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Medicina y ética
versión On-line ISSN 2594-2166versión impresa ISSN 0188-5022
Med. ética vol.33 no.2 Ciudad de México abr./jun. 2022 Epub 31-Jul-2023
https://doi.org/10.36105/mye.2022v33n2.06
Articles
The management of chronic pain -not oncological-: an emerging bioethical challenge
* Universidad Anáhuac México, Facultad de Ciencias de la Salud. México. Correo electrónico: dr.cerdio@gmail.com
Pain and suffering are substantial realities of human experience. Today we are beginning to become aware of the contextual reality of the health problem generated as a consequence of the liquid society and the discarding that has been inherited. Bioethics, as an interdisciplinary field, has a fundamental and crucial role in the orientation and guidance of health sciences. Analyzing and understanding these concepts (pain and suffering) is essential in order to be able to propose -proactively- specific strategies that favor and promote adequate multidimensional treatment. The purpose of this systematic review is to present a global and current vision of the perception that both chronic pain and suffering represent for modern society. Epidemiologically, there is a silent epidemic in this sense, which, if not comprehensively addressed, represents a risk factor for the development of social problems, in combination with the anthropological reductionisms that prevail at present.
Keywords: Opioids; interdisciplinary; human dignity; suffering
El dolor y el sufrimiento son realidades sustanciales de la experiencia humana. Hoy se comienza a concienciar en cuanto a la realidad contextual del problema sanitario generado como consecuencia de la sociedad líquida y del descarte que se ha heredado. La bioética, como campo interdisciplinar, tiene un papel fundamental y crucial en la orientación y guía de las ciencias de la salud. Analizar y comprender dichos conceptos (dolor y sufrimiento) es elemental para, entonces, poder plantear -proactivamente- estrategias puntuales que favorezcan y promuevan un adecuado tratamiento multidimensional. La presente revisión sistemática tiene como finalidad presentar una visión global y actual en cuanto a la percepción que tanto el dolor crónico como el sufrimiento representan para la sociedad moderna. Epidemiológicamente, se vive una epidemia silente en este sentido, la cual, de no ser abordada integralmente, representa un factor de riesgo para el desarrollo de problemáticas sociales, en combinación con los reduccionismos antropológicos que rigen contemporáneamente.
Palabras clave: opioides; interdisciplinar; dignidad humana; sufrimiento
1. Introduction
Pain and suffering form a substantial part -inevitably- of the experience of the human being (1); they are undeniable anthropological realities, so it is essential to present a critical analysis from the perspective of bioethics that allows the person to know and understand him/herself from this perspective. The society in which humanity is developing is increasingly characterized as a society of discarding, of a liquid world (2), where there are no fundamental values that go beyond a subjective and relative interpretation of reality. Bioethics, as a common ground for interdisciplinary and multidisciplinary work (3), has much to say about the way pain is understood today (4, 5).
Over the last century, medicine has experienced exponential growth in terms of the technical and scientific basis that characterizes it; life expectancy has been increased; diseases -previously considered invincible- have been fought and defeated. However, there seems to be an increasingly widespread perception of how the medical sciences have focused more on the technique than on the person (6, 7). This has triggered a personalist movement in health professionals, who, through awareness, have been able to identify these deviations in medical practice (8). These interdisciplinary reflections (9-11) have led the International Association for the Study of Pain (IASP) to seek to redefine and clarify what is currently understood as pain in medical society (12, 13). For more than 40 years, pain was defined as «an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage». In 2018, the IASP convened different experts in the field to put to their consideration the relevance and appropriateness of such definition, so that in 2020 a new proposal was presented, defining pain as «an unpleasant sensory and emotional experience associated with or similar to that associated with actual or potential tissue damage» (13). This new definition brought up different considerations (Table 1), which are fundamental to be able to complement, thus, the knowledge we have to date of this experience (13).
Table 1 Fundamental considerations: New definition of pain.
| Considerations | Relevance |
|---|---|
| Pain is a personal experience influenced -to varying degrees- by biological, psychological, social and spiritual factors. | - Pain is understood as an individual reality, which is influenced by the globality, individuality and indivisibility of the human person. |
| Pain and nociception are distinct phenomena. | - Pain cannot be reduced to a sensory nervous process. |
| People learn the concept of pain through life experience. | - Being an individual and personal experience, it is lived and understood only through empirical realities. |
| If a person manifests a painful experience, it must be respected. | - One of the greatest fears on the part of patients suffering pain is misunderstanding on the part of physicians. |
| Although pain usually has a protective function, when it becomes chronic it can have adverse effects on a person’s functionality and overall well-being. | - A fundamental aspect is that all chronic pain always begins as acute pain which, when it becomes chronic, becomes, in itself, a pathology. |
| One of the ways to express pain is a verbal description. The inability to communicate does not negate the possibility of a human being or animal experiencing pain. | - Based on the principle of subsistence, the
ability to communicate does not reduce or minimize the
possibility of experiencing pain, since pain is and exists,
despite the complications corresponding to its verbalized
expression. - Pain exists despite the fact that it cannot be expressed, which has led to the development of measurement scales that assess behavioral parameters, thus allowing a semiological approach in patients who cannot communicate their symptomatology. |
Source: Own elaboration.
