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Abstract

Pain is a subjective experience, albeit common to all human beings. Undertreated pain is a major contributor to suffering worldwide, although disproportionately burdening the global South, which has limited infrastructure and medications for pain control. Even in countries where opioid analgesics are available, regulations for procuring, stocking, and dispensing them are often strict, limiting access to those who need these controlled medications, particularly outside of a hospital setting. The subjectivity of pain is a challenging reality for both patients and clinicians. In particular, the lack of discernable causes in some situations makes pain an invisible condition that is difﬁcult to treat within the contemporary biomedical culture. The inevitable reliance on patients’ testimonies and concerns of iatrogenic harm from addictive medications in pain management raises ethical questions of trust, stigmatized identities, and epistemic injustice. Such challenges call for more training and education to help clinicians ﬁnd safe and effective ways to help relieve their patients’ suffering.

Introduction

Pain is an individual and subjective experience and common to all human beings. Undertreated pain is a major contributor to suffering worldwide, although disproportionately burdening the global South (International Association for the Study of Pain (IASP) 2012), which comprises of countries with medium and low human development that are mostly located in the Southern Hemisphere. Pain can arise from an injury, illness, medical problem, or unknown cause and can also be a consequence of violence, war, and natural disasters. It may be experienced as acute, chronic/ persistent, or intermittent, in combination or separately. Acute pain can last for minutes, hours, or days, and chronic pain may persist 3 months or more. Musculoskeletal disorders, pain related to operations and injuries, and spine problems represent the largest global burden of pain, with low back pain being the leading cause of years lived with disability worldwide (Vos et al. 2012). Even in countries where opioid analgesics are available, regulations for procuring, stocking, and dispensing them are often strict, limiting access to those who need these controlled medications, particularly outside of a hospital setting.

Epidemiology

Ethnographic literature and epidemiological studies on pain have been instrumental for scholars and policy makers to understand how pain is understood, experienced, embodied, and managed across various cultures and contexts. Nonetheless, since pain has been deﬁned using diverse methods, questions, and samples from different geographic areas and time frames, comparison on prevalence or impact is difﬁcult. Moreover, as a subjective experience, the incidence of pain is challenging to quantify. While good quality epidemiological studies of chronic pain in the last few decades have raised global awareness of the impact of pain and contributed to understanding of its development and chronicity, this literature mainly comes from the global North, which comprises of countries with high human development, most of which are located in the Northern Hemisphere. With limited high-quality epidemiological data available from resource-poor regions, it is challenging for policy makers to advocate for increased access to certain essential medicines in these settings or to implement pain management recommendations established by international agencies.

Variability in estimates notwithstanding, the epidemiological literature indicates high global prevalence and incidence of chronic pain. The IASP approximates that one in ﬁve adults worldwide live with persistent pain (IASP 2012), and the World Health Organization (WHO) estimates that one in ten adults are diagnosed with chronic pain every year (Gureje et al. 1998). A large-scale telephone survey of 15 European countries and Israel (Breivik et al. 2006) revealed that moderate to severe chronic pain occurs in approximately 19 % of adults. Similarly, an Australian study (Blyth et al. 2001) found the prevalence of chronic pain to be 17.1 % in men and 20 % in women.

In the USA, chronic pain affects approximately 100 million people – more people experience chronic pain than heart disease, diabetes, and cancer combined (IOM 2011). In Canada, one out of every three Canadians will likely be affected by chronic pain over the next two decades (Moulin et al. 2002). As the population ages and people live longer with multiple chronic conditions, the global prevalence and burden of chronic pain are expected to increase.

Pain can impact everyday activities, quality of life, and well-being. It contributes to the inability to participate in the workforce, strained interpersonal relationships, physical weakness, and social isolation. Pain is often accompanied by a constellation of comorbidities including depression, anxiety, and suicidal ideation (Gureje et al. 1998). While pain cuts across age, sex, gender, income, race/ethnicity, and geography, the prevalence of pain, especially chronic pain, is higher in women, older adults, and those with physically demanding employment and lower levels of formal education (IASP 2012). The higher reporting rate in women might be explained by psychosocial factors such as different tendencies to seek healthcare services in general and for pain speciﬁcally.

