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Important questions about service delivery in chronic pain management


ResearchBlogging.org
In all the time I’ve worked in health, two things have always been certain: there is never enough funding to deliver all the services to everyone who needs them, and there is never a shortage of patients. Never.

It’s time to ask some important questions about how and why we deliver the services we do for people who have chronic pain.

Now, for those of you who don’t know, I live and work in Christchurch, New Zealand, so some of the things I’ll discuss may not apply to you – but underneath I think the problems I identify in New Zealand apply everywhere else in the world too.

My questions are: – why does it take so long for people to be referred for interdisciplinary pain management? Do people get interdisciplinary pain management when they finally get referred? What happens to people before they get referred? And how do we as a society get most bang for buck to help people with chronic pain?

For people on ACC (our national accident insurer), they will usually have had many assessments, many “low-intensity” programmes usually delivered by multidisciplinary groups (physiotherapy, clinical psychology, perhaps an occupational therapist), often related to functional goals such as returning to work, or improving fitness. Their rehabilitation may plentiful, but the outcomes seem pretty much the same – some people will manage to return to work, others will be assessed as capable of work but perhaps via functional capacity testing and an occupational physician’s assessment and eventually be removed from ACC, while others will carry on waiting for “something” to help.

For those not on ACC, the disparity between what they can access and what ACC clients can access is enormous. Essentially, in Christchurch, if you happen to be diagnosed with fibromyalgia by your GP, you will not be able to get in to the Pain Management Centre. There is nowhere else to go. Not a thing. Nada. Zip. Nothing.

Why does it take so long to get referred? It would be easy to point the finger at GP’s who fail to refer people early enough, and who carry on using a biomedical approach including repeated appointments for musculoskeletal injection procedures, or refer for orthopaedic or neurology investigations. And to a certain extent this is true – but so few people can be accepted into the local pain management centre, and who would know why some people are accepted and some are not? And, of course, the outcomes are pretty variable. People don’t stop having chronic pain, they don’t get “cured”, they don’t die, they don’t go away.

It’s probably far more useful to consider the health system which doesn’t recognise chronic pain as an entity and therefore fails to consider how thoroughly under-resourced the area is.

Do people get interdisciplinary pain management when they finally get referred? This is a rather vexed question. I’m going to quote from Gatchel, McGeary, McGeary & Lippe (2014): Multidisciplinary connotes the involvement of several health care providers (physician, psychologist, physical therapist, occupational therapist). However, the integration of their services, as well as communication among providers, may be limited because these individuals may not be located in the same facility. Even when various treatment providers are co-located, they may still be considered as providing multidisciplinary care if they pursue treatments with separate goals that do not take into account the contributions of other disciplines. Interdisciplinary care consists of greater coordination of services in a comprehensive program and frequent communication among health care professionals, all providing care “under one roof” at the same facility. The key ingredients for interdisciplinary care are a common philosophy of rehabilitation, constant daily communication among on-site health care professionals, and active patient involvement.

I’m sorry, but arguing that every patient must see the same combination of clinicians, who all have prescribed roles, is not the same as interdisciplinary teamwork. If one of the team members has greater clout, or deviates from the overall model (say, by offering repeated injections, medication changes, or reinforces pain as a guide), that is not interdisciplinary. Or if the person is referred, has a comprehensive assessment – but then receives exactly the same management programme as the next person – that also is not interdisciplinary pain management. Neither is giving just one modality.

I’ve written before about the need for an integrated formulation to explain how the various factors influence the individual’s presentation. I’m not sure this is being done very often.

What happens to people before they get to pain management? Probably they get sent on more investigations, get prescribed more drugs, get more injections, perhaps see a physiotherapist for exercise and “to get moving again”. Some people cope well, many do not. Remember this probably continues afterwards, so for those who never get seen by pain management centres, it just carries on. A futile, endless waste of resources with little or no positive outcome – except some people get paid.

Does it matter? Well, yes it does. If we want to provide effective healthcare, we do need to be evidence based. And so far, while not producing amazing effect sizes, interdisciplinary pain management is the most successful approach for people with chronic pain and disability.

Because in the end, it’s not the pain that is the major problem – it’s the disability and distress that is. And these do not get addressed by pills, potions or injections.