Pain and suffering are such intertwined realities that it can sometimes be difficult to differentiate between them. As Burgos (1) said: «They are part of the experience of the human being». At this point it would be important to remember that, in order to speak of bioethics, it is essential first -I emphasize- to speak of the person. The person as an individual and indivisible unit is affected in its totality by both pain and suffering. Suffering is this biological, emotional-affective, social and spiritual experience which, from both a historical and cultural perspective, has been linked, in the Western world, with a teleological aspect of the human being (14, 15). To speak of pain and suffering is basically to speak of the person who experiences it in all its natural essence, influencing his or her individual and subjective affectivity (16).
2. Pathophysiology of chronic pain
Pain, as a subjective experience -in addition to being understood from an anthropological perspective- can and should be understood, in turn, from a pathophysiological perspective (Figure 1) (17-25).
The semiology of both acute and chronic pain is extremely complex, since an effort is made to objectify a reality that is always subjective; however, different efforts have been made to identify the characteristics of each of the painful conditions (Table 2).
Table 2 Semiology of pain (acute and chronic)
| Type of pain | Features |
|---|---|
| Nociceptive: There is an injurious stimulus. | Nociceptive pain is pain that is perceived by
direct stimulation of nociceptors. Such stimulation can be
classified as: - Parietal: well localized pain, with direct irritation of nerve fibers (example: appendicitis with peritoneal irritation). - Visceral: diffuse pain with direct irritation of nerve plexuses, with stimulation of autonomic pathways (example: abdominal distension). |
| - Neuropathic (26): There is a pathological stimulus on the nerve fibers. |
Pain -usually- understood with characteristics
other than nociceptive pain. - Tingling type pain. - Electrical and/or burning pain. |
Acute < 3 months < Chronic
Source: Own elaboration.
Chronic pain is no longer considered as an isolated symptom, but as an individual pathological process, which must be approached from this perspective. In order to simplify its study, a global division between chronic pain -oncological- and chronic pain -non oncological- has been proposed (27). The purpose of this review article is to present an overview of the global perception that both chronic -non oncological- pain and suffering represent for the modern society in which we live.
3. Methodology
A literature review was carried out, using the following platforms as search engines: PubMed, EBSCO Host, Web of Science and Scielo. The following keywords were used as key words, by means of Boléan search engines: chronic pain/chronic pain, bioethics/bioethics, opioid treatment/, pain management/pain management. As inclusion criteria, articles were taken that met these descriptions and were available for download. All those presenting aspects related to pediatric patients or with chronic pain of oncologic etiology were excluded. Subsequently, using the EndNote reference manager, duplicate articles were identified. The risk of bias can be identified in terms of the deficiency of qualitative, quantitative or review studies in this regard. Once the search was conducted, 112 articles were identified, of which 17 did not meet the inclusion criteria and 15 were eliminated due to duplication (Figure 2).
4. Results
a) Definition
Defining pain, both acute and chronic, is a fundamental aspect, since only from this conception will it be possible to understand the different spheres that comprise it, thus allowing society to work unified in comprehensive support (Table 3).
Table 3 Concept of pain and its definitions.
| Type of pain | Characteristics |
|---|---|
| IASP definition 1979 (12, 28) | An unpleasant sensory and emotional experience, associated with actual or potential tissue damage, or described in terms of such damage. |
| IASP definition 2020 (13, 17, 29) | An unpleasant sensory and emotional experience associated or similar to that associated with actual or potential tissue damage. |
Source: Own elaboration.
b) Public health and epidemiology (4):
Since the resurgence of palliative care and pain management in modern medicine (6, 7), society has become increasingly aware, so that from different areas it has been understood and evidenced that pain represents a real problem (30) of public health (17, 31-33), and that it makes up a true silent pandemic (22, 27, 34) (Table 4).
