Pain’s cause and effect: we must treat them together

IT makes perfect sense to search for and treat the cause of pain. After all, acute pain usually has a definable cause and can most often be resolved with treatment or spontaneously.

For those who have chronic pain, however, we need to move medical and societal thinking towards treating cause and effect together.

For the 3.24 million people in Australia who live with chronic pain, the initial cause of the pain will vary widely but the effects of pain on the lives of patients is often sadly similar.

When pain is persistent, and has been present for more than 3 months – and in many of our patients it has been present for years – then we have to look holistically at how the pain has affected that person in multiple different dimensions of their life.

How has it affected their sleep, mood and personal relationships? How has it affected their work? What burden of side effects have they got from medication? How are they thinking about their pain? All these questions need to be looked at alongside the aspect of the pain itself, so that you can start to move away from a never-ending focus on the cause to addressing the effects of the pain on the individual.

It is not uncommon for patients to be referred to a pain clinic when they have been in persistent pain for more than a year.

The risks of waiting too long are significant. For every extra year somebody has poorly controlled pain, the more likely it is to become consistently and permanently ingrained in the nervous system, making it more difficult and intractable to treat. The more we can get people referred at 3, 6 and 12 months, the less fixed the pain is, the more techniques there are available for that patient, and the more successful they are likely to be.

One of the common misconceptions with chronic pain is that it cannot be treated, and that is not true, even when pain has been persistent for years.

Patients fear the perception that “it’s all in your head”, that they will not be believed. Some think that a pain clinic will only be able to put them on narcotics or will simply tell them to accept their pain. Perhaps the biggest barrier to accessing effective treatment is simply the lack of community awareness that pain clinics and pain specialists exist.

There are four main buckets of therapy which a multidisciplinary practice can offer.

First, psychological therapy can assist people in changing the way they approach the pain, especially if some of their approach is maladaptive.

Second, physical therapies and physical rehabilitation can improve functional capacity.

Third, there are existing pharmacological therapies that can dampen down pain, and these therapies can have a significant role for muscular pain and neuropathic pain.

Finally, there are interventional pain therapies with procedures and surgical operations to either dampen down pain signals or provide a window of opportunity where the patient has minimal pain.

Each of these therapies has become more and more refined over the past decade, as we gain a much more fundamental understanding of the circuitry of pain. That circuitry exists not only in the peripheral nervous system, but also in the central nervous system related to the spinal cord and brain. That increased understanding of the neurobiology of pain has allowed us to fine tune each of those therapies.

For example, an advanced pain therapy such as spinal cord stimulation was perhaps 20 years ago a somewhat crude representation of how it is delivered today. Twenty years ago, it might have been given to somebody at the very end stage of the treatment continuum where everything else had failed. Now, we have realised that we want to use it much more as a neuro-rehabilitative tool, alongside other therapies, to provide better quality of life and perhaps minimise the reliance on medications. Its ability to reduce pain has increased dramatically over the past 20 years, and in fact, even over the past 5 years.

Spinal cord stimulation (SCS) is a therapy typically used for refractory neuropathic pain, although not every patient with neuropathic pain would be suitable to receive it. However, for those who are suitable, we are now able to say that 50% of patients are able to get an 80% pain reduction. And when you are getting up to those levels of pain relief, a lot of the additional problems start to dissipate simply through the pure pain reduction.

A therapy like this can be life changing. Many patients can greatly reduce their medications and lessen any associated side effects, they have control of their device with a patient controller and will typically be reviewed once a year, sometimes less, by a pain physician.

They may need occasional periodic reprogramming of the device but one of the latest versions is recharge-free so the rest of the time they will use their patient controller to adjust stimulation if they need to, and along with their self-management strategies, they can manage pain independent of the pain clinic and get on with life.

Unfortunately, many of these advances in what we can offer patients are not well known outside of our own specialty of pain medicine.

Chronic pain is a growing problem. The number of Australians living with chronic pain is set to rise to 5.2 million by 2050, according to Pain Australia.

While medicine will continue to refine and hone treatment strategies and get incremental improvement in available drug therapies, we can improve things far more dramatically by deploying what we already know works in pain medicine, and getting that out to the people who need it.

It has been estimated that only 10% of people get the treatment they need, and still maybe 90% of people with significant disabling pain who might not be getting exposure to pain clinics, specialist pain medicine physicians and multidisciplinary care. That is something that needs to be fixed.

Pain medicine as a specialty is relatively young. In 2005, it was Professor Michael Cousins AO who played the leading role in gaining recognition of pain medicine as a medical specialty by the Australian Government. Australia was the first country in the world to do this. We can surely build on this proud history to ensure more people with chronic pain receive specialist care that could transform their lives.

Dr Marc Russo is a Specialist Pain Medicine Physician based in Newcastle, and a Director at Large of the Neuromodulation Society of Australia and New Zealand, and incoming President of the International Neuromodulation Society.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.