A Brief Introduction to Palliative Care and Pain Treatment

Palliative care seeks to improve the quality of life of patients and their families facing life-limiting illness. Unlike curative healthcare, its purpose is not to cure a patient or extend his or her life. Palliative care prevents and relieves pain and other physical, psychosocial, and spiritual problems. As a quote by Dame Cicely Saunders, the founder of the first modern hospice and a lifelong advocate for palliative care, on the wall of a palliative care unit in Hyderabad, India, proclaims: palliative care is about “adding life to the days, not days to the life.” The World Health Organization recognizes palliative care as an integral part of healthcare for cancer, HIV/AIDS, and various other health conditions, that should be available to those who need it.[5] While palliative care is often associated with cancer, a much wider circle of patients with health conditions that limit their ability to live a normal life can benefit from it, including patients with dementia, heart, liver or renal disease, or chronic and debilitating injuries.

One key objective of palliative care is to offer patients relief from pain. Chronic pain is a common symptom of cancer and HIV/AIDS, as well as various other health conditions.[6]Research consistently finds that 60 to 90 percent of patients with advanced cancer experience moderate to severe pain.[7] Prevalence and severity of pain usually increase with disease progression: Several researchers have reported that up to 80 percent of patients in the last phase of cancer experience significant pain.[8] Pain symptoms are a problem for a significant proportion of people living with HIV, even as the increasing availability of antiretroviral drugs in middle- and low-income countries is prolonging lives.[9] With the advent of antiretroviral drugs (ART), the international AIDS community has understandably been strongly focused on bringing treatment to people living with HIV. Unfortunately, this has led to a widespread but incorrect perception that these people no longer needed palliative care. In fact, various studies have shown that a considerable percentage of people on ART continue to experience pain and other symptoms and that simultaneous delivery of palliative care and ART improves treatment adherence.[10] Other conditions such as chronic disease or lasting injuries due to accidents or violence are also frequently associated with significant chronic pain.[11]

Moderate to severe pain has a profound impact on quality of life. Persistent pain has a series of physical, psychological, and social consequences. It can lead to reduced mobility and consequent loss of strength; compromise the immune system; and interfere with a person’s ability to eat, concentrate, sleep, or interact with others.[12] A WHO study found that people who live with chronic pain are four times more likely to suffer from depression or anxiety.[13] The physical effect of chronic pain and the psychological strain it causes can even influence the course of disease: as the WHO notes in its cancer control guidelines, “Pain can kill.”[14] Social consequences include the inability to work, care for children or other family members, participate in social activities, and bid farewell to loved ones.[15]

According to the WHO, “Most, if not all, pain due to cancer could be relieved if we implemented existing medical knowledge and treatments” (original emphasis).[16] The mainstay medication for the treatment of moderate to severe pain is morphine, an inexpensive opioid that is made of an extract of the poppy plant. Morphine can be injected and taken orally. It is mostly injected to treat acute pain, generally in hospital settings. Oral morphine is the drug of choice for chronic pain, and can be taken both in institutional settings and at home. Morphine is a controlled medication, meaning that its manufacture, distribution, and dispensing is strictly regulated both at the international and national levels.

Medical experts have recognized the importance of opioid pain relievers for decades. In recognition of this fact, the 1961 Single Convention on Narcotic Drugs, the international treaty that governs the use of narcotic drugs, explicitly states that “the medical use of narcotic drugs continues to be indispensable for the relief of pain and suffering” and that “adequate provision must be made to ensure the availability of narcotic drugs for such purposes.”[17] The World Health Organization has included both morphine and codeine (a weak opioid) in its Model List of Essential Medicines, a list of the minimum essential medications that should be available to all persons who need them.

Yet, approximately 80 percent of the world population has either no or insufficient access to treatment for moderate to severe pain and tens of millions of people around the world, including around 5.5 million cancer patients and one million end-stage HIV/AIDS patients, suffer from moderate to severe pain each year without treatment.[18]

But palliative care is broader than just relief of physical pain. Other key objectives of palliative care may include the provision of care for other physical symptoms and psychosocial and spiritual care to both the patient and her family. In addition to pain, life-limiting illness is frequently associated with various other physical symptoms, such as nausea and breathlessness, that have significant impact on a patient’s quality of life. Palliative care seeks to alleviate these symptoms.

People with life-limiting illness and their relatives often confront profound psychosocial and spiritual questions as they face life-threatening or incurable and often debilitating illness. Anxiety and depression are common symptoms among patients with life-limiting illness.[19] Palliative care interventions like psychosocial counseling have been shown to considerably diminish incidence and severity of such symptoms and to improve the quality of life of patients and their families.[20]

The WHO has urged countries, including those with limited resources, to make palliative care services available. It has pointed out that in “countries with limited resources, it is not logical to provide extremely expensive therapies that may benefit only a few patients, while the majority of patients presenting with advanced disease and urgently in need of symptom control must suffer without relief.”[21] It recommends that countries prioritize implementing palliative care services in the community—providing care at people’s homes rather than at healthcare institutions—where it can be provided at low cost and where people with limited access to medical facilities can be reached, and in medical institutions that deal with large numbers of patients requiring palliative care services.[22]