Journal of Pain & Palliative Care Pharmacotherapy

ISSN: 1536-0288 (Print) 1536-0539 (Online) Journal homepage: www.tandfonline.com/journals/ippc20

Pain Relief in Thailand

Meg Spencer (Post Graduate Diploma of Advanced Nursing-Candidate)

To cite this article: Meg Spencer (Post Graduate Diploma of Advanced Nursing-Candidate)
(2004) Pain Relief in Thailand, Journal of Pain & Palliative Care Pharmacotherapy, 17:3-4, 53-61,
DOI: 10.1080/J354v17n03_07

To link to this article: https://doi.org/10.1080/J354v17n03_07

Published online: 17 Aug 2009.

Submit your article to this journal

Article views: 61

View related articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=ippc20
 Pain Relief in Thailand
Meg Spencer

SUMMARY. Pain is a complex problem, for both those who are endur-
ing it and those trying to relieve it. Most people in the developed world
have access to adequate treatment and management of pain, the avail-
ability of trained and educated doctors and nurses, feasible opioid pre-
scribing policies, as well as ready access to appropriate medication.
Often, this is not the case in developing countries such as Thailand. This
paper is based on recent experience in the southeast of Thailand provid-
ing pain relief for persons with HIV and AIDS in Rayong Province at the
Camillian Social Centre. The severity and frequency of pain endured by
this group of individuals presented a daily challenge. Problems encoun-
tered in providing pain relief for these patients and some potential solu-
tions are described. There is a lack of literature on pain relief in Thailand.
[Article copies available for a fee from The Haworth Document Delivery Ser-
vice: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com>
Website: <http://www.HaworthPress.com>  2003 by The Haworth Press, Inc.
All rights reserved.]

KEYWORDS. Pain relief, opioid prescribing policies, HIV and AIDS

Meg Spencer, BN, is Post Graduate Diploma of Advanced Nursing-Candidate,

Gandarra Palliative Care Unit, Ballarat, Australia.
Address correspondence to: Meg Spencer, 102 Ascot Street South, Ballarat, Victo-
ria, 3350, Australia (E-mail: megs@bhs.grampianshealth.org.au).
The author acknowledges the Camillian Social Centre for providing the opportunity
to learn and work with them, the IAHPC for assisting with the funding, her colleagues
Karen Davies and Marita Ryan for motivation and support to start and finish this paper,
and Dr. M. R. Rajagopal for his encouragement.
[Haworth co-indexing entry note]: “Pain Relief in Thailand.” Spencer, Meg. Co-published simulta-
neously in Journal of Pain and Palliative Care Pharmacotherapy (The Haworth Medical Press, an imprint of
The Haworth Press, Inc.) Vol. 17, No. 3/4, 2003, pp. 53-61; and: Pain and Palliative Care in the Developing
World and Marginalized Populations: A Global Challenge (ed: M. R. Rajagopal, David Mazza, and Arthur G.
Lipman) The Haworth Medical Press, an imprint of The Haworth Press, Inc., 2003, pp. 53-61. Single or multiple
copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH,
9:00 a.m. - 5:00 p.m. (EST). E-mail address: docdelivery@haworthpress.com].

http://www.haworthpress.com/store/product.asp?sku=J354
 2003 by The Haworth Press, Inc. All rights reserved.
10.1300/J354v17n03_07 53
54 PAIN AND PALLIATIVE CARE IN THE DEVELOPING WORLD

Thailand has an estimated population of 62 million that is growing at a rate

of 1-1.5% per year. In the past, Thailand was a major source of opioids for the
international market, but this is no longer the case. In 1999 the number of peo-
ple in Thailand who died as a result of AIDS was almost 66,000 and the num-
ber living with HIV was 755,000. In 1984, HIV was identified in Thailand
initially in intravenous drug users and prostitutes. The rate of infection esca-
lated quickly and peaked in the early 1990s.
Thailand has been an example to the rest of the world for its effective na-
tional AIDS prevention program that has prevented an estimated 200,000 peo-
ple from becoming infected with HIV since 1993.1

