Pain Medicine Around the World: Chronic Pain at the Changsha Tumor Hospital, Hunan, China
The Western stereotype of pain medicine in China is likely to conjure images of acupuncture, tai chi, or cupping therapies, but this is far from the reality of modern medicine in China today. Our own preconceived notions were corrected after spending a month working at the Changsha Tumor Hospital in the capital city of Hunan Province. The Department of Anesthesiology, Perioperative Medicine and Pain Management at the University of Miami has an ongoing exchange program with this hospital through which several residents can spend time in Changsha every year. A grant from the hospital and Chinese Government to Dr Keith Candiotti helps support the program. Several faculty from Changsha have also had the opportunity to visit the University of Miami as observers. This 10,000-mile exchange between our institutions continues to be a fruitful learning experience both culturally and medically for both parties (Figure 1).
The Changsha Tumor Hospital houses an inpatient unit with eight beds solely reserved for chronic pain admissions. This ward is unique in that most Western hospitals do not have units exclusively for chronic pain patients. Soon after the hospital opened this service, the unit reached a 100% capacity and has remained full. Although the primary population is admitted for cancer-related pain, the long waiting line for a bed includes patients with an assortment of chronic pain conditions. This demand is representative of the unmet needs existing in the region. The high population density also affects wait times, as witnessed in their anesthesiology preoperative clinic, which routinely sees 80 patients per day.
This intensive inpatient experience is structured to expedite pain relief with a goal of discharging the patients home on a stable pain medication regimen. After discharge, frequent phone calls to the patient are personally performed by the physician to adjust the home regimen as needed. Daily rounds by an attending anesthesiologist with expertise in pain are supplemented by 24/7 nursing care and an additional anesthesiologist assigned to the chronic pain unit to implement the plan of care throughout the day. Surgical, interventional, and pharmacologic treatments are used to treat patients while they remain hospitalized. A variety of pain interventions are often performed; with many blocks placed anatomically, however, sonography and fluoroscopy are also used. More advanced techniques, including neurolytic celiac plexus blocks and implantation of intrathecal drug delivery devices, are also performed. While many of these techniques have been learned from sending physicians abroad and visiting international physicians, others have been self-taught through the modern widespread availability of information.
Intravenous sufentanil patient-controlled analgesia (PCA) is often administered to patients on admission to the unit and is commonly used in this region for postoperative analgesia.1 This selection over the frequent use of hydromorphone PCAs in the United States can be attributed to the variations in global opioid market availability and pricing.2 Unlike many of their Western counterparts, Chinese pain physicians’ scope of practice includes parenteral nutrition, line placement, bowel regimens, chest tube management, and even intrapleural chemotherapeutic administration. The incentive and availability to routinely consult other specialties for every issue do not exist. The average length of stay for a chronic pain admission is typically less than 1 week.
The cultural perception of pain in China is heavily influenced by Stoicism, Buddhism, Confucianism, and socioeconomic status.3 This perception of pain can be a barrier to receiving adequate pain treatments. There exists a common theme that pain is meant to be endured, and the patient may not report symptoms until the pain has become severe. Buddhist and Confucian principles share the belief that pain is an essential element of life.4 Stoicism is displayed in that many patients will endure pain without vocalizing symptoms through groaning or displaying pain-associated body language. Expressing pain may be viewed by the patient as complaining to a doctor who should not be bothered. This notion causes chronic pain to often remain undiagnosed until it has taken a visible toll on patients, both psychologically and physically. Similar observations are seen in the reverse situation when many Chinese immigrants are treated at clinics in the United States. An additional challenge in this scenario may be a language barrier and the infrequent availability of Mandarin translation services outside of China. The growth of electronic translation services has bridged this gap and provided a readily accessible tool to all physicians encountering this scenario for nearly every known language.
As many would expect, there are a number of stark differences between the health care systems in the United States and China, but several similarities exist. At an initial 3-year cost of $125 billion starting in 2009, China launched the first stage of its plan to achieve universal health coverage by 2020.5 Patients are still responsible for at least half of the expense, which can be supplemented with the provision of additional private health care insurance. Although government assistance exists for severe events, these costs can be staggering in cases of catastrophic illness. While the US system is not based on universal health care, the Affordable Care Act in 2010 widely broadened health insurance coverage.6 Access to health care is inadequate in rural areas in both countries, while a higher concentration of hospitals exists in urban settings. The 2016 gross domestic product health expenditure percentage in the United States was 17.1%, while in China, it was 5.6%.7 As experiences shape practice, our ongoing affiliation with the Changsha Tumor Hospital continues to be an invaluable lesson in Chinese medicine and culture.
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4. Chen L-M, Miaskowski C, Dodd M, Pantilat S. Concepts within the Chinese culture that influence the cancer pain experience. Cancer Nurs. 2008;31(2):103–108.
5. Yip WC-M, Hsiao WC, Chen W, Hu S, Ma J, Maynard A. Early appraisal of China’s huge and complex health-care reforms. Lancet. 2012;379(9818):833–842.
6. Daemmrich A, Mohanty A. Healthcare reform in the United States and China: pharmaceutical market implications. J Pharm Policy Pract. 2014;7(1):9.
7. World Health Organization. Global health expenditure database. 2016. Available at: http://gamapserver.who.int/gho/interactive_charts/health_financing/atlas. html. Accessed December 6, 2016.
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