Purakaunui Falls

Should EVERYONE with chronic pain be treated?


ResearchBlogging.org
As I pointed out in a recent comment in my blog post about non-pharmacological approaches for fibromyalgia, “seeking treatment is, in itself, a pain behaviour – designed to communicate (Hadjistavropoulos et al, 2011).

Treatment seeking is associated with higher levels of distress, catastrophising, disability and it seems to be a learned behaviour developed from childhood (Ferreira, Machado, Latimer, et al, 2010). Clinicians respond to treatment seeking, and particularly to distress associated with treatment seeking, thus reinforcing the process of seeking treatment. Responding to distress with analgesia, investigations, injections, infusions may settle the distress in the short term – but it fails to address the distress long term – in fact, it can amplify distress (Salkovskis, & Warwick, 2001).”

People who are distressed and worried about what their pain means for their future are more likely to look for help than those who are confident they can carry on.  They’re also more likely to feel that their pain interferes with their ability to do everyday activities and occupations. These are the kinds of people we typically see in clinical settings – because people who don’t feel distressed and are not disabled just don’t seek help.  Von Korff (2013) cites a Portugese study that found that around 11% of people reported severe chronic pain, and a further 26% reported milder chronic pain, yet the groups were very similar in terms of how frequently they looked for treatment. 

Surely, people with more severe pain would be more likely to look for treatment?

No. Because it’s not the intensity of pain that matters: it’s the meaning we give to the experience.

But – do we as clinicians recognise this and treat people accordingly? or do we carry on doing the same old, same old?

Should everyone with chronic pain be treated? On the one hand, there are many people receiving unnecessary diagnostic procedures and treatments with little to no change in functional status – Von Korff cites three such studies in his editorial (Berwick & Hackbarth, 2012; Lenzer, 2012; and Deyo, Mirza, Turner et al, 2009). A similar argument exists for prescribing opioid medications, and for repeated passive therapies such as hands-on manipulation, acupuncture and so on.

At the same time, IASP and others have declared access to pain management a human right.  Are these stances incompatible?

I’m not sure they are, let me unpack that a little before I go on.

Ethical principles for healthcare providers (medical, allied health and “others”) are to respect (1) autonomy, (2) beneficence, (3) nonmaleficence and (4) justice (Gillon, 1994).

While alleviating suffering is the usual reason given for always providing pain reduction to people with chronic pain, I think many people conflate (squish together) having pain and suffering from pain. Suffering, according to Eric Cassell (2011) is “the specific distress that occurs when persons feel their intactness or integrity as persons threatened or disintegrating, and it continues until the threat is gone or intactness or integrity is restored.”

If a person does not feel their identity is threatened, then they are unlikely to be suffering. People who willingly undergo body suspension from hooks through their flesh are not suffering – they tell us they are euphoric, transcendent.

People who have developed acceptance of their pain also do not suffer: pain is only a part of their identity, they continue doing what is important in their lives.

On the other hand, reducing pain intensity does not inevitably mean suffering is reduced. Consider the person who has experienced an angina attack: the pain is gone but the fear and the effect on “life as we know it” remains.

There are other ways for suffering to be alleviated. One is to reconnect with aspects of “self” that are threatened by pain. Usually this occurs by engaging in the important occupations we value in life, but it can also be through relationships with others. Sometimes suffering can be reduced when the threat value of pain is reduced – yes, this pain is ongoing, no, this pain is not about harm to your body.

If a treatment provider fails to let a patient know about alternative treatments, are they respecting autonomy? If they reduce pain but don’t influence disability, are they respecting beneficence? If they maintain disability while in search of an elusive nociceptive source, are they respecting nonmaleficence? Is justice being respected if, by repeatedly providing a treatment for short-term gain, others who could access lower cost treatments such as self-management are denied access?

Should we treat everyone with chronic pain just because they ask for treatment?

I don’t think so because if people seek treatment because they have learned to do so, because treatment reduces distress and is therefore well-reinforced, we are not treating pain, we are treating distress and suffering. And we’re not doing a very good job of it because for many of these individuals, distress and suffering continues as they continue to seek treatment, because they remain disabled and lose their sense of self identity. Worse that this, because so many distressed people are receiving treatments that reduce distress for only a short time, many other people cannot access ANY treatment at all. That’s incompatible with the IASP position.

What should we do?

