Socioeconomic and CulturalInfluences on Pain Management

in Practice

Prithvi Raj1, Ilona Steigerwald2, Stefan Esser2

1Texas Tech University Health Sciences Center, Department of Anesthesiology, Lubbock, Texas, USA* 2Grünenthal GmbH, Medical Department, Aachen, Germany

INTRODUCTION

Pain management is rarely practiced in a vacuum, andalthough practitioners are conscious of certain con-straints, they are perhaps not as aware of the moresubtle variations in this branch of medicine. Some ofthese have their origins in ancient civilizations, and sinceultimately there are important considerations regardingboth ethics and the basic provision of pain relief, it isworthwhile examining these briefly.

There are various influences in pain managementpractices. Pain can be expressed differently by an adultor a young child, or a fit adult and one with Alzheimer’sDisease; in addition there can be differences betweencountries, and even within them, in the case of distinct,regional cultures. Pain management is not straightfor-ward, but nor is it a static discipline and this is evidentin the more progressive Western countries, with cloning,pharmacogenetics and a succession of exciting productsand formulation technologies offering new opportuni-ties for both physicians and patients.

In contrast, though, in many other countries, it is stillpossible to recognise other important factors affectingpain management such as influences of previous history,of culture, of nature and natural areas (cold countries

versus hot countries), which may also have an impacton deciding what is the best way to treat a patient.Financial background obviously plays a role; even if themeans to adequately treat pain are available, can theiruniversal use in any one country be supported econom-ically? The availability of certain therapeutic options isdependent upon regulatory and reimbursement agen-cies, with particular countries not allowing a specifictechnique or a product for reasons which appear to bemedically unjustifiable. In addition, there are complexdifficulties of supply: social security systems, where theyexist and when patients subscribe or pay for treatment,but this ignores those who do not or cannot be includedin such systems.

RELIGIOUS INFLUENCES

Without question, religions have been very influential inboth leading and modulating thinking about pain man-agement, and excellent examples are the Hindu religion,Islam, and Christianity. Since pain is potentially a lifelong companion, sometimes consuming Mankind’sdaily thoughts when pain is chronic and persistent, the major religions have incorporated strategies of self-help (perhaps a fore-runner of Pain Management Pro-grammes) into their teaching to help patients cope withtheir pain.

INFLUENCE OF EDUCATION

The provision and quality of education is not only aproblem in Eastern countries, but this is also apparentin Western countries. The undergraduate curriculum in

Address for correspondence: Professor Prithvi Raj, Texas Tech Univer-sity Health Sciences Center, Department of Anesthesiology, 3601 4thStreet, Room 1C282, Lubbock, TX 79430, USA

© 2003 World Institute of Pain, 1530-7085/03/$15.00Pain Practice, Volume 3, Issue 1, 2003 80–83

Socioeconomic and Cultural Influences on Pain Management in Practice • 81

medical schools rarely devotes adequate time to theprinciples of pain management and even after qualify-ing, the standard and extent of postgraduate, specialisededucation is mixed, to say the least. Unless actuallyactive in the discipline, the awareness of the role and capabilities of a multidisciplinary pain centerappears less than adequate, although there are majorefforts underway internationally to try to remedy thisproblem.

THE SCOPE OF THE PROBLEM

Most Western countries benefit from a progressiveculture, have relatively easy access to knowledge andeducation, and enjoy higher standards of life than indeveloping countries. Unfortunately, these benefitsapply to only 1 billion people from a total world pop-ulation of 6.25 billion.

Although the rate of growth is slowing, within just 5decades, the total figure could exceed 10 billion. A

falling worldwide average growth rate conceals ofcourse the considerable growth seen in many develop-ing countries. Looking at population figures from 2002,15 of the top 20 countries are classed as developing. It is, therefore, clear that inadequate health care provi-sion affects billions of people, and considering thecurrent populations and future trends, the prospects forimproving pain relief in nations for which, for example,access to clean water is an issue, would appear challenging.

The fact that 5 billion people reside in countries withless than adequate health care coverage raises the question of how to provide basic analgesia, let aloneintroduce high-technology procedures and multimodalconcepts of treatment. Successful pain management for these people introduces a completely new dimensionto the problem that is pain, and this is an area where extraordinarily rapid improvement needs to bemade.

Figure 1. Various influences on pain management in practice.

82 • raj et al.

