top two causes of disability globally in 1990 and in 2017 as well, in both males and females, which represents poor actions or responses taken to improve these conditions.[4] Globally, percentage increase in counts from 1990 to 2017 for YLDs due to musculoskeletal disorders (rheumatoid arthritis, osteoarthritis hip/knee, low back pain with or without leg pain, neck pain, gout, and others) is 38.4%.[3] Low back pain was the leading cause of YLD in 126 of the 195 countries and territories.[3] YLD counts are highly concentrated in young (20–54 years) economically active population leading to loss of functional status of the workforce.[3] This burden of disease and risk factors is even higher in LMICs.[3] When the economically active members become disabled, the family's livelihood is compromised, further pushing them to poverty and decreasing the opportunities for treatment.[38] In India, headache continues to be the second most important cause of YLD (first being iron deficiency anemia) with an increase by 22% and low back pain with an increase of 25%, moved from fifth to third most common cause for disability in India from 2007 to 2017.[9] There has been an increase in other musculoskeletal conditions too by 20%.[9] About 65% of total health expenditure in India is out of pocket; lack of health insurance further leads the chronic pain patients into misery as they are not able to afford long-term medications, and land up in a vicious circle of social and economic stress. However, chronic pain is not only limited to low back pain, neck pain, or musculoskeletal pain but also becomes a part of lives of most of the people suffering from other noncommunicable or chronic diseases such as diabetes, peripheral vascular diseases, rheumatic disorders, cancer, and HIV/AIDS among many others.[7] Therefore, the correct estimates of the overall effect of pain on people would be far more than can ever be estimated. Pain not only causes physical discomfort but also impairs a person's capacity as a social being. The basic and essential part of being human as eating and sleeping are profoundly affected by pain, and as it becomes more chronic the psychological, spiritual, and social aspects take equal or more weightage as the physical aspect, both in assessment and management.[2] It has a huge social and economic impact on society at large.[7] It is high time that we consider chronic pain as a serious public health problem. Pain management must be viewed as an ethical issue and a legal right. It is mandatory for countries to provide pain relief as a part of the right to health. Change of focus from the biomedical aspect of pain, i.e., pathophysiology-based management of pain to the biopsychosocial aspect which focusses on the concept of total pain and quality of life. Public health focus should be on preventive measures of chronic pain conditions. Prevention strategies should be implemented at primary (avoid trauma, risk factors, and increase protective factors), secondary (treating acute pain), and tertiary (rehabilitation and psychological management) levels. Focus ought to be on public awareness and education for prevention and treatment of pain with nationwide and worldwide events for the 2020 global year for the prevention of pain. Since many risk factors for low back pain and other musculoskeletal programs are common with those of other chronic conditions, we may utilize opportunities to integrate the preventive programs for chronic pain with mainstream programs such as cardiac diseases, cancer, or diabetes. Conducting research around social and economic dimensions of pain would lead to the enlightenment of health policymakers. Convincing global agencies such as the WHO to include chronic pain as a priority or at least as an optional module would encourage local governments to allocate funds and resources for the research, prevention, and treatment programs. In the long term, we must strive to balance social inequalities and health inequities across the world.