I think we should treat distress in another way. We should manage suffering by addressing the suffering rather than assuming that if pain is eliminated, suffering will automatically go.

I’m not saying we should stop providing pain reduction to people, not at all. I am suggesting it’s high time we looked at increasing function as the priority, helping people regain a sense of their own identity so that pain becomes just a small part of who they are rather than dominating their whole identity. We might need to ask more carefully about what this person is seeking when they see us. We need to think carefully about why this person is presenting at this time and in this way, and try to establish what we can do to reduce their distress AND disability. And this might mean saying no to providing our favourite treatment just because a person turned up asking for help – and perhaps hand over to another healthcare provider.

 

Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307:1513–1516.
Cassell, Eric J. (2011). Suffering, whole person care, and the goals of medicine. In T. A. E. Hutchinson (Ed.), Whole person care: A new paradigm for the 21st century (pp. 9-22). New York, NY: Springer. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=psyc7&AN=2011-24010-002  doi: 10.1007/978-1-4419-9440-00.1136/bmj.309.6948.184
Lenzer J. Unnecessary care: are doctors in denial and is profit driven healthcare to blame? BMJ. 2012;345:e6230.

Deyo RA, Mirza SK, Turner JA, et al. Overtreating chronic back pain: time to back off? J Am Board Fam Med. 2009;22:62–68.
Gillon, R (1994). Medical ethics: four principles plus attention to scope. BMJ, 309(6948), 184. doi: 1
Von Korff MR (2013). Health care for chronic pain: overuse, underuse, and treatment needs: commentary on: chronic pain and health services utilization-is there overuse of diagnostic tests and inequalities in nonpharmacologic methods utilization? Medical care, 51 (10), 857-8 PMID: 23969587

11 comments

  1. In the end, or course, every patient is an individual. I am not sure how things are in other countries, but in the U.S. the insurance company controlled doctor-patient model seems to create a lot of problems. Doctors are allotted less than 15 minutes per patient for most visits, which creates a lot of business as usual medicine. This is coming from a patient perspective, of course (though I know a lot of doctors that hate insurance companies). In my experience in our system, unnecessary treatments and diagnostic procedures must be ordered to prove the more expensive, but necessary test to be necessary (my son had a severe soft tissue injury to his shoulder, X-Rays and pain continuing beyond six weeks was required before MRI was permitted, regardless of the physician’s judgment). I realize that is acute, injury-related pain, but it is the most recent example. My wrist I won’t count against them – it was a complicated injury and not obviously a soft tissue injury from the beginning).

    Please understand that I know not every owie needs a trip to the ER, etc. It is frustrating, though, to see unnecessary X-Ray even if they are cheaper, and know it is just to meet insurance company expectations. With my own illness, there is established treatment protocol. You do one treatment, it works or doesn’t, then another, then another… a patient either quits when they find relief or when they run out of money. I am watching research for a treatment that is proven effective. I am interested in the “lidocaine pretzel,” and watching its progress.

    1. I think it’s about how much energy and weight you place on the outcome. If you’re really invested in an outcome, and life is on hold while you wait for the treatment to “work”, then I think this can contribute to disability, and distress. Patients (you and me!) can choose not to continue with the merry-go-round of treatment if you have confidence you can have a good quality life despite your pain. In NZ we also have very busy GP practices, with most GPs unable to spend more than 15 minutes with each person. I guess a solution to this would be to promote allied health to provide more of the self management approach so that GPs can do the medical part and let the professionals who know how to help people “learn to live with pain” get on with it! The problem is that GP’s (and other health professionals with a focus on cure or pain reduction) can fail to stop and don’t promote self management as a positive, life-enhancing option. They respond instead to distress and feel pressured to send people off for investigations or procedures or medications rather than being clear about the chance of cure, and positive about the wealth of information that shows people can and do live well alongside their pain. Of course, it takes time to tell someone that these are options, and to do so without the patient feeling abandoned or unheard. It also takes skills – and for some reason insurers and funders don’t rate spending time with patients and using good communication skills very highly, so people are left with a sense of being brushed off. It doesn’t need to be like that.

  2. You are right, that there can be a lot of anxiety waiting to see if the treatment will work, which treatment, etc. I was pragmatic, at least I hope so. I assumed that there would be definite improvement, and that I would wait at least six months before even applying for disability here, hoping that treatment would bring things “back to normal.”

