The incident of chronic pain is increasing with few apparent new innovations in treatment ideas. This is particularly true at the everyday level of GP's and their patients. New solutions are necessary to help doctors with, at times, challenging patients.
Solutions for those people suffering with chronic pain are mainly pills. Unfortunately, too many of the clients I see are, I believe, now beginning to see doctors as someone that just prescribes pills as the answer for chronic pain, persistent anxiety, and other chronic illnesses.
Why we Need New Solutions for Chronic Pain
Why? Because what we do at the moment doesn't work. People with pain are asked to live lesser lives and adjust the way they live to facilitate their chronic pain. I believe it must be time to do better than this. Here I ask questions about the way chronic pain is managed and present some suggestions for change.
1. How Can we Stop the Increase in Chronic Pain Patients?
Numbers of people with chronic pain are increasing, worldwide, accompanied by growing numbers of names, diagnoses and definitions for a wide variety of pain and pain syndromes.
The International Classification Of Diseases (ICD-11th revision) lists symptoms, causes and classifications used for diagnosis is constantly being updated, reworded for better clarity and purpose by a large number of extremely intelligent people. Globally a hierarchy of specialists and experts in their respective areas of expertise.
Could the number of people discussing and creating definitions be increasing more than “hands-on” patient facing healthcare providers. Are we creating a bureaucracy of specialist?
Could Expertise Create Distance Between Patients.
“I remember when I was a high school teacher; the best teachers, those that connected with and inspired pupils, were promoted. Promoted out of the classroom.”
Consequently, do we have available in many countries, an increasing number of committee members and advisors? Highly trained doctors and specialists who no longer meet patients. Incidentally, an interesting question to ask – are patients today the same as they were 15 to 20 years ago when these specialists were in face-to-face practice? I think not.
Working Face-to-Face
Another useful idea - I refer here to a television program. The CEO or owner of a large business or corporation returns, in disguise, to work in ground floor level. Positions are often interacting with the general public in service businesses. The CEO therefore gaining everyday experience of employees and customers.
“This process is always a major learning experience and valuable feedback for the CEO, for the betterment of the employees and the customers.”
Now here's an interesting idea - get many of the advisors to the World Health Organisation (WHO), pharmaceutical companies and perhaps even in specialist in hospitals and universities - bring them down to work face to face with patients in a GP practice. And suggest they stay there for two or three weeks.
“Because in reality - healthcare or the majority of healthcare starts at a GP practice.”
Technological Future of Medicine and Diagnosis
There is also another suggestion that could be useful suggested by Dr. Bertalan Mesko the Medical Futurist who is talking up the value of technology, plus the addition of AI. With the extra ability of technology to precis and analyse patient tests and results, then integrate this with the patients 5-year, 10-year, or 15-year medical history.
The time saved is an opportunity for doctors and specialists to sit and talk with patients. Therefore able to spend more time with them, getting valuable insight into their past and present life.
To this I must add a corollary, when history taking all health professionals must go beyond the symptoms to find out what is happening in someone's life realizing that every single person is unique not a collection of symptoms.
Begin with Chronic Pain Experiential Education
Often neglected due to short consultations and lack of follow-up is the educational power of experiential learning - for the doctor!
When a practitioner has the time to talk and interact with a patient or client it is an important learning experience for the practitioner. To build up real knowledge of how well their advice, suggestions or prescriptions were used or even understood!
“Patients are mostly helpful people who often say yes “I can do that” or “I understand” when they have no idea at all about what you have explained!”
2.Can we Stop Lives Lived with Pain and Disability
Quality of lives are being lost as people struggle with disability and persistent pain. Pain in all the different types and diagnoses of chronic pain is a very personal experience.
When structural pain has healed, and pain remains patients are presented with a label. In fact, we've got very used to looking for a label and often we think we must have one, because it describes what is wrong. Unfortunately, or should I say generally, we are given a diagnosis but not a cause of ongoing pain.
In the case of chronic pain, a diagnosis is a name given from those lists of definitions I mentioned earlier in the article. It is not the cause of ongoing persistent pain.
To begin to make changes in the lives of those living with chronic pain we must adopt a different attitude to the patients themselves. When a patient comes in with chronic pain it is very, very, unlikely to the be the first time in their life they have had pain.
Consequently, life happenings should be the first part of a consultation.
When did you have pain previously, before this episode?
What sort of pain was it and what was the outcome?
What was happening in your life at the time?
Were there any other times when you had a pain?
Did this previous pain go away?
Did you have treatment?
Did the treatment work?
I think the most important questions I learned to ask when training to be a naturopath were:-
What makes it better?
