I’ve worked in chronic pain management in New Zealand for about 20 years. In that time I have never, ever heard of a chronic pain management centre without a waiting list. There are always more people than places for them to go. This situation hasn’t changed one iota, and it’s the same everywhere in the developed world. It’s also going to get worse because of the aging population with chronic health problems. Somehow, though, the urgency with which we need to address this problem just hasn’t reached health policy-makers and budget-holders. Chronic pain is still pretty invisible.
If tertiary care waiting lists are enormous, then who ends up taking on the majority of care? By and large it’s General Practitioners, who by their own admission don’t feel confident, and neither do they have sufficient time, to deal with the needs of people with chronic pain. There is conflict between the focus of a GP and that of the patient, and implementing back pain guidelines for example, has not been entirely successful (Breen, Austin, Campion-Smith, Carr & Mann, 2007; Coudeyre, Rannou, Tubach, Baron, Coriat, Brin et al, 2006; Williams, Maher, Hancokc, McAuley, McLachlan, Britt et al, 2010).
What can be done?
The strategy most commonly recommended is some form of stepped care approach. This begins with simple advice and simple analgesia. It’s usually carried out by a GP, or in some cases (such as accident patients in New Zealand), other primary care clinicians such as physiotherapists, osteopaths and chiropractors can also provide this – although not usually involved in prescribing.
When this approach fails, or after a certain length of time, the next step adds in some sort of reactivation, involving a physiotherapist or similar, and perhaps a screening questionnaire to establish the presence or absence of risk factors.
When this fails, the person may then be seen by an interdisciplinary team or at a chronic pain management centre.
But someone this approach hasn’t worked – because, at least in Christchurch, people will have had their pain for roughly four years before finally being referred to the pain management centre. This delay might be because of limited chances of getting in to the service, or it might be because patients haven’t been to see their GP about their pain, or it might be because they’re still wending their way through the acute services in pursuit of a cure or cause for the pain. Whatever the case, it’s not good for people.
Some ideas rely on using technology to provide greater collaboration and communication between both the person with pain and his or her virtual team (Kroenke, Krebs, Wu, Yu, Chumbler & Bair, 2014). I think this idea has a good deal of merit, although in the article I’ve cited I think some opportunities were missed. In this study, participants were randomised into two groups – one group received usual care, while the other received automated symptom monitoring via voice-recorded phone calls or the internet, along with one face-to-face meeting with a nurse care management, who discussed medications with a pain physician, followed by a phone call to discuss the care plan, and two other calls, one at one month and one at three months. Additional calls were provided on the basis of symptom records. Patients in the intervention group benefited, with reduced scores on pain severity and interference as recorded by the Brief Pain Inventory.
What this study missed doing was use clinicians to support increased functioning and manage emotional distress. While there would have been an increase in cost, the outcomes would have, I feel, justified this expense.
Who should deliver this kind of intervention? Well, for my money, I’d go for occupational therapists, physiotherapists, perhaps nurses, social workers and counsellors. People working at the limits of their scope of practice.
You’ll note I don’t think psychologists should be involved, and not because I don’t think psychologists are very good people – but in a stepped care approach, I think their skills should be reserved for people who also present with psychopathology, things like depression, anxiety, and so on. Let’s instead use clinicians who have skills specifically aimed at increasing engagement with normal activity (or occupation, if you want to be pedantic).
I think there are other ways allied health can be used, reducing the demand on medical time.
What about group clinics where people from two or three medical practices can meet together once a week with an occupational therapist and physiotherapist? A time when people can learn new skills, be encouraged to set goals, have social support and also have a chance to learn about their pain and how to live despite it. Combine this with the prescribing practices described in the Kroenke et al (2014) study, and I think you have a great beginning for a primary care approach for people with chronic pain. If you included the local pharmacist in the mix, you’d have a very effective approach that maximises the use of clinical skills amongst a group of people who sorely need help.
If individual patients needed extra help, they could arrange appointments at the group clinic, and be seen by clinicians who already know them, and who are in contact with the primary care GP.
Because, while its the person with pain we want to help, there are other goals as well – relieving the burden of care of GP’s, reducing the use of emergency departments for what is a chronic health problem, limiting the number of health professionals the person needs to see, and using what already exists in the community.
Another alternative is to regularly provide “education” sessions to people with chronic pain. Combine this with giving people a clear indication of what to expect from seeing each health professional, and leaving the responsibility to make an appointment with those professionals, and we have the beginnings of a system based on patient’s readiness. This has already been implemented in Western Australia.
The reason I focus on supporting GP’s and using allied health instead of medication management is that we know medication has a limited effect in many forms of chronic pain (Turk, Wilson & Cahana, 2011). We also know that even when pain is reduced, without addressing underlying fears and specific concerns, people may not return to normal activity. The majority of predictive factors for ongoing disability associated with chronic pain are psychosocial – pills don’t fix beliefs, entrenched behaviours, family situations and not having a job. And a seven minute consultation with a GP cannot possibly address these things either. What does help is skilled, effective and specialised help from clinicians who understand “doing”. People with chronic pain don’t need pills, nor do they always need mental health management – what they DO need is a focus on practical ways to get on with life. I think that’s a better way to meet the needs of people with chronic pain.
Breen, A., Austin, H., Campion-Smith, C., Carr, E., & Mann, E. (2007). “You feel so hopeless”: a qualitative study of GP management of acute back pain. European Journal of Pain: Ejp, 11(1), 21-29.
Coudeyre, Emmanuel, Rannou, Francois, Tubach, Florence, Baron, Gabriel, Coriat, Fernand, Brin, Sylvie, . . . Poiraudeau, Serge. (2006). General practitioners’ fear-avoidance beliefs influence their management of patients with low back pain. Pain Vol 124(3) Oct 2006, 330-337.
Kroenke, K., Krebs, E. E., Wu, J., Yu, Z., Chumbler, N. R., & Bair, M. J. (2014). Telecare collaborative management of chronic pain in primary care: a randomized clinical trial. Jama, 312, 240-248. doi: 10.1001/jama.2014.7689
MacNeela, Padraig, Gibbons, Andrea, McGuire, Brian, & Murphy, Andrew. (2010). “We need to get you focused”: General practitioners’ representations of chronic low back pain patients. Qualitative Health Research, 20(7), 977-986.
Turk, Dennis C., Wilson, Hilary D., & Cahana, Alex. (2011). Pain 2: Treatment of chronic non-cancer pain. The Lancet, 377(9784), 2226-2235. doi: 10.111/j.1468-1331.2010.02999.x
Williams, C. M., Maher, C. G., Hancock, M. J., McAuley, J. H., McLachlan, A. J., Britt, H., . . . Latimer, J. (2010). Low back pain and best practice care: A survey of general practice physicians. Archives of Internal Medicine, 170(3), 271-277.