    I am an intellectual person, and tend to spend a lot of time analyzing what I do, if I am being rational enough, what I can do to improve things, etc. I run a gratitude group for chronically ill people, encouraging them to focus on what they do have, what they still can do. Right now the family illness has started definite symptoms in my sister, and I am learning, all over again, that every patient is individual, and what encourages one patient falls on deaf ears with another. I sometimes think it isn’t even the amount of time spent with a patient, but how – the communication you bring up. If a patient feels heard, they are more confident in their doctor and the treatment. If they leave an office visit feeling like they were an inconvenience, they tend to have less hope.

  3. Ain’t that the truth! It’s not what you say, but the way that you say it! Each person’s interpretation of their experience is unique because it’s the person who is suffering, not the body part. And each person’s identity and the meaning of symptoms and effect on what is important to them is different, so we (health providers) need to take the time to find out what the main concern really is for the person we see.

  4. When a person feels that he isn’t doing well with his pain go for treatment, most cases if the pain is bearable he thinks its okay in other case he is worried, depressed until its diagnosed. The only reason some go for treatments is to get diagnosed it gives him a relief from distress.

    1. I agree, people go for diagnosis for many reasons, and getting a diagnosis that fits with their view of their symptoms often reduces distress. Sometimes, of course, it works against them because they don’t agree with the diagnosis and end up looking for another one, and another one, and another one, getting more and more labels for their problem and ending up quite confused. Something I’ve considered is whether it’s worthwhile doing more investigations, giving new diagnoses, if it doesn’t change the management.

  5. I am not a professional. I am someone who has a myriad of health problems that are quite painful. To not treat people who have pain is barbaric, at least if you ask me. If an animal is injured or is showing signs of distress I am sure that you would have no problem treating the animal. However, when it comes to a human being then there is some sort of difference ascribed to the behavior. While I agree that there is a difference between pain and suffering there is also a difference between being humane and heartless.

    People who have chronic pain have much higher amounts of stress. If the pain is not treated properly the stress increases leading to other illnesses some of which may be life threatening. So to say that there should be a judgment call made by someone who is not in the body of the person who has the pain as to whether or not treatment is necessary is ludicrous.

    Whether something that I would rate a three is a nine to someone else also must be taken into consideration. I was in a class years ago with a woman who had fibromyalgia and she could barely function. I went to law school with fibromyalgia and a number of other painful conditions. At the time I was in this class I had nothing but contempt for this woman and her inability to tolerate pain. However, what I didn’t take into account until years later is that I have a very high pain tolerance as does my son but that does not mean everyone else in the world does. So for me to be contemptuous of her inability to function is ridiculous.

    Those who do not have chronic pain and even years ago in my case those that do should not sit in judgment of others. Maybe treatment is deserved simply because it is harmful to the person not to treat them for a number of reasons including complications from stress.

    1. Thank you so much for taking the time to comment, I appreciate your views. To a certain extent I agree with you, but not completely. What I’m referring to in this post is a single-minded focus on pain reduction as the primary outcome. What researchers who have talked to, surveyed, listened to and understood from many thousands of people with chronic pain is that the problem is not the pain as much as what the pain means to the person, that is, it’s the sleeplessness, irritability, lost relationships, fear about the future, the worries about coping with work and so on that really are the worst part of having chronic pain. Unfortunately, medications and procedures for chronic pain are pretty poor. They just don’t work very well. Some examples: “A meta-analysis has shown that less than two-thirds of patients with chronic pain obtain sufficient pain relief with available drugs” Jensen & Finnerup: Comment; The Lancet; 10.10.09, p 1218-19; “…for most the effects were small or moderate … the analgesic effects of many treatments for non-specific low back pain are small” Machado LAC et al: “Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials”; Rheumatology 2009; 48:520–527; “…the number of patients who are needed to be treated (NNT) to achieve 50% reduction in neuropathic pain in one patient is more than four, a high cost for the 3 unsuccessfully treated patients and their physicians”. Woolf, C: “Review: Overcoming obstacles to developing new analgesics”; Nature Medicine (Supplement); 16,11: 1241 – 47; November 2010. The problem with this is that very few doctors admit this – and instead, some doctors (and other professionals) carry on with fruitless investigations, procedures with a 50:50 chance of success for the very small percentage of people for whom it’s indicated, or keep on doing what they’ve always done for acute pain when the problem is chronic pain.
      As a person with chronic pain myself, I don’t sit in judgement – the decision must be made in collaboration with the person who has pain, and the clinician – but also with very clear understanding of the success rates and knowledge of ALL the options. Unfortunately, the money spent on these medical approaches leaves very little available for approaches that directly address things like sleeplessness, low mood, broken relationships, stress, ability to work or have fun. These approaches are what I contend should be provided instead of continuing to offer things that have very limited value.