Table 4 Pain, suffering and epidemiology.
| Type of pain | Characteristics |
|---|---|
| Incidence and prevalence (estimated) (31, 35, 36) | - Annually, more than 61 million people in
the world experience about 6 billion days related to
severe suffering associated with health (37). - It is estimated that in Mexico the prevalence of chronicpain is 41.5% (47.3% women) (33.6% men) (31). |
| Main pain syndromes (21, 25, 27, 29) | Epidemiological report from the United
States of America (2019) (27): - Headache: acute (7-51%), chronic (3-4.4%). - Cervicalgia: acute (16-40%), chronic (20%). - Low back pain: acute (22-33%), chronic (5-45%). - Nonspecific joint pain: chronic (40%). |
| Estimated direct and indirect costs (38) | - The United States of America reported in 2019 an estimated cost in excess of $600 billion annually (27). |
| Access to palliative care (34, 37, 39, 40) | - It is estimated that 1% of opioid drugs
are distributed in the poorest 50% of the poorest
countries (39). - 90% of opioid medications are distributed among the richest 10% of countries (39). - Mexico has <5% of opioid medications to meet theneeds in the country (39). |
Source: Own elaboration.
c) Multidimensionality of suffering
Pain is in itself such a complex experience that it cannot be approached from a single perspective. It is necessary to start from the concept of multidimensionality (41, 42), which implies, fundamentally, a multi-therapeutic approach, where the different spheres that make up human reality can be approached in an integral manner (21, 23, 43, 44) (Figure 3).
The isolated or generalized approach to pain is insufficient, since, as mentioned by the IASP, it is a subjective experience, which is why treatment should be oriented from an individualized perspective, favoring patient-centered medicine, where, based on a deliberative doctor-patient relationship, the patient is empowered in the fight against pain and suffering.
d) Bioethical aspects in pain management; responsible prescribing
Bioethical analysis (45, 46) in pain management is a challenge (4, 5, 47), since it can be approached from the perspective of social-distributive justice and promotion of human rights (34, 35), clinical research, or from the biomedical perspective (48, 49), in terms of the fundamental requirements to promote responsible prescribing (50-55) that weighs the risks and benefits of therapeutic alternatives in their complexity.
Today, opioid drugs represent an ambivalent crisis (Figure 4). On the one hand, there is a real shortage in which the human right to pain management cannot be satisfied due to a deficiency in the universality of health services and, on the other hand, there is a real epidemic in terms of excessive consumption in some countries, which calls into question the existing risk-benefit analysis of these drugs. Opioids represent a crucial and elementary tool for pain management; however, as long as there is a lack of a culture and directed training regarding their responsible prescription, we will continue to experience this ambivalent crisis, in which bioethics really has a fundamental role in terms of orientation and guidance towards the transcendental good.
5. Discussion
Chronic pain -as a disease- represents -at the same time- one of the most worrying and silent medical, legal and social problems (14, 23, 56, and 57) for the society of the 21st century. In recent years, reflection and research have been prioritized in this regard, generating greater awareness of health-related suffering (19, 58). However, it is up to bioethics (47, 59) to establish a common territory (45), where all social stakeholders (9-11) can participate in open dialogue (49, 60-62), in order to determine the best means to follow, thus being able to work directly on a fundamental aspect for the human being: quality of life (63). This problem should be approached from an integral bioethical perspective (48, 52), considering the sum of advances that have been generated in the last 40-50 years. A satisfactory solution that proactively promotes (64) the dignity of the human person (8, 65) can only be found from an integral collaboration.
Both chronic pain and suffering (18, 24, 43) might seem to be alien crises and even a little obvious; however, they are fundamentally transcendental aspects that directly concern human beings in their deepest fibers (37), which is why they should be treated with the importance that corresponds to them. History (64, 66) has taught that a social problem that is poorly confronted can unleash problems so great that they affect the very conception of the person -anthropological reductionism- and, at the same time, it also shows how a crisis is a moment of opportunity and growth. Bioethics, as an interdisciplinary science (3, 67), must be capable of recognizing social problems -concerning biomedical sciences (68) -, favoring reflection in this sense, seeking to guide professional action in advance and in anticipation, so that an adequate and consistent solution can be offered, thus guiding the harmonious construction of society, from science towards the transcendental good, based on human nature (46).
Today, chronic pain represents a social call for humanity to participate actively and concretely for the benefit of the dignity of the human being (69, 70). The bioethical challenge begins with the call (vocation) to go out to meet people and to be able to apply their deliberative methodologies individually (50), so that the human being is understood as what he or she is, an individual and indivisible substance. This will favor interdisciplinary reflection and collaboration and promote a deeply involved and integrated society (71). Pain is already a silent epidemic, which is why dialogue must begin proactively. This will allow a social transformation, in which solidarity, social justice, the value of life and respect for freedom will be the foundations that will allow the human being to achieve a life with true quality.
