|Year : 2020 | Volume
| Issue : 1 | Page : 68-74
People, medicine, and society: An overview of chronic pain management
Hema Rajappa, Chris Hayes
Hunter Integrated Pain Service, Hunter New England Health, Newcastle, New South Wales, Australia
|Date of Submission||21-May-2020|
|Date of Decision||05-Jun-2020|
|Date of Acceptance||06-Jun-2020|
|Date of Web Publication||20-Jun-2020|
Dr. Hema Rajappa
Hunter Integrated Pain Service, Hunter New England Health, Newcastle, New South Wales
Source of Support: None, Conflict of Interest: None
Chronic pain, once termed a hidden epidemic, is gaining increasing visibility around the world. It places a huge burden on patients, their families, and the wider community, with profound adverse effects on function, well-being, and quality of life. It is also a socioeconomic problem, straining health-care systems globally. This article provides an overview of the changing landscape of chronic noncancer pain. The epidemiology, classification, pain-related neuroscience, problems with overemphasis on biomedical focus, and the importance of adopting a more holistic sociopsychobiomedical framework are discussed. The article concludes with a brief discussion on health-care delivery systems in the context of chronic pain.
Keywords: Chronic pain, pain management, delivery of health care
|How to cite this article:|
Rajappa H, Hayes C. People, medicine, and society: An overview of chronic pain management. Arch Med Health Sci 2020;8:68-74
| Introduction|| |
Chronic pain is gaining global recognition as a major health priority with a substantial burden on individuals and societies alike. What has been termed a “hidden epidemic” is becoming visible. The voice of consumers has raised public awareness and begun to reduce stigma. Curiously, the widespread use of biomedical therapies has done little to reduce the burden of chronic pain and the quest for more holistic and more effective treatment is well advanced, bringing a greater measure of hope.
The causation of chronic pain is multifactorial. There are associations with increased age, chronic conditions such as osteoarthritis and obesity, and also anatomical change in spinal structure. However, these relationships are not linear. Some people with marked structural change report little pain, whereas others with little or no structural change report severe pain. Neuroscience provides an explanation for this conundrum. Nervous system sensitization can amplify “danger” messages from the tissues or in some cases contribute to a brain interpretation of pain even in the absence of tissue damage.
A significant evidence base validates the biopsychosocial model advocated by Engel in the 1970s. However, there remains very substantial variation with regard to the degree of emphasis placed on biomedical treatments. Some pain clinicians and teams rely heavily on biomedical treatments, whereas others seek to minimize the use of such. Much of this practice variation reflects the training, beliefs, and funding sources of the providers rather than the individual characteristics of the patient. Ongoing critical analysis of the evolving scientific evidence base will be crucial in reducing unwarranted clinical variation as the pain field matures.
Systems to gather large data sets for outcome measurement and benchmarking have growing influence around the world. Evidence suggests that benchmarking is a useful method to address unwarranted clinical variation and that this complements the limited capacity of clinical trials and guidelines to change clinician behavior.
| Epidemiology of Chronic Pain|| |
Chronic pain, usually defined as pain persisting beyond 3 months, is commonplace across the globe occurring on an average in about 20% of the population. There is a wide variation in the estimates of chronic pain prevalence in different developed and developing countries with differences in the study methodology, definition of chronic pain, and cultural differences in willingness to report pain, all contributing to this variation. Female gender and older age group have been consistent associations in most studies.
A noteworthy study compared the prevalence of chronic pain in nursing staff in Asian countries, using Japan as an advanced country, Thailand as a developing country, and Myanmar as one of the least developed countries. The reported prevalence of chronic pain in Myanmar was 5.9%, which was statistically significantly lower (P < 0.01) than that in Japan (17.5%) or Thailand (19.9%).
Studies in India have estimated population prevalence at 19.3%, with 33% of responders reporting inability to do routine work. Pooled data from multiple developing countries have shown a prevalence of 18%.
In Australia, chronic pain was reported by 17.1% of males and 20.0% of females. Just over half of those with chronic pain reported that it interfered with daily activities.
