A Ten-Year Anniversary: Reflecting on the Declaration of Montreal

Published June 24, 2020

On September 3, 2010, 260 delegates representing 62 countries came together at the first International Pain Summit, a day-long advocacy event hosted at the International Association for the Study of Pain (IASP) 13th World Congress on Pain, to bring attention to inadequacies in the assessment and management of pain across the globe. The document that would emerge from that meeting, the Declaration of Montreal, proclaimed that access to pain management is a “fundamental human right.” It was a bold statement – and one that has helped to shape advocacy and policy efforts with regard to pain management in the years since.

“As the leading global pain association, IASP has continued responsibility for, and dedication to, engaging politically to promote recognition of pain management as a fundamental human right,” said IASP President Lars Arendt-Nielsen, Aalborg University, Denmark. “The Montreal Declaration is an excellent example of this, and it goes hand-in-hand with last year’s approval by the World Health Organization of new codes for chronic pain, developed by IASP, for inclusion in the latest revision of the International Classification of Diseases [ICD-11]. Together, efforts like these promote better pain management as well as acceptance of pain as a disease in its own right.”

“The Declaration of Montreal was the result of a consensus of many different clinicians and researchers, from a variety of countries with very different cultural and socioeconomic backgrounds,” said Bart Morlion, Leuven Center for Algology and Pain Management, Leuven, Belgium and President of the European Pain Federation (EFIC), who participated in the original summit meeting. “It was a very important milestone for the pain community because, although there were already many different initiatives being worked on at the time to improve pain management for patients in different places, this official document was really the first step forward to having a true global plan.”

As the ten-year anniversary of the Declaration of Montreal nears, it’s a good time to take a look back at how it came about and what influence it has had over the past decade.

A “crystallizing” moment
In the late 1990s and early 2000s, converging evidence was showing that the experience of pain was not solely a biological phenomenon. Rather, this new data demonstrated that pain had psychological and social components that needed to be addressed as well.

Further, according to Sean Mackey, Stanford University, Palo Alto, US, both the medical and research communities were beginning to recognize that pain was a condition that impacted millions of people across the globe and that efforts to manage it were sorely lacking at the time. The ability to keep people alive after trauma, cancer, wartime wounds, and other injuries, as well as the growth in aging populations, meant that the prevalence of chronic pain was on the rise. Something was needed to better meet the needs of people who were living with pain.

“Pain is something that takes a tremendous toll on the individual who has it, as well as families and society as a whole, yet, from a societal standpoint, we still weren’t recognizing it as such,” Mackey said. “There was a clear need to bring more attention to the lack of fundamental awareness of how to properly assess and treat pain. The question was how to best do that.”

Holding the International Pain Summit at the conclusion of IASP’s 13th World Congress on Pain in Montreal was one approach. Michael Cousins, University of Sydney, Australia, who headed the steering committee for the event, and those who served with him, were inspired by previous advocacy efforts, including the inaugural Global Pain Day in 2004 held by IASP, EFIC, and the World Health Organization (WHO), as well as by several declarations put forth by palliative care and other organizations calling for access to pain relief to be considered a human right.

Rolf-Detlef Treede, University of Heidelberg, Germany, said Human Rights Watch, an international non-governmental organization that conducts research and advocacy on human rights around the world, even published its own statement in 2009 calling for access to pain management to be recognized as a human right. It was a “crystallizing” moment, he said – and one where a global organization like IASP could help facilitate change in how pain was perceived and treated around the world.

“The discussion of access to pain management as a human right had been ongoing for years,” he said. “There were a lot of activities in individual countries around this idea from 2004 on, and this was an opportunity for us to come together on a global level to jointly push that idea forward and help bring pain treatment to the people who needed it the most.”

The Declaration of Montreal
The resulting declaration, signed by the Summit’s delegates and later approved by the IASP Council, highlighted the inadequacies of access to pain management resulting from factors like the stigma of chronic pain with or without a diagnosis, a dearth of healthcare education regarding the mechanisms and management of pain, and a lack of national policies concerning pain as a health issue in its own right. Those deficits, the attendees argued, led to unnecessary suffering that needed to be addressed immediately.

As such, the delegates called for access to pain management to be considered a fundamental human right, declaring “The right of all people to have access to pain management without discrimination”; “The right of people in pain to acknowledgement of their pain and to be informed about how it can be assessed and managed”; and “The right of all people with pain to have access to appropriate assessment and treatment of the pain by adequately trained health care professionals.”

Treede said that, for the most part, the response to the declaration was extremely positive, though there were some concerns that the wording might lead to increased prescribing of opioid medications.

“In retrospect, some people consider this move may have contributed to the opioid crisis in the United States,” said Treede. “But this was not by design, but by misunderstanding. Our desire was to call attention to the need for a multimodal approach to the treatment of pain, not to say that more access to opioids would solve the problem.”

Tracking the Declaration of Montreal’s influence
While the Montreal Declaration was a fairly straightforward document, and did not provide a detailed action plan on how to ensure that access to pain management would be treated as a human right, Morlion said that having a short and to-the-point document to hand to policy makers was a positive step to support ongoing advocacy efforts.

“With the Declaration, you had a document in hand that you could pitch to politicians and decision makers to raise awareness and help them easily understand the issue,” he said.

Mary Cardosa, a pain specialist at Selayang Hospital, Selangor, Malaysia, and President of the Malaysian Association for the Study of Pain, said that the summit, which both she and the Malaysian government’s Deputy Director-General of Health attended, as well as the Declaration itself, were instrumental in helping to move forward hospital initiatives related to pain management in her home country.

“We used the concept of a human right to push the idea that providing adequate pain management was everyone’s responsibility,” according to Cardosa. “It had a really big impact on our success.”

Nadine Attal, INSERM, Paris, France, said that when the Montreal Declaration was released, pain specialists in France were already at work on policies to improve access to pain management.

“We had the same feeling that access to pain management is a human right even before the Declaration,” she said. “We were working on putting our own plans in place, which just happened to coincide with this Declaration. That said, it did have impact in that it helped people outside of the medical community to understand that access to pain management is a right and people should not have to suffer in silence.”

In the years since, the Declaration has been referenced in a variety of global initiatives, including EFIC’s Societal Impact of Pain platform, the United States Institute of Medicine’s Relieving Pain in America report, and the subsequent United States National Pain Strategy. Morlion and Treede said it also played a role in helping several European countries expand pain management education programs for clinicians and other healthcare workers, and in spurring the inclusion of pain codes in ICD-11.

In the end, Mackey said, the Declaration of Montreal played an important role in an ongoing story that brings the need for accessible and effective pain management into the light.

“This was one of the first steps in the societal evolution of our recognition that pain is important and needs to be appropriately assessed and managed,” he said. “The next step is to take this grand idea that was presented in that Declaration and use it to create a document of action that can make sure that this fundamental human right is met. It’s up to all of us in the greater pain community to learn, to collaborate, to speak in one voice, and to develop specific, tactical strategies that can put those words into action.”

Kayt Sukel is a freelance writer based outside Houston, Texas.