CULTURE AND MEDICINE IN INDIA

Philosophers, physicians and historians alike point toIndia as one of the oldest cultures on which reliableinformation is available. Documents and vivid picturesillustrate a considerable history in the area of pain man-agement, one that demonstrates both awareness andenlightenment regarding treatment options.

One of the most famous Indian ancient masters ofmedicine was Shushruta, the founder of plastic surgery,who taught how to perform these operations in 1000BC. Using cadavers, he was able to describe humananatomy in great detail, using this knowledge toperform rhinoplasty and ophthalmic operations. One ofthe driving forces for these procedures was the mutilat-ing punishment inflicted for certain offences, resultingin the loss of an ear or nose, and the need for recon-structive surgery thereafter.

Over the succeeding centuries, there were advancesin the way medicine was practiced in India andimprovements continually made. Consequently, numer-

ous books have been written, for example, on ArtharvaVeda, which discuss why pain occurs, how it evolves,and how it can be successfully managed.

From this literature come a multitude of words inSanskrit. One is adhyatmika, which says that physicaland mental suffering from natural causes is one of thereasons why we have pain. Additionally, adhibuatika,which is physical and mental suffering from men, birds,or animals can also be a cause of pain. There is alsoadhidaivika, which is suffering from supernatural causessuch as planets, ghosts, and demons. Thus, it was appre-ciated in ancient times that pain and suffering couldoriginate from one’s own body, from one’s immediateenvironment and also intriguingly, from supernaturalcauses.

INDIAN MEDICAL TRADITIONS AND TODAY’S PRACTICE

One of many health concepts originating from India andin practice today is Ayurveda (the science of life and

Figure 2. Distribution of medical standards.

Socioeconomic and Cultural Influences on Pain Management in Practice • 83

channels within the body, thereby deriving improvementfor painful ailments.

DEVELOPMENTS IN CHINA

In parallel to developments in India, similar thinking inother ancient civilizations was producing interestingresults, a classic example being China. Like the Indianphysicians and philosophers, the Chinese felt that natureand the environment were very important, extendingthis to believing in good versus bad energy. This isknown as the balance of yin (good: light and activity)and yang (bad: darkness and rest). The means of chang-ing bad energy into good energy was the cornerstone ofChinese philosophy and yoga, T’ai chi and acupuncturewere employed to effect such an energy alteration.When such a proper balance of forces exist, the bodyhas achieved a healthy circulation of the life force qi. InChinese medicine, it is theorized that the human bodyhas within it a natural flow of qi, travelling the bodyalong channels called “meridians.” When the flow of qiis insufficient, unbalanced, or interrupted, yin and yangbecome unbalanced, and illness may occur. An under-standing of the relationship between the body, yin andyang, and qi is necessary to understand the utility ofacupuncture.

Acupuncture remains in widespread pain practicetoday. Historically, observations after stimulating anaccessible part of the body, for example, the skin, inorder to manipulate outcome in deeper parts of the bodywere recorded and further explored, over the centuries.Since cultural influences demanded that not all the partsof the body could be exposed to acupuncture, it becameconvenient to use the ear as a replica of the body andthus many acupuncture points involve the ear. Thispractice is extremely popular today amongst acupunc-turists in the United States (auriculotherapy).

LESSONS FROM THE PAST

Whether resident in the Western or in the Eastern world,there is both a common desire and a basic human rightto live as pain-free an existence as possible. In thrivingto provide the kind of knowledge base that enablesphysicians to ensure that this battle is not lost, we areassisted by events occurring in the history of medicine.Clearly, this in isolation is not sufficient, but in point-ing the way towards a holistic appreciation of pain, aswell as the individual and their surroundings, much canbe learned and continued progress made.

longevity). This was founded by Dhanvantari and isbelieved to have originated some time between 3,500 to5,000 years ago.

Ayu means life and veda means knowledge, and agood understanding of one or the other, and preferablyboth, arms an individual (or a physician) to managepain, and the holistic approach is as relevant today asit was thousands of years ago in India. Caraka, a veryfamous Indian scholar-physician, is credited withwriting pivotal works on the Ayurevedic system of med-icine, and the broader popularity of Ayurveda can beattributed to such popular texts.

For pain practitioners today, the holistic approachcan encompass the use of yoga. Yoga is credited to thephysician Patanjali, and dates back to 3,000 BC. Patan-jali described that it is possible to induce a state of relax-ation and body-mind integration, which in a particularbody position permits a concentration of certain energy

Figure 3. Yoga—Energy channels within the body.