THE CAMILLIAN SOCIAL CENTRE

The Camillian Social Centre is located in Rayong Province in the eastern re-
gion of Thailand. This region of Thailand has the largest population of people
with HIV and AIDS in the eastern part of the nation and the third highest in the
country. The center was opened in 1996 to care for the rapidly increasing num-
bers of people living with HIV and AIDS.2 It is run by the Camillian order of
the Roman Catholic church. The Camillian Social Centre cares for people of
all ages, regardless of race, religion or creed. The average age of the adults liv-
ing in the center ranges from 20 to 40 years of age. The center also cares for
children, many of whom are orphaned because of HIV and AIDS. The age
range of these children at the time was three to 15 years of age. Of the 24 chil-
dren, 19 were HIV positive.
The center accommodates up to 80 people, excluding the fluctuating num-
ber of volunteers (mostly foreign), and the small number of resident Camillian
clergy. Two public hospitals are located within 10 kilometers of the center to
which patients are referred regularly for assessment and treatment. Patients are
usually referred to the center by word of mouth or by social workers within the
hospitals. The work done at the center for people living with HIV and AIDS is
to be commended. Without places such as the Camillian Social Centre, many
patients would suffer intolerable physical and psychological hardship as a re-
sult of their disease.
The center describes their main objectives as:

• To educate the community about HIV and AIDS, and provide them with
skills to communicate, care for and support patients with HIV and AIDS.
• To provide treatment, symptom management, care and support to people
with HIV and AIDS, within the eastern provinces of Thailand.
• To care for children with HIV and AIDS by providing them with medical
treatment and education, as well as providing support to those who are
orphans as a result of HIV and AIDS.
 Meg Spencer 55

• To provide a counselling service for HIV and AIDS patients via a ‘Net-
work,’ and to liase with NGOs in the region and throughout the country.2

Facing the Challenges

Residents of the center and those who help care for them face many chal-
lenges every day. In addition to the social isolation and negative attitudes that
unfortunately accompany a disease such as HIV/AIDS, this group of patients
and similar patients in the community have to endure unrelieved pain. Multi-
dimensional barriers to adequate pain relief pose major challenges to those
who try to care for these people. These challenges included difficulty in pro-
viding adequate pain relief utilising the mild analgesics available to the center;
gaining access to opioids such as morphine; difficulties in the delivery of
parenteral medications; obtaining adequate medical support in assessment and
treatment of the pain; and enduring the daily challenge of prejudice towards
this group of individuals because of their diagnosis.

• Providing good pain relief utilising the mild analgesics available at the
centre and gaining access to opioids such as morphine

The source of discomfort for the majority of the patients was abdominal
pain. The strongest analgesic available to the center was Tramadol (oral and
parenteral). More often than not the drug was relatively ineffective, even when
used in conjunction with adjuvants. This was primarily due to the severity of
the pain and the limitations of the strength of medication.
As the center is not a hospital, it is not legally able to be supplied, stock or
administer opioids, under Thailand’s strict policies governing drug adminis-
tration. Tramadol is therefore currently the center’s only analgesic option.
Since the 1980s the Thai government has been uncompromising in its staunch
condemnation of drug trafficking which is reflective in their national drug pol-
icies. This has had reasonably positive effects in reducing illegal drug use and
abuse within the country. Concurrently there have been major implications for
the general patient population who require pain relief from drugs such as mor-
phine. The government’s anti-drug stance has seen the general community di-
rected towards a narrow and biased awareness and understanding of opioids
and their medical use. In addition the country’s medical practitioners appear to
have limited their prescribing of opioids because of justifiable fears of legal re-
percussions. I was unable to find any guidelines or legislation for the prescrib-
ing of opioids in Thailand but was pleased to find that in the early 1990s many
of these issues were beginning to be highlighted with many positive inroads
being made.
56 PAIN AND PALLIATIVE CARE IN THE DEVELOPING WORLD