From the available data, it is difficult to know if the global prevalence of chronic pain is increasing. Commonly, chronic pain does not occur in isolation; there are often multimorbid mental and physical health problems. The prevalence of comorbid chronic conditions such as obesity and diabetes is rising in many countries, paralleling the growth of “diseasogenic” environments. It is likely that the prevalence of chronic pain will increase in societies that foster poor lifestyle choices.
| Cultural and Spiritual Perspectives|| |
The influence of cultural traditions and religious identity on pain expression is complex. Beliefs that pain and suffering were the consequences of human deviance or a test of faith often provided a rationalization, aiding the search for a meaning or purpose for pain. Christian traditions often referred to the suffering of Jesus, and pain and suffering may be viewed as redemptive and transformative. Hinduism encouraged acceptance of suffering and pain as the result of past misdeeds (i.e., the just workings of the law of “karma”). Buddhism's noble truths recognized that pain and suffering are a central part of life and detachment as the way forward.
Active acceptance is not an act of resignation, and active detachment is not an act of denial. On the other hand, lack of forgiveness and negative religious coping practices can adversely impact emotional well-being.
Pain-related traditions common to most faiths and cultures are often based on coping, finding meaning in pain, and building connections rather than abolition of pain or numbing pain through overuse of medications. Some of these traditions included the use of calming practices such as prayer, reading religious text, meditation, and group participation.
| Classification|| |
Mechanism-based classifications of pain have evolved over the years. The traditional approach differentiated nociceptive (tissue injury) and neuropathic (nerve injury) pain mechanisms. This classification worked passably for acute and cancer pain. It proved inadequate for chronic noncancer pain (CNCP) because many patients had neither a clear source of ongoing tissue injury or disease nor demonstrable nerve injury or pathology. It was recognized that chronic pain was often related primarily to nervous system sensitization or loss of descending inhibition. The term “nociplastic pain” introduced by the International Association for the Study of Pain in 2016, highlighted this altered processing of signals in the nervous system, allowing also for concurrent nociceptive or neuropathic contributors to the pain experience.
The next change in classification in 2019, is less straightforward. The updated version of the International Classification of Diseases 11 draws a categorical distinction between primary pain, due to nervous system dysfunction, and secondary pain, which is related to an underlying injury or disease process. The benefit of this new classification is that it represents a move away from the consideration of chronic pain as a “somatic symptom disorder” and mental health problem, when it is not associated with a physical disease process. However, there are significant implementation challenges with this compartmentalization with an inherent risk of significant inter-interpreter variability. The distinction is entirely dependent on clinical judgment as to the relative contributions of nervous system sensitization and “structural” generators; compartmentalization deflects from acknowledging the possibility of multiple contributors, choosing one over the other.
| Neuroscience|| |
The nervous system can be viewed as an interface between our co-expressed minds and bodies. As such, it is a medium through which our physical state impacts our psyche, by which our beliefs, thoughts, and emotions influence physical state. In this context, the nervous system can contribute to the causation of pain while also being a key target for its treatment.
Our appreciation of the role of the nervous system in pain has continued to evolve since the gate control theory first postulated neural modulation rather than hardwired transmission of nociceptive impulses to the brain. Pain-related circuitry is complex, multilayered, and plastic. Nociceptive, cognitive, and affective networks are involved, and these networks can change in both structure and function, in the context of chronic pain. The primary and secondary somatosensory cortices, the anterior cingulate cortex, the anterior and posterior insula, the medial and ventrolateral thalamus, and the hypothalamus are involved in nociceptive processing. The limbic system, including amygdala, nucleus accumbens, and hippocampus, plays a role in emotions and motivation and links to cortical systems including prefrontal cortical circuitry as the experience of pain is evaluated.
Persisting nociception after an injury or from a disease process can trigger neuroplastic change, which then amplifies the experience of pain. In other situations, psychological trauma may trigger neural change, which can cause pain in the absence of identifiable structural contributors. In addition, childhood adversity can potentially set the nervous system to persistent alert mode and increase vulnerability to chronic pain later in life, especially following physical or psychological stressors.
Although neuroplasticity may play a role in the causation of chronic pain, it may also be harnessed in its treatment. Part of the mechanism of nonpharmacological treatment may be in reversing neuroplastic change that is contributing to the maintenance of chronic pain.
| Biomedical Management of Chronic Noncancer Pain|| |
In managing CNCP, there are many negative consequences of an overemphasis on biomedicine. In terms of assessment, the scope of inquiry is narrowed with less exploration of psychological, social, cultural, and spiritual aspects. Medical investigations may be overused and overinterpreted. Formulation consequently runs the risk of excessive focus on potential biological contributors. A bulging lumbar spinal disc may be labeled as the critical diagnostic feature, failing to recognize that many people with a similar abnormality on imaging do not experience pain.
