There is a pressing need for wider recognition of the often devastating effects of chronic pain on the lives of many people, writes Sylvia Thompson.
Consider the following scenario. You are out shopping, at the cinema, in a restaurant and you meet an old friend you haven't seen for years. He explains how he had been diagnosed with bowel cancer, had surgery, radiotherapy and chemotherapy and is now slowly getting back on his feet.
You express sympathy and perhaps count yourself lucky that it wasn't you. Now consider another scenario. You meet the same friend but this time, he explains how he has suffered from back pain for years, had surgery which didn't really solve the problem, is in constant pain and has been off work for five years now, unable to function properly and get on with his life. This time, your feelings of sympathy may be marred with a tinge of suspicion wondering why if he really is in such pain, he hasn't managed to sort himself out.
Being misunderstood and dismissed by medical professionals, friends and family is a core problem for sufferers of chronic pain. So much so that the psychological fallout from their condition - anxiety, depression and withdrawal from work and social activities - can become as insurmountable as the original physical pain.
"Validating the patient's experience of pain is a very important part of helping them cope," says Dr Dermot Canavan, dentist and vice-president of the Irish Pain Society (IPS) which is holding its fourth annual scientific meeting - a multidisciplinary conference on the management of the pain patient in Dublin on Thursday and Friday - this week is designated European Pain Week by the European Federation of national pain societies.
The IPS and fellow associations in Europe have been campaigning for chronic pain to be treated as a disease in its own right for some time. "Pain is a major healthcare problem in Europe. Although acute pain may reasonably be considered a symptom of disease or injury, chronic and recurrent pain is a specific problem, a disease in its own right," declared the European federation of pain societies (EFIC) at the launch of Europe Against Pain campaign three years ago.
Defining acute pain as that following trauma or surgery, EFIC suggests such pain is useful and adaptive, warning the individual of danger and the need to escape or seek help. Chronic pain, however, is believed to be not directly related to the initial injury or disease condition, but rather to secondary changes, possibly in the pain detection system itself.
The International Association for the Study of Pain (IASP) recommends that chronic pain should only be diagnosed when all signs of the original cause have disappeared or where curative treatment of the initial condition is not possible.
Recent research into the biology of pain even suggests nerve pathways from the brain to the site of injury are different in acute and chronic pain. Hormones, memory and emotions may all play an important role alongside "pain sensors" which transmit and receive pain messages. Such discoveries are now spawning pharmacological studies which may lead to new drugs developed to target specific chronic pain conditions.
Although chronic pain is defined as pain which lasts for more than three to six months, Dr Camillus Power, director of pain medicine services at the Adelaide, Meath and National Children's Hospital in Tallaght believes it is wrong to completely separate acute pain from chronic pain since a lot of acute pain experienced post-operatively can become chronic pain.
"Chronic pain is a potential outcome of procedures such as breast surgery where the incidence of phantom breast pain one year later is 12.7 per cent. Also up to 27 per cent of patients can suffer from scar pain following surgery and up to 11 per cent of patients suffer from pain following hernia repair," he says. Many patients also suffer from chronic pain after heart surgery and removal of malignant tumours.
Dr Power believes pain hasn't received sufficient attention in the hospital setting and should be identified as the fifth vital sign (the other four being, blood pressure, temperature reading, respiratory and pulse rates) for patients. Giving patients opportunities to measure the intensity of pain pre and post-operatively may also empower them to deal with pain better. "Even children can rate their levels of pain on pain charts using sad, grumpy or smiley faces," Dr Power adds.
Although significant mainly because it is potentially preventable, chronic pain arising from surgical interventions accounts for only a small percentage of all chronic pain conditions. Much higher numbers of patients suffer for years with back pain (either from degenerative disc disease or spinal fractures).
And others are debilitated by various forms of arthritic pain. Drug therapies do offer pain relief to some of these sufferers. Interventions such as those which interrupt or alter the nerve pathway from the site of pain to the brain also work for some sufferers of back and neck pain. However, many more patients are left without relief. There is a growing belief among pain specialists that pain management programmes - currently only available in two Dublin hospitals - represent the best hope for patients with chronic pain conditions such a lower back pain, migraine or musculo-skeletal problems.
Dr Rosemary Walsh, senior clinical psychologist specialising in chronic pain conditions at St Vincent's University Hospital, Dublin says the pain management programme there is a full-time three-week course in which patients learn about the biology of pain, the medicines used to treat chronic pain as well as learning psychological techniques to deal with negative thinking, lack of motivation and the avoidance of exercise. "We help patients identify and challenge negative thinking and break down the barrier to exercise that have developed from fear of re-injury or fear of pain itself," she says.
The programme, which is run by a multidisciplinary team of pain specialists including an anaesthetist, a physiotherapist, an occupational therapist and a psychologist, also encourages participants to keep pain diaries, build up exercise routines and consider retraining.
Dr Declan O'Keefe, director of pain services at St Vincent's University Hospital, Dublin, and IPS president, believes there is a huge need for the development of such pain management programmes on a regional basis. "Approximately 60 per cent of patients will have seen complementary medicine therapists before they come to our pain service." he says.
The call for expansion of pain management programmes is part of an overall campaign by specialists and the chronic-pain patient action group, Positive Pain Power for a national pain strategy. "There is need for recognition of the devastating effects of chronic pain on the lives of sufferers by those at government, hospital and community health level," says Sandra Orr, spokeswoman for Positive Pain Power.
The group believes delays in access to pain treatments of choice often unnecessarily lengthen the time sufferers have to deal with their pain. They give an example of one patient whose treatment over five years "soaked up" finances equivalent to the cost of running a pain management programme for 200 patients over two years.
Including holistic healthcare practitioners, such as osteopaths and acupuncturists, in the multidisciplinary pain management teams may also encourage some patients to look at profoundly personal struggles which may be adding to their burden of pain. Another reason why pain specialists are keen to develop management programmes is, due to pressure from the Personal Injury Assessment Board, to wrap up legal cases for chronic-pain employees within 15 months.
If patients are waiting for more than two years to gain access to such treatment programmes, it is impossible for their cases to be settled within such a time frame. There is a deep concern among pain specialists and patient groups that the Government will probably only respond when the increasing cost of absenteeism due to chronic pain conditions outweighs the cost of setting-up such programmes on a regional basis.