Editor’s Note: Babita Ghai, MD, has been working in the pain field for more than 20 years, with a focus on pain management, pain education, pain research, and policy creation in India, and is a leading expert on chronic low back pain. She is a professor of anaesthesia and a pain management consultant at the Postgraduate Institute of Medical Education and Research (PGIMER) in Chandigarh, India. Ghai spoke with RELIEF freelance writer Kayt Sukel about the burden of low back pain, the use of opioids in Southeast Asia compared to other regions, and her vision for the future of pain management in India.
What first interested you in studying pain management?
As an anesthesiologist, I was always involved with acute pain management right from the start of my career. But I first became interested in chronic pain management during my senior residency at the All India Institute of Medical Science (AIIMS) in New Delhi, where I first worked in a pain clinic. It was a rather erratic pain clinic at that time, only running a few hours each day. But, as we worked with the chronic pain patients there, I saw that chronic pain was very different from acute pain. That was very interesting to me, and it spurred me to become a pain physician.
Much of your research has focused on low back pain. Why?
Low back pain, according to the Lancet’s Global Burden of Disease data from 2016, is the condition that causes more disability worldwide than any other medical issue. It’s among the top 5 conditions where people live with a large number of years with maximum disability—and that’s out of 358 total diseases. The prevalence of low back pain has increased nearly 50% since 1990 and is anticipated to increase further in the coming decades, as more of the population ages and our lifestyles become more sedentary. In fact, we see more and more young people coming into the clinic who have issues with low back pain.
In India, back and neck pain are ranked as the second leading cause of years lived with disability, only after anemia due to iron deficiency. The prevalence of low back pain is quite high here and due to limited access to healthcare many patients keep suffering. In my own clinical practice, I see around 50 to 70 chronic pain patients per clinic. Out of this swath of patients, I estimate about 70 to 80% have chronic low back pain. That really inspired my interest in researching the best ways to treat chronic low back pain.
What are some of the most interesting things you’ve learned about effectively treating low back pain?
I think the most important—and the most effective—treatment is patient and caretaker education and self-management, which are recommended in almost all the guidelines. To be more effective in the management of low back pain, it is important to explain to patients the anatomy of the back, common reasons for back pain, and the importance of being physically active. It’s important to eliminate so many of the myths about low back pain. Here, in India, there is still a strong view that prolonged bed rest will help. So, educating patients, showing them patient-centric exercises, and dispelling those myths play a very important role in improving the situation.
To help deliver effective care, we have created our own self-instruction module booklet about low back pain for patients. It’s available in three languages, including English, Hindi, and Punjabi, which are widely spoken in India. The booklet covers various aspects of low back pain including the anatomy of the back, common causes of pain, the importance of posture, and some exercises. It’s been very well-appreciated by the patients. And we have already conducted some research on a self-instructional module that will soon be published in the literature.
Beyond education, it is also important that physicians take care of psychosocial aspects of chronic pain, along with the biological and physical aspects. This is very important to achieving effective pain management. In acute pain management, even if you have neglected the psychosocial aspects, it may not necessarily have much impact on treatment. But with chronic pain, if you ignore the psychosocial aspects, you will have more difficulty successfully managing the issue. So, things like yoga, mindfulness, mindfulness-based stress reduction, cognitive behavioral therapy, or other psychosocial treatments can help.
In the US and other Western countries, opioid drugs are commonly used for pain. Are these medications commonplace in India?
No, they are not commonplace in India. This is mainly because there are tight regulations in India regarding these kinds of drugs, including India’s Narcotic Drugs and Psychotropic Substances Act, which was established in 1985. It is very prohibitory in nature and, despite some reforms in 2014 by the Indian Parliament, the consumption of prescription opioids in many states has still not increased; only 2% of palliative care patients have access to opioid drugs.
In the Western world, experts talk about the opioid epidemic in terms of restriction, overuse, addiction, and death, and they are working to decrease the number of prescriptions. But we, in India, probably like many developing countries, face a different end of the opioid crisis, and that is a lack of availability of these drugs for patients who really need them. In fact, the data and issues coming from Western countries have made our country quite skeptical of opioids and India is rethinking the previous reforms. In India, misuse of prescription opioids is rarely seen. Most of the opioids are not even available to patients.