Potential additional disadvantages of biomedical treatments include distraction from broader active self-management and avoidance of exposure to discomforting experiences, leading to poor patient outcomes.
The developing evidence base has uncovered specific concerns about the roles of surgery, procedural interventions, opioids, and cannabinoids in the management of CNCP.
In some cases of CNCP, unimodal biomedical treatments can be curative; for example, surgical prosthetic joint replacement. If nociception arising from the joint is the dominant contributor to the pain experience, then surgery is likely to be successful. The situation with back pain and spinal surgery is more complex and in the setting of low back pain, surgery has been consistently overused.
There is evidence for procedural interventions such as nerve blocks in acute pain and in the cancer setting. However, the picture becomes less clear in CNCP. Although in theory the recipient may use the pain reduction of a procedure to increase engagement with self-management, this is difficult to achieve in practice.
Another obstacle is the limited duration of potential benefit derived from procedures. Local anesthetic blocks last several hours, and the addition of steroid may increase duration to several weeks. Radiofrequency thermal neurotomy can last months. The difficulty is that unless the person is able to make substantial life changes, they are no better once the block wears off. Further, the therapeutic ritual of the procedure may reinforce the passive behavior of simply waiting for the next medical “fix.”
Procedural “neuromodulation” provides an interesting example of biomedical treatment and marketing, moving ahead of scientific evidence, with spinal cord stimulation a particular case in point. In high-income countries, spinal cord stimulation has increasingly been used to treat radicular leg pain and more recently axial back pain. Uptake has been fostered by enthusiastic proceduralists, device companies, and the desire of recipients for a biomedical solution. Two double-blind, randomized controlled trials have been undertaken comparing high-frequency stimulation to placebo. The first showed no difference. The second trial compared three different high-frequency patterns, two of which were no better than placebo. The third pattern was modestly better than placebo in terms of pain reduction, however there was no difference in disability compared to the other groups. Despite such modest results, spinal cord stimulation is considered by proponents to be an established treatment. Further research is required exploring the efficacy and cost-effectiveness before such an expensive therapy can be accepted into routine clinical practice.
The effectiveness of opioid therapy is context dependent. Opioids have shown benefit in randomized controlled trials in acute pain. Evidence from systematic reviews shows overall support for opioid prescription in cancer pain and palliative care. In CNCP, the picture is different. Evidence suggests that there may be modest pain reduction at commencement, however this does not lead to improvement in function, and adverse effects are problematic. Over time, the benefits reduce as tolerance and perhaps opioid-induced hyperalgesia develop. The longer the period of opioid prescription, the greater the likelihood that harms will outweigh any marginal benefits. Despite lack of efficacy, prescription of opioids for CNCP has increased dramatically in high-income countries with a parallel increase in opioid-associated death rates., Barriers to opioid prescription for CNCP in India and developing countries may thus have protective benefit.
Most opioid trials in CNCP have been of limited duration (typically up to 12 weeks), making extrapolation to long-term use questionable. The lack of well-designed, long-term opioid trials was addressed in 2018 with publication of a 12-month pragmatic randomized controlled trial that compared opioid to nonopioid medication for chronic back, hip, or knee pain. The opioid group reported greater pain intensity and more adverse effects throughout the study period. Another pivotal 2018 study found that after discontinuation of long-term opioids, pain intensity either did not change or improved slightly, even without the application of active self-management strategies. The general rule therefore, according to current evidence, is not to initiate opioids for CNCP and to consider deprescribing in those already on opioid treatment.
Some chronic pain patients have comorbid opioid dependency (substance use disorder). If this is the dominant problem, then maintenance opioid therapy via an addiction medicine pathway can be considered.
The current situation with “medicinal” cannabis is similar to that of prescription opioids in the late 1980s and 1990s. In many countries, legislation has been passed to make cannabis available for the treatment of pain despite evidence suggesting minimal to no benefit and significant risk of adverse effects. Stockings et al. reported the number needed to treat to be 24 for 50% reduction in pain, in contrast to 6, the number needed to harm. There were no significant improvements in physical or emotional functioning with cannabinoid treatment, and research is ongoing to try to delineate subgroups of people with CNCP who may have more benefit. However, if we are prepared to learn from the history of opioid mismanagement, cannabinoids should not be used for the treatment of CNCP outside a research setting at the present time.
| Biopsychosocial Management and the Whole-Person Approach|| |
Historically, the biopsychosocial model has provided a useful framework for the management of pain as it has for multiple chronic conditions. However, there have been and continue to be challenges in implementation. These challenges have led to a call to invert the biopsychosocial approach to pain training and practice. The call is made for a sociopsychobiomedical framework that prioritizes sociological and psychological aspects over biomedical.
