It’s a long road to pain management


ResearchBlogging.org
In New Zealand there are three comprehensive pain management centres where interdisciplinary three week programmes for managing chronic pain are run. That’s not a lot for a country of 4 million or so. No wonder it takes many people a long, long time to get a referral to a pain management centre for their chronic pain. Now I wish I could tell you how long it takes, on average, to get to pain management, and I wish I could say how much it costs New Zealand in lost productivity, health care costs, sickness and invalid’s benefits – but sadly, we simply don’t have that information. And yes, there is a difference between people receiving ACC and those who are not – there is a very clear disparity of access between people who have had ‘an accident’ and those who have an ‘illness’.

This paper published in BMJ, states that in the UK there is ‘…only one pain management specialist for every 250 000 citizens, [therefore] only one in seven people with persistent pain ever sees a specialist.’ The author writes of her own experience living with chronic pancreatitis, and how she views the lengthy wait that people have to obtain pain management. As she puts it:

Coping with persistent pain effectively depends on patients understanding and managing their pain. And they need to begin at the start of their “patient journey” not at the end. People need a positive message: you can make a huge difference yourself and here are some of the ways you can do it.

It’s clear that the more patients learn about how to help themselves understand pain; accept and use positive thinking; develop relaxation skills, and learn ways to manage stress; regulate activitie levels; manage medication; and develop safe ways to stay active – the less they need to rely on an over-burdened health care system. Sadly, in New Zealand anyway, the focus remains on a medical approach within the health care system – leaving the ‘wellness’ and self management message to only those hardy souls who make it to a pain management centre.

It seems back-to-front to me. Why load people up with medications, procedures and investigations when these simple strategies have few, if any, negative side-effects, have no ongoing costs, and are good for healthy living anyway? I wonder whether it has something to do with the power and orientation of those who have money to allocate to health care spending. After all, the people who make the decisions in health care are typically doctors or nurses or maybe even administrators. People who like the idea of the hero who rescues the patient from the evils of ongoing pain. Maybe people who don’t want to admit that sometimes (actually quite often) pain persists.

There are both patient and health care barriers – taking this directly from the article
Patient barriers
Resistance to change
Generally pessimistic view of life
First language other than English
Income problems and/or “benefit trap” (where someone receives more income from benefits than they would from employment)
Strong expectation of a “cure” for pain
Disability other than the disability caused by the pain
Limited availability for pain management sessions—in terms of time, place, transport, and costs

And the health system obstacles…
Pain management sessions at the end of a patient journey rather than the start
Long wait between the diagnosis of the medical condition causing the pain and the referral for pain management
Long wait for the first “pain” appointment
Medical model rather than patient partnership model
Pain assessment tools administered by clinicians rather than the provision of tools for self assessment
Jargon—for example, “psychological techniques” rather than “ways to manage pain”
Lack of follow-up

The Minister of Health suggests that health care professionals interested in developing pain management services should lobby the District Health Boards to demonstrate need and savings by providing this kind of service. I’m not sure we’re ready for this – the numbers of people who have persistent pain and who could benefit from learning ways to manage pain are overwhelming. But wouldn’t it be great to do?

I finish with this quote, especially for any doctors who may be worried I’m suggesting they don’t have a place in pain management…

A patient centred approach doesn’t undermine the clinical route. Diagnosis is still crucial, and specific treatments can still make a difference. But working in partnership right from the start with patients who take control of their own care makes things easier for clinical staff too. Then by the time a patient sees a pain consultant he or she will be informed and involved and may have more realistic expectations—especially if a “cure” may not be possible.

Ray, M., & Hester, J. (2009). Persistent pain BMJ, 339 (jul24 1) DOI: 10.1136/bmj.b2786

3 comments

  1. Many difficulties are due to the McNamara fallacy …….http://en.wikipedia.org/wiki/McNamara_fallacy
    Biomedicine makes sense , is brilliant at some things but in our culture there is too much of it ….Too much reliance on ‘it’ for things it cannot influence or has limited capacity to deal with…….
    If 8 out of 10 people have things that can’t directly be influenced by biomedicine why use this paradigm for everyone ? This is the situation in much of contemporary musculoskeletal pain wherever I have worked …..
    However, I do think that ‘science’ is not enough …….Consideration of culture , philosophy , ‘meaning’ , spirituality and suffering are all in the melting pot –see David Morris ! http://www.ucpress.edu/books/pages/8218.php

    I think we all should aim for a patient centred approach ……

    ian

    1. It’s really all about using the appropriate approach at the right time for the right reason and to achieve a specific purpose.
      The science part for me comes in when, after taking into account cultural/spiritual/social factors, we study the outcomes. If there is a demonstrable improvement in outcomes when considering these things, then that’s great – that’s also science. If it’s not measured, it won’t be done, if it’s not measured it’s not scientific. And yes, ‘intangibles’ like quality of life and being respected etc can be measured, but no-one said it would be easy.
      Thanks for the links, they’re great!

  2. Even though complaints from chronic pain patients are easier to diagnose and document we now have created a situation where doctors are under-prescribing out of fear, especially if their patient are in their last stages of life because the docs can be charged with murder if autopsies shows high traces of pain medication, this indicated findrxonline in article. I pray this madness comes to an end and I sincerely hope none of you will ever be dying in extreme pain in a hospital, nursing home or maybe at your own house while the doctor is afraid to give you that prescription or injection during your last moments. Yes, definitely keep this medication away from kids but do make it available to those who can benefit from it!

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