Costantino Benedetti

Pain: The Magnitude of the Problem and Unmet Therapeutic Needs

In “The Tragedy of Needless Pain”, an article Ronald Melzack published in the Scientific American in 1990, the author points out that over 80% of patients with cancer pain can obtain good pain relief if the available knowledge of pain therapy is properly applied. He further states that, since the majority of cancer pain patients continue to suffer agonizing pain, their pain is needless. Ten years later the tragedy of the under treatment of pain continues to be a major health problem worldwide and a disgrace for the health care profession and society. Every year in the United States of America there is one person every 1,000 people who dies after weeks or months of severe under treated cancer pain. Of the 38.8 million Americans who suffer moderate to excruciating acute pain, 51% do not receive proper pain control, while of the 50 million with chronic intractable non cancer pain proper pain relieve is achieved in less than 30% of the patients. While most advances in medicine are dependent on new discoveries prompted by basic and clinical research, pain therapy is hindered by two major barriers: lack of education on the subject and limited research funding. Pathophysiology and therapy of pain is at best marginally taught in medical, nursing and pharmacy schools. Therefore, the great majority of health care professionals have very little or no knowledge, and often have misconceptions, on the subject. For this reason, while 80 to 90% of patients suffering intense pain associated with advanced cancer could obtain proper pain control, albeit with some side effects caused by the analgesic medications, only 30% of them report acceptable pain relief. The majority of physicians also fail to appreciate that poorly treated intense pain not only causes misery for the patient but, it can have serious deleterious effects caused by inactivity, lack of sleep, anorexia, anxiety, depression of the immune system, and reactive depression. Therefore pain should be treated not only for humanitarian, but also for medical reasons. This generalized lack of education on pain is also responsible for the limited research funding granted to this field since the people entrusted with funding pain research projects suffer from the same ignorance. For instance, in 1999 the National Cancer Institute funded research projects for a total of

Patients should not suffer needlessly, especially for useless studies

3.065 billion; 0.8% of this funding, or

Adult Cancer Pain

24 million, was designated for research in pain and symptom control. It must be underlined that of all patients who are now affected by cancer 48% will die because of it and that 75% of them will develop severe pain and other distressing symptoms. The very limited funding for research on pain is responsible for the significant deficiency that still exists in the knowledge regarding the pathophysiology and therapy of pain. The most effective medication to control intense pain is morphine, or some of its derivatives. Morphine was isolated from opium almost 200 years ago, and opium has been used for pain control for over 3,500 years. Despite the great advances made in medicine during the last hundred years, the control of intense pain still relies on one of the oldest plant extracts known to mankind with all the side effects associated with its use. If we wish to eradicate unnecessary pain, which is a scourge of humanity, more education, new discoveries, and more advocacy for the suffering pain patients are needed.

NCCN clinical practice guidelines in oncology: palliative care.

Clinical Pharmacology and Therapeutics (1994) 56, 242–242; doi:10.1038/clpt.1994.131