How do we get most bang for buck? Maybe it’s time to look to expanding interdisciplinary pain management beyond the clinic door and out into primary care, where the GP really needs help. There’s more than enough evidence.

Ehde, D., Dillworth, T., & Turner, J. (2014). Cognitive-behavioral therapy for individuals with chronic pain: Efficacy, innovations, and directions for research. American Psychologist, 69 (2), 153-166 DOI: 10.1037/a0035747

Gatchel, Robert J., McGeary, Donald D., McGeary, Cindy A., & Lippe, Ben. (2014). Interdisciplinary Chronic Pain Management: Past, Present, and Future. American Psychologist, 69(2), 119-130.

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14 comments

  1. Bronnie, your succinct analysis of the NZ situation is most timely. I don’t think the situation in Australia is any better for those with persistent pain. That in the USA is nothing short of calamitous. Our Australian Government is now threatening to dismantle the only community-based health care system (Medicare Locals) that has the potential to deliver much-needed pain education to consumers and health professionals alike. Are we to be voices in the wilderness? A positive answer to this question seems unavoidable.

    1. I know, it’s depressing! And the thing is, there will be more people living with chronic pain as we become an aging population. I don’t understand why it’s so difficult for health funders and policy makers to see the value in chronic pain management services. It’s not like we have other options, and we’ve never run out of patients!

  2. Supplementary comment in the form of a question: why are people in pain who live in Christchurch and have attracted the label Fibromyalgia subject to such discriminative practice by your Pain Management Centre?

    1. It’s all people with “common” chronic pain conditions, diagnosed by their GP, who can’t be seen by the service because of limited capacity. If they’ve made their way to a “specialist” they get a higher acuity rating, although I’d suggest they’ve just learned to use the health system more effectively. Basically, if the person isn’t on ACC, and has common-or-garden chronic pain (ie not CRPS, or neuropathic pain of any type), hasn’t been put on opioids, or is “just hanging on” they’re unlikely to be considered sufficiently unwell for PMC. It’s a numbers thing. Of course, it’s not helped by the majority of people being treated by three clinicians or more, and receiving 1:1 therapy for 12 weeks. Few groups, lots of injection procedures, and the only nonprocedural physician overworked.

      1. These are the very reasons that we commenced STEPS in Fremantle! This has still left a huge gap to be filled in the provision of community-based educational services.

        I think we agree that there is an enormous sum of health dollars that potentially could be saved by regulatory authorities actively discouraging unnecessary and irrational investigations and funding ineffective treatment practices.

        Investing this money in programmes of community education would relieve the pressure on tertiary pain treatment centres and make it possible for general practitioners to better manage their patients with persistent pain.

  3. I absolutely and totally agree John, and I think your approach is the sort of one we need to use here. Now for a vexing question – why is it, do you think, that doctors don’t like telling people that their pain is chronic, is not likely to change very much given the state of pharmaceutical development, and limited applicability of procedures? This might well be part of the reason our field is so poorly served by the health funders and policy makers.

    1. Difficult question! Realizing and coming to terms with our relative therapeutic impotence is never an easy process for those of us who choose to work in health care. Today I even wondered whether the well-publicised strategy of declaring chronic pain to be a disease “in its own right” might have provided more credibility and service provision for those who suffer persistent pain. Do you think that this strategy has had any influence upon decision makers in NZ?

  4. I’ve been pondering this both because diagnosis has emerged as an important social consideration in my PhD studies, and also because of the lack of funding/recognition of the problem of chronic pain. I think there is merit in declaring it to be a disease in its own right, although this has its own problems. The reason is that a diagnostic label “stands for” or represents social sanction – it has to be a whole lot more useful than the term fibromyalgia! Essentially a diagnostic label is a useful shorthand way of expressing a cluster of experiences and signs that can be recorded. Depression is another good one.
    Because it’s a social indicator, it might provide validation that (a) the experience is real, even though we can’t directly measure it (b) it is recognised and (c) the problems posed by it can be managed. It would allow policy-makers a convenient catch-all for all those “problem patients” who currently float around the health care system chewing up resources in a fruitless quest to “find out what’s wrong” when we currently have little in the way to identify what *is* wrong. It might allow clinicians to stop trying to “find out what’s wrong” and instead give people a positive label – as long as it’s combined with an effective public health campaign like the John Kirwan Depression one in NZ, or “Like minds, like mine” campaign.
    Thus far, though, I have seen absolutely NO sign that it has had any effect whatsoever. But that could be because I am low down in the echelons of power. Very low down indeed :)

    1. Bronnie, the question that has not been answered (at least as far as I am aware) is what agreed name will be attached to the new disease? Pain itself cannot be part of the diagnosis. This was the failing of the term Fibromyalgia when it was used as a diagnosis, as well as a symptom and a syndrome. The diagnosis depended upon a circular argument and was therefore tautological.

