PainEDU interviews Kathleen Talamayan MD, MPH, a medical doctor and public health researcher interested in international health, health policy and administration. Her focus on developing countries led her to pursue an MPH at the University of the Philippines where she was a distinguished Presidential Leadership scholar. Prior to working in the U.S. she served as a research and policy consultant in Manila. Currently, she is collaborating on health research projects with the University of Texas Health Science Center and at Children's Hospital Boston-Harvard Medical School. She discusses pain management practice in the Philippines, including both western and traditional modalities.

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Questions

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Evelyn:

In 2001 the Joint Commission on Accreditation of Healthcare Organizations(JCAHO ) required U.S. hospitals to implement new standards for measuring patient pain and providing proper pain relief. Is there a similar standard-setting body in the Philippines, or have there been recent changes in the approach to patients with pain?

Kathleen Talamayan MD, MPH: There is no equivalent of the JCAHO in the Philippines. According to Dr. Laudico, the former president of the Philippine College of Surgeons, the organization is trying to come up with a Postoperative Pain Management Standard. In doing so, the organization is lobbying to remove the overly restrictive laws and regulations on strong opioid prescription and utilization. This has been found to be one of the major barriers to good pain management in the Philippines.

EC: What is the educational process for pain assessment and pain treatment in medical schools in the Philippines? Is the topic integrated into their course work or are there specific courses on pain?

KT: Some medical schools, such as the University of the Philippines, include a hospice rotation for medical students and residents and have a palliative medicine fellowship. Other schools integrate pain management in the anesthesia rotation (which is an elective clerkship rotation). With regards to continuing medical education in the Philippines on pain, lectures and seminars are conducted by individual doctors and these are often sponsored by pharmaceutical companies. The Pain Society of the Philippines offers CME courses and conferences but these are only voluntary.

EC: Are there unique social or cultural influences that we should know about to understand how physicians approach patients with pain in the Philippines?

KT: The Filipino disposition and outlook towards pain is sometimes fatalistic and guided by conservative traditional and religious beliefs. They see pain as a natural accompaniment of disease. They are also complacent to the presence of pain. And, since most indigent patients in the Philippines cannot afford to seek medical consult and hospitalization, they tend to tolerate and bear the pain as much as they can. This is very important for physicians to understand especially in evaluating the severity of the pain in the patient.

Pain management in the Philippines encompasses an integrated approach of both western and traditional medicine. Western medicine adheres to the WHO’s ‘top-to-bottom’ approach of pain management, which utilizes both the 2-step analgesic ladder of pain control and the 3-step ladder of pain control. Traditional medicine approaches include acupuncture, acupressure, aromatherapy, massage therapy and use of herbal medicine.

EC: In addition to the physician, what other health care providers treat patients with pain, and how do they collaborate?

KT: Most indigent patients who cannot afford medical consult usually seek treatment for pain from their local traditional healers or ‘hilots’ whose methods are often incongruent with western medicine. The training of traditional healers is dependent on the type of traditional healing they practice. Mainly they can be broken into four categories: healers who inherit the gift through generations of ancestors who have also been healers; healers who learn the practice by apprenticing with current traditional healers; healers who are formally trained in a school setting such as acupuncturists and massage therapists; and healers who are trained by the government, such as traditional birthing assistants.

Although the conventional western medical system is slow to accept non-evidence based practices and philosophies offered by traditional healers, there is a strong subculture that accepts and performs the practices themselves. Many practices such as acupuncture and herbal pharmacology are working their way into the mainstream as scientific research increasingly shows the benefits and efficacy of these modalities. Hospitals and some clinics have been opening “traditional healing departments” which offer various types of traditional care, but more likely than not, the healer co-manages the patient with a licensed physician. However, the lack of a defined accreditation board and standards also causes problems for the acceptance of traditional practitioners.

EC: How are hilots (traditional healers) viewed by the local people? Are they viewed differently than western practitioners?

KT: The reaction of the people varies as much as the types of modalities available. Within the same community you will find individuals who trust the healers more and others who trust the conventional practitioner more. This is often based on past success in treatment, acceptance by the family (what they grew up with), and collective community beliefs. It can be observed that the rural communities are much more likely to trust the traditional healer than the urban communities. This is partially due to access to traditional care in rural settings and to the long standing history of the healers within the rural community. When asked how long the traditional modalities have been practiced in the community it is common to hear the response, "from the beginning of time". It is easy to see why the healer would be trusted more in this type of community. Individuals who have more exposure to the traditional practices and seek this care out of necessity (e.g. they cannot afford conventional care, or do not have a conventional practitioner available) are more likely to trust the traditional healer.

EC: In your opinion, what are the principal barriers to effective pain management in the Philippines?

KT: The Philippines is a developing country and its health care services are very much limited due to financial constraints and lack of resources among others. Thus, health resources are prioritized according to the immediate demands of the country. Unfortunately, pain management is not considered a priority health issue.

Barriers to optimal pain management in the Philippines include a number of factors, including inadequate staff knowledge on pain management and inadequate pain assessment. Moreover, there are excessive government regulations for prescribing analgesics. A physician must have an S2 license from the Dangerous Drugs Board that requires presentation of 3 different licenses issued by 3 different branches of the government before s/he can prescribe strong opioids. Regulatory bodies give a low priority to pain management, and medical staff are often reluctant to prescribe strong opioids. Patients often lack the financial capability to purchase pain medications, a problem which is compounded by frequent shortages in the medical supply of medications.