Chaudakshetrin (1993) discussed cancer pain relief and identified four ma-
jor impediments to cancer pain management in Thailand. The first was the lack
of education given to doctors or patients in cancer pain management and the
supportive resources that accompany such education. This point identifies the
issue that education regarding pain relief for nurses or other health care profes-
sionals is not a priority or perhaps required. The second was the impact the
strict national drug legislation and the public’s attitudes have had on the medi-
cal use of opioids, as a result of Thailand’s fight against illegal drug trafficking.
The third impediment outlined was medical practitioners fears surrounding
opioid addiction and its side effects. Lastly was the problem of access to
opioids.3 Chaudakshetrin states that Thailand’s total national annual estimated
requirement of morphine in 1990 was 15 kilograms, but only five kilograms
was utilised for medical purposes, presumably due to the impediments men-
tioned. At that time a Thai public hospital could access 200 grams of morphine
annually, which was increased to 400 g in 1993. Private hospitals could access
only 20 g, which again increased in 1993 to 40 g. Delays in supply from the
pharmacy was also identified as a problem in large public hospitals.3 Joranson4
continues along the same vein by stating that in 1991, 86% of the world’s mor-
phine was consumed by the top 20 developed countries. The remaining 14%
was consumed by around 100 other countries which the majority of the
world’s population occupies. Joranson also identifies that awareness has in-
creased from international health and drug regulatory authorities towards a
recognition that opioid analgesics are not available in appropriate quantities in
many places throughout the world for their primary use, that of pain relief.3
The International Narcotics Control Board (INCB), responsible for the regula-
tion of global production and distribution of opioids, has recommended to all
countries to take action to ensure opioids are available for the relief of pain.4
The 2001 report of the INCB reaffirms this stance by stating that international
drug control treaties ‘support the advancement of science and the reduction of
human suffering.’ They emphasize this further by urging that drugs must be
made available to relieve pain and that an enquiry into the use of drugs to re-
lieve suffering is crucial.5 From 1984-1991 Thailand’s consumption of mor-
phine increased by 33%, raising the actual national consumption by 1 kilogram.4
Hopefully this increase resulted from increased awareness and education on
the medical use of morphine from both a governmental and health care profes-
sional perspective.
The rigid drug policy employed in Thailand restricts doctors and nurses in
their ability to prescribe and utilise opioids, including those doctors with ade-
quate education and training and a willingness to use these drugs appropri-
ately. Chaudakshetrin did, however, shed some positive light on the situation
in Thailand. Progress was beginning to be made in the form of increased edu-
cation and training for doctors and nurses with support from organisations
 Meg Spencer 57

such as the World Health Organisation (WHO), and the International Associa-
tion for the Study of Pain (IASP). In 1990 the Thai National Chapter of the
IASP was formed, with aims to improve the attitudes, knowledge and practices
of health professionals in the treatment of pain. In 1992 the IASP chapter, with
sponsorship from WHO and the Ministry of Public Health, conducted a na-
tional workshop in Thailand which acknowledged problems in cancer pain
management and promoted the WHO method of controlling cancer pain. Fol-
lowing this, participants issued a consensus recommendation that education
and training in cancer pain management was needed, urging a review of the na-
tional legislation regarding drug use for medical purposes including specific
guidelines on the use of narcotics for cancer pain, with urgent consideration of
forming a national policy for cancer pain management.3 We must be hopeful
that individuals and supporting organisations are able to continue their work to
improve cancer pain management, and trust that this may have an overflow ef-
fect for the benefit of other patient groups such as those with HIV and AIDS.
Having a diagnosis of cancer is one thing, having a diagnosis of HIV or AIDS
is another. Developed and developing countries share a common problem in
that health care professionals interested in the area of pain management will
involve themselves in the education and training, but will not necessarily be
easily accessible by patients who need them.

DIFFICULTIES IN THE DELIVERY

OF PARENTERAL MEDICATIONS

Adequate pain relief in these particular circumstances was further com-

pounded for those patients at the center who required parenteral administration
of medications, either due to problems with nausea and vomiting or in the ter-
minal phase of illness where the patients’ conscious level was compromised
and oral administration was no longer possible. Parenteral administration of
medications is an issue at the center that is staffed mainly by non-medical vol-
unteers. Two days a week a visiting nurse attends the center and one day a
month a doctor from Medicins Sans Frontiers visits. Many of the HIV patients
themselves also assist the volunteers in providing hands-on-care to patients.
The issue of the administration of parenteral medications is two fold. If there
were no legal constraints to non-medical volunteers administering parenteral
medications these patients could have access to such care. Nevertheless, these
volunteers would still need education and training on pain assessment, man-
agement and pharmacology to ensure that they possess the skills and knowl-
edge to provide appropriate care. Of course, the next dilemma is who would
and could provide this teaching to them, as education and training to health
care professionals is already limited. Also at what financial cost would this be?
Cost is a realistic concern for charity organizations such as the Camillian So-
58 PAIN AND PALLIATIVE CARE IN THE DEVELOPING WORLD

