Authors: Sid Sharma, Clare Donaldson, and Michael Plant
Last updated: November 2020
Executive summary
We all expect to experience some pain in our lives. For most of us, especially those in high-income countries, these experiences will be mild, bearable, and short. Others are not so fortunate. Millions suffer excruciating pain. Millions more suffer moderate or severe pain. They suffer despite the fact that cheap and effective treatments exist.
This report briefly discusses the measurement of pain then explores three major causes of pain and what might be done to relieve them. The findings are relevant for individuals and organisations considering if and how to put their resources (i.e. their money and/or time) towards this global problem. Problem 1: terminal conditions requiring access to opioids
First, we consider pain from terminal conditions such as advanced cancer and HIV. These cause intense suffering if untreated. If carefully treated with opioids, 95% of those with severe or moderate-pain report mild or no pain and quality of life greatly improves.
In high-income countries (HICs), some 98% of this need for opioids is met; this figure falls to 5% in low and middle-income countries (LMICs). Cost is not the main barrier, however; a course of 90 days’ opioids is as little as $8.
This ‘access abyss’ stems from an overestimate of the risks from opioids and a focus on life extending treatment (Knaul et al., 2017a). The specific issues include:
restrictive regulation designed to stop the misuse of opioids;
a lack of training and awareness among health professionals; and
fragile supply chains.
We discuss how organisations taking a multipronged approach have succeeded in improving access in India and Uganda.
Problem 2: headache disorders Second, we examine two headache disorders: migraines and cluster headaches. The former are common, affecting around one in six people, and sometimes debilitating. They impose a burden of disease roughly comparable with malaria or depression. The latter are agonising and experienced by 0.1-0.2% of the global population.
Inexpensive relief exists for migraines, such as aspirin, triptans, and propranolol. The main barriers appear to be:
patients do not seek help; and
if they do, they are often misdiagnosed by doctors who generally receive little training about these conditions.
Education campaigns for physicians, patients, and policymakers seem to be the order of the day.
Temporary relief exists for cluster headaches in oxygen and triptans, while preventative agents can be used to reduce the frequency of headaches. Like migraines, patients are often misdiagnosed and receive the wrong treatment. Yet, even with access to the right treatments, many people with cluster headaches endure a great deal of suffering. In addition to education campaigns, possible solutions include increasing access to proven treatments for people in low-resource settings or expediting the development of, and access to, novel therapies, such as psychedelics.
Problem 3: low back pain The third and final issue assessed is low back pain. This is the leading cause of years lived with disability globally.
Little is known about what causes low back pain or how to treat it. Efforts to increase access to existing treatments are therefore unpromising. However, there may be a high value of information in medical research into the nature of and intervention for this problem.
Conclusions and limitations
Our report closes with suggestions for further research and identifies some promising career and donation opportunities. We have not been able to thoroughly evaluate the best ways to make progress within this problem area; so these suggestions should be considered highly preliminary. However, donating to the Walther Centre for Global Palliative Care and Supportive Oncology may be an effective way to improve opioid policy and availability in LMICs. Regarding careers, working as a grantmaker at a foundation that funds medical research and impact evaluations is one stand-out option.
We have not attempted to compare interventions in this area against other options for doing the most good. Nevertheless, we hope this document, which draws together and pushes forward our understanding of the problem, can act as a springboard for further investigation, either by ourselves or others. Our conclusion is optimistic: although pain causes substantial suffering for millions of people, solutions are closer to hand than we might have expected.