An outworking of the biopsychosocial model in the pain context is the whole-person approach, as illustrated in [Figure 1]. The hand model provides a convenient way to represent this approach, using simple, patient-friendly language. It consists of five component parts.
The benefits of medications and procedural interventions in acute and cancer pain as opposed to their limitations in CNCP have been discussed previously. In the CNCP setting, medications and interventional procedures are likely to produce more harm than benefit. The “whole-person” framing of biomedicine as one-fifth part of overall treatment provides a suitable starting context ahead of gradual weaning and transition to engagement with the other component parts.
It is self-evident that what happens in the body effects the mind. Sensations of threat arising in the body challenge our sense of safety and resultant thought patterns. Reflecting on these thought patterns, analyzing whether or not they are helpful, and their impact on function is part and parcel of the cognitive behavioral approach, which has consistently shown benefit for pain and disability.
It is also true that what happens in our mind impacts our body. The neurobiology of threat can be reinforced by our mind's attention to or rumination on negative thought patterns. With this comes activation of the sympathetic nervous system and hypothalamic–pituitary–adrenal (HPA) axis and widespread consequences throughout the body. Alternatively, a focus on calm can be used to activate the parasympathetic nervous system, damp down the HPA axis, and harness the relaxation response. An example of this is the mindful practice of breath awareness.
The failure to adaptively process and resolve past conflicts and trauma can affect nervous system mechanisms that modulate both pain and emotions, driving somatic and psychological symptoms. Emotional awareness and expression therapy is an emerging therapeutic approach, which shows particular promise in the mind–body area with a focus on the awareness of emotions rather than cognitions.
Unhelpful connections to people, place, and purpose across the lifespan are strongly associated with the experience of pain. Adverse childhood events can increase the likelihood of chronic pain later in life. In adulthood, there is an association between the experience of chronic pain and difficulty in social and workplace environments. It has been proposed that social rejection and pain share overlapping neural pathways. As in mind–body interactions, the relationship is bidirectional. Chronic pain can, on the one hand, lead to workplace and family problems. On the other hand, aversive social interactions or isolation can worsen pain. People who are isolated from a supportive community feel under threat, whereas those who are well connected are likely to feel safe. As discussed before, a context of threat can amplify the experience of pain via nervous system sensitization while building a sense of safety can be a key part of pain recovery.,
Physical activity is important in the prevention and treatment of chronic pain due in part to its impact on nervous system function. Regular planned physical activity results in long-term neural adaptations, leading to pain reduction via activation of opioid, serotonin, and other mechanisms.
Pain may be perceived as a barrier to participation in physical activity, but the need for pain to be avoided or alleviated in relation to exercise has been challenged. Regular ongoing activity is recommended, starting with a small amount that is achievable “even on a bad day,” grading up on a time-contingent basis. This avoids the instinctual “boom and bust” and “let pain be your guide” approaches and instead aims to reduce avoidance and gradually increase function.
No one modality of physical activity has proven superior for chronic pain. Walking is easily accessible and should arguably be the default. However, strength training and other forms of exercise also have a place. Guidelines recommend a combination of aerobic (150–300 min of moderate physical activity per week) and strength-based (at least twice a week) exercise.
There is a bidirectional relationship between pain and nutrition. Pain can lead to comfort eating and difficulty accessing good-quality food. Poor nutrition can also be a contributor to pain. In part, this may be due to development of multimorbidity or excess body weight overloading tissues. There are also metabolic consequences of poor diet with the development of a state of low-grade systemic inflammation or “metaflammation,” which in turn can sensitize the nervous system and amplify the experience of pain. The impact of diet on the gut microbiome and in turn the nervous and immune system function and pain is currently a topic of considerable scientific interest.
Nutritional strategies for the treatment of chronic pain overlap with approaches to other chronic conditions and focus on eating vegetables, fruits, legumes, nuts/seeds, low glycemic index, high fiber, antioxidants, and high-quality fats. It is also important to reduce consumption of energy-dense, nutrient-poor foods (e.g., processed snacks and take-away foods).