cial Centre and developing countries in general. Governmental and/or interna-

tional assistance would be required to enable the center to provide this
education. The center’s optimistic hope for the future is to employ a full time
nurse to provide patients with consistent access to a qualified health care pro-
fessional. This trained nurse would support the volunteers and perhaps provide
basic education and training. This would directly aid those patients in need of
parenteral medications and reduce the number of patients requiring transfers to
the local hospitals for minor procedures such as the insertion of an indwelling
urinary catheter. However the center is very aware that being financially able
to employ a full time nurse, and the recruitment of an appropriate nurse, are
quite difficult issues. There is still a considerable stigma surrounding both HIV
and AIDS within Thai culture as in many places worldwide. It will not be an
easy task for the center to attract a nurse with appropriate skills and knowledge
as well as an empathy, understanding and a willingness to care for HIV and
AIDS patients on a regular basis.

ENDURING THE CHALLENGE OF PREJUDICE TOWARDS

PEOPLE WITH HIV AND AIDS

Negative attitudes towards these patients and even towards those who care
for them became apparent to me personally when a nearby hairdresser refused
to cut my hair. This attitude came through repeatedly in the stories from pa-
tients within the center. Many patients had families but when the family mem-
bers visited they introduced themselves as friends. One little boy who lived in
the center had both parents die of AIDS, but he did have close ties with his aunt
and uncle who visited weekly. They were unable to care for the boy in their
own home; they were afraid that if people found out that the child was HIV
positive they would not buy jewelry from their store, and their very livelihood
would collapse.
Another young girl who came to the center had also been orphaned as a re-
sult of AIDS. She was relieved to come and live at the center because she knew
her aunt, who had been caring for her, was concerned about the possible health
risks her niece posed to her 15 month old cousin. This young girl was also un-
able to and did not want to attend school because she had no friends and was re-
peatedly teased because she had HIV. Within moments of her arrival she was
accepted into the center’s community and was immediately invited to play. Al-
though these children were quite young, there seemed to be an unspoken un-
derstanding about how the general community felt about them. Thankfully
there were members of the wider community who did offer their varied ser-
vices to the center and visited regularly.
The center provides an education program that is aimed at particular groups
within the community, for example factory workers. The largest professional
 Meg Spencer 59

group infected with HIV is young employees, 25-29 yrs of age, and factory
workers.2 The participants are invited to the center for a two day course that
explores and discusses the transmission and prevention of HIV and AIDS and
explains the work of the center. Participants are given a guided tour of the cen-
ter, which concludes at the nine bed Palliative Care Unit. This education pro-
gram provides an opportunity for all community members to become more
aware of HIV and AIDS and brings them face to face with members of their
own community living and dying with these conditions.

MEDICAL ASSESSMENT DIAGNOSIS AND TREATMENT

TO DETERMINE THE PAIN SOURCE

Another hurdle in the management and acceptance of this group of people

was an appropriate medical assessment and diagnosis of the individual’s pain.
Patients of the center with pain management problems or other difficult physi-
cal symptoms often required medical assessment at one of the two local hospi-
tals. More often than not the patients were not adequately assessed or treated
and were returned to the center with no change to their medications and with
no improvement in their pain or other medical conditions. Verbal reports from
patients indicated that quality of care and thoroughness of assessment de-
pended on the attitude of the individual medical staff assessing them. Many pa-
tients returned to the center exhausted and suffering more pain from the
journey to and from the hospital, with no apparent review of their medications
and with no plan for further investigations.
Many of the patients reported being told by the doctors that they had HIV or
AIDS and nothing could or would be done for them. Apart from the emotional
distress that this caused them it certainly didn’t help with their pain manage-
ment. Just after being told this sort of news in this way, one patient began deny-
ing his pain even though his physical distress was apparent to all; as a result his
pain management was further complicated. Possible reasons for this lack of
management may include insufficient staff training and education in the area
of pain management, unwillingness to use opioids due to the strict guidelines
of the national drug legislation in Thailand, fears of addiction and possible se-
rious side effects of morphine use and professional and personal beliefs sur-
rounding medical treatment to patients with HIV and AIDS. There were
instances where doctors within these hospitals did more adequately assess pa-
tients from the center without prejudice and attempted to manage the patients’
pain with various combinations of medications. Despite this, opioids such as
morphine were unfortunately not prescribed. I could not comment either way
as to whether the patients’ diagnosis had any implications on the doctors deci-
sion not to prescribe opioids. Although I think it is safe to presume that many
60 PAIN AND PALLIATIVE CARE IN THE DEVELOPING WORLD

