Pain Management Programmes: Guidelines

I was wandering through the internet as I do, and came across several resources that might be useful if you’re thinking about what goes into a pain management programme.

They’re not very detailed in terms of the disciplines involved, or even the contents of a programme (such as relaxation, fitness, diet, information on chronic pain) because at the moment the literature is not clear on the necessary and sufficient components for a cognitive behavioural approach to pain management.  So it’s a bit like a ‘black box’ – all the goodies go in, and provided that the general principles are there, programmes can be said to be ‘working’.

That’s not especially helpful if you’re just starting out, or want to review what you have in your programme, so hence the guidelines that have been put together.

The first one, and the one I’ve found most useful, has been developed by the British Pain Society in 2007.  It’s a pdf document, and the link is here.

The Executive Summary would be a useful educational tool for managers within health care services who may not be entirely convinced that pain management programmes (with their need for resources!) should be provided.  Here are a couple of excerpts to give you a feel for what it’s saying:

Pain Management Progrmame are the treatment of choice for people with persistent pain which adversely affects their quality of life

There is good evidence for efficacy of cognitive behavioural pain management programmes as a package, compared with either no treatment or treatment as usual, in improving pain experience, mood, coping, negative outlook on pain, and activity levels (Morley et al., 1999; Guzmán et al., 2001; European Guidelines, 2004; Koes et al. 2006; Hoffman et al., 2007;

PMPs consist of education on pain physiology, pain psychology, healthy function and self-management of pain problems; and of guided practice on setting goals and working towards them, identifying and changing unhelpful beliefs and ways of thinking, relaxation, and changing habits which contribute to disability. Participants practise these skills in their home and other environments to become expert in their application and integration.

PMPs are delivered in a group format to normalise pain experience, to maximise possibilities of learning from other group members, and for economy.

There are chapters on the content of programmes, the team membership (although they don’t consider that occupational therapists should be a ‘required’ discipline – this probably reflects the quite different practice of occupational therapy in New Zealand compared with the UK), patient selection, integration of other treatment services, and a good list of both resources and references.

I was quite surprised at their suggestion that pain reduction treatment should be provided at the same time as the person participating in a pain management programme: our experience at Burwood Pain Management Centre over 20 years or so suggests that this doesn’t work well – but I bow to the research evidence that the authors of this guideline provide.

I was also surprised that even in the UK they recognise ‘There is an urgent need for high quality theoretical and practical training courses of various lengths and depths in the application of CBT to persistent pain problems’ – this is something I’m acutely aware of in New Zealand, and something I’m working hard to develop within the University of Otago postgraduate courses.

The Commission on Accreditation of Rehabilitation Facilities, or CARF, notes on pain management programmes are, by comparison, disappointing.  Of course what’s available free and online is nothing like the actual accreditation requirements which are extremely detailed and rigorous.  What you can read is a very brief paragraph within the Medical Programme Description ( link here).  If you go to the American Pain Society, there are several Guidelines for specific conditions (see here) but no detail without paying.  Not that US$20.00 is too much for comprehensive guidelines for, say, Fibromyalgia.

There is also a document called ‘Managed Care and Pain’, which says ‘Managed Care and Pain is designed to help pain specialists and managed care decision-makers with the complex task of developing quality pain programs and providing cost-effective pain care in the managed care environment.’ It’s US$30, and although I couldn’t find the contents list, could be a useful resource albeit North American.

I’ve talked about the Chris Main and Chris Spanswick book ‘Interdisciplinary Pain Management’ before – and the 2nd Edition, which takes a slightly broader view – and I’d recommend this if you were looking at some of the detail of how to set up an interdisciplinary service. It includes a service development plan, how to view ‘the patient journey’ (I really dislike that piece of jargon – let’s say instead ‘from referral through to outcome measurement’!), and includes a detailed discussion of different roles within a team.

Again, like most of these documents, occupational therapy gets little inclusion which is a shame because it’s an oversight that can be used by some purchasers to suggest that occupational therapists are nonessential. One of the reasons I think it’s important to obtain some local knowledge and discuss local skills rather than transplanting programmes from one context into another (for example, like the Mick Sullivan PGAP and PDP franchise) – doing this can unnecessarily restrict service provision, and doesn’t reflect the unique undergraduate and postgraduate education and practice of New Zealand professionals.

ACC has, of course, a good deal of expertise in establishing the service delivery specifications for pain management programmes. Their contracts tend to be heavy on minutiae, but light on practicality, and the links between various services are often unclear or nonexistant. It’s a shame that ACC and the Ministry of Health haven’t got their heads together with senior practitioners and academics across disciplines to prioritise pain management within the health system. I have heard it said that the Ministry of Health wants individual DHB’s to identify pain management as a priority – but with the current lack of information technology to support identifying the need for pain management, it’s hard to find out just how much poor pain management is costing the health system (is pain, whether acute or chronic even recorded as part of ICD10? I’m not sure – and I stand corrected if it is, but then I would wonder whether pain, chronic pain especially, is often identified on admission as a comorbidity).

So, information is available for developing pain management programmes, nothing especially startling for New Zealand providers (maybe that’s someone’s PhD or something the NZ Pain Society could put its collective mind to), but it’s available. Of course, networking and asking existing providers, especially those with an academic bent who have kept up with the literature could always be an option. And we do like visitors to Burwood Pain Management Centre!

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