Despite the worldwide health, social, and economic impact of pain, multimodal and multidisciplinary pain management has historically not been a priority for global health. In the global North where there is more advanced healthcare and public health infrastructure, pain is nonetheless underdiagnosed and inadequately treated. Such global impact and the lack of public policy priority in pain management motivated the US Congress to declare the 2000s the “Decade of Pain Control and Research” and the Institute of Medicine (2011) to call for a “cultural transformation in the way that health care providers and the public view pain, and its treatment” (p. 4).

Historical Definitions And Classifications

The word pain originates from the Latin words poena, loosely translated to mean penalty or punishment, and dolor, which denotes pain, grief, ache, and suffering. Despite its negative connotations, pain in human life is critical to survival and ﬂourishing. Pain may be a biological warning sign of tissue damage, infection, or future harm. Its noxious qualities may have the adaptive advantage of motivating organisms to engage in self-preservation, such as moving away from the danger, getting rest, and, for humans, seeking medical attention. From this evolutionary perspective, pain might be construed as a biological good or eudynia. Not being able to experience pain, such as having congenital insensitivity to pain, can be dangerous and even fatal.

Pain as a concept is not monolithic. It has historically held various meanings and signiﬁcance, shaped by the cultural, religious, intellectual, and political communities of the time. In the West, medical and moral descriptions of the experience and signiﬁcance of pain come from the texts and philosophies of Ancient Greece and Rome. Plato described pain and pleasure as the “twin passions of the soul,” and Aristotle suggested that they must be enjoyed and avoided respectively. Aristotle deﬁned pain, or lupē, as an emotion that can alter judgment. Along with pleasure, he considered pain as epithumia or an “appetite” which disturbs and devastates the sufferer’s character.

The Roman physician Galen emphasized the role of sensation and perception in pain. He classiﬁed and described different forms of pain based on their types and intensities. The French philosopher Descartes described pain as a reﬂexive response to a physical, mechanical stimulus – a concept that had wide inﬂuence for centuries. The contemporary McGill Pain Questionnaire (MPQ), an instrument that uses descriptive adjectives based on the experiences of pain patients, helps patients to express their pain in metaphorical language familiar to Western cultures. For example, the MPQ uses terms such as “throbbing,” “shooting,” “stabbing,” and “nagging.” Today, the prevailing international deﬁnition of pain put forward by the IASP (2010) describes “an unpleasant sensory and emotional experience associated with actual or potential tissue damage” (Pain Terms Section, paragraph 1).

Contemporary Pain Models: Definitions And Classifications

The subjective nature of pain notwithstanding, clinically, pain experiences are assessed by duration and source. These experiences are often distinguished by one of two categories: acute pain and chronic or persistent pain. Recent efforts – such as the IASP deﬁnition – attempt to provide a deﬁnition of pain that encompasses both acute and chronic pains. This entry will adhere to these distinctions, while recognizing the variable deﬁnition of pain in the literature.

Acute Pain And Chronic Pain

Acute and chronic pains differ in temporality and in kind. Acute pain may persist for up to 3 months and typically arises from acute injury, surgery, trauma, or severe medical illness. The pain is usually most intense at the onset of injury and subsides as healing occurs. Acute pain may also be recurring with alternating painful and pain-free episodes. It may transition to chronic pain if it is inadequately treated or if there is a diminished responsiveness to some therapies.

Chronic pain, as deﬁned by the IASP, is prolonged and persistent pain lasting at minimum 3–6 months in duration. However, since chronic pain is often incurable, many sufferers endure pain for much longer or even indeﬁnitely. Chronic pain may be associated with chronic tissue pathology (e.g., arthritis, cancer), or the pain may exist beyond an expected healing period for an acute injury. In some cases, the pathology may resolve, but pain persists without clear evidence of nociceptive stimulus. Chronic pain can be further classiﬁed as either nonmalignant (e.g., noncancer) or malignant (e.g., cancer) pain and bear different ethical implications.

Chronic Nonmalignant Pain (CNMP)

When pain becomes chronic, it no longer serves an adaptive role. Chronic nonmalignant pain may arise out of injury, a comorbid chronic disease, psychological trauma, and complications from surgery or may lack an identiﬁable origin or cause.