of the reasons identified by Chaudakshetrin in 1993 and discussed within this

paper are still current in 2002.
The point must be made here that time and again, both developed and devel-
oping countries make the mistake of considering that these are predominantly
medical problems or concerns. All of the issues discussed in this paper must be
seen as shared responsibilities and specifically within the health care sector,
this encompasses both medical and nursing. For any headway to be made to-
wards the resolution of the numerous barriers to pain relief anywhere in the
world, health care professionals must be united in this cause and communicate,
share information and knowledge and respect each discipline’s role in the pro-
vision of pain relief. Certainly from my own practice, providing pain relief
would be an arduous task without medical input and I think I am safe to pre-
sume that the doctors would face the same daunting task without nursing input.
By input I don’t just mean the actual prescribing and administration of analge-
sics; it entails shared assessment, knowledge, experience and support. As a
friend and colleague once said to me ‘In this task of pain relief, we as care-
givers experience many of the same doubts, fears and degree of suffering that
patients do–Will they/we control the pain? Will this work? What will they/we
do if this doesn’t work?’ I am sure these feelings are familiar to many who
work in this area of care.

CONCLUSION AND RECOMMENDATIONS

In conclusion, issues surrounding adequate pain relief for patients in a

country such as Thailand are multifaceted, and appear even more complex
when the pain relief is for people suffering with HIV and AIDS. Although
there have been considerable attempts to improve the situation by determined
individuals and international organisations, at this stage the focus of these ad-
vances seems to be limited to cancer pain. However, with the growing under-
standing and acceptance of the medical use of opioids in the management of
cancer pain, there is hope that the need for appropriate pain relief for HIV and
AIDS pain is not far off the horizon.
My intention has not been to suggest that pharmacological formulations are
the only ingredients required to relieve pain. I am all too aware that pain not
only affects us physically but psychologically and spiritually. As an experi-
enced nurse, I have first hand experience that good basic nursing care and
nonpharmacological interventions are also necessary in the relief of pain; how-
ever, alone they are not always the answer. As mentioned previously, a unified
focus is required to improve the relief of pain and no one discipline can accom-
plish this alone nor should it have to endure this burden of responsibility.
 Meg Spencer 61

For the plight of HIV positive patients and patients with AIDS to be signifi-
cantly improved, there needs to be a recognition and commitment at a govern-
mental level that pain relief for these individuals is a genuine concern and
priority. Discussions of issues surrounding the medical use of opioids such as
morphine need to be continually reignited to raise awareness of this issue. The
aim of these discussions must insist on considered, achievable goals and reso-
lutions towards improving the situation for patients and health professionals.
This of course will require a commitment from all involved in this work to un-
derstand, face and assist in the deconstruction of the economic, geographical,
attitudinal and cultural barriers involved in these issues. Key decision makers
must be provided with sound and current information and knowledge to enable
them to make appropriate recommendations that ultimately impact on so many
people’s lives in developing countries who experience pain on a daily basis.
Myths about HIV and AIDS and society’s negative and discriminatory atti-
tudes towards people living and dying with HIV and AIDS must be dispelled
so that those affected can be cared for surrounded by their own community and
be able to access appropriate pain relief to help ease their suffering. It is crucial
that a focus on prevention of diseases like HIV is highlighted, as this preven-
tion is of equal importance. Thailand’s nationwide campaign to reduce the
transmission of HIV has been a success. This campaign should not lose mo-
mentum and must be combined with palliative care initiatives.

REFERENCES

1. Avert.Org. AIDS in Thailand. 2002. Available at http://www.avert.org/aidsthai.

htm. Accessed September 25, 2002.
2. Camillian Social Centre. A Project on Home for Orphans Children with AIDS,
Rayong Province Thailand, Camillian Social Centre Rayong, 2002.
3. Chaudakshetrin, P. Thailand: Status of Cancer Pain and Palliative Care. J Pain
Symptom Manage. 1993;8(6): 434-436.
4. Joranson, D.E. Availability of Opioids for Cancer Pain: Recent Trends, Assess-
ment of System Barriers. New World Health Organization Guidelines, and the Risk of
Diversion. Journal of Pain and Symptom Management, 1993:8(6): 353-360.
5. International Narcotics Control Board. Report of the International Narcotics
Control Board for 2001. 2001. Available at http://www.incb.org/e/ar/2001/menu.htm.
Accessed September 20, 2002.