Editorial
In the second half of the XX century, fundamental problems of medicine were to the greatest degree, solved. Control of infectious diseases, maternal and infantile mortality, hospitalization of population, the possibility to correct and gesture severe health issues, complicated life-saving surgeries are not a novelty subject any more for doctors as well as for patients. Higher accessibility to qualified and specialized medical assistance was followed by certain requirements regarding offered services. The patient, in fact de payer and receiver of medical services desires a high level of comfort and security. This requirement is not characteristic only for patients from highly developed countries or large medical centers. Under social pressure, as well as under the pressure of doctors from the “new generation”, the claim of quality, comfort and security in medicine appeared on the agenda of competent authorities from East-European and ex- Soviet countries.
In the context of the above written, in the East-European and ex-Soviet countries, the problem of pain starts to be perceived in a totally different way as it was 15-20 years ago. This new perception, materialized by the new generation doctors and fortified by recommendations from patients that had a chance to benefit from medical assistance in Western Europe, impose a serious concern regarding the problem of pain. In fact, today pain is not just a simple symptom; it is a multidimensional entity that exceeds one person or one medical institution. Pain is a global transnational problem, an integrated indicator that reflects the level of development and maturity of the society, the level of democracy of the State, the state of fundamental liberties, the quality of medical services, as well as the educational and cultural level of the population. Thus, pain approach and solving in a multi-dimensional way, surprisingly and inevitably will have a positive and almost immediate impact over all parameters that define medical assistance and define the State as being “modern, free, developed, and democratic”. In order to ameliorate the situation of pain management small investments are needed that will have an enormous medical and social impact – an undiscovered field for politicians, scientists, doctors, pharmacists, psychologists, sociologists, IT specialists, administrators, attorneys, economists, didactic staff, social assistants, journalists, writers, artists…
Social and cultural dimensions of pain in Moldova
Social and cultural perception of pain among population from the Republic of Moldova can be “diagnosed” by the following myths:
- “doctor wants me to stop complaining”;
- “I don’t want to be stung, I would rather endure the pain”;
- “pain relief will blur the eventual important symptoms”;
- “talking about pain I distract doctor’s attention from other symptoms”;
- “surgery means pain, I have to resign”;
- “pain during labor is given by God, analgesia during giving birth is dangerous both for the mother and child”;
- “the doctor knows better how painful it is and how much pain killers to prescribe”;
- “Opioids cause dependency, it’s better to suffer”.
Unfortunately many of the myths mentioned above are supported by the medical community too.
Thereby, it is indispensable to perform activities that will lead to modification of social and cultural perception of pain. Only in this way the population will realize the value of quality and security of medical services, and will appreciate the fact that pain treatment avoids numerous severe complications and ameliorates the quality of life.
Instructive and educational dimension of pain management in Moldova
Generally speaking, among the actors of the health system (doctors, nurses, dentists, pharmacists, administrators), the same social and cultural perceptions run regarding pain as among population.
That is why it is needed to create a medical and institutional policy and culture, adapted to evaluation and treatment of pain, as well as to change patient’s attitude about pain, to modernize practice and implement instruments of pain measurement in daily routine, to start using devices for patient-controlled analgesia and to create facilities for acute and chronic pain management. All these measures could ameliorate the quality of medical assistance, would reduce costs and hospitals stays, and would accelerate recovery, patient’s return to work and re-socialization. All in all would make the patient regain confidence in the medical system.
Legal and political dimension of pain
Adequate therapy of pain is not a pure medical problem. Since 2004 pain is recognized as the 5th vital sign, and pain relief is a fundamental human right–fact recognized by WHO.
Republic of Moldova has a very restrictive legislation regarding availability and accessibility of opioid analgesics (opioid analgesics consumption in morphine equivalents is about 1mg/person/year, which is 20-40 times less than in countries from Western Europe). This deficit reflects a considerable non-documented suffering of the population. There is a strong correlation between the development level of the state, society, fundamental rights etc. and the consumption of opioids in the medical field. No judicial document in Moldova contains the word “pain”, but contains the word “suffering” instead. The term “suffering” does not substitute the term “pain” in none of the biological of semantic aspects. In the Republic of Moldova, chronic pain is not recognized as an independent nosological entity; medical assistance of the patient with acute or chronic pain is not recognized and is not reimbursed by the insurance companies. Thus, medical institutions are not legally obliged to create structures of pain management, to have an institutional pain policy, to monitor quality indicators focused on pain management, to use validated instruments of evaluation, standards and pain treatment protocols, to teach medical personnel about pain, to inform patients and their relatives about pain etc.
In consequence, legal expertise of legislative texts regarding the medical field is necessary, with subsequent presentation of recommendations in order to complete and modify legislation (with implication of hospital law specialists from abroad, technological and logistical transfer) in such a way that would regulate evaluation and pain treatment according to the European Union model. Legislative regulation of pain management will ensure means to create a National Program against Pain, to implement institutional policies regarding pain, to create pain management cultures among actors of the health system and population. The Fundamental Human Right of pain relief will be respected, as well as the principle of equity and nondiscrimination of patients (all patients will be informed, evaluated and treated according to unique standards and protocols). Increasing availability and accessibility of opioids analgesics for pain relief of the population, availability of galenic oral forms of morphine, removing stigma from this class of drugs, fighting with myths that circulate about opioids and pain relief would represent a huge step forward.
Applicative and clinical dimension of pain management
In the past few decades the number of natural and technological disasters, social disturbances and armed conflicts has raised exponentially. The number of victims is huge, and the spectrum of trauma is various. Pain relief in these patients is not only a legal and professional obligation, but also an impulse to elaborate and adopt new strategies in order to cope with these situations.
From the other point of view, the medical progress itself has faced a diversification and an exponential raise in invasive and painful manipulations that today, count more than 650 entities.
It looks like a paradox, but most of the patients do not receive any analgesics neither at the place of accident, nor on the way to the hospital, or during painful manipulations, or administered analgesics are not efficient.
Studies made in the Republic of Moldova identified a nonsatisfaction regarding pain treatment in hospitals, estimated to 72% of the patients. In hospitals, every 3rd patient took analgesic selfmedication to calm pain after surgery, supplementary to medication prescribed by the doctor. In the same period of time, in a medical institution, 160 combinations of analgesics were used, and the number of analgesic medications prescribed to a single patient varied from 1 to 7, most of them being from the same drug class. Prescription of medication didn’t take into consideration contraindications of certain drugs, risk factors, and were not adapted to the intensity of pain.
Non-adequate treatment of pain can lead to a raise of the incidence of immediate and late perioperative complications.
But, all of these represent branches in which the gap between the European east and west can be rapidly reduced if corresponding measures mentioned above will be taken.
In this connection, the new platform for communication between researches, clinicians, authors, readers, experts and patients like Austin Pain & Relief, will significantly contribute to ameliorate the quality of pain management, to exchange opinions, to create connections, relations and collaborations.
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