Individuals with CNMP often report a lower quality of life due to reduced mobility, loss of energy and strength, disrupted sleep patterns, ﬁnancial burden, loss of identity, as well as other physical and mental health comorbidities (Lamé et al. 2005). Uncontrolled pain can have detrimental physical and emotional impact on sufferers and their loved ones. It also has a considerable impact on public health systems. Individuals with chronic pain seek out care in various public and private healthcare contexts, imposing ﬁnancial burden on sufferers and societies directly and indirectly. Direct costs may include out-of-pocket expenses, private and third-party insurance, and time costs. The annual costs of chronic pain in the USA are estimated to fall between USD $560 and 635 billion, including USD $61.2 billion per year in lost work productivity, exceeding the combined costs of the six most expensive diagnoses such as cardiovascular diseases and neoplasms (IOM 2011).

Chronic Malignant Pain

Chronic malignant pain is a corollary of life-limiting diseases such as cancer, AIDS, amyotrophic lateral sclerosis, multiple scleroses, end-stage organ failure, chronic obstructive pulmonary disease, and Parkinson’s disease. Many people in cancer remission develop excruciating chemotherapy-induced peripheral neuropathy, radiation toxicity due to radiotherapy, and postsurgical chronic pain. In the global South, chronic pain is considered an inevitable symptom of diseases such as cancer, and patients are expected to live with their pain.

Chronic malignant pain management is particularly challenging and ethically fraught for cancer patients at the end of life. One systematic review estimated that 64 % of patients with metastatic or advanced-stage cancer experience pain (Beukenvan Everdingen et al. 2007). Children who are at the end of life may also suffer unrelieved pain, in part because their symptoms are ignored or signs of pain and suffering are not recognized. In a South African study evaluating terminal care among hospitalized children who died of HIV/AIDS, half the patients with pain and distress, including some with a comfort care plan, received no analgesia (Henley 2002).

Biopsychosocial Model Of Pain

There has been a paradigm shift in pain theory, research, and practice over the past several decades. Much of the contemporary scholarship on pain has attempted to incite a cultural shift in how pain is deﬁned and understood, moving away from conceptualizing pain as corresponding to an identiﬁable, objective pathology to focusing more on the subjective nature of pain (IOM 2011). Moreover, the increasing awareness that pain is not only a physiological event or process has led to the adoption of the biopsychosocial model of pain, which situates the subjective experience of pain as emergent from convergent biological, psychological, and social systems.

Nociception is the neurobiological process of encoding noxious stimuli and is the precursor for the experience of pain. The neuromatrix theory of pain asserts that the perception of pain emerges from signal exchanges on at least three levels of the neuroaxis: peripheral, spinal, and supraspinal areas of pain processing. The integration of multiple inputs (i.e., sensory, visual, cognitive, emotional, and signals from the stress regulation system) produces an output of an individualspeciﬁc neuromatrix – a neurosignature of nerve impulses. Pain becomes clinically intractable because the nervous system has not returned to a non-pathological baseline state after a brief healing period.

The neurophysiological processes of pain impact emotion and cognition. For example, chronic pain may be accompanied by comorbid cognitive and emotional manifestations such as anxiety, depression, somatization, fear, addiction, anger, and deﬁcits in learning and memory. Chronic pain may produce maladaptive coping mechanisms, feelings of helplessness, hopelessness, and reduced self-esteem (McWilliams et al. 2003).

Culture And Pain

People’s views about pain generally, their own pain, pain management, and the meanings of pain and suffering are historically, culturally, and socially based. People of different cultures respond differently to pain. Some cultural groups are more expressive about their pain, while other groups adopt a stoic stance and avoid vocalizing or exhibiting signs that they are in pain. For example, in many Western cultures, childbirth is regarded as a painful, distressing experience, a perspective that is not universally shared. If a speciﬁc or set of pain behaviors is congruent with a societal or cultural view of how people should behave when in pain, sufferers may receive attention, sympathy, compensation, and sick role legitimization. Accordingly, some individuals may learn to display certain behaviors in order to achieve a desired response within their speciﬁc sociocultural context.