A recent systematic review on nutritional interventions for chronic pain, showed that interventions which altered overall diet composition or altered a single macronutrient were more likely to result in significant reduction in pain intensity than those that tested a supplement or involved fasting.
| Health-Care Delivery Systems|| |
For any health-care delivery system to work efficiently, integration of the component parts is essential. In the context of CNCP, a coordinated and sustainable approach is required across the community, primary care, and specialist settings. Key messages should be relevant and consistent across different health-care contexts and different modes of health-care delivery. The goal should be person centeredness, empowering patients to undertake active self-management in partnership with health-care professionals.
In many systems across the world, there is marked clinical variation in the treatment of CNCP and care is often fragmented and not based on evidence. For example, the general practitioner (GP) may wish to reduce opioid dose while the specialist prescribes a dose increase. The clinical psychologist advocates self-management, whereas the pain physician offers procedural intervention. Beliefs of health-care providers and financial considerations including variation in health service reimbursement can also drive treatment choices.
Not every CNCP patient needs access to specialist services, but a more effective and efficient goal for health-care systems would be to enable every CNCP patient to have timely access to evidence-based support to undertake active self-management, preferably in their own community.
The behavioral change wheel provides a useful framework for addressing system change. Each circle of the wheel addresses change from the perspective of the patient (inner), the clinician (middle), and policy/governance (outer). This echoes the four “nested” level model of health-care systems: the individual patient, the care team, the organization, and the economic–political environment.
Public health approaches
Mass media campaigns can influence health-related behaviors across large populations. Good examples of harnessing this include the SunSmart campaign and anti-tobacco campaigns in countries around the world. However, effectiveness can vary depending on the message design, target, duration, funding, access to key services, opportunities for change, policies, and competing interests.
While most well-executed campaigns help increase knowledge, awareness, and intention to change, actual behavioral change can be harder to achieve and sustain. An Australian population-based public health intervention about back pain, showed the impact on beliefs among public and GPs, which also translated into reduced work cover claims.
Education and training of health-care professionals
The prevalence of chronic pain is projected to increase around the world, and there may never be enough formally trained specialist pain medicine physicians or specialist pain services to meet the needs of chronic pain patients. However, increasing access to these services may not necessarily be the most efficient use of limited resources in most countries.
Primary care providers are well placed to provide longitudinal, holistic care and facilitate active pain self-management in the community, referring a select minority to specialist pain services. However, lack of training and confidence along with limitation of time and resources poses a challenge.,
Development of short pain training courses, integrating pain training into established medical and surgical specialist training pathways, offering online pain education modules, and updating the curricula of medical and allied health students have been proposed as possible strategies in different parts of the world.
Innovations in the delivery of pain management
From a systems perspective, various innovations including early utilization of group interventions to reduce wait times and improve flow through pain services and the introduction of group self-assessment as a prelude to self-management have shown benefit.,,, Use of telehealth to deliver pain management programs to rural and remote communities with reliable internet access has also shown promise in terms of feasibility, effectiveness, and positive patient experience.
Given the multidimensional nature of chronic pain and its management, it is appropriate that outcomes measures reflect the same, tapping into the multiple dimensions of the person's experience within their family, society, and environment. Pain intensity is a critical outcome measure, but for it to be meaningful, it must be combined with measures of physical and psychological functioning. The overly enthusiastic attempt to abolish a person's chronic pain with medications that diminish cognitive and physical function often results in a poor overall outcome.
In Australia and the USA, large multidimensional data sets are now in use to compare outcome measures across pain services., Analysis of substantial data of “real-world” practice, as opposed to the somewhat “artificial” world of randomized controlled trials, will play an increasingly important part in guiding practice improvement in the new era of better value health care.
| Conclusion|| |
Chronic pain is a biopsychosocial phenomenon; it is a global health-care problem that continues to challenge health-care systems, clinicians, and patients alike. The focus thus far on a traditional narrow biomedical approach has led to neglect toward consideration of psychosocial and lifestyle factors in the lived experience of pain. The emerging evidence-based paradigm of a more comprehensive integrated model of health care with benchmarking of large datasets is likely to drive redesign and innovation in health-care delivery systems around the world.
The authors gratefully acknowledge the enthusiastic and considerable support of all members of Hunter Integrated Pain Service (HIPS) toward the development and implementation of the holistic model of chronic pain management at HIPS.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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