In all the time I’ve worked in health, two things have always been certain: there is never enough funding to deliver all the services to everyone who needs them, and there is never a shortage of patients. Never.
It’s time to ask some important questions about how and why we deliver the services we do for people who have chronic pain.
Now, for those of you who don’t know, I live and work in Christchurch, New Zealand, so some of the things I’ll discuss may not apply to you – but underneath I think the problems I identify in New Zealand apply everywhere else in the world too.
My questions are: – why does it take so long for people to be referred for interdisciplinary pain management? Do people get interdisciplinary pain management when they finally get referred? What happens to people before they get referred? And how do we as a society get most bang for buck to help people with chronic pain?
For people on ACC (our national accident insurer), they will usually have had many assessments, many “low-intensity” programmes usually delivered by multidisciplinary groups (physiotherapy, clinical psychology, perhaps an occupational therapist), often related to functional goals such as returning to work, or improving fitness. Their rehabilitation may plentiful, but the outcomes seem pretty much the same – some people will manage to return to work, others will be assessed as capable of work but perhaps via functional capacity testing and an occupational physician’s assessment and eventually be removed from ACC, while others will carry on waiting for “something” to help.
For those not on ACC, the disparity between what they can access and what ACC clients can access is enormous. Essentially, in Christchurch, if you happen to be diagnosed with fibromyalgia by your GP, you will not be able to get in to the Pain Management Centre. There is nowhere else to go. Not a thing. Nada. Zip. Nothing.
Why does it take so long to get referred? It would be easy to point the finger at GP’s who fail to refer people early enough, and who carry on using a biomedical approach including repeated appointments for musculoskeletal injection procedures, or refer for orthopaedic or neurology investigations. And to a certain extent this is true – but so few people can be accepted into the local pain management centre, and who would know why some people are accepted and some are not? And, of course, the outcomes are pretty variable. People don’t stop having chronic pain, they don’t get “cured”, they don’t die, they don’t go away.
It’s probably far more useful to consider the health system which doesn’t recognise chronic pain as an entity and therefore fails to consider how thoroughly under-resourced the area is.
Do people get interdisciplinary pain management when they finally get referred? This is a rather vexed question. I’m going to quote from Gatchel, McGeary, McGeary & Lippe (2014): Multidisciplinary connotes the involvement of several health care providers (physician, psychologist, physical therapist, occupational therapist). However, the integration of their services, as well as communication among providers, may be limited because these individuals may not be located in the same facility. Even when various treatment providers are co-located, they may still be considered as providing multidisciplinary care if they pursue treatments with separate goals that do not take into account the contributions of other disciplines. Interdisciplinary care consists of greater coordination of services in a comprehensive program and frequent communication among health care professionals, all providing care “under one roof” at the same facility. The key ingredients for interdisciplinary care are a common philosophy of rehabilitation, constant daily communication among on-site health care professionals, and active patient involvement.
I’m sorry, but arguing that every patient must see the same combination of clinicians, who all have prescribed roles, is not the same as interdisciplinary teamwork. If one of the team members has greater clout, or deviates from the overall model (say, by offering repeated injections, medication changes, or reinforces pain as a guide), that is not interdisciplinary. Or if the person is referred, has a comprehensive assessment – but then receives exactly the same management programme as the next person – that also is not interdisciplinary pain management. Neither is giving just one modality.
I’ve written before about the need for an integrated formulation to explain how the various factors influence the individual’s presentation. I’m not sure this is being done very often.
What happens to people before they get to pain management? Probably they get sent on more investigations, get prescribed more drugs, get more injections, perhaps see a physiotherapist for exercise and “to get moving again”. Some people cope well, many do not. Remember this probably continues afterwards, so for those who never get seen by pain management centres, it just carries on. A futile, endless waste of resources with little or no positive outcome – except some people get paid.
Does it matter? Well, yes it does. If we want to provide effective healthcare, we do need to be evidence based. And so far, while not producing amazing effect sizes, interdisciplinary pain management is the most successful approach for people with chronic pain and disability.
Because in the end, it’s not the pain that is the major problem – it’s the disability and distress that is. And these do not get addressed by pills, potions or injections.
How do we get most bang for buck? Maybe it’s time to look to expanding interdisciplinary pain management beyond the clinic door and out into primary care, where the GP really needs help. There’s more than enough evidence.
Ehde, D., Dillworth, T., & Turner, J. (2014). Cognitive-behavioral therapy for individuals with chronic pain: Efficacy, innovations, and directions for research. American Psychologist, 69 (2), 153-166 DOI: 10.1037/a0035747
Gatchel, Robert J., McGeary, Donald D., McGeary, Cindy A., & Lippe, Ben. (2014). Interdisciplinary Chronic Pain Management: Past, Present, and Future. American Psychologist, 69(2), 119-130.