The treatment of pain, as a human right, implies a profound social responsibility for both the medical profession and society in general (32, 72). An erroneous or incomplete approach (41, 73) can trigger multiple health complications (74):
1. Algophobic societies (with fear or refusal to recognize pain/suffering) (20, 44):
The superficiality that has been inherited following contemporary cultural changes has directly influenced the socially held conception of pain and suffering. Although human beings are not called to suffer, suffering is an inescapable experience of humanity, an experience that confronts human beings with their limits and teleological aspirations. It is crucial that, as a society, we form a sense of acceptance with respect to such circumstances, so that they can not only be accepted and overcome individually, but can be lived collectively, remembering that the person is not understood from an isolated perspective, but only through the encounter with the other.
2. Unjustified increase in the consumption of opioids (75-77):
With an epidemic crisis affecting more than 61 million people around the world, the medical reality is confronted with an inherent therapeutic limitation. This has led in certain countries to favor the prescription, sometimes indiscriminate, of opioids, which, although they are extremely beneficial drugs in pain management, also carry a risk, due to the pharmacology of the drug itself. The possibility of developing dependence and addiction is extremely high, which in the end ends up contrasting the potential benefit of pain management with the real risk of developing an addiction with the corresponding complications, not only for the patient, but also for the family and social nucleus that surrounds him/her.
3. Deficiency regarding the correct and indicated use of opioids in pain management (54, 55, 78-80):
The ambivalence in the crisis over the use of opioids is identified by contrasting two simultaneous (syndemic) realities; on the one hand, there is indiscriminate abuse of opioids in both acute and chronic pain management; on the other hand, in other less favored countries there is a palpable deficiency in terms of access to such medications (opioids). This crisis is extremely complex and there is no simple solution. There is a sparing and limited pharmacological use due to multiple circumstances, ranging from socio-cultural and contextual conditioning to ethical-moral conceptions.
For bioethics, this crisis represents an invaluable area of opportunity, since, by favoring specific and concrete strategies that allow the development of skills for responsible prescribing, a substantial problem would be reached and solved: the inadequate management of pain with the consequent severe suffering associated with health.
4. Loss of quality of life (perpetuation of a life of suffering) (42):
Adequate management of pain and suffering from an integral -multidimensional- perspective aims to promote an adequate quality of life. This particular point will lead the reader to one of the transcendental questions of the medical vocation: what is the indicator of success in medicine? What is the essence of the profession? Curing is not always possible; however, accompanying the patient in his or her suffering, seeking to provide a higher quality of life (and of death) in the moments of maximum vulnerability represented by the disease, is perhaps one of the greatest honors to which a health professional could aspire.
Quality of life is an indicator of the existing social commitment, in terms of the real involvement of the academic and scientific world in everyday life. Work and progress only make sense in their direct applicability to the quality with which we live day by day.
Today we are experiencing a reality influenced and contextualized by humanitarian crises. One could spend hours discussing and analyzing them; however, it is crucial and determining for bioethics that academic work results in transformative initiatives, which is why the recognition of these potential problems represents a courageous and creative challenge for bioethics: how to proactively guide academic work and how to prevent it from remaining in the academy, so that it can have a decisive influence on society? In a world marked by anthropological reductionism, it is time to defend the person, not with superficial solutions, but with profound anthropological reflections, so that society can be reoriented towards a more just world in which everyone has a place.
Based on this systematic review, we propose a series of research studies that can serve as a guide and orientation regarding the aspects identified as potential health complications. It is essential, therefore, to thoroughly understand that the only potentially sufficient way forward is through inter-, multi- and transdisciplinary work.
6. Conclusion
Bioethics, as a common ground for interdisciplinary work in the search for the transcendental good in the health sciences, faces in the 21st century multiple challenges that concern the human being in the deepest fibers of his being, which is why it is essential that from the academic and reflective work, at the same time, an applied field work is favored, where a direct response is given to the vocation and the call to go out to meet the person, generating a true and transformational impact on society. Such an undertaking will only be achieved through the promotion of inter, multi and transdisciplinary open dialogue between the different agents that actively participate in the harmonious construction of contemporary society.
Chronic pain and suffering represent today a true silent epidemic. For this reason it is crucial and fundamental to encourage study, research and reflection in this regard. It is time to go out to meet people, so that academic work does not remain in the academy, but really has a determined social influence. Failure to deal adequately with pain can unleash a series of unimaginable social crises. It is time to act in a proactive and directed way for the benefit of the human being in its multidimensionality; to promote an action centered on the person, recognizing him/her as a good and an end in itself, so as to overcome the main challenge of indifference and rejection, manifested through the algophobia that is lived and experienced day by day in modern societies.
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Received: October 15, 2021; Accepted: December 07, 2021
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