What makes it worse?
What gives you relief?
This question was closely followed by -
What would you like to do about your chronic pain?
Unfortunately, here I have to mention the attitude or perhaps the behaviour of the chronic pain patient who has been trained in pill therapy. Therefore, their response is nearly always - they would like to be pain free.
Perhaps this leads both patient and doctor down a dodgy road with no reverse gear?
3.Does the Medical Industry Stumble from One Solution for Chronic Pain to Another?
Once upon a time in history there was a magic cure for chronic pain. We all celebrated when opioids were developed. This was the answer for hundreds if not thousands of people suffering with chronic pain.
Because opioids worked, as I mentioned in the previous paragraph, doctors and their patients suffering with chronic pain had found what they were looking for to be pain free. Unfortunately, as we have now found, decades later, the celebration was premature. We had not found a cure for chronic pain we had found a way to bypass finding the cause of the pain, to making the symptoms go away.
Problems with Opiods Medication for Pain
Now America and other countries are seeing hundreds of people dying from prescribed medications for their pain. With all the difficulties mentioned above new solutions and real innovations are slow to reach the GP interface, but what options do they have for chronic pain patients.
It seemed that no one knew what would happen with such widespread use of opioids, which incidentally many people with chronic pain are continuing to take. Again because we lack new innovations and different solutions, or we could just still be looking for a pill and not talking to patients about their lives!
Patients nowadays are rarely put on opioids for their chronic pain that they live with. But in the back of my mind there is a worry about what is happening to medications.
We are still giving people pills for their chronic pain. Are we going to find out in decades ahead that gabapentin and tricyclic antidepressants and others could also have some really injurious consequences?
As specialists are moving towards an increased use of nonopioid medication do we really have any idea at all what will be the consequences of someone taking these pills for 5 years, 10 years or 20 years? Unfortunately, no.
A New Area to Explore for Cause of Chronic Pain
It really is time to involve patients as the control center of their chronic pain. To do this we need to begin to start to agree on the cause of chronic pain. As I've mentioned above it is by taking a full patient history. Find out what is happening in their life, crises, trauma, stress, overwhelm - this has mostly been missing for decades.
We have to recognise the fact that the doctors and specialists are highly intelligent and trained to the nth degree in their specialties. Because of this there is no way the majority of patients can be met on a level playing field.
We must all respect the hard work that goes into training for medical specialists and doctors. My parents certainly looked up to them and put them on a pedestal. But as I mentioned earlier, in the last 15 to 20 years patients have changed a lot. Also, at the same time many GP’s at patient interface have too. But what about the people who write the medical definitions and protocols in very highly paid positions?
Understand the Need for a Healthy Lifestyle
Patients, in fact all of us need to be fully aware of a healthy lifestyle and regardless of their condition the prescriptions for a healthy lifestyle need to be made by the doctor.
Yes, written down on a prescription pad perhaps to say: -
Only one takeaway meal weekly,
Drink water regularly,
Minimum of two pieces of fruit, daily,
Minimum of four vegetables, daily.
Leave sweets, desserts, and fizzy drinks as a treat as they used to be!
Finally give chronic pain patients support, ongoing support and follow-ups that encourage positivity and motivation to make changes.
With the technological advances we have now for communication, even short reminders and positive encouragement would be a very good start. This would certainly remove some patients from the race to permanent chronic pain.
4. More Surgeries have Not Solved the Chronic Pain Problem
The most recent new solutions, yes; surgical innovations to stop chronic pain are increasing in number and variety. But patients beware, unfortunately surgery is a one-way door.
I would question the amount of randomised controlled trials, as done for the medications mentioned earlier, that have been done for most of the chronic pain surgeries that are done on backs, knees, shoulders, etc?
Surely, it's time to justify these surgeries.
An easy start would be follow-ups after surgery for regular time periods: -
Collect the figures of success.
Record the levels of success.
Record the levels of failure.
Collect the figures for revisions.
Again, with the use of newly developed technology; tracking operations, metal or plastic parts inserted during replacement operations.
Include all the intricacies of living with chronic pain: -
Range of movement before operation.
Range of movement after the operation.
Rates of recovery and number of revisions,
Type of artificial body parts and their duration.
Initially start within a country. It certainly it would be a great start – get reliable information about the use, success, and real and absolute necessity of surgery for chronic pain. Again, using technology and AI we could soon find out the best way forward to use or to not use these new innovations for surgery.
Have all this information readily available to general public.
Because, without complete success of these operations, even leaving one or two percent of patients being left in total unbearable, debilitating, lifelong pain is too many.
