Crispy crunchy

What is our goal in pain management?


One of the cool things about having worked in chronic pain management since the mid-1980’s is that I’ve seen a few things come and a few things go.  Some things remain, of course, and the things that seem most long-lived are debates about pain reduction vs living with pain. On one hand, there’s an enormous industry set up to help people reduce their pain experience through pharmacology, injection procedures, surgery, hands-on therapy, movement practice, and novel approaches like brain stimulation and even mirror therapy. On the other hand, there’s a smaller but equally well-established industry established to help people live with their pain, usually involving self-management of some sort and following a cognitive behavioural approach.

The two seem almost incompatible in many respects – why would someone choose to live with pain if their pain can be reduced or alleviated? What are the ethics of not offering pain reduction if it’s available? Why focus on hard work learning to live within the constraints of pain if there’s a way to get rid of it?

I wonder if it’s time to look at the underlying reasons for offering pain management. What is the goal? (BTW occasionally I might write “our” goal – and I do this deliberately because I think there are assumptions made by people who live with pain, and treatment providers, that may not always be explicit).

Why do we offer pain treatments?

Looking beneath the “oh but it’s a good way to earn a living” economic argument, I think some of the reasons we offer pain treatment is a sense of moral concern at seeing people in distress. As a society we’ve cast pain as a “thing” that needs to be fixed, a wrong that must be righted. We have cast ill health and disease as something that should not exist, and we use words like “war” or “battle” when we discuss treatments.  The Hippocratic Oath makes it clear that physicians “must not play at God” yet defining the limits of treatment is a challenge our society has yet to fully resolve.

At the same time as we view pain as an ill that must be removed, underneath the moral argument are a few other reasons – we think it’s wrong to allow someone to suffer. We think it’s wrong that people might not be able to do as they wish. We respect individual agency, the freedom to engage in life activities, to express the self, to participate in life fully and completely. And we think it’s important that, when disease or illness strikes, we offer something to reduce the restrictions imposed on individuals.

What’s wrong with these reasons for offering treatment?

Well, superficially and in the main, nothing. As humans we do have a sense of compassion, the desire to altruistically help others. Whether this is because, as a species, we hope someone will help us if we’re in the same situation, or whether we do it because of some other less selfish reason, I’m not sure. But there are problems with this way of viewing pain as an inevitably negative harmful experience. And I think it has to do with conflating (fusing together) the concepts of pain and suffering.

We offer people some treatments create suffering: I’ve just quickly skimmed a recent paper on using long-acting opioids for chronic noncancer pain where it was found that “prescription of long-acting opioids for chronic noncancer pain, compared with anticonvulsants or cyclic antidepressants, was associated with a significantly increased risk of all-cause mortality, including deaths from causes other than overdose, with a modest absolute risk difference” (Ray, Chung, Murray, Hall & Stein, 2016).

Given the poor response to pharmacological approaches experienced by so many people living with chronic pain (see Turk, Wilson & Cahana, 2011), not to mention “failed” surgery – the rates of persistent postsurgical chronic pain range from 12% (inguinal hernia) to 52% for thoracotomy (Reddi & Curran, 2014) – it surprises me that we often don’t discuss what to do (and when) if our treatments produce pain, or make it worse.

Nonmedical treatments can also be lumped in with these medical approaches – how many years of back-cracking, pulling, pushing, prodding, needling and exercising do people living with pain go through before someone pulls the plug and says “how about learning to live with your pain?”

What’s my goal in pain management?

When I see someone who is experiencing pain, whether it’s persistent or acute, my goal is for them to be able to respond to the demands of their situation with flexibility, and to live a life in which their values can be expressed.

That means no recipe for treatment, because each person is likely to have a whole bunch of different demands, things they’re avoiding, things that limit what they’re OK with doing. Values also differ enormously between people – we might all choose to work, but the reasons for working (and the kind of work we do) is informed by what we think is important. I’m intrigued by new learning, new information, and complexity. Others might be focused on ensuring their family is secure. Others still might be working to have a great social network. All of these values are relevant and  important.

Many of our treatments actually limit how flexibly people can respond to their situation – think of “safe” lifting techniques! And sometimes even the time people take away from living their normal life means their values are not able to be expressed. The thoughts and beliefs instilled by us as treatment providers (and from within our discourse about pain treatment) may also limit flexibility – think about “pain education” where we’ve inadvertently led people to believe that their pain “should” reduce because “know they know about neuroscience”.

At some point in the trajectory of a chronic pain problem, the person experiencing pain might need to ask themselves “Is what I’m doing helping me get closer to what I value, or is it getting in the way of this?” As clinicians we might need to stop for a minute, think of this part of the Hippocratic Oath “I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick”  and begin to talk about overall wellbeing rather than just treating “the problem”.

To alleviate suffering we may not need to eliminate pain – we may instead need to think about how we can help people move in the direction of their values

 

Reddi, D. and N. Curran, Chronic pain after surgery: pathophysiology, risk factors and prevention. Postgraduate Medical Journal, 2014. 90(1062): p. 222-7

Ray, W. A., Chung, C. P., Murray, K. T., Hall, K., & Stein, C. M. (2016). Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA, 315(22), 2415-2423.

Turk, D. C., Wilson, H. D., & Cahana, A. (2011). Pain 2: Treatment of chronic non-cancer pain. The Lancet, 377(9784), 2226-2235. doi:10.111/j.1468-1331.2010.02999.x

8 comments

  1. Dear Bronnie,
    Yet again you challenge our beliefs. I had to take a step back to realize that I do correlate pain with suffering. But reflecting on how some people I’ve met are “doing” just fine; they’ve made peace with it and carry on with living and being whoever their ‘normal,’ homeostatic self is.