Diverse cultures around the world have developed their own taxonomy of pain, based on the theories of the body, health, illness, and medicine. The anthropological literature has provided scholarly insight into the diversity of pain experiences. For example, certain Japanese communities classify their pain experiences based on the features of a land or sea animal. Urdu and Hindu communities of North India use local metaphors to describe the sensory, location, intensity, temperature, and other qualities of pain. For people of certain religious or spiritual perspectives, pain may also cause its sufferers to question the meaning of life, as individuals may believe they are being punished by a higher power for some wrongdoing. Such narratives are found in, for example, Judeo-Christian traditions, highlighted in stories such as the Book of Job and the Cruciﬁxion. The role of suffering is also culturally varied. For example, among Christians in the Middle Ages, enduring physical pain and suffering was considered a divine experience that brought believers closer to salvation. Conversely, suffering and its liberation are central to religions such as Buddhism. Given varying cultural meanings of pain and suffering across the globe, pain assessment and management remain challenging despite the increasing prominence of the bio psychosocial approach.

Pain, Subjectivity, And Curative Models Of Care

The essence of pain is its phenomenological quality. Its reality is based on how it is perceived by the individual experiencing it, and external access to these experiences is often only based on people’s self-reports, raising questions of whether or how clinicians may trust their patients’ testimony. Two people diagnosed with the same pain condition may experience it differently as intertwining biological, psychological, social, and even spiritual factors mitigate their experience. Indeed, the subjectivity of pain is a challenging reality for both patients and clinicians. In particular, the lack of discernable causes in some situations makes pain an invisible condition that is complex and difﬁcult to treat within a biomedical culture that is based in observation of material phenomena.

The rise of modern medicine in eighteenth and nineteenth-century France was characterized by the view that all symptoms and health complaints are caused by discoverable, visible pathological lesions. This perspective became central to the contemporary scientiﬁc medical approach that privileges observable over unobservable phenomena. Pain, accordingly, is expressed by a predictable relationship between tissue pathology or nociceptor activity and clinical presentation. Pain without objective pathology thus cannot be easily explained from a materialist perspective.

This scientiﬁc-materialist framework points to the predominance of the curative model that operates in contemporary healthcare. Accordingly, global health efforts have prioritized the treatment and eradication of disease. As pain is generally considered a symptom of disease as opposed to a bona ﬁde condition, resources tend to be allocated toward prevention and treatment and not toward suffering produced by disease (King and Fraser 2013).

Pain And Suffering

Pain and suffering are so often related that these terms are sometimes used synonymously. Many kinds of pain bring about suffering, but the meaning of suffering is difﬁcult to deﬁne. Turk and Wilson (2009) describe pain and suffering as two distinct but inseparably linked concepts. While they reason that pain is not a necessary condition for suffering, they acknowledge that suffering can exacerbate pain, pain-related suffering does indeed occur, and healthcare professionals ought to assess for both.

Cassell (2004) argues that pain is physiological and suffering is existential and the subjective nature of suffering – like pain – makes it challenging to address with the tools of scientiﬁc medicine (i.e., the clinic pathological method). Cassell suggests that the experience of suffering is intensely personal: it is perceived “as a threat to persons’ continued existence – not merely to their lives but their integrity as persons” (p. 36). These discussions about suffering are inextricably tied to the concept of human dignity, particularly in discussions of end-of-life and palliative care. In such contexts, physicians are understood to have a primary ethical and professional duty to relieve patients’ pain and suffering as a means to promote their dignity at the end of life.

The Ethical Dimensions Of Pain

Pain has many ethical dimensions, but pain management has been largely underrepresented in bioethics. Where bioethics literature exists on pain management, contributions have tended to focus on ethical issues in end-of-life pain relief, particularly around the ethics of physician assisted death and euthanasia. Even here, the focus has mostly been on the consequences of these procedures rather than promotion of pain management. The discussions have been generally around whether these are ethically legitimate means to promote dignity, given the expected outcome of hastening or causing the person’s death. Indeed, there are questions of whether increasing support of these procedures has sidelined the discussion of promoting better access and management of pain relief at the end of life.