      1. I agree that the problems you discuss like sleeplessness, stress, ability to work, etc. do mean a great deal to the person with pain. But the underlying problem is the pain. Unless you control the pain in some fashion the other problems will only seem worse.

        My doctor at one point told me that my problem wasn’t the pain, it was the fear of the pain which really made me angry at the time. Why? Because I’d laid in my living room crying for hours on end (for four months) unable to do anything because the pain kept spreading from one area that I had nerve damage in to the next. So I left the city where I lived and drove over 100 miles to get to my old GP. After he’d treated me with prednisone for three days to deal with the inflammation caused by two medications that should never have been taken at the same time it changed my outlook completely. I began to see what he was saying was true that if I didn’t get the fear of the pain under control I was only making life worse for myself. Why? Because every time the pain started to climb my fear would increase accordingly and all I could see was another day and night and night and day in agony.

        My point is without the pain the other problems wouldn’t exist at all. I didn’t have a fear of pain prior to this issue with the medications. If you remove the pain the other issues resolve themselves as well.

        So to me the question isn’t should the people be treated? Instead it’s how do we treat people with chronic pain appropriately?

      2. In the end, it’s just really hard to experience chronic pain and think there is no relief in sight. The reality is that for many, many people there IS no pain reduction available. It’s not that we’re holding out – it’s that there just isn’t very much out there as I showed with those quotes. The question is whether the community can afford to continually fund a search for something that will “take the pain away” when our current science suggests there may not be anything available – doing so means the thousands of people who could be helped with lower cost self management just don’t get anything. That, to me, is unconscionable. Accepting that there are limits to what we can do to take chronic pain away is really hard. Having chronic pain is really hard. It’s unfair, and nobody I know LIKES their chronic pain, including me. BUT if there is a disproportionate amount of money spent on a small number of people who are persistent yet still can’t get what they want because it doesn’t exist, all those other people who currently can’t get anything are left without help.
        It’s always an individual’s personal choice as to when to stop looking for pain reduction. The decision boils down to the costs of searching for pain reduction vs the benefits of adapting to the reality of having chronic pain. And I don’t mean the monetary costs, I mean the personal, human cost of taking time away from acknowledging the things that remain in your life – the family, friends, sunny days, good coffee, warm water, cool icecream, beauty in a painting, joy in reading a good book. Because looking for pain reduction takes time and energy, and while that’s the focus of life, these other things are less of a focus. What we attend to becomes increasingly relevant and dominant. So, I personally choose to relish the good things I have, and pain becomes a smaller part of who I am and what my life is. There’s also the emotional cost of holding out hope that THIS one is “the one”, only to have that dashed when it doesn’t last, or doesn’t work. That can be incredibly disheartening.
        I can’t agree with you that once pain is removed the other problems wouldn’t exist at all. They remain, latent, in your memory, influencing your beliefs, emotions, judgements and actions in the future. You haven’t forgotten this experience – so as you remember it, you re-experience it. When you have another bout of pain (which is normal, common, and expected in chronic pain), all that fear, anxiety, distress returns, and you begin on the quest to “take the pain away”.
        What I’ve learned from the people in my study is that knowing you CAN get through periods of increased pain intensity using your own coping skills means they’re far easier to approach with calm certainty that, although they’re hard to deal with, they never remain at that intensity forever. And while the pain is high, it’s OK to withdrawn, take it quietly, be kind to yourself and make room for your pain instead of fighting against it. It ebbs away of its own accord over time, and people know they CAN cope. How awesome is that? To know YOU have the ability to get through even tough times.
        You’ve said that unless you control the pain in some fashion the other problems will only seem worse – well, if you manage the other problems, I can tell you that the pain is less of a problem too. And that’s why I encourage clinicians and people with pain to think about improving the quality of life by weighing up the costs of aiming for pain reduction alone and perhaps choosing to put less emphasis on pain reduction and more on living well.

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