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