    I am sorry for those I have pigeonholed into any diagnostic cluster, without regard for their person.

    “my goal is for them to be able to respond to the demands of their situation with flexibility, and to live a life in which their values can be expressed.”
    ~ to do the opposite of this… could be causing harm?

    Could knowing ‘proper’ lifting techniques cause more cognitive stress, performance anxiety, avoidance… could that tip the boat towards enhanced pain experience?

    1. Thank you Connie, it’s so important to know that we’re people too – and constantly learning!
      And yes I do think that “safe” handling etc can limit life and increase pain – and induce guilt as well.
      I want to acknowledge that it’s only as I’ve been reading ACT and got more into understanding that being able to vary a response offers the most options to people that I’ve started to take this idea of being human and connecting this way as seriously as I think I need to. No recipes means work is a whole lot more difficult! But a whole lot more rewarding too.

      1. Absolutely agree! I think that may be a reason I favor Louis Gifford’s TNE. Helping a person learn by coming along side them, adding to their schema, furthering their own coping skills, and building on their strengths. Works much better than trying to get someone to see my point of view or canned explanation.

  2. I like this post. I believe we need to provide information to our patients based on what we know and sometimes what we have tried and sometimes we will need to help patients come to an acceptance if after discussing alternative treatments they feel they do not want to be a part of those treatments (to try to reduce pain) and sometimes patients will want reduction in their pain to be able to come to this acceptance and we can try to help with that and then there are those who only want the pain to be completely gone and we then have to work with them to come to some understanding of what is really acceptable over time and I think this often comes down to their suffering. Does the patient feel he is suffering? If so then we need to find a way to help either reduce the suffering or for the patient to maybe see that they can live with pain without the suffering as they are not the same. this is a big task but can be done.

    1. I think it also depends on how we define suffering. I’ve used Eric Cassell’s definition that suffering is when the sense of self is eroded. This doesn’t always fit nicely with other research into self-concepts – like Higgins theories of multiple selves, but I’ll have a go at explaining what I’m driving at. Our sense of self-concept is all the things we assumed and infer about ourselves, our roles, our beliefs and preferences, capabilities etc. We also hold “idealised” self-concepts (what we’d like to be/become) and the evil twin “feared” self-concepts that reflect what we most want to avoid being. I think chronic pain and the plethora of implications of this experience can push us towards fearing that our “feared” self is becoming real. THIS is distressing and produces suffering. When we begin to accept/acknowledge different ways of “being who we really are” or enacting our self-concept, we no longer suffer although we may still feel regretful at things we can’t do the same old way any more.
      I think this allows us to work with the person to identify whether they are suffering, or just distressed. We can treat both – distress seems best managed by meeting the person in the middle, and acknowledging them as still human despite their unhappiness. Suffering, though, might involve helping the person recognise there are myriad ways to “be who you really are” to enact their self-concept and the values embedded within their self concept – irrespective of pain. After all, it’s often been said that it’s not the pain, it’s what pain represents to people that is most distressing. If pain represents losses, weakness, being unable to meet obligations, a future full of shame and failure, then it’s going to be distressing and disabling. If, on the other hand, it is a “noise in the system” and there are other ways to live out important values, then perhaps it’s far less disabling. Certainly has been for me and for people I’ve worked with too.
      What breaks my heart is when a clinician, because of his or her knowledge or attitudes towards pain, keeps offering “solutions” not to reduce the patient’s suffering, but to reduce the clinician’s discomfort at being unable to “fix” things. That’s when treatments become increasingly unhelpful. And yes, people living with pain might buy into this – especially if they’ve not been offered the opportunity to consider that there are many flexible ways to “be who you really are” in the presence of pain.

  3. As always, I am impressed by the thoughtfulness of your post. As someone who lives with chronic pain (I have rheumatoid arthritis) and in the midst of the great opioid debate in the US, I find your comments more than interesting. Thank you.

    1. Thank you so very much Carla. The opioid discussion is being had here in NZ as well. Along with discussions about repeated injection procedures, repeated surgeries and ongoing physiotherapy and passive modalities. I don’t think that we’ll settle much or see much change until we can articulate the distinction between living with pain and suffering with pain. I live with pain, I don’t suffer with it – and research studies show that it’s not the pain intensity that predicts suffering, but the erosion of a sense of self and the ability to do things that are valued by the individual (and I read this as representing a sense of self).
      While I think the opioid debate is being handled clumsily in the US (how cruel to withdraw something that helps people without concurrently introducing something to provide the support that people so sorely need?), I do agree with reducing opioid consumption.
      The thing with opioids is that they often don’t produce good pain reduction, and if they do reduce pain they don’t always result in reduced disability and distress. Hence increased prescribing, escalating the dose and subsequent adverse effects, and sadly, placing opioid provision above helping people to have access to alternatives.
      I’ve been told I’m biased because I can’t find anything to reduce my pain. I certainly feel biased but not because I’m “suffering”! I’m biased because I’ve seen the negative effects of repeated unhelpful treatments and felt the despair of folks who’ve said “If only I’d been given this approach earlier”! After years of being pushed to treatment after treatment, these people are relieved to find out they don’t have to live this way, there are alternatives that don’t involve a focus just on getting rid of the pain.
      It’s just shameful that the self management approaches that are tried and tested haven’t been promoted with as much vigour as those intrusive alternatives.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s