"Surgical care doesn't end at the operation but also involves provision of adequate pain relief. However, various barriers affect access to pain relief in India."
"I believed that I would have some pain in my leg immediately after having my hip replacement surgery and hence did not point it out to the doctor who came for rounds", said Mr Matthew (name changed). Mr Matthew was an active 70-year-old gentleman, whose goals after surgery included being able to independently do his daily activities. This required being completely pain-free, something Mr Matthew didn’t believe was possible.
"Eventually, people noticed that my heart rate was high all the time in the ward. They repeated some blood tests and wondered whether I had lost too much blood during surgery. They also said they were worried about infection. Only after some time, they asked me whether I had pain. When I said I did, they went up on the dosage of the painkillers. Just like that, as the pain disappeared, they noticed my heart rate normalised too. I wish I had known that the normal amount of pain after surgery was zero," he said.
Unawareness blocks access to pain relief
"Doctor, how much will this surgery hurt?" is probably one of the most common questions that any surgeon or anaesthetist will encounter in their office when counselling a patient for surgery. However, many patients and healthcare professionals alike carry many misconceptions about pain.
Dr Parul Raina, a consultant anaesthetist at Sharda Hospital, Noida, recalls an incident where a teenage girl was in tears because of the fear of her upcoming surgery. "Her mother was consoling her by saying that some pain would be there during surgery and afterwards. She was told that she had to adjust to it,” told Dr Parul. The fact that adjusting to the pain was considered to be the only option was shocking to Dr Parul.
“Over the years, I realised this is a widespread misconception among people - especially those of low socioeconomic status. Since then, I have made it a point to explain to patients that they do not need to adjust to pain and they must insist on adequate and complete pain relief." - Dr Parul Raina.
Pain after surgery which is often considered ‘normal’ can also suggest something sinister. However, the lack of awareness in the patient prevents them from seeking care. "After tooth extraction, if pain persists for more than a day, it might suggest that there is an infection or a dry socket (where the jawbone becomes exposed). Corrective measures can make the pain go away," said Dr Madhushree Rao, a practising dentist from Assam. “However, unaware of the problem, the patients often end up tolerating the pain.”
Similarly, pain after eye surgery could be due to an increase in the pressure within the eye. “This can be a potentially sight-threatening complication and hence, I take post-surgical pain very seriously", added Dr John Sangma, an eye surgeon serving the tribal Garo population in a Christian Mission Hospital in Babupara, West Bengal.
"Sometimes patients take pain relief into their own hands," said Dr John. One of the issues that he struggles with is the widespread use of herbal juices and steroid eye drops to relieve pain caused due to eye injuries. "Patients come to me after applying these home remedies which worsen their conditions and invariably lead to fungal ulcers." Dr Madhushree too, receives patients who self-treat their dental pain with tobacco and clove oil and has to extensively counsel them against the same.
Many patients also seem to complain of long-term pain several years post-surgery. It is a common phenomenon that physicians see in the outpatient department. "It is important to validate the patient and evaluate the pain they are complaining about", says Dr Parul, "Most doctors do not take it seriously as they feel that the correlation the patient has made between the pain and past surgery is irrelevant. However, doctors need to remember that there is always a possibility of nerve injuries during surgery which can cause longstanding pain. And even if the patient's correlation is not right, the pain itself must be evaluated as they have sought medical help for the same."
Inequitable access to pain relief
While pain relief during surgery is a right and a fundamental part of surgical healthcare, access to the same is not equitable. "We do not have an anaesthetist in my centre, hence we cannot offer general anaesthesia for eye surgery," said Dr John. "That means I cannot operate on children or patients who are uncooperative. And we are the only centre available for the Garo people who sometimes travel around 200 km to reach here."
As Dr John believes in offering robust pain relief, he uses nerve blocks instead of topical medicines. As he is a single doctor who performs dozens of surgeries per day, he has trained an assistant who administers the blocks.
However, when one speaks about inequitable access to pain relief, one does not need to look beyond labour analgesia to witness the stark reality. "Epidural analgesia during labour is almost universal in developed countries but is hard to realise in the public health setups in India", says Dr Diana Terangpi, a senior resident in Obstetrics and Gynecology in Satribari Christian Hospital, Assam.
According to Dr Parul, most government setups do not practice epidural anaesthesia and the ones that do, do not offer it to patients routinely as an option. Epidural anaesthesia is a mode of injection of a pain relief drug in the spinal column that causes significant pain relief during childbirth. The inequity in access to this form of pain relief is similar to most other health services. "Only rich people in private setups can access epidural analgesia," added Dr Parul.
The availability of the service also depends on the expertise present at these government institutions. While Dr Parul provided epidural anaesthesia to multiple patients in AIIMS Delhi, she did not get to do a single epidural while she was practising at Jammu Government Medical College. "Epidural needs regular monitoring, good operation theatre set up as well as a duty anaesthetist at all times which is not possible given the infrastructural limitations of government hospitals. So in these areas, we tend to rely on injectable drugs such as opioids to provide some pain relief to patients," says Dr Diana.
Breaking the barriers to pain relief
The ultimate solution to poor access to pain relief, i.e. making pain relief affordable and accessible, lies at the policy level. However, healthcare providers can also contribute to making pain relief more accessible. Doctors need to not just be prescribers of care but also educate patients about pain relief and bust the myths blocking access to a pain-free life. "I invest a lot of effort into creating awareness that the use of untested herbal medicines for pain relief can cause harm. I have noticed that more and more people now come to me to seek proper pain relief," said Dr John.
Not all pain relief is pharmacological according to Dr Diana. "Motivating the patient, spending time with them, counselling them about what to expect, and teaching pregnant mothers breathing exercises are all ways to add on to pain relief which does not depend on medications” said Dr Diana. Overcrowded government hospitals prevent doctors from dedicating adequate time to patient counselling. However, shifting this task to nurses and other healthcare providers can ease the burden on the doctors and improve patient care at the same time.
Often, the biggest barrier is the lack of a doctor’s ability to use available drugs to provide relief from pain. Pallium India’s online training program makes acquiring this skill possible through distance learning. “Our training program has enabled thousands of healthcare workers to be empathetic about other’s pain. Our evaluation has shown us that our course has helped healthcare workers assess and treat pain confidently,” said Dr Sreedevi Warrier, Head of Education and Skill Building Division of Pallium India.
It is high time we addressed the poor access to pain relief in India. Pain, tolerating which is often considered as the only option, should be actively addressed. Till policy changes improve the overall scenario, healthcare providers should make the best possible attempts to keep their patients pain-free.
About the authors
Dr. Christianez Ratna Kiruba is a general medicine physician with a passion for medical ethics and patient rights advocacy.
Edited by Parth Sharma
Artwork by Janvi Bokoliya
This article was originally published in Nivarana.