In fact, according to the World Health Organization (WHO), Southeast Asia consumes only about 1.7 milligrams of opioids per capita. This is just one-hundredth of the equivalent consumption in WHO’s European region. This shows just how low our consumption is here in Southeast Asia, even though we actually are one of the main producers of these drugs, and they are not commonly used here to treat chronic pain. What opioid drugs we do have are mainly used for cancer patients.
What is the most common treatment for chronic pain in India?
Pain management clinics, in tertiary medical centers, commonly use a multi-disciplinary approach, including physical therapy, minimally invasive interventions, and other medical approaches for patients who do not respond to more basic treatments. Some patients will undergo surgical interventions, too. It is not as common, but some patients will also receive newer neuromodulation techniques like spinal cord stimulation or intrathecal [spinal cord] drug delivery systems, but you will only find these in advanced pain management clinics.
If we are talking about primary and secondary healthcare, then chronic pain management is not very good. And that’s because most primary care physicians are not trained well in managing chronic pain conditions. Most don’t understand the psychosocial aspects of these conditions and, therefore, don’t know how to effectively manage them.
What role should the patient play in chronic pain management?
The patient should be at the center of care. Without involving the patient, or the caretaker, chronic pain management will not be successful. We will not be able to achieve the aims we desire with our interventions or achieve normal rehabilitation without putting the patient at the center of any care plan. It’s very important that patients and caretakers are properly educated and understand the condition of pain and what they can do to help with chronic pain management. In my practice, I make sure to tell my patients they may not be able to achieve complete pain relief but we can reduce the level of pain so that they will have a good quality of life and be able to cope with day-to-day activities. The role of patients in their pain management is very, very important.
You mentioned that primary care physicians in India lack sufficient training in chronic pain management. What’s missing?
Today, there is inadequate training in the undergraduate curriculum, both in the medical and nursing disciplines, despite pain being one of the most common reasons that patients visit the clinic. Clinical staff learn very little about pain or how to manage it. I would like to see more teaching hours incorporated both into undergraduate and postgraduate curricula, as well as more structured training programs.
To be trained myself, I had to do a fellowship in London to strengthen my knowledge. At the Indian Academy of Pain Medicine, the academic wing of the India Society for the Study of Pain, we have now started a one-and-a-half year pain fellowship, but this still needs to receive approval from the Medical Council of India (MCI), the medical policy makers here in India. We have approached the MCI and asked that they include at least 10 lectures on pain for both doctors and nurses at the undergraduate level. Hopefully, they will approve that recommendation soon.
What education do you think policymakers need in order for those changes to happen?
What is needed is for policymakers to be better educated about the epidemiology and prevalence of chronic pain in India. The numbers are rising fast and could reach epidemic levels soon. Hopefully, with that education, they would consider making opioids more available, especially to cancer patients and palliative care patients, and to include more structured training for doctors and nurses. It will take quite a bit to educate different levels of the government to convince them, since the biggest priority here is finding ways to deal with communicable diseases.
If you look at the state of pain management in India compared to other parts of the world, how are things different?
In comparison to more Westernized nations, chronic pain management is not as good as it should be. We are still in a state of infancy in that regard, and while we are making large efforts to make pain more visible to the public and policymakers, we are not as far along as I’d like to be. So, to address that, we are doing more public lectures and public awareness talks and programs to help people understand what chronic pain is, and what it is not.
In tertiary care centers and advanced pain management centers, the situation is much better. We are taking lessons from those tertiary care centers to help educate doctors and fill gaps in secondary care. We are holding lots of seminars, continuing medical education workshops, and activities for general practitioners all over India. India is a very large country, and a very diverse one, but the people involved in chronic pain management are working hard to help spread the word. Yet, despite our efforts, those pain lectures we give are not being incorporated into medical education curricula right now. But we hope that will change.
That said, the other point I’d like to make is that, compared to less-developed nations, our situation is better. But we still have a lot to achieve.
How do you see the state of pain management evolving over the next 3 to 5 years in India?
I am very passionate about chronic pain management, and I am an optimistic person by nature, so I believe we will see great improvement over the next decade in India. I hope to see MCI grant approval for better training, with more pain education being incorporated into undergraduate and post-graduate medical training. I hope to see more and more young physicians getting involved with chronic pain management and spreading the word about effective treatments so we can do what we most want to do—to help our patients lead better-quality lives.
Kayt Sukel is a freelance writer based outside Houston, Texas.
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