Jeremy Bentham, the founder of modern utilitarianism, argued that it is the greatest happiness of the greatest number that is the measure of right and wrong. Considering the fundamental role of pain and pleasure in human life and happiness, Bentham reasoned that these “two sovereign masters” alone can guide moral actions. Legislative practices, he argued, should have pleasures and the avoidance of pains as the ends. His hedonic calculus measures the intensity, duration, (un)certainty, as well as the nearness or remoteness of the sensation that may be experienced by the person. Other relevant factors in calculating the moral value of an action include whether one can expect the same sensation to follow and whether a pain may be followed by a pleasure and vice versa.

Given that the impact of pain and pleasure extends beyond the individual, Bentham believed that the extent to which others may be affected also needs to be considered. He proposed a classiﬁcation of 12 pains, which include physical and spiritual types. Despite such variety, Bentham believed that people could sum up all the values of the different kinds of pleasures and pains and then determine the morally right action by choosing the one that brings the greatest amount of pleasure and the least amount of pain.

Critics such as John Stuart Mill have pointed out the inadequacy of this hedonistic value theory by explaining that the value of life is more than a balance of pleasure over pain. These legitimate concerns notwithstanding, Bentham’s theory highlights the ethical dimensions regarding access to treatments or relief of pain, given that it can greatly affect people’s physical and mental well-being.

Contemporary utilitarian philosophers such as Peter Singer have argued that nonhuman animals are also sentient beings – they similarly have the capacity to experience pain and to suffer. These capacities, Singer argues, demand that animals’ interests in not experiencing pain or suffering should be taken seriously by human beings, based on a more general obligation to give equal moral weight to the interests of those affected by human actions. Singer argues that modern factory farming conditions create intense pain and suffering for animals and human beings are therefore ethically obligated to prevent such wrongs by being vegetarians.

Pain Through The Lens Of Major Bioethical Principles

Respect For Persons

Kant believed that the shared ability to reason is what makes humans morally signiﬁcant and bestows all humans the right to dignity and respect. In the healthcare context, respect for persons demands that patients be treated as moral agents who can voice their pain concerns in a safe therapeutic environment and engage in shared decision making with their clinicians regarding the most appropriate pain management. This last aspect is speciﬁcally captured by respect for autonomy, which requires that mentally capable patients be informed about the risks and beneﬁts of treatment, possible alternatives, and likely consequences and allowed to make voluntary treatment decisions accordingly without undue inﬂuence from others. In the context of pain management, respect for a person demands that patients’ perspectives regarding their pain tolerance and most appropriate form of pain relief be given due consideration in constructing care plans. It also calls for healthcare providers to refrain from being paternalistic toward patients.

Respect for persons and their autonomy is also relevant in pain management because severe pain can diminish people’s energy and clarity of thought, which can in turn restrict people’s capacity to exercise autonomy. Patients’ ability to access appropriate pain control is thus ethically signiﬁcant. Of concerns are situations where patients may not know how to describe their pain in ways that would allow them to get appropriate help from health professionals or where they may be too worried about being viewed as weak or demanding to even discuss pain relief. In other cases, some patients may feel distrusted or discriminated by the clinician regarding their pain complaints, particularly when their pain may not have a known origin or discernible organic cause. When patients perceive that they can make their own decisions regarding pain management, they are more likely to have better therapeutic or trust relationships with their clinicians.

However, in the discourse of pain management, there have been questions of whether complying with patients’ requests for their desired form of pain management in some situations may ironically compromise patients’ autonomy. In discussions of physician-assisted death and euthanasia, whose supporters often appeal to the principle of respect for persons and their autonomy, some have argued that these procedures require the help of another person and thus are not simply matters of one individual’s self-determination. In the area of CNMP, some clinicians may argue that paternalistic actions toward patients who are (at risk of being) addicted to pain medication are justiﬁable, if their (suspected) addiction may affect their ability to make autonomous decisions regarding their care management.

