I’ve been watching and listening to discussions about what is important in pain management over many years – the debate between reducing pain or improving function as the priority continues. Often it’s a divergence of opinion between the ‘interventionist’ medical team and the ‘self management’ therapy team – and it can lead to some mighty divisions that don’t seem to resolve. Of course, it’s not a simple one or the other… but over time the focus can and should change – when the emphasis should shift away from pain reduction is the multi-million-dollar question!
In this particular debate, the waters are very murky indeed because, as most of us know, given the possibility of removing or eliminating pain, patients (and yes, I include myself here!) would just love to at least try something that might ‘work’ – and in acute pain, usually it does.
Our problem is that as humans we all seem to have a tendency to maintain this focus on pain=bad-let’s-get-rid-of-it even when the pain is ongoing, the investigations time-consuming and tedious, and the interventions have minimal effect and it all gets in the way of living life. As humans we’re pretty good at overlooking the negative on the off-chance of a positive (think of our hardy gamblers!).
In the literature on chronic pain management, studies can focus on either pain reduction as the primary outcome (but fail to consider reduced distress, increased function, or any of the other psychosocial factors that might influence pain intensity), or on disability reduction. The problem is that even when a study looks at disability reduction, if it’s reported in the media – and pain reduction is included as one of the outcome measures – pain is the part that catches the attention! And it’s not only media, it can grab the attention of naive readers – and those with a purist set of assumptions about pain and disability such as the purely biomedical model. One medical practitioner told me that if the pain is abolished the person ‘reverts to normal’ and any psychosocial factors no longer count.
This view fails to recognise that people are not just their bodies. They’re not passive recipients of information. They live in a continuum of experience – past experiences, memories, expectations, attitudes – and future predictions, interpretations and beliefs based both on what they’ve personally experienced and what they’ve seen and heard from others (or the media). If they’ve had a successful procedure to rid them of their pain – they still process the meaning of their pain (and the procedure) and its not always ‘life as normal’.
The argument for focusing on pain reduction is often based on the ethical drive to ‘reduce suffering’. I have no problem with this at all – reducing suffering is surely one of the reasons many of us chose to work in health. The problem I have is with the idea that if someone is experiencing pain, he or she is also inevitably experiencing suffering. The concept of suffering involves the person making a judgement about his or her experience – is it ‘good’ or is it ‘bad’?
I’m sure we can all think of situations in which we as clinicians are comfortable not only with personally undergoing a painful procedure, but also inflict pain on another person. Just ask the mother cleaning a child’s graze! Or the nurse giving an injection. Or the physiotherapist carrying out a stretch on a person’s limb. There are also plenty of activities that we do as humans that involve pain – ever watched a marathon runner at the end of a race? A rugby player in a tackle?
Humans can experience pain and not suffer. And people with ongoing pain can, and do, live really good lives despite having their pain, and in many cases, decide not to look for treatment because pain is seen a simply part of life and of little consequence.
Disability in chronic pain is about the effect of pain on function. The ability to do things that are important in life. Disability is influenced by so many more things than just tissue status. It’s about the physical environment – if a checkout operator with back pain can vary her standing and sitting positions throughout the day, she can maintain her work status. It’s about the social environment – if that checkout operator’s supervisor allows her to take short breaks or stretch or wear flat shoes, she can stay working. It’s about beliefs and attitudes – if that checkout operator believes that her back pain is ‘just a sensitive nervous system’ and that it’s OK to change the way she does things, she’ll probably stay working. It’s about healthcare provider’s attitudes and beliefs – if the checkout operator’s GP thinks it’s healthy to stay at work, and supports her with a health certificate that says she is OK to work, she’ll probably do so. And so many more factors that I haven’t listed.
To return to my original observation – the divergent pathways in pain management.
There are several reasons for focusing on pain reduction especially in the early stages of an injury. Yes it’s about relieving suffering, but it’s more about facilitating return to normal movement and activity. This helps people remain in their job, their family roles, keep exercising, and probably normalises the input from the body to the neuromatrix, reducing potential neuromatrix disruption.
Usually this emphasis is only needed in the short term because acute pain does fade away over time, and most people start doing normal activity despite having a bit of an increase in pain – it’s seen as ‘normal’.
It’s when the pain doesn’t reduce over time that the debate heats up.
Because pain relief is effective (at least a bit) for most problems, it seems pretty sensible to carry on finding ways to just do this for longer. But if it’s not effective, or only partially effective, or effective only for short periods of time, or fails to change function, or becomes the focus rather than being seen as a means to an end – then it gets in the way of the real reason for living, and that is to live! To do things, to be the person we’re meant to be, to occupy that role or purpose that only you or I can do.
And so, I think part of the problem with pain management is that people forget why pain becomes a problem – it becomes a problem because it interferes with living life.
As a result of this gap in our collective memory, the pursuit of pain reduction can become all-important. Even when there are ways to reduce suffering and disability that don’t change pain but do enhance living well!
Do I think we should eliminate the search for pain reduction? Well, don’t be fooled – that’s not what I intend at all! I just think that the emphasis on reducing pain as a priority shouldn’t divert our focus from why we want to do this in the first place. I also think the emphasis shifts as pain persists.
Because of our human drive to fix on simple solutions, quick fixes, and because of our cognitive biases toward doing what has worked once (even if it doesn’t work again), following what other (influential) people suggest, confirming what we already suspect rather than looking at alternatives and so on, that’s not an easy shift to make – either for some health providers, or some people with pain.
If our focus moved from considering the problem of ‘chronic pain’ but instead redefined the problem as ‘chronic disability attributed to pain’ maybe our focus could become clearer. We could start to look at the multiple factors that influence disability rather than the simple but oh-so-poorly-correlated pain and disability equation. Maybe we would measure disability rather more than pain intensity. Measure attitudes towards activity and movement rather quality of pain. Things like sleep, mood, interference, role fulfilment would become the target of intervention rather than just pain intensity.
Would this mean pain intensity wouldn’t be addressed? Not at all – but the emphasis over time would, and the total burden of seeking and receiving treatment would be included in the equation. How many hours do people with disability attributed to pain spend sitting in waiting rooms, waiting for investigations, waiting for reports, waiting for someone and something else to happen while life passes by?
If there’s a pathway that I think has got hidden by the undergrowth of biomedical power, prestige and popularity, it’s the one leading to living well as a person. And I think the signpost to it says ‘Pain management is about living well’.