Already, we know several placebo surgeries have been done with remarkable findings. Some patients who had the placebo surgery have done as well, sometimes better than those that had real surgery.
Placebo patients are now living completely pain free, completely restored range of motion and complete restoration of their lives and future.(Professor Andrew Carr and Professor David Beard, 2017).
How is this happening – surely, this must be further explored!
We must realize that people are not machines. We are whole beings, mind, body, spirit, emotions and feelings. Perhaps, sometimes we may need to double think chronic pain treatment so that surgery is our final not our first option.
I have read of specialists, such as some orthopaedic surgeons who are turning people away. In fact often sending more people away, to alternative treatments, than following through with surgery.
This is a great start – A new innovation!
5. Stop Nocebo for Chronic Pain Patients Neural Circuit Pain.
Already in this article I've talked about placebo. For instance, in research this means a group of people receive “sugar pills” containing no active ingredients. Outcomes are then measured against the real drug therapy, operations or other treatments being given.
However, being enrolled in group research, even being selected, is already going to cause changes. Now very little can be done about this as just being part of a group research can affect the results.
Strangely enough even placebos can generate side effects. Personally, I call them brain effects!
There is a whole discussion about how to lessen placebo effects that are often described as “spoiling” results. Consequently, people who are viewed as susceptible to placebo - could that mean being optimistic? - may be removed from the research cohort so they do not cause bias in the results. Though removing them; isn't that bias?
Incidentally, often placebo can be an effective treatment - but that's for another blog.
How can Nocebo Statements Impact Chronic Pain Management?
Before entering the health care area, I had never heard the word nocebo, although familiar with placebo. Therefore let's use a definition of nocebo as a negative expectation or negative perception of treatment, illness, or injury.
I need again to stress the importance of new solutions or new ways of working with patients who have chronic pain hence this is where I want to suggest embracing placebos, that is being positive. At the same time reducing nocebo as much as possible.
Here are two stories to show the importance of what doctors and specialists say to patients. How important to take time and consider carefully the words and descriptions that you use with patients.
First Story – my personal story
My recovery from major abdominal surgery went well. However, a few years later I had what I can only describe as stiff arm disease. I would have severe pain, intermittently that resulted in virtually being unable to move or lift my arms. Some days this would spread to other parts of my body.
Following tests I was given a diagnosis of lupus. Unfortunately, when I found medication side effects too difficult and preferred not to take them, the pain specialist absolved responsibility.
“You will be back in 10 years, begging me to give you an injection in your shoulder for your pain”.
At the time my husband and I were rather surprised, he should talk in this way. This nocebo still lingers in my head (you cannot unhear those words) even ten years later. I am painfree but recalling his words can still cause a reaction in my shoulder. That's unfortunate and I believe unnecessary.
Second Story - also true.
I met a new client experiencing unbearable chronic pain. When I asked about the last couple of weeks, he had found his worsening pain followed his latest check up with his specialist. Here's his nocebo comment that he had in his head.
“Now you're getting older [over 50] your pain cannot improve. It will get worse with age.”
I'm sure like myself that this client regardless of the fact that following treatment, he has now reduced pain and in a happy place in his life; he also will not be able to unhear the specialist’s words.
Consequently, there are a lot of things that could be better left unsaid. Such expressions as
“wear and tear” or “bone on bone” are not on the ICD list of diagnoses that I mentioned at the beginning of this article.
In many ways these often used statements mean very little and it has been proven that they can have little or no influence or cause chronic pain. Consequently, these expressions should not be used as a cause of pain and to not speak such a negative way.
As the stories above imply such negative language may make pain worse or even create a "pain neural circuit" in the brain. This circuit or collection of neurons are able to create or switch on persistent pain.
This article is the thoughts and opinions of the author. Specific information, and quotes will be included in the reference section, if applicable.
However, my ideas rest on the shoulders of many specialists who are trying to make a difference. Very little is new mostly revisiting ideas already expressed. But it is time to make changes.
If you enjoyed or were stimulated by this article join the band of people who believe medicine can be done differently. Positively and patient centered able to reduce the numbers of people living in chronic pain.
Jean Jordan
Want to find simple effective ways to reduce your chronic pain without increasing your stress and overwhelm?
This is where I can help! Ideas can be found in the articles on my website. You can sign-up to regular updates or spend time using some of the collection of self-help techniques.
After over 20 years of having my own pain clinics pain clinics I started natural pain solutions to reach more people, rather than one person at a time.
Therefore when I completed my postgraduate pain management studies I wanted to spread the word about holistic self-help techniques that people can use at home.
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