Nonmaleficence And Beneficence

Nonmaleﬁcence describes a basic ethical and professional obligation to not inﬂict unnecessary harm on a patient, whereas beneﬁcence refers to a duty to promote the well-being of a patient, which is a basic tenet of clinical medicine. Symptom relief for patients suffering from painful illnesses, especially when no cure or reversal of the condition is available, is an active concern of medicine. Both ethical principles require clinicians and others to balance the risks and beneﬁts of various procedures, avoid preventable injuries and pain, and promote access to pain relief. Nonmaleﬁcence and beneﬁcence would both demand the clinical team to consider the patient’s overall context and priorities in determining appropriate management to the patient in a timely fashion.

Uncontrolled pain is also a signiﬁcant concern for patients near their end of life, where pain is the single factor accounting for patient experiences of a “bad death.” A commitment to nonmaleﬁcence thus requires clinicians to help minimize potential physical and accompanying emotional suffering. Such a commitment at a system level demands governments and public health systems to take reasonable steps to provide access to effective and safe forms of pain relief.

However, while the principles of nonmaleﬁcence and beneﬁcence may have intuitive appeal, how clinicians may fulﬁll these obligations can be challenging in some situations. Due to the side effect of certain pain management regimens, balancing harm and beneﬁts can be difﬁcult. At a system level, opioid analgesics are controlled medicines – their production, distribution, and prescription are strictly regulated. These legal parameters have tremendous impact on what HCPs may (not) be able to provide for their patients. In end-of-life care, the concern among some healthcare providers that opioid analgesics may depress respirations and thus hasten death may have contributed to pain being treated inadequately in populations with advanced illness.

The situation is also complex in CNMP due to limited physician education and training in both chronic pain and addiction. Many clinicians therefore ﬁnd it difﬁcult to determine the most appropriate management, particularly in situations where complaints of chronic pain are not matched with an obvious or a visible clinical explanation for the pain.

Some pain medications, such as opioids, are highly addictive and have limited evidence for the effectiveness of long-term use (Von Korff et al. 2011). Nonetheless, opioids have increasingly been overprescribed in North America over the past two decades, leading to a rise in morbidity and mortality associated with abuse of these prescribed drugs. This epidemic of prescription opioid abuse emerged, in part, because HCPs were relying on faulty evidence and misleading marketing strategies by drug companies about the abuse risk of medications such as OxyContin. Pharmaceutical companies have also been accused of employing physicians to aggressively promote the liberal prescribing of opioids for CNMP to other prescribers. Given this state of affairs, some HCPs are thus rightly concerned about bringing on iatrogenic harm by prescribing various pain medications, particularly for long-term use by patients with chronic conditions. Facing a challenge in balancing the risk of addiction and the harm of inadequately treating the patient’s pain, many clinicians adopt a default position of “pharmaco-vigilance” and exercise extreme caution in prescribing certain pain medications.

Justice

As cultural attitudes, social contexts, and resource availabilities vary across the globe, at least two interrelated forms of justice concerns are salient in pain management.

First, justice as a bioethical principle deals with fairness, equality, and equitable treatment of all patients. It emphasizes nondiscrimination of various populations, such as people living with chronic pain, and addresses the association of global chronic pain with various social determinants of health, which are the circumstances in which people are born, grow up, live, work, and age, as well as the systems put in place to deal with illness. Second, in the form of distributive justice, this principle demands equitable allocation of medical and social resources to correct pain inequities, i.e., avoidable inequalities in access to pain management between populations, and to support patients’ needs.

Achieving justice may be the biggest challenge in addressing pain management internationally. Regarding fair and equitable treatment, pain patients, particularly those with chronic pain, have reported perceived discrimination and stigma in society and by healthcare professionals. Stigma is important ethically – as it indicates injustice and a lack of respect for agency. Given the subjectivity of the pain experience, some physicians may question the truthfulness of patients’ testimonies and their motivations for requesting highly addictive pain medications, particularly if they appear to exhibit drug-seeking behavior. Due to social stigma, patients with chronic pain are often discredited and hold a “spoiled identity” with presumed “blemishes of individual character,” as the sociologist Goffman noted. Such default position of distrust and presumptions of credibility deﬁcit may further marginalize chronic pain patients and perpetuate inadequate treatment of pain for this population.