      By the way, in your dual roles as a researcher and an educator I believe you do have considerable power to influence those who are responsible for planning the health care of people in pain. But are they listening?

      1. I know it’s tautological, but it’s useful. We call depression “depression” – which is also tautological, and it works. There are a cluster of symptoms in depression, one of which is feeling depressed. We might call it “flat or low affect” but it typically means “feels depressed”! Similarly, there is little we can image in depression, no blood tests for diagnosis – instead, it’s all self report with corroboration from other people with regard to the impact of symptoms on behaviour. Does that sound familiar? I wonder what the harm would be in calling the problem “chronic pain”, or is there another term that has meaning to those who would be given the label, and those who give it?

  5. Bronnie, I honestly do not know the answer to your final questions.

    All I can say is that a label (diagnostic or otherwise) has to be useful. The analogy I use is to ask people how they would feel if none of the tins in their pantry bore a label. Their dog might not appreciate being feed baked beans and owner would also be disappointed if the can chosen for a meal contained dog food.

    Clinical depression (or major depressive disorder) is accepted as being a useful psychiatric label whereas fibromyalgia (a “common chronic pain condition”) has fallen foul of Cartesian “body/mind” dualism, thus becoming a stigmatizing diagnosis. Could this be yet another reason why their access to the pain clinic is being made so difficult?

    However, in my opinion a more likely reason is that Fibromyalgia is so complex and poorly understood by those who practice according to the traditional biomedical model that they have come to adopt an attitude of therapeutic nihilism.

    Of course, I may be missing your point!

    1. Not missing my point at all. You’re right, it needs to be useful – but to whom? No diagnosis is very helpful when it comes to the lived experience of a health problem, because diagnoses fail to explain how & why the illness & daily problems experienced by their own person develop & are maintained. This is why I prefer using a case formulation that incorporates biopsychosocial factors to generate hypotheses for the person’s problems. Then interventions target the various modifiable factors to produce change. Diagnoses play an important role in social validation & lumping like symptoms & signs together, but they don’t guide interventions except for medical ones.
      I’m curious that FM has garnered this negative image, I don’t think it has quite that reputation in NZ or perhaps that’s just because I don’t hear it.

  6. Bronnie, does your ACC recognize and compensate people who are given the FM diagnosis following traumatic incidents?

    1. To have cover under ACC you must have sustained “personal injury by accident” – all the terms are very carefully defined, so “personal injury” must equal physical signs of tissue damage (pain alone is insufficient), and accident is, by and large, “external force”.
      So if you are only experiencing pain – with the exception of low back pain/whiplash etc & don’t even get me started on the rationale for nonspecific low back pain’s inclusion – you won’t get cover.
      The way fibromyalgia attracts cover is when a person sustains personal injury, perhaps develops nonspecific low back pain, and this becomes widespread pain – in this case the person may continue to have cover, although they may not get much in the way of entitlements.
      There is very limited cover for exposure to traumatic events – I believe the only time you can is if you are, in the course of your normal work, exposed to trauma, eg if you are a train driver and witness a person being killed on the tracks, or you’re held up at gunpoint as a bank teller. I think this revision of the Act occurred after a police videographer successfully prosecuted the police after developing PTSD from repeatedly videoing and watching horrific crime scenes. Mental injury attracts very limited cover, and is extremely restrictive – sexual assault, or the results of criminal action. There is no cover for work-related “stress” apart from these very specific instances, so generally depression, anxiety and so on are not covered. Complicated? you bet!
      The argument behind this is that there are mental health services for individuals with mental health problems, so these should be used – of course, as for chronic pain, it’s very difficult to obtain treatment through the public health system, and to get mental health treatment requires quite a high level of disability.

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