As a consultant psychologist in chronic pain management, I spend a lot of my time exploring and refining my ideas about what pain is.
The reason I do this is because what we think pain is, has important consequences for how we all view pain and how as a society we treat it.
Over the past few months, I have been very interested to read an articles tracing some of the factors which have led to the explosion in the use of opioid medication. This is at its most serious in the US, but certainly has echoes in the UK as well.
You may know the old saying‚ the road to hell is paved with good intentions’. It came to my mind when I was reading these articles.
And a lot of the problems began around that question, what exactly is pain?’ In 1996 the American Pain Society decided that it was one of the body’s vital signs, along with temperature, blood pressure, heart rate and breathing.
The reasons behind this might have been very laudable, to acknowledge patients’ feelings and concerns over their pain, to show that professionals understood that pain was a serious issue and could have a serious impact on patients’ wellbeing. But the results were anything but laudable. This change had the effect of opening up the chance to medicalise pain. Something else happened in 1996, OxyContin, the drug which mimics the effects of morphine, was beginning to be heavily marketed as a solution to all sorts of pain.
So, there was something of a perfect storm, heightened awareness of pain by the medical profession and a pill which seemed to be the answer to it.
Morphine, and morphine-like drugs had been used for many years to treat acute pain, such as that caused by cancer or by serious injuries. But very quickly doctors began to prescribe these drugs for chronic pain. And this is where the question of what pain is becoming important.
Chronic pain and acute pain are different
The way chronic pain works is different to the way acute pain works. Acute pain is the body’s way of signalling that something is wrong. In chronic pain the signals are different, they are more like a switch which should be turned off or turned down but, because of the way the body and mind react, keeps going on full alert.
There is now a general acceptance that the treatment of chronic pain and acute pain should be different. Strong drugs may be necessary for acute pain, but a much more holistic approach is usually the way forward for chronic pain.
Another big change is an increasing recognition that opioids may not work for chronic pain. Not only are they very dangerous, but they are not even very effective in the management of chronic pain. The American Medical Association has reported this year on a study in which military veterans were given different types of pain medication and the dangerous opioids were found to be no more effective than other, less dangerous, drugs.
Treating the causes of chronic pain
One obvious thing about pills for chronic pain is that they treat the pain rather than the cause of the pain. This is a particular issue where chronic pain is involved as often reactions to chronic pain can actually make the pain worse. Any chronic pain specialist will recognise the pattern, a patient has a bad back, for example, so they stop going out for their daily walk and lose physical strength and function, they become stiff and the pain gets worse, this means they find it difficult to sleep, and they become depressed, they move about even less and stop eating properly, the pain gets worse. The patient then asks for a strong pain killer.
If their physician is working with the ‘pain as a vital sign,’ model they may ask the patient for their perception of the pain and be told that it is getting worse. For much of the previous decades their answer would have been to increase the pain medication.
So, it is a very sorry story, from the good intention to take pain seriously and listen to what patients say, to dishing out ever-increasing amounts of dangerous and addictive drugs.
In the United States a reaction against this is underway and the ‘pain as a vital sign’ practice is being reversed. There is a greater understanding that chronic pain is related to how well the patient is functioning and should be viewed as part of general health and wellbeing, not as separate.
This is where the sort of therapies that practitioners like myself use come into their own.
Chronic pain is individual and controllable, understanding how an individual perceives their pain and developing strategies to help them control it is the way forward.
This can involve lifestyle management such as an exercise and sleep regime and it often involves mental intervention as well.
Chronic pain is essentially about the perception of pain. It is about how the brain processes the messages from the body and what ideas in the mind these sparks. These patterns can be changed and the ideas the patient has can be altered or given different values and a different emotional charge.
This approach works. It is very sad to see the dangerous path the opioid model has taken us down, but it does look as if our message is finally getting through and this is a cause for hope.