Second, regarding issues of distributive justice, access to pain management is unequally distributed, with widening inequities across the globe. The poor, elderly, mentally ill, children, women, and racial and ethnic minorities bear greatest burdens of persistent and untreated pain. In many countries, chronic pain is associated with factors such as race, socioeconomic status, stress, neighborhood, and level of education. Members of disadvantaged groups are also less likely to access and beneﬁt from effective treatment. They endure various conditions and accompanying pain due to poverty and other barriers in accessing healthcare. Even when access to general healthcare is available, disparity in pain management remains.

In the USA, persons in minority groups often receive less pain medication than their white counterparts in emergency rooms, postoperatively, and in labor. One review in that country shows the persistence of ethnic disparities in acute, chronic, cancer, and palliative pain care across the life span and treatment settings, with minorities receiving lesser quality pain care than non-Hispanic whites (Anderson et al. 2009).

Geographical locations within a country can also contribute to disparate access to few pain specialists and multidisciplinary pain clinics. In Canada, 80 % of multidisciplinary pain management clinics are in major urban centers, with no clinics in the province of Prince Edward Island or the Yukon, Northwest, or Nunavut Territories (Peng et al. 2007). Wait times to see a specialist for CNMP can take several months to a year from the time of referral and are on average longer than 1 year for more than one-third of publicly funded clinics (Peng et al. 2007).

Internationally, factors related to cardiovascular disease, trauma, and cancer rank among the leading contributors to the global burden of disease. With inadequate access to effective treatments in the global South, a lengthy and painful disease progression for these conditions is common and unfortunately expected. While countries in the global North – Australia, Canada, New Zealand, the USA, and the European Union – consume more than 90 % of the global supply of pharmaceutical-grade morphine (United Nations 2009), there is very limited access to nonsteroidal anti-inﬂammatory drugs (NSAIDs) and opioid analgesics in less resourced regions (King and Fraser 2013), leaving approximately 5.5 billion people in over 150 countries with limited to no access to these medicines (Seya et al. 2011). For example, tens of millions of patients with terminal cancer are estimated to experience moderate to severe pain due to inequitable access to not only aggressive interventions but also pain medicine, since morphine is virtually nonexistent in most regions (Seya et al. 2011). Similar concerns exist for the millions of people living with conditions such as HIV/AIDS, most of whom live in regions with little or no access to treatment for moderate to severe pain. Barriers to pain management in these regions include restrictive policies and laws, limited education in pain management for health professionals, and inadequate healthcare and public health infrastructure. Poor access spans from curative treatments such as surgery, radiotherapy, and antiretroviral therapy to comfort measures such as palliative care. The International Narcotics Control Board (INCB), which has the legal mandate for the international control of both licit and illicit narcotic drugs, implements quotas on the amount of controlled narcotics that countries can obtain. Some scholars have argued that the INCB acts within the conﬁnes of the US-led global war on drugs and is a major legal barrier to accessing pain-relieving medications in lower and middle-income countries (Nickerson and Attaran 2012). They note that the INCB has approved insufﬁcient supplies of controlled narcotics for medical use based on the misestimates of the prevalence and clinical need of pain in certain countries.

It is worth noting that the global problem of pain is not simply due to challenges in availability and distribution of opioid analgesics. Although critically important for pain management, opioids are not a panacea – structural factors such as economics and political and cultural factors shape the experience of pain and contribute to treatment (in)equality. These remarkable inequities raise important questions of global distributive justice and prompted the WHO and the IASP to advocate for access to pain relief to be a human right.

Conclusion

There is a high global prevalence of chronic malignant and nonmalignant pain that incurs substantial social and economic costs on societies. Countries in the global South bear the greatest burdens. Pain is closely linked to the social gradient of health within countries and highly determined by socio-structural factors such as economic conditions. The suffering caused by the epidemic of undertreatment of pain and its sequelae is an international tragedy, impacted by widening inequalities in access to healthcare.

Various ethical theories and bioethical principles point at ethical obligations of providing pain relief, but data demonstrates a global inadequacy. International efforts that propel paradigmatic changes in pain education, culture, laws, policies, and treatment, including disparities in access, at micro-, meso-, and macro-system levels, can help identify pain as a global health priority. In doing so, the global community can work in solidarity to support healthcare providers worldwide in fulﬁlling their ethical duties to adequately treat pain and minimize suffering.

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